Icariin mitigates anxiety-like behaviors induced by hemorrhagic shock and resuscitation via inhibiting of astrocytic activation.

BACKGROUND: Abnormal activation of astrocytes in the amygdala contributes to anxiety after hemorrhagic shock and resuscitation (HSR). Nuclear factor κ-light-chain-enhancer of activated B cells (NF-κB)-associated epigenetic reprogramming of astrocytic activation is crucial to anxiety. A bioactive monomer derived from Epimedium icariin (ICA) has been reported to modulate NF-κB signaling and astrocytic activation. PURPOSE: The present study aimed to investigate the effects of ICA on post-HSR anxiety disorders and its potential mechanism of action. METHODS: We first induced HSR in mice through a bleeding and re-transfusion model and selectively inhibited and activated astrocytes in the amygdala using chemogenetics. Then, ICA (40 mg/kg) was administered by oral gavage once daily for 21 days. Behavioral, electrophysiological, and pathological changes were assessed after HSR using the light-dark transition test, elevated plus maze, recording of local field potential (LFP), and immunofluorescence assays. RESULTS: Exposure to HSR reduced the duration of the light chamber and attenuated open-arm entries. Moreover, HSR exposure increased the theta oscillation power in the amygdala and upregulated NF-κB p65, H3K27ac, and H3K4me3 expression. Contrarily, chemogenetic inhibition of astrocytes significantly reversed these changes. Chemogenetic inhibition in astrocytes was simulated by ICA, but chemogenetic activation of astrocytes blocked the neuroprotective effects of ICA. CONCLUSION: ICA mitigated anxiety-like behaviors induced by HSR in mice via inhibiting astrocytic activation, which is possibly associated with NF-κB-induced epigenetic reprogramming.

Resuscitation and Care in the Trauma Bay.

Start balanced resuscitation early (pre-hospital if possible), either in the form of whole blood or 1:1:1 ratio. Minimize resuscitation with crystalloid to minimize patient morbidity and mortality. Trauma-induced coagulopathy can be largely avoided with the use of balanced resuscitation, permissive hypotension, and minimized time to hemostasis. Using protocolized "triggers" for massive and ultramassive transfusion will assist in minimizing delays in transfusion of products, achieving balanced ratios, and avoiding trauma induced coagulopathy. Once "audible" bleeding has been addressed, further blood product resuscitation and adjunct replacement should be guided by viscoelastic testing. Early transfusion of whole blood can reduce patient morbidity, mortality, decreases donor exposure, and reduces nursing logistics during transfusions. Adjuncts to resuscitation should be guided by laboratory testing and carefully developed, institution-specific guidelines. These include empiric calcium replacement, tranexamic acid (or other anti-fibrinolytics), and fibrinogen supplementation.

[Interpretation of 2023 American Heart Association and American Academy of Pediatrics focused update on neonatal resuscitation guidelines]. / 2023美国心脏协会与美国儿科学会新生儿复苏指南要点更新解读.

In November 2023, the American Heart Association and the American Academy of Pediatrics jointly released key updates to the neonatal resuscitation guidelines based on new clinical evidence. This update serves as an important supplement to the "Neonatal resuscitation: 2020 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care". The aim of this paper is to outline the key updates and provide guidance on umbilical cord management and the selection of positive pressure ventilation equipment and its additional interfaces in neonatal resuscitation.

Correlation between intrapartum CTG findings and interleukin-6 levels in the umbilical cord arterial blood: A prospective cohort study.

OBJECTIVE: to investigate the correlation between the intrapartum CardioTocoGraphic (CTG) findings "suggestive of fetal inflammation" ("SOFI") and the interleukin (IL)-6 level in the umbilical arterial blood. STUDY DESIGN: prospective cohort study conducted at a tertiary maternity unit and including 447 neonates born at term. METHODS: IL-6 levels were systematically measured at birth from a sample of blood taken from the umbilical artery. The intrapartum CTG traces were retrospectively reviewed by two experts who were blinded to the postnatal umbilical arterial IL-6 values as well as to the neonatal outcomes. The CTG traces were classified into "suggestive of fetal inflammation (SOFI)" and "no evidence of fetal inflammation (NEFI) according to the principles of physiologic interpretation the CTG traces. The CTG was classified as "SOFI" if there was a persistent fetal heart rate (FHR) increase > 10 % compared with the observed baseline FHR observed at the admission or at the onset of labor without any preceding repetitive decelerations. The occurrence of Composite Adverse Outcome (CAO) was defined as Neonatal Intensive Care Unit (NICU) or Special Care Baby Unit (SCBU) admission due to one or more of the following: metabolic acidaemia, Apgar score at 5 min ≤ 7, need of neonatal resuscitation, respiratory distress, tachypnoea/polypnea, jaundice requiring phototherapy, hypotension, body temperature instability, poor perinatal adaptation, suspected or confirmed early neonatal sepsis. MAIN OUTCOME MEASURES: To compare the umbilical IL-6 values between the cases with intrapartum CTG traces classified as "SOFI" and those classified as "NEFI"; to assess the correlation of umbilical IL-6 values with the neonatal outcome. RESULTS: 43 (9.6 %) CTG traces were categorized as "SOFI"; IL-6 levels were significantly higher in this group compared with the "NEFI" group (82.0[43.4-325.0] pg/ml vs. 14.5[6.8-32.6] pg/mL; p <.001). The mean FHR baseline assessed 1 h before delivery and the total labor length showed an independent and direct association with the IL-6 levels in the umbilical arterial blood (p <.001 and p = 0.005, respectively). CAO occurred in 33(7.4 %) cases; IL-6 yielded a good prediction of the occurrence of the CAO with an AUC of 0.72 (95 % CI 0.61-0.81). CONCLUSION: Intrapartum CTG findings classified as "SOFI" are associated with higher levels of IL-6 in the umbilical arterial blood.

Cardiac arrest in the perioperative period: a consensus guideline for identification, treatment, and prevention from the European Society of Anaesthesiology and Intensive Care and the European Society for Trauma and Emergency Surgery.

INTRODUCTION: Cardiac arrest in the operating room is a rare but potentially life-threatening event with mortality rates of more than 50%. Contributing factors are often known, and the event is recognised rapidly as patients are usually under full monitoring. This guideline covers the perioperative period and is complementary to the European Resuscitation Council guidelines. MATERIAL AND METHODS: The European Society of Anaesthesiology and Intensive Care and the European Society for Trauma and Emergency Surgery jointly nominated a panel of experts to develop guidelines for the recognition, treatment, and prevention of cardiac arrest in the perioperative period. A literature search was conducted in MEDLINE, EMBASE, CINAHL and the Cochrane Central Register of Controlled Trials. All searches were restricted to publications from 1980 to 2019 inclusive and to the English, French, Italian and Spanish languages. The authors also contributed individual, independent literature searches. RESULTS: This guideline contains background information and recommendation for the treatment of cardiac arrest in the operating room environment, and addresses controversial topics such as open chest cardiac massage, resuscitative endovascular balloon occlusion and resuscitative thoracotomy, pericardiocentesis, needle decompression, and thoracostomy. CONCLUSIONS: Successful prevention and management of cardiac arrest during anaesthesia and surgery requires anticipation, early recognition, and a clear treatment plan. The ready availability of expert staff and equipment must also be taken into consideration. Success not only depends on medical knowledge, technical skills and a well-organised team using crew resource management, but also on an institutional safety culture embedded in everyday practice through continuous education, training, and multidisciplinary co-operation.

Restoring microcirculatory perfusion in a preclinical model of severe hemorrhagic shock: The role of microcirculatory function.

BACKGROUND: No reflow in capillaries (no reflow) is the lack of tissue perfusion that occurs once central hemodynamics are restored. This prevents oxygen transfer and debt repayment to vital tissues after shock resuscitation. Since metabolic swelling of cells and tissues can cause no reflow, it is a target for study in shock. We hypothesize no reflow secondary to metabolic cell swelling causes the problem not addressed by current strategies that increase central hemodynamics alone. METHODS: Anesthetized swine were bled until plasma lactate reached 7.5 mM to 9 mM. Intravenous low volume resuscitation solutions were administered (6.8 mL/kg over 5 minutes) consisting of; (1) lactated Ringer (LR), (2) autologous whole blood, (3) high-dose vitamin C (200 mg/kg), or (4) 10% PEG-20k, a polymer-based cell impermeant that corrects metabolic cell swelling. Outcomes were macrohemodynamics (MAP), plasma lactate, capillary flow in the gut and tongue mucosa using orthogonal polarization spectral imaging (OPSI), and survival to 4 hours. RESULTS: All PEG-20k resuscitated swine survived 240 minutes with MAP above 60 mm Hg compared with 50% and 0% of the whole blood and LR groups, respectively. The vitamin C group died at just over 2 hours with MAPs below 40 and high lactate. The LR swine only survived 30 minutes and died with low MAP and high lactate. Capillary flow positively correlated ( p < 0.05) with survival and MAP. Sublingual OPSI correlated with intestinal OPSI and OPSI was validated with a histological technique. DISCUSSION: Targeting micro-hemodynamics in resuscitation may be more important than macrohemodynamics. Fixing both is optimal. Sublingual OPSI is clinically achievable to assess micro-hemodynamic status. Targeting tissue cell swelling that occurs during ATP depletion in shock using optimized osmotically active cell impermeants in crystalloid low volume resuscitation solutions improves perfusion in shocked tissues, which leverages a primary mechanism of injury.

Hypocalcemia in Trauma is Determined by the Number of Units Transfused, Not Whole Blood Versus Component Therapy.

INTRODUCTION: Blood component resuscitation is associated with hypocalcemia (HC) (iCal <0.9 mmol/L) that contributes to coagulopathy and death in trauma patients. It is unknown whether or not whole blood (WB) resuscitation helps mitigate the risk of HC in trauma patients. We hypothesized that calcium homeostasis is maintained and mortality improved in patients who only receive WB. MATERIALS AND METHODS: This is a retrospective review of all adult trauma patients who received WB from July 2018 to December 2020. Variables included transfusions, ionized calcium levels, and calcium replacement. Patients were characterized as follows based on blood products received: WB or WB with other blood components. Groups were compared with respect to HC, correction of HC, 24 h, and inpatient mortality. RESULTS: Two hundred twenty-three patients received WB and met the inclusion criteria. 107 (48%) received WB only. HC occurred in 13% of patients who received more than one WB unit compared to 29% of WB and other blood component patients (P = 0.02). WB patients received less calcium replacement (median 250 mg versus 2000 mg, P < 0.01). HC and total units transfused within 4 h were associated with mortality in the adjusted model. HC significantly increased after 5 units of blood products were transfused, regardless of product type. WB was not protective against HC. CONCLUSIONS: HC and failure to correct HC are significant risk factors for mortality in trauma. Resuscitations with WB only and WB in combination with other blood components are associated with HC especially when more than 5 units of any blood product are transfused. Calcium supplementation should be prioritized in any large volume transfusion, regardless of blood product type.

Cardiac arrest in the perioperative period: a consensus guideline for identification, treatment, and prevention from the European Society of Anaesthesiology and Intensive Care and the European Society for Trauma and Emergency Surgery.

INTRODUCTION: Cardiac arrest in the operating room is a rare but potentially life-threatening event with mortality rates of more than 50%. Contributing factors are often known, and the event is recognised rapidly as patients are usually under full monitoring. This guideline covers the perioperative period and is complementary to the European Resuscitation Council (ERC) guidelines. MATERIAL AND METHODS: The European Society of Anaesthesiology and Intensive Care and the European Society for Trauma and Emergency Surgery jointly nominated a panel of experts to develop guidelines for the recognition, treatment and prevention of cardiac arrest in the perioperative period. A literature search was conducted in MEDLINE, EMBASE, CINAHL and the Cochrane Central Register of Controlled Trials. All searches were restricted to publications from 1980 to 2019 inclusive and to the English, French, Italian and Spanish languages. The authors also contributed individual, independent literature searches. RESULTS: This guideline contains background information and recommendation for the treatment of cardiac arrest in the operating room environment, and addresses controversial topics such as open chest cardiac massage (OCCM), resuscitative endovascular balloon occlusion (REBOA) and resuscitative thoracotomy, pericardiocentesis, needle decompression and thoracostomy. CONCLUSION: Successful prevention and management of cardiac arrest during anaesthesia and surgery requires anticipation, early recognition and a clear treatment plan. The ready availability of expert staff and equipment must also be taken into consideration. Success not only depends on medical knowledge, technical skills and a well organised team using crew resource management but also on an institutional safety culture embedded in everyday practice through continuous education, training and multidisciplinary co-operation.

Quasi-experimental quantitative study of training programme for nurses and midwives regarding provision of neonatal resuscitation in selected governmental hospital, (Sudan), 2018.

AIMS: To measure the effectiveness of educational programmes for nurses regarding knowledge and practice of advanced resuscitation for newborn infants. DESIGN: This is a quasi-experimental study in (Sudan, White Nile state), to evaluate the effectiveness of designed guidelines regarding advanced neonatal resuscitation for midwives during the period November 2020-January 2021. METHODS: Data were collected using two tools: semi-structured questionnaire and checklist. The number of the respondents to the questionnaire is 75 nurses. Statistical analyses were conducted using SPSS (version 22). Data were expressed as percentages. The results show that the level of knowledge is improved significantly after training programme interventions, with safe practice reaching (98.70%) compared with a pre-test percentage of (11.5%). This indicates a steep rise in safe practice after the simulation section, a sharp decrease in unsafe practice after the practical section, followed by subsequent decrease in neonatal mortality rate. This paper has been guided by (STROBE, cohort study) checklist. RESULTS: The study concluded that the majority of nurses and midwives have some knowledge regarding advanced neonatal resuscitation but still, there is a practice gap because of a shortage of facilities and lack of training, However, training programmes do add value on knowledge and practice for nurses and eventually decrease neonatal mortality rate.

Effect of the Helping Babies Breathe Program on Newborn Outcomes: Systematic Review and Meta-Analysis.

Background and objectives: In low- and middle-income countries, the leading cause of neonatal mortality is perinatal asphyxia. Training in neonatal resuscitation has been shown to decrease this cause of mortality. The program "Helping Babies Breathe" (HBB) is a program to teach basic neonatal resuscitation focused on countries and areas with limited economic resources. The aim of the study was to determine the effect of the implementation of the HBB program on newborn outcomes: mortality and morbidity. Material and Methods: A systematic review was carried out on observational studies and clinical trials that reported the effect of the implementation in low- and middle-income countries of the HBB program on neonatal mortality and morbidity. We carried out a meta-analysis of the extracted data. Random-effect models were used to evaluate heterogeneity, using the Cochrane Q and I2 tests, and stratified analyses were performed by age and type of outcome to determine the sources of heterogeneity. Results: Eleven studies were identified. The implementation of the program includes educational strategies focused on the training of doctors, nurses, midwives, and students of health professions. The poled results showed a decrease in overall mortality (OR 0.67; 95% CI 0.57, 0.80), intrapartum stillbirth mortality (OR 0.62; 95% CI 0.51, 0.75), and first-day mortality (OR 0.70; 95% IC 0.64, 0.77). High heterogeneity was found, which was partly explained by differences in the gestational age of the participants. Conclusions: The implementation of the program HBB in low- and medium-income countries has a significant impact on reducing early neonatal mortality.

Effect of in-hospital training in newborn resuscitation on the competence of health-care workers in resuscitating newborn infants at birth at Mboppi Baptist Hospital, Douala, Cameroon.

Introduction: neonatal mortality accounts for the most significant proportion of under-five mortality worldwide, as in Cameroon. Birth asphyxia is the leading cause of neonatal deaths in Cameroon. Training of health care workers (HCWs) in newborn resuscitation reduces neonatal morbidity and mortality. In this study, we evaluated the effect of in-hospital training on the competence (knowledge and skills) of HCWs in newborn resuscitation at Mboppi Baptist Hospital, Douala, Cameroon. Methods: this was a quasi-experimental study done in five weeks, in which we compared knowledge and skills before and after training. Assessment of knowledge and skills of HCWs in newborn resuscitation was done before training (simulations) and a week after training using World Health Organization (WHO) adapted Emergency Triage Assessment and Treatment (ETAT+) standard tool. Three key informant interviews (KIIs) and a focused group discussion (FGD) were held to determine barriers to effective newborn resuscitation. Data were analyzed using R software version 3.6.2. McNemar test and Cohen´s Kappa were used to analyze quantitative data, while major themes from KIIs and FGDs were selected for qualitative data. Results: we enrolled 30 HCWs, each HCW was observed twice, a total of 60 deliveries observed before and 60 after training. Sixteen HCWs (53%) showed adequate knowledge before and after training. Median scores for skills significantly increased by 28% (p<0.00054) for real-life observations and 26% (p=0.0004) for newborn resuscitation scenario simulations. The main barriers to adequate newborn resuscitation were inadequate knowledge, equipment, shortage of trained staff and poor teamwork between midwives and anesthetists. Conclusion: in-hospital training on newborn resuscitation improved the skills of HCWs but had no significant effect on their knowledge on newborn resuscitation. We would recommend that in-hospital training in newborn resuscitation be done often for HCWs.

Acupuncture versus pharmacological conversation in treatment of atrial fibrillation in a randomized controlled trial: a systemic review and meta-analysis.

OBJECTIVE: This study aimed to investigate the effect of conventional drugs combined with acupuncture therapy on the conversion of sinus rhythm in patients with atrial fibrillation. METHODS: We searched databases, such as PubMed, Embase, WOS, Cochrane, CNKI (China National Knowledge Infrastructure), Wan fang Data, VIP, and CBM to collect data in randomized controlled trials of acupuncture included patients with atrial fibrillation. Publication time was limited from the beginning to May 15, 2021. The primary outcome is the number of participants who converted successfully. RESULTS: A total of 11 papers were included in this study. The combined effect indicated that acupuncture significantly effectively benefitted the patients with atrial fibrillation (RR = 1.208, 95% CI 1.123, 1.298, P < 0.001). Further subgroup analysis of persistent and paroxysmal atrial fibrillation and the timing of acupuncture suggested that the addition of acupuncture was not statistically significant in the treatment of persistent AF compared to the control group (RR = 1.147, 95% CI 0.811, 1.623 P = 0.147). The combination of acupuncture was more effective in paroxysmal AF RR = 1.148 (95% CI 1.064, 1.239) P < 0.001. In addition, when the acupuncture time was limited to 20 min, it had the best treatment effect (RR = 1.510, 95% CI 1.25, 1.82). CONCLUSIONS: The combination of pharmacological resuscitation with acupuncture significantly improved the conversion of paroxysmal atrial fibrillation compared to pharmacological resuscitation only. The most significant benefit was achieved with an acupuncture duration of < 20 min. Thus, the combination of acupuncture could be considered in clinical practice for the resuscitation of patients with atrial fibrillation.

A hybrid type I, multi-center randomized controlled trial to study the implementation of a method for Sustained cord circulation And VEntilation (the SAVE-method) of late preterm and term neonates: a study protocol.

BACKGROUND: An intact umbilical cord allows the physiological transfusion of blood from the placenta to the neonate, which reduces infant iron deficiency and is associated with improved development during early childhood. The implementation of delayed cord clamping practice varies depending on mode of delivery, as well as gestational age and neonatal compromise. Emerging evidence shows that infants requiring resuscitation would benefit if respiratory support were provided with the umbilical cord intact. Common barriers to providing intact cord resuscitation is the availability of neonatal resuscitation equipment close to the mother, organizational readiness for change as well as attitudes and beliefs about placental transfusion within the multidisciplinary team. Hence, clinical evaluations of cord clamping practice should include implementation outcomes in order to develop strategies for optimal cord management practice. METHODS: The Sustained cord circulation And Ventilation (SAVE) study is a hybrid type I randomized controlled study combining the evaluation of clinical outcomes with implementation and health service outcomes. In phase I of the study, a method for providing in-bed intact cord resuscitation was developed, in phase II of the study the intervention was adapted to be used in multiple settings. In phase III of the study, a full-scale multicenter study will be initiated with concurrent evaluation of clinical, implementation and health service outcomes. Clinical data on neonatal outcomes will be recorded at the labor and neonatal units. Implementation outcomes will be collected from electronic surveys sent to parents as well as staff and managers within the birth and neonatal units. Descriptive and comparative statistics and regression modelling will be used for analysis. Quantitative data will be supplemented by qualitative methods using a thematic analysis with an inductive approach. DISCUSSION: The SAVE study enables the safe development and evaluation of a method for intact cord resuscitation in a multicenter trial. The study identifies barriers and facilitators for intact cord resuscitation. The knowledge provided from the study will be of benefit for the development of cord clamping practice in different challenging clinical settings and provide evidence for development of clinical guidelines regarding optimal cord clamping. TRIAL REGISTRATION: Clinicaltrials.gov, NCT04070560 . Registered 28 August 2019.

Trauma-induced hypocalcemia.

BACKGROUND: Trauma-induced hypocalcemia is an underappreciated complication of severe injury but is well known to result in the derangement of an array of physiological regulatory mechanisms. Existing literature provides a compelling link between hypocalcemia and worse trauma-induced coagulopathy and increased mortality after injury. STUDY DESIGN AND METHODS: This narrative review evaluates available data related to the risk factors, mechanisms, and treatment of hypocalcemia after severe injury. The authors did not perform a systemic review or meta-analysis. RESULTS AND DISCUSSION: The interplay of acidosis, hypothermia, and coagulopathy with hypocalcemia potentiates the bloody vicious cycle of hemorrhagic shock which has been the paradigm of trauma resuscitation for over half a century. However, current screening and treatment of postinjury hypocalcemia are relegated to a secondary consideration in trauma resuscitation. We conclude calcium supplementation should be a primary tier intervention for life-threatening injury.

Vitamin C improves microvascular reactivity and peripheral tissue perfusion in septic shock patients.

BACKGROUND: Vitamin C has potential protective effects through antioxidant and anti-inflammatory properties. However, the effect of vitamin C supplementation on microvascular function and peripheral tissue perfusion in human sepsis remains unknown. We aimed to determine vitamin C effect on microvascular endothelial dysfunction and peripheral tissue perfusion in septic shock patients. METHODS: Patients with septic shock were prospectively included after initial resuscitation. Bedside peripheral tissue perfusion and skin microvascular reactivity in response to acetylcholine iontophoresis in the forearm area were measured before and 1 h after intravenous vitamin C supplementation (40 mg/kg). Norepinephrine dose was not modified during the studied period. RESULTS: We included 30 patients with septic shock. SOFA score was 11 [8-14], SAPS II was 66 [54-79], and in-hospital mortality was 33%. Half of these patients had vitamin C deficiency at inclusion. Vitamin C supplementation strongly improved microvascular reactivity (AUC 2263 [430-4246] vs 5362 [1744-10585] UI, p = 0.0004). In addition, vitamin C supplementation improved mottling score (p = 0.06), finger-tip (p = 0.0003) and knee capillary refill time (3.7 [2.6-5.5] vs 2.9 [1.9-4.7] s, p < 0.0001), as well as and central-to-periphery temperature gradient (6.1 [4.9-7.4] vs 4.6 [3.4-7.0] °C, p < 0.0001). The beneficial effects of vitamin C were observed both in patients with or without vitamin C deficiency. CONCLUSION: In septic shock patients being resuscitated, vitamin C supplementation improved peripheral tissue perfusion and microvascular reactivity whatever plasma levels of vitamin C. ClinicalTrials.gov Identifier: NCT04778605 registered 26 January 2021.

Facility and care provider emergency preparedness for neonatal resuscitation in Kano, Nigeria.

INTRODUCTION: The knowledge, attitude, and practice of emergency neonatal resuscitation are critical requirements in any facility that offers obstetric and neonatal services. This study aims to conduct a needs assessment survey and obtain individual and facility-level data on expertise and readiness for neonatal resuscitation. We hypothesize that neonatal emergency preparedness among healthcare providers in Kano, Nigeria is associated with the level of knowledge, attitudinal disposition, practice and equipment availability at the facility level. METHODS: A semi-structured, self-administered questionnaire was administered to a cross-section of health providers directly involved with neonatal care (n = 112) and attending a neonatal resuscitation workshop in Kano state. Information regarding knowledge, attitude, practice and facility preparedness for neonatal resuscitation was obtained. Bloom's cut-off score and a validated basic emergency obstetric and neonatal care assessment tool were adopted to categorize outcomes. Multivariable logistic regression was employed to determine independent predictors of knowledge and practice. RESULTS: Almost half (48% and 42% respectively) of the respondents reported average level of self-assessed knowledge and comfort during resuscitation. Only 7% (95% CI:3.2-13.7) and 5% (95% CI:2.0-11.4) of health providers demonstrated good knowledge and practice scores respectively, with an overall facility preparedness of 46%. Respondents' profession as a physician compared to nurses and midwives predicted good knowledge (aOR = 0.08, 95% CI: 0.01-0.69; p = 0.01), but not practice. CONCLUSION: Healthcare provider's knowledge and practice including facility preparedness for emergency neonatal resuscitation were suboptimal, despite the respondents' relatively high self-assessed attitudinal perception. Physicians demonstrated higher knowledge compared to other health professionals. The low level of respondents' awareness, practice, and facility readiness suggest the current weak state of secondary health systems in Kano.

Experiences of community midwives receiving helping baby breathe training through the low dose high-frequency approach in Gujrat, Pakistan.

BACKGROUND: Pakistan's neonatal mortality rate has the highest proportion in the South Asian region and it is higher in the rural areas as compared to the urban areas. Poor resuscitation techniques and lack of basic newborn resuscitation skills in birth attendants are contributing factors towards neonatal deaths. Based on the significant outcomes of the Helping Baby Breath (HBB) training, similar training was implemented for Community Midwives (CMWs) in a low-resource setting in Gujrat, Pakistan, to improve their knowledge and skills. The training evaluation was conducted and participant feedback was obtained through both qualitative and quantitative methods. The findings of the quantitative assessment of the training evaluation will be published elsewhere. This paper presents the qualitative evaluation of the training. OBJECTIVE: The objective of the study was, to determine the perceptions of HBB trained CMWs about the effectiveness of the HBB training, and the challenges faced in the implementation of HBB skills for newborn resuscitation, at their work settings. METHODOLOGY: The qualitative descriptive design was used in this study. The purposive sampling technique was chosen to recruit midwives and key informants as participants of the training. Interviews were conducted by using a semi-structured interview guide. The study included a total of five interviews: two focus group interviews for CMWs (10 in each group), and three individual interviews of key informants. FINDINGS: The content analysis of the qualitative data yielded three themes: the effectiveness of training, challenges, and suggestions. The findings revealed that the HBB training was effective for the CMWs in terms of its usability, regarding improvement in newborn resuscitation knowledge and skills. Moreover, it enhanced confidence and satisfaction in CMWs. However, less volume of patients was a challenge for a few CMWs with regard to practicing their skills. CONCLUSION: Due to the inadequate number of patients and fewer opportunities of practice for several CMWs, they required such training frequently, in order to maintain their competency. The CMWs also recommended that HBB training should be part of the Midwifery program curriculum. Moreover, similar training was also recommended for other healthcare providers working in low-resource settings, including doctors and nurses.

Silent voices of the midwives: factors that influence midwives' achievement of successful neonatal resuscitation in sub-Saharan Africa: a narrative inquiry.

BACKGROUND: In Tanzania, birth asphyxia is a leading cause of neonatal death. The aim of this study was to identify factors that influence successful neonatal resuscitation to inform clinical practice and reduce the incidence of very early neonatal death (death within 24 h of delivery). METHODS: This was a qualitative narrative inquiry study utilizing the 32 consolidated criteria for reporting qualitative research (COREQ). Audio-recorded, semistructured, individual interviews with midwives were conducted. Thematic analysis was applied to identify themes. RESULTS: Thematic analysis of the midwives' responses revealed three factors that influence successful resuscitation: 1. Hands-on training ("HOT") with clinical support during live emergency neonatal resuscitation events, which decreases fear and enables the transfer of clinical skills; 2. Unequivocal commitment to the Golden Minute® and the mindset of the midwife; and. 3. Strategies that reduce barriers. Immediately after birth, live resuscitation can commence at the mother's bedside, with actively guided clinical instruction. Confidence and mastery of resuscitation competencies are reinforced as the physiological changes in neonates are immediately visible with bag and mask ventilation. The proclivity to perform suction initially delays ventilation, and suction is rarely clinically indicated. Keeping skilled midwives in labor wards is important and impacts clinical practice. The midwives interviewed articulated a mindset of unequivocal commitment to the baby for one Golden Minute®. Heavy workload, frequent staff rotation and lack of clean working equipment were other barriers identified that are worthy of future research. CONCLUSIONS: Training in resuscitation skills in a simulated environment alone is not enough to change clinical practice. Active guidance of "HOT" real-life emergency resuscitation events builds confidence, as the visible signs of successful resuscitation impact the midwife's beliefs and behaviors. Furthermore, a focused commitment by midwives working together to reduce birth asphyxia-related deaths builds hope and collective self-efficacy.

Air, Air, Air: a champion midwife programme in Tanzania using HOT neonatal resuscitation-lessons learned.

BACKGROUND: Tanzania has approximately 40 000 newborn deaths per year, with >25% of these linked to intrapartum-related hypoxia. The Helping Babies Breathe© and Golden minute© (HBB©) programme was developed to teach skilled intervention for non-breathing neonates at birth. While Helping Babies Breathe© and Golden minute©, providing training in simulated bag and mask ventilation, is theoretically successful in the classroom, it often fails to transfer to clinical practice without further support. Furthermore, the proclivity of midwives to suction excessively as a first-line intervention is an ingrained behaviour that delays ventilation, contributing to very early neonatal deaths. METHODS: The 'champion' programme provided guided instruction during a real-life resuscitation. The site was Amana Hospital, Tanzania. The labour ward conducts 13 500 deliveries annually, most of which are managed by midwives. Brief mannikin simulation practice was held two to three times a week followed by bedside hands-on training (HOT) of bag and mask skills and problem solving while reinforcing the mantra of 'air, air, air' as the first-line intervention during a real-life emergency. RESULTS: Champion midwives (trainers) guided instructions given during a real emergency at the bedside caused learners beliefs to change. Trainees observed changes in baby skin colour and the onset of spontaneous breathing after effective ventilation. CONCLUSIONS: Visible success during an actual real-life emergency created confidence, mastery and collective self-efficacy.

High Dose Ascorbic Acid During Acute Resuscitation in Critically Burn Patients.

Ascorbic acid (AA) is a potent oxygen-free radical scavenger. We hypothesized that treating severe burn patients with high doses of AA (HDAA) can reduce fluid resuscitation requirements and prevent organ dysfunction. We performed a unicentric, retrospective case-control study of 75 burn patients: 25 patients admitted from 2018 to 2019 with more than 30% Total Surface Body Surface Area (TSBA) burned who received HDAA (66 mg/kg/h as soon as possible after admission until 36 h after injury), and 50 patients admitted from 2014 to 2017 with similar Abbreviated Burn Severity Index (ABSI)/Baux scores who were treated with the same protocol but did not receive HDAA. During the first 24 hours of burn resuscitation the HDAA group required less fluids than the control group (3.06 ± 0.87 ml/kg/%TBSA vs 4.32 ± 1.51 P < .05), but the overall reduction of fluid requirements during the first 72 hours was not significant. There were no significant differences in Sequential Organ Failure Assessment (SOFA), other hemodynamic parameters, complications, or mortality. We also did not find an increase acute kidney injury in patients who received HDAA even though the mean urine oxalate/creatinine ratio was 0.61 (0.02-0.96). We conclude that in severe burn patients treated with a restrictive fluid therapy protocol, administration of HDAA can decrease only the initial fluid requirements but not total fluid intakes. We did not find differences in severity score after resuscitation or in mortality. Nor did we find an increase in renal failure in patients administered with HDAA.