The use of vasopressors during acute burn resuscitation.

BACKGROUND: Vasopressors may be required during acute burn resuscitation to support mean arterial blood pressure, but their use is not well-described in the burn literature. The purpose of this study was to examine vasopressor use during acute fluid resuscitation. METHODS: Retrospective review of adults with burns ≥ 20% TBSA admitted to an ABA-verified regional burn center. Patients administered an infusion of a vasopressor for at least 30 min during the 1 st 48 h post-burn formed the PRESSOR group while patients who did not receive vasopressors formed the NoPRESSOR group. RESULTS: We studied 52 burned adults, 85% of which had flame burns. Vasopressors were administered during resuscitation to 31% of patients. Vasopressor infusions began at 20.9 ± 10.9 h post burn and were continued for 16.8 ± 10.8 h. PRESSOR patients (N = 16) had significantly greater total (p = 0.001) and full thickness burn size (p < 0.001), and need for mechanical ventilation (p = 0.005) than NoPRESSOR patients (N = 36). PRESSOR and NoPRESSOR patients did not differ significantly in per cent predicted fluid volume received in the first 24 h (143 ± 58 Vs. 125 ± 46 respectively). PRESSOR patients compared to NoPRESSOR patients tended to have been administered 5% albumin (Alb) less often (38% Vs 47%) and high dose vitamin C (HDVC) more often during resuscitation (69% vs 17%). Multivariate regression analysis found that patient age (OR 1.189, 95% CI: 1.047, 1.351) and HDVC (OR 24.701, 95% CI: 1.558, 391.551) were independently associated with greater use of vasopressors. An inverse probability weighted propensity analysis also identified a significant association between HDVC and increased use of vasopressors (OR 6.902, 95 % CI: 2.503, 19.026), and significantly decreased vasopressor administration following Alb administration (OR 0.310, 95% CI: 0.130, 0.739). CONCLUSION: Advanced age appears to be the most important determinant of vasopressor use during resuscitation. While vasopressor requirements appear to have been increased by HDVC and decreased by Alb, this needs to be formally evaluated in a large randomized study.

Forgot calcium? Admission ionized-calcium in two civilian randomized controlled trials of prehospital plasma for traumatic hemorrhagic shock.

BACKGROUND: Randomized clinical trials (RCTs) support the use of prehospital plasma in traumatic hemorrhagic shock, especially in long transports. The citrate added to plasma binds with calcium, yet most prehospital trauma protocols have no guidelines for calcium replacement. We reviewed the experience of two recent prehospital plasma RCTs regarding admission ionized-calcium (i-Ca) blood levels and its impact on survival. We hypothesized that prehospital plasma is associated with hypocalcemia, which in turn is associated with lower survival. METHODS: We studied patients enrolled in two institutions participating in prehospital plasma RCTs (control, standard of care; experimental, plasma), with i-Ca collected before calcium supplementation. Adults with traumatic hemorrhagic shock (systolic blood pressure ≤70 mm Hg or 71-90 mm Hg + heart rate ≥108 bpm) were eligible. We use generalized linear mixed models with random intercepts and Cox proportional hazards models with robust standard errors to account for clustered data by institution. Hypocalcemia was defined as i-Ca of 1.0 mmol/L or less. RESULTS: Of 160 subjects (76% men), 48% received prehospital plasma (median age, 40 years [interquartile range, 28-53 years]) and 71% suffered blunt trauma (median Injury Severity Score [ISS], 22 [interquartile range, 17-34]). Prehospital plasma and control patients were similar regarding age, sex, ISS, blunt mechanism, and brain injury. Prehospital plasma recipients had significantly higher rates of hypocalcemia compared with controls (53% vs. 36%; adjusted relative risk, 1.48; 95% confidence interval [CI], 1.03-2.12; p = 0.03). Severe hypocalcemia was significantly associated with decreased survival (adjusted hazard ratio, 1.07; 95% CI, 1.02-1.13; p = 0.01) and massive transfusion (adjusted relative risk, 2.70; 95% CI, 1.13-6.46; p = 0.03), after adjustment for confounders (randomization group, age, ISS, and shock index). CONCLUSION: Prehospital plasma in civilian trauma is associated with hypocalcemia, which in turn predicts lower survival and massive transfusion. These data underscore the need for explicit calcium supplementation guidelines in prehospital hemotherapy. LEVEL OF EVIDENCE: Therapeutic, level II.

Newborn Resuscitation Skills in Health Care Providers at a Zambian Tertiary Center, and Comparison to World Health Organization Standards.

BACKGROUND: Birth asphyxia is a leading cause of early neonatal death. In 2013, 32% of neonatal deaths in Zambia were attributable to birth asphyxia and trauma. Basic, timely interventions are key to improving outcomes. However, data from the World Health Organization suggest that resuscitation is often not initiated, or is conducted suboptimally. Currently, there are little data on the quality of newborn resuscitation in the context of a tertiary center in a lower-middle income country. We aimed to measure the competencies of clinical practitioners responsible for newborn resuscitation. METHODS: This observational study was conducted over 5 months in Zambia. Health care professionals were recruited from anesthesia, pediatrics, and midwifery. Newborn skills and knowledge were examined using the following: (1) multiple-choice questions; (2) a ventilation skills test; and (3) 2 low-medium fidelity simulation scenarios. Participant demographics including previous resuscitation training and a self-efficacy rating score were noted. The primary outcome examined performance scores in a simulated scenario, which assessed the care of a newborn that failed to respond to basic interventions. Secondary outcome measures included apnea times after delivery and performance in the other assessments. RESULTS: Seventy-eight participants were enrolled into the study (13 physician anesthesiology residents, 13 pediatric residents, and 52 midwives). A significant difference in interprofessional performance was observed when examining checklist scores for the unresponsive newborn simulated scenario (P = .006). The median (quartiles) checklist score (out of 18) was 14.0 (13.0-14.75) for the anesthesiologists, 11.0 (8.5-12.3) for the pediatricians, and 10.8 (8.3-13.9) for the midwives. A score of 14 or more was required to pass the scenario. There was no significant difference in performance between participants with and without previous newborn resuscitation training (P = .246). The median (quartiles) apnea time after delivery was significantly different between all groups (P = .01) with anesthetic and pediatric residents performing similarly, 61 (37-97) and 63 (42.5-97.5) seconds, respectively. The midwifery participants displayed a significantly longer apnea time, 93.5 (66.3-129) seconds. Self-efficacy rating scores displayed no correlation between confidence level and the primary outcome, Spearman coefficient 0.06 (P = .55). CONCLUSIONS: Newborn resuscitation skills among health care professionals are varied. Midwives lead the majority of deliveries with anesthesiologists and pediatricians only being present at operative or high-risk births. It is therefore common that midwifery practitioners will initiate resuscitation. Despite this, midwives perform poorly when compared to anesthesia and pediatric residents. To address this discrepancy, a multidisciplinary, simulation-based newborn resuscitation program should be considered with continual clinical reenforcement of best practice.

Infant Resuscitation Practices of Midwives in a Developing Country.

BACKGROUND: Effective basic newborn resuscitation is an important strategy to reduce the incidence of birth asphyxia and associated newborn outcomes. Outcomes for newborns can be markedly improved if health providers have appropriate newborn resuscitation skills. PURPOSE: To evaluate the skills of midwives in newborn resuscitation in delivery rooms in Jordan. METHODS: Data were collected from observation of 118 midwives from National Health Service hospitals in the north of Jordan who performed basic newborn resuscitation for full-term neonates. A structured checklist of 14 items of basic skills of resuscitation was used. Descriptive statistics were used to analyze the data. RESULTS: The results highlighted the lack of appropriate performance of the 8 necessary skills at birth by midwives. About 17.8% of midwives had performed the core competencies at birth (ie, assessing breathing pattern/crying, cleaning airways) appropriately and met the standard sequence. Less than half of midwives assessed skin color (40.7%) and breathing pattern or crying (41.5%) appropriately with or without minor deviations from standard sequences. Of the 6 skills that had to be performed by midwives at 30 seconds up to 5 minutes after birth, 4 skills were not performed by about one-quarter of midwives. IMPLICATIONS FOR PRACTICE AND RESEARCH: The midwives' practices at the 2 hospitals of this study were not supported by best practice international guidelines. The study showed that a high proportion of midwives had imperfect basic newborn resuscitation skills despite a mean experience of 8 years. This highlights the critical need for continuing medical education in the area of basic newborn resuscitation. The results highlight the need for formal assessment of midwives' competence in basic newborn resuscitation. National evidence-based policies and quality assurance are needed to reflect contemporary practice.

The relation between given volume and heart rate during newborn resuscitation.

BACKGROUND: During delivery room resuscitation of depressed newborns, provision of appropriate tidal volume (TV) with establishment of functional residual capacity (FRC) is essential for circulatory recovery. Effective positive pressure ventilation (PPV) is associated with a rapid increase in heart rate (HR). The relationship between delivery of TV and HR responses remains unclear. OBJECTIVES: The study objectives were to determine (1) the relationship between a given TV during initial PPV and HR responses of depressed newborns, and (2) the optimal delivered TV associated with a rapid increase in HR. METHODS: In a Tanzanian rural hospital, ventilation and ECG signals were recorded during neonatal resuscitation and stored in Neonatal Resuscitation Monitors. Resuscitators without positive end-expiratory pressure were used for PPV. No oxygen was used. Perinatal events were observed and recorded by research assistants. RESULTS: 215 newborns of gestational age 37.3±1.9 weeks and birth weight 3115±579g were included. There was a non-linear relationship between delivered TV and HR increase. TV of 9.3ml/kg produced the largest increase in HR during PPV. Frequent interruptions of PPV sequences to provide stimulation/suctioning occurred in all cases and were associated with further HR increases, especially for newborns with initial HR<100 beats/minute. CONCLUSIONS: There was a consistent positive relationship between HR increase and delivered TV. The unanticipated finding of a further increase in HR with PPV pauses to provide stimulation/suctioning suggests that most newborns were in primary rather than secondary apnea.

Neonatal resuscitation training for midwives in Uganda: Strengthening skill and knowledge retention.

The objective of this project was to improve birth outcomes for babies in a regional referral hospital in Uganda by strengthening factors that influence the retention and application of neonatal resuscitation skills. Initial training in neonatal resuscitation is not enough on its own. In order to better understand the gap between training and effective practice, an evaluation of a neonatal resuscitation program was carried out. This included practical skill testing of local midwives using a neonatal resuscitation doll pre- and post-training, as well as follow up testing at 1 month and 12 months, followed by focus groups and interviews. Test scores revealed that participants' knowledge grew significantly immediately following the workshop, and remained high after 1 month, but fell by 12 months post-training. Interviews with hospital staff revealed a number of facilitators and barriers to practice, namely knowledge retention and skill application. The most important barrier identified is the lack of refresher training post-workshop. Importantly, the findings demonstrated a need not for refresher training alone, but for improved organizational and administrative support for the newly assigned trainers.

Basic neonatal resuscitation, knowledge assessment at primary health care centers of district Sheikhupura in Pakistan -- a cross-sectional study.

OBJECTIVE: To assess the knowledge of lady health visitors and midwives working at primary healthcare facilities about neonatal resuscitation. METHODS: The cross-sectional survey was conducted in District Sheikhupura of Pakistan's Punjab province from September to November 2013, and comprised lady health visitors and midwives at primary level healthcare facilities. Datas was gathered using a close-ended questionnaire. SPSS 16 was used for statistical analysis. RESULTS: Of the 103 health workers interviewed, 54(52.4%) were lady health visitors and 49(47.5%) were midwives. Overall, 71(69.90%) health workers had received training on neonatal resuscitation, while 32(30.10%) had no formal training. Basic neonatal resuscitative arrangements were available at all the 54(100%) basic health units and 7(100%) rural health centres. Basic neonatal care knowledge was found adequate but the knowledge of midwives on the subject was poor as only 24(49%) answered correctly. CONCLUSIONS: There is a need for regular in-service trainings of lady health visitors and midwives regarding Basic Neonatal Resuscitation.

Basic newborn care and neonatal resuscitation: a multi-country analysis of health system bottlenecks and potential solutions.

BACKGROUND: An estimated two-thirds of the world's 2.7 million newborn deaths could be prevented with quality care at birth and during the postnatal period. Basic Newborn Care (BNC) is part of the solution and includes hygienic birth and newborn care practices including cord care, thermal care, and early and exclusive breastfeeding. Timely provision of resuscitation if needed is also critical to newborn survival. This paper describes health system barriers to BNC and neonatal resuscitation and proposes solutions to scale up evidence-based strategies. METHODS: The maternal and newborn bottleneck analysis tool was applied by 12 countries in Africa and Asia as part of the Every Newborn Action Plan process. Country workshops engaged technical experts to complete the survey tool, which is designed to synthesise and grade health system "bottlenecks" that hinder the scale up of maternal-newborn intervention packages. We used quantitative and qualitative methods to analyse the bottleneck data, combined with literature review, to present priority bottlenecks and actions relevant to different health system building blocks for BNC and neonatal resuscitation. RESULTS: Eleven of the 12 countries provided grading data. Overall, bottlenecks were graded more severely for resuscitation. The most severely graded bottlenecks for BNC were health workforce (8 of 11 countries), health financing (9 out of 11) and service delivery (7 out of 9); and for neonatal resuscitation, workforce (9 out of 10), essential commodities (9 out of 10) and service delivery (8 out of 10). Country teams from Africa graded bottlenecks overall more severely. Improving workforce performance, availability of essential commodities, and well-integrated health service delivery were the key solutions proposed. CONCLUSIONS: BNC was perceived to have the least health system challenges among the seven maternal and newborn intervention packages assessed. Although neonatal resuscitation bottlenecks were graded more severe than for BNC, similarities particularly in the workforce and service delivery building blocks highlight the inextricable link between the two interventions and the need to equip birth attendants with requisite skills and commodities to assess and care for every newborn. Solutions highlighted by country teams include ensuring more investment to improve workforce performance and distribution, especially numbers of skilled birth attendants, incentives for placement in challenging settings, and skills-based training particularly for neonatal resuscitation.

In situ simulation training for neonatal resuscitation: an RCT.

OBJECTIVES: High-fidelity simulation is an effective tool in teaching neonatal resuscitation skills to professionals. We aimed to determine whether in situ simulation training (for ∼80% of the delivery room staff) improved neonatal resuscitation performed by the staff at maternities. METHODS: A baseline evaluation of 12 maternities was performed: a random sample of 10 professionals in each unit was presented with 2 standardized scenarios played on a neonatal high-fidelity simulator. The medical procedures were video recorded for later assessments. The 12 maternities were then randomly assigned to receive the intervention (a 4-hour simulation training session delivered in situ for multidisciplinary groups of 6 professionals) or not receive it. All maternities were evaluated again at 3 months after the intervention. The videos were assessed by 2 neonatologists blinded to the pre-/postintervention as well as to the intervention/control groups. The performance was assessed using a technical score and a team score. RESULTS: After intervention, the median technical score was significantly higher for scenarios 1 and 2 for the intervention group compared with the control group (P = .01 and 0.004, respectively), the median team score was significantly higher (P < .001) for both scenarios. In the intervention group, the frequency of achieving a heart rate >90 per minute at 3 minutes improved significantly (P = .003), and the number of hazardous events decreased significantly (P < .001). CONCLUSIONS: In situ simulation training with multidisciplinary teams can effectively improve technical skills and teamwork in neonatal resuscitation.

[Current neonatal resuscitation practices in Polish neonatal units - national survey]. / Stan przygotowania pod wzgledem merytorycznym i organizacyjnym oddzialów neonatologicznych o róznym stopniu referencji do prowadzenia resuscytacji noworodka po urodzeniu.

AIM: We surveyed current neonatal resuscitation practices in Polish neonatal units to determine the factors, relevant to improving practices in this area. MATERIAL AND METHODS: The study was performed within the framework of the National Standardization Programme on Neonatal Practices and Procedures in 2007. An 11 question survey included questions concerning the frequency of neonatal resuscitation, type of procedure performed during resuscitation ie.: medicaments and oxygen administration, umbilical vein catetherisation, equipment availability, resuscitation of extremely preterm babies. The survey included also questions concerning problems in resuscitation and their causes. 420 questionnaires were sent out and 274 were returned completed (65.2% response rate). 266 units providing delivery room resuscitation were included in the study. RESULTS: Neonatal resuscitation procedures were needed significantly more frequently in the centres of the highest degree reference (p<0.001). There were also marked differences between the centres according to the frequency of umbilical vessels catetherisation and availability of the necessary medical equipment. In 44.6% of neonatal units, resuscitated newborns are successfully ventilated with room air. However, in 23.5% of the surveyed units, 100% oxygen is used for ventilation. The finding of great importance is that 30.7% of neonatal units stated the need for a trained resuscitator to attend a high risk pregnancy delivery and to resuscitate asphyxiated newborns. CONCLUSIONS: There are substantial differences in neonatal resuscitation practices in different neonatal centres. These findings should stimulate appropriate authorities to start an educational programme to establish suitable polices in newborn resuscitation.

Dissemination and evaluation of AAP/AHA Neonatal Resuscitation Programme in Ireland.

We evaluated the need for a structured Neonatal Resuscitation Programme (NRP) by means of a questionnaire sent to 25 Irish maternity hospitals inquiring about staff availability and current teaching structures. Having taught NRP to almost 1000 health care providers, we present a descriptive evaluation of the programme by a sample of 429 NRP participants, exploring their opinions of NRP. Our results show that midwives were responsible for newborn resuscitation at all low risk deliveries. Only 5 units (23%) had a registrar available on-site 24 hours a day, while the remaining units (77%) had to summon additional medical help from outside, in emergency situations occurring outside of normal working hours. Resuscitation equipment was checked by nurses alone (52%), or by a nurse and physician (48%), on a daily (45%), alternate days (41%) or weekly basis (14%). Although 19 units had some form of neonatal resuscitation training available, only 35% of respondents were happy with the current training structures. Almost half of the 429 providers (45%) replied to the survey. Most (85%) indicated that NRP improved their skills and confidence. Two thirds of participants found the lesson on medications the most difficult theory lesson, while 45% found endotracheal intubation the most difficult skills station. Because of the wide geographical distribution of deliveries in this country, we conclude that all perinatal professionals should be trained to perform newborn resuscitation in a coordinated, team-approach manner. NRP provides such training with a high degree of approval from Irish health care providers.

Accidental deep hypothermia with cardiopulmonary arrest: extracorporeal blood rewarming in 11 patients.

Sixteen patients (age 13-53 years) with accidental deep hypothermia have been rewarmed in our clinic during the last 10 years, 14 by femoro-femoral cardiopulmonary bypass (CPB) of whom 11 had a cardiopulmonary arrest (asystole in 5 and ventricular fibrillation in 6). On admission, the latter were clinically dead showing wide non-reactive pupils and being supported by ventilation and external heart massage. In the survivors, the mean length of cold exposure was 4.4 h (2-5.5 h) and mean arrest interval until initiation of CPB was 2.5 h (1.4-3.7 h). Rectal temperature on admission ranged from 17.5 degrees C to 26 degrees C (mean 22.5 degrees C). The causes for hypothermia were fall into a crevasse (5), avalanche (1), drowning (2) and cold exposure (3) including 2 suicide attempts. Results are summarized in the following table: [table: see text] Eight of the 11 patients with deep hypothermia and cardiac arrest were rewarmed and resuscitated successfully with CPB. Three patients, including 2 cases of asphyxia (avalanche and drowning), could not be weaned from CPB despite adequate rewarming. The other drowned patient (53 years) died on the 3rd postoperative day (POD) from ARDS. The main complication was pulmonary edema (57%) and transient neurological deficits. All survivors became conscious during the first POD and resumed, their professional activity. We conclude that patients with accidental deep hypothermia and even prolonged cardiopulmonary arrest should be rewarmed and resuscitated rapidly by cardiopulmonary bypass. These measures are very promising particularly if the cause of accident and the circumstances suggest that cardiopulmonary arrest was induced by hypothermia alone without other asphyxiating mechanisms.