ResearchPad - resuscitation https://www.researchpad.co Default RSS Feed en-us © 2020 Newgen KnowledgeWorks <![CDATA[Development and validation of a questionnaire to assess healthcare personnel competence in cardiac arrest and resuscitation in pregnancy]]> https://www.researchpad.co/article/elastic_article_7826 Cardiac arrest is rare in pregnancy, and up-to date competence can be difficult to assess and maintain. The objective of this study was to develop and validate a questionnaire to assess healthcare personnel experiences, self-assessed competence and perception of role and resposibility related to cardiac arrest and cardio-pulmonary resuscitation (CPR) in pregnancyMethodsThe study had a cross-sectional design, developing and validating a questionnaire: the Competence in cardiac arrest and CPR in pregnancy (ComCA-P). Development and validation of the ComCA-P was conducted in three stages: 1) Literature review and expert group panel inputs, 2) a pilot study and 3) a cross-sectional questionnaire study. In stage one, the ComCA-P was developed over several iterations between the researchers, including inputs from an expert group panel consisting of highly competent professionals (n = 11). In stage two, the questionnaire was piloted in a group of healthcare personnel with relevant competence (n = 16). The ComCA-P was then used in a baseline study including healthcare personnel potentially involved in CPR in pregnancy (n = 527) in six hospital wards. Based on these data, internal consistency, intra-class correlations, and confirmatory factor analysis were utilized to validate the questionnaire.ResultsThe expert group and pilot study participants evaluated the appropriateness, relevance and accuracy to be high. Formulation of the items was considered appropriate, with no difficulties identified related to content- or face validity. Cronbach’s alpha was 0.8 on the thematic area self-assessment, and 0.73 on the theoretical knowledge area of the ComCA-P. On both the self-assessed competence items and the teoretical knowledge items, Kaiser-Meyer-Olkin was 0.8. Moreover, the Bertletts’ test of sphericity was greater than the critical value for chi-square, and significant (p < .0001).ConclusionsFindings indicate that the ComCA-P is a valid questionnaire that can be used to assess healthcare personnel competence in cardiac arrest and resuscitation in pregnancy. ]]> <![CDATA[Effects of Polyethylene Glycol‐20k on Coronary Perfusion Pressure and Postresuscitation Myocardial and Cerebral Function in a Rat Model of Cardiac Arrest]]> https://www.researchpad.co/article/Nff32a837-dc89-4acf-a48a-cd57efcd0726

Background

Epinephrine increases the rate of return of spontaneous circulation. However, it increases severity of postresuscitation myocardial and cerebral dysfunction and reduces duration of survival. We investigated the effects of aortic infused polyethylene glycol, 20 000 molecular weight (PEG‐20k) during cardiopulmonary resuscitation on coronary perfusion pressure, postresuscitation myocardial and cerebral function, and duration of survival in a rat model of cardiac arrest.

Methods and Results

Twenty‐four male rats were randomized into 4 groups: (1) PEG‐20k, (2) epinephrine, (3) saline control–intravenous, and (4) saline control–intra‐aortic. Cardiopulmonary resuscitation was initiated after 6 minutes of untreated ventricular fibrillation. In PEG‐20k and Saline‐A, either PEG‐20k (10% weight/volume in 10% estimated blood volume infused over 3 minutes) or saline was administered intra‐aortically after 4 minutes of precordial compression. In epinephrine and placebo groups, either epinephrine (20 μg/kg) or saline placebo was administered intravenously after 4 minutes of precordial compression. Resuscitation was attempted after 8 minutes of cardiopulmonary resuscitation. Sublingual microcirculation was measured at baseline and 1, 3, and 5 hours after return of spontaneous circulation. Myocardial function was measured at baseline and 2, 4, and 6 hours after return of spontaneous circulation. Neurologic deficit scores were recorded at 24, 48, and 72 hours after return of spontaneous circulation. Aortic infusion of PEG‐20k increased coronary perfusion pressure to the same extent as epinephrine. Postresuscitation sublingual microcirculation, myocardial and cerebral function, and duration of survival were improved in PEG‐20k (P<0.05) compared with epinephrine (P<0.05).

Conclusions

Aortic infusion of PEG‐20k during cardiopulmonary resuscitation increases coronary perfusion pressure to the same extent as epinephrine, improves postresuscitation myocardial and cerebral function, and increases duration of survival in a rat model of cardiac arrest.

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<![CDATA[Dissociation of Cerebral Blood Flow and Femoral Artery Blood Pressure Pulsatility After Cardiac Arrest and Resuscitation in a Rodent Model: Implications for Neurological Recovery]]> https://www.researchpad.co/article/N6b234a04-1acf-47d2-a856-f801582df03c

Background

Impaired neurological function affects 85% to 90% of cardiac arrest (CA) survivors. Pulsatile blood flow may play an important role in neurological recovery after CA. Cerebral blood flow (CBF) pulsatility immediately, during, and after CA and resuscitation has not been investigated. We characterized the effects of asphyxial CA on short‐term (<2 hours after CA) CBF and femoral arterial blood pressure (ABP) pulsatility and studied their relationship to cerebrovascular resistance (CVR) and short‐term neuroelectrical recovery.

Methods and Results

Male rats underwent asphyxial CA followed by cardiopulmonary resuscitation. A multimodal platform combining laser speckle imaging, ABP, and electroencephalography to monitor CBF, peripheral blood pressure, and brain electrophysiology, respectively, was used. CBF and ABP pulsatility and CVR were assessed during baseline, CA, and multiple time points after resuscitation. Neuroelectrical recovery, a surrogate for neurological outcome, was assessed using quantitative electroencephalography 90 minutes after resuscitation. We found that CBF pulsatility differs significantly from baseline at all experimental time points with sustained deficits during the 2 hours of postresuscitation monitoring, whereas ABP pulsatility was relatively unaffected. Alterations in CBF pulsatility were inversely correlated with changes in CVR, but ABP pulsatility had no association to CVR. Interestingly, despite small changes in ABP pulsatility, higher ABP pulsatility was associated with worse neuroelectrical recovery, whereas CBF pulsatility had no association.

Conclusions

Our results reveal, for the first time, that CBF pulsatility and CVR are significantly altered in the short‐term postresuscitation period after CA. Nevertheless, higher ABP pulsatility appears to be inversely associated with neuroelectrical recovery, possibly caused by impaired cerebral autoregulation and/or more severe global cerebral ischemia.

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<![CDATA[“She’s gone now.” A mixed methods analysis of the experiences and perceptions around the deaths of children who died unexpectedly in health care facilities in Cape Town, South Africa]]> https://www.researchpad.co/article/5c89778ed5eed0c4847d2fdb

Purpose

The sudden death of a child is a catastrophic event for both the family and the healthcare workers involved. Confidential enquiries provide a biomedical depiction of the processes and quality of care delivered and drive improvements in care. However, these rarely include an assessment of the patient/caregiver experience which is increasingly regarded as a key measure of quality of care.

Methods

A parallel convergent mixed methods design was used to compare and contrast medically-assessed clinical quality of care with caregiver perceptions of quality and care in a cohort of sudden childhood deaths in emergency facilities in Cape Town, South Africa.

Results

Amongst the 29 sudden childhood deaths, clinical quality of care was assessed as poor in 11 (38%) and the death was considered avoidable or potentially avoidable in 16 (55%). The main themes identified from the caregivers were their perception of the quality of care delivered (driven by perceived healthcare worker effort, empathy and promptness), the way the family was dealt with during the final resuscitation, and communications at the time of and after the death. Ten (35%) caregivers were predominantly negative about the care delivered, of whom four received fair clinical quality of care; 13 (49%) of caregivers had predominantly positive experiences, one of whom received poor clinical quality of care.

Conclusions

Caregivers’ experiences of the healthcare service around their child’s death are influenced largely by the way healthcare workers communicate with them, as well as the perceived clinical effort. This is not always concordant with the clinically assessed quality of care. Simple interventions such as protocols and education of healthcare workers in dealing with families of a dying or deceased child could improve families’ experiences at a time when they are most vulnerable.

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<![CDATA[Interventions to improve the quality of bystander cardiopulmonary resuscitation: A systematic review]]> https://www.researchpad.co/article/5c6dc9b8d5eed0c48452a083

Background

Performing high-quality bystander cardiopulmonary resuscitation (CPR) improves the clinical outcomes of victims with sudden cardiac arrest. Thus far, no systematic review has been performed to identify interventions associated with improved bystander CPR quality.

Methods

We searched Ovid MEDLINE, Ovid EMBASE, EBSCO CINAHL, Ovid PsycInfo, Thomson Reuters SCI-EXPANDED, and the Cochrane Central Register of Controlled Trials to retrieve studies published from 1 January 1966 to 5 October 2018 associated with interventions that could improve the quality of bystander CPR. Data regarding participant characteristics, interventions, and design and outcomes of included studies were extracted.

Results

Of the initially identified 2,703 studies, 42 were included. Of these, 32 were randomized controlled trials. Participants included adults, high school students, and university students with non-medical professional majors. Interventions improving bystander CPR quality included telephone dispatcher-assisted CPR (DA-CPR) with simplified or more concrete instructions, compression-only CPR, and other on-scene interventions, such as four-hand CPR for elderly rescuers, kneel on opposite sides for two-person CPR, and CPR with heels for a tired rescuer. Devices providing real-time feedback and mobile devices containing CPR applications or software were also found to be beneficial in improving the quality of bystander CPR. However, using mobile devices for improving CPR quality or for assisting DA-CPR might cause rescuers to delay starting CPR.

Conclusions

To further improve the clinical outcomes of victims with cardiac arrest, these effective interventions may be included in the guidelines for bystander CPR.

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<![CDATA[Outcome of exercise-related out-of-hospital cardiac arrest is dependent on location: Sports arenas vs outside of arenas]]> https://www.researchpad.co/article/5c5df33ed5eed0c484580fd5

Background

The chance of surviving an out-of-hospital cardiac arrest (OHCA) seems to be increased if the cardiac arrests occurs in relation to exercise. Hypothetically, an exercise-related OHCA at a sports arena would have an even better prognosis, because of an increased likelihood of bystander cardiopulmonary resuscitation (CPR) and higher availability of automated external defibrillators (AEDs). The purpose of the study was to compare survival rates between exercise-related OHCA at sports arenas versus outside of sports arenas.

Methods

Data from all treated exercise-related OHCA outside home reported to the Swedish Register of Cardiopulmonary Resuscitation (SRCR) from 2011 to 2014 in 10 counties of Sweden was analyzed (population 6 million). The registry has in those counties a coverage of almost 100% of all OHCAs.

Results

3714 cases of OHCA outside of home were found. Amongst them, 268(7%) were exercise-related and 164 (61.2%) of those occurred at sports arenas. The 30-day survival rate was higher for exercise-related OHCA at sports arenas compared to outside (55.7% vs 30.0%, p<0.0001). OHCA-victims at sports arenas were younger (mean age±SD 57.6±16.3 years compared to 60.9±17.0 years, p = 0.05), less likely female (4.3% vs 12.2%, p = 0.02) and had a higher frequency of shockable rhythm (73.0% vs 54.3%, p = 0.004). OHCAs at arenas were more often witnessed (83.9% vs 68.9%, p = 0.007), received bystander CPR to a higher extent (90.0% vs 56.8%, p<0.0001) and the AED-use before EMS-arrival was also higher in this group (29.8% vs 11.1%, p = 0.009).

Conclusion

The prognosis is markedly better for exercise-related OHCA occurring at sports arenas compared to outside. Victims of exercise-related OHCA at sports arenas are more likely to receive bystander CPR and to be connected to a public AED. These findings support an increased use of public AEDs and implementation of Medical Action Plans (MAP), to possibly increase survival of exercise-related OHCA even further.

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<![CDATA[Predicting neurological recovery with Canonical Autocorrelation Embeddings]]> https://www.researchpad.co/article/5c58d654d5eed0c484031bb6

Early prediction of the potential for neurological recovery after resuscitation from cardiac arrest is difficult but important. Currently, no clinical finding or combination of findings are sufficient to accurately predict or preclude favorable recovery of comatose patients in the first 24 to 48 hours after resuscitation. Thus, life-sustaining therapy is often continued for several days in patients whose irrecoverable injury is not yet recognized. Conversely, early withdrawal of life-sustaining therapy increases mortality among patients who otherwise might have gone on to recover. In this work, we present Canonical Autocorrelation Analysis (CAA) and Canonical Autocorrelation Embeddings (CAE), novel methods suitable for identifying complex patterns in high-resolution multivariate data often collected in highly monitored clinical environments such as intensive care units. CAE embeds sets of datapoints onto a space that characterizes their latent correlation structures and allows direct comparison of these structures through the use of a distance metric. The methodology may be particularly suitable when the unit of analysis is not just an individual datapoint but a dataset, as for instance in patients for whom physiological measures are recorded over time, and where changes of correlation patterns in these datasets are informative for the task at hand.

We present a proof of concept to illustrate the potential utility of CAE by applying it to characterize electroencephalographic recordings from 80 comatose survivors of cardiac arrest, aiming to identify patients who will survive to hospital discharge with favorable functional recovery. Our results show that with very low probability of making a Type 1 error, we are able to identify 32.5% of patients who are likely to have a good neurological outcome, some of whom have otherwise unfavorable clinical characteristics. Importantly, some of these had 5% predicted chance of favorable recovery based on initial illness severity measures alone. Providing this information to support clinical decision-making could motivate the continuation of life-sustaining therapies for these patients.

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<![CDATA[Volume replacement strategies do not impair the binding of dabigatran to idarucizumab: Porcine model of hemodilution]]> https://www.researchpad.co/article/5c3d012ad5eed0c484038d91

Background

Idarucizumab is a humanized Fab fragment that specifically reverses dabigatran anticoagulation. In trauma, volume expanders are used for resuscitation to compensate for blood loss and hemorrhagic shock, but it is unknown whether volume expanders influence the binding of dabigatran to its antidote. Using a porcine dilutional coagulopathy model, this study investigated whether volume replacement strategies affect binding of dabigatran to idarucizumab.

Methods

Twenty-five male pigs were treated orally with dabigatran etexilate (30 mg/kg bid) for 3 days. The following day, animals were anesthetized, infused with dabigatran (total dose 0.645 mg/kg) to achieve supratherapeutic concentrations, and randomized 1:1:1:1:1 (n = 5 per group) to control (no hemodilution) or hemodilution where ~50% of blood volume was substituted with Ringer’s solution, 6% hydroxyethyl starch 130/0.4, 6% hydroxyethyl starch 200/0.5 or 4% gelatin. Idarucizumab was then administered intravenously (30 mg/kg) and serial blood samples were taken for up to 24 hours to measure diluted thrombin time (corresponding with dabigatran activity), total dabigatran (bound to antidote and free drug) and a panel of coagulation parameters.

Results

Mean plasma dabigatran levels were 617 ± 16 ng/mL after infusion and 600 ± 114 ng/mL after ~50% hemodilution with no significant differences between groups. Following treatment with idarucizumab, plasma concentrations of unbound dabigatran decreased markedly, with similar reductions in all groups. Dabigatran-induced prolongation of coagulation parameters was rapidly reversed in all groups.

Conclusion

This study indicates that several volume expanders used for resuscitation in trauma do not interfere with the binding of idarucizumab to dabigatran.

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<![CDATA[A validation of the PAWPER XL-MAC tape for total body weight estimation in preschool children from low- and middle-income countries]]> https://www.researchpad.co/article/5c3d011ad5eed0c484038543

Importance

The PAWPER tape system is one of the three most accurate paediatric weight estimation systems in the world. The latest version of the tape, which does not rely on a subjective assessment of habitus, is the PAWPER XL-MAC method which uses length and mid-arm circumference (MAC) to estimate weight. It was derived and validated in a population in the USA and has not yet been fully validated in a population from a resource-limited setting.

Objective

The objective of this study was to evaluate the performance of the PAWPER XL-MAC tape weight estimation system in a large dataset sample of children from resource-limited settings.

Methods

This was a “virtual” study in which weight estimates were generated using the PAWPER XL-MAC tape and Broselow tape 2007B and 2011A editions in a very large open access dataset. The dataset contained anthropometric information of children aged 6 to 59 months from standardised nutritional surveys in 51 low- and middle-income countries. The performance of PAWPER XL-MAC method was compared with the Broselow tape and a new length- and habitus-based tape, the Ralston method.

Main outcomes and measures

The bias of the weight estimation methods was assessed using the mean percentage error (MPE) and precision using the 95% limits of agreement (LOA) of the MPE. The overall accuracy was denoted by the percentage of weight estimates falling within 10% and 20% of actual weight (abbreviated as p10 and p20 respectively).

Results

The MPE (LOA) for the PAWPER XL-MAC tape, the Broselow 2007B and 2011A and Ralston method were 1.9 (-15.3, 19.2), 5.4 (-15.9, 26.7), 7.7 (-13.3, 30.5) and -0.7 (-20.2, 19.3) respectively. The p10 and p20 for each method were 79.3% and 96.9% for the PAWPER XL-MAC tape, 64.3% and 91.0% for the Broselow tape 2007B, 55.5% and 85.9% for the Broselow tape 2011A and 67.4 and 94.0% for the Ralston method respectively. The PAWPER XL-MAC system was statistically significantly more accurate than the Broselow tape 2011A, the Broselow tape 2007B and the Ralston method. The relative difference in accuracy (p10) was 43% (odds ratio 4.4 (4.4, 4.5), p<0.001), 23% (odds ratio 2.9 (2.8, 2.9), p<0.001) and 18% (odds ratio 1.8 (1.8, 1.8), p<0.001) compared to each method, respectively.

Conclusions and relevance

The PAWPER XL-MAC tape performed well in this study and was statistically significantly more accurate than both the Broselow tape editions and the Ralston method. This difference was substantial and clinically important. The tape did not perform as well at extremes of habitus-type, however, and might benefit from recalibration.

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<![CDATA[Application of mechanical cardiopulmonary resuscitation devices and their value in out-of-hospital cardiac arrest: A retrospective analysis of the German Resuscitation Registry]]> https://www.researchpad.co/article/5c3667c7d5eed0c4841a63fd

Background

Cardiac arrest is an event with a limited prognosis which has not substantially changed since the first description of cardiopulmonary resuscitation (CPR) in 1960. A promising new treatment approach may be mechanical CPR devices (mechanical CPR).

Methods

In a retrospective analysis of the German Resuscitation Registry between 2007–2014, we examined the outcome after using mechanical CPR on return of spontaneous circulation (ROSC) in adults with out-of-hospital cardiac arrest (OHCA). We compared mechanical CPR to manual CPR. According to preclinical risk factors, we calculated the predicted ROSC-after-cardiac-arrest (RACA) score for each group and compared it to the rate of ROSC observed. Using multivariate analysis, we adjusted the influence of the devices’ application on ROSC for epidemiological factors and therapeutic measures.

Results

We included 19,609 patients in the study. ROSC was achieved in 51.5% of the mechanical CPR group (95%-CI 48.2–54.8%, ROSC expected 42.5%) and in 41.2% in the manual CPR group (95%-CI 40.4–41.9%, ROSC expected 39.2%). After multivariate adjustment, mechanical CPR was found to be an independent predictor of ROSC (OR 1.77; 95%-CI 1.48–2.12). Duration of CPR is a key determinant for achieving ROSC.

Conclusions

Mechanical CPR was associated with an increased rate of ROSC and when adjusted for risk factors appeared advantageous over manual CPR. Mechanical CPR devices may increase survival and should be considered in particular circumstances according to a physicians’ decision, especially during prolonged resuscitation.

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<![CDATA[Peer-assisted learning after onsite, low-dose, high-frequency training and practice on simulators to prevent and treat postpartum hemorrhage and neonatal asphyxia: A pragmatic trial in 12 districts in Uganda]]> https://www.researchpad.co/article/5c21518dd5eed0c4843fabad

An urgent need exists to improve and maintain intrapartum skills of providers in sub-Saharan Africa. Peer-assisted learning may address this need, but few rigorous evaluations have been conducted in real-world settings. A pragmatic, cluster-randomized trial in 12 Ugandan districts provided facility-based, team training for prevention and management of postpartum hemorrhage and birth asphyxia at 125 facilities. Three approaches to facilitating simulation-based, peer assisted learning were compared. The primary outcome was the proportion of births with uterotonic given within one minute of birth. Outcomes were evaluated using observation of birth and supplemented by skills assessments and service delivery data. Individual and composite variables were compared across groups, using generalized linear models. Overall, 107, 195, and 199 providers were observed at three time points during 1,716 births across 44 facilities. Uterotonic coverage within one minute increased from: full group: 8% (CI 4%‒12%) to 50% (CI 42%‒59%); partial group: 19% (CI 9%‒30%) to 42% (CI 31%‒53%); and control group: 11% (5%‒7%) to 51% (40%‒61%). Observed care of mother and newborn improved in all groups. Simulated skills maintenance for postpartum hemorrhage prophylaxis remained high across groups 7 to 8 months after the intervention. Simulated skills for newborn bag-and-mask ventilation remained high only in the full group. For all groups combined, incidence of postpartum hemorrhage and retained placenta declined 17% and 47%, respectively, from during the intervention period compared to the 6‒9 month period after the intervention. Fresh stillbirths and newborn deaths before discharge decreased by 34% and 62%, respectively, from baseline to after completion, and remained reduced 6‒9 months post-implementation. Significant improvements in uterotonic coverage remained across groups 6 months after the intervention. Findings suggest that while short, simulation-based training at the facility improves care and is feasible, more complex clinical skills used infrequently such as newborn resuscitation may require more practice to maintain skills.

Trial Registration: ClinicalTrials.gov NCT03254628.

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<![CDATA[Relationship between hemodynamic parameters and severity of ischemia-induced left ventricular wall thickening during cardiopulmonary resuscitation of consistent quality]]> https://www.researchpad.co/article/5c0841e9d5eed0c484fcb218

Ischemia-induced left ventricular (LV) wall thickening compromises the hemodynamic effectiveness of cardiopulmonary resuscitation (CPR). However, accurate assessment of the severity of ischemia-induced LV wall thickening during CPR is challenging. We investigated, in a swine model, whether hemodynamic parameters, including end-tidal carbon dioxide (ETCO2) level, are linearly associated with the severity of ischemia-induced LV wall thickening during CPR of consistent quality. We retrospectively analyzed 96 datasets for ETCO2 level, arterial pressure, LV wall thickness, and the percent of measured end-diastolic volume (%EDV) relative to EDV at the onset of ventricular fibrillation from eight pigs. Animals underwent advanced cardiovascular life support based on resuscitation guidelines. During CPR, LV wall thickness progressively increased while %EDV progressively decreased. Systolic and diastolic arterial pressure and ETCO2 level were significantly correlated with LV wall thickness and %EDV. Linear mixed effect models revealed that, after adjustment for significant covariates, systolic and diastolic arterial pressure were not associated with LV wall thickness or %EDV. ETCO2 level had a significant linear relationship with %EDV (P = 0.004). However, it could explain only 28.2% of the total variance of %EDV in our model. In conclusion, none of the hemodynamic parameters examined in this study appeared to provide sufficient information on the severity of ischemia-induced LV wall thickening.

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<![CDATA[Improved clinical management but not patient outcome in women with postpartum haemorrhage—An observational study of practical obstetric team training]]> https://www.researchpad.co/article/5bb530e440307c24312bb0b8

Objective

Postpartum haemorrhage (PPH) is the most common obstetric emergency. A well-established postpartum haemorrhage protocol in the labour ward is crucial for effective treatment. The aim of the study was to investigate if practical obstetric team training improves the patient outcome and clinical management of PPH.

Setting

The practical obstetric team training (PROBE) at Linköping University Hospital, Sweden, with approximate 3000 deliveries annually, was studied between the years of 2004–2011. Each team consisted of one or two midwives, one obstetrician or one junior doctor and one nurse assistant. Emergency obstetrics cases were trained in a simulation setting. PROBE was scheduled during work hours at an interval of 1.5 years.

Population

Pre-PROBE women (N = 419 were defined as all women with vaginal birth between the years of 2004–2007 with an estimated blood loss of ≥1000 ml within the first 24 hours of delivery. Post-PROBE women (N = 483) were defined as all women with vaginal birth between the years of 2008–2011 with an estimated blood loss of ≥1000 ml within the first 24 hours of delivery. The two groups were compared regarding blood loss parameters and management variables using retrospective data from medical records.

Results

No difference was observed in estimated blood loss, haemoglobin level, blood transfusions or the incidence of postpartum haemorrhage between the two groups. Post-PROBE women had more often secured venous access (p<0.001), monitoring of vital signs (p<0.001) and received fluid resuscitation (p<0.001) compared to pre-PROBE women. The use of uterine massage was also more common among the post-PROBE women compared with the pre-PROBE women (p<0.001).

Conclusion

PROBE improved clinical management but not patient outcome in women with postpartum haemorrhage in the labour ward. These new findings may have clinical implications since they confirm that training was effective concerning the management of postpartum haemorrhage. However, there is still no clear evidence that simulation training improve patient outcome in women with PPH.

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<![CDATA[Patterns of intravenous fluid resuscitation use in adult intensive care patients between 2007 and 2014: An international cross-sectional study]]> https://www.researchpad.co/article/5989db5aab0ee8fa60bdf78c

Background

In 2007, the Saline versus Albumin Fluid Evaluation—Translation of Research Into Practice Study (SAFE-TRIPS) reported that 0.9% sodium chloride (saline) and hydroxyethyl starch (HES) were the most commonly used resuscitation fluids in intensive care unit (ICU) patients. Evidence has emerged since 2007 that these fluids are associated with adverse patient-centred outcomes. Based on the published evidence since 2007, we sought to determine the current type of fluid resuscitation used in clinical practice and the predictors of fluid choice and determine whether these have changed between 2007 and 2014.

Methods

In 2014, an international, cross-sectional study was conducted (Fluid-TRIPS) to document current patterns of intravenous resuscitation fluid use and determine factors associated with fluid choice. We examined univariate and multivariate associations between patients and prescriber characteristics, geographical region and fluid type. Additionally, we report secular trends of resuscitation fluid use in a cohort of ICUs that participated in both the 2007 and 2014 studies. Regression analysis were conducted to determine changes in the administration of crystalloid or colloid between 2007 and 2014.

Findings

In 2014, a total of 426 ICUs in 27 countries participated. Over the 24 hour study day, 1456/6707 (21.7%) patients received resuscitation fluid during 2716 resuscitation episodes. Crystalloids were administered to 1227/1456 (84.3%) patients during 2208/2716 (81.3%) episodes and colloids to 394/1456 (27.1%) patients during 581/2716 (21.4%) episodes. In multivariate analyses, practice significantly varied between geographical regions. Additionally, patients with a traumatic brain injury were less likely to receive colloid when compared to patients with no trauma (adjusted OR 0.24; 95% CI 0.1 to 0.62; p = 0.003). Patients in the ICU for one or more days where more likely to receive colloid compared to patients in the ICU on their admission date (adjusted OR 1.75; 95% CI 1.27 to 2.41; p = <0.001).

For secular trends in fluid resuscitation, 84 ICUs in 17 countries contributed data. In 2007, 527/1663 (31.7%) patients received fluid resuscitation during 1167 episodes compared to 491/1763 (27.9%) patients during 960 episodes in 2014. The use of crystalloids increased from 498/1167 (42.7%) in 2007 to 694/960 (72.3%) in 2014 (odds ratio (OR) 3.75, 95% confidence interval (CI) 2.95 to 4.77; p = <0.001), primarily due to a significant increase in the use of buffered salt solutions. The use of colloids decreased from 724/1167 (62.0%) in 2007 to 297/960 (30.9%) in 2014 (OR 0.29, 95% CI 0.19 to 0.43; p = <0.001), primarily due to a decrease in the use of HES, but an overall increase in the use of albumin.

Conclusions

Clinical practices of intravenous fluid resuscitation have changed between 2007 and 2014. Geographical location remains a strong predictor of the type of fluid administered for fluid resuscitation. Overall, there is a preferential use of crystalloids, specifically buffered salt solutions, over colloids. There is now an imperative to conduct a trial determining the safety and efficacy of these fluids on patient-centred outcomes.

Trial registration

Clinicaltrials.gov: Fluid-Translation of research into practice study (Fluid-TRIPS) NCT02002013

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<![CDATA[Different Respiratory Rates during Resuscitation in a Pediatric Animal Model of Asphyxial Cardiac Arrest]]> https://www.researchpad.co/article/5989daf3ab0ee8fa60bc1fa1

Aims

Actual resuscitation guidelines recommend 10 respirations per minute (rpm) for advanced pediatric life support. This respiratory rate (RR) is much lower than what is physiological for children. The aim of this study is to compare changes in ventilation, oxygenation, haemodynamics and return of spontaneous circulation (ROSC) rates with three RR.

Methods

An experimental model of asphyxial cardiac arrest (CA) in 46 piglets (around 9.5 kg) was performed. Resuscitation with three different RR (10, 20 and 30 rpm) was carried out. Haemodynamics and gasometrical data were obtained at 3, 9, 18 and 24 minutes after beginning of resuscitation. Measurements were compared between the three groups.

Results

No statistical differences were found in ROSC rate between the three RR (37.5%, 46.6% and 60% in the 10, 20 and 30 rpm group respectively P = 0.51). 20 and 30 rpm groups had lower PaCO2 values than 10 rpm group at 3 minutes (58 and 55 mmHg vs 75 mmHg P = 0.08). 30 rpm group had higher PaO2 (61 mmHg) at 3 minutes than 20 and 10 rpm groups (53 and 45 mmHg P = 0.05). No significant differences were found in haemodynamics or tissue perfusion between hyperventilated (PaCO2 <30 mmHg), normoventilated (30–50 mmHg) and hypoventilated (>50 mmHg) animals. PaO2 was significantly higher in hyperventilated (PaO2 153 mmHg) than in normoventilated (79 mmHg) and hypoventilated (47 mmHg) piglets (P<0.001).

Conclusions

Our study confirms the hypothesis that higher RR achieves better oxygenation and ventilation without affecting haemodynamics. A higher RR is associated but not significantly with better ROSC rates.

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<![CDATA[A Retrospective Analysis of the Haemodynamic and Metabolic Effects of Fluid Resuscitation in Vietnamese Adults with Severe Falciparum Malaria]]> https://www.researchpad.co/article/5989da0aab0ee8fa60b77311

Background

Optimising the fluid resuscitation of patients with severe malaria is a simple and potentially cost-effective intervention. Current WHO guidelines recommend central venous pressure (CVP) guided, crystalloid based, resuscitation in adults.

Methods

Prospectively collected haemodynamic data from intervention trials in Vietnamese adults with severe malaria were analysed retrospectively to assess the responses to fluid resuscitation.

Results

43 patients were studied of whom 24 received a fluid load. The fluid load resulted in an increase in cardiac index (mean increase: 0.75 L/min/m2 (95% Confidence interval (CI): 0.41 to 1.1)), but no significant change in acid-base status post resuscitation (mean increase base deficit 0.6 mmol/L (95% CI: −0.1 to 1.3). The CVP and PAoP (pulmonary artery occlusion pressure) were highly inter-correlated (rs = 0.7, p<0.0001), but neither were correlated with acid-base status (arterial pH, serum bicarbonate, base deficit) or respiratory status (PaO2/FiO2 ratio). There was no correlation between the oxygen delivery (DO2) and base deficit at the 63 time-points where they were assessed simultaneously (rs = −0.09, p = 0.46).

Conclusions

In adults with severe falciparum malaria there was no observed improvement in patient outcomes or acid-base status with fluid loading. Neither CVP nor PAoP correlated with markers of end-organ perfusion or respiratory status, suggesting these measures are poor predictors of their fluid resuscitation needs.

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<![CDATA[Successful implementation of Helping Babies Survive and Helping Mothers Survive programs—An Utstein formula for newborn and maternal survival]]> https://www.researchpad.co/article/5989db5dab0ee8fa60be0457

Globally, the burden of deaths and illness is still unacceptably high at the day of birth. Annually, approximately 300.000 women die related to childbirth, 2.7 million babies die within their first month of life, and 2.6 million babies are stillborn. Many of these fatalities could be avoided by basic, but prompt care, if birth attendants around the world had the necessary skills and competencies to manage life-threatening complications around the time of birth. Thus, the innovative Helping Babies Survive (HBS) and Helping Mothers Survive (HMS) programs emerged to meet the need for more practical, low-cost, and low-tech simulation-based training. This paper provides users of HBS and HMS programs a 10-point list of key implementation steps to create sustained impact, leading to increased survival of mothers and babies. The list evolved through an Utstein consensus process, involving a broad spectrum of international experts within the field, and can be used as a means to guide processes in low-resourced countries. Successful implementation of HBS and HMS training programs require country-led commitment, readiness, and follow-up to create local accountability and ownership. Each country has to identify its own gaps and define realistic service delivery standards and patient outcome goals depending on available financial resources for dissemination and sustainment.

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<![CDATA[Comparison of the Combined versus Conventional Apgar Scores in Predicting Adverse Neonatal Outcomes]]> https://www.researchpad.co/article/5989db43ab0ee8fa60bd77ca

Objectives

Assessing the value of the Combined-Apgar score in predicting neonatal mortality and morbidity compared to the Conventional-Apgar.

Methods

This prospective cohort study evaluated 942 neonates (166 very preterm, 233 near term, and 543 term) admitted to a tertiary referral hospital. At 1- and 5-minutes after delivery, the Conventional and Combined Apgar scores were recorded. The neonates were followed, and the following information was recorded: the occurrence of severe hyperbilirubinemia requiring medical intervention, the requirement for mechanical ventilation, the occurrence of intraventricular hemorrhage (IVH), and neonatal mortality.

Results

Before adjusting for the potential confounders, a low Conventional (<7) or Combined (<10) Apgar score at 5-minutes was associated with adverse neonatal outcomes. However, after adjustment for the gestational age, birth weight and the requirement for neonatal resuscitation in the delivery room, a depressed 5-minute Conventional-Apgar score lost its significant associations with all the measured adverse outcomes; after the adjustments, a low 5-minute Combined-Apgar score remained significantly associated with the requirement for mechanical ventilation (OR,18.61; 95%CI,6.75–51.29), IVH (OR,4.8; 95%CI,1.91–12.01), and neonatal mortality (OR,20.22; 95%CI,4.22–96.88). Additionally, using Receiver Operating Characteristics (ROC) curves, the area under the curve was higher for the Combined-Apgar than the Conventional-Apgar for the prediction of neonatal mortality and the measured morbidities among all the admitted neonates and their gestational age subgroups.

Conclusions

The newly proposed Combined-Apgar score can be a good predictor of neonatal mortality and morbidity in the admitted neonates, regardless of their gestational age and resuscitation status. It is also superior to the Conventional-Apgar in predicting adverse neonatal outcomes in very preterm, near term and term neonates.

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<![CDATA[Defining Optimal Head-Tilt Position of Resuscitation in Neonates and Young Infants Using Magnetic Resonance Imaging Data]]> https://www.researchpad.co/article/5989d9feab0ee8fa60b72f60

Head-tilt maneuver assists with achieving airway patency during resuscitation. However, the relationship between angle of head-tilt and airway patency has not been defined. Our objective was to define an optimal head-tilt position for airway patency in neonates (age: 0–28 days) and young infants (age: 29 days–4 months). We performed a retrospective study of head and neck magnetic resonance imaging (MRI) of neonates and infants to define the angle of head-tilt for airway patency. We excluded those with an artificial airway or an airway malformation. We defined head-tilt angle a priori as the angle between occipito-ophisthion line and ophisthion-C7 spinous process line on the sagittal MR images. We evaluated medical records for Hypoxic Ischemic Encephalopathy (HIE) and exposure to sedation during MRI. We analyzed MRI of head and neck regions of 63 children (53 neonates and 10 young infants). Of these 63 children, 17 had evidence of airway obstruction and 46 had a patent airway on MRI. Also, 16/63 had underlying HIE and 47/63 newborn infants had exposure to sedative medications during MRI. In spontaneously breathing and neurologically depressed newborn infants, the head-tilt angle (median ± SD) associated with patent airway (125.3° ± 11.9°) was significantly different from that of blocked airway (108.2° ± 17.1°) (Mann Whitney U-test, p = 0.0045). The logistic regression analysis showed that the proportion of patent airways progressively increased with an increasing head-tilt angle, with > 95% probability of a patent airway at head-tilt angle 144–150°.

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<![CDATA[Different effects of fluid loading with saline, gelatine, hydroxyethyl starch or albumin solutions on acid-base status in the critically ill]]> https://www.researchpad.co/article/5989db51ab0ee8fa60bdc2d4

Introduction

Fluid administration in critically ill patients may affect acid-base balance. However, the effect of the fluid type used for resuscitation on acid-base balance remains controversial.

Methods

We studied the effect of fluid resuscitation of normal saline and the colloids gelatine 4%, hydroxyethyl starch (HES) 6%, and albumin 5% on acid-base balance in 115 clinically hypovolemic critically ill patients during a 90 minute filling pressure-guided fluid challenge by a post-hoc analysis of a prospective randomized clinical trial.

Results

About 1700 mL was infused per patient in the saline and 1500 mL in each of the colloid groups (P<0.001). Overall, fluid loading slightly decreased pH (P<0.001) and there was no intergroup difference. This mildly metabolic acidifying effect was caused by a small increase in chloride concentration and decrease in strong ion difference in the saline- and HES-, and an increase in (uncorrected) anion gap in gelatine- and albumin-loaded patients, independent of lactate concentrations.

Conclusion

In clinically hypovolemic, critically ill patients, fluid resuscitation by only 1500–1700 mL of normal saline, gelatine, HES or albumin, resulted in a small decrease in pH, irrespective of the type of fluid used. Therefore, a progressive metabolic acidosis, even with increased anion gap, should not be erroneously attributed to insufficient fluid resuscitation.

Trial registration

ISRCTN Registry ISRCTN19023197

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