Download 2011-06-17 Cardiopulmonary Resuscitation (Ana Marin, MD)

Pediatrics Grand Rounds
17 June 2011
University of Texas Health Science
Center at San Antonio
Objectives
Cardiopulmonary Resuscitation
Ana Hernandez Marin, MD, PL-6
Pediatric Critical Care Fellow
Grand Rounds
June 17, 2011
History of CPR
• The Bible mentions early attempt at mouth to
mouth
"...And he went up, and lay upon the child, and put
his mouth upon his mouth, and his eyes upon his
eyes, and his hands upon his hands; and he
stretched himself upon the child; and the flesh of
the child waxed warm."
Pulseless Cardiac Arrest
• Early recognition of cardiac arrest is
imperative
– Effective CPR and advanced life support can
optimize potential to restore life
– Lack of recognition can result in death or
neurologic devastation.
• Define cardiac arrest
• Identify the 4 phases of cardiac arrest
• Review of current evidence and practice in
post cardiac arrest care
Pulseless Cardiac Arrest
• Cessation of cardiac mechanical activity
– Absence of palpable central pulse
– Unresponsiveness
– Apnea
The Pulse Check
• Feel for a pulse
– May take up to 10 seconds
– Brachial pulse in an infant
– Carotid or femoral in child
1
Pediatrics Grand Rounds
17 June 2011
University of Texas Health Science
Center at San Antonio
The Pulse Check
Causes of Cardiac Arrest
• Problematic in infants and children
– Palpable pulse until systolic BP < 50 in adults
– Neonates Blood Pressure in 60’s
– Decrease in BP can lead to “non palpable” pulse
earlier
– Accessibility to a central pulse
Phases of Cardiac Arrest
1) Prearrest
2) No-Flow (untreated cardiac arrest)
3) Low-Flow (CPR)
4) Postresuscitation
•
Arrhythmogenic
Ventricular Fibrillation
• Rapid Ventricular
Tachycardia
Mechanical
• Asphyxia
• Ischemia
• Metabolic
• Pharmacologic
Prearrest Phase
* The greatest opportunity to impact patient
survival by preventing pulseless
cardiopulmonary arrest
Interventions:
Optimize community education regarding child safety
Optimize patient monitoring and rapid emergency response
Recognize and treat respiratory failure and shock to prevent
cardiac arrest
No-Flow Phase
• Arrest Phase
Interventions:
Minimize interval to BLS and ALS
Minimize interval to defibrillation, when indicated
Low-Flow Phase
• Resuscitation
Interventions:
“Push hard, push fast”
Allow full-chest recoil
Minimize interruptions in compressions
Avoid Overventilation
Consider adjuncts to improve vital organ perfusion during
CPR
Consider ECMO
2
Pediatrics Grand Rounds
17 June 2011
University of Texas Health Science
Center at San Antonio
Postresuscitation Phase
Postresuscitation Phase
Short-term rehabilitation
Interventions:
Longer-term rehabilitation (regenerate)
Interventions:
Optimize cardiac output and cerebral perfusion
Treat arrhythmias, if indicated
Avoid hyperglycemia, hyperthermia, hyperventilation
Consider mild post-resuscitation systemic hypothermia
Debrief to improve future responses to emergencies
Early interventions with occupational and physical therapy
Possible future role for stem cell transplantation5
Effectiveness of CPR in children
• Out-of-hospital cardiac arrest
– 6% of children survive7
– 8% of those who receive prehospital emergency
response resuscitation survive.
Effectiveness of CPR in children
• In-hospital Resuscitation
– 54% Return to Spontaneous Circulation (ROSC)
– 27% overall survival to discharge8
•
2008 pediatric data National Registry of CardioPulmonary
Resuscitation (NRCPR)
– 33% survival pulseless arrests among 758 cases
– 34% survival to discharge for patients with VF/pulseless
VT
– 38% survival for patients with pulseless electric activity
– 24% survival for patients with asystole
.Atkins DL, Everson-Stewart S, et al.. Circulation. 2009;119:1484-1491.
Nadkarni VM, Larkin GL, Peberdy MA, et al JAMA. 2006;295:50-57
New CPR Guidelines
Why CAB?
• Previously recommended sequence
Airway, Breathing, Circulation
• 2010 American Heart Association Guidelines
state Compressions, Airway, Breathing
• During cardiac arrest high-quality CPR
especially chest compressions are essential to
generate blood flow to vital organs
• All rescuers should be able to start chest
compressions almost immediately
• The CAB sequence for infants and children is
recommended to simplify training
– More victims will receive CPR.
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Pediatrics Grand Rounds
17 June 2011
Combination of Ventilation and Compressions in
Children
• Asphyxia was induced by clamping the tracheal tube of
piglets until cardiac arrest occurred.
• Mean time to loss of aortic pulsations was 8.9 +/- 0.4
minutes.
• Animals randomized to simulated bystander CPR or no
CPR until simulated emergency medical service (EMS)
arrival 8 minutes later.
• After complete cardiac arrest, 24-hour survival was
clearly superior in the group that received both cardiac
compressions and rescue breathing, compared with
either alone or no CPR.
Berg, RA, Hilwig RW, Kern KB, et al. Crit Care Med. 1999
Circulation
• Providing BLS with continuous effective chest
compressions is best way to provide circulation
during cardiac arrest.
• CRITICAL ELEMENTS:
–
–
–
–
–
Push hard and push fast
No compressions leads to no flow
Minimize interruptions in chest compressions
Allow full chest recoil to allow good venous return
Avoid overcirculation can also prevent venous return
University of Texas Health Science
Center at San Antonio
Combination of Ventilation and compressions in
Children
• Interventions at earlier point in ashyxial process :
– When pulse was “no longer palpable”
– Defined as systolic pressure less than 50 mmHg
– Before complete loss of aortic pulsations
• Results:
– 24-hour survival was best when both chest
compressions and rescue breathing provided.
– Rescue breathing or chest compressions alone were
individually better than no CPR at all.
– Most animals had return of spontaneous circulation
before EMS arrival.
Berg RA, Hilwig RW, Kern KB, et al. Circulation. 2000
History
• Closed chest cardiac massage was originally
demonstrated in small dogs.
• Investigators felt this cardiac massage might
be helpful in children.
• First patients to successfully be treated by
cardiac massage were children.
Circulation Mechanisms
Circumferential vs. Focal Sternal
Compressions
• Mechanism of blood flow was direct
compression of the heart between the
sternum and the spine in children with
compliant chest walls
• Thoracic Pump Mechanism: Chest
compressions increases intrathoracic pressure
that creates a gradient between pulmonary
vasculature, though the heart , and into the
peripheral circulation.
• Adult and animal models show circumferential
CPR provides better CPR hemodynamics than
point compressions
• In small infants, its possible to encircle the
chest with both hands and depress sternum
with thumbs
• “Two Thumb” compression method resulted
in higher systolic and diastolic blood pressures
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Pediatrics Grand Rounds
17 June 2011
Compression to Ventilation Ratio
• Ideal Compression to Ventilation (C:V) ratios
unknown
• During CPR, ventilation needed is decreased because
cardiac output only 10-25% that of sinus rhythm
• Must balance benefits of positive pressure
ventilation against negative consequences such as
impeding circulation
• Compression-only nor ventilation-only CPR can
provide oxygen delivery to periphery for prolonged
periods of CPR.
Compression to Ventilation Ratio
• optimal C:V ratio by
– Lone healthcare providers is 30 compressions
followed by 2 breathes
– If 2 rescuers: 15 compressions followed by 2
breathes
– For Lay rescuers: begin 30 compressions
University of Texas Health Science
Center at San Antonio
Compression to Ventilation Ratio
• The best ratio depends on
– Compression rate
– Tidal volume
– Blood flow generated during compressions
– Interrupted time of compressions
Airway and Breathing
• Goal of initial assisted ventilation
– Adequate oxygen delivery to meet metabolic
demands
– Removal of carbon dioxide
• Bag-Mask Ventilation cornerstone for effective
ventilation
– Tracheal intubation not necessarily required
Endotracheal intubation Vs. Bag Mask Ventilation
• JAMA 2000
– Randomized Control Trial
– 830 patients <12 years of age
– BVM (n=410) or BVM/intubation(n=420)
– Survival BVM group 123/404 [30%]) & ETI group
(110/416 [26%])
– odds ratio, 0.82; 95% confidence interval [CI],
0.61-1.11
Airway and Breathing
• Less ventilation necessary for gas exchange
because cardiac output and pulmonary blood
flow are 10 – 25% of that during normal sinus
rhythm
• Overventilation is common
– Compromise venous return and cardiac output
– In association with interruptions in cardiac
compressions can contribute to worse outcomes
Gaushe M, Lewis RJ. JAMA 2000
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Pediatrics Grand Rounds
17 June 2011
Airway and Breathing
• Animal Models of sudden VF cardiac arrest
– Pao2 and PaCo2 normal for 4 to 8 minutes during
chest compressions without rescue breathing
– outcomes as good with chest compressions alone
as with chest compressions plus rescue breathing
Why is rescue breathing not initially necessary in
VF but important in asphyxia?
• Asphyxia: respiratory arrest precede cardiac
•
•
•
•
arrest
Blood continues to flow to tissues
Arterial and venous oxygen saturations decrease
while carbon dioxide and lactate increase
Continued pulmonary blood flow before cardiac
arrest depletes the pulmonary oxygen reservoir.
Asphyxia results in significant arterial hypoxemia and
acidemia prior to resuscitation.
Commotio Cordis
Mechanically
initiated VF
due to relatively
low-energy
chest wall impact
during a narrow
window of
repolarization
University of Texas Health Science
Center at San Antonio
Why is rescue breathing not initially necessary in
VF but important in asphyxia?
• In acute fibrillatory cardiac arrest
– Aortic oxygenation and carbon dioxide do not vary from
prearrest state because there is no blood flow, aortic
oxygen consumption is minimal.
– When chest compressions are started, blood flowing from
aorta to the coronary and cerebral circulations provides
adequate oxygen delivery at an acceptable pH.
– Myocardial oxygen delivery is limited by blood flow rather
than oxygen content
– Lungs serve as reservoir for oxygen in low flow CPR
Pediatric Ventricular Fibrillation
• Uncommon but not rare
• 19% - 24 % initial rhythm in out-of-hospital
cardiac arrest
• More likely in Tricyclic antidepressant
overdose, cardiomyopathy, post cardiac
surgery and prolonged QT syndromes
Ventricular Fibrillation
• VF/ VT occur in 27% of in-hospital cardiac
arrests
• “Good” cardiac rhythm due to better
outcomes
• Survival to discharge is more common among
children with initial shockable (VT/VF)
rhythms.
• But if VT/VF was a subsequent rhythm to PEA
or asystole worse outcomes
6
Pediatrics Grand Rounds
17 June 2011
University of Texas Health Science
Center at San Antonio
Defibrillation
Defibrillation Dose
• Definition = Termination of ventricular
Fibrillation
• Defibrillation is necessary to successfully
resuscitate from VF cardiac arrest
• The goal is to return of an organized electrical
rhythm with a pulse.
• Early recognition is of VF is imperative to treat
successfully.
• 1970’s, initial defibrillation dose 200 Joules for
all children.
• Animal data >10 J/kg demonstrated
histopathological myocardial damage.
• Animal studies: 0.5-10 Joules/kg was
adequate for defibrillation in various species.
Defibrillation Dose
Defibrillation for Prolonged VF
•
•
•
•
•
•
•
Retrospective Study
71 transthoracic defibrillations attempts
27 children evaluated
Age: 3 days to 15 years
57:71 shocks were within 10 J of 2Joules/kg
91% (52:57) affective at terminating VF12
Therefore subsequent usage suggests 2J/kg effective
for short duration, in hospital defibrillation
• Animal studies: after 7 minutes of untreated
VF in piglets (4-24kg) suggests 2 J/kg
unsuccessful at terminating fibrillation in all
24 attempts
• Small clinical study: Tucson
– 11 children received 14 shocks (2 J/kg +/-10J)
– 7:14 (50%) terminated out-of-hospital prolonged
VF
– (p<.01)
Kanter RK, Boeing NM, Hannan WP, et al. Pediatrics 1992.
Defibrillation for Prolonged VF
• Lack of shock delivery of pediatric VF is 100%
lethal
• Adult defibrillation doses better than no
defibrillation doses
• Case Report:
– 3 y/o in VF
– Biphasic shock (9 J/kg)
– Survived without adverse effects
– No elevation in CK or cardiac troponin I
Intraosseous Vascular Access
•
•
•
•
Provides access to a noncollapsible marrow venous plexus
Serves as rapid, safe, and reliable route
Can be achieved in 30-60 seconds
Inserted into anterior tibial bone marrow
– Alternate sites:
• Distal femur
• Medial malleolus
• Anterior superior iliac spine
• Distal tibia
• Older children: distal radius and distal ulna
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Pediatrics Grand Rounds
17 June 2011
Intraosseous Vascular Access
• Used for fluids, resuscitation drugs,
catecholamine infusions and blood products.
• May also obtain blood specimens for
chemistry, blood gas analysis, blood typing,
and cross matching.
• Drugs levels and drug onset of action are
comparable to vascular administration via
central venous lines.
Endotracheal Drug Administration
• Less common since IO access
• “LEAN” Drugs given endotracheally
– Lidocaine
– Epinephrine
– Atropine
– Naloxone
University of Texas Health Science
Center at San Antonio
Intraosseous Vascular Access
Complications:
Reported in <1% of patients
ex: tibial fractures
lower extremity compartment syndrome
severe extravasation of drugs
osteomyelitis
Animal Models: bone marrow emboli
Endotracheal Drug Administration
• Absorption of drugs into circulation depends
– Dispersion over respiratory mucosa
• Drugs remain as droplets in ETT
– Pulmonary blood flow
• Poor chest compressions limit pulmonary blood flow
– Matching of ventilation to perfusion
• Calcium and Sodium Bicarbonate not
recommended via ET
• Pulmonary edema, pneumonitis, and airway disease
– irritating to airways and lung parenchyma
Vasopressors
• Epinephrine:
α-adrenergic effect on vascular tone important
during CPR
– Increases systemic vascular resistance
– Increases diastolic blood pressure
– Increases likelihood of Return of Spontaneous
Circulation (ROSC)
– Can increase cerebral blood flow due peripheral
vasoconstriction and directs blood to cerebral
circulation
Vasopressors
• Epinephrine:
β-adrenergic effects
– Increase myocardial contractility
– Increases heart rate
– Relaxes smooth muscle in the skeletal muscle
vascular bed and bronchi
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Pediatrics Grand Rounds
17 June 2011
Calcium
• Hypocalcemia is common in pediatric cardiac
arrest.
• Recommended during cardiac arrest due to:
– Hypocalcemia
– Hyperkalemia
– Hypermagnesemia
– Calcium-channel blocker overdose
 Commonly used in post-cardiac surgery
cardiac arrest.
Buffer Solutions
• Sodium bicarbonate indicated:
– Tricyclic antidepressants overdose
– Hyperkalemia
– Hypermagnesemia
– Sodium-channel-blocker poisoning
Antiarrhythmic
• Should not delay shock in VF
• If electrical defibrillation unsuccessful must
give medications to increase effectiveness of
shock:
1. Epinephrine
2. Amiodarone or Lidocaine
University of Texas Health Science
Center at San Antonio
Buffer Solutions
• Lactic acidosis results from inadequate organ
blood flow and poor oxygenation.
• Acidosis:
– Depresses myocardial function
– Reduces vascular resistance
– Inhibits defibrillation
• Sodium Bicarbonate not routinely used in
cardiac arrest
– Adult clinical studies and severe metabolic acidosis
did not demonstrate beneficial effects.
Buffer Solutions
• H+ + HCO2- -> CO2 and H2O
• Problems:
– Must have ventilation to clear CO2 otherwise may
counterbalance the buffer solution.
– Hypernatremia
– Hyperosmolarity
– Metabolic alkalosis
• Decreases calcium and potassium concentrations
• Shifts oxyhemoglobin curve to the left
Antiarrhythmics
• Lidocaine: traditionally recommended in
shock resistant VF in children and adults
• Amiodarone:
– Prospectively proven to improve survival in shockresistant VF when compared to placebo in adults.
– Higher survival to admission for out-of-hospital
shock resistant VF when compared to Lidocaine.
• Amiodarone is the preferred antiarrhythmic
agent for children.
9
Pediatrics Grand Rounds
17 June 2011
University of Texas Health Science
Center at San Antonio
Hypothermia
Postresuscitation Interventions
• Temperature Management
• Blood Pressure Management
• Glucose Control
•
•
Randomized, Controlled Trial
Inclusion criteria:
– Patients >18 years old
– Persistently comatose after successful resuscitation from non-traumatic VF
• 77 patients randomized
– hypothermia 33○C within 2 hours of ROSC and maintained for 12 hours
– Normothermia
• Results
– 21/43 (49%) hypothermia group survived and had good outcome
– 9/34 (26%) normothermic group survived and had good outcome
– P-value=0.046, CI 0.58-0.95
• Conclusion= Moderate hypothermia improves outcomes in patients with coma
after resuscitation from out-of-hospital arrest
Bernard SA, Gray TW, Buist MD, Jones BM, et al. New England Journal of Medicine. 2002
Hypothermia
• Multicenter trial
• Inclusion criteria:
– Patients >18 years old
– Persistently comatose after successful resuscitation from nontraumatic VF
• Goal Temperature 32 -34○ C for the first 24 hours postarrest
• Measurement: 6 month survival with good neurological outcomes
• Results:
– 75/136 (55%) hypothermic group
– 54/137 (39%) normothermic group
• Mortality at 6 months: 41% in hypothermic vs. 55% in normothermic
• Statistics: RR 1.40; 95% Confidence Interval 1.08 to 1.81
New England Journal of Medicine. 2002
Blood Pressure Management
• Animal Models:
– Brief, induced hypertension following
resuscitation results in improved neurologic
outcomes compared to normotension.
• Human Studies
– Retrospective
• Postresuscitative hypertension associated with
better neurologic outcome17
*Reasonable to aggressively treat and prevent
hypotension.
Behringer W, Kittler H, Sterz F, et al. Ann Intern Med 1998.
Blood Pressure Management
• Minimize blood pressure variability post
cardiac arrest resuscitation.
– 55% adults who survived out-of-hospital cardiac
arrest required vasoactive infusions for
hypotension.
– Impaired autoregulation of cerebral blood flow
• May not maintain cerebral perfusion pressure if
hypotensive
• May not be able to protect the brain for acute increases
blood flow if hypertensive
Laurent I, Monchi M, Chiche JD, et al. J Am Coll Cardiol 2002;.
Glucose Control
• Historical cohort observational study of all patients
admitted to hospital with a spontaneous circulation
after OHCA due to a cardiac cause in four different
regions in Norway 1995-1999.
• The in-hospital factors associated with survival
were15:
– no seizures
– base excess > 3.5 mmol
– body temperature <= 37.8○C
– serum glucose < 190mg/dL 24 h after admittance
Langhelle A, Tyvold SS, Lexow K, Hapnes SA, Sunde K, Steen PA Resuscitation. 2003;56:247-63.
10
Pediatrics Grand Rounds
17 June 2011
University of Texas Health Science
Center at San Antonio
Glucose Control
• Meta-Analysis evaluating benefits and risks of tight
glucose control vs. usual care in critically ill adult
patients.
• Data: MEDLINE, the Cochrane Library
• Twenty-nine randomized controlled trials totaling
8432 patients.
• Hospital mortality did not differ between tight
glucose control and usual care overall 21.6% vs.
23.3%; RR, 0.93; 95% CI, 0.85-1.03
Postresuscitation outcomes
• The most important post resuscitation outcome are survival
with favorable neurologic outcome and acceptable quality of
life.
• Barriers to neurologic assessment
– Changing developmental context
– Little is known about predictive value of diagnostic studies
– CT: not sensitive in predicting early neurologic injury
• MRI with diffusion weighting is valuable for hypoxic-ischemia
in subacute and recovery phases.
• Biomarkers: enolase and S100b highly sensitive and specific
for poor neurologic outcomes
Wiener RS, Wiener DC, Larson RJ JAMA 2008
Conclusions
• Pediatric cardiac arrest and CPR outcomes are
improving.
• Better understanding of pathophysiology
events revolving cardiac arrest.
• Focus on strategizing therapies at specific
phases of cardiac arrest.
• Clinical trials are necessary for appropriate
evidence based recommendations for
treatment of pediatric cardiac arrest.
Review
•
•
•
•
Quality CPR
Definition of Cardiac arrest
Phases of Cardiac Arrest
Resuscitation guidelines
Post resuscitation care strategies
References
PUSH HARD
1.
PUSH FAST
2.
3.
MINIMIZE
INTERRUPTIONS
4.
5.
6.
7.
ALLOW FULLCHEST RECOIL
8.
9.
10.
and DON’T
OVERVENTILATE
11.
12.
Nichols, DG . Roger’s Textbook of Pediatric Intensive Care. Fourth Edition. Philadelphia, PA: Lipponcott Williams &
Wilkins , 2008.
Kyriacou DN, Arcinue EL, Peek C, Kraus JF. Effect of immediate resuscitation on children with submersion injury. Pediatrics.
1994;94(pt 1): 137-142.
Berg MD, Schexnaydar SM, et al. 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and
Emergency Cardiovascular Care Science. Ciculation. 210;122:S862-S875.
Donoghue AJ, Nadkarnu V, Berg RA, Osmond MH, Wells G, Nesbitt L, Stiell IG. Out-of-hospital pediatric cardiac arrest: an
epidemiologic review and assessment of current knowledge. Ann Emerg Med. 2005;46:512-522.
Wang T, Tang W, Sun S, Xu T, Wang H, Guan J, Huang Z, Weil MH. Intravenous infusion of bone marrow mesenchymal stem
cells improves brain function after resuscitation from cardiac arrest. Crit Care Med. 2008 Nov;36(11 Suppl):S486-91.
Kouwenhoven, WB, Jude JR, Knickerbocker GG. Closed-chest cardiac massage. JAMA 1960; 173:1064-7.
Atkins DL, Everson-Stewart S, et al. Epidemiology and outcomes from out-of-hospital cardiac arrst in children: The
resuscitation outcomes consortium Epistry-cardiac arrest. Circulation. 2009;119:1484-1491.
Nadkarni VM, Larkin GL, Peberdy MA, et al. First documented rhythm and clinical outcome from in-hospital cardiac arrest
among children and adults. JAMA. 2006;295:50-57.
Berg, RA, Hilwig RW, Kern KB, et al. Simulated mouth-to-mouth ventilation and chest compressions (bystander
cardiopulmonary resuscitation) improves outcome in a swine model if prehospital pediatric asphyxial cardiac arrest.
Crit Care Med. 1999 Sep;27(9):1893-9 .
Berg RA, Hilwig RW, Kern KB, et al. Bystander chest compressions and assisted ventilation independently improve
outcome from piglet asphyxial pulseless “cardiac arrest”. Circulation. 2000;101:1743-1748.
Gaushe M, Lewis RJ. Out-of-hospital endotracheal intubation. JAMA 2000; 283:2790-2
Kanter RK, Boeing NM, Hannan WP, et al. Excess morbidity associated with interhospital transfer. Pediatrics 1992;90:
893-8.
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Pediatrics Grand Rounds
17 June 2011
University of Texas Health Science
Center at San Antonio
References
13. Bernard SA, Gray TW, Buist MD, Jones BM, Silvester W, Gutteridge G, Smith K. Treatment of comatose survivors of out-ofhospital cardiac arrest with induced hypothermia. New England Journal of Medicine. 2002 Feb 21;346(8):557-63.
14. Hypothermia after Cardiac Arrest Study Group. Mild therapeutic hypothermia to improve the neurologic outcome after cardiac
arrest. New England Journal of Medicine. 2002 Feb 21;346(8):549-56.
15. Langhelle A, Tyvold SS, Lexow K, Hapnes SA, Sunde K, Steen PA . In Hospital factors associated with improved outcome after
out-of-hospital cardiac arrest (OHCA). A comparison between four regions in Norway. Resuscitation. 2003;56:247-63 .
16. Laurent I, Monchi M, Chiche JD, et al. Reversible myocardial dysfunction in survivors of out-of-hospital cardiac arrest. J Am
Coll Cardiol 2002;240;2110-16.
17. Behringer W, Kittler H, Sterz F, et al. Cumulative eoinephrine dose during cardiopulmonary resuscitation and neurologic
outcome. Ann Intern Med 1998;129;450-6.
18. Langhelle A, Tyvold SS, Lexow K, Hapnes SA, Sunde K, Steen PA . Benefits and Risks of Tight Glucose Control in Critically Ill
AdultsA Meta-analysis. Resuscitation. 2003;56:247-63
12