Resuscitation Treatment Research Articles

Resuscitation-associated endotheliopathy (RAsE): a conceptual framework based on a systematic review and meta-analysis

IntroductionShock-induced endotheliopathy (SHINE), defined as a profound sympathoadrenal hyperactivation in shock states leading to endothelial activation, glycocalyx damage, and eventual compromise of end-organ perfusion, was first described in 2017. The aggressive resuscitation therapies utilised in treating shock states could potentially lead to further worsening endothelial activation and end-organ dysfunction.ObjectiveThis study aimed to systematically review the literature on resuscitation-associated and resuscitation-induced endotheliopathy.MethodsA predetermined structured search of literature published over an 11-year and 6-month period (1 January 2011 to 31 July 2023) was performed in two indexed databases (PubMed/MEDLINE and Embase) per PRISMA guidelines. Inclusion was restricted to original studies published in English (or with English translation) reporting on endothelial dysfunction in critically ill human subjects undergoing resuscitation interventions. Reviews or studies conducted in animals were excluded. Qualitative synthesis of studies meeting the inclusion criteria was performed. Studies reporting comparable biomarkers of endothelial dysfunction post-resuscitation were included in the quantitative meta-analysis.ResultsThirty-two studies met the inclusion criteria and were included in the final qualitative synthesis. Most of these studies (47%) reported on a combination of mediators released from endothelial cells and biomarkers of glycocalyx breakdown, while only 22% reported on microvascular flow changes. Only ten individual studies were included in the quantitative meta-analysis based on the comparability of the parameters assessed. Eight studies measured syndecan-1, with a heterogeneity index, I2 = 75.85% (pooled effect size, mean = 0.27; 95% CI − 0.07 to 0.60; p = 0.12). Thrombomodulin was measured in four comparable studies (I2 = 78.93%; mean = 0.41; 95% CI − 0.10 to 0.92; p = 0.12). Three studies measured E-selectin (I2 = 50.29%; mean = − 0.15; 95% CI − 0.64 to 0.33; p = 0.53), and only two were comparable for the microvascular flow index, MFI (I2 = 0%; mean = − 0.80; 95% CI − 1.35 to − 0.26; p < 0.01).ConclusionResuscitation-associated endotheliopathy (RAsE) refers to worsening endothelial dysfunction resulting from acute resuscitative therapies administered in shock states. In the included studies, syndecan-1 had the highest frequency of assessment in the post-resuscitation period, and changes in concentrations showed a statistically significant effect of the resuscitation. There are inadequate data available in this area, and further research and standardisation of the ideal assessment and panel of biomarkers are urgently needed.

EGS P07 Upper GI Injury trends, rates, and mortality in major trauma centre

Abstract Background Trauma is one of the leading causes of death in UK. Moderate and severe trauma presents with multi-organ / multi cavity involvement. Robust resuscitation, methodical approach, prompt diagnosis and early surgical intervention have an impact on mortality. Injury severity score (ISS) is widely used across trauma centres to estimate severity. It is found to be linked with mortality and outcome. An ISS of 9-15 classes as moderate and an ISS of &amp;gt; 15 is considered severe trauma. In this study we aimed to evaluate the mortality associated with upper GI injuries I.e., oesophagus, stomach, duodenum, liver, pancreas, spleen and diaphragm. Methods Retrospective analysis was carried out on prospectively maintained trauma data base in an urban major trauma centre (MTC) with tertiary upper GI surgical cover. All patients presenting with moderate or severe trauma based on ISS between 1st of January 2012 to 31st of Dec 2022 were included in this study. Proportion of upper GI injuries in reference to overall major trauma cases were analysed. All cause index-admission mortality associated with upper GI injuries was calculated. Results A total of 8984 patients presented in this centre with moderate - severe trauma (ISS&amp;gt;9) during study period. Overall mortality was found to be 8.6% (n=780). Liver injuries were seen in 228 (2.5%), splenic injuries in 226 (2.5%), diaphragmatic rupture in 26 (0.29%), oesophago-gastric (OG) trauma in 16 (0.2%) and duodenum and pancreatic injuries in 15 (0.17%) patients. Highest mortality was found in OG trauma with 31.2%, followed by diaphragmatic injures with 19%, liver injuries with 12.7%, splenic injuries with 9.3%. Upper GI injuries are associated with high median ISS of 28.5 and present as polytrauma spectrum. Conclusions Although oesophago-gastric injuries are rare but, have relatively high mortality. Early aggressive resuscitation, involvement of oesophago-gastric or HPB surgeons, and multidisciplinary approach is required to deal with such complex injuries to get the best outcome. Robust national collaborative mechanisms across MTCs should be encouraged to share experiences, learn lessons and promote research.

Machine learning-based analysis of regional differences in out-of-hospital cardiopulmonary arrest outcomes and resuscitation interventions in Japan

Refining out-of-hospital cardiopulmonary arrest (OHCA) resuscitation protocols for local emergency practices is vital. The lack of comprehensive evaluation methods for individualized protocols impedes targeted improvements. Thus, we employed machine learning to assess emergency medical service (EMS) records for examining regional disparities in time reduction strategies. In this retrospective study, we examined Japanese EMS records and neurological outcomes from 2015 to 2020 using nationwide data. We included patients aged ≥ 18 years with cardiogenic OHCA and visualized EMS activity time variations across prefectures. A five-layer neural network generated a neurological outcome predictive model that was trained on 80% of the data and tested on the remaining 20%. We evaluated interventions associated with changes in prognosis by simulating these changes after adjusting for time factors, including EMS contact to hospital arrival and initial defibrillation or drug administration. The study encompassed 460,540 patients, with the model’s area under the curve and accuracy being 0.96 and 0.95, respectively. Reducing transport time and defibrillation improved outcomes universally, while combining transport time and drug administration showed varied efficacy. In conclusion, the association of emergency activity time with neurological outcomes varied across Japanese prefectures, suggesting the need to set targets for reducing activity time in localized emergency protocols.

Facilitators and barriers for implementation of a novel resuscitation quality improvement package in public referral hospitals of Nepal

BackgroundImproving the healthcare providers (HCP) basic resuscitation skills can reduce intrapartum related mortality in low- and middle-income countries. However, the resuscitation intervention’s successful implementation is largely dependent on proper facilitation and context. This study aims to identify the facilitators and barriers for the implementation of a novel resuscitation package as part of the quality improvement project in Nepal.MethodsThe study used a qualitative descriptive design. The study sites included four purposively chosen public hospitals in Nepal, where the resuscitation package (Helping Babies Breathe [HBB] training, resuscitation equipment and NeoBeat) had been implemented as part of the quality improvement project. Twenty members of the HCP, who were trained and exposed to the package, were selected through convenience sampling to participate in the study interviews. Data were collected through semi-structured interviews conducted via telephone and video calls. Twenty interview data were analyzed with a deductive qualitative content analysis based on the core components of the i-PARiHS framework.ResultsThe findings suggest that there was a move to more systematic resuscitation practices among the staff after the quality improvement project’s implementation. This positive change was supported by a neonatal heart rate monitor (NeoBeat), which guided resuscitation and made it easier. In addition, seeing the positive outcomes of successful resuscitation motivated the HCPs to keep practicing and developing their resuscitation skills. Facilitation by the project staff enabled the change. At the same time, facilitators provided extra support to maintain the equipment, which can be a challenge in terms of sustainability, after the project. Furthermore, a lack of additional resources, an unclear leadership role, and a lack of coordination between nurses and medical doctors were barriers to the implementation of the resuscitation package.ConclusionThe introduction of the resuscitation package, as well as the continuous capacity building of local multidisciplinary healthcare staff, is important to continue the accelerated efforts of improving newborn care. To secure sustainable change, facilitation during implementation should focus on exploring local resources to implement the resuscitation package sustainably.Trial RegistrationNot applicable.

Temporal trends in out-of-hospital cardiac arrest with an initial non-shockable rhythm in Singapore

AimOut-of-hospital cardiac arrest (OHCA) with an initial non-shockable rhythm is the predominant form of OHCA in adults. We evaluated its 10-year trends in epidemiology and management in Singapore. MethodsUsing the national OHCA registry we studied the trends of 20,844 Emergency Medical Services-attended adult OHCA from April 2010 to December 2019. Survival to hospital discharge was the primary outcome. Trends and outcomes were analyzed using linear and logistic regression, respectively. ResultsIncidence rates of adult OHCAs increased during the study period, driven by non-shockable OHCA. Compared to shockable OHCA, non-shockable OHCAs were significantly older, had more co-morbidities, unwitnessed and residential arrests, longer no-flow time, and received less bystander cardiopulmonary resuscitation (CPR) and in-hospital interventions (p < 0.001). Amongst non-shockable OHCA, age, co-morbidities, residential arrests, no-flow time, time to patient, bystander CPR and epinephrine administration increased during the study period, while presumed cardiac etiology decreased (p < 0.05). Unlike shockable OHCA, survival for non-shockable OHCA did not improve (p < 0.001 for trend difference). The likelihood of survival for non-shockable OHCA significantly increased with witnessed arrest (adjusted odds ratio (aOR) 2.02) and bystander CPR (aOR 3.25), but decreased with presumed cardiac etiology (aOR 0.65), epinephrine administration (aOR 0.66), time to patient (aOR 0.93) and age (aOR 0.98). Significant two-way interactions were observed for no-flow time and residential arrest with bystander CPR (aOR 0.96 and 0.40 respectively). ConclusionThe incidence of non-shockable OHCA increased between 2010 and 2019. Despite increased interventions, survival did not improve for non-shockable OHCA, in contrast to the improved survival for shockable OHCA.

477 Documentation of Resuscitation Decisions in Surgical Patients in a District General Hospital

Abstract Introduction Every patient admitted into hospital has to have a clear documentation of their resuscitation decisions in their current health charts.1 This enables surgeons to provide the best and sometimes major surgical treatment without delay in the first instance. The aim of this study was to assess the completeness of the resuscitation decisions for surgical patients admitted into our department. Method All patients on our surgical handover list between 22nd August and 31st August 2022 who were admitted were included in this study. Patient charts were reviewed, and data collected in relation to the completeness of the resuscitation decisions and treatment escalation plan (TEP). Results A total of 50 patients were included. 35 patients (70%) had their resuscitation decisions documented whereas 33 patients (66%) had documented TEP. This is in contrast to guidelines as not all of admitted surgical patients had their resuscitation decisions or TEP documented. Our planned interventions were highlighting its importance in a virtual departmental meeting, educating new incoming junior doctors, sending departmental reminder emails and making the section of the proforma a mandatory field to complete. Conclusions Documentation of resuscitation decisions is important in providing quality of care for patients. Our result showed intervention is needed to ensure best practice is adhered to. We plan to achieve a better data completeness in our next audit cycle after intervention.

Impact of the hybrid emergency department on resuscitation strategies and outcomes in ventricular fibrillation

BackgroundThe Hybrid emergency room (ER) is a novel resuscitation room that includes a whole-body computed tomography scanner and angiography system, which enables physicians to seamlessly conduct resuscitation, diagnosis and therapeutic interventions without patient transfer. This study aimed to assess the impact of the Hybrid ER on mortality in patients with ventricular fibrillation cardiac arrest. MethodsThis was a retrospective cohort study conducted in a tertiary hospital in Japan. We consecutively included adult cardiac arrest patients who were transferred to the emergency departments from January 2007 to May 2020, and were confirmed to be in ventricular fibrillation within 10 min from patient arrival. The study population was divided into two groups: the conventional group (from January 2007 to July 2011) and the Hybrid ER group (from August 2011 to May 2020). The primary endpoint of this study was defined as all-cause in-hospital death. Secondary endpoints included the frequency of extracorporeal cardiopulmonary resuscitation (ECPR) and percutaneous coronary intervention (PCI), and door-to-balloon time and door-to-ECPR time. ResultsWe included 115 patients in the conventional group and 185 patients in the Hybrid ER group. In-hospital mortality was significantly decreased in the Hybrid ER group (adjusted hazard ratio, 0.79; 95% confidence interval 0.64, 0.97; p = 0.026). Door-to-ECPR time was significantly shorter in the Hybrid ER group (p < 0.001, Gehan-Breslow-Wilcoxon test), as was door-to-balloon time in this group (p = 0.004, Gehan-Breslow-Wilcoxon test). In interrupted time-series analyses, it was visually recognized that the ratio of patients who received ECPR and PCI increased, and door-to-ECPR time and door-to-balloon time were shortened from 2011 to 2012 (before and after installation of the Hybrid ER). ConclusionInstallation of the Hybrid ER was associated with a reduced time to ECPR and PCI and with a possible improvement in survival in patients with ventricular fibrillation cardiac arrest.

Understanding the Brain-based Determination of Death When Organ Recovery Is Performed With DCDD In Situ Normothermic Regional Perfusion.

Understanding the Brain-based Determination of Death When Organ Recovery Is Performed With DCDD In Situ Normothermic Regional Perfusion.

Acute Pancreatitis In Type 2 Diabetes Mellitus With Multiple Stones In The Cystic Ductus

&lt;p&gt;&lt;strong&gt;Introduction:&lt;/strong&gt; Severe upper abdominal pain is one of the symptoms of acute pancreatitis that often occurs in other diseases, such as peptic ulcer, acute hepatitis, cholangitis, and cholecystitis. Gallstone-induced acute pancreatitis has considerable morbidity and mortality.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Case illustration:&lt;/strong&gt; A 50-year-old man came to the ED with a chief complaint of severe abdominal pain in the upper abdomen, VAS 8-9. His past medical history was unknown. On arrival, blood pressure was 141/102 mmHg, pulse was 98x/minute, and temperature was 36.4ºC. CT Scan of the abdomen showed pancreatitis and multiple stones in the cystic duct. Amylase and lipase serum results were 1897U/L and &amp;gt;3000 U/L.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Discussion:&lt;/strong&gt; In acute pancreatitis caused by gallstones, stones usually get stuck in the branches of the pancreaticobiliary duct. Obstruction at this location causes reflux of bile into the pancreatic duct. Smaller gallstones are more likely to induce pancreatitis because they migrate more easily between bile ducts. This patient was suspected of having a previously unknown history of DM, which contributed to the patient's worsening condition.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusion:&lt;/strong&gt; Early management and treatment of triage, fluid resuscitation, and detection of local or systemic complications are essential. In pancreatitis due to gallstones, decisions about the need and timing of procedural intervention are critical. &lt;/p&gt;

Acute (profuse) hemorrhoidal bleeding

Objective. Hemorrhoids is one of the most common diseases in adult coloproctological practice, the main manifestation of which is bleeding of different degree of activity and complexity. The aim of the study was to analyze the results of diagnostics and treatment of patients with different stages of hemorrhoids for 3 years. Materials and methods. The results of diagnostics and treatment of patients with different stages of hemorrhoids treated in the coloproctological unit for 3 years (20192021) were analyzed. Results. The article considers the hemorrhoidal bleeding and the possibility of classification to optimize treatment; an algorithm used for rendering medical care to this group of patients is presented. The case histories of patients with hemorrhoids, treated at the First Republican Clinical Hospital of Udmurt Republic, were analyzed. Conclusions. Patients with profuse hemorrhoidal bleeding need hospitalization to the resuscitation unit, immediate identification and treatment of hemorrhagic shock. The offered protocol (algorithm) of managing patients permitted to work in a team, improve the quality of rendering medical care to patients with profuse hemorrhoidal bleeding and avoid lethal outcomes.

Microcirculation-guided resuscitation in sepsis: the next frontier?

Microcirculatory dysfunction plays a key role in the pathogenesis of tissue dysoxia and organ failure in sepsis. Sublingual videomicroscopy techniques enable the real-time non-invasive assessment of microvascular blood flow. Alterations in sublingual microvascular perfusion were detected during sepsis and are associated with poor outcome. More importantly, sublingual videomicroscopy allowed to explore the effects of commonly applied resuscitative treatments in septic shock, such as fluids, vasopressors and inotropes, and showed that the optimization of macro-hemodynamic parameters may not be accompanied by an improvement in microvascular perfusion. This loss of "hemodynamic coherence," i.e., the concordance between the response of the macrocirculation and the microcirculation, advocates for the integration of microvascular monitoring in the management of septic patients. Nonetheless, important barriers remain for a widespread use of sublingual videomicroscopy in the clinical practice. In this review, we discuss the actual limitations of this technique and future developments that may allow an easier and faster evaluation of the microcirculation at the bedside, and propose a role for sublingual microvascular monitoring in guiding and titrating resuscitative therapies in sepsis.

Pitfalls in the Diagnosis of Peri-Operative Acute Pulmonary Embolism: A Case Report

An 80 years-old man with hypertension, atrial fibrillation, and coronary artery occlusion disease presented for an elective right femur bipolar hip arthroplasty under general anesthesia. Preoperative transthoracic echocardiography (TTE) showed only preexisting regional wall motion abnormality. During the reversal of muscular relaxation following surgery, there was a sudden decrease in blood pressure associated with rapid ventricular response, which was successfully treated by cardioversion. No decrease in end-tidal carbon dioxide level was observed during the hypotensive episode. However, despite fluid and blood resuscitation and vasopressor treatment, there was a repeated hemodynamic collapse postoperatively. A portable TTE showed dilated right atrium and right ventricle (RV), D-shaped left ventricle, and septal wall motion abnormalities consistent with RV pressure overload (McConnell’s sign). Computed tomography pulmonary angiography revealed multifocal PE (pulmonary embolism). Anticoagulation therapy was continued to avoid PE recurrence. The patient discharged uneventfully 30 days later. Perioperative PE is a rare and perhaps dangerous circumstance that can be challenging to diagnose when it happens under anesthesia. The likelihood of PE should always be suspected at the time of perioperative hemodynamic collapse.

Ethics of data-driven innovation in the treatment and prevention of sudden cardiac arrest

Ethics of data-driven innovation in the treatment and prevention of sudden cardiac arrest ESCAPE-NET aims to discover inherited, acquired and environmental causes of sudden cardiac arrest (SCA) and to improve resuscitation treatment for SCA. A shared database of more than 100,000 SCA patients has been created and less than 10,000 DNA samples collected, with procedures for data access by researchers outside the project consortium. ESCAPE-NET has generated 90 peer-reviewed scientific papers.

Impact of Trauma Resuscitation Emergency Care Nurse Deployment in Trauma Activations in a Rural Trauma Center.

Although the role of a dedicated trauma nurse has been implemented in an urban setting, it has not been studied in the rural trauma setting. We instituted a trauma resuscitation emergency care (TREC) nurse role to respond to trauma activations at our rural trauma center. This study aims to determine the impact of TREC nurse deployment on the timeliness of resuscitation interventions in trauma activations. This pre- and postintervention study at a rural Level I trauma center compared the time to resuscitation interventions before (August 2018 to July 2019) and after (August 2019 to July 2020) deploying TREC nurses to trauma activations. A total of 2,593 participants were studied, of which 1,153 (44%) were in the pre-TREC group and 1,440 (56%) in the post-TREC group. After TREC deployment, the median (interquartile range [IQR]) emergency department times within the first hour decreased from 45 (31.23-53) to 35 (16-51) min ( p = .013). The median (IQR) time to the operating room within the first hour decreased from 46 (37-52) to 29 (12-46) min ( p = .001), and within the first 2 hr, decreased from 59 (43.8-86) to 48 (23-72) min ( p = .014). Our study found that TREC nurse deployment improved resuscitation intervention timeliness during the first 2 hr (early phase) of trauma activations.

Assessment of Risk Factors for Enteric Fistula and Intra-Abdominal Sepsis in Patients with Open Abdomen in Trauma: An Original Research.

In emergency surgeries, open abdomen or laparostomy, especially with perforated viscus, has been used primarily to prevent delayed ventral hernia, burst abdomen, and abdominal compartment syndrome. In the present study, the clinical and resuscitative factors that are linked with open abdomen morbidity are evaluated. A retrospective analysis was done for all the subjects who were admitted at the tertiary care center between May 2020 and May 2022 for the open abdomen surgeries. These patients were examined to see whether they needed more postoperative care than usual, including the need for resuscitative treatments and other critical clinical indicators. Patients were evaluated if they had any complications. The data that were collected were analysed for any variance using analysis of variance considering P <.05 as significant. A total of 100 subjects were analysed in this study. Forty nine patients had intra-abdominal sepsis of the 100 cases examined from historical case records and 1 had entero-cutaneous fistulas. These patients did not necessitate additional actions for intensive care unit care, resuscitation, an chest infection, extended hospital stay, or any disabilities compared to those who did not undergo laparotomy during the same period. In this group of patients with open abdomens, the immediate postoperative period was not linked to an increase in resuscitation efforts or a load on clinical staff. Once patients are stabilized, early definitive abdominal closure is advised to prevent problems associated to laparostomies. The quantity of initial fluid revival and the coagulation factors at the time of admission are not related to intra-abdominal sepsis and enteric fistula following laparostomy after significant abdominal injuries.

Pelatihan tentang Resusitasi Jantung Paru (RJP) untuk Siswa SMA Guna Membentuk Remaja Tanggap Henti Jantung

Cardiac arrest is an emergency condition that can be life-threatening and requires Cardiac Pulmonary Resuscitation (CPR) treatment as soon as possible, so it is important to be able to perform CPR quickly and accurately. SMA N 1 Kuta and SMA N 1 Kuta Utara are located in Badung Regency, Bali Province. This activity aims to increase students' knowledge and skills in performing CPR quickly and precisely. The method used is using power point and phantom media, and an evaluation was carried out by giving a pre-test and post-test in the form of a questionnaire. The activities were carried out face-to-face at SMA N 1 Kuta and SMA N 1 Kuta Utara. This activity involved 44 Red Cross Youth of SMA N 1 Kuta and 57 Red Cross Youth of SMA N 1 Kuta Utara. The results of this activity have a positive impact in increasing the knowledge and skills in performing CPR.

Superior Mesenteric Artery Syndrome: A Case Report and Literatures Review

ABSTRACT Superior mesenteric artery syndrome (SMAS) is a rare clinical disease caused by obstruction of the duodenum at the angle between the abdominal aorta and superior mesenteric artery. We report a male patient admitted to our hospital with a chief complaint of obvious postprandial vomiting and nausea. SMAS was confirmed by abdominal computed tomography images and clinical symptoms. After admission, the patient was treated with fasting, antibiotics, fluid resuscitation, parenteral nutrition, and other conservative treatments. However, the patient deteriorated rapidly and died because of multiple organ failure. SMAS is easily missed, which may delay timely treatment. Clinicians should improve their clinical understanding of SMAS.

Economic considerations for resuscitative interventions in the immediate newborn period

We present a systematic scoping review of the literature, which documents that only a very small number of interventions related to delivery room stabilization and resuscitation have been studied for their economic impact. Published analyses are mostly of programmatic interventions such as resuscitation training programs, are mostly in low-resource settings, and are of variable methodological quality. Investigators who are conducting clinical studies of delivery room interventions can address these deficiencies in the literature by engaging with health services researchers to assess economic outcomes alongside those studies. We provide a framework of five questions that clinical researchers may use to decide on when such an ancillary study is indicated, and to provide them with the necessary language to discuss the methodological details of potential evaluations with their health services colleagues. Emphasis should be given to interventions that are targeted to high volumes of patients, are expensive, or are likely to lead to changes in costly chronic outcomes.

Critical shortage of capacity to deliver safe paediatric surgery in sub-Saharan Africa: evidence from 67 hospitals in Malawi, Zambia, and Tanzania.

Paediatric surgical care is a significant challenge in Sub-Saharan Africa (SSA), where 42% of the population are children. Building paediatric surgical capacity to meet SSA country needs is a priority. This study aimed to assess district hospital paediatric surgical capacity in three countries: Malawi, Tanzania and Zambia (MTZ). Data from 67 district-level hospitals in MTZ were collected using a PediPIPES survey tool. Its five components are procedures, personnel, infrastructure, equipment, and supplies. A PediPIPES Index was calculated for each country, and a two-tailed analysis of variance test was used to explore cross-country comparisons. Similar paediatric surgical capacity index scores and shortages were observed across countries, greater in Malawi and less in Tanzania. Almost all hospitals reported the capacity to perform common minor surgical procedures and less complex resuscitation interventions. Capacity to undertake common abdominal, orthopaedic and urogenital procedures varied-more often reported in Malawi and less often in Tanzania. There were no paediatric or general surgeons or anaesthesiologists at district hospitals. General medical officers with some training to do surgery on children were present (more often in Zambia). Paediatric surgical equipment and supplies were poor in all three countries. Malawi district hospitals had the poorest supply of electricity and water. With no specialists in district hospitals in MTZ, access to safe paediatric surgery is compromised, aggravated by shortages of infrastructure, equipment and supplies. Significant investments are required to address these shortfalls. SSA countries need to define what procedures are appropriate to national, referral and district hospital levels and ensure that an appropriate paediatric surgical workforce is in place at district hospitals, trained and supervised to undertake these essential surgical procedures so as to meet population needs.

Resuscitation in the “Periviable” Period—Commentary of Opposing Views

The periviable period is defined as delivery between 20 0/7 weeks and 25 6/7 weeks of gestation. It has long been considered a “gray area,” as there are still no clear guidelines on initial resuscitation and subsequent treatment of the newborn. This lack of guidance compounds the uncertainty in decision-making in low- and middle-income countries with limited resources. The decision to treat or not has far-reaching economic, social, cultural, and sometimes even religious implications for the parents and family. This review explores the perspectives of parents, caregivers, and policymakers in detail to utilize the existing evidence better. We present arguments for and against resuscitation in the periviable period, discussing concerns surrounding neurodevelopmental outcomes, cost, parental concerns, nonuniformity of evidence, and ethical considerations. A large survival gap exists between developed and developing countries, and the infrastructure and clinical care network in low- and middle-income country are not strong enough to provide adequate support for these infants and their families. Antenatal factors, socioeconomic and cultural issues, center capacity, and resuscitation capacity of birthing centers should be considered when making decisions. The neonatologists are expected to be impartial, provide information, and not advise based on their beliefs and outlook; while preserving the autonomy of parents. The only way forward is for parents and caregivers to work together to develop a logical and ethical approach that can be accepted as national and institutional policies.