Resuscitation Treatment Research Articles

Abstract Su906: Patient and Arrest Characteristics Associated with Rearrest and Mortality Following Out of Hospital Cardiac Arrest

Background: Cardiac rearrest post-return of spontaneous circulation (ROSC) is a critical concern in emergency care, as it is associated with worse outcomes. Patient characteristics and arrest factors associated with rearrest remain poorly understood, making predicting rearrest after out of hospital cardiac arrest (OHCA) challenging. Aim: To examine rearrest patterns, identify patient-specific risk factors for rearrest, and assess the impact of rearrest on patient outcomes. Hypothesis: Patients that experience rearrest after OHCA will have greater cardiac comorbidities, unfavorable arrest characteristics, and greater mortality. Methods: We performed an observational single-site clinical trial of consecutive adult EMS OHCA patients with ROSC (1/01/2018 to 3/31/24). EMS reports, continuous EMS ECG recordings, and electronic health records were analyzed to determine rearrest occurrence at any time during EMS and ED care. Patient demographics, comorbidities, and arrest/rearrest characteristics were determined. The primary outcome was survival at 6 months. Statistical significance was determined using Chi-square and logistic regression (LR) analyses. Results: We examined 344 patients with OHCA and ROSC, of whom 173 patients rearrested and 171 did not. Patients experiencing rearrest were older (p<0.003) and more likely to be female (p<0.013). They were also more likely to have ED resuscitation medications and interventions (epinephrine, amiodarone, lidocaine, defibrillation, all p<0.001) and a higher incidence of underlying cardiovascular comorbidities, including HTN and CAD (p<0.03). Notably, PEA and asystole were the most common rearrest rhythms, and time from arrest to ROSC was greater (30±16 vs. 25±15 min, p<0.007) in rearrest patients vs. those who did not rearrest. Patients with rearrest were less likely to receive TTM (p<0.003) and importantly, had higher rates of in-hospital and six-month mortality (both p<0.001). In a LR model, no rearrest (OR 2.4, 1.1-5.2), shockable arrest rhythm (OR 9.3, 4-22), female sex (OR 3.3, 1.6-6.5), and therapeutic hypothermia (OR 3.3, 1.7-6.4), were associated with survival (all p<0.04). Conclusions: Rearrest is independently associated with mortality. Increased age, male sex, and underlying cardiac comorbidities were associated with rearrest. Patient and arrest characteristics may predict rearrest. Improved understanding of why these factors promote rearrest will be important to prevent rearrest to enhance OHCA outcomes.

Comparison of resuscitation intervention utilization in the emergency department by palliative care eligible patients between cancer and non-cancer

Resuscitation interventions are procedures for managing clinical deterioration in patients with life-threatening conditions by securing the airway, maintaining breathing, or supporting circulation. Little is known about differences in the use of resuscitation interventions and the characteristics of patients eligible for palliative care in the emergency department. The objectives of this study are to compare resuscitation interventions in the emergency department between patients with cancer and non-cancer palliative care eligibility. A retrospective cohort study was conducted by reviewing the medical records of the palliative care eligible patients who visited the emergency department of one university hospital between January and June 2019. Among the 956 visits (13.7%) by palliative care eligible patients of 7000 random visits, 480 were patients with cancer (50.2%), and 476 were non-cancer patients (49.8%). The overall median age was 72, and 54.1% were female. The mortality rates in the following year were 35.0% for patients with cancer and 18.7% for non-cancer illnesses. The patients with cancer and non-cancer received prior palliative care at 7.3% and 0.8% (p < 0.001) and initiated palliative care at the emergency department at 6.3% and 2.7%, respectively (p = 0.008). The non-cancer patients utilized overall resuscitation interventions 1.7 times more than the cancer patients (aOR = 1.7, 95% CI = 1.0–2.6, p = 0.030). For the palliative care eligible patients in the emergency department, patients with cancer and non-cancer significantly differed in their characteristics. Patients with non-cancer received more resuscitation interventions than patients with cancer.

An ovine septic shock model of live bacterial infusion

BackgroundEscherichia coli is the most common cause of human bloodstream infections and bacterial sepsis/septic shock. However, translation of preclinical septic shock resuscitative therapies remains limited mainly due to low-fidelity of available models in mimicking clinical illness. To overcome the translational barrier, we sought to replicate sepsis complexity by creating an acutely critically-ill preclinical bacterial septic shock model undergoing active 48-h intensive care management.AimTo develop a clinically relevant large-animal (ovine) live-bacterial infusion model for septic shock.MethodsSeptic shock was induced by intravenous infusion of the live antibiotic resistant extra-intestinal pathogenic E. coli sequence type 131 strain EC958 in eight anesthetised and mechanically ventilated sheep. A bacterial dose range of 2 × 105–2 × 109 cfu/mL was used for the dose optimisation phase (n = 4) and upon dose confirmation the model was developed (n = 5). Post-shock the animals underwent an early-vasopressor and volume-restriction resuscitation strategy with active haemodynamic management and monitoring over 48 h. Serial blood samples were collected for testing of pro-inflammatory (IL-6, IL-8, VEGFA) and anti-inflammatory (IL-10) cytokines and hyaluronan assay to assess endothelial integrity. Tissue samples were collected for histopathology and transmission electron microscopy.ResultsThe 2 × 107 cfu/mL bacterial dose led to a reproducible distributive shock within a pre-determined 12-h period. Five sheep were used to demonstrate consistency of the model. Bacterial infusion led to development of septic shock in all animals. The baseline mean arterial blood pressure reduced from a median of 91 mmHg (71, 102) to 50 mmHg (48, 57) (p = 0.004) and lactate levels increased from a median of 0.5 mM (0.3, 0.8) to 2.1 mM (2.0, 2.3) (p = 0.02) post-shock. The baseline median hyaluronan levels increased significantly from 25 ng/mL (18, 86) to 168 ng/mL (86, 569), p = 0.05 but not the median vasopressor dependency index which increased within 1 h of resuscitation from zero to 0.39 mmHg−1 (0.06, 5.13), p = 0.065, and. Over the 48 h, there was a significant decrease in the systemic vascular resistance index (F = 7.46, p = 0.01) and increase in the pro-inflammatory cytokines [IL-6 (F = 8.90, p = 0.02), IL-8 (F = 5.28, p = 0.03), and VEGFA (F = 6.47, p = 0.02)].ConclusionsThis critically ill large-animal model was consistent in reproducing septic shock and will be applied in investigating advanced resuscitation and therapeutic interventions.

72 Hospital level of service, rural-urban hospital location, and neonatal resuscitation interventions at birth: A population-based study in Alberta, Canada from 2000-2020

Abstract Background Advanced neonatal resuscitation interventions (ANRIs: endotracheal intubation, chest compressions, and epinephrine) are rarely needed for infants born at ≥34 weeks gestational age (GA). However, healthcare providers (HCPs) in community hospitals can encounter the need for ANRIs, while having less experience and resources than HCPs in centers with neonatal intensive care units (NICUs). Understanding practice differences between hospitals of different levels of service (LofS) and rural/urban location can inform quality improvement to reduce health disparities. Objectives To examine how hospital level of service and rural/urban location relate to ANRI rates in Alberta, Canada, a universal public health system with standardized Neonatal Resuscitation Program (NRP) training. Design/Methods All live births ≥34 weeks GA in Alberta from 2000-2020 inclusive were examined using retrospective, population-level administrative data from the Alberta Perinatal Health Program (APHP). Hospitals (n=97) were contacted to determine annual LofS during the study period, with levels (0,1A/B/C,2,3) based on provincial obstetrical triage for availability of delivery support, cesarean-sections, obstetricians, paediatricians/neonatologists, and NICUs. Hospitals were further subcategorized by population and proximity to metropolitan centers.(Table 1) Rates of individual interventions or any ANRI were compared. Results There were 971,403 live births during the study period with a mean GA of 38.9 weeks; 1.6% were missing ANRI data, 955,835 births were included. Most occurred in hospitals with level 2 (57.4%) or level 3 (21.8%) NICUs; few occurred at sites with no delivery support (Level 0, 0.1%). ANRI rates were intubation (0.8%), chest compression (0.2%), and epinephrine (0.02%), any ANRI (0.96%, ~1/1000 live births). However, chest compression rates progressively decrease, and intubation rates progressively increase as LofS increases.(Table 1, Figure 1) When considering rural/urban location, there were outliers in chest compression rates in remote 0 (25.4/1000 live births) and metro-influenced 1A (30.2/1000 live births), intubation in remote 1C (33.3/1000 live births) and metro 0 (193.5/1000 live births) and epinephrine in metro 0 (64.5/1000 live births). Conclusion In this population-based cohort study of ≥34 weeks births, there were higher chest compressions rates and lower intubations rates at hospitals without NICUs despite standardized training. Reasons for this difference require further investigation; potential solutions such as targeted outreach education and introduction of laryngeal mask airways could be explored.

Early prehospital mechanical cardiopulmonary resuscitation use for out-of-hospital cardiac arrest: an observational study

BackgroundThe use of mechanical cardiopulmonary resuscitation device has been very prevalent in out-of-hospital cardiac arrest rescue. This study aimed to investigate whether the timing of mechanical cardiopulmonary resuscitation device set-up correlated with the the outcome of cardiac arrest patients.MethodsWe retrospectively reviewed adult nontrauma cardiac arrest cases in New Taipei City, Taiwan, from January to December 2022. Demographic data, intervention-related factors, and the time variables of mechanical cardiopulmonary resuscitation were collected. The outcomes included the return of spontaneous circulation and 24-hour survival. We compared patients who achieved spontaneous circulation and those who did not with univariate and multivariable regression analyses.ResultsIn total, 1680 patients who received mechanical cardiopulmonary resuscitation were included in the analysis. Reducing the time interval from manual chest compression initiation to device setup was independently associated with the return of spontaneous circulation and 24-hour survival, especially in the subgroup of patients of initial shockable rhythm. Receiver operating characteristic analysis revealed that the outcome of patients with an initial shockable rhythm could be predicted by the mechanical cardiopulmonary resuscitation setup time, with areas under the curve of 60.8% and 63.9% for ROSC and 24-hour survival, respectively. The cutoff point was 395.5 s for patients with an initial shockable rhythm.ConclusionA positive correlation was found between early mechanical cardiopulmonary resuscitation intervention and the outcomes of out-of-hospital cardiac arrest patients. The time between manual chest compression and device setup could predict the return of spontaneous circulation and 24-hour survival in the subgroup of patients with initially shockable rhythm with the optimal cutoff point at 395.5 s.

The Association of Time to Key Prehospital Interventions Recorded by EMT-Worn video Devices and Sustained Return of Spontaneous Circulation in Out-of-Hospital Cardiac Arrest

Objectives The quality of prehospital resuscitation provided by emergency medical technicians (EMTs) is essential to ensure better outcomes following out-of-hospital cardiac arrests (OHCA). We assessed the quality of prehospital resuscitation by recording time to key prehospital interventions using EMT-worn video devices and investigated its association with outcomes of patients with OHCA. Methods This retrospective, cross-sectional study included cases of non-traumatic OHCA in adults treated by emergency medical services (EMS) in Hsinchu City, Taiwan, during 2022 and 2023. We used data from high-resolution, chest-mounted wearable cameras to define and measure six quality indices (QIs) for prehospital resuscitation interventions (i.e., time spent recognizing OHCA). To evaluate the association between QI performance and sustained return of spontaneous circulation (ROSC), we used multivariable logistic regression. Results Of 745 patients eligible for this study, 187 (25.1%) achieved sustained ROSC. Six core QIs were analyzed: recognition of OHCA (median time: 9.0 s), time from recognizing OHCA to initiating cardiopulmonary resuscitation (cardiopulmonary resuscitation [CPR]; 9.0 s), automated external defibrillator setup (34.0 s), time from recognizing OHCA to beginning ventilation (160.0 s), advanced airway management (300 s), and deploying a mechanical CPR device (50 s). The performance of the six QIs were not associated with sustained ROSC (Adjusted odds ratio [95% confidence interval]: 1.00 [0.99–1.00], 0.99 [0.98–1.00], 1.00 [1.00–1.01], 1.00 [1.00–1.00], 1.00 [1.00–1.00], and 0.99 [0.99–1.00], respectively). Conclusions This study describes the rate of sustained ROSC and time to key interventions captured by EMT-worn video devices in non-traumatic OHCA patients. Although we found no direct link between QI performance and improved OHCA outcomes, this study highlights the potential of video-assisted QIs to enhance the documentation and understanding of prehospital resuscitation processes. These findings suggest that further refinement and application of these QIs could support more effective resuscitation strategies and training programs.

International collaboration as a turning point for sudden cardiac arrest prediction and treatment: the PARQ COST Action

International collaboration as a turning point for sudden cardiac arrest prediction and treatment: the PARQ COST Action PARQ aims to create a network of researchers across Europe whose overall aim is to reduce the societal burden of sudden cardiac arrest (SCA). To reach this aim, PARQ will conduct studies that focus on two dimensions: (1) prevention of SCA through the discovery of its inherited, acquired, and environmental causes, and their interaction, and improved recognition of individuals at risk; and (2) improvement of survival chances after SCA through the development and implementation of resuscitation treatments in the community.

Delivery room resuscitation and short-term outcomes in very preterm infants: a multicenter cross-sectional study in China.

To explore the risk factors of delivery room (DR) resuscitation and assess the association of DR resuscitation with neonatal outcomes in very preterm infants (VPIs). A multicenter retrospective cross-sectional study included VPIs with gestational age (GA) <32 weeks born between January, 2022 and June, 2023 and admitted to neonatal intensive care units of six tertiary hospitals in Shenzhen within 24 h after birth. They were divided into routine care group, positive-pressure ventilation (PPV) group, and endotracheal intubation (ETT) group based on the highest intensity of resuscitation received at birth. The association of antepartum and intrapartum risk factors and short-term outcomes with the intensity of DR resuscitation was evaluated. Of 683 infants included in this study, 170 (24.9%) received routine care, 260 (38.1%) received bag and mask ventilation or T-piece ventilation and 253 (37%) received ETT. Among the antepartum and intrapartum factors, exposure to antenatal steroids (ANS) decreased the likelihood of ETT. Increasing GA decreased the likelihood of receiving a higher level of DR resuscitation. Among the neonatal outcomes, increasing intensity of DR resuscitation was associated with a raise in the risk of Bronchopulmonary dysplasia. Higher levels of DR resuscitation were associated with the risk of early-onset sepsis. ETT was significantly associated with an increased risk of death. Among VPIs, low GA and no ANS use increased the risk of high-intensity DR resuscitation interventions; and those who receiving ETT were associated with an increased risk of adverse clinical outcomes.

Changes in out-of-hospital cardiac arrest resuscitation quality during and after the COVID-19 pandemic

AimThe impact of personal protective equipment (PPE) on resuscitation quality is largely unknown. We sought to examine the effect of PPE requirements on CPR quality and resuscitation interventions during the COVID-19 pandemic in Victoria, Australia. MethodsWe performed a retrospective cohort study of adult OHCA patients of medical aetiology who received attempted resuscitation. The study consisted of three periods; a pre-COVID-19 period (1st March 2019 to 15th March 2020), the COVID-19 period (16th March 2020 to 12th October 2022) and a post-COVID-19 period (13th October 2022 to 30th June 2023). Multivariable quantile and logistic regression were used to examine changes in CPR metrics and time to resuscitation interventions across the three periods ResultsWe included 8,956 patients (2,389 pre-COVID-19, 4,935 during COVID-19 and 1,632 post-COVID-19). A number of CPR quality metrics deteriorated during the COVID-19 period compared to the pre-COVID-19 period, including: chest compression fraction (median difference [MD] −0.81 percentage points; 95% CI −1.07,-0.56), release velocity (MD −5.26 mm per second; 95% CI −9.79, −0.72) and resuscitation duration (MD −2.2 min; 95% CI −3.39, −1.05). The COVID-19 period was also associated with longer post-shock pauses (MD 0.22 s; 95% CI 0.05, 0.38), and a reduction in the risk-adjusted odds of receiving adrenaline administration within 5 mins (AOR 0.72, 95% CI 0.63 – 0.82) and laryngeal mask insertion within 10 mins of arrival (AOR 0.83, 95% CI 0.74 – 0.94). These factors, with the exception of resuscitation duration and time to larygeal mask insertion, remained significantly different from baseline for the post-COVID-19 period. ConclusionSeveral CPR quality metrics declined during the COVID-19 period and some remain below pre-pandemic levels. Further research is needed to understand these impacts on OHCA outcomes.

Improving Advanced Care Planning: Documentation of DNA CPR Orders and TEPs in Residential Care Admissions

Abstract Background Do Not Attempt Cardiopulmonary Resuscitation (DNA CPR) orders and Treatment Escalation Plans (TEPs) are key components of advanced care planning for managing patients with progressive life-limiting illnesses and significant frailty. Our study aimed to determine the proportion of such patients being transferred from residential care facilities with documented TEPs upon medical admission, examine whether these TEPs were revised during the hospital stay, and assess patient outcomes at 14 days post-presentation. Methods We reviewed the lists of patients who had been referred for medical admission via the emergency department over a one-month period and identified those presenting from residential care facilities. We excluded those under the age of 65. We reviewed relevant medical notes and collected anonymised data into an Excel spreadsheet on a password protected computer. Results We identified 34 patient’s relevant patients. Notes were available for review in 31 cases (17 male; age range 66 to 96 years old, mean age 82.3). Of the 31 cases reviewed, the mean Clinical Frailty Score was 7.4. Residential care facilities sent documentation outlining TEPs in 19/31 cases. In those cases, 4/19 specified full resuscitation. In 3/4 of these cases, the TEP was revised during their admission. In one case, documentation specified that the patient did not want to be transferred to hospital under any circumstances. A total of 14 patients had no documentation regarding TEP. Of those, 7/14 went on to have DNA CPR orders filled out during their admission. At 14 days post presentation, 7 had died in hospital, 16 were discharged back to their residential care facility, and the remainder remained inpatient. Conclusion These findings underscore the need for better advance care planning, potentially improving patient management and reducing the emotional burden on patients, healthcare providers and families during critical moments.

Anesthesia-related Complications in General Surgery: Strategies for Prevention and Management

Background: Anesthesia-related complications in general surgery remain a significant concern despite advances in anesthetic techniques. These complications can lead to increased morbidity and mortality if not effectively managed. This study aimed to evaluate the incidence, prevention, and management of anesthesia-related complications in a tertiary care hospital in Bangladesh. Methods: A prospective observational study was conducted on 60 patients who underwent general surgery at the Department of Anesthesia, Analgesia, and Intensive Care Medicine, BSMMU, Dhaka, from 2022 to 2023. Demographic data, anesthesia-related complications, preventive measures, and management strategies were recorded and analyzed. Results: Cardiovascular complications were the most common, with hypotension in 11.7% and arrhythmias in 6.7% of patients. Respiratory complications, including hypoxemia and bronchospasm, occurred in 13.3% and 5% of cases, respectively. Neurological complications, such as postoperative delirium, were observed in 10% of patients. Preventive strategies, including fluid preloading, bronchodilators, and antiemetic prophylaxis, were effective in reducing the incidence of complications. All cases of hypotension, hypoxemia, postoperative nausea and vomiting (PONV), and arrhythmias were successfully managed with standard interventions, achieving a 100% success rate. Conclusion: This study demonstrates that anesthesia-related complications can be effectively managed through vigilant perioperative care and established management protocols. Cardiovascular and respiratory complications were the most common, and prompt interventions such as fluid resuscitation, oxygen therapy, and pharmacological treatment ensured favorable outcomes. Future studies with larger sample sizes and multicenter settings are recommended to further validate these findings and optimize anesthesia practices in diverse healthcare environments.

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.

Firearm injuries in Edmonton: A decade of experience

Background: Firearms cause severe injuries that require a large amount of healthcare resources. In Canada, few studies describe the incidence and outcomes of gun violence treated in our trauma centers. Objective: From trauma registry data, we describe the demographic, social, and medical characteristics of patients presenting to the hospital with gunshot wounds. In particular, we describe their injury severity, resuscitative interventions, hospitalizations, and outcomes. Results: From 2012 to 2022, Edmonton’s two trauma centers saw 367 patients injured by firearms, predominately young males. Assault was a more common intent for injury (76%) than self-harm, accident, or law enforcement (16%, 6%, and 2%, respectively). Handguns were the most common weapon identified. Resuscitative procedures for these patients were common, including endotracheal intubation, chest decompression, and blood administration. Overall mortality was 24% with most deaths occurring on the first day. In those who survived beyond that, hospitalization duration averaged 21 days. Only 53% were discharged to routine self-care. Conclusion: Gun violence is an uncommon presentation in Edmonton’s trauma centers. Healthcare resource utilization is expected to be high, especially on the first day.

Source Control and Antibiotics in Intra-Abdominal Infections.

Intra-abdominal infections (IAIs) account for a major cause of morbidity and mortality, representing the second most common sepsis-related death with a hospital mortality of 23-38%. Prompt identification of sepsis source, appropriate resuscitation, and early treatment with the shortest delay possible are the cornerstones of management of IAIs and are associated with a more favorable clinical outcome. The aim of source control is to reduce microbial load by removing the infection source and it is achievable by using a wide range of procedures, such as definitive surgical removal of anatomic infectious foci, percutaneous drainage and toilette of infected collections, decompression, and debridement of infected and necrotic tissue or device removal, providing for the restoration of anatomy and function. Damage control surgery may be an option in selected septic patients. Intra-abdominal infections can be classified as uncomplicated or complicated causing localized or diffuse peritonitis. Early clinical evaluation is mandatory in order to optimize diagnostic testing and establish a therapeutic plan. Prognostic scores could serve as helpful tools in medical settings for evaluating both the seriousness and future outlook of a condition. The patient's conditions and the potential progression of the disease determine when to initiate source control. Patients can be classified into three groups based on disease severity, the origin of infection, and the patient's overall physical health, as well as any existing comorbidities. In recent decades, antibiotic resistance has become a global health threat caused by inappropriate antibiotic regimens, inadequate control measures, and infection prevention. The sepsis prevention and infection control protocols combined with optimizing antibiotic administration are crucial to improve outcome and should be encouraged in surgical departments. Antibiotic and antifungal regimens in patients with IAIs should be based on the resistance epidemiology, clinical conditions, and risk for multidrug resistance (MDR) and Candida spp. infections. Several challenges still exist regarding the effectiveness, timing, and patient stratification, as well as the procedures for source control. Antibiotic choice, optimal dosing, and duration of therapy are essential to achieve the best treatment. Promoting standard of care in the management of IAIs improves clinical outcomes worldwide. Further trials and stronger evidence are required to achieve optimal management with the least morbidity in the clinical care of critically ill patients with intra-abdominal sepsis.

Advantages of a Data-Capture System with Video to Record Neonatal Resuscitation Interventions

To assess the completeness and accuracy of neonatal resuscitation documentation the electronic medical record (EMR) compared with a data-capture system including video. Retrospective observational study of 226 infants assessed for resuscitation at birth between April 2019 and October 2021 at Sharp Mary Birch Hospital, San Diego. Completeness was defined as the presence of documented resuscitative interventions in the EMR. We assessed the timing and frequency of interventions to determine the accuracy of the EMR documentation using video recordings as an objective record for comparison. Inaccuracy of EMR documentation was scored as missing (not documented), under-reported, or over-reported. Overall, the completeness of resuscitation interventions documented in the EMR was high (85%-100%), but the accuracy of documentation varied between 39% and 100% Modes of respiratory support were accurately captured in 96%-100% of the EMRs. Time to successful intubation (39%) and maximum fraction of inspired oxygen (47%) were the least accurately documented interventions in the EMR. Under-reporting of interventions with several events (eg, number of positive pressure ventilation events and intubation attempts) were also common errors in the EMR. The self-reported modes of respiratory support were accurately documented in the EMR, whereas the timing of interventions was inaccurate when compared with video recordings. The use of a video-capture system in the delivery room provided a more objective record of the timing of specific interventions during neonatal resuscitations.

Detection of time of birth and cord clamping using thermal video in the delivery room.

Newborn resuscitation algorithms emphasize that resuscitation is time-critical, and all algorithm steps are related to the time of birth. Infrared thermal video has the potential to capture events in the delivery room, such as birth, cord clamping, and resuscitative interventions, while upholding the privacy of patients and healthcare providers. The objectives of this concept study were to (i) investigate the technical feasibility of using thermal video in the delivery room to detect birth and cord clamping, and (ii) evaluate the accuracy of manual real-time registrations of the time of birth and cord clamping by comparing it with the accuracy of registrations abstracted from thermal videos. An observational study with data collected at Stavanger University Hospital, Norway, from September 2022 to August 2023. The time of birth and cord clamping were manually registered on a portable tablet by healthcare providers. Thermal cameras were placed in the delivery rooms and operating theatre to capture births. Videos were retrospectively reviewed to determine the time of birth and cord clamping. Participation consent was obtained from 306 mothers, of which 195 births occurred in delivery rooms or an operating theatre with a thermal camera installed. We excluded 12 videos in which no births occurred. Births were detectable in all 183 (100%) thermal videos evaluated. There was a median (quartiles) of 1.8 (0.7, 5.4) s deviation in the manual registrations of the times of births relative to those abstracted from thermal videos. Cord clamping was detectable in 173 of the 183 (95%) thermal videos, with a median of 18.3 (3.3, 108) s deviation in the manual registrations of the times of cord clampings relative to those abstracted from thermal videos. Recognizing the time of birth and cord clamping from thermal videos is technically feasible and provides a method for determining when resuscitative events occur.

Apelin-13 administration allows for norepinephrine sparing in a rat model of cecal ligation and puncture-induced septic shock

BackgroundInfusion of exogenous catecholamines (i.e., norepinephrine [NE] and dobutamine) is a recommended treatment for septic shock with myocardial dysfunction. However, sustained catecholamine infusion is linked to cardiac toxicity and impaired responsiveness. Several pre-clinical and clinical studies have investigated the use of alternative vasopressors in the treatment of septic shock, with limited benefits and generally no effect on mortality. Apelin-13 (APL-13) is an endogenous positive inotrope and vasoactive peptide and has been demonstrated cardioprotective with vasomodulator and sparing life effects in animal models of septic shock. A primary objective of this study was to evaluate the NE-sparing effect of APL-13 infusion in an experimental sepsis-induced hypotension.MethodsFor this goal, sepsis was induced by cecal ligation and puncture (CLP) in male rats and the arterial blood pressure (BP) monitored continuously via a carotid catheter. Monitoring, fluid resuscitation and experimental treatments were performed on conscious animals. Based on pilot assays, normal saline fluid resuscitation (2.5 mL/Kg/h) was initiated 3 h post-CLP and maintained up to the endpoint. Thus, titrated doses of NE, with or without fixed-doses of APL-13 or the apelin receptor antagonist F13A co-infusion were started when 20% decrease of systolic BP (SBP) from baseline was achieved, to restore SBP values ≥ 115 ± 1.5 mmHg (baseline average ± SEM).ResultsA reduction in mean NE dose was observed with APL-13 but not F13A co-infusion at pre-determined treatment time of 4.5 ± 0.5 h (17.37 ± 1.74 µg/Kg/h [APL-13] vs. 25.64 ± 2.61 µg/Kg/h [Control NE] vs. 28.60 ± 4.79 µg/Kg/min [F13A], P = 0.0491). A 60% decrease in NE infusion rate over time was observed with APL-13 co-infusion, (p = 0.008 vs NE alone), while F13A co-infusion increased the NE infusion rate over time by 218% (p = 0.003 vs NE + APL-13). Associated improvements in cardiac function are likely mediated by (i) enhanced left ventricular end-diastolic volume (0.18 ± 0.02 mL [Control NE] vs. 0.30 ± 0.03 mL [APL-13], P = 0.0051), stroke volume (0.11 ± 0.01 mL [Control NE] vs. 0.21 ± 0.01 mL [APL-13], P < 0.001) and cardiac output (67.57 ± 8.63 mL/min [Control NE] vs. 112.20 ± 8.53 mL/min [APL-13], P = 0.0036), and (ii) a reduced effective arterial elastance (920.6 ± 81.4 mmHg/mL/min [Control NE] vs. 497.633.44 mmHg/mL/min. [APL-13], P = 0.0002). APL-13 administration was also associated with a decrease in lactate levels compared to animals only receiving NE (7.08 ± 0.40 [Control NE] vs. 4.78 ± 0.60 [APL-13], P < 0.01).ConclusionAPL-13 exhibits NE-sparing benefits in the treatment of sepsis-induced shock, potentially reducing deleterious effects of prolonged exogenous catecholamine administration.

Exploration of alive-and-ventilator free days as an outcome measure for clinical trials of Resuscitative interventions.

Outcome selection is a critically important aspect of clinical trial design. Alive-and-ventilator free days is an outcome measure commonly used in critical care clinical trials, but has not been fully explored in resuscitation science. A simulation study was performed to explore approaches to the definition and analysis of alive-and-ventilator free days in cardiac arrest populations. Data from an in-hospital cardiac arrest observational cohort and from the Pragmatic Airway Resuscitation Trial were used to inform and conduct the simulations and validate approaches to alive-and-ventilator free days measurement and analysis. Alive-and-ventilator-free days is a flexible outcome measure in cardiac arrest populations. An approach to alive-and-ventilator free days that assigns -1 days when return of spontaneous circulation is not achieved provides a wider distribution of the outcome and improves statistical power. The optimal approach to the analysis of alive-and-ventilator free days varies based on the expected impact of the intervention under study on rates of return of spontaneous circulation, survival, and ventilator-free survival. Alive-and-ventilator free days adds to the armamentarium of clinical trialists in the field of resuscitation science.

Dependent contrast layering sign on CT in patients irrespective of cardiac dysfunction and its clinical implications: A preliminary retrospective study

Purpose: CT findings of contrast layering in dependent areas of the central venous system and solid organs have been reported in the literature to be associated with imminent cardiac arrest. However, no systematic research has explored the association of this distinctive CT finding with cardiac arrest and mortality. Therefore, we investigated the radiological manifestations of dependent layering of contrast in various vascular structures and organs and its clinical implications. Methods: A computerized search of radiological database was conducted using keywords “layering contrast” between January 2008 and January 2022. After reviewing CT scans of 226 patients that met the keyword criteria, 21 patients who exhibited the dependent contrast layering sign (DCLS) in vascular structures and organs were included in the final study population. Clinical data such as cardiac arrest within 2 hours, in-hospital mortality, and shock index ≥ 0.9 were collected. Number of involved structures in each patient is also investigated. Statistical significance and frequency regarding the association between radiologic findings and clinical data were analyzed. Results: The distribution of DCLS across anatomical structures reveals IVC is involved in 90.5% of patients and followed by hepatic vein (80.9%), liver parenchyma and right atrium. Cardiac arrest within 2 hours is significantly more common in patients with DCLS in right atrium (p=0.02, odds ratio = 21.6) and liver parenchyma (p=0.01, odds ratio = 24.8). DCLS in liver parenchyma is associated with the highest rate of in-hospital mortality (4 of 7, 57.1%). The total number of involved structures (p=0.01) and the number of common structures (p=0.001) are significantly higher in patients with cardiac arrest within 2 hours. Conclusions: The presence of DCLS in the right atrium and liver, as well as the larger number of involved structures, are significantly associated with impending cardiac arrest. Thus, it may offer additional insights for both radiologists and clinicians and aid in prompt initiation of resuscitative interventions before the onset of cardiac arrest. Nevertheless, larger prospective studies are warranted to validate the clinical relevance of DCLS across various vascular structures and organs.

Consensus recommendations for acute trauma care & outcomes in LMICs from the transdisciplinary research, advocacy & implementation network for trauma in India.

Background & objectives Injuries profoundly impact global health, with substantial deaths and disabilities, especially in low- and middle-income countries (LMICs). This paper presents strategic consensus from the Transdisciplinary Research, Advocacy, and Implementation Network for Trauma in India (TRAIN Trauma India) symposium, advocating for enhanced, system-level trauma care to address this challenge. Methods Five working groups conducted separate literature reviews on pre-hospital trauma care, in-hospital trauma resuscitation and training, trauma systems, trauma registries, and India's Towards Improving Trauma Care Outcomes (TITCO) registry. Using a Delphi approach, the TRAIN Trauma India Symposium generated consensus statements and recommendations for interventions to streamline trauma care and reduce preventable trauma mortality in India and LMICs. Experts prioritized interventions based on cost and difficulty. Results An expert panel agreed on four pre-hospital consensus statements, eight hospital resuscitation consensus statements, six system-level consensus statements, and six trauma registry consensus statements. The expert panel recommended six pre-hospital interventions, four hospital resuscitation interventions, nine system-level interventions, and seven trauma registry interventions applicable to the Indian context. Of these, 14 interventions were ranked as low cost/low difficulty, five high cost/low difficulty, five low cost/high difficulty, and three high cost/high difficulty. Interpretation & conclusions This consensus underscores the urgent need for integrated and efficient trauma systems to reduce preventable mortality, emphasizing the importance of comprehensive care that includes community engagement and robust pre-hospital and acute hospital trauma care pathways. It highlights the critical role of inclusive, system-wide approaches, from enhancing pre-hospital care and in-hospital resuscitation to implementing effective trauma registries to improve outcomes and streamline care across contexts.