Mechanics of the circulation during cardiopulmonary resuscitation. Pathophysiology and techniques (Part II)

Resuscitation and conjunctival petechial hemorrhages

In recent years, cardiopulmonary resuscitation (CPR) has been discussed as a cause of petechial hemorrhage in eyelids and conjunctivae, which could be of substantial significance to forensic expertises in cases of suspected strangulation. In the reported series or case observations, the combination of CPR and petechiae seemed to be sufficient to explain such a causal connection. Nearly all presented cases were victims for which the mechanisms resulting in death were themselves well-known causes explaining the development of such petechiae; and said mechanisms can frequently be observed in victims that did not receive CPR. An earlier, also retrospective, analysis of a series of forensic autopsies did not confirm CPR as a significant cause of conjunctival petechiae. Now we present the result of a prospective examination of 196 resuscitations of adult patients with separate assessment of petechiae being present even prior to resuscitation. Petechiae were present in 12 cases - but in eight of them prior to resuscitation already. Three other persons with petechiae found only after CPR were in the group of successfully resuscitated persons and exhibited petechiae hours after CPR during therapy in intensive care units - during a phase of ongoing cardiac insufficiency, which obviously caused them. The only case with petechiae observed neither immediately prior to nor after unsuccessful resuscitation, but during a follow-up examination one day later, needs to be discussed. It is not interpreted as reliable evidence for the causality of CPR though. Our interpretation of reports in literature as well as our experiences confirm the absence of actual proof of petechiae being generated by CPR and in the presence of generally significant doubts of this relation.

Congestion bleedings of the face and cardiopulmonary resuscitation--an attempt to evaluate their relationship

OBJECTIVES

Are any other factors besides the factor "cause of death" involved in the development of petechial hemorrhages (PET) of the head? The significance of the cause of death is well known, other factors have been rarely investigated in medical literature. Do they include cardiopulmonary resuscitation (CPR), as has been claimed in several forensic publications?

MATERIALS AND METHODS

(a) 473 consecutive autopsy cases (without strangulation) evaluated by one examiner, which were appropriate for this investigation; (b) analysis of 181 cardiac deaths (investigated by all physicians of our institute).

RESULTS

Petechiae were found in 13.3% of all cases and were clearly dependent on the cause of death, up to 20% were found in burn victims, intensive-care patients and cardiac fatalities. Petechiae were more frequently observed in the middle age groups (>20%) than in old persons (<10%). The number of PET cases increased with body mass but was lower in extremely obese persons, a greater number of cases with PET was also observed with increasing heart weight. PET were observed in 11% of the deaths without CPR compared to 19% with CPR. This difference was predominantly caused by the subgroup "acute coronary death", especially if victims younger than 60 years were considered, whereas in many other causes of death no difference in the prevalence of PET with or without CPR could be observed.

CONCLUSION

Besides the cause of death, other factors (age, body mass and possibly even heart weight) influence the development of petechiae. The hypothesis that CPR alone produces PET is not confirmed by our experience.

Endotoxin concentration in neutropenic patients with suspected gram-negative sepsis: correlation with clinical outcome and determination of anti-endotoxin core antibodies during therapy with polyclonal immunoglobulin M-enriched immunoglobulins

We carried out a study in patients with severe neutropenia from hematologic malignancy and suspected gram-negative sepsis to evaluate the clinical significance of endotoxin concentrations in plasma before and during a therapeutic intervention with a human polyclonal immunoglobulin M (IgM)-enriched immunoglobulin preparation (Pentaglobin; Biotest, Dreieich, Germany). Twenty-one patients with acute leukemia or non-Hodgkin's lymphoma entered the study upon the development of clinical signs of gram-negative sepsis and received the IgM-enriched immunoglobulin preparation every 6 h for 3 days (total dose, 1.3 liter with 7.8 g of IgM, 7.8 g of IgA, and 49.4 g of IgG), in addition to standardized antibiotic treatment. Concentrations of endotoxin and IgM and IgG antibodies against lipid A and Re lipopolysaccharide (LPS) in plasma were determined by a modified chromogenic Limulus amebocyte lysate test and semiquantitative enzyme linked immunosorbent assay, respectively, before each immunoglobulin infusion and during the following 25 days. Seventeen patients were endotoxin positive; in five of these patients, gram-negative infection was confirmed by microbiologic findings. Prior to therapy, endotoxemia correlated significantly with the occurrence of fever, and a quantitative correlation between the endotoxin concentration and body temperature was found during the individual course of infection in 8 of the 17 patients. Overall mortality from endotoxin-positive sepsis was 41% (7 of 17) and 64% (7 of 11) in patients with symptoms of septic shock. Nonsurvivors had significantly higher maximum concentration of endotoxin in plasma compared with those of survivors at the first study day (median of 126 versus 34 pg/ml; P < 0.05) and during the whole septic episode (median of 126 versus 61 pg/ml; P < 0.05). In survivors, immunoglobulin therapy resulted in a significant decrease in endotoxin levels in plasma within the initial 18-h treatment period, from a pretreatment median value of 28 pg/ml to a value of 8 pg/ml (P< 0.05). In the seven patients who died from uncontrollable infection, no effect of therapy on endotoxin levels in plasma was observed. IgM and IgG antibodies against lipid A and Re LPS increased significantly under immunoglobulin treatment, with significant correlations between antibodies against lipid A and Re LPS. These data strongly suggest a prognostic significance of the endotoxin levels in plasma and a potential effect of treatment with a polyclonal IgM-enriched immunoglobulin preparation. Further studies are needed to substantiate these findings and to assess the impact on the clinical course by way of a prospective placebo-controlled clinical trial.

Dopamine and renal salvage in the critically ill patient

Dopamine is a catecholamine used widely in critically ill patients and those undergoing major surgery, often as a 'renal protective' agent. Direct renal vasodilatation with 'low-dose' dopamine is the widely accepted basis for its use--hence the term 'renal dose' dopamine. However, recent evidence has revealed that the renal effects of this agent are far more complex. Moreover, some of these effects may be undesirable in the 'at-risk' kidney. The increased renal blood flow (RBF) of dopamine may be largely attributable to its inotropic (myocardial) action, even with low doses (i.e. less than 5 micrograms/kg/min). Similar increases in RBF can also be demonstrated with other (non-dopaminergic) inotropes. The early evidence for direct renal vasodilatation in response to dopamine has been brought into question by more recent research. The diuresis and natriuresis commonly seen following dopamine administration is now known to be due to a direct renal tubular (or 'diuretic') action. Furthermore, increasing knowledge regarding the pathophysiology of acute (ischaemic) renal failure, including RBF and the concept of 'oxygen supply and demand' in relation to tubular function, suggests that dopamine may mask important signs of renal ischaemia. Whether or not dopamine is truly beneficial to renal function currently remains unanswered. As it stands however, there is sufficient evidence to question its routine use in the setting of renal dysfunction in the critically ill patient.