Obstetric units' preparedness to manage critically ill women. The second report from the MaCriCare study.

PURPOSE: We aimed to describe the availability of 31 distinct services and facilities to diagnose, resuscitate, and treat critically unwell obstetric patients. METHODS: Using a network of anesthesiologists, intensive care clinicians, obstetricians, critical care nurses, and midwives (MaCriCare) from September 2021 to January 2022, we conducted a descriptive international multicenter cross-sectional survey in centers with obstetric units (OUs) in the WHO Europe Region. RESULTS: The MaCriCare network covers 26 countries and received 1133 responses, corresponding to 2.5 million annual deliveries. The survey identified significant disparities in the availability of the measured 31 services among the OUs, with some services not immediately available and some not available at all. Point-of-care hemoglobin measurements were lacking in 13.8% of OUs. 15.2% of OUs lacked pointof-care lactate measurement, and 11% lacked transfusion services. 23.8% of OUs lacked the ability to administer hypotensive agent infusions in the labor ward. Samebuilding access to cell saver and thromboelastometry was unavailable to 45.5% and 64.4% of OUs, respectively. Access to invasive ventilation was unavailable to 3.4% of OUs, 11.7% were unable to offer same-building access to non-invasive ventilation, and extracorporeal membranous oxygenation was unavailable to 38.3% of the OUs. CONCLUSION: Critically ill obstetric patients have access to markedly different resources in the WHO Europe Region depending on the OU where they are managed. Consensus on which facilities and services should be universally available is urgently needed.

Preparedness for severe maternal morbidity in European hospitals: The MaCriCare study.

PURPOSE: To evaluate obstetric units (OUs) and intensive care units (ICUs) preparedness for severe maternal morbidity (SMM). METHODS: From September 2021 to January 2022, an international multicentre cross-sectional study surveyed OUs in 26 WHO Europe Region countries. We assessed modified early obstetric warning score usage (MEOWS), approaches to four SMM clinical scenarios, invasive monitoring availability in OUs, and access to high-dependency units (HDUs) and onsite ICUs. Within ICUs, we examined the availability of trained staff, response to obstetric emergencies, leadership, and data collection. RESULTS: 1133 responses were evaluated. MEOWS use was 34.5%. Non-obstetric early warning scores were being used. 21.4% (242) of OUs provided invasive monitoring in the OU. A quarter lacked access to onsite HDU beds. In cases of SMM, up to 13.8% of all OUs indicated the need for transfer to another hospital. The transfer rate was highest (74.0%) in small units. 81.9% of centers provided onsite ICU facilities to obstetric patients. Over 90% of the onsite ICUs provided daily specialist obstetric reviews but lacked immediate access to key resources: 3.4% - uterotonic drugs, 7.5% - neonatal resuscitation equipment, 9.2% - neonatal resuscitation team, 11.4% - perimortem cesarean section equipment. 41.2% reported obstetric data to a national database. CONCLUSION: Gaps in provision exist for obstetric patients with SMM in Europe, potentially compromising patient safety and experience. MEOWS use in OUs was low, while access to invasive monitoring and onsite HDU and ICU facilities was variable. ICUs frequently lacked resources and did not universally collect obstetric data for quality control.

Physician-staffed prehospital units: a retrospective follow-up from an urban area in Scandinavia.

BACKGROUND: The aim of this study was to determine when and how rapid response vehicles (RRVs) make a difference in prehospital care by investigating the number and kinds of RRV assignment dispatches and the prehospital characteristics and interventions involved. METHODS: This retrospective cohort study was based on data from a quality assurance system where all assignments are registered. RRV staff register every assignment directly at the site, using a smartphone, tablet, or computer. There is no mandatory information requirement or time limit for registration. The study includes data for all RRVs operating in Region Stockholm, three during daytime hours and one at night - from January 1, 2021 to December 31, 2021. RESULTS: In 2021, RRVs in Stockholm were dispatched on 11,283 occasions, of which 3,571 (31.6%) resulted in stand-downs. In general, stand-downs were less common for older patients. The most common dispatch category was blunt trauma (1,584 or 14.0%), which accounted for the highest frequency of stand-downs (676 or 6.0%). The second most common category was cardiac arrest (1,086 or 9.6%), followed by shortness of breath (691 or 6.1%), medical not specified (N/S) (596 or 5.3%), and seizures (572 or 5.1%). CONCLUSION: The study findings confirm that RRVs provide valuable assistance to the ambulance service in Stockholm, especially for cardiac arrest and trauma patients. In particular, RRV personnel have more advanced medical knowledge and can administer medications and perform interventions that the regular ambulance service cannot provide.

Blue Rubber Bleb Nevus Syndrome in the Obstetric Patient: A Case Report of Anesthetic Implications and Management.

Blue rubber bleb nevus syndrome (BRBNS) is a rare systemic syndrome characterized by venous malformations usually found in the skin and visceral organs. To date, 11 case reports describing BRBNS during pregnancy have been published. To our knowledge, this is the first report describing intracranial, airway, epidural, and birth canal involvement of venous malformations in the same parturient. Key lessons learned include clinical presentation, workup, team management, and care of obstetric patients with this disorder.

[EXIT: Experiences from Karolinska University Hopsital]. / EXIT ­ säkraste förlossningsmetod för foster med livshotande luftvägshinder - Samlade erfarenheter från Karolinska universitetssjukhuset.

The main, but not sole, indication for an Ex-utero Intrapartum Treatment (EXIT) delivery is an airway obstruction due to either laryngeal atresia or tumors in the head and neck region. Here we present our Institution's experience with eleven cases: three teratomas, four lymphatic malformations, two laryngeal atresias and two dermoid cysts. The EXIT procedure was used to secure the fetal airway while maintaining uteroplacental gas exchange and fetal hemodynamic stability through the umbilical circulation. Five fetuses required tracheostomy. Only one fetal death occurred due to extensive growth of a teratoma preventing us from establishing an airway. No other fetal or major maternal complication occurred. The EXIT procedure is a complex procedure and these rare cases should be referred to a center with a dedicated and experienced multidisciplinary team.

Massive air embolism as a complication of upper gastrointestinal endoscopy: A case report illustrating a stroke mimic, literature review, and suggested management.

Cerebral air embolism should be considered in case of stroke symptoms during any invasive procedure. Transport to a hospital with neurosurgical/hyperbaric oxygen treatment (HBOT) facility could improve the outcome for the patient. Absence of air on computed tomography (CT) scan should not disqualify a patient from HBOT if air embolism is suspected.

[The impact of an Anaesthesia and Intensive Care collaboration between Sweden and Tanzania]. / Samarbete Tanzania-Sverige för bättre anestesi och intensivvård - 22 anestesiologer på 47 miljoner tanzanier men nu börjar samarbetsprojektet ge resultat.

The impact of an Anaesthesia and Intensive Care collaboration between Sweden and Tanzania Anaesthesia and intensive care is a neglected specialty in low-income countries. Many countries have less than 1 anaesthesia provider per 100,000 population and few hospitals in Africa have the resources for managing critically ill patients. Health partnerships between institutions in high- and low-income countries have been proposed as an effective way to strengthen health systems. This article describes a partnership in anaesthesia and intensive care between institutions in Sweden and Tanzania and its impact at regional and national levels. The partnership, initiated in 2008 on the request of Muhimbili National Hospital in Dar es Salaam, conducts training, exchanges, research, equipment, routines and guidelines projects. Through the newly formed Life Support Foundation, the partnership has expanded to all hospitals in Dar es Salaam, has assisted in the reactivation of the Society of Anaesthesiologists of Tanzania and has seen a marked increase in the number of trainee doctors.

Establishing an Anaesthesia and Intensive Care partnership and aiming for national impact in Tanzania.

Anaesthesia and Intensive Care is a neglected specialty in low-income countries. There is an acute shortage of health workers - several low-income countries have less than 1 anaesthesia provider per 100,000 population. Only 1.5% of hospitals in Africa have the intensive care resources needed for managing patients with sepsis. Health partnerships between institutions in high and low-income countries have been proposed as an effective way to strengthen health systems. The aim of this article is to describe the origin and conduct of a health partnership in Anaesthesia and Intensive Care between institutions in Tanzania and Sweden and how the partnership has expanded to have an impact at regional and national levels.The Muhimbili-Karolinska Anaesthesia and Intensive Care Collaboration was initiated in 2008 on the request of the Executive Director of Muhimbili National Hospital in Dar es Salaam. The partnership has conducted training courses, exchanges, research projects and introduced new equipment, routines and guidelines. The partnership has expanded to include all hospitals in Dar es Salaam. Through the newly formed Life Support Foundation, the partnership has had a national impact assisting the reanimation of the Society of Anaesthesiologists of Tanzania and has seen a marked increase of the number of young doctors choosing a residency in Anaesthesia and Intensive Care.

Quality of anaesthesia for Caesarean sections: a cross-sectional study of a university hospital in a low-income country.

OBJECTIVE: To evaluate the quality of anaesthesia for Caesarean sections at Muhimbili National Hospital, Dar es Salaam, Tanzania. METHOD: We developed an instrument consisting of 40 quality indicators using an expert group process based on the existing literature. Using the instrument, we observed 50 Caesarean sections. Twenty-eight of the indicators were structural indicators, such as essential drugs, oxygen supply and anaesthetic equipment. Twelve were process indicators such as evaluation of airway, blood pressure assessment or insertion of an intravenous line. RESULTS: The median patient age was 28.5 years. A total of 75% (range 61-82%) of the structural indicators were present in the operating theatres, and 55% (range 33-83%) of the process indicators were performed. The neonates' median Apgar score was 9 (range 3-10). Seven babies required ventilation, four babies were stillborn, and all others were alive at follow-up 2 days after partus. All mothers were alive 2 days post-surgery. CONCLUSION: The low process score suggests that quality improvement initiatives should focus on the processes of anaesthesia for Caesarean sections rather than new drugs and equipment.

Synergistic interaction between Gdf1 and Nodal during anterior axis development.

Growth and Differentiation Factor 1 (GDF-1) has been implicated in left-right patterning of the mouse embryo but has no other known function. Here, we demonstrate a genetic interaction between Gdf1 and Nodal during anterior axis development. Gdf1-/-;Nodal+/- mutants displayed several abnormalities that were not present in either Gdf1-/- or Nodal+/- single mutants, including absence of notochord and prechordal plate, and malformation of the foregut; organizing centers implicated in the development of the anterior head and branchial arches, respectively. Consistent with these deficits, Gdf1-/-;Nodal+/- mutant embryos displayed a number of axial midline abnormalities, including holoprosencephaly, anterior head truncation, cleft lip, fused nasal cavity, and lack of jaws and tongue. The absence of these defects in single mutants indicated a synergistic interaction between Nodal and GDF-1 in the node, from which the axial mesendoderm that gives rise to the notochord, prechordal plate, and foregut endoderm originates, and where the two factors are co-expressed. This notion was supported by a severe downregulation of FoxA2 and goosecoid in the anterior primitive streak of double mutant embryos. Unlike that in the lateral plate mesoderm, Nodal expression in the node was independent of GDF-1, indicating that both factors act in parallel to control the development of mesendodermal precursors. Receptor reconstitution experiments indicated that GDF-1, like Nodal, can signal through the type I receptors ALK4 and ALK7. However, analysis of compound mutants indicated that ALK4, but not ALK7, was responsible for the effects of GDF-1 and Nodal during anterior axis development. These results indicate that GDF-1 and Nodal converge on ALK4 in the anterior primitive streak to control the formation of organizing centers that are necessary for normal forebrain and branchial arch development.

ALK7, a receptor for nodal, is dispensable for embryogenesis and left-right patterning in the mouse.

Mesendoderm formation and left-right patterning during vertebrate development depend upon selected members of the transforming growth factor beta superfamily, particularly Nodal and Nodal-related ligands. Two type I serine/threonine kinase receptors have been identified for Nodal, ALK4 and ALK7. Mouse embryos lacking ALK4 fail to produce mesendoderm and die shortly after gastrulation, resembling the phenotype of Nodal knockout mice. Whether ALK4 contributes to left-right patterning is still unknown. Here we report the generation and initial characterization of mice lacking ALK7. Homozygous mutant mice were born at the expected frequency and remained viable and fertile. Viability at weaning was not different from that of the wild type in ALK7(-/-); Nodal(+/-) and ALK7(-/-); ALK4(+/-) compound mutants. ALK7 and ALK4 were highly expressed in interdigital regions of the developing limb bud. However, ALK7 mutant mice displayed no skeletal abnormalities or limb malformations. None of the left-right patterning abnormalities and organogenesis defects identified in mice carrying mutations in Nodal or in genes encoding ActRIIA and ActRIIB coreceptors, including heart malformations, pulmonary isomerism, right-sided gut, and spleen hypoplasia, were observed in mice lacking ALK7. Finally, the histological organization of the cerebellum, cortex, and hippocampus, all sites of significant ALK7 expression in the rodent brain, appeared normal in ALK7 mutant mice. We conclude that ALK7 is not an essential mediator of Nodal signaling during mesendoderm formation and left-right patterning in the mouse but may instead mediate other activities of Nodal and related ligands in the development or function of particular tissues and organs.