Is cerebral perfusion maintained during full and partial resuscitative endovascular balloon occlusion of the aorta in hemorrhagic shock conditions?

BACKGROUND

Partial resuscitative endovascular balloon occlusion of the aorta (pREBOA) is a technology that occludes aortic flow and allows for controlled deflation and restoration of varying distal perfusion. Carotid flow rates (CFRs) during partial deflation are unknown. Our aim was to measure CFR with the different pREBOA balloon volumes and correlate those to the proximal mean arterial pressure (PMAP) and a handheld pressure monitoring device (COMPASS; Mirador Biomedical, Seattle, WA).

METHODS

Ten swine underwent a hemorrhagic injury model with carotid and iliac arterial pressures monitored via arterial lines. Carotid and aortic flow rates were monitored with Doppler flow probes. A COMPASS was placed to monitor proximal pressure. The pREBOA was inflated for 15 minutes then partially deflated for an aortic flow rate of 0.7 L/min for 45 minutes. It was then completely deflated. Proximal mean arterial pressures and CFR were measured, and correlation was evaluated. Correlation between CRF and COMPASS measurements was evaluated.

RESULTS

Carotid flow rate increased 240% with full inflation. Carotid flow rate was maintained at 100% to 150% of baseline across a wide range of partial deflation. After full deflation, CFR transiently decreased to 45% to 95% of baseline. There was strong positive correlation (r > 0.85) between CFR and PMAP after full inflation, and positive correlation with partial inflation (r > 0.7). Carotid flow rate had strong correlation with the COMPASS with full REBOA (r > 0.85) and positive correlation with pREBOA (r > 0.65).

CONCLUSION

Carotid flow rate is increased in a hemorrhagic model during full and partial inflation of the pREBOA and correlates well with PMAP. Carotid perfusion appears maintained across a wide range of pREBOA deflation and could be readily monitored with a handheld portable COMPASS device instead of a standard arterial line setup.

Focal intra-colon cooling reduces organ injury and systemic inflammation after REBOA management of lethal hemorrhage in rats

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a lifesaving maneuver for the management of lethal torso hemorrhage. However, its prolonged use leads to distal organ ischemia-reperfusion injury (IRI) and systemic inflammatory response syndrome (SIRS). The objective of this study is to investigate the blood-based biomarkers of IRI and SIRS and the efficacy of direct intestinal cooling in the prevention of IRI and SIRS. A rat lethal hemorrhage model was produced by bleeding 50% of the total blood volume. A balloon catheter was inserted into the aorta for the implementation of REBOA. A novel TransRectal Intra-Colon (TRIC) device was placed in the descending colon and activated from 10 min after the bleeding to maintain the intra-colon temperature at 37 °C (TRIC37°C group) or 12 °C (TRIC12°C group) for 270 min. The upper body temperature was maintained at as close to 37 °C as possible in both groups. Blood samples were collected before hemorrhage and after REBOA. The organ injury biomarkers and inflammatory cytokines were evaluated by ELISA method. Blood based organ injury biomarkers (endotoxin, creatinine, AST, FABP1/L-FABP, cardiac troponin I, and FABP2/I-FABP) were all drastically increased in TRIC37°C group after REBOA. TRIC12°C significantly downregulated these increased organ injury biomarkers. Plasma levels of pro-inflammatory cytokines TNF-α, IL-1b, and IL-17F were also drastically increased in TRIC37°C group after REBOA. TRIC12°C significantly downregulated the pro-inflammatory cytokines. In contrast, TRIC12°C significantly upregulated the levels of anti-inflammatory cytokines IL-4 and IL-10 after REBOA. Amazingly, the mortality rate was 100% in TRIC37°C group whereas 0% in TRIC12°C group after REBOA. Directly cooling the intestine offered exceptional protection of the abdominal organs from IRI and SIRS, switched from a harmful pro-inflammatory to a reparative anti-inflammatory response, and mitigated mortality in the rat model of REBOA management of lethal hemorrhage.

Neonatal resuscitation: EN-BIRTH multi-country validation study

BACKGROUND

Annually, 14 million newborns require stimulation to initiate breathing at birth and 6 million require bag-mask-ventilation (BMV). Many countries have invested in facility-based neonatal resuscitation equipment and training. However, there is no consistent tracking for neonatal resuscitation coverage.

METHODS

The EN-BIRTH study, in five hospitals in Bangladesh, Nepal, and Tanzania (2017-2018), collected time-stamped data for care around birth, including neonatal resuscitation. Researchers surveyed women and extracted data from routine labour ward registers. To assess accuracy, we compared gold standard observed coverage to survey-reported and register-recorded coverage, using absolute difference, validity ratios, and individual-level validation metrics (sensitivity, specificity, percent agreement). We analysed two resuscitation numerators (stimulation, BMV) and three denominators (live births and fresh stillbirths, non-crying, non-breathing). We also examined timeliness of BMV. Qualitative data were collected from health workers and data collectors regarding barriers and enablers to routine recording of resuscitation.

RESULTS

Among 22,752 observed births, 5330 (23.4%) babies did not cry and 3860 (17.0%) did not breathe in the first minute after birth. 16.2% (n = 3688) of babies were stimulated and 4.4% (n = 998) received BMV. Survey-report underestimated coverage of stimulation and BMV. Four of five labour ward registers captured resuscitation numerators. Stimulation had variable accuracy (sensitivity 7.5-40.8%, specificity 66.8-99.5%), BMV accuracy was higher (sensitivity 12.4-48.4%, specificity > 93%), with small absolute differences between observed and recorded BMV. Accuracy did not vary by denominator option. < 1% of BMV was initiated within 1 min of birth. Enablers to register recording included training and data use while barriers included register design, documentation burden, and time pressure.

CONCLUSIONS

Population-based surveys are unlikely to be useful for measuring resuscitation coverage given low validity of exit-survey report. Routine labour ward registers have potential to accurately capture BMV as the numerator. Measuring the true denominator for clinical need is complex; newborns may require BMV if breathing ineffectively or experiencing apnoea after initial drying/stimulation or subsequently at any time. Further denominator research is required to evaluate non-crying as a potential alternative in the context of respectful care. Measuring quality gaps, notably timely provision of resuscitation, is crucial for programme improvement and impact, but unlikely to be feasible in routine systems, requiring audits and special studies.

A novel partial resuscitative endovascular balloon aortic occlusion device that can be deployed in zone 1 for more than 2 hours with minimal provider titration

BACKGROUND

Hemorrhage is a leading cause of mortality in trauma. Resuscitative endovascular balloon occlusion of the aorta (REBOA) can control hemorrhage, but distal ischemia, subsequent reperfusion injury, and the need for frequent balloon titration remain problems. Improved device design can allow for partial REBOA (pREBOA) that may provide hemorrhage control while also perfusing distally without need for significant provider titration.

METHODS

Female Yorkshire swine (N = 10) were subjected to 40% hemorrhagic shock for 1 hour (mean arterial pressure [MAP], 28-32 mm Hg). Animals were then randomized to either complete aortic occlusion (ER-REBOA) or partial occlusion (novel pREBOA-PRO) without frequent provider titration or distal MAP targets. Detection of a trace distal waveform determined partial occlusion in the pREBOA-PRO arm. After 2 hours of zone 1 occlusion, the hemorrhaged whole blood was returned. After 50% autotransfusion, the balloon was deflated over a 10-minute period. Following transfusion, the animals were survived for 2 hours while receiving resuscitation based on objective targets: lactated Ringer's fluid boluses (goal central venous pressure, ≥ 6 mm Hg), a norepinephrine infusion (goal MAP, 55-60 mm Hg), and acid-base correction (goal pH, >7.2). Hemodynamic variables, arterial lactate, lactate dehydrogenase, aspartate aminotransferase, and creatinine levels were measured.

RESULTS

All animals survived throughout the experiment, with similar increase in proximal MAPs in both groups. Animals that underwent partial occlusion had slightly higher distal MAPs. At the end of the experiment, the partial occlusion group had lower end levels of serum lactate (p = 0.006), lactate dehydrogenase (p = 0.0004) and aspartate aminotransferase (p = 0.004). Animals that underwent partial occlusion required less norepinephrine (p = 0.002), less bicarbonate administration (p = 0.006), and less fluid resuscitation (p = 0.042).

CONCLUSION

Improved design for pREBOA can decrease the degree of distal ischemia and reperfusion injury compared with complete aortic occlusion, while providing a similar increase in proximal MAPs. This can allow pREBOA zone-1 deployment for longer periods without the need for significant balloon titration.

A Randomized Trial of Laryngeal Mask Airway in Neonatal Resuscitation

BACKGROUND

Face-mask ventilation is the most common resuscitation method for birth asphyxia. Ventilation with a cuffless laryngeal mask airway (LMA) has potential advantages over face-mask ventilation during neonatal resuscitation in low-income countries, but whether the use of an LMA reduces mortality and morbidity among neonates with asphyxia is unknown.

METHODS

In this phase 3, open-label, superiority trial in Uganda, we randomly assigned neonates who required positive-pressure ventilation to be treated by a midwife with an LMA or with face-mask ventilation. All the neonates had an estimated gestational age of at least 34 weeks, an estimated birth weight of at least 2000 g, or both. The primary outcome was a composite of death within 7 days or admission to the neonatal intensive care unit (NICU) with moderate-to-severe hypoxic-ischemic encephalopathy at day 1 to 5 during hospitalization.

RESULTS

Complete follow-up data were available for 99.2% of the neonates. A primary outcome event occurred in 154 of 563 neonates (27.4%) in the LMA group and 144 of 591 (24.4%) in the face-mask group (adjusted relative risk, 1.16; 95% confidence interval [CI], 0.90 to 1.51; P = 0.26). Death within 7 days occurred in 21.7% of the neonates in the LMA group and 18.4% of those in the face-mask group (adjusted relative risk, 1.21; 95% CI, 0.90 to 1.63), and admission to the NICU with moderate-to-severe hypoxic-ischemic encephalopathy at day 1 to 5 during hospitalization occurred in 11.2% and 10.1%, respectively (adjusted relative risk, 1.27; 95% CI, 0.84 to 1.93). Findings were materially unchanged in a sensitivity analysis in which neonates with missing data were counted as having had a primary outcome event in the LMA group and as not having had such an event in the face-mask group. The frequency of predefined intervention-related adverse events was similar in the two groups.

CONCLUSIONS

In neonates with asphyxia, the LMA was safe in the hands of midwives but was not superior to face-mask ventilation with respect to early neonatal death and moderate-to-severe hypoxic-ischemic encephalopathy. (Funded by the Research Council of Norway and the Center for Intervention Science in Maternal and Child Health; NeoSupra ClinicalTrials.gov number, NCT03133572.).

Validation of a novel partial resuscitative endovascular balloon occlusion of the aorta device in a swine hemorrhagic shock model: Fine tuning flow to optimize bleeding control and reperfusion injury

OBJECTIVES

Partial restoration of aortic flow during resuscitative endovascular balloon occlusion of the aorta (REBOA) is advocated by some to mitigate distal ischemia. Our laboratory has validated the mechanics and optimal partial REBOA (pREBOA) flow rates using a prototype device. We hypothesize that pREBOA will increase survival when compared with full REBOA (fREBOA) in prolonged nonoperative management of hemorrhagic shock.

METHODS

Twenty swine underwent placement of aortic flow probes, zone 1 REBOA placement, and 20% blood volume hemorrhage. They were randomized to either solid organ or abdominal vascular injury. The pREBOA arm (10 swine) underwent full inflation for 10 minutes and then deflation to a flow rate of 0.5 L/min for 2 hours. The fREBOA arm (10 swine) underwent full inflation for 60 minutes, followed by deflation/resuscitation. The primary outcome is survival, and secondary outcomes are serologic/pathologic signs of ischemia-reperfusion injury and quantity of hemorrhage.

RESULTS

Two of 10 swine survived in the fREBOA group (2/5 solid organ injury; 0/5 abdominal vascular injury), whereas 7 of 10 swine survived in the pREBOA group (3/5 solid organ injury, 4/5 abdominal vascular injury). Survival was increased (p = 0.03) and hemorrhage was higher in the pREBOA group (solid organ injury, 1.36 ± 0.25 kg vs. 0.70 ± 0.33 kg, p = 0.007; 0.86 ± 0.22 kg vs. 0.71 ± 0.28 kg, not significant). Serum evidence of ischemia was greater with fREBOA, but this was not significant (e.g., lactate, 16.91 ± 3.87 mg/dL vs. 12.96 ± 2.48 mg/dL at 120 minutes, not significant). Swine treated with pREBOA that survived demonstrated trends toward lower alanine aminotransferase, lower potassium, and higher calcium. The potassium was significantly lower in survivors at 60 minutes and 90 minutes time points (5.97 ± 0.60 vs. 7.53 ± 0.90, p = 0.011; 6.67 ± 0.66 vs. 8.15 ± 0.78, p = 0.029). Calcium was significantly higher at 30 minutes, 60 minutes, and 90 minutes (8.56 ± 0.66 vs. 7.50 ± 0.40, p = 0.034; 8.63 ± 0.62 vs. 7.15 ± 0.49, p = 0.019; 8.96 ± 0.64 vs. 7.00, p = 0.028).

CONCLUSION

Prolonged pREBOA at a moderate distal flow rate provided adequate hemorrhage control, improved survival, and had evidence of decreased ischemic injury versus fREBOA. Prophylactic aggressive calcium supplementation may have utility before and during the reperfusion phase.

Decision space and participation of primary healthcare facility managers in the Ideal Clinic Realisation and Maintenance programme in two South African provinces

In South Africa, the introduction of a national health insurance (NHI) system is the most prominent health sector reform planned to achieve universal health coverage in the country. Primary health care (PHC) is the foundation of the proposed NHI system. This study draws on policy implementation theory and Bossert's notion of decision space to analyse PHC facility managers' decision space and their participation in the implementation of the Ideal Clinic Realisation and Maintenance (ICRM) programme. We conducted a cross-sectional survey among 127 PHC facility managers in two districts in Gauteng and Mpumalanga provinces. A self-administered questionnaire elicited socio-demographic information, the PHC managers' participation in the conceptualization and implementation of the ICRM programme, their decision space and an optional open-ended question for further comments. We obtained a 100% response rate. The study found that PHC facility managers reported lack of involvement in the conceptualization of the ICRM programme, high levels of participation in implementation [mean score 5.77 (SD ±0.90), and overall decision space mean score of 2.54 (SD ±0.34)]. However, 17 and 21% of participants reported narrow decision space on the critical areas of the availability of essential medicines and on basic resuscitation equipment respectively. The qualitative data revealed the unintended negative consequences of striving for 'ideal clinic status', namely that of creating an illusion of compliance with the ICRM standards. The study findings suggest the need for greater investment in the health workforce, special efforts to involve frontline managers and staff in health reforms, as well as provision of adequate resources, and an enabling practice environment.

Hemostatic agents for prehospital hemorrhage control: a narrative review

Hemorrhage is the leading cause of preventable death in combat trauma and the secondary cause of death in civilian trauma. A significant number of deaths due to hemorrhage occur before and in the first hour after hospital arrival. A literature search was performed through PubMed, Scopus, and Institute of Scientific Information databases for English language articles using terms relating to hemostatic agents, prehospital, battlefield or combat dressings, and prehospital hemostatic resuscitation, followed by cross-reference searching. Abstracts were screened to determine relevance and whether appropriate further review of the original articles was warranted. Based on these findings, this paper provides a review of a variety of hemostatic agents ranging from clinically approved products for human use to newly developed concepts with great potential for use in prehospital settings. These hemostatic agents can be administered either systemically or locally to stop bleeding through different mechanisms of action. Comparisons of current hemostatic products and further directions for prehospital hemorrhage control are also discussed.

Systematic assessment of fluid responsiveness during early septic shock resuscitation: secondary analysis of the ANDROMEDA-SHOCK trial

BACKGROUND

Fluid boluses are administered to septic shock patients with the purpose of increasing cardiac output as a means to restore tissue perfusion. Unfortunately, fluid therapy has a narrow therapeutic index, and therefore, several approaches to increase safety have been proposed. Fluid responsiveness (FR) assessment might predict which patients will effectively increase cardiac output after a fluid bolus (FR+), thus preventing potentially harmful fluid administration in non-fluid responsive (FR-) patients. However, there are scarce data on the impact of assessing FR on major outcomes. The recent ANDROMEDA-SHOCK trial included systematic per-protocol assessment of FR. We performed a post hoc analysis of the study dataset with the aim of exploring the relationship between FR status at baseline, attainment of specific targets, and clinically relevant outcomes.

METHODS

ANDROMEDA-SHOCK compared the effect of peripheral perfusion- vs. lactate-targeted resuscitation on 28-day mortality. FR was assessed before each fluid bolus and periodically thereafter. FR+ and FR- subgroups, independent of the original randomization, were compared for fluid administration, achievement of resuscitation targets, vasoactive agents use, and major outcomes such as organ dysfunction and support, length of stay, and 28-day mortality.

RESULTS

FR could be determined in 348 patients at baseline. Two hundred and forty-two patients (70%) were categorized as fluid responders. Both groups achieved comparable successful resuscitation targets, although non-fluid responders received less resuscitation fluids (0 [0-500] vs. 1500 [1000-2500] mL; p 0.0001), exhibited less positive fluid balances, but received more vasopressor testing. No difference in clinically relevant outcomes between FR+ and FR- patients was found, including 24-h SOFA score (9 [5-12] vs. 8 [5-11], p = 0.4), need for MV (78% vs. 72%, p = 0.16), need for RRT (18% vs. 21%, p = 0.7), ICU-LOS (6 [3-11] vs. 6 [3-16] days, p = 0.2), and 28-day mortality (40% vs. 36%, p = 0.5). Only thirteen patients remained fluid responsive along the intervention period.

CONCLUSIONS

Systematic assessment allowed determination of fluid responsiveness status in more than 80% of patients with early septic shock. Fluid boluses could be stopped in non-fluid responsive patients without any negative impact on clinical relevant outcomes. Our results suggest that fluid resuscitation might be safely guided by FR assessment in septic shock patients.

TRIAL REGISTRATION

ClinicalTrials.gov identifier, NCT03078712. Registered retrospectively on March 13, 2017.

In-situ simulation for the detection of latent risk threats in a hyperbaric medicine department

Simulation (SIM) can be used in the quality improvement process to discover latent risk threats (LRTs) by running in-situ simulation cases in the clinical environment. We utilized this methodology in the hyperbaric chamber to run six in-situ SIM sessions between February 2017 and January 2019. The debriefing portion of each SIM was used to discuss and document all discovered LRTs. These safety threats were aggregated and categorized, resulting in a total of 22 unique LRTs. LRTs included problems or challenges with equipment, team education, policy/processes, communications, and medications. At a three-month follow-up, the hyperbaric leadership team had addressed each of the 22 unique LRTs. SIM can be used to identify, categorize and prioritize LRTs in an effective manner, in order to improve the health care delivery system in a hyperbaric medicine department.

A Novel Auditory Display for Neonatal Resuscitation: Laboratory Studies Simulating Pulse Oximetry in the First 10 Minutes After Birth

OBJECTIVE

We tested whether enhanced sonifications would improve participants' ability to judge the oxygen saturation levels (SpO₂) of simulated neonates in the first 10 min after birth.

BACKGROUND

During the resuscitation of a newborn infant, clinicians must keep the neonate's SpO₂ levels within the target range, however the boundaries for the target range change each minute during the first 10 min after birth. Resuscitation places significant demand on the clinician's visual attention, and the pulse oximeter's sonification could provide eyes-free monitoring. However, clinicians have difficulty judging SpO₂ levels using the current sonification.

METHOD

In two experiments, nonclinicians' ability to detect SpO₂ range and direction-while performing continuous arithmetic problems-was tested with enhanced versus conventional sonifications. In Experiment 1, tremolo signaled when SpO₂ had deviated below or above the target range. In Experiment 2, tremolo plus brightness signaled when SpO₂ was above target range, and tremolo alone when SpO₂ was below target range.

RESULTS

The tremolo sonification improved range identification accuracy over the conventional display (81% vs. 63%, p < .001). The tremolo plus brightness sonification further improved range identification accuracy over the conventional display (92% vs. 62%, p <.001). In both experiments, there was no difference across conditions in arithmetic task accuracy ( p >.05).

CONCLUSION

Using the enhanced sonifications, participants identified SpO₂ range more accurately despite a continuous distractor task.

APPLICATION

An enhanced pulse oximetry sonification could help clinicians multitask more effectively during neonatal resuscitations.

Automated Balloon Control in Resuscitative Endovascular Balloon Occlusion of the Aorta

OBJECTIVE

The goal of this study was to demonstrate the technical feasibility of automated balloon pressure management during resuscitative endovascular balloon occlusion of the aorta (REBOA) in the pre-clinical setting.

METHODS

This paper presents an intelligent balloon management device which automates the balloon inflation process, preventing the possibility of balloon over or under inflation, optimizes inflation pressure, and if indicated, deflates automating partial REBOA to allow the distal organ perfusion. Edwards TruWave pressure transducers are used to monitor the blood pressure proximal and distal to the balloon, as well as the internal balloon pressure. A faux PID controller, implemented on an Arduino platform, is used in a feedback control loop to allow a user-defined mean arterial pressure setpoint to be reached, via a syringe driver which allows intelligent inflation and deflation of the catheter balloon.

RESULTS

Ex vivo testing on a vascular perfusion simulator provided the characteristic behavior of a fully occluded aorta, namely the decrease of distal pressure to zero. In vivo testing on live porcine models indicated that automated partial REBOA is achievable and by enabling partial occlusion may offer improved medical outcomes compared to the manual control.

CONCLUSION

Automated balloon pressure management of endovascular occlusion is feasible and can be successfully implemented without changes on current clinical workflows.

SIGNIFICANCE

With further development, automated balloon management may significantly improve clinical outcomes in REBOA.

Anatomical investigations on intraosseous access in stillborns - Comparison of different devices and techniques

AIM

Intraosseous (IO)-access plays an alternative route during resuscitation. Our study was performed to investigate the successful rate of IO-access in preterm and term stillborns using different devices and techniques.

METHODS

The cadavers used were legal donations. 16 stillborns, median: 29.2 weeks (IQR 27.2-38.4) were investigated. Two different needles (a: Butterfly needle, 21G, Venofix^® Fa.Braun; b: Arrow^®EZ-IO^®15G, Teleflex, Dublin, Ireland) were used. Needles were inserted i: manually, using a Butterfly needle; ii: manually, using EZ-IO^® needle or iii: using a battery-powered semi-automatic drill (Arrow^®EZ-IO^®). Spectral-CT's were performed. The diameter of the corticalis was determined from the CT-images. Successful hit rates with 95% confidence intervals (CI) and odds ratios between the three methods were estimated using a generalised linear mixed model (GLMM).

RESULTS

Estimated success rate was 61.1% (95%CI:39.7%-78.9%) for the Butterfly needle, 43.0% (95%CI:23.4%-65.0%) for hand-twisted EZ-IO^® screwing and 39.7% (95%CI:24.1-57.7%) for the semi-automatic drill (Arrow^®EZ-IO^®), all referring to an average diameter of the corticalis of 1.2 mm. The odds of a correct position were 2.4 times higher (95%CI:0.8-7.6) when using the Butterfly needle than with the drill. In contrast, the odds of correct positioning when inserting the needle by hand were not significantly different from using the drill (odds ratio 1.1, 95%CI: 0.4-3.3). Neither of these effects nor the diameter of the corticalis with an odds ratio near one were significant in the model. Median diameter of the bone marrow cavity was 4.0 mm [IQR 3.3-4.7].

CONCLUSION

Intraosseous access for premature and neonatal infants could be best achieved by using a manually twisted Butterfly needle.

Measuring the preparedness of health facilities to deliver emergency obstetric care in a South African district

BACKGROUND

Improving the delivery of emergency obstetric care (EmNOC) remains critical in addressing direct causes of maternal mortality. United Nations (UN) agencies have promoted standard methods for evaluating the availability of EmNOC facilities although modifications have been proposed by others. This study presents an assessment of the preparedness of public health facilities to provide EmNOC using these methods in one South African district with a persistently high maternal mortality ratio.

METHODS

Data collection took place in the final quarter of 2014. Cross-sectional surveys were conducted to classify the 7 hospitals and 8 community health centres (CHCs) in the district as either basic EmNOC (BEmNOC) or comprehensive EmNOC (CEmNOC) facilities using UN EmNOC signal functions. The required density of EmNOC facilities was calculated using UN norms. We also assessed the availability of EmNOC personnel, resuscitation equipment, drugs, fluids, and protocols at each facility. The workload of skilled EmNOC providers at hospitals and CHCs was compared.

RESULTS

All 7 hospitals in the district were classified as CEmNOC facilities, but none of the 8 CHCs performed all required signal functions to be classified as BEmNOC facilities. UN norms indicated that 25 EmNOC facilities were required for the district population, 5 of which should be CEmNOCs. None of the facilities had 100% of items on the EmNOC checklists. Hospital midwives delivered an average of 36.4±14.3 deliveries each per month compared to only 7.9±3.2 for CHC midwives (p<0.001).

CONCLUSIONS

The analysis indicated a shortfall of EmNOC facilities in the district. Full EmNOC services were centralised to hospitals to assure patient safety even though national policy guidelines sanction more decentralisation to CHCs. Studies measuring EmNOC availability need to consider facility opening hours, capacity and staffing in addition to the demonstrated performance of signal functions.

Laryngeal mask airway versus bag-mask ventilation or endotracheal intubation for neonatal resuscitation

BACKGROUND

Providing effective positive pressure ventilation is considered to be the single most important component of successful neonatal resuscitation. Ventilation is frequently initiated manually with bag and face mask (BMV) followed by endotracheal intubation if respiratory depression continues. These techniques may be difficult to perform successfully resulting in prolonged resuscitation or neonatal asphyxia. The laryngeal mask airway (LMA) may achieve initial ventilation and successful resuscitation faster than a bag-mask device or endotracheal intubation.

OBJECTIVES

Among newborns requiring positive pressure ventilation for cardio-pulmonary resuscitation, is LMA more effective than BMV or endotracheal intubation for successful resuscitation? When BMV is either insufficient or ineffective, is effective positive pressure ventilation and successful resuscitation achieved faster with the LMA compared to endotracheal intubation?

SEARCH METHODS

We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL 2017, Issue 1), MEDLINE via PubMed (1966 to 15 February 2017), Embase (1980 to 15 February 2017), and CINAHL (1982 to 15 February 2017). We also searched clinical trials registers, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials.

SELECTION CRITERIA

We included randomised and quasi-randomised controlled trials that compared LMA for neonatal resuscitation with either BMV or endotracheal intubation and reported on any outcomes related to neonatal resuscitation specified in this review.

DATA COLLECTION AND ANALYSIS

Two review authors independently evaluated studies for risk of bias assessments, and extracted data using Cochrane Neonatal criteria. Categorical treatment effects were described as relative risks and continuous treatment effects were described as the mean difference, with 95% confidence intervals (95% CI) of estimates.

MAIN RESULTS

We included seven trials that involved a total of 794 infants. Five studies compared LMA with BMV and three studies compared LMA with endotracheal intubation. We added six new studies for this update (754 infants).LMA was associated with less need for endotracheal intubation than BMV (typical risk ratio (RR) 0.24, 95% CI 0.12 to 0.47 and typical risk difference (RD) -0.14, 95% CI -0.14 to -0.06; 5 studies, 661 infants; moderate-quality evidence) and shorter ventilation time (mean difference (MD) -18.90 seconds, 95% CI -24.35 to -13.44; 4 studies, 610 infants). Babies resuscitated with LMA were less likely to require admission to neonatal intensive care unit (NICU) (typical RR 0.60, 95% CI 0.40 to 0.90 and typical RD -0.18, 95% CI -0.31 to -0.04; 2 studies,191 infants; moderate-quality evidence). There was no difference in deaths or hypoxic ischaemic encephalopathy (HIE) events.Compared to endotracheal intubation, there were no clinically significant differences in insertion time or failure to correctly insert the device (typical RR 0.95, 95% CI 0.17 to 5.42; 3 studies, 158 infants; very low-quality evidence). There was no difference in deaths or HIE events.

AUTHORS' CONCLUSIONS

LMA can achieve effective ventilation during neonatal resuscitation in a time frame consistent with current neonatal resuscitation guidelines. Compared to BMV, LMA is more effective in terms of shorter resuscitation and ventilation times, and less need for endotracheal intubation (low- to moderate-quality evidence). However, in trials comparing LMA with BMV, over 80% of infants in both trial arms responded to the allocated intervention. In studies that allowed LMA rescue of infants failing with BMV, it was possible to avoid intubation in the majority. It is important that the clinical community resorts to the use of LMA more proactively to provide effective ventilation when newborn is not responding to BMV before attempting intubation or initiating chest compressions.LMA was found to offer comparable efficacy to endotracheal intubation (very low- to low-quality evidence). It therefore offers an alternate airway device when attempts at inserting endotracheal intubation are unsuccessful during resuscitation.Most studies enrolled infants with birth weight over 1500 g or 34 or more weeks' gestation. As such, there is lack of evidence to support LMA use in more premature infants.

Methods for Early Control of Abdominal Hemorrhage: An Assessment of Potential Benefit

BACKGROUND

Noncompressible truncal hemorrhage (NCTH) after injury is associated with a mortality increase that is unchanged during the past 20 years. Current treatment consists of rapid transport and emergent intervention. Three early hemorrhage control interventions that may improve survival are placement of a resuscitative endovascular balloon occlusion of the aorta (REBOA), injection of intracavitary self-expanding foam, and application of the Abdominal Aortic Junctional Tourniquet (AAJT™). The goal of this work was to ascertain whether patients with uncontrolled abdominal or pelvic hemorrhage might benefit by the early or prehospital use of one of these interventions.

METHODS

This was a single-center retrospective study of patients who received a trauma laparotomy from 2013 to 2015. Operative reports were reviewed. The probable benefit of each hemorrhage control method was evaluated for each patient based on the location(s) of injury and the severity of their physiologic derangement. The potential scope of applicability of each control method was then directly compared.

RESULTS

During the study period, 9,608 patients were admitted; 402 patients required an emergent trauma laparotomy. REBOA was potentially beneficial for hemorrhage control in 384 (96%) of patients, foam in 351 (87%), and AAJT in 35 (9%). There was no statistically significant difference in the potential scope of applicability between REBOA and foam (ρ = .022). There was a significant difference between REBOA and AAJT (ρ < .001) and foam and AAJT™ (ρ < .001). The external surface location of signs of injury did not correlate with the internal injury location identified during laparotomy.

CONCLUSION

Early use of REBOA and foam potentially benefits the largest number of patients with abdominal or pelvic bleeding and may have widespread applicability for patients in the preoperative, and potentially the prehospital, setting. AAJT may be useful with specific types of injury. The site of bleeding must be considered before the use of any of these tools.

Exchange of supraglottic airways for endotracheal tube using the Eschmann Introducer during simulated child resuscitation: A randomized study comparing 4 devices

BACKGROUND

The aim of this study was to examine the application of the Eschmann tracheal tube introducer (ETTI) with 4 types of supraglottic airway devices (SADs) using a child-manikin.

METHODS

A total of 79 paramedics were asked to exchange the 4 SADs for an endotracheal tube with the ETTI in 3 different scenarios using a randomized crossover study format: normal airway without chest compression; normal airway with uninterrupted chest compression; and difficult airway with uninterrupted chest compression. The primary outcome was time to SAD exchange, with the secondary outcome measuring the success of SAD exchange. Each attempt was assessed by a trained assistant.

RESULTS

The mean exchange times for LMA, Cobra PLA, Air-Q, and SALT were as follows: 21, 23, 21, and 18, respectively for Scenario A; 23, 27, 22.5, and 21 for Scenario B; and 23, 28, 23, and 23 for Scenario C. The percent efficacy of SADs exchange with LMA, Cobra PLA, Air-Q and SALT were 98.7%, 94.9%, 100%, and 100% for scenario A; 98.7%, 88.6%, 98.7%, and 97.5% for scenario B; and 93.7%, 87.3%, 94.9%, and 93.7% for scenario C.

CONCLUSIONS

In this model of pediatric resuscitation, the SAD exchange using an ETTI has (LMA, Cobra PLA, Air-Q and SALT) proved to be effective in paramedics with no previous experience. Furthermore, experimental findings indicated that SAD exchange can be achieved without interrupting chest compression.

A Magnetic Resonance Imaging-Conditional External Cardiac Defibrillator for Resuscitation Within the Magnetic Resonance Imaging Scanner Bore

BACKGROUND

Subjects undergoing cardiac arrest within a magnetic resonance imaging (MRI) scanner are currently removed from the bore and then from the MRI suite, before the delivery of cardiopulmonary resuscitation and defibrillation, potentially increasing the risk of mortality. This precludes many higher-risk (acute ischemic and acute stroke) patients from undergoing MRI and MRI-guided intervention. An MRI-conditional cardiac defibrillator should enable scanning with defibrillation pads attached and the generator ON, enabling application of defibrillation within the seconds of MRI after a cardiac event. An MRI-conditional external defibrillator may improve patient acceptance for MRI procedures.

METHODS AND RESULTS

A commercial external defibrillator was rendered 1.5 Tesla MRI-conditional by the addition of novel radiofrequency filters between the generator and commercial disposable surface pads. The radiofrequency filters reduced emission into the MRI scanner and prevented cable/surface pad heating during imaging, while preserving all the defibrillator monitoring and delivery functions. Human volunteers were imaged using high specific absorption rate sequences to validate MRI image quality and lack of heating. Swine were electrically fibrillated (n=4) and thereafter defibrillated both outside and inside the MRI bore. MRI image quality was reduced by 0.8 or 1.6 dB, with the generator in monitoring mode and operating on battery or AC power, respectively. Commercial surface pads did not create artifacts deeper than 6 mm below the skin surface. Radiofrequency heating was within US Food and Drug Administration guidelines. Defibrillation was completely successful inside and outside the MRI bore.

CONCLUSIONS

A prototype MRI-conditional defibrillation system successfully defibrillated in the MRI without degrading the image quality or increasing the time needed for defibrillation. It can increase patient acceptance for MRI procedures.

History of Resuscitation :4. Development of Resuscitation in the Mid-18 Century-4 : External Stimulation to the Body

From the mid-18th century, several different stimulations were used to attempt to resuscitate apparently dead people. These include sound, smell, and light stimulation to the ear, nose and eyes, rubbing the body surface and spirit given to the oral cavity. The most notable stimulation was use of electricity, which was initiated by better understanding of its power by Benjamin Franklin and Luigi A. Galvani. Charles Kite developed the first electrical machine to stimulate the heart, and by 1800, it was found that the most effective site for applying electricity was over the heart.

[History of Resuscitation: 2. Development of Resuscitation in the Mid-18 Century-2 : Background of Development of Resuscitation and Rescue Methods]

In the mid-18th century, a growing number of peo- ple started to attempt resuscitation of "apparently dead" people as a result of drowning or other causes. In this article, I describe the background for this movement (which was likely to be related to a fear of being buried alive and of being dissected alive). I also describe a historical development of rescue methods of drowned people.

Comparison of Melatonin, Hypertonic Saline, and Hydroxyethyl Starch for Resuscitation of Secondary Intra-Abdominal Hypertension in an Animal Model

A variety of agents may have a beneficial effect in reducing injury-induced intestinal edema of fluid, but studies confirming the efficacy and mechanisms of these agents in secondary intra-abdominal hypertension (IAH) are lacking. This study was to compare the effectiveness of melatonin, 7.5% hypertonic saline (HS), and hydroxyethyl starch 130/0.4 (HES) on the resuscitation of secondary IAH in a rat model. Female SD rats were divided into: sham group, shock group, lactated Ringer solution (LR) group, melatonin group, HS group, and HES group. Except for the sham group, all rats underwent a combination of inducing portal hypertension, hemorrhaging to a MAP of 40 mmHg for 2 hr, and using an abdominal restraint device. The collected blood was reinfused and the rats were treated with LR (30ml/h), melatonin (50 mg/kg) + LR, HS (6 ml/kg) + LR, and HES (30 ml/kg) + LR, respectively. The shock group received no fluids. LR was continuously infused for 6hr. The intestinal permeability, immunofluorescence of tight junction proteins, transmission electron microscopy, level of inflammatory mediators (TNF-a, IL-1β, IL-6) and of biochemical markers of oxidative stress (malondialdehyde, myeloperoxidase activity, and glutathione peroxidase) were assessed. Expressions of the protein kinase B (Akt) and of tight junction proteins were detected by Western blot. Compared with LR, HS, and HES, melatonin was associated with less inflammatory and oxidative injury, less intestinal permeability and injury, and lower incidence of secondary IAH in this model. The salutary effect of melatonin in this model was associated with the upregulation of intestinal Akt phosphorylation.

Manual Ventilation and Sustained Lung Inflation in an Experimental Model: Influence of Equipment Type and Operator's Training

Aim

To compare the influence of devices for manual ventilation and individual experience on the applied respiratory mechanics and sustained lung inflation.

Methods

A total of 114 instructors and non-instructors from the Neonatal Resuscitation Program of the Brazilian Society of Pediatrics participated in this study. Participants ventilated an intubated manikin. To evaluate respiratory mechanics and sustained lung inflation parameters, a direct comparison was made between the self-inflating bag and the T-shaped resuscitator (T-piece), followed by an analysis of the effectiveness of the equipment according to the participants’ education and training.

Results

A difference between equipment types was observed for the tidal volume, with a median (interquartile range) of 28.5 mL (12.6) for the self-inflating bag and 20.1 mL (8.4) for the T-piece in the instructor group and 31.6 mL (14) for the self-inflating bag and 22.3 mL (8.8) for the T-piece in the non-instructor group. Higher inspiratory time values were observed with the T-piece in both groups of professionals, with no significant difference between them. The operator’s ability to maintain the target pressure over the 10 seconds of sustained lung inflation was evaluated using the area under the pressure-time curve and was 1.7-fold higher with the use of the T-piece. Inspiratory pressure and mean airway pressure applied during sustained lung inflation were greater with the self-inflating bag, as evaluated between the beginning and the end of the procedure.

Conclusion

The T-piece resulted in lower tidal volume and higher inspiratory time values, irrespective of the operator’s experience, and increased the ease of performing the sustained lung inflation maneuver, as demonstrated by the maintenance of target pressure for the desired period and a higher mean airway pressure than that obtained using the self-inflating bag.

Improvement Initiatives of Resuscitation Service in a Regional Rehabilitation Hospital in Hong Kong

Limited accessibility to resuscitation equipment and non-standardized instrument layout in trolleys would cause difficulty for the team members to access appropriate emergency equipment for delivering prompt resuscitation service in Tung Wah Eastern Hospital (TWEH). Improvement initiatives were implemented in September 2012 after endorsement by the resuscitation subcommittee: (i) standardization and installation of resuscitation equipment including resuscitation trolleys, emergency drug kits, automatic emergency defibrillators, designated response team (DRT) kit; (ii) guidelines revision involves the workflow, staff deployment, and designated areas for resuscitation during different service hours and (iii) staff training by workshop and video. Periodic resuscitation drill was held to monitor staff performance after training and the debriefing provided a chance for discussion and feedback from frontline staff. The compliance audit result for this exercise and the staff performance in the drills were improved, showing that the initiatives were successful.

KEY WORDS

Resuscitation, Accessibility, Standardization, Drill.

A novel rescue-tube device for in-water resuscitation

BACKGROUND

In-water resuscitation (IWR) is recommended in the 2010 guidelines of the European Resuscitation Council. As IWR represents a physical challenge to the rescuer, a novel Rescue Tube device with an integrated "Oxylator" resuscitator might facilitate IWR. The aim of the present study was the assessment of IWR using the novel Rescue Tube device.

METHODS

Tidal and minute volumes were recorded using a modified Laerdal Resusci Anne mannequin. Furthermore, rescue time, water aspiration, submersions, and physical exertion were assessed. In this randomized cross-over trial, 17 lifeguards performed four rescue maneuvers over a 100-m distance in open water in random order: no ventilation (NV), mouth-to-mouth ventilation (MMV), Oxylator-aided mask ventilation (OMV), and Oxylator-aided laryngeal tube ventilation (OLTV).

RESULTS

OLTV resulted in effective ventilation over the entire rescue distance with the highest mean minute volumes (NV 0, MMV 2.9, OMV 4.1, OLTV 7.6 L · min(-1)). NV was the fastest rescue maneuver while IWR prolonged the rescue maneuver independently of the method of ventilation (mean total rescue time: NV 217, MMV 280, OMV 292, OLTV 290 s). Aspiration of substantial amounts of water occurred only during MMV (mean NV 20, MMV 215, OMV 15, OLTV 6 ml). NV and OLTV were rated as moderately challenging by the lifeguards, whereas MMV and OMV were rated as substantially demanding on a 0-10 visual analog scale (NV 5.3, MMV 7.8, OMV 7.6, OLTV 5.9).

DISCUSSION

The device might facilitate IWR by providing effective ventilation with minimal aspiration and by reducing physical effort. Another advantage is the possibility of delivering 100% oxygen.

EZ-IO(®) intraosseous device implementation in German Helicopter Emergency Medical Service

BACKGROUND

Intraosseous access (IO) is a rapid and safe alternative when peripheral venous access is difficult. Our aim was to summarize the first three years experience with the use of a semi-automatic IO device (EZ-IO(®)) in German Helicopter Emergency Medical Service (HEMS).

METHODS

Included were all patients during study period (January 2009-December 2011) requiring an IO access performed by HEMS team. Outcome variables were IO rate, IO insertion success rates, site of IO access, type of EZ-IO(®) needle set used, strategy of vascular access, procedure related problems and operator's satisfaction.

RESULTS

IO rate was 0.3% (348/120.923). Overall success rate was 99.6% with a first attempt success rate of 85.9%; there was only one failure (0.4%). There were three insertion sites: proximal tibia (87.2%), distal tibia (7.5%) and proximal humerus (5.3%). Within total study group IO was predominantly the second-line strategy (39% vs. 61%, p<0.001), but in children<7 years, in trauma cases and in cardiac arrest IO was more often first-line strategy (64% vs. 28%, p<0.001; 48% vs. 34%, p<0.032; 50% vs. 29%, p<0.002 respectively). Patients with IO access were significantly younger (41.7±28.7 vs. 56.5±24.4 years; p<0.001), more often male (63.2% vs. 57.7%; p=0.037), included more trauma cases (37.3% vs. 30.0%; p=0.003) and more often patients with a NACA-Score≥5 rating (77.0% vs. 18.6%; p<0.001). Patients who required IO access generally presented with more severely compromised vital signs associated with the need for more invasive resuscitation actions such as intubation, chest drains, CPR and defibrillation. In 93% EZ-IO(®) needle set handling was rated "good". Problems were reported in 1.6% (needle dislocation 0.8%, needle bending 0.4% and parafusion 0.4%).

CONCLUSIONS

The IO route was generally used in the most critically ill of patients. Our relatively low rate of usage would indicate that this would be compatible with the recommendations of established guidelines. The EZ-IO(®) intraosseous device proved feasible with a high success rate in adult and pediatric emergency patients in HEMS.

Self-inflating bags versus T-piece resuscitator to deliver sustained inflations in a preterm lamb model

OBJECTIVE

In neonatal resuscitation, the use of a sustained inflation (SI) may facilitate lung aeration. Previous studies comparing different resuscitation devices have shown that one model of self-inflating bag (SIB) could not deliver an SI. We aimed to compare the delivery of an SI using four SIBs with that of a T-piece.

STUDY DESIGN

In intubated preterm lambs, we compared four models of SIB fitted with a positive end expiratory pressure (PEEP) valve to a T-piece using a gas flow of 8 L/min. Four operators aimed to deliver three SIs of 20 cm H₂O for 30 s. The study was repeated with the PEEP valve removed and again with no flow. We measured duration of SI, average inflation pressure (IP) and analysed the shape of the pressure curves.

RESULTS

204 combinations were analysed. Mean (SD) duration of SI was Ambu 6(2)s, Laerdal 14(8)s, Parker Healthcare 5(1)s, Mayo Healthcare 33(2)s and T-piece 33(1)s. Mean (SD) average IP was Ambu 17(3)cm H₂O, Laerdal 17(3)cm H₂O, Parker Healthcare 12(5)cm H₂O, Mayo Healthcare 21(2)cm H₂O and T-piece 20(0)cm H₂O. Duration of SI and average IP was significantly different between SIBs (all p<0.001). The findings were substantially unchanged when PEEP valve and flow were removed (all p>0.05). Only the Mayo system delivered SIs with duration and average IP not significantly different from the T-piece (p>0.05).

CONCLUSIONS

The performance of the four SIBs tested varied considerably. Some are able to deliver an SI even in the absence of gas flow. This may be useful in a resource-limited setting with no gas supply.

[Implementation of focused ultrasonography in an acute care setting]

The legitimacy of intensivists and emergency physicians to use ultrasound in their daily practice is no longer questioned. This new tool is now considered essential in the acute care setting. After overcoming the technological and political obstacles, the current challenge is to implement technology in units. Here we give some recommendations based on our experience of the last fifteen years.

[Do double gloves protect against contamination during cannulation of blood vessels? A prospective randomized study]

BACKGROUND

Undamaged medical gloves protect medical personnel from contact with physiological fluids of the patient. Thus they protect the assistance provider from hand skin contamination with potentially infectious biological materials. The aim of the study was to evaluate the occurrence of pierce, perforations or damage of medical gloves during cannulation of blood vessels.

MATERIALS AND METHODS

In the prospective randomized study 303 pairs of gloves, used during cannulation of blood vessels under simulated resuscitation, were analyzed. Gloves were tested by the water leak test.

RESULTS

The water test revealed 44 cases of damage to the gloves used during cannulation of blood vessels. Significant differences were noted in the frequency of damage to both the outer and single pairs of gloves and the inner pair of gloves.

CONCLUSIONS

The study showed that the use of double gloves provides a higher level of security for a paramedic than the use of a single pair of gloves, however, double gloves reduce the manual dexterity of a paramedic. A large number of damages to gloves are not noticed by medical personnel during surgery.

Intraosseous access in the military operational setting

INTRODUCTION

In an operational military environment, circulatory access can prove difficult for a variety of reasons including profound hypovolaemia, and limited first responder experience. With many injuries that cause catastrophic haemorrhage, such as traumatic limb amputations, circulatory access is needed as quickly as possible. Since 2006, the Defence Medical Services have been using the EZ-IO and FAST1 devices as a means of obtaining circulatory access.

METHODS

A prospective observational study was conducted between March and July 2011 at the Emergency Department, Camp Bastion, Afghanistan. All patients with an intraosseous device had data recorded that included if the device successfully flushed (functionality) and if any problems were encountered.

RESULTS

117 patients presented with a total of 195 devices: 149 were EZ-IO (76%) and 46 were FAST1 (24%). Functionality was recorded for 111 (57%), with 17 failing to function, yielding an overall success rate of 84.7%. Device failure was observed to be more prevalent in the humerus; inability to flush the device was the leading cause, followed by mechanical failure. There were 2 complications, device breaking on removal being the reason for both.

CONCLUSIONS

The devices in the study were tested for a period of time following insertion (median 32 minutes), and still the success rates mirror those found in the literature. Observed differences between sites were not found to be significant with confidence intervals overlapping. Further work is proposed to investigate the long-term complications of intraosseous devices.

Design and evaluation of RFID deployments in a trauma resuscitation bay

We examined configuring a radio frequency identification (RFID) equipment for the best object use detection in a trauma bay. Unlike prior work on RFID, we 1) optimized the accuracy of object use detection rather than just object detection; and 2) quantitatively assessed antenna placement while addressing issues specific to tag placement likely to occur in a trauma bay. Our design started with an analysis of the environment requirements and constraints. We designed several antenna setups with different number of components (RFID tags or antennas) and their orientations. Setups were evaluated under scenarios simulating a dynamic medical setting. We used three metrics with increasing complexity and bias: read rate, received signal strength indication distribution distance, and target application performance. Our experiments showed that antennas above the regions with high object density are most suitable for detecting object use. We explored tagging strategies for challenging objects so that sufficient readout rates are obtained for computing evaluation metrics. Among the metrics, distribution distance was correlated with target application performance, and also less biased and simpler to calculate, which made it an excellent metric for context-aware applications. We present experimental results obtained in the real trauma bay to validate our findings.

Rescue of drowning victims and divers: is mechanical ventilation possible underwater? A pilot study

INTRODUCTION

In-water resuscitation has recently been proposed in the European resuscitation guidelines. Initiation of mechanical ventilation underwater might be considered when an immediate ascent to the surface is impossible or dangerous. The present study evaluated the feasibility of such ventilation underwater.

METHODS

A resuscitation manikin was ventilated using an Interspiro® MK II full-face mask or with an Oxylator® ventilator via a facemask or a laryngeal tube, or with mouth-to-tube inflation. Tidal volumes achieved by the individual methods of ventilation were assessed. The ventilation tests were performed during dives in the wet compartment of a recompression chamber and in a lake. Ventilation was tested at 40, 30, 20, 12, 9 and 6 metres' depth.

RESULTS

Ventilation was impossible with the cuffed mask and only sufficient after laryngeal intubation for a small number of breaths. Laryngeal tube ventilation was associated with the aspiration of large amounts of water and the Oxylator failed during the ascent. Efficient ventilation with the MK II full-face mask was also possible only for a short period. An absolutely horizontal position of the manikin was required for successful ventilation, which is likely to be difficult to achieve in open water. Leakage at the sealing lip of the full-face mask and the cuff of the laryngeal tube led to intrusion of water and resulted in subsequent complete failure of ventilation.

CONCLUSIONS

The efficacy of underwater ventilation seems to be poor with any of the techniques trialed. Water aspiration frequently makes ventilation impossible and might foster emphysema aquosum-like air trapping and, therefore, increase the risk of pulmonary barotrauma during ascent. Because the limitations of underwater ventilation are substantial even under ideal conditions, it cannot be recommended presently for real diving conditions.

The "Resus:Station": the use of clinical simulations in a randomised crossover study to evaluate a novel resuscitation trolley

BACKGROUND AND AIM

Inadequately designed equipment has been implicated in poor efficiency and critical incidents associated with resuscitation. A novel resuscitation trolley (Resus:Station) was designed and evaluated for impact on team efficiency, user opinion, and teamwork, compared with the standard trolley, in simulated cardiac arrest scenarios.

METHODS

Fifteen experienced cardiac arrest teams were recruited (45 participants). Teams performed recorded resuscitation simulations using new and conventional trolleys, with order of use randomised. After each simulation, efficiency ("time to drugs", un-locatable equipment, unnecessary drawer opening) and team performance (OSCAR) were assessed from the video recordings and participants were asked to complete questionnaires scoring various aspects of the trolley on a Likert scale.

RESULTS

Time to locate the drugs was significantly faster (p=0.001) when using the Resus:Station (mean 5.19s (SD 3.34)) than when using the standard trolley (26.81s (SD16.05)). There were no reports of missing equipment when using the Resus:Station. However, during four of the fifteen study sessions using the standard trolley participants were unable to find equipment, with an average of 6.75 unnecessary drawer openings per simulation. User feedback results clearly indicated a highly significant preference for the newly designed Resus:Station for all aspects. Teams performed equally well for all dimensions of team performance using both trolleys, despite it being their first exposure to the Resus:Station.

CONCLUSION

We conclude that in this simulated environment, the new design of trolley is safe to use, and has the potential to improve efficiency at a resuscitation attempt.

Do bulb syringes conform to neonatal resuscitation guidelines?

OBJECTIVE

To reduce airway injury secondary to high suction pressures, the American Academy of Pediatrics Neonatal Resuscitation Program (NPR) recommends that suction pressures be less than 100 mm Hg. This study was conducted to determine if suction bulbs conform to these recommendations.

STUDY DESIGN

In this prospective in vitro study, 25 personnel involved in neonatal resuscitation squeezed a new bulb three times for each of six commercially available bulbs using their delivery suite technique. A calibrated, pneumatic transducer measured the pressure of each squeeze.

RESULTS

Only one bulb met the NRP guidelines with none of the participants exceeding 100mm Hg (p<0.001).

CONCLUSIONS

Only one bulb met the NRP guidelines of generating pressures less than 100 mm Hg. This bulb's large size (3 oz) may preclude its use in premature infants. Individuals involved in resuscitating newborns need to be aware of the pressures generated to avoid injuring the delicate oral airway.

Introducing RFID technology in dynamic and time-critical medical settings: requirements and challenges

We describe the process of introducing RFID technology in the trauma bay of a trauma center to support fast-paced and complex teamwork during resuscitation. We analyzed trauma resuscitation tasks, photographs of medical tools, and videos of simulated resuscitations to gain insight into resuscitation tasks, work practices and procedures. Based on these data, we discuss strategies for placing RFID tags on medical tools and for placing antennas in the environment for optimal tracking and activity recognition. Results from our preliminary RFID deployment in the trauma bay show the feasibility of our approach for tracking tools and for recognizing trauma team activities. We conclude by discussing implications for and challenges to introducing RFID technology in other similar settings characterized by dynamic and collocated collaboration.

Impact of a nationwide training program for neonatal resuscitation in China

BACKGROUND

Seventeen million births occur in China each year. Neonatal mortality is the leading cause of under 5-year-old child deaths, and intrapartum-related injury accounts for much of mental retardation in young children. The Chinese Ministry of Health sought to improve infant and child survival through a nationwide initiative to have at least one person trained in neonatal resuscitation at every birth. The aim of the current study was to evaluate the impact of China Neonatal Resuscitation Program (NRP) on policy and infrastructure changes and its effectiveness in decreasing the incidence of mortality among newborn infants.

METHODS

The Chinese NRP incorporated policy change, professional education, and creation of a sustainable health system infrastructure for resuscitation. Multidisciplinary teams from all 31 provinces and municipal states disseminated NRP in a train-the-trainer cascade. The intervention targeted 20 provinces with high neonatal mortality and programs to reduce maternal mortality. Program evaluation data came from 322 representative hospitals in those provinces.

RESULTS

Changes in policy permitted midwives to initiate resuscitation and required resuscitation training for licensure. From 2004 through 2009 more than 110,659 professionals received NRP training in the 20 target provinces, with 94% of delivery facilities and 99% of counties reached. Intrapartum-related deaths in the delivery room decreased from 7.5 to 3.4 per 10,000 from 2003 to 2008, and the incidence of Apgar ≤ 7 at 1 minute decreased from 6.3% to 2.9%.

CONCLUSIONS

The Chinese NRP achieved policy changes promoting resuscitation, trained large numbers of professionals, and contributed to reduction in delivery room mortality. Improved adherence to the resuscitation algorithm, extension of training to the township level, and coverage of births now occurring outside health facilities can further increase the number of lives saved.

Novel target volume marked adult bag to deliver accurate tidal volume for paediatric and adolescent resuscitation

AIM

To overcome limitations of inaccurate tidal volume (TV) delivery by conventional selfinflating paediatric and adult bags during paediatric and adolescent resuscitation, we designed a novel target volume marked bag (TVMB) with four compression points marked on an adult bag surface. The aim of this study was to evaluate the TVMB in delivering preset TV.

METHODS

Fifty-three subjects (28 doctors, 17 nurses, 8 paramedics) participated in this simulation trial. TVMB, paediatric bag and adult bag were connected to a gas flow analyser for measuring TV and peak inspiratory pressure (PIP). In a random cross-over setting, participants delivered 10 ventilations using the adult bag, paediatric bag or TVMB in each of four target volume ranges (100-200 ml, 200-300 ml, 300-400 ml, 400-500 ml). We compared TV and PIP for the adult bag, paediatric bag and TVMB in each subject.

RESULTS

Compared with the paediatric bag, TVMB showed higher rates of accurate TV delivery in the 200-300 ml target volume range (87-90% versus 32-35%; p < 0.05). Compared with the adult bag, TVMB showed higher rates of accurate TV delivery in all target volume ranges (75-90% versus 45-50%; p < 0.05). The frequency of too high or low TV delivery was higher with the adult bag than TVMB (20-30% versus 0-5%; p < 0.05). There was no significant difference in PIP between the paediatric bag and TVMB (within 5 cm H(2)O; p < 0.05).

CONCLUSIONS

TVMB could deliver accurate TV in various target volume ranges for paediatric and adolescent resuscitation.