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PubMedDate not supplied

Demystifying the cardiopulmonary code team response.

OBJECTIVE: To familiarize the reader with the sequence of events in a hospital-based cardiopulmonary resuscitation. DATA SOURCES: The American Heart Association's Textbook of Advanced Cardiac Life Support and the Standards and Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiac Care. DATA EXTRACTION: The roles and responsibilities of members of the cardiopulmonary code team are discussed. DATA SYNTHESIS: A typical code sequence is described, with emphasis on drug therapy. CONCLUSIONS: This information will provide a better understanding of the cardiopulmonary resuscitation team response and, in particular, the role of the pharmacist as an integral team member.

Cardiopulmonary Resuscitation↗

PubMed2006

Using simulation for training and to change protocol during the outbreak of severe acute respiratory syndrome.

INTRODUCTION: During the 2003 severe acute respiratory syndrome (SARS) crisis, we proposed and tested a new protocol for cardiac arrest in a patient with SARS. The protocol was rapidly and effectively instituted by teamwork training using high-fidelity simulation. METHODS: Phase 1 was a curriculum design of a SARS-specific cardiac arrest protocol in three steps: planning the new protocol, repeated simulations of this protocol in a classroom, and a subsequent simulation of a cardiac arrest on a hospital ward. Phase 2 was the training of 275 healthcare workers (HCWs) using the new protocol. Training involved a seminar, practice in wearing the mandatory personal protection system (PPS), and cardiac arrest simulations with subsequent debriefing. RESULTS: Simulation provided insights that had not been considered in earlier phases of development. For example, a single person can don a PPS worn for the SARS patient in 1 1/2 minutes. However, when multiple members of a cardiac arrest team were dressing simultaneously, the time to don the PPS increased to between 3 1/2 and 5 1/2 minutes. Errors in infection control as well as in medical management of advanced cardiac life support (ACLS) were corrected. CONCLUSION: During the SARS crisis, real-time use of a high-fidelity simulator allowed the training of 275 HCWs in 2 weeks, with debriefing and error management. HCWs were required to manage the SARS cardiac arrest wearing unfamiliar equipment and following a modified ACLS protocol. The insight gained from this experience will be valuable for future infectious disease challenges in critical care.

Canada↗

PubMed2006

Vasopressin combined with epinephrine during cardiac resuscitation: a solution for the future?

Epinephrine given during cardiopulmonary resuscitation (CPR) may cause beta-mimetic complications in the postresuscitation phase. Vasopressin may be an alternative vasopressor drug during CPR. A subgroup analysis of a large prospective CPR investigation and of retrospective CPR studies suggests that vasopressin may be especially beneficial when combined with epinephrine. Beneficial effects of adding vasopressin were observed in other catecholamine-refractory shock states as well, such as vasodilatory shock and haemorrhagic shock. In order to maximize effects of any vasopressor during CPR, rapid aggressive chest compressions must be ensured to maximize blood flow and to enable advanced cardiac life support drugs to reach the arterial vasculature. We suggest alternating injections of 1 mg epinephrine i.v. and 40 IU vasopressin i.v. every 3-5 minutes during CPR until spontaneous circulation can be achieved or CPR efforts are terminated.

Cardiopulmonary Resuscitation↗

PubMed1991

Role of experience in the response to simulated critical incidents.

Eight experienced anesthesiologists (faculty or private practitioners) were presented with the same simulated critical incidents that had previously been presented to 19 anesthesia trainees. The detection and correction times for these incidents were measured, as was compliance with Advanced Cardiac Life Support (ACLS) guidelines during cardiac arrest, and the occurrence of unplanned incidents. Experienced personnel tended to react more rapidly than did trainees, but differences between second-year anesthesia residents (CA2) and experienced anesthesiologists were not statistically significant. There was a high variability in performance between incidents and within each group. Unplanned errors and management flaws still occurred with experience subjects. The response to incidents during anesthesia is a complex process that involves multiple levels of cognitive activity and is vulnerable to error regardless of experience. Most trainees seemed to acquire adequate response routines by the end of the CA2 year. Formal reasoning appeared to play a minor role in responding to intraoperative events, but the exact nature of the anesthesiologist's cognition remains to be thoroughly investigated.

Anesthesiology↗

PubMed2006

An audible indication of exhalation increases delivered tidal volume during bag valve mask ventilation of a patient simulator.

Self-inflating manual resuscitators (SIMRs) can mislead caregivers because the bag, unlike a Mapleson-type device, reinflates even without patient exhalation. We added a whistle as an audible indicator to the exhalation port of a SIMR. In randomized order, each participant provided two sets of breaths via mask ventilation with a SIMR, one with and one without audible feedback, to a Human Patient Simulator modified to log lung volume changes. The last three breaths in each set were used to compare average tidal volume (Vt) under both conditions. Eighty-seven advanced cardiac life support trainees (54 males, 33 females) with clinical experience averaging 6.4 +/- 9.4 yr were recruited. Average Vt delivered with the standard SIMR was 486 +/- 166 mL and 624 +/- 96 mL with the modified SIMR. Average Vt delivered by a modified SIMR was significantly larger by 40% when it followed standard SIMR use and 19% when using the modified SIMR first. Use of a SIMR with an audible indicator of exhalation significantly (P < 0.001) increased mask ventilation of a patient simulator, suggesting that mask ventilation of a patient with a SIMR may also be increased by objective, real-time feedback of exhaled Vt.

Acoustic Stimulation↗

PubMed2002

Event and sideline management of sudden cardiac death.

The increasing use of automated external defibrillators (AEDs), coupled with methods to improve cardiopulmonary resuscitation and implementation of early defibrillation, have significantly improved survival from sudden cardiac death (SCD) in the prehospital setting. This article reviews the evidence and principles of management of SCD in the sports setting. It is noted that ventricular fibrillation is the most common arrhythmia causing SCD in athletes. When it occurs, survival is reduced by 7% to 10% per minute pending defibrillation. This statistic is true for athletes as well as nonathletes, and underscores the critical need for a rapid defibrillation response. Use of the AED in the sports setting and suggestions on whether to implement an AED program are reviewed. Despite increasing application of this technology, outcomes data on the use of AEDs in the sports arena are lacking, partly due to the relatively rare occurrence of SCD therein. New evidence on pharmacotherapy in SCD is also reviewed. Although drug administration in SCD is unlikely to be required in the sports setting, clinicians are updated on some of the newer considerations. Finally, selected articles from the recent literature on advanced cardiac life support are provided to guide the team physician in using the most current approach to the management of SCD.

Airway Obstruction↗

PubMed1994

Biphasic extrathoracic pressure CPR. A human pilot study.

HYPOTHESIS: Alternating intrathoracic pressure by means of a chest cuirass can cause perfusion and ventilation equal to or better than standard cardiopulmonary resuscitation (CPR) for humans in cardiac arrest. DESIGN: Nonrandomized, nonblinded, crossover pilot study. SETTING: Large urban emergency department. SUBJECTS: Five adult normothermic, nontraumatic, out-of-hospital cardiac arrest patients unresponsive to standard advanced cardiac life support. METHOD: Right atrial and aortic catheters were inserted for pressure measurement and blood gas analysis while the patient was receiving standard CPR by a pneumatic compression device (Thumper). The Thumper was then replaced by a chest cuirass (Hayek Oscillator). Pressure and blood gas measurements were then repeated. RESULTS: The coronary perfusion pressure increased from -1.2 +/- 8.6 mm Hg to 6.2 +/- 6.9 mm Hg for a mean change of 7.4 +/- 3.1 mm Hg (p = 0.006). The compression phase gradient increased 10.0 +/- 21.9 mm Hg (p = 0.364). The venous to arterial PCO2 gradient decreased 44.5 +/- 32.3 mm Hg (p = 0.070). The oxygen extraction ratio increased 1.6 +/- 9.4 percent (p = 0.761). The mean arterial PO2 and PCO2 changed from 252 to 240 mm Hg (p = 0.836) and from 53 to 66 (p = 0.172) mm Hg, respectively. CONCLUSION: The Hayek Oscillator chest cuirass produced a significant improvement in the coronary perfusion pressure. There was a trend for improved systemic perfusion as indicated by an improved compression phase gradient and venous to arterial PCO2 gradient, although this was not supported by the lack of improvement in the oxygen extraction ratio. The cuirass also adequately oxygenates and ventilates unassisted by positive pressure ventilation.

Cardiopulmonary Resuscitation↗

PubMed1994

The effect of the total cumulative epinephrine dose administered during human CPR on hemodynamic, oxygen transport, and utilization variables in the postresuscitation period.

BACKGROUND: Studies evaluating the dose of epinephrine required to optimize return of spontaneous circulation and survival after CPR have shown that doses greater than recommended by advanced cardiac life support (ACLS) improve coronary perfusion pressure and short-term resuscitation rates. Since survival has not improved, it is possible that higher doses of epinephrine may be physiologically detrimental in the postresuscitation period. OBJECTIVE: The object of this study is to measure the effect of the total cumulative dose of epinephrine given during ACLS on the hemodynamic, oxygen transport, and utilization variables in the postresuscitation period. DESIGN: A prospective nonrandomized control trial of inception cohorts. SETTING: A large urban emergency department and intensive care unit. PATIENTS: Forty-nine successfully resuscitated witnessed, normothermic, nontraumatic, out-of-hospital patients, who had suffered cardiac arrests. INTERVENTIONS: All patients were treated according to ACLS guidelines; however, the epinephrine dose (0.01 to 0.2 mg/kg or 1 to 14 mg) was selected at the clinician's discretion and given through central venous access every 3 to 5 min. Hemodynamic, oxygen transport, and utilization variables were measured on a return of spontaneous circulation, and at least every 30 min thereafter under a standardized postresuscitation protocol. MAIN OUTCOME MEASURES: Hemodynamic, oxygen transport/utilization variables, and mortality in patients resuscitated from cardiac arrest. The total cumulative dose of epinephrine given during ACLS until a return of spontaneous circulation was recorded. RESULTS: A total cumulative epinephrine dose of 15 mg was found to best predict 24-h mortality. Of the 49 patients, 20 received less than 15 mg (group 1) and 29 received greater than 15 mg (group 2). Age, premorbid health status, sex, presenting rhythm, and duration of cardiac arrest were similar in both groups. The 24-h survival was 17 of 20 (85%) and 12 of 29 (41%) in group 1 and 2, respectively (p < 0.002). Over the first 6 h of the postresuscitation period, both groups had similar mean arterial pressure (MAP), mixed venous oxygen saturation, and systemic oxygen extraction ratio (all p > 0.1). Group 2, however, had a significantly lower cardiac index (CI), systemic oxygen consumption (VO2), and systemic oxygen delivery (DO2) (all p < 0.01). Systemic vascular resistance index (SVRI), initial and 6-h lactic acid levels were significantly higher in group 2 (all p < 0.03). CONCLUSIONS: The administration of all doses of epinephrine during the resuscitation of out-of-hospital cardiac arrest is associated with impairment of DO2 and VO2 in the postresuscitation period. Both duration and severity of these impairments correlate with the total cumulative epinephrine dose given during the resuscitation. Thus, inadvertent catecholamine toxicity represents a further complicating factor in the production of postresuscitation disease. Diagnostic and therapeutic interventions addressed toward mitigating these potentially reversible adverse effects may impact morbidity and mortality in out-of-hospital cardiac arrests.

Adult↗

PubMed1994

The composition of gas given by mouth-to-mouth ventilation during CPR.

STUDY OBJECTIVE: To compare the concentration of a rescuer's exhaled O2 and CO2 during mouth-to-mouth ventilation with or without chest compression. DESIGN: Prospective repeated measures study. Simulated one- and two-rescuer cardiopulmonary resuscitation (CPR) was performed as recommended by the American Heart Association. SETTING: University laboratory. PARTICIPANTS: Fifty-five healthcare professionals certified in basic and advanced cardiac life support volunteered as rescuers in this study. MEASUREMENTS AND RESULTS: Thirty-three volunteers performed one-rescuer CPR, and 22 volunteers performed two-rescuer CPR. Minute ventilation for both groups increased 50% to 130% during CPR (p < 0.05). During the performance of CPR, the concentration of exhaled O2 increased from 16.4 +/- 0.7% to 16.9 +/- 0.5% in the one-rescuer CPR group and from 16.5 +/- 0.9% to 17.8 +/- 0.6% in the two-rescuer CPR group (p < 0.05). The concentration of exhaled CO2 in the one-rescuer CPR group did not change significantly throughout the entire experiment, but decreased in the two-rescuer CPR group from a baseline measurement of 4.0 +/- 0.6% to 3.5 +/- 0.4% (p < 0.05). During CPR, the concentration of exhaled CO2 was 4.0 +/- 0.4% in the one-rescuer CPR group compared with 3.5 +/- 0.4% in the two-rescuer CPR group (p < 0.05). CONCLUSIONS: The gas given by mouth-to-mouth ventilation is a hypercarbic and hypoxic mixture compared with room air. Mouth-to-mouth ventilation is the only circumstance in which a hypercarbic and hypoxic gas is given as therapy. Further laboratory and clinical studies are necessary to determine the effect of mouth-to-mouth ventilation during CPR.

Carbon Dioxide↗

PubMed1997

Analysis of the ventricular fibrillation ECG signal amplitude and frequency parameters as predictors of countershock success in humans.

OBJECTIVE: The purpose of this study was to assess from the ventricular fibrillation ECG signal whether certain amplitude parameters, or frequency parameters derived using fast Fourier transform analysis, are predictive of countershock success (defined as a stable supraventricular rhythm following countershock). DESIGN: Retrospective, descriptive study. SETTING: Emergency medical service at a university hospital. PATIENTS: Twenty-six patients with out-of-hospital cardiac arrest, whose initial ECG rhythm was identified as ventricular fibrillation. METHODS AND RESULTS: In all patients, advanced cardiac life support was performed in the out-of-hospital setting and a semiautomatic defibrillator was used for countershock therapy and simultaneous on-line ECG recording. For each patient, ECG data were stored in modules in digitized form over a period of 20 min and analyzed retrospectively. Using fast Fourier transform analysis of the ventricular fibrillation ECG signal in the frequency range of 0.3 to 30 Hz (mean +/- SD), median frequency, dominant frequency, edge frequency, and amplitude were as follows: 5.17 +/- 1.05 Hz, 4.56 +/- 0.99 Hz, 10.74 +/- 3.46 Hz, and 1.33 +/- 0.44 mV before successful countershock (n = 20); and 4.21 +/- 1.17 Hz (p = 0.0034), 3.31 +/- 1.57 Hz (p = 0.0004), 9.46 +/- 2.93 Hz (p = 0.5390), and 1.15 +/- 0.69 mV (p = 0.0134) before unsuccessful countershock (n = 134). Using software filters to completely eliminate interference due to manual cardiopulmonary resuscitation from the ventricular fibrillation power spectrum, only amplitude remained statistically different (p < or = 0.03) in predicting countershock success. CONCLUSIONS: We conclude that in patients, median frequency, dominant frequency, and amplitude are predictive of countershock success in humans.

Electric Countershock↗

PubMed1998

Emergency department cardiopulmonary bypass in the treatment of human cardiac arrest.

OBJECTIVE: To study the use of emergency department (ED) femoro-femoral cardiopulmonary bypass (CPB) in the resuscitation of medical cardiac arrest patients. DESIGN: Prospective, uncontrolled trial. SETTING: Urban academic ED staffed with board-certified emergency physicians (EPs). PARTICIPANTS: Ten patients with medical cardiac arrest unresponsive to standard therapy. INTERVENTIONS: Femoro-femoral CPB instituted by EPs. RESULTS: The time of cardiac arrest prior to CPB (mean+/-SD) was 32.0+/-13.6 min. The cardiac output while on CPB was 4.09+/-1.03 L/min with an average of 229+/-111 min on bypass. All 10 patients had resumption of spontaneous cardiac activity while on CPB. Seven of these were weaned from CPB with intrinsic spontaneous circulation. Of these, six patients were transferred from the ED to the operating room for cannula removal and vessel repair while the other patient died in the ED soon after discontinuing CPB. Mean survival was 47.8+/-44.7 h in the six patients leaving the ED. Although these patients had successful hemodynamic resuscitation, there were no long-term survivors. CONCLUSION: CPB instituted by EPs is feasible and effective for the hemodynamic resuscitation of cardiac arrest patients unresponsive to advanced cardiac life support therapy. Future efforts need to focus on improving long-term outcome.

Adolescent↗

PubMed2006

Achieving housestaff competence in emergency airway management using scenario based simulation training: comparison of attending vs housestaff trainers.

STUDY OBJECTIVES: To evaluate a teaching protocol comparing a critical care attending to a housestaff team in training medical interns in initial airway management skills using a computer-controlled patient simulator (CPS) and scenario-based simulation training (SST). DESIGN: Prospective, randomized, controlled, unblinded trial. SETTING: Internal medicine residency training program in an urban teaching hospital. PARTICIPANTS: Forty-nine starting internal medicine interns in July 2003, all of whom had been certified in advanced cardiac life support in June 2003. INTERVENTIONS: All interns were tested and scored with a CPS while responding to a standardized respiratory arrest scenario. Random allocation to either training by a single experienced teaching attending or by a housestaff team occurred immediately following testing. All interns were retested using the same scenario 6 weeks following the initial training, and their clinical performance of airway management was scored during actual patient events throughout the year. MEASUREMENTS: Initial airway management was divided into specific scorable steps. For each intern, individual step scores and total scores were recorded before and after training. For 10 consecutive months following training, intern airway management scores were recorded for actual patient airway events. RESULTS: All starting medical interns demonstrated poor initial airway management skills. SST was effective in improving these skills, both on retesting with the patient simulator and in actual patient situations. Interns trained by a housestaff team performed as well as interns trained by the attending. CONCLUSIONS: SST is effective in training medical interns, and the results are equivalent whether the training is provided by an experienced teaching attending or by a housestaff training team.

Apnea↗

PubMed1990

Early predictors of mortality for hospitalized patients suffering cardiopulmonary arrest.

Few if any prearrest or intraarrest variables have been identified as highly predictive of inhospital mortality following cardiopulmonary arrest. A total of 310 consecutive patients requiring advanced cardiac life support during the calendar years 1985 and 1986 were reviewed with respect to eight specific variables. These included age, diagnosis, location, mechanism of the event, duration of resuscitation, whether the event was witnessed or unwitnessed, the initial observed rhythm and medications administered. A total of 37.1 percent of the patients were successfully resuscitated, but only 9.7 percent survived until discharge. Factors strongly associated with inhospital mortality included unwitnessed events (p = 0.0316), the need for epinephrine (p = 0.0003), identification of electromechanical dissociation or asystole as initial rhythms (p = 0.0000), and cardiac vs respiratory mechanism of arrest (p = 0.0000).

Age Factors↗

PubMed1995

Serum potassium concentration as a predictor of resuscitation outcome in hypothermic cardiac arrest.

The purpose of this study was to determine whether serum potassium concentration (SK) can predict resuscitation outcome in a canine model of severe hypothermic cardiac arrest. Fifteen adult mongrel anesthetized dogs were immersed to the neck in a 4 degrees C water bath and ventilated with room air, with ventilation halved at 45 min and stopped at 90 min. After cardiac arrest, 14 of the dogs were kept in the water bath for periods of 2-7 h, and another was held in arrest for 13 h. Following 10 min of closed chest cardiopulmonary resuscitation (CPR) (simulating a short transport time to a hospital), animals were placed on cardiopulmonary bypass and rapidly rewarmed. With appearance of ventricular fibrillation, animals were defibrillated up to three times. Standard advanced cardiac life support was initiated at a core temperature (Tc) of 30 degrees C. Eight of the 15 dogs had return of spontaneous circulation (ROSC), at Tc ranging from 30.4 to 36.5 degrees C. The eight dogs with ROSC did not differ from the seven without ROSC in time to arrest (128 +/- 48 versus 128 +/- 23 min) (mean +/- SD) or Tc at arrest (18.1 +/- 2.2 versus 17.9 +/- 3.1 degrees C), but had higher Tc at the end of the arrest period (9.7 +/- 3.0 versus 5.2 +/- 2.0 degrees C), reflecting a shorter arrest period in the dogs with ROSC (225 +/- 95 versus 420 +/- 193 min). SK (mEq liter(-1)) did not differ between dogs with and without ROSC at baseline (3.5 +/- 0.4 versus 3.7 +/- 0.4) or at arrest (3.4 +/- 0.7 versus 4.3 +/- 2.2), but there was a trend toward higher SK at the end of arrest in the group without ROSC (4.6 +/- 1.5 versus 9.4 +/- 6.3; range 3.2-7.8 versus 3.5-21.4; p = .053). SK was similar after 10 min of CPR in the groups with and without ROSC (6.6 +/- 2.9 versus 9.0 +/- 2.4; range 2.5-11.1 versus 4.5-11.0; p = .107). SK after 10 min of CPR was higher in some animals with ROSC (9.6 and 11.1) than in others which did not have ROSC (4.5 and 7.9). We conclude that very high SK following prolonged hypothermic cardiac arrest may be suggestive of an inability to resuscitate. However, SK after both prolonged hypothermic cardiac arrest and a brief period of CPR is not a good predictor of resuscitation using cardiopulmonary bypass rewarming in an animal model.

Animals↗

PubMed2006

Evolving role of vasopressin in the treatment of cardiac arrest.

Sudden cardiac arrest is a major public heath problem, affecting more than 450,000 individuals annually. Response time and the initiation of cardiopulmonary resuscitation (CPR) remain the most important factors determining successful revival. During resuscitation, sympathomimetics are given to enhance cerebral and coronary perfusion pressures in an attempt to achieve restoration of spontaneous circulation. Epinephrine has been the preferred vasopressor since the inception of advanced cardiac life support, although the lack of definitive evidence regarding its effectiveness has created much controversy surrounding its use, including the optimum dosage. Vasopressin is an alternative vasopressor that, when given at high doses, causes vasoconstriction by directly stimulating smooth muscle V1 receptors. The 2000 American Heart Association (AHA) guidelines commented that vasopressin is a reasonable first-line vasopressor in patients with ventricular fibrillation or pulseless ventricular tachycardia. Since release of those guidelines, additional human studies support an expanded role for vasopressin, whereas other studies cast doubt regarding its efficacy compared with epinephrine. The AHA recently released revised guidelines for CPR and emergency cardiovascular care. The consensus was that vasopressors should remain a part of pulseless sudden cardiac arrest management, with epinephrine 1 mg every 3-5 minutes being the recommended adrenergic of choice. In these revised guidelines, the role of vasopressin expanded beyond previous recommendations, despite the recommendation being downgraded to class indeterminate. The guidelines comment that one dose of vasopressin 40 U may replace the first or second dose of epinephrine in all pulseless sudden cardiac arrest scenarios, including asystole and pulseless electrical activity. A consistent theme with all vasopressors in sudden cardiac arrest is that additional studies are necessary to clearly document greater efficacy compared with no treatment. Further evaluation is warranted to better assess the role of vasopressin in asystolic sudden cardiac arrest, as well as its use with epinephrine, and to determine its optimal timing of administration and potential synergistic effects.

Arginine Vasopressin↗

PubMed2005

Analysis of the outcomes of cardiopulmonary resuscitation in an emergency department.

OBJECTIVE: The aim of this study is to analyse the factors affecting emergency department (ED) cardiopulmonary resuscitation (CPR) outcome. METHODS: A standard CPR protocol was performed in all patients and certain pre and postresuscitation parameters including age, sex, initial arrest rhythm, primary underlying disease, initiation time of advanced cardiac life support, duration of return of spontaneous circulation were recorded. Patients were followed up to determine rates of successful CPR, survival and one-year survival. RESULTS: From December 1999 to May 2001, 80 consecutive adult patients in whom a standard CPR was performed in the ED were prospectively included in the study. The overall rate for successful CPR, survival and one-year survival were found to be 58.8% (47/80), 15% (12/80) and 10% (8/80), respectively. Survival and one-year survival rates were better in patients with an initial arrest rhythm of ventricular fibrillation or pulseless ventricular tachycardia (VF/pVT) than both pulseless electrical activity (pEA) and asystole; survival and one-year survival rates were better in patients with a primary underlying disease of cardiac origin than non-cardiac origin. Acute myocardial infarction had the best prognosis among conditions causing arrest. Presence of sudden death was found to have a better survival and one-year survival rate. CONCLUSION: Initial cardiac rhythm of VF/pVT, cardiac origin as the primary disease causing cardiopulmonary arrest and presence of sudden death were found to be good prognostic factors in CPR.

Adult↗

PubMed1990

Overview of monitoring in endoscopy.

Gastrointestinal endoscopy has evolved rapidly over the past 30 years and has become one of the larger specialities in medicine. An increasing number of diagnostic and therapeutic procedures are being performed with the aid of the flexible endoscope. With this expansion in the use of endoscopy came the routine administration of premedication. The endoscopist thus became a part-time anaesthetist. The lack of proper studies to evaluate the untoward effects of diazepam and, later, midazolam, at their introduction led to an unfortunate increase in reports of fatalities after the introduction of midazolam. Later studies showed the safety of these agents when properly administered, but the affair served to focus attention on monitoring in gastrointestinal endoscopy. The benefits of using extracorporeal monitoring equipment during endoscopy has not been proved in clinical trials, and because of this those bodies that issue guidelines on medical practice, such as the American Society for Gastrointestinal Endoscopy, have not mandated the use of these devices. The guidelines issued have emphasized the importance of training and recertification in advanced cardiac life support. Many endoscopists are reluctant to recognize their role as anaesthetist, and to adopt new practices recommended in the guidelines. However, these changes represent the evolution of medicine and reflect the desire to ensure a uniform high quality of care and as such should not be resisted.

Anesthesia↗

PubMedDate not supplied

Rural-urban partnering in continuing education.

BACKGROUND: One urban center provided an Advanced Cardiac Life Support (ACLS) course to a rural hospital using a minimum of on-site instructors. METHOD: Interactive television (ITV) conferencing was used to educate health care providers in a hospital more than 100 miles away. RESULTS: Nurses and physicians from a small rural hospital in northern Nevada were able to "attend" a full-scale ACLS course without having to leave their hospital, resulting in minimal cost to the agency. CONCLUSION: Rural and urban hospitals can partner to provide high-quality, cost-effective education to nurses and other health care providers through the use of ITV conferencing.

Curriculum↗