thiopental and Heart-Arrest

The purpose of this research utilization article is to familiarize cardiovascular nurses with the Brain Resuscitation Clinical Trials (BRCTs) I and II and discuss the application of these trials to nursing practice. The BRCTs are a series of studies that examine the effects of selected interventions on neurologic outcome after cardiac arrest.

Topics: Brain Injuries; Calcium Channel Blockers; Cardiopulmonary Resuscitation; Heart Arrest; Humans; Hypnotics and Sedatives; Lidoflazine; Thiopental; Trauma Severity Indices; Vasodilator Agents

Despite advances in the understanding of the pathophysiology of cerebral ischemia, no single brain resuscitation therapy has yet been shown to be clinically superior to brain-oriented intensive care. Basic concepts in cardiopulmonary-cerebral resuscitation (CPCR) are discussed, as are two specific phases of CPCR, cerebral preservation and cerebral resuscitation. Cerebral preservation is initiated during cardiac arrest (ie, prior to restoration of spontaneous circulation [ROSC]) and includes use of artificial perfusion techniques and drugs to produce cerebral perfusion during this phase. Cerebral resuscitation is brain-oriented therapy initiated after ROSC. Pharmacologic agents currently under study for cerebral resuscitation include the barbiturates, calcium antagonists, and iron chelators. With respect to defining efficacy of the pharmacologic agents, the concept of therapeutic window is important. Although no agent has been proven clinically, several appear to be promising.

Topics: Animals; Brain Ischemia; Calcium Channel Blockers; Cerebrovascular Circulation; Chelating Agents; Heart Arrest; Humans; Resuscitation; Thiopental

To assess survival after cardiac arrest and to determine whether age is an independent determinant of late mortality or poor neurologic outcome.. Analyses using results of Brain Resuscitation Clinical Trial I (1979 to 1984) and Brain Resuscitation Clinical Trial II (1984 to 1989), two randomized, double-blind studies of outcome following cardiac arrest.. A multicenter study in 12 acute care hospitals in nine countries (Brain Resuscitation Clinical Trial I), and 24 hospitals in eight countries (Brain Resuscitation Clinical Trial II).. A total of 774 patients who were initially comatose after successful resuscitation from cardiac arrest. The analyses include both in- and out-of-hospital cardiac arrests.. The 6-month mortality rate for the entire group was 81%. Mortality rate was 94% for the oldest group (> 80 yrs) compared with 68% for the youngest group (< or = 45 yrs) (p < .01). Other independent predictors of mortality were history of diabetes mellitus, inhospital arrests, arrest time of > 5 mins, history of congestive heart failure, a noncardiac cause of arrest, and cardiopulmonary resuscitation time of > 20 mins. Of the 774 patients, 27% recovered good neurologic function. There was no statistically significant difference in neurologic recovery rates by age. Multivariate analysis showed that independent predictors of good neurologic recovery were: no history of diabetes mellitus, a cardiac cause of arrest, short arrest time, and short cardiopulmonary resuscitation time.. Increasing age was a factor in postresuscitation mortality, but was not an independent predictor of poor neurologic outcome.

Topics: Age Factors; Aged; Aged, 80 and over; Cardiopulmonary Resuscitation; Coma; Double-Blind Method; Female; Glasgow Coma Scale; Heart Arrest; Humans; Lidoflazine; Male; Middle Aged; Neurologic Examination; Prognosis; Risk Factors; Thiopental

When a patient resuscitated from cardiac arrest remains unconscious the clinician would like to have a reliable early method for predicting the outcome. The objective of our study was to predict cerebral outcome after cardiac arrest by clinical neurological examination. The data were drawn from an international multicentre controlled clinical trial of thiopentone. Twelve hospitals in nine countries took part. 262 comatose cardiac arrest survivors were followed up for one year. These patients were given advanced life support (American Heart Association guidelines) followed by intensive care to a standardised protocol. Glasgow and Glasgow-Pittsburgh coma scores and their constituent signs were recorded at fixed times. Outcome was taken to be the best cerebral performance at any time during follow-up, and for that purpose we used cerebral performance categories (CPC 1-5) of the Glasgow outcome categories. A poor outcome (CPC 3-5) could be predicted immediately after reperfusion (at entry into the study) with an accuracy ranging from 52% to 84% for various signs and scores. On the third day it was possible to identify severely disabled or permanently comatose survivors without false predictions using both coma scores and several of their constituent variables. The best predictor was absence of motor response to pain. This modelling exercise now needs to be repeated on a new series of patients but the results do suggest that, after 3 days, stringent ethical criteria can be met and used in decision-making about termination of care in comatose cardiac arrest survivors.

Topics: Brain; Cardiopulmonary Resuscitation; Coma; False Positive Reactions; Female; Follow-Up Studies; Glasgow Coma Scale; Heart Arrest; Humans; International Cooperation; Male; Middle Aged; Neurologic Examination; Predictive Value of Tests; Prognosis; Prospective Studies; Survivors; Thiopental; Treatment Outcome; Withholding Treatment

Levels of brain creatine phosphokinase (CPK), glutamic oxalic transaminase, lactate dehydrogenase, and lactate in lumbar cerebrospinal fluid (CSF) were analyzed as an adjunctive study in a randomized clinical trial evaluating the effects of thiopental loading intravenously in comatose survivors of cardiac arrest. Three hospitals participated and a total of 62 cases of enzyme changes were studied. Enzyme levels but not lactate were higher at 48 hours than at 24 hours after restoration of spontaneous circulation. All enzymes were highly correlated with one another at 24 and 48 hours (P < .001). There was a significant negative correlation between cerebral recovery and increased CPK levels at 24 hours (P < .05), and a highly significant correlation with all three enzyme levels at 48 hours (P < .0001). The increase of cytosolic enzyme activity in lumbar CSF reflects permanent brain damage, and there is a relationship between activity levels and cerebral outcome.

Topics: Aspartate Aminotransferases; Brain Chemistry; Coma; Creatine Kinase; Heart Arrest; Humans; Injections, Intravenous; L-Lactate Dehydrogenase; Lactates; Lactic Acid; Prognosis; Survivors; Thiopental; Time Factors

We studied the effect of thiopental loading during resuscitation of 53 patients following cardiopulmonary arrest and compared the outcome with that found in 54 patients treated conventionally in the 30 previous months. Thiopental therapy (10 mg/kg i.v.) was begun within 30 min of the arrest once hemodynamic stability had been established. Thiopental infusion (20 mg/kg over 6 h) was followed by phenobarbital sodium (125 mg every 12 h), tolerance to the initial dose having been assessed. The in-hospital mortality rate for both groups was similar. In patients with ischemic heart disease, the mortality rate within the first 6 h was significantly higher in the thiopental group (p less than 0.05), although for the remaining patients there were more survivors among the thiopental treated patients (p less than 0.05). Excluding the patients who died within the first 6 h, 61% of the patients in the thiopental group survived cardiac arrest with normal cerebral performance, whereas only 37% in the standard treatment group showed normal functional outcome (p less than 0.03). These results suggest a favorable neurologic effect of thiopental loading during resuscitation of patients without ischemic heart disease. In patients with ischemic heart disease, an initial hemodynamic deterioration may contribute to minimising the beneficial effect of barbiturate therapy.

Topics: Adult; Aged; Brain Damage, Chronic; Clinical Trials as Topic; Critical Care; Female; Heart Arrest; Humans; Male; Middle Aged; Phenobarbital; Prognosis; Resuscitation; Thiopental

After restoration of spontaneous circulation and adequate oxygenation, 262 comatose survivors of cardiac arrest were randomly assigned to receive standard brain-oriented intensive care or the same standard therapy plus a single intravenous loading dose of thiopental (30 mg per kilogram of body weight). The study was designed to have an 80 percent probability of detecting a 20 percent reduction in the incidence of permanent postischemic cerebral dysfunction. Base-line characteristics were similar in the two treatment groups. At the end of one year of follow-up, there was no statistically significant difference between treatment groups in the proportion of patients who died (77 percent of the thiopental vs. 80 percent of the standard-therapy group), survived with "good" cerebral recovery (20 percent of the thiopental vs. 15 percent of the standard-therapy group), or survived with permanent severe neurologic damage (2 percent of the thiopental vs. 5 percent of the standard-therapy group). The results of this study do not support the use of thiopental for brain resuscitation after cardiac arrest.

Topics: Adolescent; Adult; Aged; Brain Damage, Chronic; Brain Ischemia; Child; Child, Preschool; Clinical Trials as Topic; Coma; Female; Follow-Up Studies; Heart Arrest; Humans; Infant; Male; Middle Aged; Random Allocation; Resuscitation; Thiopental

The Brain Resuscitation Clinical Trial (BRCT) was established as a multi-institutional, clinical study of brain resuscitation. The BRCT was designed to test the hypothesis that the addition of thiopental loading to the protocol of standard therapy for cardiac arrest survivors, comatose at 10-50 minutes after restoration of spontaneous circulation, would significantly increase the number of patients recovering good cerebral function. Twelve hospitals in nine countries collaborated in this randomized, controlled clinical trial. The study was designed to take into account numerous problems including the reliability of information on complex events surrounding cardiac arrest, the difficulty of maintaining uniform treatment protocols, and the difficulty of obtaining informed consent within the constraints of the time the therapy was hypothesized to be effective. The major outcome measurements of the study were neurological status at the end of various time intervals following resuscitation and the best neurological performance ever attained during follow-up. Mortality and other untoward events were closely monitored to establish treatment safety. Of the 262 patients entered into the study between 1979 and 1982, 45% were over 65 years of age, and 75% were men. The majority of the arrests (74%) occurred out of hospital, and major pathology underlying arrest was cardiac. Arrest time was greater than 5 minutes in 36% of the patients. As a result of randomization, patient characteristics at entry as well as the characteristics associated with the brain insult in the standard group were similar to those in the thiopental group.

Topics: Aged; Clinical Trials as Topic; Coma; Critical Care; Data Collection; Follow-Up Studies; Heart Arrest; Humans; Hypoxia, Brain; Infusions, Parenteral; Injections, Intravenous; Male; Methods; Neurologic Examination; Random Allocation; Recurrence; Research Design; Resuscitation; Thiopental; Time Factors

Topics: Adolescent; Adult; Aged; Brain Ischemia; Child; Child, Preschool; Clinical Trials as Topic; Data Collection; Female; Heart Arrest; Humans; Infant; Male; Middle Aged; Random Allocation; Resuscitation; Thiopental

Brain protection during ischemia by barbiturates has been clearly demonstrated in many different experiments. Only recently the therapeutic value of large doses of thiopental administered early after cerebral circulatory arrest has been demonstrated experimentally in monkey. Noncontrolled studies in humans also indicate beneficial effect, however the treatment is not without potential complication. Controlled randomized studies in humans are needed to document its beneficial effect. Such studies have several unique medico-legal and ethical implications since the treatment has to be started in an unconscious patient and as early as possible after a totally unexpected cardiac arrest. Informed consent, ethical and medicolegal consideration of randomized controlled clinical trials is discussed and a modified approach to clinical trials in humans is suggested. The modification would not alter the scientific value of the studies, but resolve the ethical and medico-legal problems.

Topics: Barbiturates; Clinical Trials as Topic; Ethics, Medical; Heart Arrest; Humans; Informed Consent; Legislation, Drug; Random Allocation; Thiopental; United States

Topics: Animals; Depression, Chemical; Fat Emulsions, Intravenous; Heart Arrest; Hypnotics and Sedatives; Intestinal Absorption; Male; Octreotide; Pilot Projects; Rats; Rats, Sprague-Dawley; Respiratory Mechanics; Survival; Thiopental

Induced hypothermia has improved neurological outcome after cardiac arrest. Even though anoxic insults to the brain often provoke epileptic activity, it is unclear whether EEG monitoring is necessary in these patients. We report the case of a 53-year-old female who suffered cardiac arrest. During induced hypothermia extensive shivering was managed by sedation and curare. After their discontinuation convulsions appeared and status epilepticus was disclosed on EEG recording, and was treated by thiopental infusion for 10 days. The patient recovered slowly and has now regained independent living (CPC 1). In induced hypothermia several factors including the use of curare, may conceal clinical signs of epileptic activity. We therefore suggest a broader use of EEG in these patients.

Topics: Curare; Electroencephalography; Female; Heart Arrest; Humans; Hypnotics and Sedatives; Hypothermia, Induced; Middle Aged; Monitoring, Physiologic; Neuromuscular Nondepolarizing Agents; Shivering; Status Epilepticus; Thiopental

Much is known about the interaction of intravenous anesthetics and opioids at the therapeutic level, but less is known regarding their combined lethal effect, leaving some uncertainty regarding the window of safety for their clinical use. We set out to document the type of interaction between thiopental and fentanyl for both the hypnotic effect (loss of righting reflex) and lethal effect in mice. Hypnotic and lethal dose-response curves were constructed for thiopenthal alone and in combination with fentanyl (0.8 microg/kg, each based on five to seven subgroups of six to ten ICR mice. The dose of fentanyl was that needed to double the lag time to tail flick following a noxious stimulus (the equivalent of human analgesia). While fentanyl did not change the median effective hypnotic dose of thiopental (8.9 mg/kg [95% confidence interval {CI} 8.0-9.9 mg/kg] alone versus 7.8 mg/kg [95% CI 6.7-8.7 mg/kg] in combination), it significantly reduced its median lethal dose from 71.8 mg/kg (95% CI 68.3-74.8 mg/kg) to 64.5 mg/kg (95% CI 63.7-65.2 mg/kg). Most remarkably, it increased the slope of the curve from 0.17 (95% CI 0.10-0.36) to 0.61 (95% CI 0.24-1.10), virtually eliminating the difference between the non-lethal and lethal ranges. We conclude that the type of interaction between thiopental and fentanyl is stronger for the lethal effect than for the hypnotic effect. This may become relevant to clinical situations in humans when higher doses of thiopental are used.

Topics: Anesthetics, Intravenous; Animals; Dose-Response Relationship, Drug; Drug Administration Schedule; Drug Interactions; Fentanyl; Heart Arrest; Hypnotics and Sedatives; Lethal Dose 50; Mice; Mice, Inbred ICR; Thiopental

Topics: Adrenergic beta-Antagonists; Coronary Disease; Drug Overdose; Heart Arrest; Humans; Thiopental

The cerebral metabolic effects of a massive dose of thiopental (177 mg/kg) were investigated in seven dogs. The systemic circulation was supported with an extracorporeal circuit. At an infusion rate of 2 mg/kg/min, cerebral oxygen consumption (CMR(O(2))) decreased progressively until cerebral electrical silence was produced. This occurred after a mean dose of 72 mg/kg, which caused a mean decrease in CMR(O(2)) to 58% of the control value (measured at 1.5% halothane inspired). Thereafter, despite continued at 4 mg/kg/min, CMR(O(2)) did not decrease further. The oxygen-glucose index never changed during the infusion period and, at the termination of the infusion, brain assays for ATP, phosphocreatine, lactate, and pyruvate revealed normal concentrations. It is concluded that there was no alteration in normal cerebral metabolic pathways, that cerebral metabolic effects of thiopental are secondary to functional effects, that thiopental would provide no cerebral protection during hypoxia sufficient to abolish cerebral function, and that thiopental does not uncouple oxidative phosphorylation.

Topics: Anesthetics; Animals; Brain Chemistry; Brain Diseases; Dogs; Electroencephalography; Heart Arrest; Hypnotics and Sedatives; Oxygen Consumption; Thiopental

We are systematically exploring in our exsanguination cardiac arrest (CA) outcome model in dogs suspended animation (SA), i.e. immediate preservation of brain and heart for resuscitative surgery during CA, with delayed resuscitation. We have shown in dogs that inducing moderate cerebral hypothermia with an aortic arch flush of 500 ml normal saline solution of 4 degrees C, at start of CA 20 min no-flow, leads to normal functional outcome. We hypothesized that, using the same model, adding thiopental (or even better thiopental plus phenytoin) to the flush at ambient temperature (24 degrees C), which would be more readily available in the field, will also achieve normal functional outcome. Thirty dogs (20-28 kg) were exsanguinated over 5 min to CA of 20 min no-flow, and resuscitated by closed-chest cardiopulmonary bypass. They received assisted circulation to 2 h, 34 degrees C post-CA to 12 h, controlled ventilation to 20 h, and intensive care to 72 h. At CA 2 min, the dogs received an aortic arch flush of 500 ml saline at 24 degrees C by a balloon-tipped catheter, inserted through the femoral artery (control group 1, n=14). In group 2 (n=9), thiopental (variable total doses of 15-120 mg/kg) was added to the flush and given with reperfusion. In group 3 (n=7), thiopental (15 or 45 mg/kg) plus phenytoin (10, 20, or 30 mg/kg) was given by flush and with reperfusion. Outcome was assessed in terms of overall performance categories (OPC 1, normal; 2, moderate disability; 3, severe disability; 4, coma; 5, brain death), neurologic deficit scores (NDS 0-10%, normal; 100%, brain death), and histologic deficit scores (HDS, total and regional). The flush reduced tympanic temperature to about 36 degrees C in all groups. In control group 1, one dog achieved OPC 1, three OPC 2, six OPC 3, and four OPC 4. In thiopental group 2, two dogs achieved OPC 1, two OPC 3, and five OPC 4. In thiopental/phenytoin group 3, one dog achieved OPC 1, two OPC 3, and four OPC 4 (p=0.5). Median NDS were 36% (IQR 22-62%) in group 1; 51% (IQR 22-56%) in group 2; and 55% (IQR 38-59%) in group 3 (p=0.7). Median total HDS were 67 (IQR 56-127) in group 1; 60 (IQR 52-138) in group 2; and 76 (IQR 48-132) in group 3 (p=1.0). Thiopental and thiopental/phenytoin dogs achieved significantly lower HDS only in the putamen. Thiopental in large doses caused side effects. We conclude that neither thiopental alone nor thiopental plus phenytoin by flush, with or without additional intravenous infusion, can cons

Topics: Animals; Anticonvulsants; Aorta, Thoracic; Brain Ischemia; Cardiopulmonary Resuscitation; Cerebrovascular Circulation; Dogs; Heart Arrest; Hypnotics and Sedatives; Male; Phenytoin; Reperfusion Injury; Thiopental; Time Factors

Intravenous (i.v.) drug combinations are used in clinical anaesthesia in order to combine the desired effects and minimize toxicity from large doses of single agents. This fundamental assumption has not been systematically evaluated. We examined its validity by testing the influence of midazolam on the lethal effect of i.v. thiopental and ketamine in mice. Dose-response curves were constructed for the lethal effect of i.v. thiopental and ketamine, and for the loss of righting reflex effect by midazolam, in sexually mature male ICR mice weighing 20-40 g. For each curve, six or seven groups of eight to 10 mice each were used. A quarter of the median effective dose (ED50) for loss of righting reflex by midazolam was combined with the two other drugs to deduce dose-response curves for the lethal effect of the combinations. The ED50 for loss of righting reflex by i.v. midazolam was 43.5 mg x kg(-1) (95% confidence interval [CI], 40.4-46.5). The median lethal dose (LD 50) of i.v. thiopental was 50.6 mg x kg(-1) (95% CI, 50.0-54.9) and that of ketamine 42.9 mg x kg(-1) (95% CI, 32.3-52). In the presence of 10 mg x kg(-1) midazolam, the LD50 of thiopental was reduced to 20 mg x kg(-1) (17.7-22.2), but that of ketamine remained 44.4 mg x kg(-1) (37.7-54.9). Midazolam increased the lethal effect of thiopental 2.5-fold, but did not affect that of ketamine. Interactions at the toxic level between commonly used anaesthetic agents may differ from those at the hypnotic or analgesic levels, which should prompt evaluation of such combinations before their introduction to routine clinical use.

Topics: Anesthetics, Dissociative; Anesthetics, Intravenous; Animals; Dose-Response Relationship, Drug; Drug Interactions; Heart Arrest; Ketamine; Lethal Dose 50; Male; Mice; Mice, Inbred ICR; Midazolam; Thiopental; Ultrasonography

We postulate that mitigating the multifactorial pathogenesis of postischemic encephalopathy requires multifaceted treatments. In preparation for expensive definitive studies, we are reporting here the results of small exploratory series, compared with historic controls with the same model. We hypothesized that the brain damage mitigating effect of mild hypothermia after cardiac arrest can be enhanced with thiopental loading, and even more so with the further addition of phenytoin and methylprednisolone. Twenty-four dogs (four groups of six dogs each) received VF 12.5 min no-flow, reversed with brief cardiopulmonary bypass (CPB), controlled ventilation to 20 h, and intensive care to 96 h. Group 1 with normothermia throughout and randomized group 2 with mild hypothermia (from reperfusion to 2 h) were controls. Then, group 3 received in addition, thiopental 90 mg/kg i.v. over the first 6 h. Then, group 4 received, in addition to group 2 treatment, thiopental 30 mg/kg i.v. over the first 90 min (because the larger dose had produced cardiopulmonary complications), plus phenytoin 15 mg/kg i.v. at 15 min after reperfusion, and methylprednisolone 130 mg/kg i.v. over 20 h. All dogs survived. Best overall performance categories (OPC) achieved (OPC 1 = normal, OPC 5 = brain death) were better in group 2 than group 1 (< 0.05) and numerically better in groups 3 or 4 than in groups 1 or 2. Good cerebral outcome (OPC 1 or 2) was achieved by all six dogs only in group 4 (P < 0.05 group 4 vs. 2). Best NDS were 44 +/- 3% in group 1; 20 +/- 14% in group 2 (P = 0.002); 21 +/- 15% in group 3 (NS vs. group 2); and 7 +/- 8% in group 4 (P = 0.08 vs. group 2). Total brain histologic damage scores (HDS) at 96 h were 156 +/- 38 in group 1; 81 +/- 12 in group 2 (P < 0.001 vs. group 1); 53 +/- 25 in group 3 (P = 0.02 vs. group 2); and 48 +/- 5 in group 4 (P = 0.02 vs. group 2). We conclude that after prolonged cardiac arrest, the already established brain damage mitigating effect of mild immediate postarrest hypothermia might be enhanced by thiopental, and perhaps then further enhanced by adding phenytoin and methylprednisolone.

Topics: Animals; Anticonvulsants; Brain; Brain Damage, Chronic; Dogs; Drug Therapy, Combination; Heart Arrest; Male; Methylprednisolone; Neuroprotective Agents; Phenytoin; Resuscitation; Thiopental; Time Factors; Treatment Outcome

Topics: Adult; Catheterization, Central Venous; Heart Arrest; Heart Atria; Humans; Intraoperative Complications; Male; Sinoatrial Node; Thiopental; Vena Cava, Superior

A 24-year-old pregnant woman was scheduled for Caesarean section during the 31st week of pregnancy. The patient had been treated with MgSO4 for premature labor and toxemia. During anesthesia, cardiac arrest occurred twice. The first cardiac arrest occurred immediately after induction of anesthesia and seemed to be due to combined effects of hypermagnesemia, thiopental and supine hypotensive syndrome. Three babies were delivered during cardiac massage. The second one occurred immediately after administration of methyl-ergometrine malate and seemed to be due to combined effects of hypermagnesemia and methyl-ergometrine malate. The patient and three babies did not develop any complication. In giving anesthesia for patients with hypermagnesemia, anesthetists should take account of interactions between magnesium, anesthetics and other drugs.

Topics: Adult; Anesthesia, General; Anesthesia, Obstetrical; Cesarean Section; Drug Interactions; Female; Heart Arrest; Humans; Intraoperative Complications; Magnesium; Magnesium Sulfate; Obstetric Labor, Premature; Pre-Eclampsia; Pregnancy; Thiopental

Topics: Adult; Ambulatory Surgical Procedures; Anesthesia, General; Cardiomyopathy, Dilated; Heart Arrest; Humans; Male; Thiopental

Local anaesthetic systemic toxicity is a rare but often dramatic complication of regional anaesthesia. Convulsions often follow warning signs, easily recognized when looked for; but they may occur from the first. They are rapidly followed by hypoxia and hypercapnia which greatly enhance the risk of severe cardiac depression, mainly with bupivacaine or etidocaine. Thiopentone is able to stop convulsions quickly, but may further depress the cardiovascular system. Diazepam has been shown to be effective in the treatment of local anaesthetic-induced convulsions. It gives less myocardial depression, but is much slower in effect. Midazolam, a new short-acting benzodiazepine, should be the best choice. Should tracheal intubation become necessary, suxamethonium can be used. Indeed, the principal use of these drugs is to make ventilation easier, so as to restore rapidly correct oxygenation. Severe cardiac depression, often leading to cardiac arrest, may occur from the first or after the appearance of convulsions. It generally follows a regional block carried out with bupivacaine. A few antiarrhythmic drugs have been used to treat ventricular arrhythmias, either in experimental studies (lidocaine, bretylium) or after clinical accidents (lidocaine). Their efficacy and innocuity have to be proved before they can be proposed to treat these accidents. Bradycardia only needs treatment with atropine when it causes severe haemodynamic disturbances. When cardiac arrest occurs, cardiopulmonary resuscitation must be carried out; its mainstays are: oxygen, sodium bicarbonate, adrenaline, calcium and perhaps glucagon. This must be continued for a long time, as late successes have been published.

Topics: Anesthetics, Local; Anti-Anxiety Agents; Arrhythmias, Cardiac; Benzodiazepines; Calcium Gluconate; Epinephrine; Glucagon; Heart Arrest; Heart Diseases; Humans; Seizures; Succinylcholine; Thiopental

Cardiac arrest is followed by complete cerebral ischemia, which is characterized by delayed hypoperfusion and transient hypermetabolism. Brain metabolism depressant drugs, such as barbiturates, were suggested to improve neuronal outcome. The hypothesis of a cerebroprotective effect of barbiturates remained nevertheless controversial. In order to define the utility of large doses of thiopentone, the effect of thiopentone on carbohydrate and energy metabolism of 1-year old Wistar rats was investigated in an experimental model of complete reversible ischemia followed by a recovery period. No beneficial effect of high-dose thiopentone could be demonstrated by means of changes in the carbohydrate metabolism and the energyrich compounds. There were no differences between the treated group and the spontaneous recovery group. These results are mainly confirmed by other investigators. In contrast to focal ischemia and hypoxemia beneficial effects of barbiturates can not be demonstrated after complete cerebral ischemia in experimental studies and in clinical studies as well. In conclusion there is no indication for high-dose barbiturate therapy after cardiac arrest and successfull resuscitation.

Topics: Animals; Barbiturates; Brain Ischemia; Cerebral Cortex; Cerebrovascular Circulation; Energy Metabolism; Glycolysis; Heart Arrest; Male; Neurons; Rats; Rats, Inbred Strains; Resuscitation; Thiopental

Topics: Anesthesia; Barbiturates; Brain; Cardiopulmonary Bypass; Coma; Heart Arrest; Humans; Statistics as Topic; Thiopental

Topics: Animals; Barbiturates; Brain; Brain Ischemia; Heart Arrest; Humans; Macaca mulatta; Resuscitation; Thiopental; Time Factors

Initial cardiac failure in anaphylactoid shock is rare, classically related to cardiac anaphylaxis occurring in a highly sensitized patient. However, this anaphylaxis is not always found; the case described here of a histamine shock with ventricular fibrillation after the injection of thiopentone is a good example of this. The severity of the shock may be explained by the presence of a prolapse of the small flap of the mitral valve.

Topics: Adult; Anaphylaxis; Female; Heart Arrest; Humans; Intraoperative Complications; Mitral Valve Prolapse; Thiopental

Topics: Adult; Heart Arrest; Humans; Male; Resuscitation; Thiopental

Topics: Animals; Brain Damage, Chronic; Brain Injuries; Cerebrovascular Disorders; Coma; Heart Arrest; Humans; Resuscitation; Thiopental

Topics: Aged; Ambulatory Care; Coma; Emergency Medical Technicians; Follow-Up Studies; Heart Arrest; Humans; Middle Aged; Prognosis; Thiopental

The cardiovascular and electroencephalographic (EEG) effects of thiopental were investigated, with and without preceding global brain ischemia (GBI). Four groups of pigtailed monkeys were used: Group I received thiopental 90 mg/kg over 1 h after 16 min GBI. Group II received thiopental 90 mg/kg over 1 h without preceding brain ischemia. Group III received 90 mg/kg over 1, 3, 6, or 8 h with varying infusion rates and no brain ischemia. Group IV, after 16 min GBI, received thiopental 90 mg/kg over 12 h with a gradually reduced infusion rate, keeping thiopental serum levels around 120-140 mumol X l-1 throughout the infusion. Large doses of thiopental (Group II) produced serious cardiovascular side-effects. With co-existing brain ischemia (Group I), these side-effects were much worse; five of six animals not receiving lidocaine prophylaxis suffered circulatory arrest. A prolongation of the Q-T interval on the electrocardiogram may be of pathogenetic importance. In contrast, lower thiopental blood levels, sufficient to depress the EEG to burst suppression or isoelectricity, were well tolerated with and without preceding brain ischemia (Groups IV and III).

Topics: Animals; Arrhythmias, Cardiac; Brain; Brain Ischemia; Electrocardiography; Electroencephalography; Female; Heart Arrest; Heart Block; Hemodynamics; Macaca nemestrina; Male; Thiopental

Topics: Brain Ischemia; Combined Modality Therapy; Heart Arrest; Humans; Middle Aged; Prognosis; Random Allocation; Resuscitation; Thiopental; Time Factors

Topics: Heart Arrest; Humans; Hypoxia, Brain; Male; Middle Aged; Thiopental

Pharmacologic protection should be used cautiously. The author reviews its rationale, use, and recommendations in three clinical conditions associated with ischemic brain damage: stroke, cardiac arrest, and head trauma.

Topics: Adult; Animals; Arterial Occlusive Diseases; Barbiturates; Brain Injuries; Brain Ischemia; Cats; Cerebral Arteries; Cerebrovascular Disorders; Dogs; Female; Heart Arrest; Humans; Intracranial Pressure; Male; Middle Aged; Models, Biological; Papio; Phenobarbital; Saimiri; Thiopental

To define the utility of high-dose barbiturate therapy following an episode of complete global cerebral ischemia, we investigate the effects of 60 mg/kg of thiopental given to cats five minutes after resuscitation from 12, 14, or 16 min of electrically induced ventricular fibrillation (VF). All aspects of the arrest, resuscitation, with post-arrest care were carefully controlled, with the EEG becoming isoelectric 20-25 s after the onset mean resuscitation time of 2.5 +/- 0.2 (SEM) min. For any given duration of VF, there were no differences (control vs thiopental) in any pre- or post-arrest parameters (blood pressure, blood gases, electrolytes, etc.) A total of 68 resuscitated cats were entered into various treatment and control groups, and all but one group received 20-24 h of post-resuscitation paralysis, mechanical ventilation, and ICU support before being extubated. Cats received an additional six days of aggressive nursing care, and daily examinations were performed with the assignment of a neurologic deficit score (NDS) between 0 (normal) and (brain dead). Autopsies were performed to determine the cause of death in animals which died before the end of the seven-day observation period. The early post-arrest period was marked by the occurrence of repetitive, rhythmic bursts of high-frequency electroencephalographic (EEG) activity (? seizures) in 38 per cent of control animals (16/42, all arrest times combined). Ten of these animals died as a result of severe neurologic injuries. By contrast, only 12 per cent of treated cats (3/26) developed similar EEG patterns (P less than 0.05) and there were no neurologic deaths in the thiopental groups. The differences in the incidence of neurologic deaths (control vs. thiopental) was significant (P less than 0.02). The change in overall mortality did not quite reach significance (36 per cent vs. 21 per cent), and treatment had no effect on the incidence of deaths due to cardiovascular causes (e.g., myocardial infarctions). In spite of the effects on mortality, treatment had no effect on the neurologic function of survivors (assessed by NDS). These findings suggest that thiopental improved survival rates by suppressing an unusual post-arrest EEG pattern (? anticonvulsant effect), but had no additional cerebral protective effects.

Topics: Animals; Brain Diseases; Brain Ischemia; Cats; Disease Models, Animal; Electroencephalography; Heart Arrest; Resuscitation; Thiopental; Ventricular Fibrillation

Topics: Adult; Brain Diseases; Female; Heart Arrest; Humans; Male; Middle Aged; Thiopental

The case of a 7-year-old child is presented, who suffered circulatory arrest during induction of anaesthesia for surgery for a posterior fossa tumour. A brain ischaemia lasting 6 minutes duration had to be assumed. After restoration of circulation, 825 mg ethiopenta were administered in order to ameliorate a possible post-ischaemic anoxia of the brain according to a protocol by Safar [18]. 11 hours after circulatory arrest the child awoke. Except for a more pronounced left sided hemiparesis and paresis of the left n. abducens no additional neurological deficit was observed compared to the neurological status before induction of anaesthesia.

Topics: Anesthesia; Cerebellar Neoplasms; Child; Dose-Response Relationship, Drug; Female; Glioma; Heart Arrest; Heart Massage; Hemiplegia; Humans; Hypoxia, Brain; Thiopental

Twenty patients suffering from post-ischaemic encephalopathy were treated with high doses of barbiturates during the period immediately following resuscitation. The duration of cerebral ischaemia was assessed retrospectively. The degree of ischaemic damage was evaluated on the one hand by the pupillary signs seen 10 minutes after the reestablishment of the circulation and secondly by enzyme levels in the CSF. This barbiturate load was not associated with major complications and the excretion of barbiturate continued for several days. The clinical signs seen 12 hours after ischaemia and continuous observation of the tracing of the cerebral function monitor made it possible to give an early favourable prognosis from a neurological standpoint. In all the patients (apart from one) in whom there was total cerebral ischaemia for less than 10 minutes, neurological recovery was complete.

Topics: Adolescent; Adult; Aged; Aspartate Aminotransferases; Brain Ischemia; Female; Heart Arrest; Humans; L-Lactate Dehydrogenase; Lactates; Male; Middle Aged; Pyruvates; Reflex, Pupillary; Resuscitation; Thiopental; Time Factors

Topics: Anesthesia, Intravenous; Animals; Dog Diseases; Dogs; Female; Heart Arrest; Phenobarbital; Phenytoin; Thiopental

Topics: Anesthesia, General; Appendectomy; Child; Halothane; Heart Arrest; Humans; Male; Malignant Hyperthermia; Muscle Rigidity; Nitrous Oxide; Succinylcholine; Thiopental

Topics: Adult; Anesthesia; Arteriovenous Fistula; Atropine; Carotid Artery Diseases; Cavernous Sinus; Dexamethasone; Diazepam; Droperidol; Female; Fentanyl; Heart Arrest; Humans; Hypothermia, Induced; Naloxone; Neostigmine; Neuroleptanalgesia; Pancuronium; Preanesthetic Medication; Thiopental

A case of cardiac arrest is presented which was caused by improper connection of a modified Mapleson D circuit (Bain breathing circuit). Excessive enternal deadspace was created by interchanging the gas inflow line and the attachment for an airway pressure manometer. This resulted in a marked respiratory acidosis, clinically undetected until the concomitant hypoxia produced a severe cardiac depression and arrest. The sequence of events was reproduced in a dog under comparable anaesthetic conditions. In order to avoid this error it is recommended to permanently fuse the connecting piece placed in the circuit with the tubing leading to the airway pressure manometer of the respirator.

Topics: Adolescent; Anesthesia, Inhalation; Animals; Carbon Dioxide; Dogs; Female; Halothane; Heart Arrest; Humans; Hydrogen-Ion Concentration; Hypercapnia; Male; Nitrous Oxide; Oxygen; Succinylcholine; Thiopental

All physicians performing surgery while the patient is under general anesthesia must be aware of the existence of idiopathic malignant hyperthermia. A young adult had a malignant hyperthermic reaction despite four prior uneventful administrations of general anesthetics. To my knowledge, this is the first report of a patient who survived following a hyperthermic reaction, having sustained considerable residual brain damage. There is a great need for continuous body-temperature monitoring during general anesthesia.

Topics: Adolescent; Anesthesia, Inhalation; Brain Damage, Chronic; Chlorides; Heart Arrest; Humans; Male; Malignant Hyperthermia; Methoxyflurane; Sodium; Strabismus; Succinylcholine; Tachycardia; Thiopental

Topics: Adult; Anesthesia, Intravenous; Electrocardiography; Fentanyl; Gallamine Triethiodide; Heart Arrest; Humans; Hyperkalemia; Lumbosacral Region; Male; Nitrous Oxide; Paraplegia; Potassium; Spinal Cord Compression; Spinal Cord Injuries; Succinylcholine; Thiopental; Tubocurarine; Urinary Bladder, Neurogenic

Topics: Aged; Anesthesia, Intravenous; Electrocardiography; Heart; Heart Arrest; Heart Massage; Humans; Male; Thiopental

Topics: Animals; Blood Pressure; Central Venous Pressure; Dogs; Electric Countershock; Electrocardiography; Heart Arrest; Heart Massage; Thiopental; Ventricular Fibrillation

Topics: Anesthesia, General; Blood Pressure Determination; Cardiac Surgical Procedures; Electrocardiography; Electroencephalography; Extracorporeal Circulation; Heart Arrest; Humans; Hypotension; Methods; Nitrous Oxide; Opium; Oxygen; Preanesthetic Medication; Respiration, Artificial; Scopolamine; Thiopental

Topics: Acidosis; Adolescent; Adult; Anesthesia; Anesthetics; Female; Halothane; Heart Arrest; Humans; Kidney Transplantation; Male; Middle Aged; Nitrous Oxide; Oxygen; Pulmonary Edema; Succinylcholine; Thiopental; Transplantation, Homologous; Tubocurarine; Vomiting

Topics: Anesthesia, Inhalation; Halothane; Heart Arrest; Humans; Hyperkalemia; Male; Military Medicine; Paraplegia; Succinylcholine; Thiopental; Wounds and Injuries

Topics: Anesthesia, Local; Bronchial Neoplasms; Carcinoma, Adenoid Cystic; Child; Child, Preschool; Drainage; Echinococcosis, Pulmonary; Female; Heart Arrest; Hemangioma; Humans; Male; Mepivacaine; Middle Aged; Oxygen Inhalation Therapy; Postoperative Complications; Shock; Thiopental; Thoracic Neoplasms

Topics: Anesthesia; Animals; Barbiturates; Drug Synergism; Guinea Pigs; Heart; Heart Arrest; Hexobarbital; In Vitro Techniques; Succinylcholine; Thiopental

Topics: Adolescent; Adult; Aged; Anesthesia; Halothane; Heart Arrest; Heart Rate; Humans; Intubation, Intratracheal; Laryngoscopy; Middle Aged; Nitrous Oxide; Oxygen; Succinylcholine; Thiopental; Tubocurarine

Topics: Anesthesia, Dental; Anesthesia, Inhalation; Halothane; Heart Arrest; Humans; Hypoxia, Brain; Jurisprudence; Malpractice; Nitrous Oxide; Ontario; Succinylcholine; Thiopental

Topics: Apnea; Electroconvulsive Therapy; Heart Arrest; Humans; Muscle Relaxants, Central; Succinylcholine; Thiopental; Toxicology

Topics: Adolescent; Anesthesia; Anuria; Child; Heart Arrest; Heart Massage; Humans; Hydropneumothorax; Kidneys, Artificial; Pleural Effusion; Pulmonary Edema; Respiration, Artificial; Respiratory Insufficiency; Thiopental; Toxicology

Topics: Anesthesia; Atropine; Blood Transfusion; Digestive System Surgical Procedures; Electrocardiography; Gastrointestinal Tract; Heart Arrest; Humans; Morphine; Pentobarbital; Pharmacology; Physiology; Preanesthetic Medication; Preoperative Care; Respiration; Scopolamine; Thiopental

Topics: Anesthetics; Animals; Blood Transfusion; Ether; Heart Arrest; Platelet Transfusion; Thiopental