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The clinical state of shock constitutes a relative or absolute deficiency of circulating volume for adequate oxygen delivery to meet the metabolic demands.1 Although shock states differ in epidemiology, etiology, and pathophysiologic pathways, a common denominator of shock is endothelial barrier dysfunction.2, 3 Different kinds of shock states, such as occurring after major surgery, trauma, and in sepsis, can result in strong pro‐inflammatory host responses with ensuing endothelial hyperpermeability.4, 5, 6 Loss of endothelial barrier results in leakage of fluid into surrounding tissue, contributing to edema, tissue hypoxia, and organ failure.6 This loss of fluids further aggravates the intravascular circulatory volume deficiency during shock. Obviously, septic and traumatic shock are different entities, with different etiologies and differences in initiation of host response and coagulation response. However, endothelial activation with loss of endothelial barrier integrity is a common finding in both shock states. In trauma‐induced shock, current resuscitation strategies consist of the early transfusion of whole blood or a balanced ratio of plasma, platelets, and red blood cells.7, 8 The aim of resuscitation is to ensure adequate oxygen delivery and to correct coagulopathy. Plasma transfusion may play a key role, as trials point toward improved survival with high dose or early use of plasma transfusion compared to standard care.9, 10, 11 Upon reaching surgical hemostasis, it is general practice to stop transfusion. However, as a result of ongoing inflammation and endothelial activation, patients can continue to be fluid dependent, which is often responded to with crystalloids. However, liberal use of crystalloids in traumatic hemorrhagic shock is associated with increased mortality and increased endothelial permeability, inflammation, and reduced perfusion of vital organs.12, 13, 14 In septic shock, the primary treatment of shock is volume resuscitation with crystalloid or colloids, as advocated in guidelines.15 However, comparable to traumatic hemorrhagic shock, use of a restrictive fluid balance reduces the occurrence of organ failure as well as mortality in sepsis.16, 17, 18 most likely, the association between the amount of infused volume and adverse outcome in shock states is related to increased shedding of the glycocalix, breakdown of adherent junctions, and tight junctions resulting in an increased gradient of leakage over the hyper permeable endothelium.19 Taken together, due to a relative or absolute deficiency of intravascular volume, patients with shock are likely to need volume expansion to maintain perfusion pressure. This poses a challenge to the treatment of shock, as fluid therapy is both a cornerstone of therapy as well as a foe. Different fluids may have differential effects on endothelial integrity. Low‐protein‐content fluids seem to aggravate shedding of glycocalix,20 whereas protein‐rich fluids such as plasma may be superior to normal saline in protecting the glycocalix and endothelial barrier function.21 Transfusion with plasma as a volume expander in shock may seem controversial at first, but one needs to consider that despite the fact that plasma is transfused in millions of patients annually, there currently is limited understanding of its mechanisms of action. In traumatic blood loss, transfusion of plasma may improve survival by decreasing exsanguination.7, 10 The common perception is that plasma is a pro‐coagulant blood product, by replenishing coagulation factors. However, as plasma contains coagulation factors but also anticoagulant proteins, the net effect of plasma on coagulation may be neutral. In line with this, plasma transfusion increases the amount of coagulation factors as well as levels of anti‐coagulant proteins,22 resulting in unchanged thrombin generation, at least in non‐bleeding critically ill patients with an inflammatory‐driven consumption coagulopathy. In patients with traumatic hemorrhagic shock, it is not apparent whether the mechanism of effect of plasma is directly related to the correction of coagulopathy.23 In rats with hemorrhagic shock, deranged thrombin formation was somewhat restored with resuscitation with plasma but not with crystalloids, but whether this relates to prevention of dilutional coagulopathy or to a specific pro‐coagulant effect of plasma is not clear.24, 25 Other mechanisms of the protective effect of plasma may be at hand. These may include preservation of the glycocalix, decreasing inflammation and decreasing endothelial leak. This review aims to discuss the potential of plasma as a resuscitation fluid in shock, with an emphasis on possible mechanisms of benefit on the activated endothelium. Studies comparing plasma with other fluids on (markers of) endothelial integrity have found effects both in (models of) trauma‐induced shock and in septic shock. As loss of endothelial integrity may be a common denominator of shock, we will discuss both these shock states.

ObjectivesTo assess the feasibility of using video recordings of neonatal resuscitation (NR) to evaluate the quality of care in a low-resource district hospital.DesignProspective observational feasibility study.SettingChake-Chake Hospital, a district hospital in Pemba, Tanzania, in April and May 2019.ParticipantsAll delivering women and their newborns were eligible for participation.Main outcome measuresMotion-triggered cameras were mounted on resuscitation tables and provided recordings that were analysed for quality of care indicators based on the national NR algorithm. Assessment of feasibility was conducted using Bowen’s 8-point framework for feasibility studies.Results91% (126 of 139) of women and 96% (24 of 26) of health workers were comfortable or very comfortable with the video recordings. Of 139 newborns, 8 underwent resuscitation with bag and mask ventilation. In resuscitations, heat loss prevention measures were not performed in half of the cases (four of eight), clearing the airway was not performed correctly in five of eight cases, and all newborns were suctioned vigorously and repeatedly, even when not indicated. In a quarter (two of eight) of cases, the newborn’s head was not positioned correctly. Additionally, two of the eight newborns needing ventilation were not ventilated within the first minute of life. In none of the eight cases did ventilation appear to be performed effectively.ConclusionsIt proved feasible to use video recordings to assess quality of care during NR in a low-resource setting, and the method was considered acceptable for the delivering women and health workers. Recordings of eight resuscitations all demonstrated deviations from NR guidelines.

Introduction: Leadership skills are described by the American College of Surgeons’ Advanced Trauma Life Support (ATLS) course as necessary to provide care for patients during resuscitations. However, leadership is a complex concept, and the tools used to assess the quality of leadership are poorly described, inadequately validated, and infrequently used. Despite its importance, dedicated leadership education is rarely part of physician training programs. The goals of this investigation were the following: 1. Describe how leadership and leadership style affect patient care; 2. Describe how effective leadership is measured; and 3. Describe how to train future physician leaders. Methods: We searched the PubMed database using the keywords “leadership” and then either “trauma” or “resuscitation” as title search terms, and an expert in emergency medicine and trauma then identified prospective observational and randomized controlled studies measuring leadership and teamwork quality. Study results were categorized as follows: 1) how leadership affects patient care; 2) which tools are available to measure leadership; and 3) methods to train physicians to become better leaders. Results: We included 16 relevant studies in this review. Overall, these studies showed that strong leadership improves processes of care in trauma resuscitation including speed and completion of the primary and secondary surveys. The optimal style and structure of leadership are influenced by patient characteristics and team composition. Directive leadership is most effective when Injury Severity Score (ISS) is high or teams are inexperienced, while empowering leadership is most effective when ISS is low or teams more experienced. Many scales were employed to measure leadership. The Leader Behavior Description Questionnaire (LBDQ) was the only scale used in more than one study. Seven studies described methods for training leaders. Leadership training programs included didactic teaching followed by simulations. Although programs differed in length, intensity, and training level of participants, all programs demonstrated improved team performance. Conclusion: Despite the relative paucity of literature on leadership in resuscitations, this review found leadership improves processes of care in trauma and can be enhanced through dedicated training. Future research is needed to validate leadership assessment scales, develop optimal training mechanisms, and demonstrate leadership’s effect on patient-level outcome.

International audience; OBJECTIVES: Accidental hypothermia increases mortality and morbidity after hemorrhage, but controversial data are available on the effects of therapeutic hypothermia. Therefore, we tested the hypothesis whether moderate pretreatment hypothermia would beneficially influence organ dysfunction during long-term, porcine hemorrhage and resuscitation. DESIGN: Prospective, controlled, randomized study. SETTING: University animal research laboratory. SUBJECTS: Twenty domestic pigs of either gender. INTERVENTIONS: Using an extracorporeal heat exchanger, anesthetized and instrumented animals were maintained at 38 degrees C, 35 degrees C, or 32 degrees C core temperature and underwent 4 hours of hemorrhage (removal of 40% of the blood volume and subsequent blood removal/retransfusion to maintain mean arterial pressure at 30 mm Hg). Resuscitation comprised of hydroxyethyl starch and norepinephrine infusion titrated to maintain mean arterial pressure at preshock values. MEASUREMENTS AND MAIN RESULTS: Before, immediately at the end of, and 12 and 22 hours after hemorrhage, we measured systemic and regional hemodynamics (portal vein, hepatic and right kidney artery ultrasound flow probes) and oxygen transport, and nitric oxide and cytokine production. Hemostasis was assessed by rotation thromboelastometry. Postmortem biopsies were analyzed for histomorphology (hematoxylin and eosin staining) and markers of apoptosis (kidney Bcl-xL and caspase-3 expression). Hypothermia at 32 degrees C attenuated the shock-related lactic acidosis but caused metabolic acidosis, most likely resulting from reduced carbohydrate oxidation. Although hypothermia did not further aggravate shock-related coagulopathy, it caused a transitory attenuation of kidney and liver dysfunction, which was ultimately associated with reduced histological damage and more pronounced apoptosis. CONCLUSIONS: During long-term porcine hemorrhage and resuscitation, moderate pretreatment hypothermia was associated with a transitory attenuation of organ dysfunction and less severe histological tissue damage despite more pronounced metabolic acidosis. This effect is possibly due to a switch from necrotic to apoptotic cell death, ultimately resulting from reduced tissue energy deprivation during the shock phase.

RESUMO A administração de fluidos em tempo adequado é crucial para a manutenção da perfusão tissular nos pacientes com choque séptico. Entretanto, a questão da escolha do fluido a ser utilizado para ressuscitação no choque séptico ainda é um assunto em debate. É crescente o corpo de evidência que sugere que o tipo, a quantidade e o momento da administração de fluidos durante a evolução da sepse podem afetar os desfechos do paciente. Os cristaloides têm sido recomendados como fluidos a serem administrados em primeira linha na ressuscitação do choque. No entanto, à luz da natureza inconclusiva da literatura disponível, não se podem fazer recomendações definitivas quanto à solução cristaloide mais apropriada. A ressuscitação de pacientes críticos sépticos e não sépticos com cristaloides não balanceados, principalmente a solução salina a 0,9%, tem sido associada a uma maior incidência de desordens do equilíbrio ácido-base e a distúrbios eletrolíticos, além de poder se associar à maior incidência de lesão renal aguda, à maior necessidade de terapia de substituição renal e à mortalidade. Foi proposto o uso de soluções cristaloides balanceadas como uma alternativa às soluções de cristaloides não balanceados, para mitigar seus efeitos deletérios. Entretanto, a segurança e a eficácia dos cristaloides balanceados para ressuscitação do choque séptico necessitam ser mais bem exploradas em estudos clínicos bem delineados, randomizados e controlados, multicêntricos e pragmáticos. ABSTRACT Timely fluid administration is crucial to maintain tissue perfusion in septic shock patients. However, the question concerning which fluid should be used for septic shock resuscitation remains a matter of debate. A growing body of evidence suggests that the type, amount and timing of fluid administration during the course of sepsis may affect patient outcomes. Crystalloids have been recommended as the first-line fluids for septic shock resuscitation. Nevertheless, given the inconclusive nature of the available literature, no definitive recommendations about the most appropriate crystalloid solution can be made. Resuscitation of septic and non-septic critically ill patients with unbalanced crystalloids, mainly 0.9% saline, has been associated with a higher incidence of acid-base balance and electrolyte disorders and might be associated with a higher incidence of acute kidney injury. This can result in greater demand for renal replacement therapy and increased mortality. Balanced crystalloids have been proposed as an alternative to unbalanced solutions in order to mitigate their detrimental effects. Nevertheless, the safety and effectiveness of balanced crystalloids for septic shock resuscitation need to be further addressed in a well-designed, multicenter, pragmatic, randomized controlled trial.

BACKGROUND: Total body surface area (TBSA) burned, expressed as percentage is one of the most important aspects of the initial care of a burn victim. It determines whether transfer to a burn centre is necessary as well as the need for, and amount of, intravenous fluid resuscitation. Numerous studies, however, have highlighted inaccuracies in TBSA assessment. Therefore, the differences in burn size estimates between referrers and burn centre's in children and its consequences in terms of transfer and intravenous fluid resuscitation were investigated. METHODS: This study involved two time periods from January 2002 until March 2004 and January 2007 until August 2008. All referred children admitted to a Dutch Burn centre within 24h post burn were eligible. Data were obtained from patient records retrospectively and in part prospectively. RESULTS: A total of 323 and 299 children were included in periods 1 and 2, respectively. Referring physicians overestimated burn size with a factor two (mean difference: 6% TBSA ± 5.5). About one in five children was referred to a burn centre without fulfilling the criteria for referral with regard to burn size (assessed by burn specialists) special localisation or inhalation trauma. Proportions of children receiving intravenous fluid resuscitation regardless of indication increased from 33% to 49% (p

To the Editor: As noted by Asfar et al. (April 24 issue),1 a major concern related to targeting a relatively low mean arterial blood pressure in patients with septic shock is that the brain is at risk for ischemia in this condition. The risk of potential brain ischemia is particularly pertinent among patients with a history of arterial hypertension, because their cerebral autoregulatory curve may be shifted to the right.2 Indeed, cerebral ischemia may contribute to sepsis-associated encephalopathy and persistent neurocognitive dysfunction.3 However, neither the primary nor the secondary outcomes in the study by Asfar et al. involved any measures of neurocognitive function. A mean arterial blood pressure of approximately 65 to 90 mm Hg describes the lower limit of autoregulation in healthy persons,4 and the same level appears to be present in critically ill patients with sepsis who do not have a history of hypertension.5 Before the findings by Asfar et al. are implemented in major guidelines, we think that further studies should address the way in which cerebral hemodynamics are specifically affected in patients with sepsis and a history of hypertension, as well as whether targeting a relatively high mean arterial blood pressure improves long-term neurocognitive function.

Prior to 2001 there was no standard for early management of severe sepsis and septic shock in the emergency department. In the presence of standard or usual care, the prevailing mortality was over 40-50 %. In response, a systems-based approach, similar to that in acute myocardial infarction, stroke and trauma, called early goal-directed therapy was compared to standard care and this clinical trial resulted in a significant mortality reduction. Since the publication of that trial, similar outcome benefits have been reported in over 70 observational and randomized controlled studies comprising over 70,000 patients. As a result, early goal-directed therapy was largely incorporated into the first 6 hours of sepsis management (resuscitation bundle) adopted by the Surviving Sepsis Campaign and disseminated internationally as the standard of care for early sepsis management. Recently a trio of trials (ProCESS, ARISE, and ProMISe), while reporting an all-time low sepsis mortality, question the continued need for all of the elements of early goal-directed therapy or the need for protocolized care for patients with severe and septic shock. A review of the early hemodynamic pathogenesis, historical development, and definition of early goal-directed therapy, comparing trial conduction methodology and the changing landscape of sepsis mortality, are essential for an appropriate interpretation of these trials and their conclusions.

Timely fluid administration is crucial to maintain tissue perfusion in septic shock patients. However, the question concerning which fluid should be used for septic shock resuscitation remains a matter of debate. A growing body of evidence suggests that the type, amount and timing of fluid administration during the course of sepsis may affect patient outcomes. Crystalloids have been recommended as the first-line fluids for septic shock resuscitation. Nevertheless, given the inconclusive nature of the available literature, no definitive recommendations about the most appropriate crystalloid solution can be made. Resuscitation of septic and non-septic critically ill patients with unbalanced crystalloids, mainly 0.9% saline, has been associated with a higher incidence of acid-base balance and electrolyte disorders and might be associated with a higher incidence of acute kidney injury. This can result in greater demand for renal replacement therapy and increased mortality. Balanced crystalloids have been proposed as an alternative to unbalanced solutions in order to mitigate their detrimental effects. Nevertheless, the safety and effectiveness of balanced crystalloids for septic shock resuscitation need to be further addressed in a well-designed, multicenter, pragmatic, randomized controlled trial.

We challenged the current management of uncontrolled haemorrhagic shock (UHS) and put forward a hypothesis that therapeutic mild hypothermia combined with delayed fluid resuscitation will improve the survival rate. After an initial blood withdrawal of 3 ml/100 g for 15 min, the rat’s tail was amputated up to 75% to induce UHS phase I. The mean arterial blood pressure (MAP) was maintained at 40 mmHg or 80 mmHg, according to the assigned study group. This was followed by homeostasis of the tail wound and increase of the MAP up to 100 mmHg during resuscitation phase II. Finally, phase III was an observation of phase up to 72 h. Rats were anaesthetised and randomised into four groups. Group 1 received immediate fluid resuscitation and normothermia. Group 2 received immediate fluid resuscitation and therapeutic mild hypothermia. Group 3 received limited fluid solutions to maintain MAP at 40 mmHg and normothermia. Group 4 also received limited fluid solution, but the rats were subjected to therapeutic mild hypothermia. In groups 2 and 4, the body temperature was kept at 34 °C throughout the UHS phase I and resuscitation phase II. At the end of the observation phase III, the brains of the animals were fixed and analysed histologically. The blood loss from the tail during the UHS phase I was significantly higher in groups 1 and 2. The survival rate was 33.3, 83.3, 58.3 and 91.7%, respectively in groups 1–4. In all surviving rats, no histological brain damage was observed. These results indicate that therapeutic mild hypothermia or delayed fluid resuscitation increase the survival rate in this model. However, when mild hypothermia and limited fluid resuscitation were combined, the survival rate was the highest.

The ex utero intrapartum treatment (EXIT) procedure is designed to guarantee sufficient oxygenation for a foetus at risk of airway obstruction. This is achieved by improving lung ventilation, usually by establishing an airway during caesarean delivery whilst preserving the foetal-placental circulation temporarily. Indications for the EXIT procedure have extended from its original use in reversing iatrogenic tracheal obstruction in congenital diaphragmatic hernia to naturally occurring upper airway obstructions. We report our experience with a new and rarely mentioned indication for the EXIT procedure, intra-thoracic volume expansions. The elaboration of lowest risk scenarios through balancing risks with alternative options, foetal or neonatal intervention and coordination between professionals from various disciplines are the most important conditions for a successful EXIT procedure. The EXIT procedure requires a caesarean section that specifically differs from the traditional caesarean section during which uterine tone is maintained to minimize maternal bleeding. To guarantee foetal oxygenation during the EXIT procedure, profound uterine relaxation is desired. To gain time with optimal placental oxygenation in order to safely perform an airway intervention in a baby at risk of hypoxia may require deep inhalation anaesthesia and/or tocolytic agents. We review the EXIT procedure and present a case series from the University Hospital of Geneva that contrasts with the common indication for the EXIT procedure usually based on upper airway obstruction by its exclusive indication for intra-thoracic malformations/diseases.

Objective: To test the hypothesis that resuscitative mild hypothermia (MH) (34 degrees C) or breathing fractional inspired oxygen (FIo(2)) of 1.0 would prolong survival time during lethal uncontrolled haemorrhagic shock (UHS) in mechanically ventilated rats. Methods: Forty Wistar rats were anaesthetized with halothane, nitrous oxide and oxygen (70/30%), intubated and mechanically ventilated. UHS was induced by volume-controlled blood withdrawal of 3 ml/100 g over 15 min, followed by 75% tail amputation of its length. The animals were randomly divided into four UHS treatment groups (10 rats in each group): group 1 was maintained on an FIo(2) of 0.21 and rectal temperature of 37.5 degrees C. Group 2 was maintained on an FIo(2) of 0.21 and induced MH. Group 3 was maintained on an FIo(2) of 1.0 and 37.5 degrees C. Group 4 was maintained on an FIo(2) of 1.0 and MH. Rats were observed otherwise untreated until death. Results: During the initial blood withdrawal, mean arterial pressure (MAP) decreased to 40 mmHg, and the heart rate (HR) increased up to 400 beats/min. The induction of MH increased MAP to 60mmHg and increased survival time. Moreover, it reduced the HR to 300 beats/min but did not increase bleeding. Ventilation with an FIo(2) of 1.0 did not influence MAP, blood loss or survival time, but increased arterial oxygen tension. The mean survival time was 62, 202, 68 and 209 min in groups 1, 2, 3 and 4, respectively. Blood loss from the tail was 1.0, 1.2, 0.9 and 0.7 ml, respectively, in groups 1, 2, 3 and 4. Conclusion: MH prolonged the survival time during UHS in mechanically ventilated rats. However, an FIo(2) of 1.0 did not influence the survival time or blood loss from the tail. (C) 2004 Lippincott Williams & Wilkins.

Resuscitative mild hypothermia is and will increasingly be used in the emergency department as protection for the brain after an ischaemic insult. The clinical application of resuscitative mild hypothermia and its limitations will be summarized in this paper. The evidence for each application and its underlying mechanism will also be reviewed.