The source of coronary perfusion during partial bypass for extracorporeal membrane oxygenation (ECMO).

The proper siting of cannulas to return oxygenated blood to patients on long-term membrane oxygenator support is as yet undecided. This experimental study on adult sheep shows the problems of obtaining perfusion of the coronary arterial tree when blood is returned to the ascending aorta. Our 11 experiments demonstrate that the coronary arterial tree is perfused with blood ejected from the left ventricle except during very high bypass flows (85% bypass) or when the aortic valve is rendered incompetent.

Near-drowning: an unusual case.

This paper reports the case of a 2 1/2-year-old male who appeared to have drowned in the family swimming pool. Immediate continuous cardiopulmonary resuscitation eventually restored circulation and respiration. Subsequently, in the intensive care unit, he appeared to "cone" and suffer brain "death". Prompt and continuous use of measures to support cerebral resuscitation were successful and the child subsequently was completely normal. A reevaluation of current information seems indicated in regard to the prognosis of the near-drowned child.

The fate of phenobarbitone in children in hypothermia and at normal body temperature.

Four critically injured children receiving large doses of phenobarbitone were studied during hypothermia (30 degrees - 31 degrees C) and at normal body temperature. The volume of distribution of phenobarbitone varied from 0.79 to 1.01 litres per kg and the serum t 1/2 ranged from 36.8 +/- 9.4 to 86.2 +/- 10.5 hrs. The percentage of dose recovered in urine in 16 days ranged from 40.5 to 65.5 per cent: 2.7 to 12.4 per cent as hydroxyphenobarbitone, 1.7 to 19.7 per cent as conjugated hydroxyphenobarbitone, 6.0 to 22.4 per cent as phenobarbitone-N-glucoside and 17.8 to 23.1 per cent as unchanged drug. After the body temperature was allowed to return to normal the rate of excretion of metabolites increased substantially and the rate of excretion of the unchanged drug decreased markedly. It is concluded that reduction in body temperature influences the volume of distribution, rate of metabolism and excretion of phenobarbitone.

A canine study of cold water drowning in fresh versus salt water.

OBJECTIVE: To compare the pathophysiologic changes occurring during drowning in cold fresh water and cold salt water with reference to viability. DESIGN: Randomized, prospective, controlled submersion experiments in two contrasting cold liquids. SETTING: A laboratory at a large university-affiliated medical institution. SUBJECTS: Thirteen healthy, anesthetized mongrel dogs. Three dogs served as controls and were immersed but not submerged. The remainder were submerged in cold fresh water or cold salt water (4 degrees C). INTERVENTIONS: Catheters were placed in the femoral artery, right carotid artery and right internal jugular vein. Electrocardiogram, pneumogram, and rectal temperatures were measured continuously during submersion/immersion. MEASUREMENTS AND MAIN RESULTS: Cold water submersion with drowning produced a large initial decrease in carotid artery temperature (approximately 7.5 degrees C in the first 2 mins) compared with a minor decrease (approximately 0.8 degrees C with immersion). No significant differences were noted in the rate of decrease of temperature between drowning in fresh water and salt water. During cold fresh water drowning, aspiration produced gross hemodilution with an average increase in body weight of 16.5%. Hematocrit values, serum sodium concentrations, and osmolality decreased while serum potassium concentrations, catecholamines, and free hemoglobin increased. All measured biochemical data (except PaO2) remained at viable levels. By contrast, during cold salt water drowning, average body weight increased by only 6%, with hemoconcentration and a shrinkage of vascular volume. Hematocrit and hemoglobin values increased by 30%, but initial plasma free hemoglobin values remained unchanged. Serum sodium concentrations, osmolality, and potassium concentrations increased rapidly to critical levels. CONCLUSIONS: On submersion in cold water, all of the experimental animals developed tachypnea immediately, followed by aspiration with predictable effects. The biochemical and pathophysiologic changes in cold water drowning approximated those changes reported for warm water drowning for both fresh and salt water with one exception and continued aspiration of cold water produced extremely rapid core cooling as long as the circulation remained intact. This process of acute submersion hypothermia may protect the brain temporarily from lethal damage, as reported in cases of cold fresh water drowning. Concentrations of circulating catecholamines increased exponentially in both groups of test animals. Clinically, their acute effects on the circulation, compounded by significant hypothermia and extreme anoxia, must hamper the detection of residual circulation at rescue and may play a role in sudden death from cold water in the absence of drowning.

Influence of hypothermia, barbiturate therapy, and intracranial pressure monitoring on morbidity and mortality after near-drowning.

We retrospectively evaluated the clinical and pathologic effects of hypothermia and high-dose barbiturate therapy on hypoxic/ischemic cerebral injury after near-drowning in children. Of 40 near-drowned patients admitted to the ICU, 13 died, seven had permanent cerebral damage, and 20 survived. Twenty-four patients (group 1) were treated with a regime of hyperventilation, hypothermia, and high-dose phenobarbitone while intracranial pressure (ICP) was continuously monitored. Of ten who died in this group, three were diagnosed as having cerebral death shortly after admission; autopsy revealed severe cerebral edema with herniation. The remaining seven nonsurvivors had severe cerebral hypoxia without raised ICP and had the features of severe adult respiratory distress syndrome and hypoxic/ischemic damage to other organs. Six of these seven patients developed septicemia which was invariably associated with a profound neutropenia. Sixteen patients (group 2) were treated with a similar protocol but without hypothermia. Three of these patients died but only one developed septicemia. Neutropenia after resuscitation from near-drowning seemed to indicate a poor prognosis; the mean polymorphonuclear leukocyte count in nonsurvivors (1.9 +/- 0.5 X 10(9) cell/L) was significantly (p less than .01) lower than that in survivors (6.4 +/- 1.1 X 10(9) cell/L). Hypothermia was associated with a decreased number of circulating PMNs but did not increase the number of neurologically intact survivors. Similarly, although barbiturates may control ICP, their use did not improve outcome. Because severe cerebral edema and herniation after near-drowning is usually associated with irreversible brain damage, measures to control brain swelling such as hypothermia and barbiturates will be of little benefit.(ABSTRACT TRUNCATED AT 250 WORDS)