Resuscitation Period Research Articles

Quantifying the benefit of whole blood on mortality in trauma patients requiring emergent laparotomy.

Whole blood (WB) transfusions in trauma represent an increasingly utilized resuscitation strategy in trauma patients. Previous reports suggest a probable mortality benefit with incorporating WB into massive transfusion protocols. However, questions surrounding optimal WB practices persist. We sought to assess the association between the proportion of WB transfused during the initial resuscitative period and its impact on early mortality outcomes for traumatically injured patients. We performed a retrospective analysis of severely injured patients requiring emergent laparotomy and ≥3 units of red blood cell containing products (WB or packed red blood cells) within the first hour from an ACS Level I Trauma Center (2019-2022). Patients were evaluated based on the proportion of WB they received compared with packed red blood cells during their initial resuscitation (high ratio cohort ≥50% WB vs. low ratio cohort <50% WB). Multilevel Bayesian regression analyses were performed to calculate the posterior probabilities and risk ratios (RR) associated with a WB predominant resuscitation for early mortality outcomes. Two hundred sixty-six patients were analyzed (81% male; mean age, 36 years; 61% penetrating injury; mean Injury Severity Score, 30). The mortality was 11% at 4 hours and 14% at 24 hours. The high ratio cohort demonstrated a 99% (RR, 0.12; 95% credible interval, 0.02-0.53) and 99% (RR, 0.22; 95% credible interval, 0.08-0.65) probability of decreased mortality at 4 hours and 24 hours, respectively, compared the low ratio cohort. There was a 94% and 88% probability of at least a 50% mortality relative risk reduction associated with the WB predominate strategy at 4 hours and 24 hours, respectively. Preferential transfusion of WB during the initial resuscitation demonstrated a 99% probability of being superior to component predominant resuscitations with regards to 4-hour and 24-hour mortality suggesting that WB predominant resuscitations may be superior for improving early mortality. Prospective, randomized trials should be sought. Therapeutic/Care Management; Level IV.

Longer preoperative fluid resuscitation decreased anesthetic fluid interventions in 297 dogs undergoing surgery for gastrointestinal foreign body obstruction.

The objectives were to (1) compare the impact of preoperative fluid resuscitation on anesthetic parameters and interventions and (2) assess the impact of preoperative resuscitation duration on the integrity of intestinal tissue and postoperative complications in dogs with gastrointestinal foreign body obstruction. Medical records from 1 academic hospital were reviewed for 297 client-owned dogs that underwent gastrointestinal foreign body obstruction surgery between May 2017 and August 2022. Data collected included the following: signalment, preoperative fluid resuscitation, surgical findings, anesthetic parameters and interventions, postoperative complications, and timing of the first meal. Variables for preoperative length of fluid resuscitation (hours), total preoperative fluid bolus (mL/kg), and preoperative fluid rate (mL/kg/d) were changed to categorical variables. Associations between anesthetic interventions, postoperative outcomes, preoperative fluid resuscitation length, and total fluid bolus were assessed with ordered logistic regression. Shorter preoperative fluid resuscitation length was associated with higher anesthetic fluid rates (P = .033) and fluid boluses performed (P = .023). Increased total volume of preoperative fluid boluses was associated with anesthetic synthetic colloid use (P = .028). There was insufficient evidence to claim an association between the impact of preoperative fluid resuscitation length and intestinal wall compromise (perforation, P = .912; enterectomy performed, P = .711). Shorter preoperative fluid resuscitation was associated with increased anesthetic fluid interventions but not the need for more complex surgeries. Longer fluid resuscitation periods are associated with fewer anesthetic interventions in dogs.

Pediatric safety profile of low titer O whole blood with increasing Anti-A and Anti-B titers

Abstract Objectives To add additional evidence to the safety of using low-titer O whole blood (LTOWB) in the massively hemorrhaging pediatric population, even with increasing allowance of anti-A and anti-B titers, up to 200. Methods A retrospective review from December 2021 to March 2023 of the blood bank and surgical massive transfusion protocols was performed with IRB approval to identify patients less than 18 years old who had received LTOWB as part of trauma resuscitation. In addition to patient characteristics, volume of LTOWB and other components were assessed, as well as Day 1-3 of serum potassium, creatinine, and total bilirubin. Wilcoxon rank-sum tests were performed to compare continuous variables and Fisher’s exact tests were performed to compare categorical variables between group O blood groups patients and non-O blood group patients. Results Only ten patients were identified under 18 years of age who had received LTOWB during trauma resuscitation, with five being blood group O and five non-O. Patient characteristics were similar between the two groups; however, only 10% were female and 10% self-reported as Black or African American. Age in the non-O group was 15 +/- 3.0 and 16.2 +/- 1.3 in the O group, p=0.75. Weight was 56.16 kg +/- 7.17 in the non-O group and 64.02+/- 14.23 in the O group, p=0.35. LTOWB transfused was 10.46 mL/kg +/- 2.42 in the non-O group and 10.32 +/- 6.53 in the O group, p=0.25. Potassium, creatinine, and total bilirubin were similar on Days 1-3 in both groups, except a single high total bilirubin in the non-O group, and this value normalized on Day 3. Conclusion A small data set was extracted from the available massive transfusion protocol data, reflecting the small amount of pediatric patients requiring massive transfusion for trauma compared to adults. Moreover, the predominance of males requiring massive transfusion for trauma corresponds with general trauma trends in the United States. These data reflect and are similar to previous safety reviews of pediatric trauma patients receiving LTOWB. This retrospective review records, however, a time period when the titer of anti-A and anti-B had been relaxed to 200 (rather than 50 in previous studies). This study, although small, reflects an additional Level I trauma site delivering LTOWB at potentially higher titers without negative sequelae in potassium, creatinine, or total bilirubin. With upcoming randomized controlled trials, such as Massive Transfusion in Children (MATIC-2), these data continue to reassure that the practice of using LTOWB is likely safe during the resuscitation period.

The effect of using low dose norepinephrine before hypotensive resuscitation in hemorrhagic shock; a randomized controlled trial

Background &amp; Objectives: Hemorrhagic shock is not a very rare occurrence in big hospitals. It might be encountered in the emergency room (ER) or in the operating rooms (OR). A rapid response and systematic management will save the life of the victim. The objective of this research was to investigate the impact of a low dose of norepinephrine (NE) administered prior to the initiation of hypotensive resuscitation in patients with hemorrhagic shock. Methodology: This randomized controlled trial was conducted on 200 participants, at least 18 years old, classified as severely traumatized and had significant hemorrhage with mean arterial pressure ranging from 65 to 75 mmHg. We divided the patients into two equal groups. Group I received a low dose of NE (&lt; 0.3 µg/kg/min) concurrently with resuscitation fluids. Group II received resuscitative fluids only. If the resuscitative fluids failed to keep mean arterial pressure (MAP) &gt; 65 mmHg, the patient was progressively administered NE even with high doses (0.05 to more than 0.3 µg/kg/min). The primary outcome was 24-hour mortality. In-hospital mortality, incidence of acute kidney injury (AKI), and duration of hospital and intensive care unit (ICU) stay constituted the secondary outcomes. Results: Group I had lower 24-hour mortality compared to Group II (3% vs 13%; P &lt; 0.05). Compared to Group II, Group I needed reduced amount of fluid resuscitation within 24 h, had lower serum lactate levels at 6 and 12 h, and lower serum creatinine at 6, 12, and 18 h (P &lt; 0.001). Group I had a lower incidence of mechanical ventilation (13% vs 27%), hospital and ICU stays, and in-hospital mortality (9% vs 21%) (P &lt; 0.05). There was a lack of disparity seen in the incidence of AKI and duration of mechanical ventilation. Conclusion: Low-dose norepinephrine infusion during the early period of hypotensive resuscitation reduces resuscitative fluid requirement, improves tissue perfusion, preserves renal function, and lowers mortality in hemorrhagic shock patients. Abbreviations: AKI - acute kidney injury; APACHE III - Acute Physiology And Chronic Health Evaluation III; HS - hemorrhagic shock; ICU - intensive care unit; MAP - mean arterial pressure; NE - Norepinephrine Keywords: Hemorrhagic Shock; Hypotensive Resuscitation; Norepinephrine; Fluid Therapy; Renal Protection; Mortality; Low Dose Citation: Mohamed RM, Anwar AG, Eid AA. The effect of using low dose norepinephrine before hypotensive resuscitation in hemorrhagic shock; a randomized controlled trial. Anaesth. pain intensive care 2024;28(5):914−921; DOI: 10.35975/apic.v28i5.2560 Received: April 17, 2024; Reviewed: August 03, 2024; Accepted: September 04, 2024

Capillary Refill Time as a Part of Routine Physical Examination in Critically Ill Patients Undergoing Vasoactive Therapy: A Prospective Study.

Background/Objectives: In critically ill patients, achieving a mean arterial pressure (MAP) of 65 mmHg is a recommended resuscitation goal to ensure proper tissue oxygenation. Unfortunately, some patients do not benefit from providing such a value, suggesting that other indices are needed for better hemodynamic assessment. Capillary refill time (CRT) has emerged as an established marker for peripheral perfusion and a therapeutic target in critical illness, but its relationship with other exponents of hypoperfusion during vasopressor support after resuscitation period still warrants further research. This study aimed to investigate whether in critically ill patients after initial resuscitation, CRT would provide information independent of other, readily accessible hemodynamic variables. Methods: Critically ill patients who were mechanically ventilated after the resuscitation period and receiving vasopressors were prospectively studied between December 2022 and June 2023. Vasopressor support was measured using norepinephrine equivalent doses (NEDs). CRT, MAP and NED were assessed simultaneously and analyzed using Spearman's rank correlation. Results: A total of 92 patients were included and 210 combined MAP-CRT-NED-Lactate records were obtained. There was no correlation between CRT and MAP (R = -0.1, p = 0.14) or lactate (R = 0.11, p = 0.13), but there was a positive weak correlation between CRT and NED (R = 0.25, p = 0.0005). In patients with hypotension, in 83% of cases (15/18), CRT was within normal range, despite different doses of catecholamines. When assessing patients with high catecholamine doses, in 58% cases (11/19), CRT was normal and MAP was usually above 65 mmHg. Conclusions: Capillary refill time provides additional hemodynamic information that is not highly related with the values of mean arterial pressure, lactate level and vasopressor doses. It could be incorporated into routine physical examination in critically ill patients who are beyond initial resuscitation.

Fibrinolytic Dysfunction and Endotheliopathy After Major Thermal Injury: Considerations Needed for New Approaches to Burn Shock Resuscitation.

In recent years, it has become apparent that fibrinolytic dysfunction and endotheliopathy develop in up to 40% of patients during the first hours following thermal injury and are associated with poor outcomes and increased resuscitation requirements. Rapidly following burn injury, the fibrinolytic system is activated, with activation generally greater with increased severity of injury. Very high plasma concentrations of plasmin-antiplasmin complex (marker of activation), have been associated with mortality. Patients display hyperfibrinolytic, physiologic/normal or hypofibrinolytic/fibrinolytic shutdown phenotypes, as assessed by viscoelastic assay. Phenotypes change in over 50% of patients during the acute burn resuscitation period, with some patterns (maladaptive) associated with increased mortality risk and others (adaptive, trending toward the physiologic phenotype) associated with survival. Endotheliopathy, as reflected in elevated plasma concentrations of syndecan-1 has also been associated with increased mortality. Here we review the incidence and effects of these responses after burn injury and explore mechanisms and potential interactions with the early inflammatory response. Available data from burn and non-burn trauma suggest that the fibrinolytic, endothelial, and inflammatory systems interact extensively and that dysregulation in one may exacerbate dysregulation in the others. This raises the possibility that successful treatment of one may favorably impact the others.

Impact of routine extracorporeal cardiopulmonary resuscitation service on the availability of donor organs

In refractory cardiac arrest, extracorporeal cardiopulmonary resuscitation may increase the survival chance. However, in cases of unsuccessful treatment, extracorporeal cardiopulmonary resuscitation may additionally provide an important source of organ donors. Therefore, we hypothesized that implementing extracorporeal cardiopulmonary resuscitation service into a high-volume cardiac arrest center's routine would increases organ donors' availability. MethodsOur retrospective observational study analyzed out-of-hospital cardiac arrest patients admitted to the General University Hospital in Prague between 2007 and 2020.The following groups were analyzed regarding the recruitment of donors: before and after extracorporeal cardiopulmonary resuscitation implementation. We assessed the number of donors referred, the number of organs harvested, and the organ's survival. ResultsWe analyzed the results of 1158 patients after out-of-hospital cardiac arrest. In the conventional approach period, 11 donors were referred, of which seven were accepted. During the extracorporeal cardiopulmonary resuscitation period, the number of donors increased to 80, of whom 42 were accepted. The number of donated organs was 18 and 119 in the respective periods, corresponding to 3.6 vs. 13.2 (p = 0.033) harvested organs per year. One-year survival of transplanted organs was 94.4% vs. 99.2%, and five-year survival was 94.4% vs. 95.9% in relevant periods. Conventional and extracorporeal cardiopulmonary resuscitation did not affect donor organ survival. ConclusionEstablishing a high-volume cardiac arrest centre providing an extracorporeal cardiopulmonary resuscitation service may increase not only the number of prolonged cardiac arrest survivors but also the number of organ donors. In addition, the performances of donated organs were high and comparable between both treatment methods.

Early Vasopressor Requirement Among Hypotensive Trauma Patients: Does It Cause More Harm Than Good?

Optimal utilization of vasopressors during early post-injury resuscitation remains unclear. Our study aims to describe the relationship between the timing of vasopressor administration and outcomes among hypotensive trauma patients. This was a retrospective analysis of the 2017-2018 ACS-TQIP database. We included adult (≥18years) trauma patients presenting with hypotension (lowest SBP <90mmHg) who received vasopressors within 6hours of admission. We excluded patients who had a severe head injury (Head-AIS >3) and those with spinal cord injury (Spine-AIS >3). Patients were stratified based on the time to receive vasopressors. Multivariable regression analyses were performed to identify the independent association between timing of vasopressor initiation and outcomes. 1049 patients were identified. Mean age was 55 ± 20years, and 70% of patients were male. The median ISS was 16 [9-24], 80% had a blunt injury, and the mean SBP was 61 ± 24mmHg. The median time to first vasopressor administration was 319 [68-352] minutes. Overall, 24-hour and in-hospital mortality rates were 19% and 33%, respectively. Every one-hour delay in vasopressor administration beyond the first hour was independently associated with decreased odds of 24-hour mortality (aOR: 0.65, P < 0.001), in-hospital mortality (aOR: 0.65, P < 0.001), major complications (aOR: 0.77, P = 0.003), and increased odds of longer ICU LOS (β + 2.53, P = 0.012). There were no associations between the timing of early vasopressor administration and 24-hour PRBC transfusion requirements (P > 0.05). Earlier vasopressor requirement among hypotensive trauma patients was independently associated with increased mortality and major complications. Further research on the utility and optimal timing of vasopressors during the post-injury resuscitative period is warranted. III therapeutic/care management.

The impact of inhalation injury on fluid resuscitation in major burn patients: a 10-year multicenter retrospective study

BackgroundIt remains unclear whether additional fluid supplementation is necessary during the acute resuscitation period for patients with combined inhalational injury (INHI) under the guidance of the Third Military Medical University (TMMU) protocol.MethodsA 10-year multicenter, retrospective cohort study, involved patients with burns ≥ 50% total burn surface area (TBSA) was conducted. The effect of INHI, INHI severity, and tracheotomy on the fluid management in burn patients was assessed. Cumulative fluid administration, cumulative urine output, and cumulative fluid retention within 72 h were collected and systematically analyzed.ResultsA total of 108 patients were included in the analysis, 85 with concomitant INHI and 23 with thermal burn alone. There was no significant difference in total fluid administration during the 72-h post-burn between the INHI and non-INHI groups. Although no difference in the urine output and fluid retention was shown in the first 24 h, the INHI group had a significantly lower cumulative urine output and a higher cumulative fluid retention in the 48-h and 72-h post-burn (all p < 0.05). In addition, patients with severe INHI exhibited a significantly elevated incidence of complications (Pneumonia, 47.0% vs. 11.8%, p = 0.012), (AKI, 23.5% vs. 2.9%, p = 0.037). For patients with combined INHI, neither the severity of INHI nor the presence of a tracheotomy had any significant influence on fluid management during the acute resuscitation period.ConclusionsAdditional fluid administration may be unnecessary in major burn patients with INHI under the guidance of the TMMU protocol.

Oxygen in the neonatal ICU: a complicated history and where are we now?

Despite major advances in neonatal care, oxygen remains the most commonly used medication in the neonatal intensive care unit (NICU). Supplemental oxygen can be life-saving for term and preterm neonates in the resuscitation period and beyond, however use of oxygen in the neonatal period must be judicious as there can be toxic effects. Newborns experience substantial hemodynamic changes at birth, rapid energy consumption, and decreased antioxidant capacity, which requires a delicate balance of sufficient oxygen while mitigating reactive oxygen species causing oxidative stress. In this review, we will discuss the physiology of neonates in relation to hypoxia and hyperoxic injury, the history of supplemental oxygen in the delivery room and beyond, supporting clinical research guiding trends for oxygen therapy in neonatal care, current practices, and future directions.

Abstract 3093: Can Inhibiting Ferroptosis And Subsequent Endothelial Glycocalyx Shedding Reduce The Morbidity And Mortality Of Hemorrhagic Shock?

Background: Trauma patients with hemorrhagic shock accounts for 40% of preventable death. Shock-induced endotheliopathy has garnered interest recently and one aspect of this, endothelial glycocalyx shedding, has shown to promote coagulopathy following hemorrhage. Ferroptosis is an iron dependent, non-apoptotic form of controlled cell death triggered by the oxidation of membrane phospholipids. Liproxstatin-1 (LPX1) is an inhibitor of this process and can protect against oxidative damage to the endothelial cell membrane and subsequent shedding of glycocalyx. We hypothesized that LPX1 would reduce endothelial glycocalyx damage in hemorrhagic shock. Methods: A rat model of hemorrhagic shock and resuscitation was used to assess glycocalyx disruption in the lungs via fluorescent-labeled wheat germ agglutinin staining in frozen tissue and by Syndecan-1 ELISA on plasma samples. A control group (n=5) resuscitated only with Lactated Ringer’s solution, following hemorrhage and resuscitation (H/R) was compared against an experimental group (n=5) that received LPX1 following hemorrhage and before resuscitation. Results: Glycocalyx shedding (assessed by an increase in plasma Syndecan-1 levels) was prevented in the LPX1 treated group compared to control group. Lung tissue staining of the glycocalyx also showed a greater glycocalyx level in the LPX1 group than in the control (40.4 vs 36.3 arbitrary units). Additionally, LPX1 treated animals were able to sustain a higher mean arterial pressure (82 vs 45mmHg), and oxygen saturation throughout the resuscitation period measured at 15 and 30 minutes following LPX1 infusion (98.4% SpO2 vs. 99.0% SpO2 at 30 minutes resuscitation). Conclusions: Ferroptosis inhibitor LPX1 can reduce morbidity acutely during hemorrhagic shock and can protect the endothelial cell glycocalyx from oxidative damage due to its ability to slow the generation of reactive oxygen species and lipid hydroperoxides.

761 Transforming Fluid Resuscitation Documentation to Improve Quality Outcomes

Abstract Introduction Accurate and readily available documentation of burn fluid resuscitation is essential for decision-making by the multidisciplinary team during the first 24 to 48 hours of care. Fluid resuscitation documentation in the electronic medical record (EMR) is ideal. However, due to the limitations of the EMR, bedside nurses must navigate to various tabs to document fluids, view orders, document events, review labs, and notify providers. To decrease burden of care and improve the accessibility of accurate fluid resuscitation information, our multidisciplinary team embarked on a journey to create a new format in the EMR for fluid resuscitation with our information technology (IT) department. Methods In April 2022, the burn team initiated discussions to build a new and streamlined process for documentation of fluid resuscitation. The goal was to decrease the amount of navigation in the EMR during fluid resuscitation by the bedside nurse and improve the accessibility of meaningful hourly documentation for the multidisciplinary team. During monthly meetings, a multidisciplinary team of nurses, a pharmacist, educators, and IT professionals collaborated on each component needed to capture the desired detailed documentation of each fluid resuscitation. Results The new format for fluid resuscitation documentation in the EMR is constructed as a navigator flowsheet and initiated in September 2023. The bedside nurse performs all documentation on this one flowsheet. Information from the Lund-Browder calculates initial fluid resuscitation rates and goal hourly urine output. Once the bedside nurse initiates the fluid resuscitation, navigating to any additional flowsheets or tabs in the EMR is unnecessary. Certain information also pulls in automatically from devices, such as vitals, bladder pressure, and urine output. Documentation of hourly fluids infused, vital signs, urinary output, fluids changes, bedside procedures performed, provider notification, nursing notes, and consulting team interventions are all performed in the narrator. The bedside nurse can also access all orders, labs, and notes without navigating elsewhere in the EMR. Real-time documentation using the narrator allows multidisciplinary team access without disrupting the patient’s nursing care. The post-resuscitation report provides hour-by-hour documentation for debriefing and reviewing each fluid resuscitation. Conclusions The development of this new tool has afforded bedside nurses more time spent caring for the patient rather than navigating the EMR. Providers no longer go to the patient room to retrieve information to help guide fluid resuscitation and disrupt patient care. The post-resuscitation report provides an accurate account of the fluid resuscitation period for debriefing and review. Applicability of Research to Practice Our process can be shared with other burn centers hoping to replicate this process.

Preferential whole blood transfusion during the early resuscitation period is associated with decreased mortality and transfusion requirements in traumatically injured patients

IntroductionWhole blood (WB) transfusion represents a promising resuscitation strategy for trauma patients. However, a paucity of data surrounding the optimal incorporation of WB into resuscitation strategies persists. We hypothesized that...

Endovascular aortic occlusion improves return of spontaneous circulation after longer periods of cardiopulmonary resuscitation: A translational study in pigs

IntroductionResuscitative endovascular balloon occlusion of the aorta (REBOA) has emerged as an adjunct to CPR for nontraumatic cardiac arrest (NTCA). This translational study investigated the impact of varying low-flow duration (15- vs 30-mins) on REBOA's hemodynamic performance and ability to achieve return of spontaneous circulation (ROSC) in a porcine model. MethodsThirty-two pigs were anesthetized and placed into ventricular fibrillation. All animals received a 4-min no-flow period before CPR was initiated. Animals were randomized into four groups: 15- vs 30-minutes of CPR; REBOA vs. no-REBOA. After completion of 15- or 30-minute low-flow, ACLS was initiated and REBOA was inflated in experimental animals. ResultsIn the 15-mins groups, there were no differences in the rates of ROSC between REBOA (4/8, 50%) and control (4/8, 50%; p = 0.99). However, in the 30-min groups, the REBOA animals had a significantly higher rate of ROSC (6/8, 75%) compared to control (1/8, 12.5%; p = 0.04). In the 7-mins after REBOA deployment in the 30-min animals there was a statistically significant difference in coronary perfusion pressure (REBOA 42.1 mmHg, control 3.6 mmHg, p = 0.038). Importantly, 5/6 animals that obtained ROSC in the 30-min group with REBOA re-arrested at least once, with 3/6 maintaining ROSC until study completion. ConclusionIn our porcine model of NTCA, REBOA preferentially improved hemodynamics and ROSC after a 30-mins period of low-flow CPR. REBOA may be a viable strategy to improve ROSC after prolonged downtime, however, more hemodynamic support will be required to maintain ROSC.

The timing of death in burn patients.

When treating burn patients, some patients die in the chronic phase, even if they overcome the acute phase of the burn. To elucidate the timing of death and its underlying causes among burn patients. Patients evaluated were admitted to our burn center between January 2015, and December 2019. Patient information, time, and cause of death were retrospectively collected from their medical records. Among 342 admitted patients, 49 died. The time of death was as follows: within 24 h (n = 9), within 3 days (n = 7), within 1 week (n = 5), within 2 weeks (n = 4), within 3 weeks (n = 3), within 30 days (n = 6), within 60 days (n = 5), and after 60 days (n = 9). The causes of death within 3 days were hypoxic encephalopathy, extensive burns (>80%), severe heat stroke, and acute coronary syndrome. The causes of death after 3 days were sepsis, pneumonia, intestinal ischemia, pancreatitis, and worsening of chronic diseases. The mortality rate was similar for patients ≥65 years of age and those with a burn area of ≥20%, with both groups showing a particularly poor prognosis. The timing of death in hospitalized burn patients showed a bimodal distribution as approximately 40% of patients who survived the resuscitation period died after 30 days. Elderly patients were at particularly high risk for mortality. In burn care, treatment planning should consider not only the short-term but also the long-term prognosis.

Changes in coagulation factor XIII activity during resuscitation for hemorrhagic shock.

Little is known about the coagulation activity of factor XIII (FXIII) during resuscitation for hemorrhagic shock and the effects of plasma transfusions. We performed a single-center observational study to evaluate the changes in FXIII activity during resuscitation for hemorrhagic shock. Twenty-three adult patients with hemorrhagic shock were enrolled in this study. Blood samples were drawn upon arrival (T1), at the time of hemostasis completion (T2), and on day 2 (T3). Baseline and changes in FXIII activity and the proportion of patients with adequate levels of FXIII activity (FXIII activity >70%) were evaluated. The effects of plasma transfusion on these parameters were also investigated. At T1, the median (interquartile range) FXIII activity was 53% (47-85%), which did not increase (T1 vs. T3: 53% [47-85%] vs. 63% [52-70%], P=0.8766). The proportion of patients with adequate FXIII activity decreased throughout the resuscitation period (T1, T2, and T3: 30, 34, and 21%, respectively). Plasma transfusion did not affect FXIII activity (T1 vs. T2, 66.4% [23.4] vs. 70.0% [16.2%], P=0.3956; T2 vs. T3, 72.0% [19.5] vs. 63.5% [8.6%], P=0.1161) or the proportion of adequate levels of FXIII activity at 44% at T2 and 27% at T3. FXIII activity is low during the early phase of a hemorrhagic shock. Even with plasma transfusion, FXIII levels were not adequately maintained throughout resuscitation.

Determining Consensus Alignment and Barriers of Neonatal Thermal Management in Nepal Using a Modified Delphi Process.

Objective. Neonatal hypothermia is a worldwide health burden with an incidence ranging from 32% to 85% in hospitals and 11% to 92% in homebirths. It is prevalent in Nepal and associated with increased morbidity and mortality. The study objective was to identify key practice standards of newborn thermal management in Nepal. Methods. Our subjects included 6 lead newborn physicians from major birthing centers in Kathmandu. A modified Delphi process was used to identify the top 5 key practice standards for newborn thermoregulation in the hospital, health post, and home, compiled from 14 World Health Organization recommended practices. Results. There was consensus in all ranked practices except using radiant heat sources in the hospital and performing Kangaroo Mother Care in the homebirths. Comments conveyed that interventions during the immediate delivery phase were most impactful and feasible. Conclusion. Nepali physicians prioritized thermoregulatory practices during the immediate resuscitation period over the post-resuscitation period.

Orthopaedic Trauma and Anemia: Conservative versus Liberal Transfusion Strategy: A Prospective Randomized Study

OBJECTIVES: To determine whether it is safe to use a conservative packed red blood cell transfusion hemoglobin (Hgb) threshold (5.5 g/dL) compared with a liberal transfusion threshold (7.0 g/dL) for asymptomatic musculoskeletal injured trauma patients who are no longer in the initial resuscitative period. METHODS: Design: Prospective, randomized, multicenter trial. Setting: Three level 1 trauma centers. Patient Selection Criteria: Patients aged 18–50 with an associated musculoskeletal injury with Hgb less than 9 g/dL or expected drop below 9 g/dL with planned surgery who were stable and no longer being actively resuscitated were randomized once their Hgb dropped below 7 g/dL to a conservative transfusion threshold of 5.5 g/dL versus a liberal threshold of 7.0 g/dL. Outcome Measures and Comparisons: Postoperative infection, other post-operative complications and Musculoskeletal Functional Assessment scores obtained at baseline, 6 months, and 1 year were compared for liberal and conservative transfusion thresholds. RESULTS: Sixty-five patients completed 1 year follow-up. There was a significant association between a liberal transfusion strategy and higher rate of infection (P = 0.01), with no difference in functional outcomes at 6 months or 1 year. This study was adequately powered at 92% to detect a difference in superficial infection (7% for liberal group, 0% for conservative, P &lt; 0.01) but underpowered to detect a difference for deep infection (14% for liberal group, 6% for conservative group, P = 0.2). CONCLUSIONS: A conservative transfusion threshold of 5.5 g/dL in an asymptomatic young trauma patient with associated musculoskeletal injuries leads to a lower infection rate without an increase in adverse outcomes and no difference in functional outcomes at 6 months or 1 year. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Abstract 315: Endovascular Aortic Occlusion Preferentially Improves Hemodynamics and Return of Spontaneous Circulation After Longer Periods of Cardiopulmonary Resuscitation: A Translational Study in Swine

Introduction: Non-traumatic cardiac arrest (NTCA) is associated with low survival and substantial societal cost. Standard-of-care treatments, such as cardiopulmonary resuscitation (CPR) and advanced cardiac life support (ACLS), have limitations in restoring cardiac function and improving outcomes. Resuscitative endovascular balloon occlusion of the aorta (REBOA) has emerged as an adjunct to CPR for NTCA. However, the optimal patient population that will benefit most from REBOA remains uncertain. Goals: This translational study investigated the impact of varying low-flow duration (15- vs 30-mins) on REBOA's hemodynamic performance and ability to achieve return of spontaneous circulation (ROSC) in a swine model of NTCA. Methods: Thirty-two swine were anesthetized and placed into ventricular fibrillation. All animals received a 4-min “no-flow” period before mechanical CPR was initiated. Animals were randomized into four groups to receive: 1) 15- vs 30-minutes of CPR; 2) REBOA vs. no-REBOA (control). After completion of the 15- or 30-minute low-flow period, ACLS was initiated and REBOA was fully-inflated in experimental animals. Results: There were no differences in demographics or hemodynamics at baseline (T = -10-mins) or at randomization (T = +10-mins). In the 15-mins groups, there were no differences in the rates of ROSC between REBOA (4 / 8, 50%) and control (4 / 8, 50%; p = 0.99). However, in the 30-min group the REBOA animals had a significantly higher rate of ROSC (6 / 8, 75%) compared to control (1 / 8, 12.5%; p = 0.04). In the 7-mins (T = 34 - 41 mins) after REBOA deployment in the 30-min animals there was a statistically significant difference in diastolic blood pressure (repeated measures ANOVA; p = 0.027). Importantly, 5 / 6 (83%) animals that received ROSC in the 30-min group with REBOA re-arrested at least once with 3 / 6 (50%) maintaining ROSC until study completion. Conclusion: In our swine model of NTCA, REBOA preferentially improved hemodynamics and ROSC after a 30-mins period of low-flow CPR, compared to 15-mins of low-flow CPR. REBOA may be a viable strategy to improve ROSC after prolonged downtime. More hemodynamic support will be required to maintain ROSC. This has implications for patient selection in upcoming human trials of REBOA in NTCA.

Effect of no-flow period on the vasopressor effect of initial epinephrine administration in cardiac arrest

ObjectivesWhether a longer no-flow (NF) interval affects the magnitude of response to epinephrine in the resuscitation has not been well studied. Therefore, this study aimed to evaluate the effect of NF interval on the vasopressor effect of initial epinephrine administration in a porcine model. MethodsWe enrolled 20 pigs from two randomized porcine experimental studies using a ventricular fibrillation (VF) cardiac arrest model. The first experiment subjects were resuscitated after 4 min of NF (Short NF group), followed by three cycles (6 min) of chest compression using a mechanical cardiopulmonary resuscitation device before epinephrine administration. Second experiment subjects received 6 min of NF (Long NF group), two cycles (4 min) of chest compressions, and administration of epinephrine. Defibrillation for VF was delivered 8 and 10 min after VF induction in the Short NF and Long NF groups, respectively. The mean arterial pressure (MAP) and cerebral perfusion pressure (CePP) in the 2-min resuscitation period after epinephrine administration were compared between the study groups using the Wilcoxon rank-sum test. The mean differences in the parameters between phases were also compared. ResultsSeven pigs in the Short NF group and 13 pigs in the Long NF group were included in the analysis. All 2-min resuscitation phases from 6 to 16 min after VF induction were compared between the study groups. The Short NF group showed higher MAP and CePP in all phases (p < 0.01). Change of mean MAP after the epinephrine administration was significantly different between the study groups: mean difference (95% confidence interval) of 16.6 (15.8–17.4) mmHg in the Short NF group and 4.2 (3.9–4.5) mmHg in the Long NF group. ConclusionIn the porcine VF cardiac arrest model, 6 min of NF before resuscitation may affect the vasopressor effect of the initial epinephrine administered compared to 4 min of NF. A short NF may play a role in maximizing the effect of epinephrine in advanced cardiovascular life support.