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Serious Did NS Absconder Janil Puthucheary kaykiang and made Ah Heng's condition worse?

Papsmearer

Alfrescian (InfP) - Comp
Generous Asset
So, let me get this right. A SCDF paramedic who does CPR several times every day, and who has seen and dealt with many stroke victims, happens to tell Janil that his is deviating from established SCDF protocol and i bagging the patient too fast. Does Janil step aside and let her take over? No. When was the last time Janil did CPR and handled a stroke victim? Can we say its been a very long time? Was Janil, Minister of state for Communications, and Information and MP for Punggol only working as Part time Minister and MP, while keeping his job as Senior Consultant, KK Hospital?

When was the last time you actually saw a Doctor draw Blood? Or give CPR in a hospital? Or perform blood work? Out in an IV line? The answer is no and never. You have nurses for that, blood techs for that, etc. Janil should have step aside and let the SCDF team take over. They are the ones that deal with these sort of situations every day, he does not. Really, I think he is symptomatic of the disease in the PAP. They have some knowledge, maybe its old, maybe its been little use, but when the situation presents itself where there are clearly better people in the room to do the same job, a job that they are not at present paid to do, they refuse to budge and want to mouth back at the superior person.

Janil, you were clearly NOT THE BEST PERSON in the room, for the job of administering to Ah Heng in an emergency situation. You should have step aside, shut up, and assisted the response team if they ask for it.

SINGAPORE: Prime Minister Lee Hsien Loong has written to the Singapore Civil Defence Force (SCDF) Commissioner Eric Yap to thank his team for their speedy response to the situation after Finance Minister Heng Swee Keat collapsed during a Cabinet meeting on Thursday (May 12).

In a letter released by the Prime Minister's Office (PMO) on Saturday, Mr Lee said the team were "highly professional" and in control throughout the incident. Sharing the letter on Facebook, the Prime Minister said he saw how they dealt with the emergency firsthand and was "deeply impressed" by the "confident and competent" team.

Mr Lee said that when Mr Heng collapsed at 5.34pm on Thursday, the SCDF team responded within seven minutes from the time 995 was dialled. The nearest SCDF station to the Istana is the Central Fire Station at Hill Street.

Dr Janil Puthucheary, who is a medical doctor, was already resuscitating Mr Heng when they entered the Cabinet Room at the Istana. He had been using the bag and mask resuscitation kit that the security team had on hand, Mr Lee related. The SCDF team jumped in to support Dr Janil, recording what happened and monitoring his vitals.

However one SCDF paramedic, SSG Janice Lee Yi Ping, "observed that Dr Janil was deviating from paramedic SOP and appropriately asked him if he was bagging the patient too fast," PM Lee wrote.

"Dr Janil shared his presumptive diagnosis and explained that he was hyper-ventilating the patient to relieve pressure on the brain and reduce the swelling," Mr Lee said, adding that SSG Lee was satisfied with the explanation and continued to support Dr Janil in maintaining and securing the airway of Mr Heng.

The SCDF team then took the lead and conveyed Mr Heng in an ambulance to Tan Tock Seng Hospital (TTSH), with Dr Janil supporting them.

"My colleagues and I observed how your team kept cool and were in control throughout the incident, working as a team with Dr Janil. Each knew their roles and all had the presence of mind to stay completely focused on the patient.

"Your team was highly competent and professional, unfazed by the surroundings or the presence of ministers. They asserted themselves where necessary and played an important role in stabilising the patient," PM Lee stated.

The SCDF team included EMT SSG Mohd Imran Abd Samad, NSF EMT CPL Ian Lok Yu Hern and Paramedic Trainee Sheena Chiang Yanpin as well.

"Your officers are a credit to the SCDF. They reflected the professionalism and sense of mission that they display daily as they go about their duties to protect and save lives and property for a safe and secure Singapore," Mr Lee concluded.

Sharing Mr Lee's Facebook post, Foreign Minister Vivian Balakrishnan said Dr Janil "deserves full credit for saving Heng Swee Keat's life. I believe those early minutes made all the difference".

"We appreciated SSG Janice Lee's willingness to question Janil. It shows that we are a society that doesn't allow protocol or rank to get in the way of performance," he wrote.

Dr Balakrishnan added that what happened in the Cabinet Room was "Team Singapore at its best".

"The next time you meet a SCDF officer or your son enlists for National Service with SCDF - remember to salute them. They save lives everyday."

In a Facebook post on Saturday, SCDF said SSG Janice Lee, SSG Mohd Imran, PMT Sheena Chiang and CPL (NSF) Ian Lok "are part of the SCDF emergency responders, comprising career officers, full time National Servicemen (NSF), Operationally Ready National Servicemen (ORNS) and volunteers from the Civil Defence Auxiliary Unit (CDAU)".

SCDF added that they "attend to approximately 500 calls daily and (work) tirelessly round the clock to go about their duties in quiet but impactful ways to save lives and property".


Mr Heng is currently in stable condition at TTSH, but will be in the intensive care unit "for some time", Mr Lee said in an update on Friday. He added that Mr Heng is "in very good hands".

Finance Minister Heng had collapsed at a Cabinet meeting on Thursday. He had suffered a stroke due to an aneurysm and underwent surgery that evening to alleviate pressure in the brain due to bleeding.

On Saturday, President Tony Tan Keng Yam and his wife Mary visited Mr Heng at the hospital and said he is "relieved" to know he is in stable condition and well cared for by his family members and TTSH staff.
 

Dreamer1

Alfrescian
Loyal
Foreign Minister Vivian Balakrishnan said Dr Janil "deserves full credit for saving Heng Swee Keat's life? so traitor to his Dad Dr Janil is a saver (Saviour)? PM Lee must have agreed, as he put this out in fb, so what does the family of Mr Heng think? no time for them to think now, in due course, they will show by Bouquet Of Flowers or spitting on traitor's face. Time will tell, but why another traitor Foreign Minister Vivian Balakrishnan so quick to run to praise him? TRAIORS' UNION, isit???????
 
Last edited:

JohnTan

Alfrescian (InfP)
Generous Asset
Dr. Janil saved our finance minister's life, assholes! We should all be on our knees, thanking him and sucking his cock. Otherwise, there would have been a stock market crash the next day if our Finance Minister died suddenly.
 

scroobal

Alfrescian
Loyal
Jainil's discipline is paediatrics and ICU management. Resuscitation is the daily bread of the latter. Ng is an oncologist surgeon and Viv B is an ophthalmologist. Janil is not a cabinet minister but he happened to attend.
 

Wunderfool

Alfrescian (Inf)
Asset
Heng could get a stroke anytime and anywhere . Aneurysm is like a time bomb . Imagine if Heng had it in his own private study room or in the toilet, the consequence would be disastrous. We should thank the doctors who attended to him when he collapsed at the Cabinet meeting.

It was the Cabinet that saved his life .
 

scroobal

Alfrescian
Loyal
I am not sure if the PM did the right thing here. I am sure people will not be wondering if the paramedics are applying the wrong technique for suspected stroke patients. Credit though to the paramedic for asking what Janil was doing.
 

Seee3

Alfrescian (Inf)
Asset
If HV is useful for stroke, it will be part of sop for paramedics. It should also be reflected in the instruction manual of the equipment. Just read an article on HV and stroke and found opposite views.
 

shiokalingam

Alfrescian
Loyal
I am not sure if the PM did the right thing here. I am sure people will not be wondering if the paramedics are applying the wrong technique for suspected stroke patients. Credit though to the paramedic for asking what Janil was doing.



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attachment.php
 

winnipegjets

Alfrescian (Inf)
Asset
Dr. Janil saved our finance minister's life, assholes! We should all be on our knees, thanking him and sucking his cock. Otherwise, there would have been a stock market crash the next day if our Finance Minister died suddenly.

So, if Heng dies subsequently, we can then charge Janil for killing him? Idiot!
 

shiokalingam

Alfrescian
Loyal
So, let me get this right. A SCDF paramedic who does CPR several times every day, and who has seen and dealt with many stroke victims, happens to tell Janil that his is deviating from established SCDF protocol and i bagging the patient too fast. Does Janil step aside and let her take over? No. When was the last time Janil did CPR and handled a stroke victim? Can we say its been a very long time? Was Janil, Minister of state for Communications, and Information and MP for Punggol only working as Part time Minister and MP, while keeping his job as Senior Consultant, KK Hospital?

When was the last time you actually saw a Doctor draw Blood? Or give CPR in a hospital? Or perform blood work? Out in an IV line? The answer is no and never. You have nurses for that, blood techs for that, etc. Janil should have step aside and let the SCDF team take over. They are the ones that deal with these sort of situations every day, he does not. Really, I think he is symptomatic of the disease in the PAP. They have some knowledge, maybe its old, maybe its been little use, but when the situation presents itself where there are clearly better people in the room to do the same job, a job that they are not at present paid to do, they refuse to budge and want to mouth back at the superior person.

Janil, you were clearly NOT THE BEST PERSON in the room, for the job of administering to Ah Heng in an emergency situation. You should have step aside, shut up, and assisted the response team if they ask for it.

SINGAPORE: Prime Minister Lee Hsien Loong has written to the Singapore Civil Defence Force (SCDF) Commissioner Eric Yap to thank his team for their speedy response to the situation after Finance Minister Heng Swee Keat collapsed during a Cabinet meeting on Thursday (May 12).

In a letter released by the Prime Minister's Office (PMO) on Saturday, Mr Lee said the team were "highly professional" and in control throughout the incident. Sharing the letter on Facebook, the Prime Minister said he saw how they dealt with the emergency firsthand and was "deeply impressed" by the "confident and competent" team.

Mr Lee said that when Mr Heng collapsed at 5.34pm on Thursday, the SCDF team responded within seven minutes from the time 995 was dialled. The nearest SCDF station to the Istana is the Central Fire Station at Hill Street.

Dr Janil Puthucheary, who is a medical doctor, was already resuscitating Mr Heng when they entered the Cabinet Room at the Istana. He had been using the bag and mask resuscitation kit that the security team had on hand, Mr Lee related. The SCDF team jumped in to support Dr Janil, recording what happened and monitoring his vitals.

However one SCDF paramedic, SSG Janice Lee Yi Ping, "observed that Dr Janil was deviating from paramedic SOP and appropriately asked him if he was bagging the patient too fast," PM Lee wrote.

"Dr Janil shared his presumptive diagnosis and explained that he was hyper-ventilating the patient to relieve pressure on the brain and reduce the swelling," Mr Lee said, adding that SSG Lee was satisfied with the explanation and continued to support Dr Janil in maintaining and securing the airway of Mr Heng.

The SCDF team then took the lead and conveyed Mr Heng in an ambulance to Tan Tock Seng Hospital (TTSH), with Dr Janil supporting them.

"My colleagues and I observed how your team kept cool and were in control throughout the incident, working as a team with Dr Janil. Each knew their roles and all had the presence of mind to stay completely focused on the patient.

"Your team was highly competent and professional, unfazed by the surroundings or the presence of ministers. They asserted themselves where necessary and played an important role in stabilising the patient," PM Lee stated.

The SCDF team included EMT SSG Mohd Imran Abd Samad, NSF EMT CPL Ian Lok Yu Hern and Paramedic Trainee Sheena Chiang Yanpin as well.

"Your officers are a credit to the SCDF. They reflected the professionalism and sense of mission that they display daily as they go about their duties to protect and save lives and property for a safe and secure Singapore," Mr Lee concluded.

Sharing Mr Lee's Facebook post, Foreign Minister Vivian Balakrishnan said Dr Janil "deserves full credit for saving Heng Swee Keat's life. I believe those early minutes made all the difference".

"We appreciated SSG Janice Lee's willingness to question Janil. It shows that we are a society that doesn't allow protocol or rank to get in the way of performance," he wrote.

Dr Balakrishnan added that what happened in the Cabinet Room was "Team Singapore at its best".

"The next time you meet a SCDF officer or your son enlists for National Service with SCDF - remember to salute them. They save lives everyday."

In a Facebook post on Saturday, SCDF said SSG Janice Lee, SSG Mohd Imran, PMT Sheena Chiang and CPL (NSF) Ian Lok "are part of the SCDF emergency responders, comprising career officers, full time National Servicemen (NSF), Operationally Ready National Servicemen (ORNS) and volunteers from the Civil Defence Auxiliary Unit (CDAU)".

SCDF added that they "attend to approximately 500 calls daily and (work) tirelessly round the clock to go about their duties in quiet but impactful ways to save lives and property".


Mr Heng is currently in stable condition at TTSH, but will be in the intensive care unit "for some time", Mr Lee said in an update on Friday. He added that Mr Heng is "in very good hands".

Finance Minister Heng had collapsed at a Cabinet meeting on Thursday. He had suffered a stroke due to an aneurysm and underwent surgery that evening to alleviate pressure in the brain due to bleeding.

On Saturday, President Tony Tan Keng Yam and his wife Mary visited Mr Heng at the hospital and said he is "relieved" to know he is in stable condition and well cared for by his family members and TTSH staff.



SSG Janice Lee vs Dr Janil


Sir maybe Dr Janil did not wear his name tag and maybe
SSG Janice Lee doesnt know recognise Dr Janil.
Even 5 Stars Hotel senior waiter can mistake Mrs Lee for
Kopi Soh ? :confused::confused::confused:
 

CoffeeAhSoh

Alfrescian
Loyal
SSG Janice Lee vs Dr Janil


Sir maybe Dr Janil did not wear his name tag and maybe
SSG Janice Lee doesnt know recognise Dr Janil.
Even 5 Stars Hotel senior waiter can mistake Mrs Lee for
Kopi Soh ? :confused::confused::confused:



janil-puthucheary.jpg




Good point raised Bro Shiok,
Dr Janil most likely not even wearing
a tie and dress as a doctor. Cant
fault SSG Janice Lee for questioning Dr Janil.
SSG Janice Lee though Dr Janil might be the Istana's Gardener
. :biggrin:
 

Leongsam

High Order Twit / Low SES subject
Admin
Asset
When my aunt collapsed it took 35 minutes for medics to arrive. :rolleyes:

It seems that response times vary depending upon who collapses.
 

songsongjurong

Alfrescian
Loyal
janil, the turncoat from bolehland will pin the blame on Janice should his rapid bagging kill Hrng , "SSG, why didnt you step in and stopped me when you , as a professional paramedic knew I was bagging too little too fast?"

full media praise on Janil, Heng's benefactor!!! SCDF saves life day in day out....

kind of remind in another thread, how "tonto" Danabalan was kowtowing to the dead Lee, LHL found his sidekick?
 

Leongsam

High Order Twit / Low SES subject
Admin
Asset
One of the reasons why there is so much pain and suffering in this world is because humans intervene in the natural process of dying.

Strokes are supposed to kill. Keeping stroke victims alive condemns them to a long period of suffering which is not what nature intended.
 

Brightkid

Alfrescian
Loyal
The asshole Doctor did a CPR on an old man while on his election rounds, happened to have few photographers with him. He did a different style of CPR too, without mouth-to-mouth to force air into victim's lung. Unfortunately, if I did not recall correctly, no one called SCDF and unfortunately the old man died.

On a less serious note, the SSG vindicated my point that no one really recognise most MPs PAP camp. Not surprises she questioned Janil. She probably thought he is a cleaner in the room. I would too if in same situation. If he is LKY, am sure no one dared to question what he is doing. It's not that the SCDF will question regardless if he is a some-body.
 

scroobal

Alfrescian
Loyal
I know of girl who was aged 14 who collapsed in school and was rushed to hospital by ambulance. She has the same thing as Swee Keat - aneurysm. They surgically intervened and she then had to go thru the various rehabilitative processes such as physiotherapy. Fast forward and she is now a medical student. I saw her at a function recently and forgot that she was the one who had the stroke. She was absolutely normal. I did recall the parents saying that she had to go for follow-up surgery and that she recovered fully.

Sadly this is the only case I personally know of a stroke victim recovering fully. But it does say there is hope.

One of the reasons why there is so much pain and suffering in this world is because humans intervene in the natural process of dying.

Strokes are supposed to kill. Keeping stroke victims alive condemns them to a long period of suffering which is not what nature intended.
 

Leongsam

High Order Twit / Low SES subject
Admin
Asset
I know of girl who was aged 14 who collapsed in school and was rushed to hospital by ambulance. She has the same thing as Swee Keat - aneurysm. They surgically intervened and she then had to go thru the various rehabilitative processes such as physiotherapy. Fast forward and she is now a medical student. I saw her at a function recently and forgot that she was the one who had the stroke. She was absolutely normal. I did recall the parents saying that she had to go for follow-up surgery and that she recovered fully.

Sadly this is the only case I personally know of a stroke victim recovering fully. But it does say there is hope.

There are always exceptions but in my case I have left strict instructions not to intervene if I suffer a medical emergency. I don't know whether my instructions will be followed though.
 

scroobal

Alfrescian
Loyal
The authorities have a clear protocol when it comes certain people of importance. I remember talking to a US official who told me that when the US President travels, the secret service would have mapped out the nearest hospital, the fastest route, the blood type availability, the quality of the doctors. etc. If not medical staff, blood etc on Air Force One. Its just too expensive to replace the head honcho of a country.

I can guarantee you if an ambulance was heading to attend a case in the vicinity of Sri Temasek and a call came from the Istana or Oxley, that ambulance would be diverted and second one sent to attack the original case.

When my aunt collapsed it took 35 minutes for medics to arrive. :rolleyes:

It seems that response times vary depending upon who collapses.
 

scroobal

Alfrescian
Loyal
Its the best thing to do for yourself and your loved ones. Without one, very few people would have the courage to do the right thing.

There are always exceptions but in my case I have left strict instructions not to intervene if I suffer a medical emergency. I don't whether my instructions will be followed though.
 

nayr69sg

Super Moderator
Staff member
SuperMod
ahem.....I say let the SCDF people who regularly update their BCLS and ACLS do their job. Things have changed quite a bit in the last few years as far as resuscitating is concerned.

http://www.trauma.org/archive/neuro/icpcontrol.html

"Previously, hyperventilation was used routinely to maximally reduce PaCO2. No studies have shown this to improve outcome in these patients. Additionally, transcranial doppler (TCD) assessment and positron emission tomography (PET) shows this can induce significant constriction of cerebral vessels and this increase in cerebral vascular resistance may reduce cerebral blood flow to below the ischaemic threshold. One study has shown an improvement in long-term outcome when hyperventilation is not used routinely.

Consequently hyperventilation should be used only for short periods when immediate control of ICP is necessary. For example in the patient who has an acute neurological deterioration prior to CT scanning and surgical intervention. Hyperventilation should not take the PaCO2 level to below 3.5-4 kPa as there is minimal beneficial effect on ICP below this level."

"Hyperventilation should not be used routinely."


https://www.uptodate.com/contents/e...sed+intracranial+pressure&selectedTitle=1~150

"Hyperventilation — Use of mechanical ventilation to lower PaCO2 to 26 to 30 mmHg has been shown to rapidly reduce ICP through vasoconstriction and a decrease in the volume of intracranial blood; a 1 mmHg change in PaCO2 is associated with a 3 percent change in CBF [108]. Hyperventilation also results in respiratory alkalosis, which may buffer post-injury acidosis [108]. The effect of hyperventilation on ICP is short-lived (1 to 24 hours) [109-111]. Following therapeutic hyperventilation, the patient's respiratory rate should be tapered back to normal over several hours to avoid a rebound effect [112].

Therapeutic hyperventilation should be considered as an urgent intervention when elevated ICP complicates cerebral edema, intracranial hemorrhage, and tumor. Hyperventilation should not be used on a chronic basis, regardless of the cause of increased ICP.

Hyperventilation should be minimized in patients with traumatic brain injury or acute stroke. In these settings, vasoconstriction may cause a critical decrease in local cerebral perfusion and worsen neurologic injury, particularly in the first 24 to 48 hours [24,109,111,113-116]. Thus, the need for hyperventilation should be carefully considered, and prophylactic hyperventilation in the absence of elevated ICP should be avoided. (See "Management of acute severe traumatic brain injury", section on 'Hyperventilation'.)"

Medline ® Abstracts for References 24,109,111,113-116
of 'Evaluation and management of elevated intracranial pressure in adults'
24 PubMed

Management of head trauma.
Marik PE, Varon J, Trask T
Chest. 2002;122(2):699.

Traumatic brain injury (TBI) is a major cause of disability and death in most Western nations and consumes an estimated $100 billion annually in the United States alone. In the last 2 decades, the management of TBI has evolved dramatically, as a result of a more thorough understanding of the physiologic events leading to secondary neuronal injury as well as advances in the care of critically ill patients. However, it is likely that many patients with TBI are not treated according to current treatment principles. This article presents an overview of the current management of patients with TBI.
AD
Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA 15261, USA. [email protected]
PMID
12171853
109
PubMed


Adverse effects of prolonged hyperventilation in patients with severe head injury: a randomized clinical trial.
Muizelaar JP, Marmarou A, Ward JD, Kontos HA, Choi SC, Becker DP, Gruemer H, Young HF
J Neurosurg. 1991;75(5):731.

There is still controversy over whether or not patients should be hyperventilated after traumatic brain injury, and a randomized trial has never been conducted. The theoretical advantages of hyperventilation are cerebral vasoconstriction for intracranial pressure (ICP) control and reversal of brain and cerebrospinal fluid (CSF) acidosis. Possible disadvantages include cerebral vasoconstriction to such an extent that cerebral ischemia ensues, and only a short-lived effect on CSF pH with a loss of HCO3-buffer from CSF. The latter disadvantage might be overcome by the addition of the buffer tromethamine (THAM), which has shown some promise in experimental and clinical use. Accordingly, a trial was performed with patients randomly assigned to receive normal ventilation (PaCO2 35 +/- 2 mm Hg (mean +/- standard deviation): control group), hyperventilation (PaCO2 25 +/- 2 mm Hg: HV group), or hyperventilation plus THAM (PaCO2 25 +/- 2 mm Hg: HV + THAM group). Stratification into subgroups of patients with motor scores of 1-3 and 4-5 took place. Outcome was assessed according to the Glasgow Outcome Scale at 3, 6, and 12 months. There were 41 patients in the control group, 36 in the HV group, and 36 in the HV + THAM group. The mean Glasgow Coma Scale score for each group was 5.7 +/- 1.7, 5.6 +/- 1.7, and 5.9 +/- 1.7, respectively; this score and other indicators of severity of injury were not significantly different. A 100% follow-up review was obtained. At 3 and 6 months after injury the number of patients with a favorable outcome (good or moderately disabled) was significantly (p less than 0.05) lower in the hyperventilated patients than in the control and HV + THAM groups. This occurred only in patients with a motor score of 4-5. At 12 months posttrauma this difference was not significant (p = 0.13). Biochemical data indicated that hyperventilation could not sustain alkalinization in the CSF, although THAM could. Accordingly, cerebral blood flow (CBF) was lower in the HV + THAM group than in the control and HV groups, but neither CBF nor arteriovenous difference of oxygen data indicated the occurrence of cerebral ischemia in any of the three groups. Although mean ICP could be kept well below 25 mm Hg in all three groups, the course of ICP was most stable in the HV + THAM group. It is concluded that prophylactic hyperventilation is deleterious in head-injured patients with motor scores of 4-5.(ABSTRACT TRUNCATED AT 400 WORDS)
AD
Division of Neurological Surgery, Medical College of Virginia, Richmond.
PMID
1919695
111
PubMed


Hypocapnia.
Laffey JG, Kavanagh BP
N Engl J Med. 2002;347(1):43.

AD
Department of Physiology, Conway Institute of Biomolecular and Biomedical Research, University College Dublin, Dublin, Ireland.
PMID
12097540
113
PubMed


Hyperventilation in head injury: a review.
Stocchetti N, Maas AI, Chieregato A, van der Plas AA
Chest. 2005;127(5):1812.

The aim of this review was to consider the effects of induced hypocapnia both on systemic physiology and on the physiology of the intracranial system. Hyperventilation lowers intracranial pressure (ICP) by the induction of cerebral vasoconstriction with a subsequent decrease in cerebral blood volume. The downside of hyperventilation, however, is that cerebral vasoconstriction may decrease cerebral blood flow to ischemic levels. Considering the risk-benefit relation, it would appear to be clear that hyperventilation should only be considered in patients with raised ICP, in a tailored way and under specific monitoring. Controversy exists, for instance, on specific indications, timing, depth of hypocapnia, and duration. This review has specific reference to traumatic brain injury, and is based on an extensive evaluation of the literature and on expert opinion.
AD
Neuroscience ICU, Ospedale Maggiore Policlinico, Milan University, IRCCS, Milan. [email protected]<[email protected]>
PMID
15888864
114
PubMed

Effect of hyperventilation on extracellular concentrations of glutamate, lactate, pyruvate, and local cerebral blood flow in patients with severe traumatic brain injury.
Marion DW, Puccio A, Wisniewski SR, Kochanek P, Dixon CE, Bullian L, Carlier P
Crit Care Med. 2002;30(12):2619.

OBJECTIVE: To determine the potential adverse effects of brief periods of hyperventilation commonly used for acute neurologic deterioration.
DESIGN: Prospective clinical trial.
SETTING: University medical school.
PATIENTS: Twenty patients with severe traumatic brain injury.
INTERVENTIONS: The effect of 30 mins of hyperventilation (mean PaCO2, 24.6 mm Hg) on the extracellular metabolites associated with ischemia, and on local cerebral blood flow was studied by using microdialysis and local cerebral blood flow techniques. Normal appearing brain adjacent to evacuated hemorrhagic contusions or underlying evacuated subdural hematomas was studied. Hyperventilation trials were done 24-36 hrs after injury and again at 3-4 days after injury. Dialysate concentrations of glutamate, lactate, and pyruvate were measured before and for 4 hrs after the hyperventilation trials.
MEASUREMENTS AND MAIN RESULTS: At 24-36 hrs, hyperventilation led to a>or=10% increase in the extracellular concentrations of glutamate in 14 of 20 patients, with concentrations in those 14 patients 13.7-395% above baseline; a>or=10% increase in lactate in 7 of 20 patients (11.6-211% above baseline); and a>or=10% increase in the lactate/pyruvate ratio in eight of 20 patients (10.8-227% above baseline). At 3-4 days after injury, ten of 13 patients had an increase in glutamate of>or=10%, while only three of 13 patients had an increase in extracellular lactate and two of 13 patients had an increase in the lactate/pyruvate ratio of this magnitude. The hyperventilation associated increases in extracellular glutamate and lactate concentrations were significant ( P<.05; one-sample Student's -test) at both time points after injury, as was the lactate/pyruvate ratio at 24-36 hrs. A>or=10% decline in local cerebral blood flow was observed with hyperventilation in five of 20 patients at 24-36 hrs (range, 10.2-18.7% below baseline), and in ten of 13 patients studied at 3-4 days (11.3-54% below baseline). There was no correlation with the presence or absence of local CO2 vasoresponsivity and increases in the extracellular metabolites at either the early or late time points.
CONCLUSIONS: In brain tissue adjacent to cerebral contusions or underlying subdural hematomas, even brief periods of hyperventilation can significantly increase extracellular concentrations of mediators of secondary brain injury. These hyperventilation-induced changes are much more common during the first 24-36 hrs after injury than at 3-4 days.
AD
Brain Trauma Research Center, Department of Neurological Surgery, University of Pittsburgh School of Medicine, 200 Lothrop Street, Suite B400, Pittsburgh, PA 15213, USA. [email protected]
PMID
12483048
115
PubMed


Effect of hyperventilation on cerebral blood flow in traumatic head injury: clinical relevance and monitoring correlates.
Coles JP, Minhas PS, Fryer TD, Smielewski P, Aigbirihio F, Donovan T, Downey SP, Williams G, Chatfield D, Matthews JC, Gupta AK, Carpenter TA, Clark JC, Pickard JD, Menon DK
Crit Care Med. 2002;30(9):1950.

OBJECTIVE: To investigate the effect of hyperventilation on cerebral blood flow in traumatic brain injury.
DESIGN: A prospective interventional study.
SETTING: A specialist neurocritical care unit.
PATIENTS: Fourteen healthy volunteers and 33 patients within 7 days of closed head injury.
INTERVENTIONS: All subjects underwent positron emission tomography imaging of cerebral blood flow. In patients, PaCO2 was reduced from 36 +/- 1 to 29 +/- 1 torr (4.8 +/- 0.1 to 3.9 +/- 0.1 kPa) and measurements repeated. Jugular venous saturation (SjvO2 ) and arteriovenous oxygen content differences (AVDO2 ) were monitored in 25 patients and values related to positron emission tomography variables.
MEASUREMENTS AND MAIN RESULTS: The volumes of critically hypoperfused and hyperperfused brain (HypoBV and HyperBV, in milliliters) were calculated based on thresholds of 10 and 55 mL.100g(-1).min(-1), respectively. Whereas baseline HypoBV was significantly higher in patients ( p<.05), baseline HyperBV was similar to values in healthy volunteers. Hyperventilation resulted in increases in cerebral perfusion pressure (p<.0001) and reductions in intracranial pressure (p<.001), whereas SjvO2 (>50%) and AVDO2 (<9 mL/mL) did not exceed global ischemic thresholds. However, despite these beneficial effects, hyperventilation shifted the cerebral blood flow distribution curve toward the hypoperfused range, with a decrease in global cerebral blood flow (31 +/- 1 to 23 +/- 1 mL.100g(-1).min(-1); p<.0001) and an increase in HypoBV (22 [1-141]to 51 [2-428]mL; p<.0001). Hyperventilation-induced increases in HypoBV were apparently nonlinear, with a threshold value between 34 and 38 torr (4.5-5 kPa).
CONCLUSIONS: Hyperventilation increases the volume of severely hypoperfused tissue within the injured brain, despite improvements in cerebral perfusion pressure and intracranial pressure. Significant hyperperfusion is uncommon, even at a time when conventional clinical management includes a role for modest hyperventilation. These reductions in regional cerebral perfusion are not associated with ischemia, as defined by global monitors of oxygenation, but may represent regions of potentially ischemic brain tissue.
AD
Division of Anaesthesia, University of cambridge, Addenbrooke's Hospital, Cambridge, UK. [email protected]
PMID
12352026
116
PubMed

Cerebral tissue PO2 and SjvO2 changes during moderate hyperventilation in patients with severe traumatic brain injury.
Imberti R, Bellinzona G, Langer M
J Neurosurg. 2002;96(1):97.

OBJECT: The aim of this study was to investigate the effects of moderate hyperventilation on intracranial pressure (ICP), jugular venous oxygen saturation ([SjvO2], an index of global cerebral perfusion), and brain tissue PO2 (an index of local cerebral perfusion). METHODS: Ninety-four tests consisting of 20-minute periods of moderate hyperventilation (27-32 mm Hg) were performed on different days in 36 patients with severe traumatic brain injury (Glasgow Coma Scale score<or = 8). Moderate hyperventilation resulted in a significant reduction in average ICP, but in seven tests performed in five patients it was ineffective. The response of SjvO2 and brain tissue PO2 to CO2 changes was widely variable and unpredictable. After 20 minutes of moderate hyperventilation in most tests (79.8%), both SjvO2 and brain tissue PO2 values remained above the lower limits of normality (50% and 10 mm Hg, respectively). In contrast, in 15 tests performed in six patients (16.6% of the studied population) brain tissue PO2 decreased below 10 mm Hg although the corresponding SjvO2 values were greater than 50%. The reduction of brain tissue PO2 below 10 mm Hg was favored by the low prehyperventilation values (10 tests), higher CO2 reactivity, and, possibly, by lower prehyperventilation values of cerebral perfusion pressure. In five of those 15 tests, the prehyperventilation values of SjvO2 were greater than 70%, a condition of relative hyperemia. The SjvO2 decreased below 50% in four tests; the corresponding brain tissue PO2 values were less than 10 mm Hg in three of those tests, whereas in the fourth, the jugular venous O2 desaturation was not detected by brain tissue PO2. The analysis of the simultaneous relative changes (prehyperventilation - posthyperventilation) of SjvO2 and brain tissue PO2 showed that in most tests (75.5%) there was a reduction of both SjvO2 and brain tissue PO2. In two tests moderate hyperventilation resulted in an increase of both SjvO2 and brain tissue PO2. In the remaining 17 tests a redistribution of the cerebral blood flow was observed, leading to changes in SjvO2 and brain tissue PO2 in opposite directions. CCONCLUSIONS. Hyperventilation, even if moderate, can frequently result in harmful local reductions of cerebral perfusion that cannot be detected by assessing SjvO2. Therefore, hyperventilation should be used with caution and should not be considered safe. This study confirms that SjvO2 and brain tissue PO2 are two parameters that provide complementary information on brain oxygenation that is useful to reduce the risk of secondary damage. Changes in SjvO2 and brain tissue PO2 in opposite directions indicate that data obtained from brain tissue PO2 monitoring cannot be extrapolated to evaluate the global cerebral perfusion.
AD
Servizio di Anestesia e Rianimazione II, IRCCS Policlinico San Matteo, Pavia, Italy. [email protected]
PMID
11794610


While there is no question that Dr Puthucheary had the best intentions for the patient, the medical evidence suggests otherwise with regard to Dr Puthucheary's actions to hyperventilate his patient.
 
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