ASSESSMENT OF ABNORMAL SKELETAL MUSCLE PERFUSION BY CONTRAST-ENHANCED ULTRASOUND WITH PARAMETRIC IMAGING IN RATS AFTER SEVERE INJURY, HEMORRHAGIC SHOCK, AND WHOLE BLOOD RESUSCITATION.

ABSTRACT: Background: After severe injury, optical measures of microvascular blood flow (MBF) decrease and do not normalize with resuscitation to normal blood pressure. These changes are associated with organ dysfunction, coagulopathy, and death. However, the pathophysiology is not well understood. Several possible pathways could also contribute to the development of trauma-induced coagulopathy (TIC). A small-animal model of trauma-related MBF derangement that persists after resuscitation and includes TIC would facilitate further study. Parametric contrast-enhanced ultrasound (CEUS) is particularly advantageous in this setting, because it noninvasively assesses MBF in large, deep vascular beds. We sought to develop such a model, measuring MBF with CEUS. Methods: Sixteen male Sprague-Dawley rats were anesthetized, ventilated, and cannulated. Rats were subjected to either no injury (sham group) or a standardized polytrauma and pressure-targeted arterial catheter hemorrhage with subsequent whole blood resuscitation (trauma group). At prespecified time points, CEUS measurements of uninjured quadriceps muscle, viscoelastic blood clot strength, and complete blood counts were taken. Results: After resuscitation, blood pressure normalized, but MBF decreased and remained low for the rest of the protocol. This was primarily driven by a decrease in blood volume with a relative sparing of blood velocity. Viscoelastic blood clot strength and platelet count also decreased and remained low throughout the protocol. Conclusion: We present a rat model of MBF derangement in uninjured skeletal muscle and coagulopathy after polytrauma that persists after resuscitation with whole blood to normal macrohemodynamics. Parametric CEUS analysis shows that this change is primarily due to microvascular obstruction. This platform can be used to develop a deeper understanding of this important process.

Direct assessment of microcirculation in shock: a randomized-controlled multicenter study.

PURPOSE: Shock is a life-threatening condition characterized by substantial alterations in the microcirculation. This study tests the hypothesis that considering sublingual microcirculatory perfusion variables in the therapeutic management reduces 30-day mortality in patients admitted to the intensive care unit (ICU) with shock. METHODS: This randomized, prospective clinical multicenter trial-recruited patients with an arterial lactate value above two mmol/L, requiring vasopressors despite adequate fluid resuscitation, regardless of the cause of shock. All patients received sequential sublingual measurements using a sidestream-dark field (SDF) video microscope at admission to the intensive care unit (± 4 h) and 24 (± 4) hours later that was performed blindly to the treatment team. Patients were randomized to usual routine or to integrating sublingual microcirculatory perfusion variables in the therapy plan. The primary endpoint was 30-day mortality, secondary endpoints were length of stay on the ICU and the hospital, and 6-months mortality. RESULTS: Overall, we included 141 patients with cardiogenic (n = 77), post cardiac surgery (n = 27), or septic shock (n = 22). 69 patients were randomized to the intervention and 72 to routine care. No serious adverse events (SAEs) occurred. In the interventional group, significantly more patients received an adjustment (increase or decrease) in vasoactive drugs or fluids (66.7% vs. 41.8%, p = 0.009) within the next hour. Microcirculatory values 24 h after admission and 30-day mortality did not differ [crude: 32 (47.1%) patients versus 25 (34.7%), relative risk (RR) 1.39 (0.91-1.97); Cox-regression: hazard ratio (HR) 1.54 (95% confidence interval (CI) 0.90-2.66, p = 0.118)]. CONCLUSION: Integrating sublingual microcirculatory perfusion variables in the therapy plan resulted in treatment changes that do not improve survival at all.

Perspectives on peripheral perfusion assessment.

PURPOSE OF REVIEW: The ANDROMEDA-SHOCK trial positioned capillary refill time (CRT) assessment as a novel resuscitation target for septic shock.The purpose of this article is to summarize pathophysiological determinants of CRT, review new technical developments on peripheral perfusion assessment, and explore recent evidence on the role of CRT monitoring in septic shock and other critical conditions. RECENT FINDINGS: A growing body of evidence supports the role of peripheral perfusion assessment as a warning and prognostic signal in a variety of clinical conditions among severely ill patients. Recent physiological studies demonstrated a rapid improvement of CRT after a single fluid bolus or a passive leg raising maneuver, a fact which may have diagnostic and therapeutic implications. Moreover, a couple of posthoc analyses of ANDROMEDA-SHOCK trial, reinforce that a normal CRT at the start of septic shock resuscitation, or its rapid normalization, thereafter may be associated with significant better outcomes. SUMMARY: Recent data confirm the relevance of peripheral perfusion assessment in septic shock and other conditions in critically ill patients. Future studies should confirm these findings, and test the potential contribution of technological devices to assess peripheral perfusion.

Retrospective value assessment of a dedicated, trauma hybrid operating room.

BACKGROUND: In traumatic hemorrhage, hybrid operating rooms offer near simultaneous performance of endovascular and open techniques, with correlations to earlier hemorrhage control, fewer transfusions, and possible decreased mortality. However, hybrid operating rooms are resource intensive. This study quantifies and describes a single-center experience with the complications, cost-utility, and value of a dedicated trauma hybrid operating room. METHODS: This retrospective cohort study evaluated 292 consecutive adult trauma patients who underwent immediate (<4 hours) operative intervention at a Level I trauma center. A total of 106 patients treated before the construction of a hybrid operating room served as historical controls to the 186 patients treated thereafter. Demographics, hemorrhage-control procedures, and financial data as well as postoperative complications and outcomes were collected via electronic medical records. Value and incremental cost-utility ratio were calculated. RESULTS: Demographics and severity of illness were similar between cohorts. Resuscitative endovascular occlusion of the aorta was more frequently used in the hybrid operating room. Hemorrhage control occurred faster (60 vs. 49 minutes, p = 0.005) and, in the 4- to 24-hour postadmission period, required less red blood cell (mean, 1.0 vs. 0 U, p = 0.001) and plasma (mean, 1.0 vs. 0 U, p < 0.001) transfusions. Complications were similar except for a significant decrease in pneumonia (7% vs. 4%, p = 0.008). Severe complications (Clavien-Dindo classification, ≥3) were similar. Across the patient admission, costs were not significantly different ($50,023 vs. $54,740, p = 0.637). There was no change in overall value (1.00 vs. 1.07, p = 0.778). CONCLUSION: The conversion of our standard trauma operating room to an endovascular hybrid operating room provided measurable improvements in hemorrhage control, red blood cell and plasma transfusions, and postoperative pneumonia without significant increase in cost. Value was unchanged. LEVEL OF EVIDENCE: Economic/Value-Based Evaluations; Level III.

A Pilot Medic-based Assessment of the Novel Handheld LifeFlow Device for Rapid Infusion of Blood Products.

INTRODUCTION: Uncontrolled hemorrhage remains the leading cause of preventable death in the prehospital, combat setting. Treatment guidelines emphasize immediate hemorrhage control and early resuscitation with whole blood or blood products. Current methods for the delivery of blood products are often insufficient to provide trauma resuscitation. The novel LifeFlow device is a hand-powered device that can rapidly infuse fluids, including blood products. However, successful use of this device in the hands of the intended end user has not been demonstrated. MATERIALS AND METHODS: We conducted a pilot study to assess how quickly and effectively medics could set up the LifeFlow device and infuse mock blood products into a casualty. They were provided with a brief block of instruction (<10 min) and the opportunity to handle the device. The time to set up the device and proportion of successful completion were recorded. Participants were surveyed regarding the use of the device including post-study interview. RESULTS: Forty medics, who were recruited and eligible to participate, completed the study procedures. All medics were able to successfully set up the device and perform the infusion. We had two instances of fluid leakage owing to malfunctions with the simulation arm, not the LifeFlow device. The mean time to device setup was 112 s (95% confidence interval [CI], 101-124). The mean time for infusion of 500 mL of fluid was 94 s (95% CI, 83-105). The mean time for all procedures was 197 s (95% CI, 178-213). On product feedback, they generally found it easier to use, easy to manipulate, possessing a useful grip, easily set up, and requiring minimal training. CONCLUSIONS: The medics were able to reliably assemble and use the LifeFlow rapid infusion device. However, there were concerns about the packaging and the single indication for the device.

Examining the Validity of Pediatric Resident Self-Assessment in the Delivery Room.

OBJECTIVE: The validity of resident self-assessment of competence in neonatal resuscitation skills has not been studied. This study was designed to test the hypothesis that residents are accurate in self-assessment of basic delivery room resuscitation and bag-and-mask ventilation (BMV) skills by comparing resident self-assessed performance with assessment by observers. STUDY DESIGN: We conducted a prospective repeated measures observational study. After each delivery residents and observers completed 13-question standardized assessments evaluating resident performance. RESULTS: A total of 99 paired assessments were completed by 36 residents. Residents competently performed and identified correct versus incorrect performance of basic resuscitation steps. Residents were less competent in recognizing the need for BMV and were unable to self-assess BMV-associated performance accurately. In multivariable analysis, only basic resuscitation steps versus BMV were significantly associated with accurate self-assessment. CONCLUSION: Pediatric residents are less competent at performing advanced neonatal resuscitation skills and are unable to accurately self-assess performance of skills essential for neonatal resuscitation. KEY POINTS: · Pediatric residents can competently identify and perform basic neonatal resuscitation steps.. · Pediatric residents are less competent at performing advanced neonatal resuscitation skills.. · Self-assessment is not a valid method for determining resident competence in neonatal resuscitation..

Combined application of various quality assessment tools in neonatal resuscitation.

INTRODUCTION: In neonatal resuscitation, it is important to know whether the use of a combination of quality assessment tools has an impact on the preparation of the resuscitation bed and equipment, the correct performance of the procedure and the clinical outcomes of the most vulnerable neonates. MATERIAL AND METHODS: Multicentre, prospective, quasi-experimental interventional study in five level III-A neonatal units. In the pre- and post-intervention phases, both of which lasted 1 year, there were weekly random audits of the stabilization beds in the delivery room to assess their preparation. In the post-intervention phase, checklists, briefings and debriefings were used in the resuscitation of neonates delivered before 32 weeks. We compared the performance of the procedure and early post-resuscitation outcomes in the 2 periods. RESULTS: Total of 852 audits were carried out in the pre-intervention period and 877 in the post-intervention period. There was a greater percentage of audits that did not identify defects in the second phase (63% vs 81%; P < .001). The first phase included 75 resuscitations and the second 48, out of which all the quality assessment tools had been used in 36 (75%). We did not find any differences in the main clinical variables during stabilization, although we observed a trend towards fewer technical problems during the procedure in the second period. CONCLUSIONS: The use of random audits, checklists, briefings and debriefings in the resuscitation of newborns delivered before 32 weeks is feasible but has no impact on short-term clinical outcomes or correct performance of the procedure. Audits of neonatal resuscitation beds significantly improved their preparation.

The effectiveness and cost-effectiveness of resuscitative endovascular balloon occlusion of the aorta (REBOA) for trauma patients with uncontrolled torso haemorrhage: study protocol for a randomised clinical trial (the UK-REBOA trial).

BACKGROUND: Haemorrhage is the most common cause of preventable death after injury. REBOA is a novel technique whereby a percutaneously inserted balloon is deployed in the aorta, providing a relatively quick means of temporarily controlling haemorrhage and augmenting cerebral and coronary perfusion, until definitive control of haemorrhage can be attained. The aim of the UK-REBOA trial is to establish the clinical and cost-effectiveness of a policy of standard major trauma centre treatment plus REBOA, as compared with standard major trauma centre treatment alone, for the management of uncontrolled torso haemorrhage caused by injury. METHODS: Pragmatic, Bayesian, group-sequential, randomised controlled trial, performed in 16 major trauma centres in England. We aim to randomise 120 injured patients with suspected exsanguinating haemorrhage to either standard major trauma centre care plus REBOA or standard major trauma centre care alone. The primary clinical outcome is 90-day mortality. Secondary clinical outcomes include 3-h, 6-h, and 24-h mortality; in-hospital mortality; 6-month mortality; length of stay (in hospital and intensive care unit); 24-h blood product use; need for haemorrhage control procedure (operation or angioembolisation); and time to commencement of haemorrhage control procedure (REBOA, operation, or angioembolisation). The primary economic outcome is lifetime incremental cost per QALY gained, from a health and personal social services perspective. DISCUSSION: This study, which is the first to randomly allocate patients to treatment with REBOA or standard care, will contribute high-level evidence on the clinical and cost-effectiveness of REBOA in the management of trauma patients with exsanguinating haemorrhage and will provide important data on the feasibility of implementation of REBOA into mainstream clinical practice. TRIAL REGISTRATION: ISRCTN16184981.

Video recording as an objective assessment tool of health worker performance in neonatal resuscitation at a district hospital in Pemba, Tanzania: a feasibility study.

OBJECTIVES: To assess the feasibility of using video recordings of neonatal resuscitation (NR) to evaluate the quality of care in a low-resource district hospital. DESIGN: Prospective observational feasibility study. SETTING: Chake-Chake Hospital, a district hospital in Pemba, Tanzania, in April and May 2019. PARTICIPANTS: All delivering women and their newborns were eligible for participation. MAIN OUTCOME MEASURES: Motion-triggered cameras were mounted on resuscitation tables and provided recordings that were analysed for quality of care indicators based on the national NR algorithm. Assessment of feasibility was conducted using Bowen's 8-point framework for feasibility studies. RESULTS: 91% (126 of 139) of women and 96% (24 of 26) of health workers were comfortable or very comfortable with the video recordings. Of 139 newborns, 8 underwent resuscitation with bag and mask ventilation. In resuscitations, heat loss prevention measures were not performed in half of the cases (four of eight), clearing the airway was not performed correctly in five of eight cases, and all newborns were suctioned vigorously and repeatedly, even when not indicated. In a quarter (two of eight) of cases, the newborn's head was not positioned correctly. Additionally, two of the eight newborns needing ventilation were not ventilated within the first minute of life. In none of the eight cases did ventilation appear to be performed effectively. CONCLUSIONS: It proved feasible to use video recordings to assess quality of care during NR in a low-resource setting, and the method was considered acceptable for the delivering women and health workers. Recordings of eight resuscitations all demonstrated deviations from NR guidelines.

Needs assessment of resuscitative endovascular balloon occlusion of the aorta (REBOA) in patients with major haemorrhage: a cross-sectional study.

BACKGROUND: Resuscitative endovascular balloon occlusion of the aorta (REBOA) can be used as an adjunct treatment in traumatic abdominopelvic haemorrhage, ruptured abdominal aortic aneurysms, postpartum haemorrhage (PPH), gastrointestinal bleeding and iatrogenic injuries during surgery. This needs assessment study aims to determine the number of patients eligible for REBOA in a typical Norwegian population. METHODS: This was a retrospective cross-sectional study based on data obtained from blood bank registries and the Norwegian Trauma Registry for the years 2017-2018. Patients who received ≥4 units of packed red blood cells (PRBCs) within 6 hours and met the anatomical criteria for REBOA or patients with relevant Abbreviated Injury Scale codes with concurrent hypotension or transfusion of ≥4 units of PRBCs within 6 hours were identified. A detailed two-step chart review was performed to identify potentially eligible REBOA candidates. Descriptive data were collected and compared between subgroups using non-parametric tests for statistical significance. RESULTS: Of 804 patients eligible for inclusion, 53 patients were regarded as potentially REBOA eligible (corresponding to 5.7 per 100 000 adult population/year). Of these, 19 actually received REBOA. Among the identified eligible patients, 44 (83%) had a non-traumatic aetiology. Forty-two patients (79%) were treated at a tertiary care hospital. Fourteen (78%) of the REBOA procedures were due to PPH. CONCLUSION: The number of patients potentially eligible for REBOA after haemorrhage is low, and most cases are non-traumatic. Most patients were treated at a tertiary care hospital. The exclusion of non-traumatic patients results in a substantial underestimation of the number of potentially REBOA-eligible patients.

Reliable and valid assessment of procedural skills in resuscitative endovascular balloon occlusion of the aorta.

BACKGROUND: Valid and reliable assessment of skills is essential for improved and evidence-based training concepts. In a recent study, we presented a novel tool to assess procedural skills in resuscitative endovascular balloon occlusion of the aorta (REBOA), REBOA-RATE, based on international expert consensus. Although expert consensus is a strong foundation, the performance of REBOA-RATE has not been explored. The study aimed to examine the reliability and validity of REBOA-RATE. METHODS: This was an experimental simulation-based study. We enrolled doctors with three levels of expertise to perform two REBOA procedures in a simulated scenario of out-of-hospital cardiac arrest. Procedures were video-recorded, and videos were blinded and randomized. Three clinical experts independently rated all procedures using REBOA-RATE. Data were analyzed using Messick's framework for validity evidence, including generalizability analysis of reliability and determination of a pass/fail standard. RESULTS: Forty-two doctors were enrolled: 16 novices, 13 anesthesiologists, and 13 endovascular experts. They all performed two procedures, yielding 84 procedures and 252 ratings. The REBOA-RATE assessment tool showed high internal consistency (Cronbach's α = 0.95) and excellent interrater reliability (intraclass correlation coefficient, 0.97). Assessment using one rater and three procedures could ensure overall reliability suitable for high-stakes testing (G-coefficient >0.80). Mean scores (SD) for the three groups in the second procedure were as follows: novices, 32% (24%); anesthesiologists, 55% (29%); endovascular experts, 93% (4%) (p < 0.001). The pass/fail standard was set at 81%, which all experts but no novices passed. CONCLUSION: Data strongly support the reliability and validity of REBOA-RATE, which successfully discriminated between all experience levels. The REBOA-RATE assessment tool requires minimal instruction, and one rater is sufficient for reliable assessment. Together, these are strong arguments for the use of REBOA-RATE to assess REBOA skills, allowing for competency-based training and certification concepts. LEVEL OF EVIDENCE: Diagnostic test, no or poor gold standard, level V.

Accuracy assessment methods for physiological model selection toward evaluation of closed-loop controlled medical devices.

Physiological closed-loop controlled (PCLC) medical devices are complex systems integrating one or more medical devices with a patient's physiology through closed-loop control algorithms; introducing many failure modes and parameters that impact performance. These control algorithms should be tested through safety and efficacy trials to compare their performance to the standard of care and determine whether there is sufficient evidence of safety for their use in real care setting. With this aim, credible mathematical models have been constructed and used throughout the development and evaluation phases of a PCLC medical device to support the engineering design and improve safety aspects. Uncertainties about the fidelity of these models and ambiguities about the choice of measures for modeling performance need to be addressed before a reliable PCLC evaluation can be achieved. This research develops tools for evaluating the accuracy of physiological models and establishes fundamental measures for predictive capability assessment across different physiological models. As a case study, we built a refined physiological model of blood volume (BV) response by expanding an original model we developed in our prior work. Using experimental data collected from 16 sheep undergoing hemorrhage and fluid resuscitation, first, we compared the calibration performance of the two candidate physiological models, i.e., original and refined, using root-mean-squared error (RMSE), Akiake information criterion (AIC), and a new multi-dimensional approach utilizing normalized features extracted from the fitting error. Compared to the original model, the refined model demonstrated a significant improvement in calibration performance in terms of RMSE (9%, P = 0.03) and multi-dimensional measure (48%, P = 0.02), while a comparable AIC between the two models verified that the enhanced calibration performance in the refined model is not due to data over-fitting. Second, we compared the physiological predictive capability of the two models under three different scenarios: prediction of subject-specific steady-state BV response, subject-specific transient BV response to hemorrhage perturbation, and leave-one-out inter-subject BV response. Results indicated enhanced accuracy and predictive capability for the refined physiological model with significantly larger proportion of measurements that were within the prediction envelope in the transient and leave-one-out prediction scenarios (P < 0.02). All together, this study helps to identify and merge new methods for credibility assessment and physiological model selection, leading to a more efficient process for PCLC medical device evaluation.

Collaboration and Decision-Making on Trauma Teams: A Survey Assessment.

INTRODUCTION: Leadership, communication, and collaboration are important in well-managed trauma resuscitations. We surveyed resuscitation team members (attendings, fellows, residents, and nurses) in a large urban trauma center regarding their impressions of collaboration among team members and their satisfaction with patient care decisions. METHODS: The Collaboration and Satisfaction About Care Decisions in Trauma (CSACD.T) survey was administered to members of ad hoc trauma teams immediately after resuscitations. Survey respondents self-reported their demographic characteristics; the CSACD.T scores were then compared by gender, occupation, self-identified leader role, and level of training. RESULTS: The study population consisted of 281 respondents from 52 teams; 111 (39.5%) were female, 207 (73.7%) were self-reported White, 78 (27.8%) were nurses, and 140 (49.8%) were physicians. Of the 140 physician respondents, 38 (27.1%) were female, representing 13.5% of the total surveyed population. Nine of the 52 teams had a female leader. Men, physicians (vs nurses), fellows (vs attendings), and self-identified leaders trended toward higher satisfaction across all questions of the CSACD.T. In addition to the comparison groups mentioned, women and general team members (vs non-leaders) gave lower scores. CONCLUSION: Female residents, nurses, general team members, and attendings gave lower CSACD.T scores in this study. Identification of nuances and underlying causes of lower scores from female members of trauma teams is an important next step. Gender-specific training may be necessary to change negative team dynamics in ad hoc trauma teams.

Is there a role for REBOA? A system assessment.

INTRODUCTION: To analyze our experience to quantify potential need for resuscitative endovascular balloon occlusion of the aorta (REBOA). METHODS: Retrospective review of patients over a three-year period who presented as a trauma with hemorrhagic shock. Patients were divided into two groups: REBOA Candidate vs. Non-candidates. Injuries, outcomes, and interventions were compared. RESULTS: Of 7643 trauma activations, only 37 (0.44%) fit inclusion criteria, of which 16 met criteria for candidacy for potential REBOA placement. The groups did not differ in terms of injury severity, physiology, age, timing of intervention, nor massive transfusion. Survival was linked to TRISS (p = 0.01) and Emergency Room Thoracotomy (p = 0.002). Of Candidates, 8 (50%) had injuries that could have benefited from REBOA, while 7 (44%) had injuries that could be associated with potential harm. DISCUSSION: The volume of patients who would potentially benefit from REBOA appears to be small and does not appear to support system wide adoption in the studied region. LEVEL OF EVIDENCE: IV.

Economical provision of blood components for critical patient transport across a large geographic area.

BACKGROUND: Rapid air transport of critically injured patients to sites of appropriate care can save lives. The provision of blood products on critical care transport flights may save additional lives by starting resuscitation earlier. METHODS: Our regional trauma center transfusion service provided 2 units of O-negative red blood cells and 2 units of A low-titer anti-B liquid plasma in an internally monitored and sealed eutectic box weighing 10.4 pounds to eight air bases once weekly. Flight crews were instructed to transfuse plasma units first. Unused blood was returned to the transfusion service. Total blood use and wastage were recorded. RESULTS: Over a 6-year period, ≈ 7400 blood components were provided, and >1000 were used by the air transport service in patient care. Plasma units were 57% of all units given. Unused units were returned to the providing transfusion service and used in hospital patient care with <3% loss. Estimated cost of providing blood per mission was $63 and per patient transfused was $1940. CONCLUSIONS: With appropriate attention to detail, it is possible to provide life-saving blood components to aeromedical transport services across a large geographic area with efficient blood component usage, minimal blood wastage, and low cost.

When dispatcher assistance is not saving lives: assessment of process compliance, barriers and outcomes in out-of-hospital cardiac arrest in a metropolitan city in China.

BACKGROUND: Several Chinese cities have implemented dispatcher-assisted cardiopulmonary resuscitation (DA-CPR), although out-of-hospital cardiac arrest (OHCA) survival rates remain low. We aimed to assess the process compliance, barriers and outcomes of OHCA in one of the earliest implemented (DA-CPR) programmes in China. METHODS: We retrospectively reviewed OHCA emergency dispatch records of Suzhou emergency medical service from 2014 to 2015 and included adult OHCA victims (>18 years) with a bystander-witnessed atraumatic OHCA that was subsequently confirmed by on-site emergency physician. The circumstances and DA-CPR process related to the OHCA event were analysed. Dispatch audio records were reviewed to identify potential barriers to implementation during the DA-CPR process. RESULTS: Of the 151 OHCA victims, none survived. The median time from patient collapse to call for emergency services and that from call to provision of cardiopulmonary resuscitation instructions was 30 (IQR 20-60) min and 115 (IQR 90-153) s, respectively. Only 110 (80.3%) bystanders/rescuers followed the dispatcher instructions; of these, 51 (46.3%) undertook persistent chest compressions. Major barriers to following the DA-CPR instructions were present in 104 (68.9%) cases, including caller disconnection of the call, distraught mood or refusal to carry out either compressions or ventilations. CONCLUSIONS: The OHCA survival rate and the DA-CPR process were far from optimal. The zero survival rate is disproportionally low compared with survival statistics in high-income countries. The prolonged delay in calling the emergency services negated and rendered futile any DA-CPR efforts. Thus, efforts targeted at developing public awareness of OHCA, calling for help and competency in DA-CPR should be increased.

Liquid plasma reduces waste and health care expenses compared with thawed plasma at a Level I trauma center.

BACKGROUND: Balanced resuscitation strategies have led to increased utilization of plasma. Fresh frozen plasma that is thawed and never used is a large source of blood component wastage. Thawed plasma (TP) and can only be stored for 5 days. Liquid plasma (LP) has never been frozen and can be stored for 26 days. Due to longer storage duration, we hypothesized that using LP would result in decreased waste and cost savings compared with TP. METHODS: We performed a retrospective review of all trauma patients at our Level I trauma center in the years 2015 to 2016. We compared 2015 when only TP was used to 2016 when both TP and LP were used. All plasma units ordered for trauma patients were tracked until the time of transfusion or wastage. Wastage rates were compared between years and plasma type. RESULTS: There were 5,789 trauma patients admitted to our institution from 2015 to 2016. There were 4,107 plasma units ordered with 487 (11.9%) units wasted. During 2015, 2,021 total units of plasma were ordered with 273 (13.5%) units wasted which was a significantly higher rate than 2016 when 2,086 total units of plasma were ordered and 214 (10.3%) units were wasted (p = 0.0013). During 2016, 1,739 units of TP were ordered and 204 (11.7%) units were wasted which was significantly higher than LP wastage, 347 units ordered and 10 (2.9%) units wasted (p < 0.001). Of the 477 wasted TP units, 76.9% were ordered no more than two times before being wasted and 95.8% were ordered no more than three times before being wasted. Of the 10 LP units wasted, 40% were ordered no more than two times before being wasted, and 50% were ordered no more than three times before being wasted. If TP was wasted at the same rate as LP, 368 fewer units of plasma would have been wasted representing US $39,376 (US $107/unit) of wasted health care expenses. CONCLUSION: At a Level I trauma center, the addition of LP to the blood bank for trauma resuscitations significantly reduced plasma wastage rates and health care expenses. LEVEL OF EVIDENCE: Level III, Economic/Decision.

Critical Care Delivery Solutions in the Emergency Department: Evolving Models in Caring for ICU Boarders.

The National Academy of Medicine has identified emergency department (ED) crowding as a health care delivery problem. Because the ED is a portal of entry to the hospital, 25% of all ED encounters are related to critical illness. Crowding at both an ED and hospital level can thus lead to boarding of a number of critically ill patients in the ED. EDs are required to not only deliver immediate resuscitative and stabilizing care to critically ill patients on presentation but also provide longitudinal care while boarding for the ICU. Crowding and boarding are multifactorial and complex issues, for which different models for delivery of critical care in the ED have been described. Herein, we provide a narrative review of different models of delivery of critical care reported in the literature and highlight aspects for consideration for successful local implementation.

Resuscitation Opportunities for Fellows of Very Low Birth Weight Infants in the Vermont Oxford Network.

BACKGROUND: Neonatal-perinatal medicine (NPM) fellowship programs must provide adequate delivery room (DR) experience to ensure that physicians can independently provide neonatal resuscitation to very low birth weight (VLBW) infants. The availability of learning opportunities is unknown. METHODS: The number of VLBW (≤1500 g) and extremely low birth weight (ELBW) (<1000 g) deliveries, uses of continuous positive airway pressure, intubation, chest compressions, and epinephrine over 3 years at accredited civilian NPM fellowship program delivery hospitals were determined from the Vermont Oxford Network from 2012 to 2017. Using Poisson distributions, we estimated the expected probabilities of fellows experiencing a given number of cases over 3 years at each program. RESULTS: Of the 94 NPM fellowships, 86 programs with 115 delivery hospitals and 62 699 VLBW deliveries (28 703 ELBW) were included. During a 3-year fellowship, the mean number of deliveries per fellow ranged from 14 to 214 (median: 60) for VLBWs and 7 to 107 (median: 27) for ELBWs. One-half of fellows were expected to see ≤23 ELBW deliveries and 52 VLBW deliveries, 24 instances of continuous positive airway pressure, 23 intubations, 2 instances of chest compressions, and 1 treatment with epinephrine. CONCLUSIONS: The number of opportunities available to fellows for managing VLBW and ELBW infants in the DR is highly variable among programs. Fellows' exposure to key, high-risk DR procedures such as cardiopulmonary resuscitation is low at all programs. Fellowship programs should track fellow exposure to neonatal resuscitations in the DR and integrate supplemental learning opportunities. Given the low numbers, the number of new and existing NPM programs should be considered.