Despite the unprecedented improvement in child health in last 15 years, burden of stillbirth and neonatal death remain the key challenge in Nepal and the reduction of these deaths will be crucial for reaching the health targets for Sustainable development goal by 2030. The aim of this thesis was to explore the risk factors for stillbirth and neonatal death and change in perinatal outcomes after the introduction of the Helping Babies Breathe Quality Improvement Cycle (HBB QIC) in Nepal. This was a prospective cohort study with a nested case-control design completed in a tertiary hospital in Nepal. Information were collected from the women who had experienced perinatal death and live birth among referent population; a video recording was done in the neonatal resuscitation corner to collect information on the health workers’ performance in neonatal resuscitation.  Lack of antenatal care had the highest association with antepartum stillbirth (aOR 4.2, 95% CI 3.2–5.4), births that had inadequate fetal heart rate monitoring were associated with intrapartum stillbirth (aOR 1.9, CI 95% 1.5–2.4), and babies who were born premature and small-for-gestational-age had the highest risk for neonatal death in the hospital (aOR 16.2, 95% CI 12.3–21.3). Before the introduction of the HBB QIC, health workers displayed poor adherence to the neonatal resuscitation protocol. After the introduction of HBB QIC, the health workers demonstrated improvement in their neonatal resuscitation skills and these were retained until six months after training. Daily bag-and-mask skill checks (RR 5.1 95% CI 1.9–13.5), preparation for birth (RR 2.4, 95% CI 1.0–5.6), self-evaluation checklists (RR 3.8, 95% CI 1.4–9.7) and weekly review and reflection meetings (RR 2.6, 95% 1.0–7.4) helped the health workers to retain their neonatal resuscitation skills. The health workers demonstrated improvement in ventilation of babies within one minute of birth and there was a reduction in intrapartum stillbirth (aOR 0.46, 95% CI 0.32–0.66) and first-day neonatal mortality (aOR 0.51, 95% CI 0.31–0.83).  The study provides information on challenges in reducing stillbirth and neonatal death in low income settings and provides a strategy to improve health workers adherence to neonatal resuscitation to reduce the mortality. The HBB QIC can be implemented in similar clinical settings to improve quality of care and survival in Nepal, but for primary care settings, the QIC need to be evaluated further.

In this work, new methods of feature extraction, feature selection, stochastic data characterization/modeling, variance reduction and measures for parametric discrimination are proposed. These methods have implications for data mining, machine learning, and information theory. A novel decision-support system is developed in order to guide intervention during cardiac arrest. The models are built upon knowledge extracted with signal-processing, non-linear dynamic and machine-learning methods. The proposed ECG characterization, combined with information extracted from PetCO2 signals, shows viability for decision-support in clinical settings. The approach, which focuses on integration of multiple features through machine learning techniques, suits well to inclusion of multiple physiologic signals. Ventricular Fibrillation (VF) is a common presenting dysrhythmia in the setting of cardiac arrest whose main treatment is defibrillation through direct current countershock to achieve return of spontaneous circulation. However, often defibrillation is unsuccessful and may even lead to the transition of VF to more nefarious rhythms such as asystole or pulseless electrical activity. Multiple methods have been proposed for predicting defibrillation success based on examination of the VF waveform. To date, however, no analytical technique has been widely accepted. For a given desired sensitivity, the proposed model provides a significantly higher accuracy and specificity as compared to the state-of-the-art. Notably, within the range of 80-90% of sensitivity, the method provides about 40% higher specificity. This means that when trained to have the same level of sensitivity, the model will yield far fewer false positives (unnecessary shocks). Also introduced is a new model that predicts recurrence of arrest after a successful countershock is delivered. To date, no other work has sought to build such a model. I validate the method by reporting multiple performance metrics calculated on (blind) test sets.

United Nations has lately stated ambitious health targets for 2030 in the Sustainable Development Goal agenda, following the already achieved progress between 1990 and 2015 when the number of children dying before the age of five was reduced by more than half. However, the mortality reduction in the first month of life after birth has not kept the same pace. Furthermore, a large number of stillbirths have previously not been accounted for. The aim of this thesis was to evaluate the impact of clinical training in neonatal resuscitation, and to identify strategies for an effective implementation at a maternal health facility in Nepal. Focus group discussions were used to explore the perceptions of teamwork among staff working closest to the infant at the facility. A prospective cohort study with nested referents was applied to determine effect on birth outcomes after an intervention with Helping Babies Breathe, a simplified protocol for neonatal resuscitation. Sustainability of the acquired skills after training was addressed by employing a quality improvement cycle. Video recordings of health workers performance were collected to analyse adherence to protocol. Midwives described the need for universal protocols in neonatal resuscitation and management involvement in clinical audit and feedback. There was a reduction of intrapartum stillbirth (aOR 0.46, 95% CI 0.32–0.66) and neonatal mortality within 24 hours of life (aOR 0.51, 95% CI 0.31–0.83) after the intervention. Ventilation of infants increased (OR 2.56, 95% CI 1.67–3.93) and potentially harmful suctioning was reduced (OR 0.13, 95% CI 0.09–0.17). Neonatal death from intrapartum-related complications was reduced and preterm infants survived additional days in the neonatal period after the intervention. Low birth weight was not found to be a predictor of deferred resuscitation in the studied context. This study confirmed the robustness of Helping Babies Breathe as an educational tool for training in neonatal resuscitation. Accompanied with a quality improvement cycle it reduced intrapartum stillbirth and mortality on the day of delivery in a low-income facility setting. Improved postnatal care is needed to maintain the gains in survival through the neonatal period. Increased management involvement in audit and quality of care could improve clinical performance among health workers.

Introdução: O desenvolvimento e a aplicação das Tecnologias de Informação e Comunicação associadas à internet exercem mudanças no processo de ensino aprendizagem e podem contribuir para a educação permanente em enfermagem, favorecendo a capacitação de enfermeiros, para reconhecer imediatamente a situação de parada cardiorrespiratória (PCR) de adultos e sistematizar as intervenções de suporte avançado de vida (SAV), a fim de que colaborem para o sucesso da reanimação cardiopulmonar e maior sobrevida dos pacientes. Objetivos: Desenvolver e avaliar a qualidade do curso on-line para enfermeiros sobre suporte avançado de vida nos casos de parada cardiorrespiratória em adultos. Método: Pesquisa metodológica aplicada, na modalidade de produção tecnológica de natureza quantitativa, exploratória e descritiva. Para o desenvolvimento do curso on-line, utilizou-se o modelo de Design Instrucional Contextualizado (DIC). A seleção dos participantes foi aleatória, intencional e não probabilística. Participaram do estudo dezesseis enfermeiros especialistas na área de urgência e emergência adultos e/ou de educação on-line. A coleta de dados ocorreu no período de novembro a dezembro de 2016. A avaliação do curso on-line foi baseada em critérios validados de Avaliação da Qualidade de Objetos de Aprendizagem. Resultados: O curso on-line foi implementado no ambiente virtual de aprendizagem (AVA) Moodle®, em nove unidades de aprendizagem e obtiveram índices de alta e boa qualidade em quinze (75%) critérios referentes à pertinência, contextualização, qualidade da informação, navegação, referências, portabilidade, correção de conteúdo, clareza das informações, facilidade de aprendizagem na interação e de localização das informações, interatividade, eficiência de utilização, utilização de recursos audiovisuais, ergonomia e estética. Foram avaliados cinco (25%) critérios como qualidade mediana relacionados à facilidade de retorno, uso de marcas especiais, gestão de erros, múltiplas janelas, ajuda aos usuários. Conclusões: os resultados mostraram que os referenciais teórico-metodológicos e pedagógicos adotados possibilitaram o desenvolvimento do curso on-line sobre SAV em PCR de adultos conferindo-lhe viabilidade de integrar tecnologias e estratégias educacionais inovadoras na implementação de capacitação e atualização de enfermeiros nas situações de emergência utilizando AVA. / Introduction: The development and application of Information and Communication Technologies associated to internet bring evidence-based changes in the processes of teaching and learning and may contribute for permanent education in nursing, promoting the training and the qualification of nurses on recognition of situations of cardiorespiratory arrest (CPR) in adults and on the systematization of advanced life-support interventions, in order to collaborate for the success of cardiopulmonary resuscitation and longer survival of adult patients. Objectives: Develop and evaluate the quality of the on-line course on advanced life support in adult cardiorespiratory arrest for nurses. Method: Applied methodological research, in the form of technological production based on quantitative, exploratory and descriptive research. For the development of the on-line course the Contextualized Instrumental Design (DIC) model was used. The selection of participants was random, intentional and non-probabilistic. Sixteen nurses specialists in the area of urgency and emergency to adult and/or on-line education participated in the study. Data collection has taken place from November to December 2016. The evaluation of the on-line course was based on assessed criteria of Learning Object Quality Assessment. Results: The on-line course was implemented in the Moodle® virtual learning environment in nine learning units and obtained high quality indexes in fifteen (75%) criteria regarding pertinence, contextualization, information quality, navigation, references, portability, content correction, technical information, ease of learning in interaction and location of information, interactivity, efficiency of use, use of audiovisual resources, ergonomics and aesthetics. Five (25%) criteria were evaluated a median quality related to ease of return, use of special brands, error management, multiple windows, and user assistance were also evaluated. Conclusions: The results showed that the theoretical, methodological and pedagogical frameworks adopted allowed the development of the on-line course on life-support interventions in adult CPR focused on adult learning, making it possible to integrate innovative educational technologies in the implementation of training and professional updating for nurses in the emergency situations using virtual learning environment.

Introdução: É provável que o tratamento precoce da sepse grave e do choque séptico possa melhorar o desfecho dos pacientes. Objetivo: O objetivo deste estudo foi avaliar como o atraso no início da ressuscitação da sepse influencia a gravidade da doença, a intensidade das medidas de ressuscitação necessárias para atingir estabilidade hemodinâmica, o desenvolvimento da disfunção orgânica e a função mitocondrial. Métodos: Estudo experimental, prospectivo, randomizado e controlado, realizado em um laboratório experimental de um hospital universitário. Trinta e dois porcos submetidos à anestesia geral e ventilados mecanicamente foram randomizados (8 animais por grupo) em um grupo controle sadio ou para um de três grupos em que induziu-se peritonite fecal (instilação peritoneal de 2,0 g/kg de fezes autólogas) e, após 6 (deltaT-6h), 12 (deltaT-12h) ou 24 (deltaT-24h) horas, iniciou-se um período de 48 horas de ressuscitação protocolada. Resultados: O retardo no início da ressuscitação da sepse foi associada a sinais progressivos de hipovolemia e ao aumento dos níveis plasmáticos de interleucina-6 e do fator de necrose tumoral alfa. O atraso no início do tratamento da sepse resultou em balanço hídrico progressivamente positivo (2,1 ± 0,5 mL/kg/h, 2,8 ± 0,7 mL/kg/h e 3,2 ± 1,5 mL/kg/h, respectivamente, para os grupos deltaT-6h, deltaT-12h, e deltaT-24h, p < 0,01), maior necessidade de administração de noradrenalina durante as 48 horas de ressuscitação (0,02 ± 0,04 mcg/kg/min, 0,06 ± 0,09 mcg/kg/min e 0,13 ± 0,15 mcg/kg/min, p=0,059), redução da capacidade máxima de respiração mitocondrial cerebral dependente do Complexo II (p=0,048) e tendência a aumento da mortalidade (p=0,08). Houve redução do trifosfato de adenosina (ATP) na musculatura esquelética em todos os grupos estudados (p < 0,01), com os valores mais baixos nos grupos deltaT-12h e deltaT-24h. Conclusões: O aumento do tempo entre o início da sepse e o início das manobras de ressuscitação resultou no aumento da gravidade da doença, na maior intensidade das manobras de ressuscitação e na disfunção mitocondrial cerebral associada à sepse. Nossos resultados suportam o conceito da existência de uma janela crítica de oportunidade para ressuscitação da sepse / Introduction: Early treatment in sepsis may improve outcome. Objective: The aim of this study was to evaluate the impact of delays in resuscitation on disease severity, need for resuscitation, and the development of sepsis-associated organ and mitochondrial dysfunction. Methods: Prospective, randomized, controlled experimental study performed at an experimental laboratory in a university hospital. Thirty-two anesthetized and mechanically ventilated pig were randomly assigned (n = 8 per group) to a nonseptic control group or one of three groups in which fecal peritonitis (peritoneal instillation of 2 g/kg autologous feces) was induced, and a 48 hour period of protocolized resuscitation started 6 (deltaT-6 hrs), 12 (deltaT-12 hrs), or 24 (deltaT-24 hrs) hours later. Results: Any delay in starting resuscitation was associated with progressive signs of hypovolemia and increased plasma levels of interleukin-6 and tumor necrosis factor-alfa prior to resuscitation. Delaying resuscitation increased cumulative net fluid balances (2.1 ± 0.5 mL/kg/hr, 2.8 ± 0.7 mL/kg/ hr, and 3.2 ± 1.5 mL/kg/hr, respectively, for groups deltaT-6 h rs, delta T-12 hrs, and ?T-24 hrs; p < 0.01) and norepinephrine requirements during the 48-hr resuscitation protocol (0.02 ± 0.04 mcg/kg/min, 0.06 ± 0.09 mcg /kg/min, and 0.13 ± 0.15 mcg/kg/min; p=0.059), decreased maximal brain mitochondrial Complex II respiration (p=0.048), and tended to increase mortality (p=0.08). Muscle tissue adenosine triphosphate decreased in all groups (p < 0.01), with lowest values at the end in groups deltaT-12 hrs and deltaT-24 hrs. Conclusions: Increasing the delay between sepsis initiation and resuscitation increases disease severity, need for resuscitation, and sepsis-associated brain mitochondrial dysfunction. Our results support the concept of a critical window of opportunity in sepsis resuscitation

Introdução: Apesar do desenvolvimento tecnológico, permanece baixa a sobrevida hospitalar das vítimas de parada cardiorrespiratória extra-hospitalar. Há importante dúvida na literatura quanto à retenção de habilidades de ressuscitação cardiopulmonar (RCP) e a periodicidade adequada de treinamento para manutenção dessas habilidades. O presente estudo investigou a retenção, em alunos a partir de treinamento no primeiro semestre de ingresso no curso médico, das habilidades práticas de RCP até 42 meses após o referido treinamento. Métodos: Estudo de corte transversal, realizado com 298 alunos de graduação de uma faculdade de Medicina, treinados com base nas diretrizes de ressuscitação de 2010 da American Heart Association. Foram avaliados 205 alunos sem retreinamento das habilidades, divididos em quatro grupos conforme o tempo decorrido desde o treinamento de ingresso: 73 alunos após 1 mês, 55 após 18 meses, 41 após 30 meses e 36 após 42 meses. A análise da retenção das habilidades foi comparada com 93 alunos que referiram ter realizado retreinamento em RCP. Dezenove habilidades de RCP e nove potenciais erros de técnica na execução das ventilações pulmonares e compressões torácicas foram avaliados por meio de simulação realística e revisados com utilização de filmagem e avaliadores independentes. Resultados: A média de retenção das dezenove habilidades nos alunos sem retreinamento foi: 90% após 1 mês, 74% após 18 meses, 62% após 30 meses e 61% após 42 meses (p < 0,001). Nos alunos que referiram retreinamento, a retenção foi de 74% após 18 meses, 70% após 30 meses e 66% após 42 meses do treinamento inicial. Realizada curva de predição da retenção de habilidades, com estimativa de 80% das habilidades mantidas após 10 meses, 70% após 21 meses e 60% após 42 meses. A profundidade das compressões torácicas foi a habilidade com maior retenção ao longo do tempo (87,8%), sem diferença estatística entre os quatro grupos. Houve aumento da prevalência de compressões realizadas com menos de 5 cm de profundidade quando realizadas em frequência maior que 120 por minuto. A média da frequência de compressões torácicas obtidas nos grupos após 1, 18, 30 e 42 meses foi, respectivamente, 114, 114, 104 e 108 compressões por minuto; 104 (50,7%) alunos mantiveram frequência média entre 100-120 por minuto. As ventilações pulmonares apresentaram diminuição progressiva de retenção, de 93% após 1 mês até 19% após 42 meses (p < 0,001). Todos os alunos efetivaram o choque com o desfibrilador externo automático, porém com o grupo após 1 mês do treinamento com menor tempo para efetivação do choque e maior prevalência de posicionamento adequado das pás do desfibrilador. Conclusões: O presente estudo demonstrou diferentes níveis de retenção para as habilidades de RCP e diferentes níveis de decréscimo de tais habilidades ao longo de 42 meses. A profundidade das compressões torácicas e o uso do desfibrilador externo automático foram as habilidades com maior retenção ao longo do tempo. Treinamentos adicionais ao longo do curso de Medicina atenuaram a perda de habilidades, mas sem retorno ao desempenho observado após 1 mês do treinamento. Sugerimos que o intervalo mínimo de retreinamento para manutenção de pelo menos 70% das habilidades deva ser de 18 a 24 meses / Introduction: Despite technological development, the survival of victims of out-ofhospital cardiac arrest remains low. There are important questions in the literature regarding the retention of cardiopulmonary resuscitation (CPR) skills and the ideal frequency of retraining required to enhance retention of skills. This study investigated the retention of practical CPR skills by medical students over 42 months after training in the first semester of admission to the medical course. Methods: A cross-sectional study was conducted with 298 undergraduate medical students who were trained based on the 2010 American Heart Association resuscitation guidelines. A total of 205 students divided into four groups according to the time elapsed since the entrance training were evaluated without retraining (73 students after 1 month, 55 students after 18 months, 41 students after 30 months and 36 students after 42 months). The analysis of the retention of skills was compared to 93 students who reported having performed retraining in CPR. Nineteen CPR skills and nine potential technical errors in ventilations and chest compressions were evaluated by realistic simulation and reviewed using filming by independent examiners. Results: The mean retention of the nineteen skills in not retrained students was: 90% after 1 month, 74% after 18 months, 62% after 30 months and 61% after 42 months (p < 0.001). In retraining students, retention was 74% after 18 months, 70% after 30 months, and 66% after 42 months of initial training, with statistical difference between the students with and without retraining in the 30-month group (p=0.005). The estimation of mean skill retention was 80% after 10 months, 70% after 21 months and 60% after 42 months. The depth of chest compressions was the skill with greater retention over time (87.8%), with no statistical difference among groups. There was an increase in the prevalence of compressions performed with less than 5 cm depth when performed at a frequency greater than 120 per minute. The mean chest compressions rate obtained in the groups after 1, 18, 30 and 42 months were 114, 114, 104 and 108 per minute, respectively, and 104 (50.7%) students maintained a mean frequency of 100-120 per minute. Pulmonary ventilation showed a progressive decrease in retention from 93% after 1 month to 19% after 42 months (p < 0.001). All students delivered the shock with the automated external defibrillator; however, for the group one month post-training, the time for the application of the shock was lower, and the prevalence of adequate positioning of the defibrillator pads was greater. Conclusion: This study showed different retention levels for CPR skills and different decrease levels of these skills over 42 months. Depth of chest compressions and use of automated external defibrillator were the skills with the highest retention over time. Additional training throughout the medical course attenuated the loss of skills, but no return to the initial performance achieved after 1 month. We suggest that the minimum retraining interval for maintenance of at least 70% of skills should be 18 to 24 months

Introdução: A assistência ao parto no Brasil tem enfrentado desafios nos últimos anos, no sentido de reduzir práticas desnecessárias e inseguras. No entanto, medidas utilizadas para acelerar o trabalho de parto e demais intervenções durante o trabalho de parto e parto ainda são frequentes e podem impactar negativamente as condições de vitalidade do recém-nascido. Objetivos: Analisar a associação entre os fatores sociodemográficos, organizacionais, obstétricos e assistenciais e desfecho neonatal desfavorável entre RNs de termo e estimar sua frequência. Método: Estudo transversal, a partir dos dados do inquérito nacional Nascer no Brasil, referentes à região Sudeste. A amostra foi composta por puérperas que tiveram RNs vivos, natimortos (peso 500 gramas e/ou idade gestacional 22 semanas), nascidos em hospitais com 500 partos em 2011 e 2012. Foram excluídos os recém-nascidos prematuros, gemelares e aqueles com malformações. A variável dependente desfecho neonatal desfavorável foi construída por meio da composição das variáveis intubação traqueal, massagem cardíaca, uso de drogas na reanimação neonatal, internação em UTI neonatal e Apgar <7 no 5.o minuto de vida no período pós-natal imediato. A associação entre as variáveis de interesse e a variável desfecho foi estimada por meio de regressão logística binária univariada e múltipla, calculando-se Odds ratio (OR) brutas e ajustadas com intervalos de confiança de 95 por cento (IC 95 por cento ). Resultados: A amostra foi composta por 8.783 mulheres e seus RNs. A proporção de RNs que apresentou desfecho neonatal desfavorável foi de 9,6 por cento (844). Ensino fundamental incompleto (OR=2,139; IC 95 por cento 1,292-3,540), baixo peso ao nascer (peso 2.500g; OR=2,822; IC 95 por cento 1,641-4,851), intercorrência obstétrica (OR=1,421; IC 95 por cento 1,055-1,914) e parto fórceps (OR=3,761; IC 95 por cento 1,824-7,754) constituíram fatores associados ao desfecho neonatal desfavorável. Discussão: Os fatores independentemente associados ao desfecho neonatal desfavorável na Região Sudeste do Brasil foram em sua maioria condições clínicas que têm influência sobre a condição do recém-nascido no período pós-parto imediato. Recém-nascidos com baixo peso e aqueles filhos de mulheres com problemas obstétricos têm condições como líquido amniótico reduzido ou insuficiência placentária que resultam em alterações da vitalidade. Mulheres com baixa escolaridade têm maior dificuldade em acessar os serviços de saúde, o que pode dificultar a identificação e tratamento de problemas obstétricos e baixo peso ao nascer. O parto fórceps pode representar a resolução de trabalhos de parto distócicos e também ser um marcador para os fetos cuja vitalidade encontrava-se alterada durante o trabalho de parto. Conclusões: Fatores clínicos e associados a desigualdades sociais têm impacto negativo sobre a vitalidade dos recém-nascidos. Os desfechos neonatais desfavoráveis ainda são pouco investigados, por isso ações que visem à melhoria da atenção pré-natal e do trabalho de parto, principalmente entre mulheres com baixa escolaridade e aquelas com complicações obstétricas, podem resultar em melhores desfechos de saúde para o recém-nascido. Encontramos uma proporção de 9,6 por cento (844) entre os recém-nascidos no termo gestacional que apresentaram desfecho neonatal desfavorável. Neste estudo foi possível observar a existência de associação entre fatores sociodemográficos, clínicos e assistenciais maternos e desfechos neonatais desfavoráveis entre os RNs de termo / Introduction: Childbirth care in Brazil has faced challenges in recent years to reduce unnecessary and unsafe practices. However, measures used to accelerate labour and other interventions during labour and delivery are still frequent and may negatively impact the vitality of the newborn. Objectives: To analyze the association between sociodemographic, organizational, obstetric and care factors and unfavorable neonatal outcomes among term newborns and to estimate the frequency of these outcomes. Method: A cross-sectional study, based on data from the national survey \"Birth in Brazil\" in the the Southeast region of Brazil. The sample consisted of mothers who had live births, stillbirths (weight 500 grams and / or gestational age 22 weeks) in hospitals with 500 births in 2011 and 2012. Premature babies, twins, preterm newborns and those with malformations were excluded from the analysis. The dependent variable \"unfavorable neonatal outcome\" was constructed through the composition of the variables tracheal intubation, cardiac massage, drug use in neonatal resuscitation, neonatal ICU admission, and Apgar <7 at the 5th minute of life in the immediate postnatal period. The association between the variables of interest and the outcome variable was estimated using univariate and multiple binary logistic regression, calculating crude and adjusted Odds Ratio (OR) with 95 per cent confidence intervals (95 per cent CI). Results: The sample consisted of 8,773 women and their newborns. The proportion of newborns who presented an unfavorable neonatal outcome was 9.6 per cent (844). Incomplete primary education (OR = 2.139, 95 per cent CI 1.292-3.540), low birth weight (weight 2.500g, OR = 2.822, 95 per cent CI 1.641-4.851), obstetric complication (OR = 1.421, 95 per cent CI 1.055-1.914) and Forceps (OR = 3.761, 95 per cent CI, 1.824-7.754) were factors associated with unfavorable neonatal outcome. Discussion: Factors independently associated with unfavorable neonatal outcomes in the Southeast Region of Brazil were mostly clinical conditions that influence the condition of the newborn in the immediate postpartum period. Infants with low birth weight and those of women with obstetric problems have conditions such as reduced amniotic fluid or placental insufficiency that result in changes in vitality. Women with low schooling have greater difficulty in accessing health services, which make it difficult to identify and treat obstetric problems and low birth weight. Forceps delivery may represent resolution of dystocic labor and was also be a marker for fetuses whose vitality was altered during labor. Conclusions: Clinical factors associated with social inequalities have a negative impact on the vitality of newborns. Negative neonatal outcomes are still poorly investigated, so actions aimed at improving prenatal care and labor, especially among women with low schooling and those with obstetric complications, may result in better health outcomes for the newborn. We found a proportion of 9.6 per cent (844) among neonates in the gestational term who presented an unfavorable neonatal outcome. In this study it was possible to observe the existence of an association between sociodemographic, clinical and maternal care factors and unfavorable neonatal outcomes among the term newborns

Introdução: A assistência ao parto no Brasil tem enfrentado desafios nos últimos anos, no sentido de reduzir práticas desnecessárias e inseguras. No entanto, medidas utilizadas para acelerar o trabalho de parto e demais intervenções durante o trabalho de parto e parto ainda são frequentes e podem impactar negativamente as condições de vitalidade do recém-nascido. Objetivos: Analisar a associação entre os fatores sociodemográficos, organizacionais, obstétricos e assistenciais e desfecho neonatal desfavorável entre RNs de termo e estimar sua frequência. Método: Estudo transversal, a partir dos dados do inquérito nacional Nascer no Brasil, referentes à região Sudeste. A amostra foi composta por puérperas que tiveram RNs vivos, natimortos (peso 500 gramas e/ou idade gestacional 22 semanas), nascidos em hospitais com 500 partos em 2011 e 2012. Foram excluídos os recém-nascidos prematuros, gemelares e aqueles com malformações. A variável dependente desfecho neonatal desfavorável foi construída por meio da composição das variáveis intubação traqueal, massagem cardíaca, uso de drogas na reanimação neonatal, internação em UTI neonatal e Apgar <7 no 5.o minuto de vida no período pós-natal imediato. A associação entre as variáveis de interesse e a variável desfecho foi estimada por meio de regressão logística binária univariada e múltipla, calculando-se Odds ratio (OR) brutas e ajustadas com intervalos de confiança de 95 por cento (IC 95 por cento ). Resultados: A amostra foi composta por 8.783 mulheres e seus RNs. A proporção de RNs que apresentou desfecho neonatal desfavorável foi de 9,6 por cento (844). Ensino fundamental incompleto (OR=2,139; IC 95 por cento 1,292-3,540), baixo peso ao nascer (peso 2.500g; OR=2,822; IC 95 por cento 1,641-4,851), intercorrência obstétrica (OR=1,421; IC 95 por cento 1,055-1,914) e parto fórceps (OR=3,761; IC 95 por cento 1,824-7,754) constituíram fatores associados ao desfecho neonatal desfavorável. Discussão: Os fatores independentemente associados ao desfecho neonatal desfavorável na Região Sudeste do Brasil foram em sua maioria condições clínicas que têm influência sobre a condição do recém-nascido no período pós-parto imediato. Recém-nascidos com baixo peso e aqueles filhos de mulheres com problemas obstétricos têm condições como líquido amniótico reduzido ou insuficiência placentária que resultam em alterações da vitalidade. Mulheres com baixa escolaridade têm maior dificuldade em acessar os serviços de saúde, o que pode dificultar a identificação e tratamento de problemas obstétricos e baixo peso ao nascer. O parto fórceps pode representar a resolução de trabalhos de parto distócicos e também ser um marcador para os fetos cuja vitalidade encontrava-se alterada durante o trabalho de parto. Conclusões: Fatores clínicos e associados a desigualdades sociais têm impacto negativo sobre a vitalidade dos recém-nascidos. Os desfechos neonatais desfavoráveis ainda são pouco investigados, por isso ações que visem à melhoria da atenção pré-natal e do trabalho de parto, principalmente entre mulheres com baixa escolaridade e aquelas com complicações obstétricas, podem resultar em melhores desfechos de saúde para o recém-nascido. Encontramos uma proporção de 9,6 por cento (844) entre os recém-nascidos no termo gestacional que apresentaram desfecho neonatal desfavorável. Neste estudo foi possível observar a existência de associação entre fatores sociodemográficos, clínicos e assistenciais maternos e desfechos neonatais desfavoráveis entre os RNs de termo / Introduction: Childbirth care in Brazil has faced challenges in recent years to reduce unnecessary and unsafe practices. However, measures used to accelerate labour and other interventions during labour and delivery are still frequent and may negatively impact the vitality of the newborn. Objectives: To analyze the association between sociodemographic, organizational, obstetric and care factors and unfavorable neonatal outcomes among term newborns and to estimate the frequency of these outcomes. Method: A cross-sectional study, based on data from the national survey \"Birth in Brazil\" in the the Southeast region of Brazil. The sample consisted of mothers who had live births, stillbirths (weight 500 grams and / or gestational age 22 weeks) in hospitals with 500 births in 2011 and 2012. Premature babies, twins, preterm newborns and those with malformations were excluded from the analysis. The dependent variable \"unfavorable neonatal outcome\" was constructed through the composition of the variables tracheal intubation, cardiac massage, drug use in neonatal resuscitation, neonatal ICU admission, and Apgar <7 at the 5th minute of life in the immediate postnatal period. The association between the variables of interest and the outcome variable was estimated using univariate and multiple binary logistic regression, calculating crude and adjusted Odds Ratio (OR) with 95 per cent confidence intervals (95 per cent CI). Results: The sample consisted of 8,773 women and their newborns. The proportion of newborns who presented an unfavorable neonatal outcome was 9.6 per cent (844). Incomplete primary education (OR = 2.139, 95 per cent CI 1.292-3.540), low birth weight (weight 2.500g, OR = 2.822, 95 per cent CI 1.641-4.851), obstetric complication (OR = 1.421, 95 per cent CI 1.055-1.914) and Forceps (OR = 3.761, 95 per cent CI, 1.824-7.754) were factors associated with unfavorable neonatal outcome. Discussion: Factors independently associated with unfavorable neonatal outcomes in the Southeast Region of Brazil were mostly clinical conditions that influence the condition of the newborn in the immediate postpartum period. Infants with low birth weight and those of women with obstetric problems have conditions such as reduced amniotic fluid or placental insufficiency that result in changes in vitality. Women with low schooling have greater difficulty in accessing health services, which make it difficult to identify and treat obstetric problems and low birth weight. Forceps delivery may represent resolution of dystocic labor and was also be a marker for fetuses whose vitality was altered during labor. Conclusions: Clinical factors associated with social inequalities have a negative impact on the vitality of newborns. Negative neonatal outcomes are still poorly investigated, so actions aimed at improving prenatal care and labor, especially among women with low schooling and those with obstetric complications, may result in better health outcomes for the newborn. We found a proportion of 9.6 per cent (844) among neonates in the gestational term who presented an unfavorable neonatal outcome. In this study it was possible to observe the existence of an association between sociodemographic, clinical and maternal care factors and unfavorable neonatal outcomes among the term newborns

Realizamos este estudo com o objetivo de analisar as principais variáveis clínicas dos pacientes que sofreram parada cardiorrespiratória e detectar fatores prognósticos de sobrevivência a curto e longo prazos, tentando oferecer subsídios aos profissionais de saúde que estão envolvidos com reanimação. Analisamos prospectivamente 452 pacientes que receberam reanimação em hospitais gerais de Salvador. Utilizou-se análise bivariada e estratificada nas associações entre as variáveis e a curva de sobrevida para análise de nove anos de evolução. Observamos 24% de sobrevida imediata e 5% de sobrevida à alta hospitalar. Os fatores prognósticos de sobrevida imediata foram: ter doença de base, a enfermidade cardiovascular, diagnosticar o ritmo cardíaco , ritmo de fibrilação ou taquicardia ventricular, tempo estimado pré-reanimação menor ou igual a cinco minutos; tempo de reanimação menor ou igual a 15 minutos. As variáveis prognósticas sobrevida a longo prazo foram: não usar adrenalina; ser reanimado em hospital privado;tempo de reanimação menor ou igual a 15 minutos / The objectives of this study are to analyze the main clinical and demographic characteristics of patients who suffer cardiac arrest and identify variables involved in survival outcomes. The study enrolled 452 patients, which received cardiopulmonary resuscitation in general hospitals. We prospectively analyzed the main variables associated with ROSC and survival to hospital discharge utilizing bivariate and stratified. The Kaplan-Meier technique was used to analyze the survival curves after nine years. Of the 452 resuscitation attempts, 107 (24%) patients had ROSC and only 22 (5%) were discharge from hospital. The variables with greatest prognostic value for immediate survival were: having a co-morbid condition, cardiovascular disease as the etiology, determination of cardiac rhythm, ventricular arrhythmia as rhythm of arrest, estimated pre-resuscitation time less than or equal to 5 minutes and the resuscitation effort duration less than or equal to 15 minutes. The variables associated with better long term survival were: not using adrenaline, being resuscitated in a private hospital and resuscitation efforts lasting less than or equal to 15 minutes

Introduction: The most appropriate airway management technique for use by paramedics in out-of-hospital cardiac arrest is yet to be determined and evidence relating to the influence of airway management strategy on outcome remains equivocal. In cases where return of spontaneous circulation (ROSC) occurs following out-of-hospital cardiac arrest, patients may undergo direct transfer to a specialist heart attack centre (HAC) where the post resuscitation 12 lead ECG demonstrates evidence of ST elevation myocardial infarction. To date, no studies have investigated the role of airway management strategy on outcomes in this sub-set of patients. The AMICABLE (Airway Management In Cardiac Arrest, Basic, Laryngeal mask airway, Endotracheal intubation) study therefore sought to investigate the influence of prehospital airway management strategy on outcomes in patients transferred by the ambulance service directly to a HAC post ROSC. Methods: Adults with ROSC post out-of-hospital cardiac arrest who met local criteria for transfer to a HAC were identified prospectively. Ambulance records were reviewed to determine prehospital airway management approach and collect physiological and demographic data. HAC notes were obtained to determine in-hospital course and quantify neurological outcome via the Cerebral Performance Category (CPC) scale. Neurologically intact survivors were contacted post discharge to assess quality of life via the SF-36 health survey. Statistical analyses were performed via Chi-square, Mann Whitney U test, odds ratios, and binomial logistic regression. Results: A total of 220 patients were recruited between August 2013 and August 2014, with complete outcome data available for 209. The age of patients ranged from 22-96 years and 71.3% were male (n=149). Airway management was undertaken using a supraglottic airway (SGA) in 72.7% of cases (n=152) with the remainder undergoing endotracheal intubation (ETI). There was no significant difference in the proportion of patients with good neurological outcome (CPC 1&2) between the SGA and ETI groups (p=.286). Similarly, binomial logistic regression incorporating factors known to influence outcome demonstrated no significant difference between the SGA and ETI groups (Adjusted OR 0.725, 95% CI 0.337-1.561). Clinical and demographic variables associated with good neurological outcome included the presence of a shockable rhythm (p < .001), exposure to angiography (p < .001), younger age (p < .001) and shorter time to ROSC (p < .001). Due to an inadequate response rate (25.4%, n=15) analysis of SF36 data was limited to descriptive statistics. Limitations: The study only included patients who achieved ROSC and met the criteria for direct transfer to a HAC. Results are therefore not generalisable to more heterogenous resuscitation populations. Accuracy of clinical decision making and ECG interpretation were not assessed and therefore some patients included in the study may have been inappropriately transferred to a HAC. The low SF-36 survey response rate limited the level of neurological outcome analysis that could be undertaken. Conclusion: In this study, there was no significant difference in the proportion of good neurological outcomes in patients managed with SGA versus ETI during cardiac arrest. Further research incorporating randomised controlled trials is required to provide more definitive evidence in relation to the optimal airway management strategy in out-of-hospital cardiac arrest.