Resuscitation
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The authors analyse the incidence of puncture, catheterization and failures of positioning in a series of 420 central venous catheterizations performed in 388 patients, using six transcutaneous approaches: supraclavicular and infraclavicular subclavian, external and internal transjugular, antecubital and brachiocephalic. Puncture failures were recorded at 7.9% per 36 failures from 456 attempts, catheterization failures at 5.8% per 26 failures from 446 attempts, and misplacements at a rate of 5.7% per 23 misplacements during 420 catheterizations. ⋯ A high rate of failures and misplacements was recorded in the antecubital and external jugular groups. The antecubital veins, however, should be reserved for orthopnoeic sitting patients, the success rate being significantly increased if the patients are sitting.
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A transcutaneous oxygen sensor was used continuously during surgical management of a ruptured abdominal aortic aneurysm. Closed chest compression initiated for intraoperative cardiac arrest gave an inadequate cardiac output on the basis of falling PtcO2 despite transmitted femoral pulses and an excellent PaO2. ⋯ It reflects the PaO2 in hemodynamically stable patients as well as providing a sensitive indicator for inadequate cardiac output during shock. In patients undergoing cardiopulmonary resuscitation, a falling PtcO2 with an acceptable PaO2 indicates poor tissue perfusion and, in select circumstances, may warrant open cardiac massage.
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Case Reports
Pulmonary artery pressure versus pulmonary capillary wedge pressure and central venous pressure in shock.
Evidence is presented from 43 dogs and 30 patients that under conditions of severe hemorrhagic, traumatic or septic shock, there may be partial obstruction of the pulmonary microcirculation due to disseminated intravascular coagulation (DIC) particularly in the pulmonary venules. This may cause the left atrial pressure to fall and the pulmonary artery pressure to rise, in some cases drastically. Pulmonary edema may result. ⋯ It is concluded that pulmonary artery pressure measurements are very important in monitoring intravenous fluid administration in severe shock. Wedged pulmonary artery pressures monitor the left heart but may be misleading if taken alone. Central venous pressure gives a delayed response to fluid overload.
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The frequency and duration of interruptions of cardiopulmonary resuscitation (CPR) were evaluated in a hospital to determine whether or not CRP was being performed properly according to American Heart Association (AHA) standards. The frequency of interruptions were 0.41 per min. ⋯ Eighty percent of these interruptions of greater than 20 s duration were of unjustified duration. CPR education should reflect these unjustified deviations and their reasons in an attempt to limit such interruptions in future patient CPR.