We sent out questionnaires on the timing and condition for the discontinuation of cardiopulmonary resuscitation (CPR) in cardiac arrest patients to 392 elder members of the Japanese Society of Reanimatology, Japan Society of Intensive Care Medicine and Japan Society of Anesthesiology, and received 229 replies (58.4%) . The results were as follows: Important factors in the decision of discontinuation of CPR were, 1) whether the cardiac arrest occurred more than 30 min before the start of CPR, 2) cardiac standstill on ECG, 3) terminal stage of cancer, and 4) massive traumatic injury including burn. The most respondents usually performed CPR for about 30 min in cases where the cardiac arrest occurred less than 30 min prior to initiation of CPR, but the CPR time is extended to over 1 h in previously healthy victims, victims under 15 y/o, arresting time less than 5 min, hypothermia of 25°C or less, and in victims without history of critical basic disorders. If closed chest CPR is not effective, 46% of respondents are willing to perform open chest CPR and 28% cardiopulmonary bypass procedure. The respondents requested our committee to produce a manual for the discontinuance of CPR. At present, it is not feasible for our committee to make the manual, but we are planning to make a guideline.

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First, historical aspects in the development of closed chest cardiopulmonary resuscitation (CC-CPR) are re-viewed. CC-CPR is a combination of external, cardiac defibrillation and closed chest cardiac compression (CCCC) . Kouwenhoven had been developing cardiac defibrillation when by chance he discovered the effectiveness of CCCC. He united CCCC and external cardiac defibrillation and made it possible to use CC-CPR in daily clinical activity. The mechanism by which blood flows during CCCC is discussed also.
Second, active compression-decompression (ACD) CPR was reviewed with special reference to its characteristics and the blood flow mechanism during the compression-decompression cycle.

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Influences of brief apnea to the structure of rat Purkinje cells were examined electron microscopically and the same effects were produced by the intraventricular administration of glutamate or its metabotropic receptor. These procedures induced conformational changes from tubular to lamellar in the smooth endoplasmic reticulum (SER) of the neurons. Lamellar bodies formed by stacks of the flat cisterns were connected by the regularly arranged intercisternal bridges of short tubes, about 15 nm in length and in diameter. The formation of lamellar bodies might be a protective reaction for the extraordinary excitation to the neurons by a head-to-head contact of opposing Ca²⁺ releas-ing channels, which usually release Ca²⁺ from the SER into the cytoplasm.

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We have organized cardio-pulmonary resuscitation (CPR) training course of primary level for 105 medical staffs in our hospital. The written test in CPR before the beginning of training course revealed that the ratio of medical staffs having enough knowledge for CPR was lower than that expected. In addition, staffs who were educated formerly did not obtain excellent achievement.These results indicate that improvement of teaching quality and repeated attendance to the training course may be of great importance to master and spread CPR technique.

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We reviewed retrospectively the anesthetic managements of 7 patients with acute mesenteric ischemia (AMI) . There was an occlusion of the superior mesenteric artery in 3 patients, an occlusion of the inferior mesenter-ic artery in 1 patient, and an occlusion of both arte ries in 3 patients. The average age of the patients was 71±15 (mean±SD) years old. The surgical treatments were per-formed at 12 to 192 hours from the onset of AMI. At the start of anesthesia, the mean blood pressure was 72±34 mmHg and the mean heart rate was 122±23 beats/min. General anesthesia with inhalation agents was chosen to be used along with a variety of drugs such as dopamine, dobutamine, vasodilators and diuretics, during anesthesia. The rate of early postoperative mortality was 43%, and the causes were sepsis or multiple organ failure. In an 89-year-old AMI patient with severe shock and acute renal failure, we performed continuous hemodiafiltration and the patient recovered from critical condition. From our experiences we emphasize: 1) careful anesthesia management with circulatory and renal functional supports must be exercised, and 2) hemofiltration must be indicat-ed immediately after surgery in patients who have difficulty in maintaining adequate blood pressure or showing low platelet counts.

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A 45-year-old female was referred to our hospital ICU because of abdominal pain, high fever (39.5°C), persistent hypotension, consciousness disturbance. Low urinary output with increased BUN and creatinine, and leukocytosis were revealed. Fluid transfusion (4, 500 ml/7 hrs) increased urinary output, but the blood pressure remained low. Cardiac index was high, 4.91/min/m², and systemic vascular resistance index was low, 690 dynes·sec/cm⁵⋅m². We suspected septic shock and did direct hemoperfusion with polymixin B fixed column, which dramatically improved her circulatory condition. The cause of the shock was revealed sarumonella food poisoning due to green colored diarrhea and the culture of the feces. The concentration of endotoxine revealed only transient elevation during the course. The patient was discharged on 15 th day.

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We experienced a case of cardiac arrest in a 78-year-old man during total gastrectomy. He was diagnosed with hypertension, diabetes mellitus and premature ventricular constriction, and medicated with β-blocker and calcium channel blocker. Anesthesia was maintained with oxygen -nitrous oxide-isoflurane and epidural block. Upon expos-ing the peritoneal region, heart rate suddenly decreased to 30 bpm and 3 rd degree A-V block was observed. One minute after the onset of bradycardia, cardiac arrest occurred, and percutaneous cardiopulmonary support (PCPS) was started 30 min after cardiac arrest. Coronary angiography showed a right coronary artery spasm. Intracoronary injection of nitroglycerin relieved the spasm and heart beat was acquired. Reexploration for intraab-dominal bleeding and splenotomy for rupture of the spleen, respectively, caused by cardiac massage were performed under PCPS. The patient regained conciousness 8 hr after cardiac arrest, and exhibited no neurological complications. We concluded that PCPS with heparin coated artificial lung and cannulas was effective for advanced life support for cardiac arrest occurring during operation.

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A 52-year-old man was scheduled for coronary artery bypass grafting. Twenty minutes after institution of cardiopulmonary bypass (CPB), the aortic arch was ruptured, which caused massive bleeding resulting in ventricular fibrillation, when core temperature was 34.5°C. Separat-ed cerebral perfusion was established through the brachiocephalic trunk and the left common carotid artery followed by CPB at a blood temperature of 20°C. Thereafter, coronary artery bypass grafting and the aortic arch reconstruction were performed. He showed uneventful postoperative recovery and was discharged without any neurological abnormality.
The hypothermia and the rapid institution of cerebral perfusion would have contributed to the good outcome in this case.

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A 54-year-old male with a history of variant angina and hypertension suddenly developed severe hypotention associated with massive bleeding due to a rupture of the right common carotid artery, after an uneventful neck surgery for tumor resection. For treatment of hemorrhagic shock, we gave a rapid and massive infusion of lactated Ringer's solution (5 1 for 45 minuets until blood for transfusion get available) . The rectal temperature dropped 33°C and hemoglobin was 2.7 g/dl and mean arterial blood pressure remained below 60 mmHg. The episode of complete occulusion of the right internal carotid artery associated with surgical preparation and prolonged hypotension and severe anemia made us suspect that the patient should develop sever brain damage. However, the patient recovered almost completely with a minimal neurological deficits. Mild hypothermia induced by a massive and rapid infusion might contribute to a protection of brain function in this patient.

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