[Rehabilitation and nursing-care robots]

In the extremely aged society, rehabilitation staff will be required to provide ample rehabilitation training for more stroke patients and more aged people with disabilities despite limitations in human resources. A nursing-care robot is one potential solution from the standpoint of rehabilitation. The nursing-care robot is defined as a robot which assists aged people and persons with disabilities in daily life and social life activities. The nursing-care robot consists of an independent support robot, caregiver support robot, and life support robot. Although many nursing-care robots have been developed, the most appropriate robot must be selected according to its features and the needs of patients and caregivers in the field of nursing-care.

Global paediatric advanced life support: improving child survival in limited-resource settings

Nearly all global mortality in children younger than 5 years (99%) occurs in developing countries. The leading causes of mortality in children younger than 5 years worldwide, pneumonia and diarrhoeal illness, account for 1·396 and 0·801 million annual deaths, respectively. Although important advances in prevention are being made, advanced life support management in children in developing countries is often incomplete because of limited resources. Existing advanced life support management guidelines for children in limited-resource settings are mainly empirical, rather than evidence-based, written for the hospital setting, not standardised with a systematic approach to patient assessment and categorisation of illness, and taught in current paediatric advanced life support training courses from the perspective of full-resource settings. In this Review, we focus on extension of higher quality emergency and critical care services to children in developing countries. When integrated into existing primary care programmes, simple inexpensive advanced life support management can improve child survival worldwide.

[The development of a portable life support device for transporting pre-hospital critically ill patients]

OBJECTIVE

To describe a portable life support device for transportation of pre-hospital patients with critical illness.

METHODS

The characteristics and requirements for urgent management during transportation of critically ill patients to a hospital were analyzed. With adoption of the original equipment, with the aid of staple of the art soft ware, the overall structure, its installation, fixation, freedom from interference, operational function were studied, and the whole system of life support and resuscitation was designed.

RESULTS

The system was composed by different modules, including mechanical ventilation, transfusion, aspiration, critical care, oxygen supply and power supply parts. The system could be fastened quickly to a stretcher to form portable intensive care unit (ICU), and it could be carried by different size vehicles to provide nonstop treatment by using power supply of the vehicle, thus raising the efficiency of urgent care.

CONCLUSION

With characteristics of its small size, lightweight and portable, the device is particularly suitable for narrow space and extreme environment.

Development of simulated and ovine models of extracorporeal life support to improve understanding of circuit-host interactions

BACKGROUND

Extracorporeal life support (ECLS) is a lifesaving technology that is being increasingly used in patients with severe cardiorespiratory failure. However, ECLS is not without risks. The biosynthetic interface between the patient and the circuit can significantly alter inflammation, coagulation, pharmacokinetics and disposition of trace elements. The relative contributions of the pump, disease and patient in propagating these alterations are difficult to quantify in critically ill patients with multiple organ failure.

OBJECTIVE

To design a model where the relevance of individual components could be assessed, in isolation and in combination.

DESIGN AND SUBJECTS

Four ECLS models were developed and tested - an in-vitro simulated ECLS circuit; and ECLS in healthy sheep, sheep with acute lung injury (ALI), and sheep with ALI together with transfusion of old or new blood.

MAIN OUTCOME MEASURES

Successful design of in-vitro and in-vivo models.

RESULTS

We successfully conducted multiple experiments in the simulated circuits and ECLS runs in healthy and ALI sheep. We obtained preliminary data on inflammation, coagulation, histology, pharmacokinetics and trace element disposition during ECLS.

CONCLUSIONS

The establishment of in-vitro and in-vivo models provides a powerful means for enhancing knowledge of the pathophysiology associated with ECLS and identification of key factors likely to influence patient outcomes. A clearer description of the contribution of disease and therapeutic interventions may allow improved design of equipment, membranes, medicines and physiological goals for improved patient care.

Study on advanced life support devices in the ambulances for emergency cases in Klang Valley, Malaysia

BACKGROUND AND AIMS

In an effort to improve pre-hospital care, the authors assessed the availability and utility of ambulance devices. The study aimed to identify commonly used devices for managing emergency cases in Klang Valley of Malaysia.

MATERIALS AND METHODS

This was a prospective study comprising of 1075 emergency ambulances running on 30 days. The study analyzed the availability and utilization of life support equipment in nine ambulance providers of Klang Valley in Malaysia. The devices were classified into: (a) airway and ventilation, (b) immobilization and haemorrhage control and (c) communication. The percentage of device utilization was analysed using computerised software.

RESULTS

Results showed only one ambulance service had complete equipment in accordance to international standards. In term of utilisation of life support equipment, oxygen delivery devices were used in 493 (45.86%) runs. The most used devices in immobilisation and haemorrhage control were:- (a) scoop stretcher in 321 (29.86%) runs, (b) wound dressings in 250 (23.26%) runs and (c) rigid spinal board in 206 (19.16%) runs. Two-way radios were used in 745 (69.30%) runs while mobile phones were used in 429 (39.91%) runs.

CONCLUSION

In conclusion, ambulances in Klang Valley had a large variation in the availability of life support devices. This emphasizes a need for standardization of equipment.

Efficacy and safety of percutaneous life support during high-risk percutaneous coronary intervention, refractory cardiogenic shock and in-laboratory cardiopulmonary arrest

BACKGROUND

High-risk percutaneous coronary interventions (PCI), refractory cardiogenic shock and in-lab cardiac arrest are all associated with significant mortality. Percutaneous left ventricular assist devices (pLVAD) and CPS (cardiopulmonary support) have been used to support such patients. However, the extent to which the use of these devices can improve outcomes in this patient subset is not known.

METHODS

We evaluated clinical features, efficacy and safety outcomes in a retrospective cohort of 39 patients, treated either with pLVAD or CPS for support of high-risk PCI, cardiogenic shock or in-lab cardiac arrest. The Tandem-Heart and a new versatile Multifunctional Percutaneous Heart (MPH) system, with both CPS and LVAD capability, were used and assessed.

RESULTS

19 patients received the TandemHeart and 20 received the MPH system. The MPH system was used as a pLVAD in 12 and to provide CPS in 8 patients. Procedural efficacy was 100%. Emergent institution of CPS, in the setting of cardiac arrest, was able to support 7 out of 8 patients and resulted in a 50% survival to hospital discharge rate. Overall, in-hospital death and 30-day major adverse cardiac event rates were 28.2% and 35.9%, respectively. The risk of vascular complications and bleeding was relatively small.

CONCLUSIONS

pLVADs are effective in supporting patients during high-risk cardiac (coronary and structural heart) interventions, with a low risk of device-related complications. Further, the expeditious use of CPS in the catheterization laboratory can improve survival in a selected subset of patients with refractory cardiogenic shock and cardiac arrest.

[Machines and arguments: from life support technologies to the definition of brain death]

The article analyzes academic production about the debate surrounding the definition of brain death, based on bibliographic and documental research of international medical periodicals in the 1960s. The development and adoption of life support technologies during the twentieth century sparked a heated debate that sought to legitimize new procedures like organ transplants. As its practices changed, medical science set about inventing new knowledge about these practices. Discussions as to the definition of brain death turned it into a 'black box', dismantled by anthropological studies into the topic starting in 1980s. The present article explores the deconstruction of brain death as a black box.

[Advanced development of blood-gas exchanger]

In order to simplify the technique of extracorporeal membrane oxygenation (ECMO) and apply extracorporeal life support ( ECLS) broadly for assisting the treatment of severe respiratory failure patients, we have developed a blood-gas exchanger (BGE) with the characteristics of small volume and simple structure. The exchange between blood and gas of BGE adopts cross-flowing model; blood flows along the outer hollow fiber and gas flows in the inner hollow fiber with the reverse direction of blood flowing. The interface of blood flow in and out was designed as the internal spiral, and the caliber of BGE is matched with the blood interface of dialysis. Thus it may successfully make single-use spiral connectors link up mutually in the extracorporeal blood circulation of dialysis, may help clinical operations become safe, convenient and easily-controlled, and may simplify the technique of EGMO.

Priority dilemmas in dialysis: the impact of old age

AIM

This study explores priority dilemmas in dialysis treatment and care offered elderly patients within the Norwegian public healthcare system.

BACKGROUND

Inadequate healthcare due to advanced age is frequently reported in Norway. The Norwegian guidelines for healthcare priorities state that age alone is not a relevant criterion. However, chronological age, if it affects the risk or effect of medical treatment, can be a legitimate criterion.

METHOD

A qualitative approach is used. Data were collected through semistructured interviews and analysed through hermeneutical content analysis. The informants were five physicians and four nurses from dialysis wards.

FINDINGS

Pressing priority dilemmas centre around decision-making concerning withholding and withdrawal of dialysis treatment. Advanced age is rarely an absolute or sole priority criterion. It seems, however, that advanced age appears to be a more subtle criterion in relation with, for example, comorbidity, functional status and cognitive impairment. Nurses primarily prioritise specialised dialysis care and not comprehensive nursing care. The complex needs of elderly patients are therefore often not always met.

CONCLUSIONS

Clinical priorities should be made more transparent in order to secure legitimate and fair resource allocation in dialysis treatment and care. Difficult decisions concerning withholding or withdrawal of dialysis ought to be openly discussed within the healthcare team as well as with patients and significant others. The biomedical focus and limitations on comprehensive care during dialysis should be debated.

A preliminary feasibility study of a short DVD-based distance-learning package for basic life support

OBJECTIVE

To test the hypothesis that laypeople who learn CPR using an 8-min self-instructional DVD acquire a level of skill that is comparable to that achieved with conventional courses.

METHODS

Forty volunteers used a short DVD with replay facility, and a simple inflatable training manikin, for self-instruction in basic life support. A further 40 volunteers (control group) attended a conventional 1-h instructor-led course. Skill acquisition was measured for each group.

RESULTS

After training, the self-instructional group achieved remarkably similar results compared with the control group for all measured skill variables except compression depth, which was significantly greater for the control group.

CONCLUSION

Very short, DVD-based, self-instructional packages may be suitable for more widespread use, including distance-learning and other circumstances in which educational opportunities and resources are limited.

The baby MB case: medical decision making in the context of uncertain infant suffering

The recent MB case involved a dispute between an infant's parents and his medical team about the appropriateness of continued life support. The dispute reflected uncertainty about two key factors that inform medical decision making for seriously ill infants: both the amount of pain MB experiences and the extent of his cognitive capacities are uncertain. Uncertainty of this order makes decision making in accordance with the best-interests principle very problematic. This article addresses two of the problems that cases such as that of MB pose for those charged with making medical decisions for infants. First, the question of the moral significance of the interest in avoiding pain is considered. It is claimed that this interest can be outweighed by higher-order interests such as those related to autonomy but that where such higher-order interests do not exist, the interest in avoiding pain should be prioritised. Second, the question of how to proceed in cases in which the level of pain or the extent of an infant's higher-order interests cannot be decisively established is considered. It is suggested that when genuine uncertainty over the interests of an infant exists, parental views about treatment should prevail.

Retrospective analysis comparing hollow fiber and silicone membrane oxygenators for neonates on ECMO

There is little information showing the use of microporous polypropylene hollow fiber oxygenators during extra-corporeal life support (ECLS). Recent surveys have shown increasing use of these hollow fibers amongst ECLS centers in the United States. We performed a retrospective analysis comparing the Terumo BabyRx hollow fiber oxygenator to the Medtronic 800 silicone membrane oxygenator on 14 neonatal patients on extracorporeal membrane oxygenation (ECMO). The aim of this study was to investigate the similarities and differences when comparing pressure drops, prime volumes, oxygenator endurance, and gas transfer capabilities between the two groups.

[Technology of the future applied to the present: Life Support for Trauma and Transport (LSTAT)]

One of the most recent innovations coalescing computer technology and medical care is the development of integrated medical component technology coupled with a computer system. One such example is the patient transport system known as the Life Support for Trauma and Transport (LSTAT). LSTAT is a self-contained stretcher-based intensive care unit designed by the United States Army to provide care for critically injured patients during transport and in remote settings where resources are limited. It contains conventional medical equipment that has been reduced in size and integrated into a single platform. This article presents the latest technology applied to the field of medicine, which should not be limited to patients injured during warfare but should also be used to assist the injured civilian population who need transport from remote settings to urban trauma centers.

[Intensive home-based care: is it a possible reality for the public health system?]

A qualitative investigation characterized as an exploratory study of individual case. The guiding point was inquiring into how the Public Health System (SUS) provides intensive home-based care. The study was aimed at analyzing how this health support is made available--that is, what kind of assistance is given and what is the equipment maintenance and warranty like--and at examining how the subject of this study obtained this service, that is, how the service reached him/her and how long it usually takes to do so. The results show that the paths to get life support are full of obstacles and that this path in search of home-based care through the SUS dynamics involves bureaucracy, professionals, and equipment that often make it difficult for the population to have access to public health services.

Extracorporeal life support for children with meningococcal septicaemia

OBJECTIVE

To describe the short-term outcome of children with meningococcal sepsis treated with extracorporeal membrane oxygenation (ECMO) in a single centre.

DESIGN

Retrospective analysis of case notes.

SETTING

The Heartlink ECMO Centre, Glenfield Hospital, Leicester.

PATIENTS

Eleven children (8 boys) out of a total caseload of 800 patients were treated for meningococcal sepsis with ECMO.

INTERVENTIONS

Extracorporeal membrane oxygenation.

RESULTS

All children with meningococcal sepsis treated with ECMO had a Glasgow Meningococcal Septicaemia Prognostic Score (GMSPS) > or = 12 (positive predictive risk of death of approximately 90%). Five children had adult respiratory distress syndrome (ARDS) and six had refractory shock with multi-organ dysfunction syndrome (MODS) at presentation for ECMO. All five children in the ARDS group survived, four of five receiving veno-venous (VV-) ECMO therapy. In contrast, only one of six children with refractory shock with MODS survived, all of whom required veno-arterial (VA-) ECMO therapy.

CONCLUSIONS

Most children with meningococcal sepsis and severe ARDS can be successfully treated with VV-ECMO. In contrast, children with refractory shock and MODS die despite treatment with VA-ECMO. This report does not resolve whether ECMO therapy offers any advantage over conventional therapy in treating severe meningococcal sepsis.

Life support for trauma and transport: a mobile ICU for safe in-hospital transport of critically injured patients

BACKGROUND

In-hospital transport of newly injured patients is complicated by inadequate monitoring and adverse events. LSTAT (Life Support for Trauma and Transport, Integrated Medical Systems Inc) is a platform with multiple integrated systems (ventilator, defibrillator, suction, hemodynamic monitors, infusion and invasive monitoring channels, capnography, blood analysis, and electrocardiography) that allow seamless monitoring and effective life-saving interventions during transport. The platform functions as a mobile ICU and has preliminarily been tested with success in combat settings. This is the first evaluation of LSTAT in the civilian transport arena.

STUDY DESIGN

Major trauma patients requiring trauma team activation, who were transported from the Emergency Department through different hospital departments (usually CT or angiography) to the ICU or operating room were included prospectively (December 2002 through April 2003). Patients were monitored and transported either by conventional means (conventional group) or by LSTAT (LSTAT group). Primary outcomes related to resource consumption and process of care; secondary outcomes related to clinical events. A questionnaire was completed by the surgeons participating in transports to document perceptions and preferences about means of in-hospital transport.

RESULTS

Of 178 patients enrolled, 85 (48%) were in the LSTAT and 93 (52%) in the conventional groups. The two groups were similar except for age and mechanism of injury. Time of hand-bagging, preparation for transport, and return of blood results was significantly shorter in the LSTAT than in the conventional group (p < 0.001 for all). Significantly fewer LSTAT than conventional transports required more than one escorting physician (p < 0.001). Significantly more surveyed surgeons preferred LSTAT to conventional methods to transfer patients. There were no differences in adverse events, hospital stay, or mortality between the two groups.

CONCLUSIONS

LSTAT emerges as a safe and convenient method of in-hospital transport. It allows uninterrupted monitoring, immediate response to physiologic changes, and reduction in human resource consumption. Process of care is improved. LSTAT's potential to improve clinical outcomes needs to be tested in different environments, including the prehospital setting.

Measurement of carbon dioxide levels during use of ELSA and the effect of venting on these levels

DESIGN

A prospective, objective assessment of ELSA use, in order to determine whether venting of the ELSA influences carbon dioxide (CO2) levels.

PRIMARY ENDPOINT

Inspired and expired CO2 levels.

SETTING

On board RFA ARGUS during Operation TELIC.

METHODS

10 volunteers had a baseline of inspired and expired CO2 levels taken. These levels were measured at one minute intervals during use of an ELSA in 3 conditions--sitting, jogging and jogging with venting.

RESULTS

There was no difference in expired CO2 levels between baseline and use of ELSA whilst sitting. Periodic venting of the ELSA made no difference to inspired and expired CO2 levels.

CONCLUSIONS

Venting of the ELSA during use makes no difference to CO2 levels whether inspired or expired. Therefore, venting is unnecessary and potentially wastes vital time during escape from a smoke-filled compartment and adds additional stress to the escapee.

Maximizing a transport platform through computer technology

One of the most recent innovations coalescing computer technology and medical care is the further development of integrated medical component technology coupled with a computer subsystem. One such example is the self-contained patient transport system known as the Life Support for Trauma and Transport (LSTAT(tm)). The LSTAT creates a new transport platform that integrates the most current medical monitoring and therapeutic capabilities with computer processing capacity, creating the first "smart litter". The LSTAT is built around a computer system that is network capable and acts as the data hub for multiple medical devices and utilities, including data, power, and oxygen systems. The system logs patient and device data in a simultaneous, time-synchronized, continuous format, allowing electronic transmission, storage, and electronic documentation. The third-generation LSTAT includes an oxygen system, ventilator, clinical point-of-care blood analyzer, suction, defibrillator, infusion pump, and physiologic monitor, as well as on-board power and oxygen systems. The developers of LSTAT and other developers have the ability to further expand integrative component technology by developing and integrating clinical decision support systems.

Clinical evaluation of the Life Support for Trauma and Transport (LSTAT) platform

INTRODUCTION

The Life Support for Trauma and Transport (LSTAT trade mark ) is a self-contained, stretcher-based miniature intensive care unit designed by the United States Army to provide care for critically injured patients during transport and in remote settings where resources are limited. The LSTAT contains conventional medical equipment that has been integrated into one platform and reduced in size to fit within the dimensional envelope of a North Atlantic Treaty Organization (NATO) stretcher. This study evaluated the clinical utility of the LSTAT in simulated and real clinical environments. Our hypothesis was that the LSTAT would be equivalent to conventional equipment in detecting and treating life-threatening problems.

METHODS

Thirty-one anesthesiologists and recovery room nurses compared the LSTAT with conventional monitors while managing four simulated critical events. The time required to reach a diagnosis and treatment was recorded for each simulation. Subsequently, 10 consenting adult patients were placed on the LSTAT after surgery for postoperative care in the recovery room. Questionnaires about aspects of LSTAT functionality were completed by nine nurses who cared for the patients placed on the LSTAT.

RESULTS

In all of the simulations, there was no clinically significant difference in the time to diagnosis or treatment between the LSTAT and conventional equipment. All clinicians reported that they were able to manage the simulated patients properly with the LSTAT. Nursing staff reported that the LSTAT provided adequate equipment to care for the patients monitored during recovery from surgery and were able to detect critical changes in vital signs in a timely manner.

DISCUSSION

Preliminary evaluation of the LSTAT in simulated and postoperative environments demonstrated that the LSTAT provided appropriate equipment to detect and manage critical events in patient care. Further work in assessing LSTAT functionality in a higher-acuity environment is warranted.

The 9 ALS triads--an alphabetical checklist for advanced life support providers

The successful outcome of a resuscitation attempt relies frequently on the performance of many advanced life support interventions. A checklist of 27 procedures, following an alphabetical sequence, is presented as an educational memory aid for healthcare providers.

Optimisation of tidal volumes given with self-inflatable bags without additional oxygen

The European Resuscitation Council has recommended smaller tidal volumes of 500 ml during basic life support ventilation in order to minimise gastric inflation. One method of delivering these tidal volumes may be to use paediatric instead of adult self-inflatable bags; however, we have demonstrated in other studies that only 350 ml may be delivered, using this technique. The reduced risk of gastric inflation was offset by oxygenation problems, rendering the strategy of attempting to deliver tidal volumes of 500 ml with a paediatric self-inflatable bag questionable, at least when using room-air. In this report, we assessed the effects of a self-inflatable bag with a size between the maximum size of a paediatric (700 ml) and an adult (1500 ml) self-inflatable bag on respiratory variables and blood gases during bag-valve-mask ventilation. After induction of anaesthesia, 50 patients were block-randomised into two groups of 25 each. They were ventilated with room-air with either an adult (maximum volume, 1500 ml) or a newly developed medium-size (maximum volume, 1100 ml; Dräger, Lübeck, Germany) self-inflatable bag for 5 min before intubation. When compared with the adult self-inflatable bag, the medium-size bag resulted in significantly lower exhaled tidal volumes and tidal volumes per kg bodyweight (624 + 24 versus 738 +/- 20 ml, and 8.5 +/- 0.3 versus 10.7 +/- 0.3 ml kg(-1), respectively; P < 0.001), oxygen saturation (95 +/- 0.4 versus 96 +/- 0.3%; P < 0.05), and partial pressure of oxygen (78 +/- 3 versus 87 +/- 3 mmHg; P < 0.05). Carbon dioxide levels were comparable (37 +/- 1 versus 37 +/- 1 mmHg). Our results indicate that smaller tidal volumes of about 8 ml x kg(-1) (approximately 600 ml), given with a new medium-size self-inflatable bag and room-air, maintained adequate carbon dioxide elimination and oxygenation during bag-valve-mask ventilation. Accordingly, the new medium-size self-inflatable bag may combine both adequate ventilatory support and reduced risk of gastric inflation during bag-valve-mask ventilation.

The use of basic life support kits in general practice

Donegal is a predominantly rural area with many general practices situated considerable distances from a district hospital. Fifty Life Support Kits were supplied to General Practitioners by the Donegal Pre-Hospital Emergency Care Project in 1995 following appropriate training. This is a survey of the use of items in these kits. To determine the frequency of use of the equipment, the type and location of the incidents, the kit items utilised and patient outcome. Retrospective questionnaire survey of 49 participating GPs. 208 patient incidents were described by 46 doctors (average 4.5 per doctor) Most incidents were outside the surgery (88.24%). Road Traffic Accidents (36%) were the commonest reason for use, followed by cardiac emergencies (28%), other medical emergencies (14%) and other trauma (11%). All items except the burns sheet had been used. The most used items were cannulae, (64.7% of incidents) and fluids (50.9% incidents). Other useful items were emergency drugs, dressings, collars, airways, suction and torch. Regarding outcome, 162 patients required hospital transfer and 25 died. Eleven did not require hospital treatment. The participating doctors judged that the basic life support kits positively contributed to outcome in 79.4% of cases described. Basic Life Support kits contribute to the pre-hospital care of patients when used by GPs with immediate care training.

Life support and first aid in a mental health setting

While there is much talk of holistic care in psychiatric care settings, emphasis on physical care is rare. Emergency aspects of care are always considered but their effectiveness is never certain until tested by real situations. With this in mind, and with some recent experiences to provide a focus, St Andrew's Hospital, Northampton, a national charity providing mental health services, implemented a review of life-support and first-aid provision. With financial and skills investment, the new systems and their associated maintenance and training are now in place.

A prospective comparison of atrio-femoral and femoro-atrial flow in adult venovenous extracorporeal life support

INTRODUCTION

In the United States, venovenous extracorporeal life support has traditionally been performed with atrial drainage and femoral reinfusion (atrio-femoral flow). Although flow reversal (femoro-atrial flow) may alter recirculation and extracorporeal flow, no direct comparison of these 2 modes has been undertaken.

OBJECTIVE

Our goal was to prospectively compare atrio-femoral and femoro-atrial flow in adult venovenous extracorporeal life support for respiratory failure.

METHODS

A modified bridge enabling conversion between atrio-femoral and femoro-atrial flow was incorporated in the extracorporeal circuit. Bypass was initiated in the direction that provided the highest pulmonary arterial mixed venous oxygen saturation, and the following measurements were taken: (1) maximum extracorporeal flow, (2) highest achievable pulmonary arterial mixed venous oxygen saturation, and (3) flow required to maintain the same pulmonary arterial mixed venous oxygen saturation in both directions. Flow direction was then reversed, and the measurements were repeated. Data were compared with paired t tests and are presented as mean +/- standard deviation.

RESULTS

Ten patients were studied, and 9 were included in the data analysis. Femoro-atrial bypass provided (1) higher maximal extracorporeal flow (femoro-atrial flow = 55.6 +/- 9.8 mL/kg per minute, atrio-femoral flow = 51.1 +/- 11.1 mL/kg per minute; P = .04) and (2) higher pulmonary arterial mixed venous oxygen saturation (femoroatrial flow = 89.9% +/- 6.6%, atrio-femoral flow = 83.2% +/- 4.2%; P = .006); (3) furthermore, it required less flow to maintain an equivalent pulmonary arterial mixed venous oxygen saturation (femoro-atrial flow = 37.0 +/- 12.2 mL/kg per minute, atrio-femoral flow = 46.4 +/- 8.8 mL/kg per minute; P = .04).

CONCLUSIONS

During venovenous extracorporeal life support, femoro-atrial bypass provided higher maximal extracorporeal flow, higher pulmonary arterial mixed venous oxygen saturation, and required comparatively less flow to maintain an equivalent mixed venous oxygen saturation than did atrio-femoral bypass.

A comparison of standard and a modified method of two resuscitator adult cardiopulmonary resuscitation: description of a new system for research into advanced life support skills

The study compares two methods of Advanced Life Support by a pair of resuscitators using a bag-valve-mask (BVM) technique. Standard two resuscitator cardiopulmonary resuscitation (CPR) was compared with a modified method of two resuscitator CPR. During the modified CPR one resuscitator held the face mask while the other resuscitator alternates between squeezing the self inflating bag and performing simulated cardiac compressions. Standard CPR was performed at a ventilation:compression ratio of 1:5 while modified CPR was performed at a ventilation:compression ratio of 2:15. Comparisons were made during induction of anaesthesia in 30 ASA I and II patients. Modified CPR produced a greater tidal volume (TV) (P < 0.001), a slower respiratory rate (RR) (P < 0.001) and a faster compression rate (CR) (P < 0.01) (means with (S.D.): modified CPR: TV 990 (220) ml, RR 6 (1) min(-1), CR 82 (8) min(-1); standard CPR: TV 570 (190) ml, RR 10 (2) min(-1), CR 65 (11) min(-1)). A new method for the simultaneous computerised recording of simulated cardiac compressions together with mask pressure and expired gas composition in anaesthetised patients is described.

[Effect of mobile phone on life-saving and life-sustaining systems]

Since the beginning of the nineties there have been warnings not to use mobile phones in the vicinity of medical devices. Functional failures of dialysis machines, respirators and defibrillators prompted the banning of their use in many hospitals in Scandinavia, and then in other countries. Since we believe that a general ban in hospitals is problematic, we decided to investigate the influence of mobile telephone on life-saving and/or life-support systems, with the aim of establishing rules for its use in hospitals. We investigated available phones of varying power of the C-, D- and E-net, as also of a cordless phone meeting the DECT standard. The aim was to identify the devices susceptible to interference and determine the minimum distances at which interference occurred. A total of 224 devices classified into 23 types of devices were examined. Nine different sets of transmission conditions were applied, giving a total of 2016 tests. Our results permit the conclusion that the ban on mobile phones in hospitals is based not on actual events, but on theoretical considerations in the absence of any practical information on the actual susceptibility of devices and their reaction to the electromagnetic fields involved. The fact that hazardous situations are very rare is due firstly to the need for the simultaneous occurrence of four coincidences, and the fail-save feature of medical devices. We would therefore recommend that all life-saving and life-support systems that can also be used outside the hospital should be made mobile phone-proof. When apnoea monitors and respirators are protected from such interference, hazardous situations could be avoided by establishing the rule: "No portables, and mobile phones only at a distance of at least 1 metre from medical devices". With regard to emergency telephones, the minimum distance to medical devices should be at least 1.5 metres.

Advanced life support for acute toxic injury (TOXALS)

The need to consider the problem of acute toxic injury in the prehospital context emphasized by the recent use of highly toxic agents of warfare in terrorist attacks. Toxic agents differ widely in their nature but may be considered to have four distinct properties: toxicity, latency, persistency and transmissibility. Toxicity and latency determine the onset and pathophysiology of the poisoning and therefore the clinical management. Persistency and transmissibility determine the level of hazard to rescue personnel and the evacuation system and therefore the rationale of logistic management. Previously, special emphasis has been given to the importance of isolation and decontamination of the patient before any medical intervention can occur. This approach, however, although essential for the safety of medical responders may not be in the best interests of the patient who may be in a life-threatening situation within a contaminated zone (CONZONE). Toxic injury may require more rapid help than traumatic injury; moreover, traumatic and toxic injury may co-exist, as in the case of explosion with toxic emission. The special skills required are defined in the TOXALS programme and must now become a standard part of the training and practice of prehospital care medical care.