FUTURE-DIRECTIONS FOR RESUSCITATION RESEARCH .5. ULTRA-ADVANCED LIFE-SUPPORT

Standard external cardiopulmonary resuscitation (SECPR) frequently pro duces very low perfusion pressures, which are inadequate to achieve re storation of spontaneous circulation (ROSC) and intact survival, parti cularly when the heart is diseased. Ultra-advanced life support (UALS) techniques may allow support of vital organ systems until either the heart recovers or cardiac repair or replacement is performed. Closed-c hest emergency cardiopulmonary bypass (CPB) provides control of blood flow, pressure, composition and temperature, but has so far been appli ed relatively late. This additional low-flow time may preclude conscio us survival. An easy, quick method for vessel access and a small prepr imed system that could be taken into the field are needed. Open-chest CPR (OCCPR) is physiologically superior to SECPR, but has also been in itiated too late in prior studies. Its application in the field has re cently proven feasible. Variations of OCCPR, which deserve clinical tr ials inside and outside hospitals, include 'minimally invasive direct cardiac massage' (MIDCM), using a pocket-size plunger-like device inse rted via a small incision and 'direct mechanical ventricular actuation ' (DMVA), using a machine that pneumatically drives a cup placed aroun d the heart. Other novel UALS approaches for further research include the use of an aortic balloon catheter to improve coronary and cerebral blood flow during SECPR, aortic flush techniques and a double-balloon aortic catheter that could allow separate perfusion (and cooling) of the heart, brain and viscera for optimal resuscitation of each. Decisi on-making, initiation of UALS methods and diagnostic evaluations must be rapid to maximize the potential for ROSC and-facilitate decision-ma king regarding long-term circulatory support versus withdrawal of life support for hopeless cases. Research and development of UALS techniqu es needs to be coordinated with cerebral resuscitation research. (C) 1 997 Elsevier Science Ireland Ltd.