Resuscitation Care Research Articles

2024 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces.

This is the eighth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations; a more comprehensive review was done in 2020. This latest summary addresses the most recent published resuscitation evidence reviewed by the International Liaison Committee on Resuscitation task force science experts. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the quality of the evidence, using Grading of Recommendations Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections. In addition, the task forces list priority knowledge gaps for further research.

2024 American Heart Association and American Academy of Pediatrics Focused Update on Special Circumstances: Resuscitation Following Drowning: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.

Drowning is the third leading cause of death from unintentional injury worldwide, accounting for 7% of all injury-related deaths. In the United States, drowning is the leading cause of death in children 1 to 4 years of age and second leading cause of death due to unintentional injury in those aged 5 to 14 years. Drowning generally progresses from initial respiratory arrest due to submersion-related hypoxia to cardiac arrest; thus, it can be challenging to distinguish respiratory arrest from cardiac arrest because pulses are difficult to accurately palpate within the recommended 10-second window. Therefore, resuscitation from cardiac arrest due to this specific circumstance must focus on restoring breathing as much as it does circulation. Resuscitation from drowning may begin with in-water rescue breathing when safely provided by rescuers trained in the technique and should continue with chest compressions, in keeping with basic life support guidelines, once the drowned individual and the rescuer are in a safe environment (eg, dry land, boat). This focused update incorporates systematic reviews from 2021 to 2023 performed by the International Liaison Committee on Resuscitation related to the resuscitation of drowning. These clinical guidelines are the product of a committee of experts representing the American Academy of Pediatrics and the American Heart Association. The writing group reviewed the recent International Liaison Committee on Resuscitation systematic reviews, including updated literature searches, prior guidelines related to resuscitation from cardiac arrest following drowning, and other drowning-related publications from the American Academy of Pediatrics and the American Heart Association. The writing group used these reviews to update its recommendations aimed at resuscitation from cardiac arrest following drowning in children.

2024 American Heart Association and American Academy of Pediatrics Focused Update on Special Circumstances: Resuscitation Following Drowning: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.

Drowning is the third leading cause of death from unintentional injury worldwide, accounting for 7% of all injury-related deaths. The World Health Organization estimates that there are ≈236 000 deaths due to drowning worldwide each year. Significant efforts have focused on creating systems to prevent drowning, but an average of 4000 fatal and 8000 nonfatal drownings still occur annually in the United States-likely an underestimate. Drowning generally progresses from initial respiratory arrest due to submersion-related hypoxia to cardiac arrest; thus, it can be challenging to distinguish respiratory arrest from cardiac arrest because pulses are difficult to accurately palpate within the recommended 10-second window. Therefore, resuscitation from cardiac arrest attributable to this specific circumstance must focus on restoring breathing as much as it does circulation. Resuscitation from drowning may begin with in-water rescue breathing when safely provided by rescuers trained in the technique and should continue with chest compressions, in keeping with basic life support guidelines, once the drowned individual and the rescuer are in a safe environment (eg, dry land, a boat). This focused update incorporates systematic reviews from 2021 to 2023 performed by the International Liaison Committee on Resuscitation related to the resuscitation of drowning. These clinical guidelines are the product of a committee of experts representing the American Heart Association and the American Academy of Pediatrics. The writing group reviewed the recent International Liaison Committee on Resuscitation systematic reviews, including updated literature searches, prior guidelines related to resuscitation from cardiac arrest following drowning, and other drowning-related publications from the American Heart Association and American Academy of Pediatrics. The writing group used these reviews to update its recommendations aimed at resuscitation of cardiac arrest following drowning in adults and children.

Comparison of direct and indirect admission to a cardiac arrest centre for intubated out-of-hospital cardiac arrest patients in the Northwest England: an audit

Abstract Background Despite concerted global efforts to enhance cardio-pulmonary resuscitation (CPR) and post-resuscitation care, out-of-hospital cardiac arrest (OHCA) remains a significant cause of mortality. Current guidelines promote the concept of Cardiac Arrest Center (CAC), offering advanced post-resuscitation management with the aim of improving survival rates. However, it remains uncertain whether directly transporting OHCA patients from the scene to these centers would enhance their prognosis. Purpose This study aimed to assess whether direct transport of intubated OHCA patients to a higher-level cardiac arrest center in the Northwest of England yielded better outcomes compared to initial resuscitation in smaller local emergency departments followed by transfer. Methods Conducted as a retrospective analysis, the audit examined OHCA patients presenting at a single cardiac arrest center between October 2018 and April 2022. Only intubated patients were included. The study compared two groups based on the route of admission: direct admission to the cardiac arrest center from the field by emergency medical service providers versus indirect admission via inter-hospital transfer to the center. The primary outcomes assessed were inpatient survival and 30-day survival. Statistical analysis employed Student's T-test and Chi-square test for clinical significance. Results The audit included 214 patients, with 112 (52.34%) in the direct group and 102 (47.66%) in the indirect group. Baseline characteristics between the groups were similar, including age, gender, downtime, bystander CPR, haemodynamic status, initial presenting rhythm (VT/VF), post-arrest ECG (STEMI), comorbidities, and procedural outcomes (Table 1). However, the direct group exhibited significantly shorter average arrival times at the cardiac arrest center (72 minutes vs. 190 minutes, p=0.017), along with improved in-hospital survival (52.68% vs. 41.18%, p=0.009) and 30-day survival rates (52.68% vs. 37.25%, p=0.002). Conclusion The direct admission of intubated OHCA patients to a cardiac arrest center, as observed in this audit, was associated with improved outcomes attributed to expedited admission times. The study’s design limitations, including its non-randomized nature and single-center approach, underscore the need for further research.

Influence of blood pressure targets on inflammation and associations between inflammatory markers and vasopressor usage after cardiac arrest - a substudy of a randomized clinical trial

Abstract Background Following resuscitation from cardiac arrest, a profound systemic inflammatory response may develop. In observational studies of critically ill patients an association between levels of inflammation and vasopressor usage has been found. Higher levels of inflammation may lead to higher vasopressor needs due to vasoplegia and cardiac dysfunction, however, catecholamines, including vasopressors also have immune modulatory effects. In the Blood Pressure and Oxygenation Targets in Post resuscitation Care (BOX) trial patients were randomized to a high or low blood pressure target, and vasopressor usage was increased in the high blood pressure target group. Therefore, the inflammatory response evoked by cardiac arrest, may have been altered by differences in vasopressor usage according to blood pressure target in this trial. Purpose To determine if differences in vasopressor and inotropy usage associated with randomization to a high compared to a low blood pressure target affects the inflammatory response after OHCA, and to investigate the association between inflammation and vasopressor and inotropy usage. Methods In the BOX trial, comatose OHCA patients with a presumed cardiac etiology were randomized to a blinded intervention of either a high (77mmHg) or a low blood pressure target (63mmHg). The inflammatory markers of leukocytes and CRP were measured at 0, 24, 48, and 72 hours. The average Vasoactive-Inotropic Score (VIS) was determined during initial 72 hours. The associations between average CRP, leukocytes, and VIS during initial 72 hours were determined by Spearman’s correlation analysis. Results The BOX trial included 789 resuscitated comatose OHCA patients, and 788 patients had at least 1 measurement of leukocytes and CRP. The median age was 64 (IQR 54-73), females constituted 19%, 1 year mortality was 36%. There was no difference in leukocytes and CRP at admission between the high and low blood pressure target groups (Figure 1). Leukocytes were slightly higher at 24 hours (p<0.01) in the high blood pressure target group, but no group differences were found at 48 and 72 hours, and CRP levels did not differ at 24, 48, or 72 hours. The average VIS was 19 (11-32) and 11 (5-19), p<0.01, in the two groups, with VIS being consistently higher at all timepoints beyond ICU admission (all p<0.01, data not shown) in patients with a high blood pressure target. Both average CRP and leukocytes were weakly correlated with average VIS at 0-72 hours for both blood pressure targets, r=0.17 and r=0.20, respectively for a high target (both p<0.01), and r=0.17 and r=0.20, respectively for a low target (both p<0.01). Conclusions In conclusion, increased vasopressor and inotropy usage in this randomized, blinded study of blood pressure targets after OHCA, did not lead to clinically relevant changes in inflammation. Inflammatory markers and VIS were correlated to a similar degree for both blood pressure targets.Figure 1, LeukocytesFigure 2, CRP

Fire at Sea: A 70-year Review of Fire-Related Mass Casualty Events on U.S. Aircraft Carriers.

A major fire at sea is among the most devastating events that can occur while a U.S. Navy combatant vessel is underway. Since World War II, no attack on a large U.S. Navy capital ship has occurred during combat operations. However, increasing global tensions raise the threat of future peer adversary naval combat, and shipboard medical caregivers must be prepared for mass casualty events in the deployed maritime environment. To better prepare modern naval caregivers for this possibility, we reviewed mass casualty events from major fires aboard large U.S. Navy aircraft carriers from 1950 through 2020 to summarize available objective data and identify lessons learned. Underway fires from any cause aboard U.S. Navy aircraft carriers and large amphibious assault ships causing more than 10 casualties (injuries + deaths) were reviewed from 1950 through 2020 using available open access sources including literature review, the Naval Safety Command mishap database, and U.S. Navy Judge Advocate Manual reports. Of 246 fires identified, 27 met inclusion criteria resulting in 1,634 casualties with a combined crew mortality of 23% of those injured. In the 16 events with at least 1 death, 2.0% of the total crew was injured with a combined mortality of 28%. All mishaps occurred while underway during routine training or combat operations; none were caused by an enemy combatant attack. Those events affecting more than 5% of the crew were particularly devastating resulting in a mortality rate of 29% of 1,056 total casualties. Given that main medical spaces may be damaged or destroyed during major fires from any cause, identified lessons learned included the need for (1) distributed medical supplies, (2) flexible medical treatment locations throughout the ship, (3) specific training to prepare non-physician caregivers and non-medical first responders to provide burn and hemorrhagic shock resuscitation, airway management, and prolonged care at or near the point of injury, and (4) the prolonged holding capability of critically ill burned and injured patients if evacuation off the ships is unavailable. Shipboard fires underway pose a significant threat to crew safety with a mortality of nearly a quarter of those injured. These fire mass casualty events immediately overwhelm shipboard medical capabilities requiring a complex response from all hands beginning with non-medical first responders. Notably, all events occurred outside of direct enemy combat, potentially underestimating the impact and number of casualties of a shipboard fire during naval combat. Advances in peer weaponry and the threat of future conflict emphasize the need for pre-deployment burn care training for all shipboard medical caregivers as well as advanced airway and resuscitation training for non-physician caregivers. This review underscores the profound impact of shipboard fires on crew safety, highlighting the critical need for enhanced preparedness and response strategies to prepare for fire-related mishaps during routine operations and naval combat.

66 Survival and school-age outcomes of extremely premature neonates with intraventricular hemorrhage

Abstract Background Extremely low gestational age (ELGA) neonates are at risk for intraventricular hemorrhage (IVH) and periventricular hemorrhagic infarction (PVHI). There is no clear consensus on the prognosis of these conditions. Objectives The aim of this study was to compare the survival, and the neurodevelopmental outcomes (NDO) at school-age for neonates with IVH and/or PVHI, to those without. Design/Methods This retrospective single-center study (2012-2017) included neonates less than 26 weeks gestational age (GA) who received resuscitation and early intensive care. Imaging data were collected from cranial US for the presence of IVH described by Papile grading. Survival was defined as survival to discharge. NDO were classified as no neurodevelopmental impairment (NDI), no NDI with multidisciplinary referrals, and the adverse outcome was defined as NDI at school-age. NDI included any diagnosis of cerebral palsy, global developmental delay, intellectual disability, visual or hearing impairment. Autism spectrum disorder (ASD) was included as an outcome of interest. Results 164 infants met inclusion criteria, of whom 156 survived resuscitation. Mean GA was 24 weeks and 6 days (SD 6 days) and mean birth weight 701g (SD 125g), grade I-II IVH was present in 43 (28%) infants, and grade III-IV IVH was present in 48 (31%) infants. Survival was 45% for those with bilateral grade III-IV IVH, 53% for unilateral grade III-IV IVH, 78% for bilateral grade I-II IVH, 80% for unilateral grade I-II IVH, and 81% for no IVH groups. 108 infants survived to discharge and 90 had complete follow up at school age. 30% of children had NDI and ASD was diagnosed in 12%. Logistic regression for adverse outcome demonstrated an adjusted odds-ratio (OR) 0.30 (95% CI 0.14, 0.56) for gestational age (p <0.001). The logistic regression resulted in adjusted OR 0.72 (95% CI 0.21, 2.37) for grade I-II IVH and OR 1.43 (95% CI 0.4, 5.03) for Grade III-IV IVH (p=0.63). Conclusion In neonates born ELGA, survival decreased with increasing severity of IVH. Decreasing GA, but not severity of IVH, was predictive of neurodevelopmental impairment. Extremely preterm infants born < 26 weeks are at high risk of NDI and of ASD.

2024 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces.

This is the eighth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations; a more comprehensive review was done in 2020. This latest summary addresses the most recent published resuscitation evidence reviewed by the International Liaison Committee on Resuscitation task force science experts. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the quality of the evidence, using Grading of Recommendations Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections. In addition, the task forces list priority knowledge gaps for further research.

Artificial intelligence and informatics in neonatal resuscitation

Neonatal intensive care unit resuscitative care continually evolves and increasingly relies on data. Data driven precision resuscitation care can be enabled by leveraging informatics tools and artificial intelligence. Despite technological advancements, these data are often underutilized due to suboptimal data capture, aggregation, and low adoption of artificial intelligence and analytic tools. This review describes the fundamentals and explores the evidence behind informatics and artificial intelligence tools supporting neonatal intensive care unit resuscitative care, training and education. Key findings include the need for effective interface design for accurate data capture followed by storage and translation to wisdom using analytics and artificial intelligence tools. This review addresses the issues of data privacy, bias, liability and ethical frameworks when adopting these tools. While these emerging technologies hold great promise to improve resuscitation, further study of these applications in neonatal population and awareness of informatics and artificial intelligence principles among clinicians is imperative.

Talking to Unconscious? - Therapeutic Communication During General Anaesthesia, Resuscitation and Therapy of Coma

There are numerous reports from patients concerning perceptions during deep unconsciousness, be it general anaesthesia, cardiopulmonary resuscitation or intensive care and coma treatment. These experiences can cause considerable traumatisation. The most stressful experience is apparently not feeling pain, but the lack of communication, i.e. being recognised and being able to express oneself. Although there are already indications of positive effects of positive communication during general anaesthesia, these findings have not yet markedly changed the way we deal with the unconscious.

Resuscitation education for NICU providers: Current practice and recommendations for NRP and PALS in the NICU

The Neonatal Resuscitation Program (NRP) is the most used resuscitation algorithm for infants requiring resuscitation in the neonatal intensive care unit (NICU). The population of infants cared for in the NICU is varied and complex with resuscitation needs that may extend beyond the NRP algorithm. To provide resuscitation care that addresses these needs, institutions may choose to incorporate algorithms from the Pediatric Advanced Life Support or a “hybrid” approach that includes NRP. Limited evidence exists to support one algorithm or approach over another. In this article, we identify potential gaps in the application of using NRP or PALS in the NICU population, present select patient decompensations and discuss the resuscitation management approach using the NRP or PALS algorithms. Challenges associated with NICU resuscitation education will be explored as well as approaches to overcome some of the identified resuscitation education obstacles.

337 Operational Effects of the Organic Implementation of an Emergency Department-Based Resuscitative Care Unit Model

337 Operational Effects of the Organic Implementation of an Emergency Department-Based Resuscitative Care Unit Model

Management of analgosedation during noninvasive respiratory support: an expert Delphi consensus document developed by the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI)

BackgroundDiscomfort can be the cause of noninvasive respiratory support (NRS) failure in up to 50% of treated patients. Several studies have shown how analgosedation during NRS can reduce the rate of delirium, endotracheal intubation, and hospital length of stay in patients with acute respiratory failure. The purpose of this project was to explore consensus on which medications are currently available as analgosedatives during NRS, which types of patients may benefit from analgosedation while on NRS, and which clinical settings might be appropriate for the implementation of analgosedation during NRS.MethodsThe Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI) selected a panel of experts and asked them to define key aspects of the use of analgesics and sedatives during NRS treatment. The methodology applied is in line with the principles of the modified Delphi and RAND-UCLA methods. The experts developed statements and supportive rationales which were then subjected to blind votes for consensus.ResultsThe use of an analgosedation strategy in adult patients with acute respiratory failure of different origins may be useful where there is a need to manage discomfort. This strategy should be considered after careful assessment of other potential factors associated with respiratory failure or inappropriate noninvasive respiratory support settings, which may, in turn, be responsible for NRS failure. Several drugs can be used, each of them specifically targeted to the main component of discomfort to treat. In addition, analgosedation during NRS treatment should always be combined with close cardiorespiratory monitoring in an appropriate clinical setting.ConclusionsThe use of analgosedation during NRS has been studied in several clinical trials. However, its successful application relies on a thorough understanding of the pharmacological aspects of the sedative drugs used, the clinical conditions for which NRS is applied, and a careful selection of the appropriate clinical setting.

Perioperative Management for Microvascular Free Tissue Transfer for Head and Neck Reconstruction – Commentary

Le et al. provided a comprehensive commentary on perioperative management for head and neck oncologic patients undergoing microvascular reconstructive surgery. This commentary is based on a detailed review and consensus statements from the Society for Head and Neck Anesthesia (SHANA), an international organization dedicated to enhancing perioperative care for these patients. The consensus statement, published in 2021 by Healy et al., addressed preoperative, intraoperative, and postoperative considerations to optimize clinical outcomes. It included 14 statements from 16 SHANA members across 11 institutions, following two rounds of literature reviews. The commentary emphasized the importance of preoperative nutrition optimization, tobacco cessation, and early recognition of alcohol withdrawal symptoms. In the intraoperative phase, key aspects such as airway management in cases of extensive tumor burden (including awake fiberoptic intubation and tracheostomy), fluid management, hemodynamic monitoring, and multimodal analgesia were briefly discussed. Notably, vasopressors can be used to optimize hemodynamic management without compromising flap perfusion. Additionally, careful fluid resuscitation is crucial to avoid fluid overload, which could increase the risk of flap failure. Multimodal pain management strategies were highlighted, including inhalational anesthetics, anti-inflammatories, narcotics, and regional anesthesia. In the postoperative period, effective communication between healthcare provider teams is essential. Airway management was linked to three of the five consensus statements, underscoring the need for clear and concise communication between the anesthesia and surgical teams. This includes coordinating ventilatory support weaning, extubation planning, and preparation for reintubation if necessary. Such measures help reduce intensive care unit (ICU) utilization, minimize airway-related adverse events, and shorten the length of hospitalization. Overall, the commentary hopes to serve as a guide for multidisciplinary head and neck oncology units across all international centers in managing this complex patient population.

Echocardiography in Cardiac Arrest: Incremental Diagnostic and Prognostic Role during Resuscitation Care.

Cardiac arrest (CA) is a life-critical condition. Patients who survive after CA go into a defined post-cardiac arrest syndrome (PCAS). In this clinical context, the role of the echocardiogram in recent years has become increasingly important to assess the causes of arrest, the prognosis, and any direct and indirect complications dependent on cardiopulmonary resuscitation (CPR) maneu-vers. We have conduct a narrative revision of literature. The aim of our review is to evaluate the increasingly important role of the transthoracic and transesophageal echocardiogram in the CA phase and especially post-arrest, analyzing the data already present in the literature. Transthoracic and transesophageal echocardiogram in the CA phase take on important diagnostic and prognostic role.

Divide and Save: A Critical Care Air Transport Team Case With Prolonged Field Care

ABSTRACT Critical care air transport teams (CCATTs) specialize in providing intensive medical and postoperative resuscitative care during air evacuations. In a 2014 mission, a seasoned CCATT was urgently deployed to evacuate 6 American service members with gunshot wounds. Despite only having 2 hours of premission preparation and no further injury or treatment details, CCATT secured additional equipment, medications, and blood supply. Upon arrival to a foreign nonmilitary hospital, they discovered that American ground commanders had lost trust in local medical capabilities. One patient experienced prolonged extremity tourniquet time and surgical delay. This led to acute renal failure, preventing immediate evacuation without continuous renal replacement therapy (CRRT). Deviating from the standard procedure, the CCATT obtained permission to split their team. The CCATT nurse attended 5 stabilized patients during unregulated critical care air transport with plans to swiftly return with CRRT equipment for the critical sixth patient. The physician and respiratory therapist remained at the foreign hospital for 2 days to provide prolonged field care. This case demonstrates the evolving mission scope of CCATT, which may encompass ground triage, prolonged field care, unregulated movement, and atypical CCATT equipment such as CRRT, occasionally necessitating a split team construct. To adapt to these evolving needs, updated policies and training now incorporate these diverse CCATT concepts, emphasizing the importance of flexibility in en route critical care missions.

Разработка системы управления конфликтами в отделении реанимации и интенсивной терапии многопрофильного стационара с помощью LEAN-технологий: пилотное исследование.

Objective: to develop and evaluate the effectiveness of a conflict management system using the example of the intensive care unit of a multidisciplinary hospital Materials and methods. The study was conducted on the basis of City Clinical Hospital No. 1 named after. N. I. Pirogov, resuscitation and intensive care units in 2023. The study included 74 department employees‑42 medical (34 male (80.9%) and 8 female (19.1%), and 47 nursing staff: 12 male (25.3%) and 35 female (74.5%). In order to identify the presence of conflict situations (incidents), their causes and factors provoking them, questionnaires were developed: questionnaire 1—initial assessment (input) and questionnaire 2—assessment of the results of the proposed conflict management model. analysis of operational activities, a Gantt chart was drawn up for medical and paramedical personnel, a comparative and statistical analysis of the results was performed and an algorithm for making management decisions was developed. Results. A tool for identifying conflict situations in a universal electronic form has been created. According to the survey results: conflicts do occur, they are regular, and the participants in the conflicts are department employees. The main cause of conflicts is the conditions of daily operating activities and non-compliance with ethical and deontological standards. Losses in the provision of medical care were identified and assessed: defects in the provision of medical care (defects); waiting is the time before the provision of medical services; untapped potential of employees; transport losses. An algorithm for managing conflicts and preventing future incidents has been developed and implemented. Conclusions. The study demonstrated the need for clear organization of operational activities; formation of protocols for improving professional competencies; formation of a motivational system; creation of an information analytical system for control and monitoring of current processes.

The Relationship between Pediatric Medical Training and Neonatal Care in the Delivery Room and Beyond.

The modern neonate differs greatly from newborns cared for a half-century ago, when the neonatal-perinatal medicine certification examination was first offered by the American Board of Pediatrics. Delivery room resuscitation and neonatal care are constantly evolving, as is the neonatal workforce. Similarly, the Accreditation Council for Graduate Medical Education review committees revise the requirements for graduate medical education programs every 10 years, and the modern pediatric medical trainee is also constantly evolving. Delivery room resuscitation, neonatal care, and pediatric residency training are codependent; changes in one affect the other and subsequently influence neonatal outcomes. In this educational perspective, we explore this relationship and outline strategies to mitigate the impact of decreased residency training in neonatal-perinatal medicine.

Neonatal Resuscitation and Delivery Room Care: A Changing Global Landscape.

With 98% of neonatal deaths occurring in low- and middle-income countries (LMICs), leading health organizations continue to focus on global reduction of neonatal mortality. The presence of a skilled clinician at delivery has been shown to decrease mortality. However, there remain significant barriers to training and maintaining clinician skills and ensuring that facility-specific resources are consistently available to deliver the most essential, evidence-based newborn care. The dynamic nature of resource availability poses an additional challenge for essential newborn care educators in LMICs. With increasing access to advanced neonatal resuscitation interventions (ie, airway devices, code medications, umbilical line placement), the international health-care community is tasked to consider how to best implement these practices safely and effectively in lower-resourced settings. Current educational training programs do not provide specific instructions on how to scale these advanced neonatal resuscitation training components to match available materials, staff proficiency, and system infrastructure. Individual facilities are often faced with adapting content for their local context and capabilities. In this review, we discuss considerations surrounding curriculum adaptation to meet the needs of a rapidly changing landscape of resource availability in LMICs to ensure safety, equity, scalability, and sustainability.

Association between measures of resuscitation in the critical care resuscitation unit and in-hospital mortality among patients with sepsis.

We hypothesized that lactate clearance and reduction of the Sequential Organ Failure Assessment (SOFA) score during patients' critical care resuscitation unit (CCRU) stay would be associated with lower in-hospital mortality. This was a retrospective study of adult patients who had sepsis diagnoses and were admitted to the CCRU in 2018. Multivariable logistic regression analysis was performed to assess the association of clinical factors, lactate clearance, and SOFA reduction with hospital mortality. A total of 401 patients with lactate clearance data and 455 patients with SOFA score data were included in the study. The mean (SD) lactate and SOFA score on admission were 2.2 (1.8) mmol/L and 4.4 (4.3), respectively. Average lactate clearance was 0.1 (2.6) mmol/L, and average SOFA score reduction was 0.65 (5.9). Patients with a one point reduction in SOFA score during their CCRU stay had a 31% reduction of mortality (odds ratio [OR] 0.69, 95% confidence interval [CI] 0.62-0.77, p<0.001). SOFA score reduction was associated with lower hospital mortality for both surgical patients (OR 0.69, 95% CI 0.58-0.81, p<0.001) and non-surgical patients (OR 0.71 95% CI 0.06-0.83, p<0.001). SOFA score reduction, but not lactate clearance during the CCRU stay, was associated with lower odds of in-hospital mortality. These findings suggest that resuscitative efforts leading to an early improvement in SOFA score may benefit patients with sepsis.