Aspects of intensive care after cardiac arrest

Background: Cardiovascular disease, and in particular cardiac arrest with the subsequent associated brain injury, is the most common cause of death in many countries. Annually, around 6000 people suffer from Out-of-Hospital Cardiac Arrest (OHCA) in Sweden and only around 10% survive to hospital discharge. Apart from early cardiopulmonary resuscitation (CPR) and defibrillation, it has been difficult to find interventions that can increase survival in OHCA, in particular in the post-resuscitation phase. Methods and results: Study I. A national observational retrospective study, evaluating the adherence to Targeted Temperature Management (TTM) guidelines in Sweden after the publication of the TTM trial, and if the change in targeted temperature level (from 33 oC to 36 oC) influences 6-month survival. In total, 2899 OHCA patients were included, and of those, 1038 were treated by means of TTM. The proportion of patients with initial shockable rhythm receiving any TTM, i.e., following international guidelines, decreased after publication of the TTM trial (from 70.5% to 54.5%). There was no difference in 6-month survival between the TTM33 (47.2%) and the TTM36 (47.3%) groups (adjusted odds OR 1.12, 95% CI 0.80–1.56). Study II. A sub-analysis of the PRINCESS trial, in which 677 OHCA patients were randomized to trans-nasal intra-arrest cooling initiated by the emergency medical services (EMS) or cooling started after hospital arrival. In this sub-analysis, the association between early initiation of intra-arrest cooling and neurological outcome was evaluated. Early cooling (intervention group, n=150) was defined as cooling initiated ≤ 20 minutes from collapse, and these patients were propensity score-matched with comparable controls (n=150). The primary outcome was survival with good neurological outcome (defined as Cerebral Performance Category [CPC] 1–2) at 90 days. The proportion of cases with CPC 1–2 at 90 days was 23.3% in the intervention group vs. 16% in the control group (OR 1.92, 95% CI 0.95–3.85). In patients with shockable rhythm the corresponding figures were 50.9% (intervention) vs. 29.8% (control) (OR 3.25, 95% CI 1.06–9.97). Study III. A nationwide observational retrospective study, evaluating the association between different levels of hyperoxemia at Intensive Care Unit (ICU) arrival after cardiac arrest, and 30-day survival. Partial oxygen pressure (PaO2) was recorded in a standardized way at ICU admission (± one hour). Hyperoxemia was defined as mild (13.4–20 kPa), moderate (20.1–30 kPa), severe (30.1–40 kPa) or extreme (>40 kPa). Normoxaemia was defined as PaO2 8–13.3 kPa and hypoxemia as PaO2 <8 kPa. In total, 9735 patients were included. Of these, 44.6% were hyperoxemic, 44.8% were normoxaemic and 10.5% were hypoxemic. Compared with the normoxemia group, the adjusted risk ratios (RRs) for 30-day survival in the hyperoxemia groups were: mild 0.91 (95% CI 0.85–0.91), moderate 0.88 (95% CI 0.82–0.95), severe 0.79 (95% CI 0.7– 0.89), and extreme 0.68 (95% CI 0.58–0.79). Study IV. A post-hoc analysis of the TTM2 trial, in which 1900 resuscitated OHCA patients were randomized to either hypothermia (TTM of 33 oC) or normothermia (<37.8 oC) groups for 28 hours. This sub-analysis was carried out to evaluate if there is any association between the cooling method used, i.e., intravascular (IC) vs. surface cooling (SFC), in the TTM 33oC group, and neurological outcome. The primary outcome was survival with good neurological outcome (defined as modified Rankin scale [mRS] result of 0–3) at six months. In total, 876 patients were included in this study, in which 30% were treated by means of IC and 70% by SFC. At six months, after propensity score matching, 53.0% of the patients in the IC group and 42.3% of the patients in the SFC group were alive, with mRS scores of 0–3 (OR 1.5, 95% CI 1.05–2.15). The IC group demonstrated better cooling speed and precision compared with the SFC group. Conclusions: After publication of the TTM trial, fewer OHCA patients in Sweden received any TTM and this change of practice did not affect six-month survival among patients who underwent TTM. In the PRINCESS trial, intra-arrest cooling started within 20 minutes of arrest, compared with cooling started after hospital admission, was not associated with a significantly better neurological outcome. In the subgroup with shockable rhythms, early cooling was associated with better neurological outcome. Among resuscitated OHCA patients, hyperoxaemia at ICU admission, compared with normoxemia, was associated with lower 30-day survival. The association was stronger in connection with higher PaO2 levels. In OHCA patients in the TTM2 trial treated by means of TTM 33 oC, intravascular cooling, compared with surface cooling, was associated with better cooling performance and better neurological outcomes after six months

Time to intra-arrest therapeutic hypothermia in out-of-hospital cardiac arrest patients and its association with neurologic outcome: a propensity matched sub-analysis of the PRINCESS trial

© 2020, The Author(s). Purpose: To study the association between early initiation of intra-arrest therapeutic hypothermia and neurologic outcome in out-of-hospital cardiac arrest. Methods: A prespecified sub-analysis of the PRINCESS trial (NCT01400373) that randomized 677 bystander-witnessed cardiac arrests to transnasal evaporative intra-arrest cooling initiated by emergency medical services or cooling started after hospital arrival. Early cooling (intervention) was defined as intra-arrest cooling initiated \u3c 20 min from collapse (i.e., ≤ median time to cooling in PRINCESS). Propensity score matching established comparable control patients. Primary outcome was favorable neurologic outcome, Cerebral Performance Category (CPC) 1–2 at 90 days. Complete recovery (CPC 1) was among secondary outcomes. Results: In total, 300 patients were analyzed and the proportion with CPC 1–2 at 90 days was 35/150 (23.3%) in the intervention group versus 24/150 (16%) in the control group, odds ratio (OR) 1.92, 95% confidence interval (CI) 0.95–3.85, p =.07. In patients with shockable rhythm, CPC 1–2 was 29/57 (50.9%) versus 17/57 (29.8%), OR 3.25, 95%, CI 1.06–9.97, p =.04. The proportion with CPC 1 at 90 days was 31/150 (20.7%) in the intervention group and 17/150 (11.3%) in controls, OR 2.27, 95% CI 1.12–4.62, p =.02. In patients with shockable rhythms, the proportion with CPC 1 was 27/57 (47.4%) versus 12/57 (21.1%), OR 5.33, 95% CI 1.55–18.3, p =.008. Conclusions: In the whole study population, intra-arrest cooling initiated \u3c 20 min from collapse compared to cooling initiated at hospital was not associated with improved favorable neurologic outcome. In the subgroup with shockable rhythms, early cooling was associated with improved favorable outcome and complete recovery

Surgical site infection after gastrointestinal surgery in high-income, middle-income, and low-income countries: a prospective, international, multicentre cohort study

Background: Surgical site infection (SSI) is one of the most common infections associated with health care, but its importance as a global health priority is not fully understood. We quantified the burden of SSI after gastrointestinal surgery in countries in all parts of the world. Methods: This international, prospective, multicentre cohort study included consecutive patients undergoing elective or emergency gastrointestinal resection within 2-week time periods at any health-care facility in any country. Countries with participating centres were stratified into high-income, middle-income, and low-income groups according to the UN's Human Development Index (HDI). Data variables from the GlobalSurg 1 study and other studies that have been found to affect the likelihood of SSI were entered into risk adjustment models. The primary outcome measure was the 30-day SSI incidence (defined by US Centers for Disease Control and Prevention criteria for superficial and deep incisional SSI). Relationships with explanatory variables were examined using Bayesian multilevel logistic regression models. This trial is registered with ClinicalTrials.gov, number NCT02662231. Findings: Between Jan 4, 2016, and July 31, 2016, 13 265 records were submitted for analysis. 12 539 patients from 343 hospitals in 66 countries were included. 7339 (58·5%) patient were from high-HDI countries (193 hospitals in 30 countries), 3918 (31·2%) patients were from middle-HDI countries (82 hospitals in 18 countries), and 1282 (10·2%) patients were from low-HDI countries (68 hospitals in 18 countries). In total, 1538 (12·3%) patients had SSI within 30 days of surgery. The incidence of SSI varied between countries with high (691 [9·4%] of 7339 patients), middle (549 [14·0%] of 3918 patients), and low (298 [23·2%] of 1282) HDI (p < 0·001). The highest SSI incidence in each HDI group was after dirty surgery (102 [17·8%] of 574 patients in high-HDI countries; 74 [31·4%] of 236 patients in middle-HDI countries; 72 [39·8%] of 181 patients in low-HDI countries). Following risk factor adjustment, patients in low-HDI countries were at greatest risk of SSI (adjusted odds ratio 1·60, 95% credible interval 1·05–2·37; p=0·030). 132 (21·6%) of 610 patients with an SSI and a microbiology culture result had an infection that was resistant to the prophylactic antibiotic used. Resistant infections were detected in 49 (16·6%) of 295 patients in high-HDI countries, in 37 (19·8%) of 187 patients in middle-HDI countries, and in 46 (35·9%) of 128 patients in low-HDI countries (p < 0·001). Interpretation: Countries with a low HDI carry a disproportionately greater burden of SSI than countries with a middle or high HDI and might have higher rates of antibiotic resistance. In view of WHO recommendations on SSI prevention that highlight the absence of high-quality interventional research, urgent, pragmatic, randomised trials based in LMICs are needed to assess measures aiming to reduce this preventable complication

Quality of Life, Needs and Fears of Mothers of Children with Disabilities in Saudi Arabia during the COVID-19 Lockdown

Substantial changes in life dynamics resulting from the outbreak of the coronavirus disease 2019 (COVID-19) could have an impact on the quality of life (QoL) of mothers of children with and without disabilities. This study compared the quality of life (QoL) of mothers of children with disabilities (MCD) to the QoL of mothers of children without disabilities (CON) in Saudi Arabia during COVID-19 lockdown. It explored mothers’ concerns and the type of support they need during the quarantine. A comparative cross-sectional study was conducted during the lockdown. An online questionnaire was distributed to mothers raising children with and without disabilities in Saudi Arabia. A total of 340 mothers participated in the study by completing the survey: 93 MCD and 247 CON. The QoL of MCD and CON was assessed using the WHOQOL-BREF questionnaire. Furthermore, detailed information was provided by the mothers regarding their needs and concerns during the lockdown. The results of the study revealed that the overall QoL was significantly higher in the CON group, compared to the MCD group, during the COVID-19 lockdown. The social well-being and environmental well-being reported by MCD were significantly lower on the total scale of the WHOQOL-BREF than those reported by the CON group. The comparison between the two groups revealed significant differences in the support required by mothers during the COVID-19 pandemic: a higher percentage of MCD needed emotional and psychological support, especially from family members. The major concerns reported by MCD were the deterioration of their children’s medical conditions and the lack of medical supplies during the lockdown.</jats:p

Thermal and dynamic performance of kenaf/washingtonia fibre-based hybrid composites

The application of hybrid natural fibres incorporated with bio phenolic composites is significant due to their sustainability and low-cost rates. In this paper, two natural fibres composites were prepared using a hand lay-up technique. The thermal stability, dynamic-mechanical, and thermo-mechanical characterisations of kenaf fibre (KF)/Washingtonia Leaf Stalk Fibres (AW)/epoxy biocomposite were investigated in this paper. Thermomechanical analysis (TMA) and dynamic mechanical analysis (DMA), respectively, were used to examine the thermal stability and the coefficient of thermal expansion (CTE) and the dynamic mechanical properties of composites, respectively. The Thermogravimetric (TG) analyses showed that the addition of KF and AW enhanced the thermal stability of the epoxy composites. 7AW/3KENAF showed the most significant improvement in thermal stability (Tonset; 284.52 °C and Tmax; 368.25. Furthermore, the hybrid biocomposite exhibited the highest storage modulus (2668.9 MPa) among all other pure and hybrid biocomposites. On the other hand, the TMA findings illustrated that the 50% AW sample exhibited the highest value of CTE (242 μm/m °C) at the maximum temperature (175 °C) among all samples. Briefly, it is obvious that the combination of WA with KENAF enhanced the potential in improving thermal, dimensional and dynamic mechanical characterisations of epoxy composites and can be utilised in building applications that dictate elevated dimensional stability. It was proven that the hybrid biocomposites prepared in this work supported by hybrid natural fibres as strengthened bio fillers might benefit the performance of epoxy composites, which could broaden the application range of industrial and engineering applications and provide novel ways for its effective uses

Quality of Life, Needs and Fears of Mothers of Children with Disabilities in Saudi Arabia during the COVID-19 Lockdown

Substantial changes in life dynamics resulting from the outbreak of the coronavirus disease 2019 (COVID-19) could have an impact on the quality of life (QoL) of mothers of children with and without disabilities. This study compared the quality of life (QoL) of mothers of children with disabilities (MCD) to the QoL of mothers of children without disabilities (CON) in Saudi Arabia during COVID-19 lockdown. It explored mothers’ concerns and the type of support they need during the quarantine. A comparative cross-sectional study was conducted during the lockdown. An online questionnaire was distributed to mothers raising children with and without disabilities in Saudi Arabia. A total of 340 mothers participated in the study by completing the survey: 93 MCD and 247 CON. The QoL of MCD and CON was assessed using the WHOQOL-BREF questionnaire. Furthermore, detailed information was provided by the mothers regarding their needs and concerns during the lockdown. The results of the study revealed that the overall QoL was significantly higher in the CON group, compared to the MCD group, during the COVID-19 lockdown. The social well-being and environmental well-being reported by MCD were significantly lower on the total scale of the WHOQOL-BREF than those reported by the CON group. The comparison between the two groups revealed significant differences in the support required by mothers during the COVID-19 pandemic: a higher percentage of MCD needed emotional and psychological support, especially from family members. The major concerns reported by MCD were the deterioration of their children’s medical conditions and the lack of medical supplies during the lockdown