CO2 gap changes compared with cardiac output changes in response to intravenous volume expansion and/or vasopressor therapy in septic shock.

Background: The difference in partial pressure of carbon dioxide (PCO2) between mixed or central venous blood and arterial blood, known as the ∆PCO2 or CO2 gap, has demonstrated a strong relationship with cardiac index during septic shock resuscitation. Early monitoring of the ∆PCO2 can help assess the cardiac output (CO) adequacy for tissue perfusion. Objectives: To investigate the value of ∆PCO2 changes in early septic shock management compared with CO. Methods: This observational prospective study included 76 patients diagnosed with septic shock admitted to Cairo University Hospital's Critical Care Department between December 2020 and March 2022. Patients were categorised by initial resuscitation response, initial ∆PCO2 and 28-day mortality. The primary outcome was the relationship between the ∆PCO2 and CO changes before and after initial resuscitation, with secondary outcomes including ICU length of stay (LOS) and 28-day mortality. Results: Peri-resuscitation ∆PCO2 changes predicted a ≥15% change in the cardiac index (CI) (area under the curve (AUC) 0.727; 95% CI 0.614 - 0.840) with 66.7% sensitivity and 62.8% specificity. The optimal ∆PCO2 change cut-off value was <-1.85, corresponding to a <-22% threshold for a 15% cardiac index increase. The PCO2 gap ratio (gap/gap ratio of T1- PCO2 gap to T0 -PCO2 gap) also predicted a ≥15% change in cardiac index (AUC 745; 95% CI 0.634 - 0.855) with 63.6% sensitivity and 79.1% specificity. The optimal CO2 gap/gap ratio cut-off value was <0.71. A significant difference in 28-day mortality was noted based on the gap/gap ratio. Conclusion: Peri-resuscitation ∆PCO2 and the gap/gap ratio are useful non-invasive bedside markers for predicting changes in CO and preload responsiveness. Contribution of the study: The current study provides an insight to the PCO2 gap changes during and after early resuscitation of septic shock patients, which correlate to cardiac output changes and might also serve as a fluid responsiveness indicator.

Novel gas mixture combined with an auto-transfusion tourniquet enhances cerebral O2 transport and hemodynamic indices in CPR swine. Part B - A pilot experimental study.

Objectives: The cognitive outcome of CPR is poor. This study aims to evaluate if enhancing blood flow to the brain and oxygen dissociation from the hemoglobin improve cerebral O2 transport during CPR in cardiac arrest swine. Methods: Standard swine-CPR model of induced VF and recovery was treated with an auto-transfusion tourniquet (A-TT®; HemaShock® (HS) Oneg HaKarmel Ltd. Israel) and ventilation with a novel mixture of 30% Oxygen, 5% CO2, and 65% Argon (COXAR™). Five swine received the study treatment and 5 controls standard therapy. Animals were anesthetized, ventilated, and instrumented for blood draws and pressure measurements. Five minutes of no-CPR arrest were followed by 10 min of mechanical CPR with and without COXAR-HS™ enhancement followed by defibrillation and 45 min post ROSC follow-up. Results: All 5 COXAR-HS™ animals were resuscitated successfully as opposed to 3 of the control animals. Systolic (p < 0.05), and diastolic (p < 0.01) blood pressures, and coronary (p < 0.001) and cerebral (p < 0.05) perfusion pressures were higher in the COXAR-HS™ group after ROSC, as well as cerebral flow and O2 provided to the brain (p < 0.05). Blood pressure maintenance after ROSC required much higher doses of norepinephrine in the 3 resuscitated control animals vs. the 5 COXAR-HS™ animals (p < 0.05). jugular vein PO2 and SO2 exceeded 50 mmHg and 50%, respectively with COXAR-HS™. Conclusions: In this pilot experimental study, COXAR-HS™ was associated with higher diastolic blood pressure and coronary perfusion pressure with lower need of vasopressors after ROSC without significant differences prior to ROSC. The higher PjvO2 and SjvO2 suggest enhanced O2 provision to the brain mitochondria, while limb compression by the HS counteracts the vasodilatory effect of the CO2. Further studies are needed to explore and validate the COXAR-HS™ effects on actual post-ROSC brain functionality.

Touching the unconscious in the unconscious - hypnotic communication with unconscious patients.

If hypnosis means contact to the unconscious to modulate psychological and physiological functions by means of suggestions, and if this is facilitated by attenuation of the critical mind, then the question arises as to whether suggestions also have an effect when waking consciousness is otherwise eliminated, namely by coma or anesthesia. A prerequisite would be perception, which actually is evidenced by reports of patients after traumatic brain injury, artificial coma, resuscitation or general anesthesia. Moreover, posttraumatic stress disorder (PTSD) frequently observed after these medical situations is hardly explainable without some sort of awareness under such conditions. Even advanced neurophysiological diagnostic cannot yet rule out consciousness or sensory processing. Especially reference to perception during unconsciousness is given by the results of a recent multicenter study on the effects of hypnotic communication with patients under controlled adequate deep general anesthesia. The observed reductions in incidence and severity of postoperative pain, opioid use, nausea and vomiting cannot be explained by the reaction of a few but only by a considerable proportion of patients. This leads to a strong plea for a more careful treatment of unconscious patients in the emergency room, operating theater or intensive care unit, for the abandonment of the restriction of therapeutic communication to awake patients, and for new aspects of communication and hypnosis research. Obviously, loss of consciousness does not protect against psychological injury, and continuation of communication is needed. But how and what to talk to unconscious patients? Generally addressing the unconscious mind with suggestions that generally exert their effects unconsciously, hypnotic communication appears to be the adequate language. Especially addressing meaningful topics, as derived from the basic psychological needs and known stressors, appears essential. With respect to negative effects by negative or missing communication or to the proposed protective and supporting effects of therapeutic communication with patients clinically rated as unconscious, the role of consciousness is secondary. For the effects of perceived signals and suggestions it does not matter whether consciousness is absent, or partial, or unrecognized present.

Factors Influencing Successful Weaning From Venoarterial Extracorporeal Membrane Oxygenation: A Systematic Review.

With advancements in extracorporeal life support (ECLS) technologies, venoarterial extracorporeal membrane oxygenation (VA-ECMO) has emerged as a crucial cardiopulmonary support mechanism. This review explores the significance of VA-ECMO system configuration, cannulation strategies, and timing of initiation. Through an analysis of medication management strategies, complication management, and comprehensive preweaning assessments, it aims to establish a multidimensional evaluation framework to assist clinicians in making informed decisions regarding weaning from VA-ECMO, thereby ensuring the safe and effective transition of patients.

Associated Factors of Patients' Survival in Out of Hospital Cardiac Arrest; a Cross-sectional Study.

Introduction: Chinese populations have an increasingly high prevalence of cardiac arrest. This study aimed to investigate the prehospital associated factors of survival to hospital admission and discharge among out-of-hospital cardiac arrest (OHCA) adult cases in Macao Special Administrative Region (SAR), China. Methods: Baseline characteristics as well as prehospital factors of OHCA patients were collected from publicly accessible medical records and Macao Fire Services Bureau, China. Demographic and other prehospital OHCA characteristics of patients who survived to hospital admission and discharge were analyzed using multivariate logistic regression analysis. Results: A total of 904 cases with a mean age of 74.2±17.3 (range: 18-106) years were included (78%>65 years, 62% male). Initial shockable cardiac rhythm was the strongest predictor for survival to both hospital admission (OR=3.57, 95% CI: 2.26-5.63; p<0.001) and discharge (OR=12.40, 95% CI: 5.70-26.96; p<0.001). Being male (OR=1.63, 95% CI:1.08-2.46; p =0.021) and the lower emergency medical service (EMS) response time (OR=1.62, 95% CI: 1.12-2.34; p =0.010) were also associated with a 2-fold association with survival to hospital admission. In addition, access to prehospital defibrillation (OR=4.25, 95% CI: 1.78-10.12; p <0.001) had a 4-fold association with survival to hospital discharge. None of these associations substantively increased with age. Conclusion: The major OHCA predictors of survival were initial shockable cardiac rhythm, being male, lower EMS response time, and access to prehospital defibrillation. These findings indicate a need for increased public awareness and more education.

The Effect of Targeted Temperature Therapy on Antioxidant Levels in Patients With Spontaneous Circulation After Cardiac Arrest.

Introduction In this study, we aimed to measure the change in total antioxidant status (TAS), total oxidant stress (TOS), oxidative stress index (OSI), and nuclear factor erythroid 2 (Nrf-2) levels during the treatment period in patients who restored spontaneous circulation return after cardiac arrest with targeted temperature management (TTM) therapy in our hospital. Methods The study included 36 patients who were hospitalized in the anesthesia intensive care unit and coronary intensive care unit of our hospital and were treated with TTM therapy after cardiac arrest. TAS, TOS, OSI, and Nrf-2 levels were measured at 0 (beginning), 12, 24, and 48 (end) hours of TTM therapy. Results The mean age of the patients participating in the study was 54.25±17.10. TAS and TOS levels decreased gradually during TTM therapy, but statistically significant decrease was observed at the end of the hour. When Nrf-2 and OSI levels were evaluated, it was found that no statistically significant difference was observed during the TTM therapy. Conclusion In our study, the oxidant-antioxidant balance was preserved in patients who received TTM therapy after cardiac arrest. We predict TTM therapy is effective on oxidative stress after cardiac arrest and should be applied for at least 48 hours.

Central Venous Catheter Misplacement Into Pleural Cavity Causing Hypertensive Pleural Effusion: A Case Report.

Central venous catheter (CVC) insertion is a routine procedure in the management of critically ill patients. We report a clinical case of inadvertent placement of an internal jugular vein CVC into the right pleural cavity, despite employing clinical and imaging-based techniques to ensure proper catheter positioning. Infusion of fluids and vasopressors through this misplaced catheter led to hypertensive pleural effusion and subsequent cardiorespiratory arrest. Return of spontaneous circulation was achieved after two cycles of cardiopulmonary resuscitation. While multiple imaging modalities are recommended for confirming appropriate CVC placement, each method has inherent limitations. This case highlights the imperative need for a high index of suspicion to avert such complications and pretends to review some of each method's limitations.

What are the training needs of emergency department resuscitation nurses? A scoping review.

BACKGROUND: The emergency resuscitation nurse is a challenging and specialised role at the forefront of critical care practice in the emergency department. Despite their extensive specialist knowledge and skill requirements, in Australia there is no state-wide or nationally agreed approach to how to best provide training that meets a set of fixed objectives and requisite skills for resuscitation nurses. Due to an ageing nursing population and increasing workforce attrition, an efficacious accelerated pathway to acquire specialist resuscitation nursing knowledge, is necessary. AIM: The aim of this review is to identify, consolidate and summarise the available evidence on the training needs for the requisite clinical and non-technical skills of emergency resuscitation nurses ELIGIBILITY CRITERIA: Papers about nurses currently working in the emergency department; including Nurse Unit Managers (NUMs), Clinical Nurse Educators (CNEs), Clinical Nurse Consultants (CNCs), Clinical Nurse Specialists (CNSs), Registered Nurses (RNs) and Enrolled Nurses (ENs) were included. The review included primary and non-primary research, including papers addressing how emergency nurses are trained. There was no date limitation set to ensure all results could be reviewed. Papers that were not published in English, included nurses who were not working in the ED, or included doctors, allied health, and other staff where population cohorts could not be distinguished, were excluded. Abstract only, editorials, conference posters or oral presentations, were also excluded. SOURCES OF EVIDENCE: Searches were conducted in MEDLINE, CINAHL and EMCARE. The authors conducted extensive hand-searching of the included study reference lists as well as the grey literature to ensure that all relevant literature was captured. METHODS: A scoping literature review was conducted. RESULTS: Data extraction was conducted on the final 33 articles (23 peer reviewed studies and 10 competency and practice standards documents). Specific training requirements to achieve competence in the requisite clinical and non-technical skills in resuscitation nursing do not exist. A decline in competency without regular reinforcement was reported. Multi-modal approaches, incorporating diverse teaching methods, show potential in enhancing knowledge retention and skill acquisition. CONCLUSION: Resuscitation nursing lacks a standardised training approach in Australia, leading to a gap in ensuring consistent skill acquisition and knowledge among nurses. Research is required to identify what resuscitation nursing skills and training are necessary to ensure practice effectively meets the needs of patients.

Critical Event Checklists for Simulated In-Hospital Dysrhythmias in Children with Heart Disease.

Children with heart disease are at increased risk of unstable dysrhythmias and in-hospital cardiac arrest (IHCA). Clinician adherence to lifesaving processes of care is an important contributor to improving patient outcomes. This study evaluated whether critical event checklists improve adherence to lifesaving processes during simulated acute events secondary to unstable dysrhythmias. A randomized controlled trial was conducted in a cardiac ward in a tertiary care, academic children's hospital. Unannounced simulated emergencies involving dysrhythmias in pediatric patients with underlying cardiac disease were conducted weekly. Responders were pediatric and anesthesiology residents, respiratory therapists, and bedside registered nurses. Six teams were randomized into two groups-three received checklists (intervention) and three did not (control). Each team participated in four simulated scenarios over a 4-week pediatric cardiology rotation. Participants received a brief slideshow presentation, which included a checklist orientation, at the start of their rotation. Simulations were video and audio recorded and those with three or more participants were included for analysis. The primary outcome was team adherence to lifesaving processes, expressed as the percentage of completed critical management steps. Secondary outcomes included participant perceptions of the checklist usefulness in identifying and managing dysrhythmias. We used generalized estimating equations (GEE) models, which accounted for clustering within groups, to evaluate the effects of the intervention. A total of 24 simulations were conducted; one of the 24 simulations was excluded due to an insufficient number of participants. In our GEE analysis, 81.21% (78.96%, 83.47%) of critical steps were completed with checklists available versus 68.06% (59.38%, 76.74%) without checklists (p = 0.004). Ninety-three percent of study participants reported that they would use the checklists during an unstable dysrhythmia of a child with underlying cardiac disease. Checklists were associated with improved adherence to lifesaving processes during simulated resuscitations for unstable pediatric dysrhythmias. These findings support the use of scenario specific checklists for the management of unstable dysrhythmias in simulations involving pediatric patients with underlying cardiac disease. Future studies should investigate whether checklists are as effective in actual pediatric in-hospital emergencies.

Viable but non-culturable state formation and resuscitation of different antibiotic-resistant Escherichia coli induced by UV/chlorine.

The presence of "viable but nonculturable" (VBNC) state and bacterial antibiotic resistance (BAR) both pose significant threats to the safety of drinking water. However, limited data was available that explicitly addressed the contribution of bacterial VBNC state in the maintenance and propagation of BAR. Here, the VBNC state induction and resuscitation of two antibiotic-resistant Escherichia coli K12 strains, one carrying multidrug-resistant plasmid (RP4 E. coli) and the other with chromosomal mutation (RIF E. coli) were characterized by subjecting them to different doses of UV/chlorine. The results illustrated that the induction, resuscitation, and associated mechanisms of VBNC ARB exhibit variations based on resistance determinants. RP4 E. coli exhibited a higher susceptibility to enter VBNC state compared to the RIF E. coli., and most VBNC state and resuscitated RP4 E. coli retained original antibiotic resistance. While, reverse mutation in the rpoB gene was observed in VBNC state and recovered RIF E. coli strains induced by high doses of UV/chlorine treatment, leading to the loss of rifampicin resistance. According to RT-qPCR results, ARGs conferring efflux pumps appeared to play a more significant role in the VBNC state formation of RP4 E. coli and the down-regulation of rpoS gene enhanced the speed at which this plasmid-carrying ARB entered into the dormant state. As to RIF E. coli, the induction of VBNC state was supposed to be regulated by the combination of general stress response, SOS response, stringent response, and TA system. Above all, this study highlights that ARB could become VBNC state during UV/chlorine treatments and retain, in some cases, their ability to spread ARGs. Importantly, compared with chromosomal mutation-mediated ARB, both VBNC and resuscitated state ARB that carries multidrug-resistant plasmids poses more serious health risks. Our study provides insights into the relationship between the VBNC state and the propagation of BAR in drinking water systems.

Regulatory role of Mycobacterium tuberculosis MtrA on dormancy/resuscitation revealed by a novel target gene-mining strategy.

Introduction: The unique dormancy of Mycobacterium tuberculosis plays a significant role in the major clinical treatment challenge of tuberculosis, such as its long treatment cycle, antibiotic resistance, immune escape, and high latent infection rate. Methods: To determine the function of MtrA, the only essential response regulator, one strategy was developed to establish its regulatory network according to high-quality genome-wide binding sites. Results and discussion: The complex modulation mechanisms were implied by the strong bias distribution of MtrA binding sites in the noncoding regions, and 32.7% of the binding sites were located inside the target genes. The functions of 288 potential MtrA target genes predicted according to 294 confirmed binding sites were highly diverse, and DNA replication and damage repair, lipid metabolism, cell wall component biosynthesis, cell wall assembly, and cell division were the predominant pathways. Among the 53 pathways shared between dormancy/resuscitation and persistence, which accounted for 81.5% and 93.0% of the total number of pathways, respectively, MtrA regulatory genes were identified not only in 73.6% of their mutual pathways, but also in 75.4% of the pathways related to dormancy/resuscitation and persistence respectively. These results suggested the pivotal roles of MtrA in regulating dormancy/resuscitation and the apparent relationship between dormancy/resuscitation and persistence. Furthermore, the finding that 32.6% of the MtrA regulons were essential in vivo and/or in vitro for M. tuberculosis provided new insight into its indispensability. The findings mentioned above indicated that MtrA is a novel promising therapeutic target for tuberculosis treatment since the crucial function of MtrA may be a point of weakness for M. tuberculosis.

Chronic pericarditis and recurrent pericardial effusion of unknown origin in a kitten: a case report.

A 3-month-old kitten was presented after successful cardiopulmonary resuscitation, including a presumed intracardial injection by its primary care veterinarian. Throughout the subsequent hospitalization in the intensive care unit, the cat exhibited recurrent hemorrhagic pericardial effusions, along with concurrent pleural and abdominal effusions, resulting in multiple clinical deteriorations, necessitating pericardiocentesis and thoracocentesis. Despite more than 3 days of intensive care, the cat experienced another cardiopulmonary arrest with unsuccessful attempts to achieve the return of spontaneous circulation. Necropsy and histopathological findings revealed diffuse chronic-active pericarditis and hemorrhagic pericardial effusion, a condition that has not been documented in the context of cardiopulmonary resuscitation or pericardiocentesis.

Multiple factors trigger the formation and resuscitation of the VBNC state in alcohol-producing Klebsiella pneumoniae.

Klebsiella pneumoniae can enter a viable but nonculturable (VBNC) state to survive in unfavorable environments. Our research found that high-, medium-, and low-alcohol-producing K. pneumoniae strains are associated with nonalcoholic fatty liver disease. However, the presence of the three Kpn strains has not been reported in the VBNC state or during resuscitation. In this study, the effects of different strains, salt concentrations, oxygen concentrations, temperatures, and nutrients in K. pneumoniae VBNC state were evaluated. The results showed that high-alcohol-producing K. pneumoniae induced a slower VBNC state than medium-alcohol-producing K. pneumoniae, and low-alcohol-producing K. pneumoniae. A high-salt concentration and micro-oxygen environment accelerated the loss of culturability. Simultaneously, both real-time quantitative PCR and droplet digital PCR were developed to compare the quantitative comparison of three Kpn strain VBNC states by counting single-copy gene numbers. At 22°C or 37°C, the number of culturable cells decreased significantly from about 108 to 105-106 CFU/mL. In addition, imipenem, ciprofloxacin, polymyxin, and phiW14 inhibited cell resuscitation but could not kill VBNC-state cells. These results revealed that the different environments evaluated play different roles in the VBNC induction process, and new effective strategies for eliminating VBNC-state cells need to be further studied. These findings provide a better understanding of VBNC-state occurrence, maintenance, detection, and absolute quantification, as well as metabolic studies of resuscitation resistance and ethanol production.IMPORTANCEBacteria may enter VBNC state under different harsh environments. Pathogenic VBNC bacteria cells in clinical and environmental samples pose a potential threat to public health because cells cannot be found by routine culture. The alcohol-producing Kpn VBNC state was not reported, and the influencing factors were unknown. The formation and recovery of VBNC state is a complete bacterial escape process. We evaluated the influence of multiple induction conditions on the formation of VBNC state and recovery from antibiotic and bacteriophage inhibition, and established a sensitive molecular method to enumerate the VBNC cells single-copy gene. The method can improve the sensitivity of pathogen detection in clinical, food, and environmental contamination monitoring, and outbreak warning. The study of the formation and recovery of VBNC-state cells under different stress environments will also promote the microbiological research on the development, adaptation, and resuscitation in VBNC-state ecology.

Twenty percent human albumin solution fluid bolus administration therapy in patients after cardiac surgery-II: a multicentre randomised controlled trial.

PURPOSE: After cardiac surgery, fluid bolus therapy (FBT) with 20% human albumin may facilitate less fluid and vasopressor administration than FBT with crystalloids. We aimed to determine whether, after cardiac surgery, FBT with 20% albumin reduces the duration of vasopressor therapy compared with crystalloid FBT. METHODS: We conducted a multicentre, parallel-group, open-label, randomised clinical trial in six intensive care units (ICUs) involving cardiac surgery patients deemed to require FBT. We randomised 240 patients to receive up to 400 mL of 20% albumin/day as FBT, followed by 4% albumin for any subsequent FBT on that day, or to crystalloid FBT for at least the first 1000 mL, with use of crystalloid or 4% albumin FBT thereafter. The primary outcome was the cumulative duration of vasopressor therapy. Secondary outcomes included fluid balance. RESULTS: Of 480 randomised patients, 466 provided consent and contributed to the primary outcome (mean age 65 years; median EuroSCORE II 1.4). The cumulative median duration of vasopressor therapy was 7 (interquartile range [IQR] 0-19.6) hours with 20% albumin and 10.8 (IQR 0-22.8) hours with crystalloids (difference - 3.8 h, 95% confidence interval [CI] - 8 to 0.4; P = 0.08). Day one fluid balance was less with 20% albumin FBT (mean difference - 701 mL, 95% CI - 872 to - 530). CONCLUSIONS: In patients after cardiac surgery, when compared to a crystalloid-based FBT, 20% albumin FBT was associated with a reduced positive fluid balance but did not significantly reduce the duration of vasopressor therapy.

Provision of bubble continuous positive airway pressure for the stabilisation of extremely and very preterm infants after birth: A single-centre experience.

AIM: To describe the effect of resuscitation with bubble CPAP (bCPAP) versus T-piece device at birth on early clinical parameters and hospital outcomes in infants born <32 weeks gestation. METHODS: This is a single-centre pre- and post-implementation study comparing outcomes in two epochs. In epoch 1 (1 July 2013-31 December 2014), infants were managed with non-humidified gas using Neopuff® T-piece devices to support breathing after birth. In epoch 2 (1 March 2020-31 December 2021), routine application of bCPAP with humidified gas was introduced at birth. RESULTS: Three hundred fifty-seven patients were included (176 epoch 1, 181 epoch 2). The mean gestational age was 28 ± 2 weeks. The demographics of the two epochs were comparable. There were significant improvements in outcomes of infants in epoch 2 with less infants intubated at delivery (16% vs. 4%, P ≤ 0.001), improved 5 min Apgar (7 vs. 8, P ≤ 0.001), reduced need for ventilation (21% vs. 8.8%, P ≤ 0.001), duration of ventilation in the first 72 h (9.6 vs. 4.6 h) and mortality (10.8% vs. 1.7%, P ≤ 0.001). There was, increased incidence of chronic lung disease (30% vs. 55%, P = 0.02) but no increase in infants discharged on oxygen (3.8% vs. 5%, P = 0.25). Similar findings were observed in a subgroup of infants born <25 weeks' gestation with no increase in the incidence of CLD. CONCLUSION: Introducing application of bCPAP from the first breaths in infants <32 weeks' gestation was associated with better short-term outcomes and mortality, albeit with increased incidence of CLD. The subgroup of infants born <25 weeks' gestation showed similar change in outcomes, with no increase in CLD.

Association between video laryngoscopy characteristics and successful neonatal tracheal intubation: a prospective study.

OBJECTIVE: To identify associations between procedural characteristics and success of neonatal tracheal intubation (NTI) using video laryngoscopy (VL). DESIGN: Prospective single-centre observational study. SETTING: Quaternary neonatal intensive care unit. PATIENTS: Infants requiring NTI at the Children's Hospital of Philadelphia. INTERVENTIONS: VL NTI recordings were evaluated to assess 11 observable procedural characteristics hypothesised to be associated with VL NTI success. These characteristics included measures of procedural time and performance, glottic exposure and position, and laryngoscope blade tip location. MAIN OUTCOME MEASURE: VL NTI attempt success. RESULTS: A total of 109 patients underwent 109 intubation encounters with 164 intubation attempts. The first attempt success rate was 65%, and the overall encounter success rate was 100%. Successful VL NTI attempts were associated with shorter procedural duration (36 s vs 60 s, p<0.001) and improved Cormack-Lehane grade (63% grade I vs 49% grade II, p<0.001) compared with unsuccessful NTIs. Other factors more common in successful NTI attempts than unsuccessful attempts were laryngoscope blade placement to lift the epiglottis (45% vs 29%, p=0.002), fewer tracheal tube manoeuvres (3 vs 8, p<0.001) and a left-sided or non-visualised tongue location (76% vs 56%, p=0.009). CONCLUSION: We identified procedural characteristics visible on the VL screen that are associated with NTI procedural success. Study results may improve how VL is used to teach and perform neonatal intubation.

Investigation of fingolimod-induced lymphocyte sequestration on inflammatory response and neurological damages after cardiac arrest.

BACKGROUND: A sepsis-like syndrome is known to occur after cardiac arrest, leading to cerebral infiltration by white blood cells (WBC). We hypothesized that pharmacological sequestration of WBC, and more specifically lymphocytes within lymphoid tissues, could reduce the cerebral infiltration by these inflammatory cells and subsequent acute brain injury in a porcine model of cardiac arrest. Lymphocyte sequestration was induced by the sphingosine-1 phosphate receptors agonist fingolimod. METHODS: In a first set of experiments, anesthetized pigs underwent a sham instrumentation with no cardiac arrest (n = 4). They received an administration of fingolimod (1 mg/kg, i.v.) in order to confirm its effect on WBC. In a second set of experiments, animals randomly received fingolimod or saline two hours prior to an episode of ventricular fibrillation (14 min) with subsequent resuscitation (n = 6 in each group). Neurological injury was assessed 24 h after resuscitation. RESULTS: In the first set of experiments, WBC and blood lymphocyte counts were significantly reduced by - 61 ± 10% and - 75 ± 6% two hours after fingolimod administration. In the second set of experiments, blood lymphocyte counts, but not WBC, were also significantly reduced after cardiac arrest in Fingolimod vs Control group. However, most cytokine blood levels were not different among groups, including Interleukin (IL)-1ra, IL-8 or IL-18 blood levels. A difference was only observed for IL-6, which decreased in Fingolimod vs Control (e.g., 5.6 ± 4.8 vs 59.4 ± 20.6 pg/ml at 2 h after cardiac arrest, respectively; p = 0.126). Neurofilament light chain (NFL) blood levels were not different among groups (57 ± 25 vs 84 ± 41 pg/ml in Fingolimod vs Control at 6 h after resuscitation, respectively). After awakening, 3 and 2 animals were prematurely euthanized for ethical reasons due to recurrent seizures in Fingolimod and Control groups, respectively. At Day 1, neurological dysfunction score was not different between groups (87 ± 7 vs 87 ± 5% in Fingolimod vs Control, respectively). Conversely, a decrease in the number of CD3 + cells was observed in the brain of surviving animals in Fingolimod vs Control group (3.10 ± 0.50 vs 7.53 ± 0.57 CD3 + cells/field, respectively; p = 0.0286). CONCLUSION: Fingolimod-induced WBC sequestration, and more specifically lymphocytes sequestration, did not improve clinical neurological dysfunction following cardiac arrest although it reduced cerebral infiltration by lymphocytes.

Analysis of hemodynamics and impedance using bioelectrical impedance analysis in hypovolemic shock-induced swine model.

To treat hypovolemic shock, fluid infusion or blood transfusion is essential to address insufficient volume. Much controversy surrounds resuscitation in hypovolemic shock. We aimed to identify the ideal fluid combination for treating hypovolemic shock-induced swine model, analyzing bioelectrical impedance and hemodynamics. Fifteen female three-way crossbred pigs were divided into three different groups. The three resuscitation fluids were (1) balanced crystalloid, (2) balanced crystalloid + 5% dextrose water, and (3) balanced crystalloid + 20% albumin. The experiment was divided into three phases and conducted sequentially: (1) controlled hemorrhage (1 L bleeding, 60 min), (2) resuscitation phase 1 (1 L fluid infusion, 60 min), and (3) resuscitation phase 2 (1 L fluid infusion, 60 min). Bioelectrical impedance analysis was implemented with a segmental multifrequency bioelectrical impedance analyzer. A total of 61 impedance measurements were assessed for each pig at six different frequencies in five segments of the pig. Pulse rate (PR), mean arterial pressure (MAP), stroke volume (SV), and stroke volume variation (SVV) were measured using a minimally invasive hemodynamic monitoring device. The three-dimensional graph showed a curved pattern when infused with 1 L of balanced crystalloid + 1 L of 5% dextrose water and 1.6 L of balanced crystalloid + 400 ml of 20% albumin. The 1M impedance increased in all groups during the controlled hemorrhage, and continuously decreased from fluid infusion to the end of the experiment. Only balanced crystalloid + 20% albumin significantly restored MAP and SV to the same level as the start of the experiment after the end of fluid infusion. There were no significant differences in MAP and SV from the time of recovery to the initial value of 1M impedance to the end of fluid infusion in all groups. The change and the recovery of hemodynamic indices such as MAP and SV coincide with the change and the recovery of 1M impedance. Using balanced crystalloid mixed with 20% albumin in hypovolemic shock-induced swine model may be helpful in securing hemodynamic stability, compared with balanced crystalloid single administration.

Low-dose tenecteplase during cardiopulmonary resuscitation in massive pulmonary embolism.

We report the case of an 18-year-old male who presented to the Emergency Department with sudden onset dyspnea. The patient was intubated on arrival, but suffered a cardiac arrest soon after. Point-of-care echocardiography during cardiopulmonary resuscitation revealed a grossly dilated right atrium and right ventricle, which alerted the Emergency physician to the possibility of massive pulmonary embolism leading to cardiac arrest. Due to no discernible history or risk factors in favour of pulmonary embolism, a decision was taken for thrombolysis with half dose Tenecteplase. Return of spontaneous circulation was achieved 14 min after thrombolysis, with massive pulmonary embolism subsequently being confirmed on CT Pulmonary Angiography.

An observer tool to enhance learning of medical students during simulation training of cardiopulmonary resuscitation: a randomised controlled trial.

BACKGROUND: Simulation training in cardiopulmonary resuscitation (CPR) is effective but active practice time is limited given the large number of students and the learning effect size remains small. To improve learning during observation, the use of an observer tool (OT) has been advocated. The aim was to assess the value of OT to improve medical students' learning outcomes during CPR simulation training. METHODS: This prospective, randomized study took place during CPR training of medical students. The workshop targeted recognition of unconsciousness, absence of breathing, call for help, cardiac massage and defibrillation. Students practicing in dyads were randomized to use an OT (i.e., a checklist summarizing CPR skills and step-by-step actions) (OT +) or not (OT-) when observing others. At the end of the training, the global performance of the dyad was assessed by an evaluator using the OT checklist (primary outcome). The non-technical skills (NTS), chest compression quality, perceived improvement in knowledge and skills and knowledge score (MCQ) were also recorded. RESULTS: The student dyads were included (OT + : n = 40 and OT-: n = 41). Immediately after training, the global performance was similar between the two groups: OT + : 24 [23-25] and OT-: 23 [21-24] (out of 25), p = 0.052. However, better learning of breathing assessment and cardiac massage performance, as well as a better knowledge score, were found in the OT + group. No significant difference was observed for NTS or perceived improvement in knowledge and skills. Satisfaction was higher in the OT- group. CONCLUSIONS: The use of an OT during CPR simulation did not show any pedagogical benefit on the global performance of medical students. However, a potential benefit was found for several important secondary outcomes. Further studies are needed to confirm these positive results.