1
|
Xiao T, Hu L, Chen H, Gu X, Zhou J, Zhu Y, Lei X, Jiang S, Lu Y, Dong X, Du L, Lee SK, Ju R, Zhou W. The performance of the practices associated with the occurrence of severe intraventricular hemorrhage in the very premature infants: data analysis from the Chinese neonatal network. BMC Pediatr 2024; 24:394. [PMID: 38877528 PMCID: PMC11179376 DOI: 10.1186/s12887-024-04664-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 02/21/2024] [Indexed: 06/16/2024] Open
Abstract
BACKGROUND The occurrence of severe intraventricular hemorrhage (sIVH) was high in the very preterm infants (VPIs) in China. The management strategies significantly contributed to the occurrence of sIVH in VPIs. However, the status of the perinatal strategies associated with sIVH for VPIs was rarely described across the multiple neonatal intensive care units (NICUs) in China. We aim to investigate the characteristics of the perinatal strategies associated with sIVH for VPIs across the multiple NICUs in China. METHODS This was a retrospective analysis of data from a prospective cohort of Chinese Neonatal Network (CHNN) dataset, enrolling infants born at 24+0-31+6 from 2019 to 2021. Eleven perinatal practices performed within the first 3 days of life were investigated including antenatal corticosteroids use, antenatal magnesium sulphate therapy, intubation at birth, placental transfusion, need for advanced resuscitation, initial inhaled gas of 100% FiO2 in delivery room, initial invasive respiratory support, surfactant and caffeine administration, early enteral feeding, and inotropes use. The performances of these practices across the multiple NICUs were investigated using the standard deviations of differences between expected probabilities and observations. The occurrence of sIVH were compared among the NICUs. RESULTS A total of 24,226 infants from 55 NICUs with a mean (SD) gestational age of 29.5 (1.76) and mean (SD) birthweight of 1.31(0.32) were included. sIVH was detected in 5.1% of VPIs. The rate of the antenatal corticosteroids, MgSO4 therapy, and caffeine was 80.0%, 56.4%, and 31.5%, respectively. We observed significant relationships between sIVH and intubation at birth (AOR 1.52, 95% CI 1.13 to 1.75) and initial invasive respiratory support (AOR 2.47, 95% CI 2.15 to 2.83). The lower occurrence of sIVH (4.8%) was observed corresponding with the highest utility of standard antenatal care, the lowest utility of invasive practices, and early enteral feeding administration. CONCLUSIONS The current evidence-based practices were not performed in each VPI as expected among the studied Chinese NICUs. The higher utility of the invasive practices could be related to the occurrence of sIVH.
Collapse
Affiliation(s)
- Tiantian Xiao
- Department of Neonatology, School of Medicine, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Liyuan Hu
- Department of Neonatology, NHC Key Laboratory of Neonatal Diseases, Fudan University, Children's Hospital of Fudan University, Shanghai, China
| | - Huiyao Chen
- Center for Molecular Medicine, Children's Hospital of Fudan University, Shanghai, China
| | - Xinyue Gu
- NHC Key Laboratory of Neonatal Diseases, Children's Hospital of Fudan University, Shanghai, China
| | - Jianguo Zhou
- Department of Neonatology, NHC Key Laboratory of Neonatal Diseases, Fudan University, Children's Hospital of Fudan University, Shanghai, China
| | - Yanping Zhu
- Department of Neonatology, First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China
| | - Xiaoping Lei
- Division of Neonatology, Department of Pediatrics, the Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China
| | - Siyuan Jiang
- Department of Neonatology, NHC Key Laboratory of Neonatal Diseases, Fudan University, Children's Hospital of Fudan University, Shanghai, China
| | - Yulan Lu
- Center for Molecular Medicine, Children's Hospital of Fudan University, Shanghai, China
| | - Xinran Dong
- Center for Molecular Medicine, Children's Hospital of Fudan University, Shanghai, China
| | - Lizhong Du
- Neonatal Intensive Care Unit, Children's Hospital, Zhejiang University School of Medicine, Hangzhou, China
- National Clinical Research Center for Child Health, National Children's Regional Medical Center, Hangzhou, China
| | - Shoo K Lee
- Maternal-Infant Care Research Centre and Department of Pediatrics, Mount Sinai Hospital, Toronto, ON, Canada
| | - Rong Ju
- Department of Neonatology, School of Medicine, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China.
| | - Wenhao Zhou
- Department of Neonatology, NHC Key Laboratory of Neonatal Diseases, Fudan University, Children's Hospital of Fudan University, Shanghai, China.
| |
Collapse
|
2
|
Dunajova K, Lamberska T, Nguyen TA, Kubica A, Kudrna P, Plavka R. A stylet use may be beneficial for elective and rescue intubation of prematurely born infants < 30 weeks. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2024. [PMID: 38818790 DOI: 10.5507/bp.2024.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2024] Open
Abstract
BACKGROUND Recent studies have reported that using a stylet does not provide any advantages during intubation within a diverse infant population. Our research focuses on the issue, specifically in premature infants who undergo elective or rescue intubation (EI or RI) in the delivery room (DR). METHODS We conducted a single-center retrospective observational study comparing the number of intubation attempts, the duration of intubation procedure until successful, and the rate of associated desaturations exceeding 20%. We derived outcomes from video recordings and performed statistical analyses. RESULTS We have analyzed 104 intubation attempts in 70 infants with a mean gestational age and birth weight of 25±1.9 weeks and 736±221 grams, respectively; 39 of these attempts involved stylet use, and 65 did not. 75% of infants requiring intubation were less than 26 weeks of gestational age. The use of a stylet increased the rate of successful initial attempts [OR (95% CI) 4.3 (1.3-14.8), P=0.019], reduced the duration of the intubation procedure [median (IQR) seconds: 43 (30-72) vs 140 (62-296), P<0.001], and decreased the occurrences of desaturation exceeding 20% (13% vs 50%, P=0.003). CONCLUSION The benefits of using a stylet during rescue and elective intubations of premature infants in the delivery room outweigh the potential harms. Its use may be advantageous in settings where proactive approaches are implemented for periviable infants.
Collapse
Affiliation(s)
- Klara Dunajova
- Division of Neonatology, Department of Obstetrics and Gynecology, General Faculty Hospital and 1st Faculty of Medicine, Charles University in Prague, Czech Republic
| | - Tereza Lamberska
- Division of Neonatology, Department of Obstetrics and Gynecology, General Faculty Hospital and 1st Faculty of Medicine, Charles University in Prague, Czech Republic
| | - Truong An Nguyen
- Division of Neonatology, Department of Obstetrics and Gynecology, General Faculty Hospital and 1st Faculty of Medicine, Charles University in Prague, Czech Republic
| | - Adam Kubica
- Division of Neonatology, Department of Obstetrics and Gynecology, General Faculty Hospital and 1st Faculty of Medicine, Charles University in Prague, Czech Republic
| | - Petr Kudrna
- Division of Neonatology, Department of Obstetrics and Gynecology, General Faculty Hospital and 1st Faculty of Medicine, Charles University in Prague, Czech Republic
- Department of Biomedical Technology, Faculty of Biomedical Engineering, Czech Technical University in Prague, Czech Republic
| | - Richard Plavka
- Division of Neonatology, Department of Obstetrics and Gynecology, General Faculty Hospital and 1st Faculty of Medicine, Charles University in Prague, Czech Republic
| |
Collapse
|
3
|
Solanki S, Dogra S, Gupta PK, Peters NJ, Malik MA, Mahajan JK. Randomized controlled trial to evaluate the rate of successful neonatal endotracheal intubation performed with a stylet versus without a stylet. Paediatr Anaesth 2024; 34:448-453. [PMID: 38305632 DOI: 10.1111/pan.14845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 12/20/2023] [Accepted: 01/09/2024] [Indexed: 02/03/2024]
Abstract
INTRODUCTION Neonates in intensive care units often require endotracheal intubation and mechanical ventilation. During this intubation procedure, a stylet is frequently used along with an endotracheal tube. Despite the widespread use of a stylet, it is still not known whether its use increases the intubation success rate. This study examined the association between stylet use and the intubation success rate in surgical neonates. METHODOLOGY This single-center study was conducted between December 2021 and December 2022 in the Neonatal surgical intensive care unit of a tertiary care center in Northern India. Infants were randomized to have the endotracheal intubation procedure performed using either an endotracheal tube alone or with a stylet. The primary outcome of the study was to assess the successful first-attempt neonatal endotracheal intubation rate with and without using a stylet. Apart from the rate of successful intubation, the duration of the intubation and complications during the intubation procedures as measured by bradycardia, desaturation episodes, and local trauma were also recorded. Both groups were thus compared on above mentioned outcomes. RESULTS The total number of neonates enrolled were 200, and the overall success rate (81% in the stylet group vs. 73% in the non-stylet group) was not statistically significant. Intubation time was however less, when stylet was used (16.2 ± 4.3 vs. 17.5 ± 5.0 s, p = .046). When the endotracheal tube size was 3 or less, the success rate was substantially higher in the stylet group (80%) than the non-stylet group (63%), p = .03. No statistical difference was recorded for bleeding and local trauma, though the esophageal intubation rate was higher when intubation was attempted without the stylet. CONCLUSION Endotracheal intubation using a stylet did not significantly improve the success rate of the procedure, however, intubation time significantly varied between groups and in different conditions. The rigidity and curvature provided by the stylet may facilitate the process of intubation when smaller caliber endotracheal tubes are used.
Collapse
Affiliation(s)
| | - Shivani Dogra
- Department of Paediatric Surgery, PGIMER, Chandigarh, India
| | - Pramod K Gupta
- Department of Paediatric Surgery, PGIMER, Chandigarh, India
| | - Nitin J Peters
- Department of Paediatric Surgery, PGIMER, Chandigarh, India
| | - Muneer A Malik
- Department of Paediatric Surgery, PGIMER, Chandigarh, India
| | - J K Mahajan
- Department of Paediatric Surgery, PGIMER, Chandigarh, India
| |
Collapse
|
4
|
Curtis SF, Cotten CM, Laughon M, Younge N, Peterson J, Clark RH, Greenberg RG. Indomethacin Prophylaxis in Preterm Infants: Changes over Time. Am J Perinatol 2024; 41:e680-e688. [PMID: 35973793 DOI: 10.1055/a-1925-5173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
OBJECTIVE Our objective was to examine changes in the use of indomethacin prophylaxis in the neonatal intensive care unit (NICU) between 2008 and 2018. STUDY DESIGN The design of the study included cohort of 19,715 infants born between 220/7 and 266/7 weeks' gestation from 213 NICUs. A nonparametric trend test evaluated indomethacin prophylaxis and the percentage of sites using any prophylaxis over time. We evaluated the prevalence of indomethacin prophylaxis by the center and the correlation between indomethacin prophylaxis and severe intraventricular hemorrhage prevalence among 12 centers with the largest relative change in indomethacin prophylaxis prevalence. RESULTS In total, 16% of infants received indomethacin prophylaxis. The use of indomethacin prophylaxis did not significantly decrease between 2008 and 2018 but it significantly decreased between 2014 and 2018 (p = 0.046). Among 74 centers with ≥10 infants included, 20% increased the use of indomethacin prophylaxis, while 57% decreased the use over the study period. Of the 12 centers with the largest relative change in indomethacin prophylaxis prevalence, 50% showed an inverse correlation between indomethacin prophylaxis prevalence and severe intraventricular hemorrhage, while 50% showed a positive correlation. CONCLUSION Receipt of indomethacin prophylaxis remained similar until 2014, decreased from 2014 to 2018, and varied by the center.Key Points · The receipt of indomethacin prophylaxis decreased over time.. · Center change in the use of indomethacin prophylaxis does not correlate with the center prevalence of IVH.. · Variability in the use of indomethacin prophylaxis across centers persists..
Collapse
Affiliation(s)
- Samantha F Curtis
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina
| | - C Michael Cotten
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina
| | - Matthew Laughon
- Department of Pediatrics, The University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina
| | - Noelle Younge
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina
| | - Jennifer Peterson
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina
| | | | - Rachel G Greenberg
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| |
Collapse
|
5
|
Massirio P, Cardiello V, Andreato C, Caruggi S, Battaglini M, Calandrino A, Polleri G, Mongelli F, Malova M, Minghetti D, Parodi A, Calevo MG, Tortora D, Rossi A, Ramenghi LA. Ventilatory Support, Extubation, and Cerebral Perfusion Changes in Pre-Term Neonates: A Near Infrared Spectroscopy Study. Neurotrauma Rep 2024; 5:409-416. [PMID: 38655113 PMCID: PMC11035839 DOI: 10.1089/neur.2023.0092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2024] Open
Abstract
Early extubation is considered to be beneficial for pre-term neonates. On the other hand, premature extubation can cause lung derecruitment, compromised gas exchange, and need for reintubation, which may be associated with severe brain injury caused by sudden cerebral blood flow changes. We used near infrared spectroscopy (NIRS) to investigate changes in cerebral oxygenation (rScO2) and fractional tissue oxygen extraction (+) after extubation in pre-term infants. This is a single-center retrospective study of NIRS data at extubation time of all consecutive pre-term neonates born at our institution over a 1-year period. Comparison between subgroups was performed. Nineteen patients were included; average gestational age (GA) was 29.4 weeks. No significant change was noted in rScO2 and cFTOE after extubation in the whole population. GA and germinal matrix hemorrhage (GMH)-intraventricular hemorrhage (IVH) showed a significant change in rScO2 and cFTOE after extubation. A significant increase in cFTOE was noted in patients with previous GMH-IVH (+0.040; p = 0.05). To conclude, extubation per se was not associated with significant change in cerebral oxygenation and perfusion. Patients with a diagnosed GMH-IVH showed an increase in cFTOE, suggesting perturbation in cerebral perfusion suggesting further understanding during this challenging phenomenon. Larger studies are required to corroborate our findings.
Collapse
Affiliation(s)
- Paolo Massirio
- Neonatal Intensive Care Unit, Maternal and Neonatal Department, IRCCS Istituto Giannina Gaslini, Genoa, Italy
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), and University of Genoa, Genoa, Italy
| | - Valentina Cardiello
- Neonatal Intensive Care Unit, Maternal and Neonatal Department, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Chiara Andreato
- Neonatal Intensive Care Unit, Maternal and Neonatal Department, IRCCS Istituto Giannina Gaslini, Genoa, Italy
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), and University of Genoa, Genoa, Italy
| | - Samuele Caruggi
- Neonatal Intensive Care Unit, Maternal and Neonatal Department, IRCCS Istituto Giannina Gaslini, Genoa, Italy
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), and University of Genoa, Genoa, Italy
| | - Marcella Battaglini
- Neonatal Intensive Care Unit, Maternal and Neonatal Department, IRCCS Istituto Giannina Gaslini, Genoa, Italy
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), and University of Genoa, Genoa, Italy
| | - Andrea Calandrino
- Neonatal Intensive Care Unit, Maternal and Neonatal Department, IRCCS Istituto Giannina Gaslini, Genoa, Italy
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), and University of Genoa, Genoa, Italy
| | - Giulia Polleri
- Neonatal Intensive Care Unit, Maternal and Neonatal Department, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Federica Mongelli
- Neonatal Intensive Care Unit, Maternal and Neonatal Department, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Mariya Malova
- Neonatal Intensive Care Unit, Maternal and Neonatal Department, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Diego Minghetti
- Neonatal Intensive Care Unit, Maternal and Neonatal Department, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Alessandro Parodi
- Neonatal Intensive Care Unit, Maternal and Neonatal Department, IRCCS Istituto Giannina Gaslini, Genoa, Italy
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), and University of Genoa, Genoa, Italy
| | - Maria Grazia Calevo
- Epidemiology and Biostatistic Unit, Scientific Direction, and IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Domenico Tortora
- Neuroradiology Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Andrea Rossi
- Neuroradiology Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
| | - Luca Antonio Ramenghi
- Neonatal Intensive Care Unit, Maternal and Neonatal Department, IRCCS Istituto Giannina Gaslini, Genoa, Italy
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), and University of Genoa, Genoa, Italy
| |
Collapse
|
6
|
Johnson MD, Tingay DG, Perkins EJ, Sett A, Devsam B, Douglas E, Charlton JK, Wildenhain P, Rumpel J, Wagner M, Nadkarni V, Johnston L, Herrick HM, Hartman T, Glass K, Jung P, DeMeo SD, Shay R, Kim JH, Unrau J, Moussa A, Nishisaki A, Foglia EE. Factors that impact second attempt success for neonatal intubation following first attempt failure: a report from the National Emergency Airway Registry for Neonates. Arch Dis Child Fetal Neonatal Ed 2024:fetalneonatal-2023-326501. [PMID: 38418208 DOI: 10.1136/archdischild-2023-326501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 02/21/2024] [Indexed: 03/01/2024]
Abstract
OBJECTIVE To determine the factors associated with second attempt success and the risk of adverse events following a failed first attempt at neonatal tracheal intubation. DESIGN Retrospective analysis of prospectively collected data on intubations performed in the neonatal intensive care unit (NICU) and delivery room from the National Emergency Airway Registry for Neonates (NEAR4NEOS). SETTING Eighteen academic NICUs in NEAR4NEOS. PATIENTS Neonates requiring two or more attempts at intubation between October 2014 and December 2021. MAIN OUTCOME MEASURES The primary outcome was successful intubation on the second attempt, with severe tracheal intubation-associated events (TIAEs) or severe desaturation (≥20% decline in oxygen saturation) being secondary outcomes. Multivariate regression examined the associations between these outcomes and patient characteristics and changes in intubation practice. RESULTS 5805 of 13 126 (44%) encounters required two or more intubation attempts, with 3156 (54%) successful on the second attempt. Second attempt success was more likely with changes in any of the following: intubator (OR 1.80, 95% CI 1.56 to 2.07), stylet use (OR 1.65, 95% CI 1.36 to 2.01) or endotracheal tube (ETT) size (OR 2.11, 95% CI 1.74 to 2.56). Changes in stylet use were associated with a reduced chance of severe desaturation (OR 0.74, 95% CI 0.61 to 0.90), but changes in intubator, laryngoscope type or ETT size were not; no changes in intubator or equipment were associated with severe TIAEs. CONCLUSIONS Successful neonatal intubation on a second attempt was more likely with a change in intubator, stylet use or ETT size.
Collapse
Affiliation(s)
- Mitchell David Johnson
- Neonatal Medicine, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
- Neonatal Research, Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - David Gerald Tingay
- Neonatal Medicine, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
- Neonatal Research, Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Elizabeth J Perkins
- Neonatal Research, Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Arun Sett
- Neonatal Research, Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Newborn Services, Western Health, St Albans, Victoria, Australia
| | - Bianca Devsam
- Neonatal Medicine, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
- Neonatal Research, Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Ellen Douglas
- Neonatal Research, Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Julia K Charlton
- Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
- Division of Neonatology, British Columbia Women's Hospital and Health Centre, Vancouver, British Columbia, Canada
| | - Paul Wildenhain
- The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Jennifer Rumpel
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Michael Wagner
- Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Department of Pediatrics, Medical University Vienna, Vienna, Austria
| | - Vinay Nadkarni
- Department of Anesthesiology, Critical Care, and Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Lindsay Johnston
- Department of Pediatrics, Yale University, New Haven, Connecticut, USA
| | - Heidi M Herrick
- Division of Neonatology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Tyler Hartman
- Department of Pediatrics, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Kristen Glass
- Department of Pediatrics, Penn State Health Children's Hospital/Penn State College of Medicine, Hershey, Pennsylvania, USA
| | - Philipp Jung
- Department of Pediatrics, University Hospital Schleswig-Holstein, Luebeck, Germany
| | - Stephen D DeMeo
- Division of Neonatology, WakeMed Health and Hospitals, Raleigh, North Carolina, USA
| | - Rebecca Shay
- Department of Pediatrics, Division of Neonatology, University of Colorado, Aurora, Colorado, USA
| | - Jae H Kim
- Perinatal Institute, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Jennifer Unrau
- Newborn Critical Care, Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Ahmed Moussa
- Division of Neonatology, Department of Pediatrics, Centre Hospitalier Universitaire Sainte-Justine, Montreal, Quebec, Canada
- CHU Sainte-Justine Research Centre, Université de Montréal, Montreal, Quebec, Canada
| | - Akira Nishisaki
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Elizabeth E Foglia
- Division of Neonatology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| |
Collapse
|
7
|
Li X, Zhao F, Bai X, Wang X. Application value of cranial ultrasonography in quantitative evaluation of neonatal intracranial hemorrhage. Minerva Pediatr (Torino) 2024; 76:51-56. [PMID: 33182993 DOI: 10.23736/s2724-5276.20.05841-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2024]
Abstract
BACKGROUND Intracranial hemorrhage is a severe cranial disease in the perinatal period. We aimed to explore the feasibility and accuracy of three-dimensional (3D) ultrasonography for the quantitative evaluation of neonatal intracranial hemorrhage. METHODS A total of 374 neonates with suspected intracranial hemorrhage from January 2017 to December 2019 were selected to be primarily screened by cranial ultrasonography and then diagnosed by cranial CT scan. The examination results were compared to analyze the feasibility and accuracy of 3D ultrasonography in quantifying blood loss. RESULTS CT scan showed that there were 102 cases of Papile grade I, 106 cases of grade II, 124 cases of grade III and 42 cases of grade IV. 3D ultrasonography showed that there were 108 cases of Papile grade I, 98 cases of grade II, 130 cases of grade III and 38 cases of grade IV. The diagnostic results of these two methods were not significantly different (P>0.05). The accuracies of CT scan for subventricular, intraventricular, subdural, subarachnoid and intraparenchymal hemorrhages were 47.33%, 31.24%, 94.62%, 91.73% and 91.35% respectively, and those of 3D ultrasonography were 98.74%, 96.37%, 91.51%, 90.41% and 97.64% respectively. The accuracies of 3D ultrasonography were significantly superior to those of CT scan for subependymal, intraventricular and intraparenchymal hemorrhages (P<0.05). CONCLUSIONS Neonatal intracranial hemorrhage can be well diagnosed by cranial ultrasonography which timely provides evidence for clinicians, thereby elevating the cure rate and reducing the mortality rate and incidence rate of sequelae. 3D ultrasonography is feasible and accurate for the quantitative evaluation of neonatal intracranial hemorrhage, thus being of great significance to prognostic determination in clinical practice.
Collapse
Affiliation(s)
- Xiujing Li
- Gansu Provincial Maternity and Child-Care Hospital, Lanzhou, China
| | - Fangping Zhao
- Gansu Provincial Maternity and Child-Care Hospital, Lanzhou, China
| | - Xiang Bai
- Gansu Provincial Maternity and Child-Care Hospital, Lanzhou, China -
| | - Xiang Wang
- Department of Ultrasonography, The Third Hospital of Chongqing Medical University, Chongqing, China
| |
Collapse
|
8
|
Ali MA, Raju MP, Miller G, Vora N, Beeram M, Raju V, Shetty A, Govande V, Nguyen N, Chiruvolu A. Pre-Medications for Non-Emergency Tracheal Intubation in the United States Neonatal Intensive Care Units. Cureus 2024; 16:e53512. [PMID: 38440038 PMCID: PMC10911687 DOI: 10.7759/cureus.53512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/03/2024] [Indexed: 03/06/2024] Open
Abstract
BACKGROUND Premedication in neonates undergoing elective intubation effectively minimizes the negative physiological events of bradycardia, systemic hypertension, intracranial hypertension, and hypoxia. Premedication decreases procedure-related pain and discomfort. This study aimed to evaluate the current practice of pre-intubation medications for non-emergent intubations in preterm and term neonates in the United States. STUDY DESIGN A cross-sectional survey (Appendix) was sent via e-mail to all level 3 and 4 Neonatal Intensive Care Units (NICUs) of the Organization of Neonatal Perinatal Medicine Training Program Directors (ONTPD), NICU directors with pediatric residency only, and Baylor Scott and White Health, Mednax, and Envision health services systems. RESULTS Of 170 responses, 41% (69/168) routinely premedicate, 38% (64/168) premedicate under specific circumstances, and 21% (35/168) do not administer any routine pre-intubation medications. Only 46% (77/168) of units had a written policy. The most frequently used drugs were fentanyl (68%, 116/170), atropine (39%, 66/170), midazolam (38%, 64/170), and morphine (26%, 45/170). 21% (36/170) used a two-drug combination, and 38% (64/170) used a three-drug combination. The most commonly used two-drug combination was atropine and fentanyl, and the most common three-drug combination was atropine, fentanyl, and a paralytic agent. CONCLUSION Despite the well-documented benefits of premedication for NICU intubations, as aligned with AAP recommendations, the US lags behind other nations, with stagnant rates since 2006. This disparity persists despite a rise in written policies, which exhibit significant content variations. The authors advocate for the adoption of standardized, AAP-aligned policies across all NICUs in the US. Continued research is vital to monitor the progress of this crucial practice and address any underlying barriers to implementation.
Collapse
Affiliation(s)
- Mahmoud A Ali
- Pediatrics/Neonatology, West Virginia University, Morgantown, USA
- Neonatology, Baylor Scott & White Health, Temple, USA
| | | | - Greg Miller
- Neonatology, Baylor Scott & White Health, Temple, USA
| | - Niraj Vora
- Neonatology, Baylor Scott & White Health, Temple, USA
| | | | - Venkata Raju
- Neonatology, Baylor Scott & White Health, Temple, USA
| | - Ashith Shetty
- Neonatology, Baylor Scott & White Health, Temple, USA
| | | | - Nguyen Nguyen
- Pediatrics, Baylor Scott & White Health, Temple, USA
| | - Arpitha Chiruvolu
- Neonatology, Baylor University Medical Center, Dallas, USA
- Neonatology, Pediatrix Medical Group, Dallas, USA
| |
Collapse
|
9
|
Neches SK, DeMartino C, Shay R. Pharmacologic Adjuncts for Neonatal Tracheal Intubation: The Evidence Behind Premedication. Neoreviews 2023; 24:e783-e796. [PMID: 38036442 DOI: 10.1542/neo.24-12-e783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Abstract
Premedication such as analgesia, sedation, vagolytics, and paralytics may improve neonatal tracheal intubation success, reduce intubation-associated adverse events, and create optimal conditions for performing this high-risk and challenging procedure. Although rapid sequence induction including a paralytic agent has been adopted for intubations in pediatric and adult critical care, neonatal clinical practice varies. This review aims to summarize details of common classes of neonatal intubation premedication including indications for use, medication route, dosage, potential adverse effects in term and preterm infants, and reversal agents. In addition, this review shares the literature on national and international practice variations; explores evidence in support of establishing premedication guidelines; and discusses unique circumstances in which premedication use has not been established, such as during catheter-based or minimally invasive surfactant delivery. With increasing survival of extremely preterm infants, clear guidance for premedication use in this population will be necessary, particularly considering potential short- and long-term side effects of procedural sedation on the developing brain.
Collapse
Affiliation(s)
- Sara K Neches
- Department of Pediatrics, Division of Neonatology, University of Washington School of Medicine and Seattle Children's Hospital, Seattle, WA
| | - Cassandra DeMartino
- Department of Pediatrics, Division of Neonatology, Yale New Haven Hospital, New Haven, CT
| | - Rebecca Shay
- Department of Pediatrics, Division of Neonatology, University of Colorado School of Medicine and Children's Hospital of Colorado, Denver, CO
| |
Collapse
|
10
|
Katheria A, Ines F, Banerji A, Hopper A, Uy C, Chundu A, Coughlin K, Hutson S, Morales A, Sauberan J, Poeltler D, Dorner R, Rich W, Finer N. Caffeine and Less Invasive Surfactant Administration for Respiratory Distress Syndrome of the Newborn. NEJM EVIDENCE 2023; 2:EVIDoa2300183. [PMID: 38320499 DOI: 10.1056/evidoa2300183] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
BACKGROUND: Management strategies for preterm neonates with respiratory distress syndrome include early initiation of continuous positive airway pressure (CPAP) and titration of fractional inspired oxygen and may include the use of less invasive surfactant administration (LISA) to avoid the need for endotracheal intubation. This randomized trial investigated whether early administration of caffeine and LISA would decrease the need for endotracheal intubation in the first 72 hours of life (HoL) compared with caffeine and CPAP alone. METHODS: Eligible neonates born at 24 weeks 0 days to 29 weeks 6 days of gestational age were randomly assigned to receive intravenous caffeine in the first 2 HoL followed by surfactant administration via the LISA method (intervention) or caffeine followed by CPAP (control). The primary outcome was the frequency of neonates requiring endotracheal intubation or meeting respiratory failure criteria between groups (caffeine and LISA vs. caffeine and CPAP) within the first 72 HoL. Multivariable logistic regression modeling was used to adjust for gestational age strata in normally distributed primary and secondary outcomes. RESULTS: Enrollment occurred between January 2020 and December 2022. Endotracheal intubation or meeting respiratory failure criteria within the first 72 HoL occurred in 21 (23%) of 92 neonates randomly assigned to receive caffeine and LISA compared with 47 (53%) of 88 neonates in the caffeine and CPAP group (odds ratio, 0.258; 95% confidence interval, 0.136 to 0.490; P<0.001), which remained significant after adjusting for gestational age strata (odds ratio, 0.227; 95% confidence interval, 0.112 to 0.460; P<0.001). Adverse events were similar between groups, except bronchopulmonary dysplasia, which occurred in 26% of the LISA group and 39% of the control group (P=0.049). CONCLUSIONS: In preterm neonates supported with CPAP, early caffeine and LISA resulted in a lower frequency of endotracheal intubation within the first 72 HoL. (Funded by Chiesi USA; ClinicalTrials.gov number, NCT04209946.)
Collapse
Affiliation(s)
- Anup Katheria
- Sharp Mary Birch Hospital for Women & Newborns, San Diego, CA
| | - Felix Ines
- Sharp Mary Birch Hospital for Women & Newborns, San Diego, CA
| | | | - Andrew Hopper
- Loma Linda University Children's Hospital, Loma Linda, CA
| | - Cherry Uy
- University of California Irvine Medical Center, Irvine, CA
| | - Anupama Chundu
- University of California Irvine Medical Center, Irvine, CA
| | | | - Shandee Hutson
- Sharp Mary Birch Hospital for Women & Newborns, San Diego, CA
| | - Ana Morales
- Sharp Mary Birch Hospital for Women & Newborns, San Diego, CA
| | - Jason Sauberan
- Sharp Mary Birch Hospital for Women & Newborns, San Diego, CA
| | - Debra Poeltler
- Sharp Mary Birch Hospital for Women & Newborns, San Diego, CA
| | - Rebecca Dorner
- Sharp Mary Birch Hospital for Women & Newborns, San Diego, CA
| | - Wade Rich
- Sharp Mary Birch Hospital for Women & Newborns, San Diego, CA
| | - Neil Finer
- Sharp Mary Birch Hospital for Women & Newborns, San Diego, CA
| |
Collapse
|
11
|
Yousef N, Soghier L. Neonatal airway management training using simulation-based educational methods and technology. Semin Perinatol 2023; 47:151822. [PMID: 37778883 DOI: 10.1016/j.semperi.2023.151822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/03/2023]
Abstract
Airway management is a fundamental component of neonatal critical care and requires a high level of skill. Neonatal endotracheal intubation (ETI), bag-mask ventilation, and supraglottic airway management are complex technical skills to acquire and continually maintain. Simulation training has emerged as a leading educational modality to accelerate the acquisition of airway management skills and train interprofessional teams. However, current simulation-based training does not always replicate neonatal airway management needed for patient care with a high level of fidelity. Educators still rely on clinical training on live patients. In this article, we will a) review the importance of simulation-based neonatal airway training for learners and clinicians, b) evaluate the available training modalities, instructional design, and challenges for airway procedural skill acquisition, especially neonatal ETI, and c) describe the human factors affecting the transfer of airway training skills into the clinical environment.
Collapse
Affiliation(s)
- Nadya Yousef
- Division of Pediatrics and Neonatal Critical Care, "A. Béclère" Medical Center, Paris-Saclay University Hospitals, APHP, Paris, France
| | - Lamia Soghier
- Children's National Hospital, Washington, DC, United States; The George Washington University School of Medicine and Health Sciences, United States.
| |
Collapse
|
12
|
Walterspiel JN. Design and Superior Performance of a New Endotracheal Tube to Avoid the Asphyxiation of Premature Infants. Cureus 2023; 15:e47655. [PMID: 38021521 PMCID: PMC10679846 DOI: 10.7759/cureus.47655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/25/2023] [Indexed: 12/01/2023] Open
Abstract
Background Neonatal endotracheal intubation attempts often fail, with failures typically attributable to unintended esophageal intubation, with asphyxia, brief or prolonged, as the consequence. Standard-of-care neonatal endotracheal tubes have changed little over recent decades, even as the gestational age of neonates thought eligible for resuscitation and intensive care has decreased. Methods A new neonatal endotracheal tube was patterned after the soft steering mechanism of a two-string fishing line trocar. The new tube remains patent throughout the intubation for air movement and CO2 detection and allows for a finger on the intubator's hand to stiffen, curve, and elevate the tip of the tube over the epiglottis and into the trachea without occluding the vision through a laryngoscope. This tube's engineering principles were studied prospectively in a controlled open-label pilot study in premature infants. Infants were observed during 12 intubations in a one-to-one comparison with standard practice. Results The new design in comparison to a conventional neonatal endotracheal tube (CNETT) was found to be superior. The average intubation time (mean 36.6 sec, median 30 sec) was shorter (mean 44.6 sec, median 45 sec) in the new design. Intubation attempts were fewer (0 vs. 3), and unintended esophageal intubations were also fewer (0 vs. 4). Conclusion Tracheal intubation of premature infants with the new soft-steering mechanism endotracheal tube was associated with less asphyxia, fewer intubation attempts, and fewer esophageal intubations.
Collapse
Affiliation(s)
- Juan N Walterspiel
- Pediatrics, Independent Medical Contractor, LocumTenens, Menlo Park, USA
| |
Collapse
|
13
|
Tamai K, Matsumoto N, Yorifuji T, Takeuchi A, Nakamura M, Nakamura K, Kageyama M. Delivery room intubation and severe intraventricular hemorrhage in extremely preterm infants without low Apgar scores: A Japanese retrospective cohort study. Sci Rep 2023; 13:14990. [PMID: 37696821 PMCID: PMC10495461 DOI: 10.1038/s41598-023-41010-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 08/20/2023] [Indexed: 09/13/2023] Open
Abstract
The purpose of this study was to assess the associations between delivery room intubation (DRI) and severe intraventricular hemorrhage (IVH), as well as other neonatal outcomes, among extremely preterm infants without low Apgar scores using data from a large-scale neonatal registry data in Japan. We analyzed data for infants born at 24-27 gestational weeks between 2003 and 2019 in Japan using robust Poisson regression. Infants with low Apgar scores (≤ 1 at 1 min or ≤ 3 at 5 min) were excluded. The primary outcome was severe IVH. Secondary outcomes were other neonatal morbidities and mortality. The full cohort included 16,081 infants (intubation cohort, 13,367; no intubation cohort, 2714). The rate of DRI increased over time (78.6%, 2003-2008; 83.4%, 2009-2014; 87.8%, 2015-2019), while the rate of severe IVH decreased (7.1%, 2003-2008; 5.7%, 2009-2014; 5.3%, 2015-2019). Infants with DRI had a higher risk of severe IVH than those without DRI (6.8% vs. 2.3%; adjusted risk ratio, 1.86; 95% confidence interval, 1.33-2.58). The results did not change substantially when stratified by gestational age. Despite conflicting changes over time in DRI and severe IVH, DRI was associated with an increased risk of severe IVH among extremely preterm infants in Japan.
Collapse
Affiliation(s)
- Kei Tamai
- Division of Neonatology, Okayama Medical Center, National Hospital Organization, 1711-1 Tamasu, Kita-Ku, Okayama, 701-1192, Japan.
| | - Naomi Matsumoto
- Department of Epidemiology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Takashi Yorifuji
- Department of Epidemiology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Akihito Takeuchi
- Division of Neonatology, Okayama Medical Center, National Hospital Organization, 1711-1 Tamasu, Kita-Ku, Okayama, 701-1192, Japan
| | - Makoto Nakamura
- Division of Neonatology, Okayama Medical Center, National Hospital Organization, 1711-1 Tamasu, Kita-Ku, Okayama, 701-1192, Japan
| | - Kazue Nakamura
- Division of Neonatology, Okayama Medical Center, National Hospital Organization, 1711-1 Tamasu, Kita-Ku, Okayama, 701-1192, Japan
- Department of Epidemiology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Misao Kageyama
- Division of Neonatology, Okayama Medical Center, National Hospital Organization, 1711-1 Tamasu, Kita-Ku, Okayama, 701-1192, Japan
| |
Collapse
|
14
|
Neches SK, Brei BK, Umoren R, Gray MM, Nishisaki A, Foglia EE, Sawyer T. Association of full premedication on tracheal intubation outcomes in the neonatal intensive care unit: an observational cohort study. J Perinatol 2023; 43:1007-1014. [PMID: 36801956 DOI: 10.1038/s41372-023-01632-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 02/01/2023] [Accepted: 02/06/2023] [Indexed: 02/20/2023]
Abstract
OBJECTIVE Evaluate the association of short-term tracheal intubation (TI) outcomes with premedication in the NICU. STUDY DESIGN Observational single-center cohort study comparing TIs with full premedication (opiate analgesia and vagolytic and paralytic), partial premedication, and no premedication. The primary outcome is adverse TI associated events (TIAEs) in intubations with full premedication compared to those with partial or no premedication. Secondary outcomes included change in heart rate and first attempt TI success. RESULTS 352 encounters in 253 infants (median gestation 28 weeks, birth weight 1100 g) were analyzed. TI with full premedication was associated with fewer TIAEs aOR 0.26 (95%CI 0.1-0.6) compared with no premedication, and higher first attempt success aOR 2.7 (95%CI 1.3-4.5) compared with partial premedication after adjusting for patient and provider characteristics. CONCLUSION The use of full premedication for neonatal TI, including an opiate, vagolytic, and paralytic, is associated with fewer adverse events compared with no and partial premedication.
Collapse
Affiliation(s)
- Sara K Neches
- University of Washington School of Medicine and Seattle Children's Hospital, Department of Pediatrics, Division of Neonatology, Seattle, WA, USA.
| | - Brianna K Brei
- University of Nebraska Medical Center, Department of Pediatrics, Division of Neonatology, Omaha, NE, USA
| | - Rachel Umoren
- University of Washington School of Medicine and Seattle Children's Hospital, Department of Pediatrics, Division of Neonatology, Seattle, WA, USA
| | - Megan M Gray
- University of Washington School of Medicine and Seattle Children's Hospital, Department of Pediatrics, Division of Neonatology, Seattle, WA, USA
| | - Akira Nishisaki
- Children's Hospital of Philadelphia. Department of Anesthesiology and Critical Care Medicine, Philadelphia, PA, USA
| | - Elizabeth E Foglia
- Children's Hospital of Philadelphia. Department of Pediatrics, Division of Neonatology, Philadelphia, PA, USA
| | - Taylor Sawyer
- University of Washington School of Medicine and Seattle Children's Hospital, Department of Pediatrics, Division of Neonatology, Seattle, WA, USA
| |
Collapse
|
15
|
Glenn T, Fischer L, Markowski A, Carr CB, Malay S, Hibbs AM. Complicated Intubations are Associated with Bronchopulmonary Dysplasia in Very Low Birth Weight Infants. Am J Perinatol 2023; 40:1245-1252. [PMID: 34500482 PMCID: PMC9239052 DOI: 10.1055/s-0041-1736130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE This study aimed to evaluate the association between desaturation <60% (severe desaturation) during intubation and a total number of intubation attempts in the first week of life in very low birth weight (VLBW) infants with adverse long-term outcomes including bronchopulmonary dysplasia (BPD) and severe periventricular/intraventricular hemorrhage grade 3 or 4 (PIVH). STUDY DESIGN A retrospective chart review was performed on VLBW infants intubated in the neonatal intensive care unit during the first week of life between January 2017 and July 2020. Descriptive tables were generated for two outcomes including BPD and PIVH. Multivariable logistic regression was performed for each outcome including significant predictors that differed between groups with a p-value of <0.2. RESULTS A total of 146 patients were included. Patients with BPD or PIVH had a lower gestational age, and patients with BPD had a lower BW. Patients with BPD had a greater number of intubation attempts in the first week of life (4 vs. 3, p < 0.001). In multivariable logistic regression controlling for confounding variables, the odds developing BPD were higher for patients with increased cumulative number of intubation attempts in the first week of life (odds ratio [OR]: 1.29, 95% confidence interval [CI]: 1.03-1.62, p = 0.029). Post hoc analyses revealed increased odds of developing BPD with increased number of intubation encounters in the first week of life (OR: 2.20, 95% CI: 1.04-4.82, p = 0.043). In this post hoc analysis including intubation encounters in the model; desaturation <60% during intubation in the first week of life was associated with increased odds of developing BPD (OR: 2.35, 95% CI: 1.02-5.63, p = 0.048). CONCLUSION The odds of developing BPD for VLBW infants were higher with increased intubation attempts and intubation encounters. In a post hoc analysis, the odds of developing BPD were also higher with desaturation during intubation. Further research is needed to determine mechanisms of the relationship between complicated intubations and the development of BPD. KEY POINTS · Neonatal intubations often require multiple attempts.. · Neonates frequently desaturate during intubation.. · Intubation attempts are positively associated with BPD.. · Severe desaturation may be positively associated with BPD..
Collapse
Affiliation(s)
- Tara Glenn
- Division of Neonatology, Department of Pediatrics, UH Rainbow Babies and Children’s Hospital, Cleveland, OH
- Case Western Reserve University School of Medicine, Cleveland, OH
| | - Linnea Fischer
- Case Western Reserve University School of Medicine, Cleveland, OH
| | - Ashley Markowski
- Division of Neonatology, Department of Pediatrics, UH Rainbow Babies and Children’s Hospital, Cleveland, OH
| | - Cara Beth Carr
- Division of Neonatology, Department of Pediatrics, UH Rainbow Babies and Children’s Hospital, Cleveland, OH
| | - Sindhoosha Malay
- Case Western Reserve University School of Medicine, Cleveland, OH
| | - Anna Maria Hibbs
- Division of Neonatology, Department of Pediatrics, UH Rainbow Babies and Children’s Hospital, Cleveland, OH
- Case Western Reserve University School of Medicine, Cleveland, OH
| |
Collapse
|
16
|
Cavallin F, Sala C, Maglio S, Bua B, Villani PE, Menciassi A, Tognarelli S, Trevisanuto D. Applied forces with direct versus indirect laryngoscopy in neonatal intubation: a randomized crossover mannequin study. Can J Anaesth 2023; 70:861-868. [PMID: 36788198 DOI: 10.1007/s12630-023-02402-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 10/05/2022] [Accepted: 10/18/2022] [Indexed: 02/16/2023] Open
Abstract
PURPOSE In adult mannequins, videolaryngoscopy improves glottic visualization with lower force applied to upper airway tissues and reduced task workload compared with direct laryngoscopy. This trial compared oropharyngeal applied forces and subjective workload during direct vs indirect (video) laryngoscopy in a neonatal mannequin. METHODS We conducted a randomized crossover trial of intubation with direct laryngoscopy, straight blade videolaryngoscopy, and hyperangulated videolaryngoscopy in a neonatal mannequin. Thirty neonatal/pediatric/anesthesiology consultants and residents participated. The primary outcome measure was the maximum peak force applied during intubation. Secondary outcome measures included the average peak force applied during intubation, time needed to intubate, and subjective workload. RESULTS Direct laryngoscopy median forces on the epiglottis were 8.2 N maximum peak and 6.8 N average peak. Straight blade videolaryngoscopy median forces were 4.7 N maximum peak and 3.6 N average peak. Hyperangulated videolaryngoscopy median forces were 2.8 N maximum peak and 2.1 N average peak. The differences were significant between direct laryngoscopy and straight blade videolaryngoscopy, and between direct laryngoscopy and hyperangulated videolaryngoscopy. Significant differences were also found in the top 10th percentile forces on the epiglottis and palate, but not in the median forces on the palate. Time to intubation and subjective workload were comparable with videolaryngoscopy vs direct laryngoscopy. CONCLUSIONS The lower force applied during videolaryngoscopy in a neonatal mannequin model suggests a possible benefit in reducing potential patient harm during intubation, but the clinical implications require assessment in future studies. REGISTRATION ClinicalTrials.gov (NCT05197868); registered 20 January 2022.
Collapse
Affiliation(s)
| | - Chiara Sala
- Department of Women and Children Health, University Hospital of Padua, Via Giustiniani, 3, 35128, Padua, Italy
| | - Sabina Maglio
- The BioRobotics Institute, Scuola Superiore Sant'Anna, Pisa, Italy
- Department of Excellence in Robotics & AI, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Benedetta Bua
- Department of Women and Children Health, University Hospital of Padua, Via Giustiniani, 3, 35128, Padua, Italy
| | - Paolo Ernesto Villani
- Department of Woman's and Child's Health, Poliambulanza Hospital, Fondazione Poliambulanza, Brescia, Italy
| | - Arianna Menciassi
- The BioRobotics Institute, Scuola Superiore Sant'Anna, Pisa, Italy
- Department of Excellence in Robotics & AI, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Selene Tognarelli
- The BioRobotics Institute, Scuola Superiore Sant'Anna, Pisa, Italy
- Department of Excellence in Robotics & AI, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Daniele Trevisanuto
- Department of Women and Children Health, University Hospital of Padua, Via Giustiniani, 3, 35128, Padua, Italy.
| |
Collapse
|
17
|
Hoshino Y, Arai J, Cho K, Yukitake Y, Kajikawa D, Hinata A, Miura R. Diagnosis and management of neonatal respiratory distress syndrome in Japan: A national survey. Pediatr Neonatol 2023; 64:61-67. [PMID: 36089536 DOI: 10.1016/j.pedneo.2022.08.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 07/28/2022] [Accepted: 08/16/2022] [Indexed: 02/09/2023] Open
Abstract
BACKGROUND Respiratory distress syndrome (RDS) is characterized by a lack of lung surfactant; therefore, biochemical evidence of surfactant deficiency is needed to diagnose RDS. European guidelines recommend surfactant administration when patients need fraction of inspired oxygen exceeding 0.3 on continuous positive airway pressure or intubation. We hypothesized that the European guidelines for surfactant administration were not adopted in Japan because of the lack of RDS diagnosis. This study aimed to investigate neonatologists' attitudes and practices regarding the diagnosis and management of RDS in Japan. METHODS A mail-based survey regarding the diagnosis and management of RDS was conducted at 111 level III or ΙV neonatal intensive care units in Japan. The questionnaire was completed by the person in charge of each unit. RESULTS The overall response rate for the questionnaire was 91% (101/111 centers). All respondents referred to chest radiography, and the majority (83%) of respondents referred to stable microbubble rating (SMR) for establishing the diagnosis of RDS. Surfactant administration was chiefly based on clinical conditions, chest radiography, and/or SMR. Most units in Japan do not adopt the European criteria for surfactant administration. CONCLUSION In Japan, chest radiography and/or SMR are commonly used for the diagnosis of RDS and as the rationale for surfactant administration. Further studies from other countries are required to establish the ideal criteria for surfactant administration.
Collapse
Affiliation(s)
- Yusuke Hoshino
- Department of Neonatology, Ibaraki Children's Hospital, Mito, Japan; Child Health and Cancer Research Center, Ibaraki Children's Hospital, Mito, Japan.
| | - Junichi Arai
- Department of Neonatology, Ibaraki Children's Hospital, Mito, Japan
| | - Kazutoshi Cho
- Maternity and Perinatal Care Center, Hokkaido University Hospital, Sapporo, Japan
| | - Yoshiya Yukitake
- Department of Neonatology, Ibaraki Children's Hospital, Mito, Japan
| | - Daigo Kajikawa
- Department of Neonatology, Ibaraki Children's Hospital, Mito, Japan; Child Health and Cancer Research Center, Ibaraki Children's Hospital, Mito, Japan
| | - Ayako Hinata
- Department of Neonatology, Ibaraki Children's Hospital, Mito, Japan
| | - Rena Miura
- Department of Neonatology, Ibaraki Children's Hospital, Mito, Japan
| |
Collapse
|
18
|
Zhao Y, Zhang W, Tian X. Analysis of risk factors of early intraventricular hemorrhage in very-low-birth-weight premature infants: a single center retrospective study. BMC Pregnancy Childbirth 2022; 22:890. [PMID: 36456995 PMCID: PMC9713978 DOI: 10.1186/s12884-022-05245-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Accepted: 11/25/2022] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND This study aimed to determine the risk factors of early intraventricular hemorrhage (IVH) in very-low-birth-weight (VLBW) premature infants in China to guide early interventions and improve the survival and quality of life of these infants. METHODS Data on 421 VLBW premature infants admitted to the neonatal intensive care unit of Tianjin Central Hospital of Gynecology Obstetrics between July 2017 and July 2019 were retrospectively evaluated. Data on head ultrasound results, maternal pregnancy complications, and perinatal conditions were reviewed to evaluate the association between maternal and neonatal factors and the development and severity of IVH. RESULTS Univariate analysis showed that the incidence of early IVH was significantly higher in neonates with early gestational age, delivered after spontaneous labor, low birth weight, 5-minute Apgar score ≤ 7, invasive mechanical ventilation, and early onset sepsis (χ2 = 11.087, 16.868, 4.779, 11.170, 6.655, and 6.260, respectively; P < 0.05), but it was significantly lower in the presence of gestational hypertension (χ2 = 4.373, P = 0.037). In addition, severe IVH was significantly associated with early gestational age, low birth weight, 5-minute Apgar score ≤ 7, and neonatal sepsis (χ2 = 11.599, 8.263, 11.172, and 7.749, respectively; P < 0.05). Logistic regression analysis showed that antenatal glucocorticoid use was associated with significantly reduced incidence of severe IVH (OR = 0.095, 95% CI = 0.012-0.739, P = 0.024). CONCLUSION Appropriate mode of delivery may effectively reduce the incidence of IVH in VLBW premature infants. The antenatal glucocorticoid use may also protect against severe IVH. The focus on steroid prophylaxis, mode of delivery and prevention of perinatal asphyxia should be stressed in China.
Collapse
Affiliation(s)
- Ying Zhao
- grid.216938.70000 0000 9878 7032Department of Neonatology, Tianjin Central Hospital of Gynecology and Obstetrics, Tianjin Key Laboratory of Human Development and Reproductive Regulation, Nankai University Maternity Hospital, No.156, Sanlu Road, Nankai district, Tianjin, 300052 China
| | - Wanxian Zhang
- grid.216938.70000 0000 9878 7032Department of Neonatology, Tianjin Central Hospital of Gynecology and Obstetrics, Tianjin Key Laboratory of Human Development and Reproductive Regulation, Nankai University Maternity Hospital, No.156, Sanlu Road, Nankai district, Tianjin, 300052 China
| | - Xiuying Tian
- grid.216938.70000 0000 9878 7032Department of Neonatology, Tianjin Central Hospital of Gynecology and Obstetrics, Tianjin Key Laboratory of Human Development and Reproductive Regulation, Nankai University Maternity Hospital, No.156, Sanlu Road, Nankai district, Tianjin, 300052 China
| |
Collapse
|
19
|
Curtis SF, Cotten CM, Laughon M, Younge N, Peterson J, Clark RH, Greenberg RG. Indomethacin Prophylaxis in Preterm Infants: Changes over Time. Am J Perinatol 2022. [PMID: 36174589 DOI: 10.1055/s-0042-1756678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
OBJECTIVE Our objective was to examine changes in the use of indomethacin prophylaxis in the neonatal intensive care unit (NICU) between 2008 and 2018. STUDY DESIGN The design of the study included cohort of 19,715 infants born between 220/7 and 266/7 weeks' gestation from 213 NICUs. A nonparametric trend test evaluated indomethacin prophylaxis and the percentage of sites using any prophylaxis over time. We evaluated the prevalence of indomethacin prophylaxis by the center and the correlation between indomethacin prophylaxis and severe intraventricular hemorrhage prevalence among 12 centers with the largest relative change in indomethacin prophylaxis prevalence. RESULTS In total, 16% of infants received indomethacin prophylaxis. The use of indomethacin prophylaxis did not significantly decrease between 2008 and 2018 but it significantly decreased between 2014 and 2018 (p = 0.046). Among 74 centers with ≥10 infants included, 20% increased the use of indomethacin prophylaxis, while 57% decreased the use over the study period. Of the 12 centers with the largest relative change in indomethacin prophylaxis prevalence, 50% showed an inverse correlation between indomethacin prophylaxis prevalence and severe intraventricular hemorrhage, while 50% showed a positive correlation. CONCLUSION Receipt of indomethacin prophylaxis remained similar until 2014, decreased from 2014 to 2018, and varied by the center.Key Points · The receipt of indomethacin prophylaxis decreased over time.. · Center change in the use of indomethacin prophylaxis does not correlate with the center prevalence of IVH.. · Variability in the use of indomethacin prophylaxis across centers persists..
Collapse
Affiliation(s)
- Samantha F Curtis
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina
| | - C Michael Cotten
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina
| | - Matthew Laughon
- Department of Pediatrics, The University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina
| | - Noelle Younge
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina
| | - Jennifer Peterson
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina
| | | | - Rachel G Greenberg
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| |
Collapse
|
20
|
Miller KE, Singh N. Association of multiple tracheal intubation attempts with clinical outcomes in extremely preterm infants: a retrospective single-center cohort study. J Perinatol 2022; 42:1216-1220. [PMID: 35474128 DOI: 10.1038/s41372-022-01406-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 04/06/2022] [Accepted: 04/14/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE We examined the association between the number of tracheal intubation (TI) attempts and clinical outcomes in extremely preterm infants. METHOD This is a single-center retrospective cohort study examining infants born at ≤28 weeks gestation intubated within the first four postnatal days. We analyzed infant, provider, and practice characteristics and clinical outcomes by exposure groups (1 vs. 2 vs. ≥3 TI attempts). Primary outcomes were death prior to NICU discharge or severe intraventricular hemorrhage (IVH). RESULT Ninety-nine infants were included. 46.5% required one TI attempt, 29.3% required two, and 24.2% required three or more. Increasing attempts was significantly associated with death (p = 0.004), adverse tracheal intubation-associated events (TIAEs; p = 0.004), and the training level of the first attempt provider (p = 0.002). No association was found with severe IVH or complications of prematurity. CONCLUSIONS Increasing attempts was associated with death and adverse TIAEs. Careful selection of providers could decrease adverse TIAEs and improve outcomes.
Collapse
Affiliation(s)
| | - Neetu Singh
- Department of Pediatrics, Children's Hospital at Dartmouth, Lebanon, NH, USA
| |
Collapse
|
21
|
Impact of multiple intubation attempts on adverse tracheal intubation associated events in neonates: a report from the NEAR4NEOS. J Perinatol 2022; 42:1221-1227. [PMID: 35982243 DOI: 10.1038/s41372-022-01484-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 06/20/2022] [Accepted: 07/27/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To determine the relationship between number of attempts and adverse events during neonatal intubation. STUDY DESIGN A retrospective study of prospectively collected data of intubations in the delivery room and NICU from the National Emergency Airway Registry for Neonates (NEAR4NEOS) in 17 academic centers from 1/2016 to 12/2019. We examined the association between tracheal intubation attempts [1, 2, and ≥3 (multiple attempts)] and clinical adverse outcomes (any tracheal intubation associated events (TIAE), severe TIAE, and severe oxygen desaturation). RESULTS Of 7708 intubations, 1474 (22%) required ≥3 attempts. Patient, provider, and practice factors were associated with higher TI attempts. Increasing intubation attempts was independently associated with a higher risk for TIAE. The adjusted odds ratio for TIAE and severe oxygen desaturation were significantly higher in TIs with 2 and ≥3 attempts than with one attempt. CONCLUSION The risk of adverse safety events during intubation increases with the number of intubation attempts.
Collapse
|
22
|
Neonatal resuscitation practices in Italy: a survey of the Italian Society of Neonatology (SIN) and the Union of European Neonatal and Perinatal Societies (UENPS). Ital J Pediatr 2022; 48:81. [PMID: 35655278 PMCID: PMC9164545 DOI: 10.1186/s13052-022-01260-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 04/15/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Providing appropriate care at birth remains a crucial strategy for reducing neonatal mortality and morbidity. We aimed to evaluate the consistency of practice and the adherence to the international guidelines on neonatal resuscitation in level-I and level-II Italian birth hospitals. METHODS This was a cross-sectional electronic survey. A 91-item questionnaire focusing on current delivery room practices in neonatal resuscitation was sent to the directors of 418 Italian neonatal facilities. RESULTS The response rate was 61.7% (258/418), comprising 95.6% (110/115) from level-II and 49.0% (148/303) from level-I centres. In 2018, approximately 300,000 births occurred at the participating hospitals, with a median of 1664 births/centre in level-II and 737 births/centre in level-I hospitals. Participating level-II hospitals provided nasal-CPAP and/or high-flow nasal cannulae (100%), mechanical ventilation (99.1%), HFOV (71.0%), inhaled nitric oxide (80.0%), therapeutic hypothermia (76.4%), and extracorporeal membrane oxygenation ECMO (8.2%). Nasal-CPAP and/or high-flow nasal cannulae and mechanical ventilation were available in 77.7 and 21.6% of the level-I centres, respectively. Multidisciplinary antenatal counselling was routinely offered to parents at 90.0% (90) of level-II hospitals, and 57.4% (85) of level-I hospitals (p < 0.001). Laryngeal masks were available in more than 90% of participating hospitals while an end-tidal CO2 detector was available in only 20%. Significant differences between level-II and level-I centres were found in the composition of resuscitation teams for high-risk deliveries, team briefings before resuscitation, providers qualified with full resuscitation skills, self-confidence, and use of sodium bicarbonate. CONCLUSIONS This survey provides insight into neonatal resuscitation practices in a large sample of Italian hospitals. Overall, adherence to international guidelines on neonatal resuscitation was high, but differences in practice between the participating centres and the guidelines exist. Clinicians and stakeholders should consider this information when allocating resources and planning perinatal programs in Italy.
Collapse
|
23
|
Debay A, Patel S, Wintermark P, Claveau M, Olivier F, Beltempo M. Association of Delivery Room and Neonatal Intensive Care Unit Intubation, and Number of Tracheal Intubation Attempts with Death or Severe Neurological Injury among Preterm Infants. Am J Perinatol 2022; 39:776-785. [PMID: 33075843 DOI: 10.1055/s-0040-1718577] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE The study aimed to assess the association of tracheal intubation (TI) and where it is performed, and the number of TI attempts with death and/or severe neurological injury (SNI) among preterm infants. STUDY DESIGN Retrospective cohort study of infants born 23 to 32 weeks, admitted to a single level-3 neonatal intensive care unit (NICU) between 2015 and 2018. Exposures were location of TI (delivery room [DR] vs. NICU) and number of TI attempts (1 vs. >1). Primary outcome was death and/or SNI (intraventricular hemorrhage grade 3-4 and/or periventricular leukomalacia). Multivariable logistic regression analysis was used to assess association between exposures and outcomes and to adjust for confounders. RESULTS Rate of death and/or SNI was 2.5% (6/240) among infants never intubated, 12% (13/105) among NICU TI, 32% (31/97) among DR TI, 20% (17/85) among infants with one TI attempt and 23% (27/117) among infants with >1 TI attempt. Overall, median number of TI attempts was 1 (interquartile range [IQR]: 1-2). Compared with no TI, DR TI (adjusted odds ratio [AOR]: 9.04, 95% confidence interval [CI]: 3.21-28.84) and NICU TI (AOR: 3.42, 95% CI: 1.21-10.61) were associated with higher odds of death and/or SNI. The DR TI was associated with higher odds of death and/or SNI compared with NICU TI (AOR: 2.64, 95% CI: 1.17-6.22). The number of intubation attempts (1 vs. >1) was not associated with death and/or SNI (AOR: 0.95, 95% CI: 0.47-2.03). CONCLUSION The DR TI is associated with higher odds of death and/or SNI compared with NICU TI, and may help identify higher risk infants. There was no association between the number of TI attempts and death and/or SNI. KEY POINTS · Delivery room intubation correlates with morbidity.. · Less than 2 intubation attempts are not associated with IVH.. · Provider training reduces intubation attempts..
Collapse
Affiliation(s)
- Anthony Debay
- Faculty of Medicine, McGill University, Montreal, Quebec, Canada
| | - Sharina Patel
- McGill University Health Center Research Institute, Montreal, Quebec, Canada
| | - Pia Wintermark
- McGill University Health Center Research Institute, Montreal, Quebec, Canada.,Department of Pediatrics, Montreal Children's Hospital - McGill University Health Centre, Montreal, Quebec, Canada
| | - Martine Claveau
- Department of Pediatrics, Montreal Children's Hospital - McGill University Health Centre, Montreal, Quebec, Canada
| | - François Olivier
- Department of Pediatrics, Montreal Children's Hospital - McGill University Health Centre, Montreal, Quebec, Canada
| | - Marc Beltempo
- Department of Pediatrics, Montreal Children's Hospital - McGill University Health Centre, Montreal, Quebec, Canada
| |
Collapse
|
24
|
Hodgson KA, Owen LS, Kamlin COF, Roberts CT, Newman SE, Francis KL, Donath SM, Davis PG, Manley BJ. Nasal High-Flow Therapy during Neonatal Endotracheal Intubation. N Engl J Med 2022; 386:1627-1637. [PMID: 35476651 DOI: 10.1056/nejmoa2116735] [Citation(s) in RCA: 36] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Neonatal endotracheal intubation often involves more than one attempt, and oxygen desaturation is common. It is unclear whether nasal high-flow therapy, which extends the time to desaturation during elective intubation in children and adults receiving general anesthesia, can improve the likelihood of successful neonatal intubation on the first attempt. METHODS We performed a randomized, controlled trial to compare nasal high-flow therapy with standard care (no nasal high-flow therapy or supplemental oxygen) in neonates undergoing oral endotracheal intubation at two Australian tertiary neonatal intensive care units. Randomization of intubations to the high-flow group or the standard-care group was stratified according to trial center, the use of premedication for intubation (yes or no), and postmenstrual age of the infant (≤28 or >28 weeks). The primary outcome was successful intubation on the first attempt without physiological instability (defined as an absolute decrease in the peripheral oxygen saturation of >20% from the preintubation baseline level or bradycardia with a heart rate of <100 beats per minute) in the infant. RESULTS The primary intention-to-treat analysis included the outcomes of 251 intubations in 202 infants; 124 intubations were assigned to the high-flow group and 127 to the standard-care group. The infants had a median postmenstrual age of 27.9 weeks and a median weight of 920 g at the time of intubation. A successful intubation on the first attempt without physiological instability was achieved in 62 of 124 intubations (50.0%) in the high-flow group and in 40 of 127 intubations (31.5%) in the standard-care group (adjusted risk difference, 17.6 percentage points; 95% confidence interval [CI], 6.0 to 29.2), for a number needed to treat of 6 (95% CI, 4 to 17) for 1 infant to benefit. Successful intubation on the first attempt regardless of physiological stability was accomplished in 68.5% of the intubations in the high-flow group and in 54.3% of the intubations in the standard-care group (adjusted risk difference, 15.8 percentage points; 95% CI, 4.3 to 27.3). CONCLUSIONS Among infants undergoing endotracheal intubation at two Australian tertiary neonatal intensive care units, nasal high-flow therapy during the procedure improved the likelihood of successful intubation on the first attempt without physiological instability in the infant. (Funded by the National Health and Medical Research Council; Australian New Zealand Clinical Trials Registry number, ACTRN12618001498280.).
Collapse
Affiliation(s)
- Kate A Hodgson
- From the Newborn Research Centre, Royal Women's Hospital (K.A.H., L.S.O., C.O.F.K., P.G.D., B.J.M.), Monash Newborn, Monash Children's Hospital (C.T.R.), the Department of Paediatrics, Monash University (C.T.R.), the Ritchie Centre, Hudson Institute of Medical Research (C.T.R.), and the Department of Neonatal Medicine, Royal Children's Hospital (S.E.N.), Melbourne, VIC, and the Departments of Obstetrics and Gynaecology (K.A.H., L.S.O., C.O.F.K., P.G.D., B.J.M.) and Paediatrics (S.M.D.), University of Melbourne, and Murdoch Children's Research Institute (L.S.O., C.O.F.K., K.L.F., S.M.D., P.G.D., B.J.M.), Parkville, VIC - all in Australia
| | - Louise S Owen
- From the Newborn Research Centre, Royal Women's Hospital (K.A.H., L.S.O., C.O.F.K., P.G.D., B.J.M.), Monash Newborn, Monash Children's Hospital (C.T.R.), the Department of Paediatrics, Monash University (C.T.R.), the Ritchie Centre, Hudson Institute of Medical Research (C.T.R.), and the Department of Neonatal Medicine, Royal Children's Hospital (S.E.N.), Melbourne, VIC, and the Departments of Obstetrics and Gynaecology (K.A.H., L.S.O., C.O.F.K., P.G.D., B.J.M.) and Paediatrics (S.M.D.), University of Melbourne, and Murdoch Children's Research Institute (L.S.O., C.O.F.K., K.L.F., S.M.D., P.G.D., B.J.M.), Parkville, VIC - all in Australia
| | - C Omar F Kamlin
- From the Newborn Research Centre, Royal Women's Hospital (K.A.H., L.S.O., C.O.F.K., P.G.D., B.J.M.), Monash Newborn, Monash Children's Hospital (C.T.R.), the Department of Paediatrics, Monash University (C.T.R.), the Ritchie Centre, Hudson Institute of Medical Research (C.T.R.), and the Department of Neonatal Medicine, Royal Children's Hospital (S.E.N.), Melbourne, VIC, and the Departments of Obstetrics and Gynaecology (K.A.H., L.S.O., C.O.F.K., P.G.D., B.J.M.) and Paediatrics (S.M.D.), University of Melbourne, and Murdoch Children's Research Institute (L.S.O., C.O.F.K., K.L.F., S.M.D., P.G.D., B.J.M.), Parkville, VIC - all in Australia
| | - Calum T Roberts
- From the Newborn Research Centre, Royal Women's Hospital (K.A.H., L.S.O., C.O.F.K., P.G.D., B.J.M.), Monash Newborn, Monash Children's Hospital (C.T.R.), the Department of Paediatrics, Monash University (C.T.R.), the Ritchie Centre, Hudson Institute of Medical Research (C.T.R.), and the Department of Neonatal Medicine, Royal Children's Hospital (S.E.N.), Melbourne, VIC, and the Departments of Obstetrics and Gynaecology (K.A.H., L.S.O., C.O.F.K., P.G.D., B.J.M.) and Paediatrics (S.M.D.), University of Melbourne, and Murdoch Children's Research Institute (L.S.O., C.O.F.K., K.L.F., S.M.D., P.G.D., B.J.M.), Parkville, VIC - all in Australia
| | - Sophie E Newman
- From the Newborn Research Centre, Royal Women's Hospital (K.A.H., L.S.O., C.O.F.K., P.G.D., B.J.M.), Monash Newborn, Monash Children's Hospital (C.T.R.), the Department of Paediatrics, Monash University (C.T.R.), the Ritchie Centre, Hudson Institute of Medical Research (C.T.R.), and the Department of Neonatal Medicine, Royal Children's Hospital (S.E.N.), Melbourne, VIC, and the Departments of Obstetrics and Gynaecology (K.A.H., L.S.O., C.O.F.K., P.G.D., B.J.M.) and Paediatrics (S.M.D.), University of Melbourne, and Murdoch Children's Research Institute (L.S.O., C.O.F.K., K.L.F., S.M.D., P.G.D., B.J.M.), Parkville, VIC - all in Australia
| | - Kate L Francis
- From the Newborn Research Centre, Royal Women's Hospital (K.A.H., L.S.O., C.O.F.K., P.G.D., B.J.M.), Monash Newborn, Monash Children's Hospital (C.T.R.), the Department of Paediatrics, Monash University (C.T.R.), the Ritchie Centre, Hudson Institute of Medical Research (C.T.R.), and the Department of Neonatal Medicine, Royal Children's Hospital (S.E.N.), Melbourne, VIC, and the Departments of Obstetrics and Gynaecology (K.A.H., L.S.O., C.O.F.K., P.G.D., B.J.M.) and Paediatrics (S.M.D.), University of Melbourne, and Murdoch Children's Research Institute (L.S.O., C.O.F.K., K.L.F., S.M.D., P.G.D., B.J.M.), Parkville, VIC - all in Australia
| | - Susan M Donath
- From the Newborn Research Centre, Royal Women's Hospital (K.A.H., L.S.O., C.O.F.K., P.G.D., B.J.M.), Monash Newborn, Monash Children's Hospital (C.T.R.), the Department of Paediatrics, Monash University (C.T.R.), the Ritchie Centre, Hudson Institute of Medical Research (C.T.R.), and the Department of Neonatal Medicine, Royal Children's Hospital (S.E.N.), Melbourne, VIC, and the Departments of Obstetrics and Gynaecology (K.A.H., L.S.O., C.O.F.K., P.G.D., B.J.M.) and Paediatrics (S.M.D.), University of Melbourne, and Murdoch Children's Research Institute (L.S.O., C.O.F.K., K.L.F., S.M.D., P.G.D., B.J.M.), Parkville, VIC - all in Australia
| | - Peter G Davis
- From the Newborn Research Centre, Royal Women's Hospital (K.A.H., L.S.O., C.O.F.K., P.G.D., B.J.M.), Monash Newborn, Monash Children's Hospital (C.T.R.), the Department of Paediatrics, Monash University (C.T.R.), the Ritchie Centre, Hudson Institute of Medical Research (C.T.R.), and the Department of Neonatal Medicine, Royal Children's Hospital (S.E.N.), Melbourne, VIC, and the Departments of Obstetrics and Gynaecology (K.A.H., L.S.O., C.O.F.K., P.G.D., B.J.M.) and Paediatrics (S.M.D.), University of Melbourne, and Murdoch Children's Research Institute (L.S.O., C.O.F.K., K.L.F., S.M.D., P.G.D., B.J.M.), Parkville, VIC - all in Australia
| | - Brett J Manley
- From the Newborn Research Centre, Royal Women's Hospital (K.A.H., L.S.O., C.O.F.K., P.G.D., B.J.M.), Monash Newborn, Monash Children's Hospital (C.T.R.), the Department of Paediatrics, Monash University (C.T.R.), the Ritchie Centre, Hudson Institute of Medical Research (C.T.R.), and the Department of Neonatal Medicine, Royal Children's Hospital (S.E.N.), Melbourne, VIC, and the Departments of Obstetrics and Gynaecology (K.A.H., L.S.O., C.O.F.K., P.G.D., B.J.M.) and Paediatrics (S.M.D.), University of Melbourne, and Murdoch Children's Research Institute (L.S.O., C.O.F.K., K.L.F., S.M.D., P.G.D., B.J.M.), Parkville, VIC - all in Australia
| |
Collapse
|
25
|
Bernardo J, Makker K. Is aerosolized calfactant effective and safe in the treatment of respiratory distress syndrome? J Perinatol 2022; 42:540-543. [PMID: 35177794 DOI: 10.1038/s41372-022-01321-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 11/03/2021] [Accepted: 01/14/2022] [Indexed: 11/09/2022]
Affiliation(s)
- Janine Bernardo
- Division of Neonatology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA. .,Division of Neonatology, Massachusetts General Hospital for Children, Instructor in Pediatrics, Harvard Medical School, Massachusetts General Hospital, 55 Fruit Street, Austen 5, Boston, MA, 02114, USA.
| | - Kartikeya Makker
- Division of Neonatology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| |
Collapse
|
26
|
Abstract
Chronic pain and agitation in neonatal life impact the developing brain. Oral sweet-tasting solutions should be used judiciously to mitigate behavioral responses to mild painful procedures, keeping in mind that the long-term impact is unknown. Rapidly acting opioids should be used as part of premedication cocktails for nonemergent endotracheal intubations. Continuous low-dose morphine or dexmedetomidine may be considered for preterm or term neonates exhibiting signs of stress during mechanical ventilation and therapeutic hypothermia, respectively. Further research is required regarding the pharmacokinetics, pharmacodynamics, safety, and efficacy of pharmacologic agents used to mitigate mild, moderate, and chronic pain and stress in neonates.
Collapse
Affiliation(s)
- Christopher McPherson
- Department of Pharmacy, St. Louis Children's Hospital, 1 Children's Place, St. Louis, MO 63110, USA; Department of Pediatrics, Washington University School of Medicine, 660 South Euclid Avenue, St. Louis, MO 63110, USA.
| | - Ruth E Grunau
- Department of Pediatrics, University of British Columbia, F605B, 4480 Oak Street, Vancouver, BC V6H 3V4, Canada; BC Children's Hospital Research Institute, 938 West 28th Avenue, Vancouver BC V5Z 4H4, Canada
| |
Collapse
|
27
|
Kramer KP, Minot K, Butler C, Haynes K, Mason A, Nguyen L, Wynn S, Liebowitz M, Rogers EE. Reduction of Severe Intraventricular Hemorrhage in Preterm Infants: A Quality Improvement Project. Pediatrics 2022; 149:184903. [PMID: 35229127 DOI: 10.1542/peds.2021-050652] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/01/2021] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES The aim of this quality improvement project was to reduce the rate of severe intraventricular hemorrhage (sIVH) by 50% within 3 years for extremely preterm infants born at a children's teaching hospital. METHODS A multidisciplinary team developed key drivers for the development of intraventricular hemorrhage in preterm infants. Targeted interventions included the development of potentially better practice guidelines, promoting early noninvasive ventilation, consistent use of rescue antenatal betamethasone, and risk-based indomethacin prophylaxis. The outcome measure was the rate of sIVH. Process measures included the rate of intubation within 24 hours and receipt of rescue betamethasone and risk-based indomethacin prophylaxis. Common markers of morbidity were balancing measures. Data were collected from a quarterly chart review and analyzed with statistical process control charts. The preintervention period was from January 2012 to March 2016, implementation period was from April 2016 to December 2018, and sustainment period was through June 2020. RESULTS During the study period, there were 268 inborn neonates born at <28 weeks' gestation or <1000 g (127 preintervention and 141 postintervention). The rate of sIVH decreased from 14% to 1.2%, with sustained improvement over 2 and a half years. Mortality also decreased by 50% during the same time period. This was associated with adherence to process measures and no change in balancing measures. CONCLUSIONS A multipronged quality improvement approach to intraventricular hemorrhage prevention, including evidence-based practice guidelines, consistent receipt of rescue betamethasone and indomethacin prophylaxis, and decreasing early intubation was associated with a sustained reduction in sIVH in extremely preterm infants.
Collapse
Affiliation(s)
- Katelin P Kramer
- Department of Pediatrics, University of California, San Francisco, San Francisco, California.,University of California, San Francisco, Benioff Children's Hospital, San Francisco, California
| | - Kacy Minot
- University of California, San Francisco, Benioff Children's Hospital, San Francisco, California
| | - Colleen Butler
- University of California, San Francisco, Benioff Children's Hospital, San Francisco, California
| | - Kathryn Haynes
- University of California, San Francisco, Benioff Children's Hospital, San Francisco, California
| | - Amber Mason
- University of California, San Francisco, Benioff Children's Hospital, San Francisco, California
| | - Lan Nguyen
- University of California, San Francisco, Benioff Children's Hospital, San Francisco, California
| | - Samantha Wynn
- University of California, San Francisco, Benioff Children's Hospital, San Francisco, California
| | - Melissa Liebowitz
- Department of Pediatrics, University of California, San Francisco, San Francisco, California.,University of California, San Francisco, Benioff Children's Hospital, San Francisco, California
| | - Elizabeth E Rogers
- Department of Pediatrics, University of California, San Francisco, San Francisco, California.,University of California, San Francisco, Benioff Children's Hospital, San Francisco, California
| |
Collapse
|
28
|
Ndakor SM, Pezzano CJ, Spilman L, Geis G, Munshi U, Dunton C, Pinheiro JMB. Wide Variation in Unplanned Extubation Rates Related to Differences in Operational Definitions. J Patient Saf 2022; 18:e92-e96. [PMID: 32398535 DOI: 10.1097/pts.0000000000000707] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
OBJECTIVES Unplanned extubation (UE) rate is a patient safety metric for which there are varied and inconsistently interpreted definitions. We aimed to test the sensitivity of UE rates to the application of different operational definitions. METHODS We analyzed neonatal intensive care unit (NICU) quality improvement data on UE events defined inclusively as "any extubation that was not performed electively, or not previously intended for that time." Unplanned extubations were classified as involving an endotracheal tube (ETT) that was either objectively "dislodged" or "removed" without proof of prior dislodgement. We used descriptive statistics to explore how UE rates vary when applying alternate UE definitions. RESULTS For 33 months, 241 UEs were documented, 70% involving dislodged tubes and 30% ETTs removed by staff. Among dislodged ETTs, only 9% were found completely externalized, whereas 77% were at an adequate depth but in the esophagus. Thirteen percent of events occurred outside the NICU and 13% were initially unreported. The overall UE rate was 4.9/100 ventilator days. If the least inclusive definition was used (i.e., counting only "self-extubations" by patients, requiring reintubation, and occurring within the NICU), 83% of UEs would have been excluded. CONCLUSIONS Most UEs in our NICU population involved staff either removing ETTs from the trachea or partly removing them after internal dislodgement. In settings where ETTs removed by staff are not counted, UE rates may be substantially lower and associated risks underestimated. An inclusive, patient-centric operational definition along with a standardized classification would allow benchmarking, while enabling targeted approaches to minimize locally predominant causes of UEs.
Collapse
Affiliation(s)
| | | | - Lynn Spilman
- Nursing Education, Albany Medical Center, Albany, New York
| | - Gina Geis
- From the Department of Pediatrics, Albany Medical College
| | - Upender Munshi
- From the Department of Pediatrics, Albany Medical College
| | - Cheryl Dunton
- Nursing Education, Albany Medical Center, Albany, New York
| | | |
Collapse
|
29
|
Shay R, Weikel BW, Grover T, Barry JS. Standardizing premedication for non-emergent neonatal tracheal intubations improves compliance and patient outcomes. J Perinatol 2022; 42:132-138. [PMID: 34584197 DOI: 10.1038/s41372-021-01215-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 08/26/2021] [Accepted: 09/10/2021] [Indexed: 11/09/2022]
Abstract
OBJECTIVE We sought to standardize and improve compliance with evidence-based premedication for non-emergent neonatal intubations in two academic-affiliated Neonatal Intensive Care Units. STUDY DESIGN A multidisciplinary team created guidelines and electronic medical record order sets for intubation. Compliance with recommended premedication, number of intubation attempts, and frequency of bradycardia and desaturation were assessed. RESULTS 387 intubation procedures were reviewed. Provision of recommended premedication increased by 36% and 75% at the level III and IV units, respectively. Decreased frequency of bradycardia during intubation (p = 0.0003) occurred in the level III unit. A reduction in number of intubation attempts (p ≤ 0.001), improvement in first-attempt intubation success (p ≤ 0.001), and decreased frequency of bradycardia (p = 0.01) and desaturation (p = 0.02) during intubation occurred in the level IV unit. CONCLUSIONS This quality improvement initiative improved standardized premedication compliance and decreased adverse events associated with non-emergent neonatal intubations in two separate units.
Collapse
Affiliation(s)
- Rebecca Shay
- University of Colorado School of Medicine, Department of Pediatrics, Aurora, CO, USA. .,Children's Hospital Colorado, Section of Neonatology, Aurora, CO, USA.
| | - Blair W Weikel
- University of Colorado School of Medicine, Department of Pediatrics, Aurora, CO, USA.,Children's Hospital Colorado, Section of Neonatology, Aurora, CO, USA
| | - Theresa Grover
- University of Colorado School of Medicine, Department of Pediatrics, Aurora, CO, USA.,Children's Hospital Colorado, Section of Neonatology, Aurora, CO, USA
| | - James S Barry
- University of Colorado School of Medicine, Department of Pediatrics, Aurora, CO, USA.,Children's Hospital Colorado, Section of Neonatology, Aurora, CO, USA
| |
Collapse
|
30
|
Durrmeyer X, Walter-Nicolet E, Chollat C, Chabernaud JL, Barois J, Chary Tardy AC, Berenguer D, Bedu A, Zayat N, Roué JM, Beissel A, Bellanger C, Desenfants A, Boukhris R, Loose A, Massudom Tagny C, Chevallier M, Milesi C, Tauzin M. Premedication before laryngoscopy in neonates: Evidence-based statement from the French society of neonatology (SFN). Front Pediatr 2022; 10:1075184. [PMID: 36683794 PMCID: PMC9846576 DOI: 10.3389/fped.2022.1075184] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 12/01/2022] [Indexed: 01/06/2023] Open
Abstract
CONTEXT Laryngoscopy is frequently required in neonatal intensive care. Awake laryngoscopy has deleterious effects but practice remains heterogeneous regarding premedication use. The goal of this statement was to provide evidence-based good practice guidance for clinicians regarding premedication before tracheal intubation, less invasive surfactant administration (LISA) and laryngeal mask insertion in neonates. METHODS A group of experts brought together by the French Society of Neonatology (SFN) addressed 4 fields related to premedication before upper airway access in neonates: (1) tracheal intubation; (2) less invasive surfactant administration; (3) laryngeal mask insertion; (4) use of atropine for the 3 previous procedures. Evidence was gathered and assessed on predefined questions related to these fields. Consensual statements were issued using the GRADE methodology. RESULTS Among the 15 formalized good practice statements, 2 were strong recommendations to do (Grade 1+) or not to do (Grade 1-), and 4 were discretionary recommendations to do (Grade 2+). For 9 good practice statements, the GRADE method could not be applied, resulting in an expert opinion. For tracheal intubation premedication was considered mandatory except for life-threatening situations (Grade 1+). Recommended premedications were a combination of opioid + muscle blocker (Grade 2+) or propofol in the absence of hemodynamic compromise or hypotension (Grade 2+) while the use of a sole opioid was discouraged (Grade 1-). Statements regarding other molecules before tracheal intubation were expert opinions. For LISA premedication was recommended (Grade 2+) with the use of propofol (Grade 2+). Statements regarding other molecules before LISA were expert opinions. For laryngeal mask insertion and atropine use, no specific data was found and expert opinions were provided. CONCLUSION This statement should help clinical decision regarding premedication before neonatal upper airway access and favor standardization of practices.
Collapse
Affiliation(s)
- Xavier Durrmeyer
- Neonatal Intensive Care Unit, Centre Hospitalier Intercommunal de Créteil, Créteil, France.,Université Paris Est Créteil, Faculté de Santé de Créteil, IMRB, GRC CARMAS, Créteil, France
| | - Elizabeth Walter-Nicolet
- Neonatal Medicine and Intensive Care Unit, Saint Joseph Hospital, Paris, France.,University of Paris-Cité, CRESS, Obstetrical Perinatal and Pediatric Epidemiology Research Team, EPOPé, INSERM, INRAE, Paris, France
| | - Clément Chollat
- Department of Neonatology, Hôpital Armand Trousseau, APHP, Sorbonne Université, Paris, France
| | - Jean-Louis Chabernaud
- Division of Neonatal and Pediatric Critical Care Transportation, Hôpital Antoine Beclere, AP-HP, Paris - Saclay University Hospital, Clamart, France
| | - Juliette Barois
- Department of Neonatology and Neonatal Intensive Care, CH de Valenciennes, Valenciennes, France
| | - Anne-Cécile Chary Tardy
- Department of Neonatology and Neonatal Intensive Care, Centre Hospitalier Universitaire de Dijon, Dijon, France
| | - Daniel Berenguer
- Department of Pediatric Anesthesia and Pediatric Transport (SMUR Pédiatrique), Hôpital des Enfants, CHU de Bordeaux, Bordeaux, France
| | - Antoine Bedu
- Department of Neonatal Pediatrics and Intensive Care, Limoges University Hospital, Limoges, France
| | - Noura Zayat
- Department of Neonatal Intensive Care and Pediatric Transport, CHU de Nantes, Nantes, France
| | - Jean-Michel Roué
- Department of Pediatric and Neonatal Critical Care, Brest University Hospital, Brest, France
| | - Anne Beissel
- Neonatal Intensive Care Unit, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Bron, France
| | - Claire Bellanger
- Department of Neonatology and Neonatal Intensive Care, AP-HP, Hôpital Necker-Enfants Malades, Paris, France
| | - Aurélie Desenfants
- Department of Neonatology, CHU Nimes, Université Montpellier, Nimes, France
| | - Riadh Boukhris
- Department of Neonatology, Pôle Femme-Mère-Nouveau-Né, Hôpital Jeanne de Flandre, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Anne Loose
- Department of Neonatology, CHRU de Tours, Hôpital Bretonneau, Tours, France
| | - Clarisse Massudom Tagny
- Department of Neonatology and Neonatal Intensive Care, Grand Hôpital de L'Est Francilien, Meaux, France
| | - Marie Chevallier
- Department of Neonatal Intensive Care Unit, CHU Grenoble, Grenoble, France.,TIMC-IMAG Research Department, Grenoble Alps University, Grenoble, France
| | - Christophe Milesi
- Department of Neonatal Medicine and Pediatric Intensive Care, Montpellier University Hospital, Université de Montpellier, Montpellier, France
| | - Manon Tauzin
- Neonatal Intensive Care Unit, Centre Hospitalier Intercommunal de Créteil, Créteil, France
| |
Collapse
|
31
|
Kalikkot Thekkeveedu R, Dankhara N, Desai J, Klar AL, Patel J. Outcomes of multiple gestation births compared to singleton: analysis of multicenter KID database. Matern Health Neonatol Perinatol 2021; 7:15. [PMID: 34711283 PMCID: PMC8554969 DOI: 10.1186/s40748-021-00135-5] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 10/15/2021] [Indexed: 11/10/2022] Open
Abstract
Background The available data regarding morbidity and mortality associated with multiple gestation births is conflicting and contradicting. Objective To compare morbidity, mortality, and length of stay (LOS) outcomes between multiple gestation (twin, triplet and higher-order) and singleton births. Methods Data from the national multicenter Kids’ Inpatient Database of the Healthcare Cost and Utilization Project from the years 2000, 2003, 2006, 2009, 2012, and 2016 were analyzed using a complex survey design using Statistical Analysis System (SAS) 9.4 (SAS Institute, Cary NC). Neonates with ICD9 and ICD10 codes indicating singletons, twins or triplets, and higher-order multiples were included. Mortality was compared between these groups after excluding transfer outs to avoid duplicate inclusion. To analyze LOS, we included inborn neonates and excluded transfers; who died inpatient and any neonates who appear to have been discharged less than 33 weeks PMA. The LOS was compared by gestational age groups. Results A total of 22,853,125 neonates were analyzed for mortality after applying inclusion-exclusion criteria; 2.96% were twins, and 0.13% were triplets or more. A total of 22,690,082 neonates were analyzed for LOS. Mean GA, expressed as mean (SD), for singleton, twins and triplets, were 38.30 (2.21), 36.39 (4.21), and 32.72 (4.14), respectively. The adjusted odds for mortality were similar for twin births compared to singleton (aOR: 1.004, 95% CI:0.960–1.051, p = 0.8521). The adjusted odds of mortality for triplet or higher-order gestation births were higher (aOR: 1.33, 95% CI: 1.128–1.575, p = 0.0008) when compared to the singleton births. Median LOS (days) was significantly longer in multiple gestation compared to singleton births overall (singletons: 1.59 [1.13, 2.19] vs. twins 3.29 [2.17, 9.59] vs. triplets or higher-order multiples 19.15 [8.80, 36.38], p < .0001), and this difference remained significant within each GA category. Conclusion Multiple gestation births have higher mortality and longer LOS when compared to singleton births. This population data from multiple centers across the country could be useful in counseling parents when caring for multiple gestation pregnancies. Supplementary Information The online version contains supplementary material available at 10.1186/s40748-021-00135-5.
Collapse
Affiliation(s)
| | - Nilesh Dankhara
- Newborn Medicine, University of Mississippi Medical Center, 2500 N State St, W154, Jackson, MS, 39216, USA
| | - Jagdish Desai
- Newborn Medicine, University of Mississippi Medical Center, 2500 N State St, W154, Jackson, MS, 39216, USA
| | - Angelle L Klar
- Newborn Medicine, University of Mississippi Medical Center, 2500 N State St, W154, Jackson, MS, 39216, USA
| | - Jaimin Patel
- Newborn Medicine, University of Mississippi Medical Center, 2500 N State St, W154, Jackson, MS, 39216, USA
| |
Collapse
|
32
|
Ramaswamy VV, Abiramalatha T, Bandyopadhyay T, Pullattayil S AK, Trevisanuto D. Digital tracheal intubation and finger palpation to confirm endotracheal tube tip position in neonates: A systematic review and meta-analysis. Pediatr Pulmonol 2021; 56:2893-2902. [PMID: 34265176 PMCID: PMC8457083 DOI: 10.1002/ppul.25551] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 05/21/2021] [Accepted: 06/21/2021] [Indexed: 11/11/2022]
Abstract
BACKGROUND To evaluate digital tracheal intubation (DTI) when compared to laryngoscope-assisted TI; finger palpation of endotracheal tube (ETT) tip position when compared to any standard method. DESIGN A systematic review of Medline, Embase, CENTRAL, and CINAHL with synthesis of data using meta-analysis was performed. MAIN OUTCOME MEASURE The proportion of successful TI and correct ETT tip positioning were the main outcome measures. RESULTS Five studies (one observational study and four RCTs) enrolling 310 neonates were included. 94% (81%-98%) of the DTI were successful on the first attempt (certainty of evidence [CoE]: low). The proportion of successful intubation on the first attempt was higher with DTI when compared to laryngoscope-assisted TI (RR 95% CI: 1.81 [1.18; 2.76]) (CoE: very low). Time to successful TI with DTI was 7.4 (95% CI: 6.3, 8.5) s (CoE: low). Time to successful TI was significantly shorter with DTI when compared to laryngoscope assisted TI (MD [95% CI]: -4.9 [-7.3, -2.4] s) (CoE: very low). There was a trend towards a higher proportion of correct ETT tip positions with finger palpation when compared to weight-based formulae alone (RR 95% CI: 1.12 [0.96; 1.31]) (CoE: very low). CONCLUSIONS DTI and finger palpation to ascertain ETT tip position in neonates are promising strategies. Future studies with emphasis on their learning trajectory and generalizability are needed.
Collapse
Affiliation(s)
| | | | - Tapas Bandyopadhyay
- Dr Ram Manohar Lohia Hospital & Post Graduate Institute of Medical Education and Research, New Delhi, India
| | | | - Daniele Trevisanuto
- Department of Women's and Children's Health, University Hospital of Padua, Padua, Italy
| |
Collapse
|
33
|
Johnston L, Sawyer T, Ades A, Moussa A, Zenge J, Jung P, DeMeo S, Glass K, Singh N, Howlett A, Shults J, Barry J, Brei B, Foglia E, Nishisaki A. Impact of Physician Training Level on Neonatal Tracheal Intubation Success Rates and Adverse Events: A Report from National Emergency Airway Registry for Neonates (NEAR4NEOS). Neonatology 2021; 118:434-442. [PMID: 34111869 PMCID: PMC8376802 DOI: 10.1159/000516372] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 04/07/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Neonatal tracheal intubation (TI) outcomes have been assessed by role, but training level may impact TI success and safety. Effect of physician training level (PTL) on the first-attempt success, adverse TI-associated events (TIAEs), and oxygen desaturation was assessed. METHODS Prospective cohort study in 11 international NEAR4NEOS sites between October 2014 and December 2017. Primary TIs performed by pediatric/neonatal physicians were included. Univariable analysis evaluated association between PTL, patient/practice characteristics, and outcomes. Multivariable analysis with generalized estimating equation assessed for independent association between PTL and outcomes (first-attempt success, TIAEs, and oxygen desaturation ≥20%; attending as reference). RESULTS Of 2,608 primary TIs, 1,298 were first attempted by pediatric/neonatal physicians. PTL was associated with patient age, weight, comorbidities, TI indication, difficult airway history, premedication, and device. First-attempt success rate differed across PTL (resident 23%, fellow 53%, and attending 60%; p < 0.001). There was no statistically significant difference in TIAEs (resident 22%, fellow 20%, and attending 25%; p = 0.34). Desaturation occurred more frequently with residents (60%), compared to fellows and attendings (46 and 53%; p < 0.001). In multivariable analysis, adjusted odds ratio of the first-attempt success was 0.18 (95% CI: 0.11-0.30) for residents and 0.80 (95% CI: 0.51-1.24) for fellows. PTL was not independently associated with adjusted odds of TIAEs or severe oxygen desaturation. CONCLUSION Higher PTL was associated with increased first-attempt success but not TIAE/oxygen desaturation. Identifying strategies to decrease adverse events during neonatal TI remains critical.
Collapse
Affiliation(s)
- Lindsay Johnston
- Department of Pediatrics, Yale School of Medicine, New Haven, CT, USA
| | - Taylor Sawyer
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
| | - Anne Ades
- Department of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Ahmed Moussa
- Department of Pediatrics, CHU Sainte-Justine, University of Montreal, Montreal, Canada
| | - Jeanne Zenge
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Philipp Jung
- Department of Pediatrics, University Hospital Schleswig Holstein, Luebeck, Germany
| | - Stephen DeMeo
- Department of Pediatrics, WakeMed Health and Hospitals, Raleigh, NC, USA
| | - Kristen Glass
- Department of Pediatrics, Penn State College of Medicine, Hershey, PA, USA
| | - Neetu Singh
- Department of Pediatrics, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| | | | - Justine Shults
- Department of Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - James Barry
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Brianna Brei
- Department of Pediatrics, University of Nebraska Medical Center, Omaha, NE, USA
| | - Elizabeth Foglia
- Department of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Akira Nishisaki
- Department of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | | |
Collapse
|
34
|
Walter‐Nicolet E, Marchand‐Martin L, Guellec I, Biran V, Moktari M, Zana‐Taieb E, Magny J, Desfrère L, Waszak P, Boileau P, Chauvin G, Saint Blanquat L, Borrhomée S, Droutman S, Merhi M, Zupan V, Karoui L, Cimerman P, Carbajal R, Durrmeyer X. Premedication practices for neonatal tracheal intubation: Results from the EPIPPAIN 2 prospective cohort study and comparison with EPIPPAIN 1. PAEDIATRIC AND NEONATAL PAIN 2021; 3:46-58. [PMID: 35547594 PMCID: PMC8975199 DOI: 10.1002/pne2.12048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 02/17/2021] [Accepted: 03/03/2021] [Indexed: 11/25/2022]
Abstract
To describe the frequency and nature of premedication practices for neonatal tracheal intubation (TI) in 2011; to identify independent risk factors for the absence of premedication; to compare data with those from 2005 and to confront observed practices with current recommendations. Data concerning TI performed in neonates during the first 14 days of their admission to participating neonatal/pediatric intensive care units were prospectively collected at the bedside. This study was part of the Epidemiology of Procedural Pain in Neonates study (EPIPPAIN 2) conducted in 16 tertiary care units in the region of Paris, France, in 2011. Multivariate analysis was used to identify factors associated with premedication use and multilevel analysis to identify center effect. Results were compared with those of the EPIPPAIN 1 study, conducted in 2005 with a similar design, and to a current guidance for the clinician for this procedure. One hundred and twenty‐one intubations carried out in 121 patients were analyzed. The specific premedication rate was 47% and drugs used included mainly propofol (26%), sufentanil (24%), and ketamine (12%). Three factors were associated with the use of a specific premedication: nonemergent TI (Odds ratio (OR) [95% CI]: 5.3 [1.49‐20.80]), existence of a specific written protocol in the ward (OR [95% CI]:4.80 [2.12‐11.57]), and the absence of a nonspecific concurrent analgesia infusion before TI (OR [95% CI]: 3.41 [1.46‐8.45]). No center effect was observed. The specific premedication rate was lower than the 56% rate observed in 2005. The drugs used were more homogenous and consistent with the current recommendations than in 2005, especially in centers with a specific written protocol. Premedication use prior to neonatal TI was low, even for nonemergent procedures. Scientific consensus, implementation of international or national recommendations, and local written protocols are urgently needed to improve premedication practices for neonatal intubation.
Collapse
Affiliation(s)
- Elizabeth Walter‐Nicolet
- Medicine and Neonatal Intensive Care Unit Saint Joseph Hospital Paris France
- INSERM U1153, Epidemiology and Statistics Sorbonne Paris Cité Research Center Obstetrical, Perinatal and Pediatric Epidemiology Team Paris France
| | - Laetitia Marchand‐Martin
- INSERM U1153, Epidemiology and Statistics Sorbonne Paris Cité Research Center Obstetrical, Perinatal and Pediatric Epidemiology Team Paris France
| | - Isabelle Guellec
- INSERM U1153, Epidemiology and Statistics Sorbonne Paris Cité Research Center Obstetrical, Perinatal and Pediatric Epidemiology Team Paris France
- Paediatric and Neonatal Intensive Care Unit, Trousseau Hospital Assistance Publique – Hôpitaux de Paris Paris France
- Medicine Sorbonne University Paris France
| | - Valérie Biran
- Neonatal Intensive Care Unit Assistance Publique – Hôpitaux de Paris CHU Robert Debré University Paris Diderot, Sorbonne Paris Cité Paris France
- Inserm U1141 University Paris Diderot, Sorbonne Paris Cité Paris France
| | - Mostafa Moktari
- Pediatric and Neonatal Intensive Care Unit Bicêtre Hospital Assistance Publique – Hôpitaux de Paris Paris France
- Espace Ethique/Ile de France ‐ Saint‐Louis Hospital Assistance Publique ‐Hôpitaux de Paris Paris France
| | - Elodie Zana‐Taieb
- Port‐Royal Maternity Neonatal Intensive Care Unit Cochin‐Port Royal Hospital Assistance Publique‐Hôpitaux de Paris Paris France
| | - Jean‐François Magny
- Neonatal Intensive Care Unit Necker‐Enfants Maladies Hospital Assistance Publique – Hôpitaux de Paris Paris France
| | - Luc Desfrère
- Neonatal Intensive Care Unit Louis Mourier Hospital Assistance Publique – Hôpitaux de Paris Paris France
| | - Paul Waszak
- Medicine and Neonatal Intensive Care Unit Delafontaine Hospital Saint Denis France
| | - Pascal Boileau
- Neonatal Intensive Care Unit Centre Hospitalier Intercommunal Poissy‐Saint Germain Poissy France
- Inserm U1185 Université Paris Saclay Le Kremlin‐Bicêtre France
| | - Gilles Chauvin
- Neonatal Intensive Care Unit Argenteuil Hospital Argenteuil France
| | - Laure Saint Blanquat
- Pediatric and Neonatal Intensive Care Unit Necker‐enfants Malades Hospital Assistance Publique – Hôpitaux de Paris Paris France
| | | | - Stéphanie Droutman
- Pediatric and Neonatal Intensive Care Unit Centre Hospitalier Intercommunal André Grégoire Montreuil France
| | - Mona Merhi
- Neonatal Intensive Care Unit Centre Hospitalier Sud Francilien Corbeil‐Essonnes France
| | - Véronique Zupan
- Neonatal Intensive Care Unit Antoine Béclère Hospital Assistance Publique – Hôpitaux de Paris Clamart France
| | - Leila Karoui
- Neonatal Intensive Care Unit, Grand hôpital de l’Est francilien, site de Meaux Meaux France
| | - Patricia Cimerman
- Centre National de Ressources de lutte contre la Douleur, Trousseau Hospital Assistance Publique – Hôpitaux de Paris Paris France
| | - Ricardo Carbajal
- INSERM U1153, Epidemiology and Statistics Sorbonne Paris Cité Research Center Obstetrical, Perinatal and Pediatric Epidemiology Team Paris France
- Medicine Sorbonne University Paris France
- Paediatric Emergency Department, Trousseau Hospital Assistance Publique – Hôpitaux de Paris Paris France
| | - Xavier Durrmeyer
- INSERM U1153, Epidemiology and Statistics Sorbonne Paris Cité Research Center Obstetrical, Perinatal and Pediatric Epidemiology Team Paris France
- Neonatal Intensive Care Unit Centre Hospitalier Intercommunal de Créteil University Paris Est Créteil Créteil France
- Faculté de Médecine de Créteil IMRB, GRC CARMAS Université Paris Est Créteil Créteil France
| |
Collapse
|
35
|
Law JA, Duggan LV, Asselin M, Baker P, Crosby E, Downey A, Hung OR, Jones PM, Lemay F, Noppens R, Parotto M, Preston R, Sowers N, Sparrow K, Turkstra TP, Wong DT, Kovacs G. Canadian Airway Focus Group updated consensus-based recommendations for management of the difficult airway: part 1. Difficult airway management encountered in an unconscious patient. Can J Anaesth 2021; 68:1373-1404. [PMID: 34143394 PMCID: PMC8212585 DOI: 10.1007/s12630-021-02007-0] [Citation(s) in RCA: 56] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 03/11/2021] [Accepted: 03/14/2021] [Indexed: 02/08/2023] Open
Abstract
PURPOSE Since the last Canadian Airway Focus Group (CAFG) guidelines were published in 2013, the literature on airway management has expanded substantially. The CAFG therefore re-convened to examine this literature and update practice recommendations. This first of two articles addresses difficulty encountered with airway management in an unconscious patient. SOURCE Canadian Airway Focus Group members, including anesthesia, emergency medicine, and critical care physicians, were assigned topics to search. Searches were run in the Medline, EMBASE, Cochrane Central Register of Controlled Trials, and CINAHL databases. Results were presented to the group and discussed during video conferences every two weeks from April 2018 to July 2020. These CAFG recommendations are based on the best available published evidence. Where high-quality evidence was lacking, statements are based on group consensus. FINDINGS AND KEY RECOMMENDATIONS Most studies comparing video laryngoscopy (VL) with direct laryngoscopy indicate a higher first attempt and overall success rate with VL, and lower complication rates. Thus, resources allowing, the CAFG now recommends use of VL with appropriately selected blade type to facilitate all tracheal intubations. If a first attempt at tracheal intubation or supraglottic airway (SGA) placement is unsuccessful, further attempts can be made as long as patient ventilation and oxygenation is maintained. Nevertheless, total attempts should be limited (to three or fewer) before declaring failure and pausing to consider "exit strategy" options. For failed intubation, exit strategy options in the still-oxygenated patient include awakening (if feasible), temporizing with an SGA, a single further attempt at tracheal intubation using a different technique, or front-of-neck airway access (FONA). Failure of tracheal intubation, face-mask ventilation, and SGA ventilation together with current or imminent hypoxemia defines a "cannot ventilate, cannot oxygenate" emergency. Neuromuscular blockade should be confirmed or established, and a single final attempt at face-mask ventilation, SGA placement, or tracheal intubation with hyper-angulated blade VL can be made, if it had not already been attempted. If ventilation remains impossible, emergency FONA should occur without delay using a scalpel-bougie-tube technique (in the adult patient). The CAFG recommends all institutions designate an individual as "airway lead" to help institute difficult airway protocols, ensure adequate training and equipment, and help with airway-related quality reviews.
Collapse
Affiliation(s)
- J. Adam Law
- grid.55602.340000 0004 1936 8200Department of Anesthesia, Pain Management and Perioperative Medicine, QEII Health Sciences Centre, Dalhousie University, Halifax Infirmary Site, 1796 Summer Street, Room 5452, Halifax, NS B3H 3A7 Canada
| | - Laura V. Duggan
- grid.28046.380000 0001 2182 2255Department of Anesthesiology and Pain Medicine, The Ottawa Hospital Civic Campus, University of Ottawa, Room B307, 1053 Carling Avenue, Mail Stop 249, Ottawa, ON K1Y 4E9 Canada
| | - Mathieu Asselin
- grid.23856.3a0000 0004 1936 8390Département d’anesthésiologie et de soins intensifs, Université Laval, 2325 rue de l’Université, Québec, QC G1V 0A6 Canada ,grid.411081.d0000 0000 9471 1794Département d’anesthésie du CHU de Québec, Hôpital Enfant-Jésus, 1401 18e rue, Québec, QC G1J 1Z4 Canada
| | - Paul Baker
- grid.9654.e0000 0004 0372 3343Department of Anaesthesiology, Faculty of Medical and Health Science, University of Auckland, Private Bag 92019, Auckland, 1142 New Zealand
| | - Edward Crosby
- grid.28046.380000 0001 2182 2255Department of Anesthesiology and Pain Medicine, The Ottawa Hospital, University of Ottawa, Suite CCW1401, 501 Smyth Road, Ottawa, ON K1H 8L6 Canada
| | - Andrew Downey
- grid.1055.10000000403978434Department of Anaesthesia, Perioperative and Pain Medicine, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Orlando R. Hung
- grid.55602.340000 0004 1936 8200Department of Anesthesia, Pain Management and Perioperative Medicine, QEII Health Sciences Centre, Dalhousie University, 1796 Summer Street, Halifax, NS B3H 3A7 Canada
| | - Philip M. Jones
- grid.39381.300000 0004 1936 8884Department of Anesthesia & Perioperative Medicine, Department of Epidemiology & Biostatistics, Schulich School of Medicine & Dentistry, University of Western Ontario, LHSC- University Hospital, 339 Windermere Rd., London, ON N6A 5A5 Canada
| | - François Lemay
- grid.417661.30000 0001 2190 0479Département d’anesthésiologie, CHU de Québec – Université Laval, Hôtel-Dieu de Québec, 11, Côte du Palais, Québec, QC G1R 2J6 Canada
| | - Rudiger Noppens
- grid.39381.300000 0004 1936 8884Department of Anesthesia & Perioperative Medicine, Schulich School of Medicine & Dentistry, University of Western Ontario, LHSC- University Hospital, 339 Windermere Road, London, ON N6A 5A5 Canada
| | - Matteo Parotto
- grid.17063.330000 0001 2157 2938Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto General Hospital, Toronto, ON Canada ,grid.17063.330000 0001 2157 2938Interdepartmental Division of Critical Care Medicine, University of Toronto, EN 442 200 Elizabeth St, Toronto, ON M5G 2C4 Canada
| | - Roanne Preston
- grid.413264.60000 0000 9878 6515Department of Anesthesia, BC Women’s Hospital, 4500 Oak Street, Vancouver, BC V6H 3N1 Canada
| | - Nick Sowers
- grid.55602.340000 0004 1936 8200Department of Emergency Medicine, QEII Health Sciences Centre, Dalhousie University, 1796 Summer Street, Halifax, NS B3H 3A7 Canada
| | - Kathryn Sparrow
- grid.25055.370000 0000 9130 6822Discipline of Anesthesia, St. Clare’s Mercy Hospital, Memorial University of Newfoundland, 300 Prince Phillip Drive, St. John’s, NL A1B V6 Canada
| | - Timothy P. Turkstra
- grid.39381.300000 0004 1936 8884Department of Anesthesia & Perioperative Medicine, Schulich School of Medicine & Dentistry, University of Western Ontario, LHSC- University Hospital, 339 Windermere Road, London, ON N6A 5A5 Canada
| | - David T. Wong
- grid.17063.330000 0001 2157 2938Department of Anesthesia, Toronto Western Hospital, University Health Network, University of Toronto, 399, Bathurst St, Toronto, ON M5T2S8 Canada
| | - George Kovacs
- grid.55602.340000 0004 1936 8200Department of Emergency Medicine, QEII Health Sciences Centre, Dalhousie University, 1796 Summer Street, Halifax, NS B3H 3A7 Canada
| | | |
Collapse
|
36
|
Gray MM, Rumpel JA, Brei BK, Krick JA, Sawyer T, Glass K, DeMeo S, Barry J, Ades A, Napolitano N, Johnston L, Moussa A, Jung P, Quek BH, Mehrem AA, Zenge J, Shults J, Nadkarni V, Kim J, Singh N, Tisnic A, Foglia E, Nishisaki A. Associations of Stylet Use during Neonatal Intubation with Intubation Success, Adverse Events, and Severe Desaturation: A Report from NEAR4NEOS. Neonatology 2021; 118:470-478. [PMID: 33946064 PMCID: PMC8376756 DOI: 10.1159/000515872] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 03/12/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Intubations are frequently performed procedures in neonatal intensive care units (NICU) and delivery rooms (DR). Unsuccessful first attempts are common as are tracheal intubation-associated events (TIAEs) and severe desaturations. Stylets are often used during intubation, but their association with intubation outcomes is unclear. OBJECTIVE To compare intubation success, rate of relevant TIAEs, and severe desaturations in neonates intubated with and without stylets. METHODS Tracheal intubations of neonates in the NICU or DR from 16 centers between October 2014 and December 2018, performed by neonatology or pediatric providers, were collected from the NEAR4NEOs international registry. Primary oral intubations with a laryngoscope were included in the analysis. First-attempt success, the occurrence of relevant TIAEs, and severe oxygen desaturation (≥20% saturation drop from baseline) were compared between intubations performed with versus without a stylet. Logistic regression with generalized estimate equations was used to control for covariates and clustering by sites. RESULTS Out of 5,292 primary oral intubations, 3,877 (73%) utilized stylets. Stylet use varied considerably across the centers with a range between 0.5 and 100%. Stylet use was not associated with first-attempt intubation success, esophageal intubation, mainstem intubation, or severe desaturations after controlling for confounders. Patient size was associated with these outcomes and much more predictive of success. CONCLUSIONS Stylet use during neonatal intubation was not associated with higher first-attempt intubation success, fewer relevant TIAEs, or less severe desaturations. These data suggest that stylets can be used based on individual preference, but stylet use may not be associated with better intubation outcomes.
Collapse
Affiliation(s)
- Megan M Gray
- University of Washington School of Medicine, Seattle, Washington, USA
| | - Jennifer A Rumpel
- Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Research Institute, Little Rock, Arkansas, USA
| | - Brianna K Brei
- Department of Pediatrics, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | | | - Taylor Sawyer
- University of Washington School of Medicine, Seattle, Washington, USA
| | - Kristen Glass
- Penn State College of Medicine, Penn State Health, Hershey, Pennsylvania, USA
| | - Stephen DeMeo
- Division of Neonatology, WakeMed Health and Hospitals, Raleigh, North Carolina, USA
| | - James Barry
- University of Colorado School of Medicine, Department of Pediatrics, Section of Neonatology, Aurora, Colorado, USA
| | - Anne Ades
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | | | - Lindsay Johnston
- Yale University School of Medicine, Department of Pediatrics, New Haven, Connecticut, USA
| | - Ahmed Moussa
- Department of Pediatrics, University of Montreal, Montreal, Québec, Canada
| | - Phillip Jung
- Department of Pediatrics, Universitaetsklinikum Schleswig-Holstein, Campus Luebeck, Luebeck, Germany
| | - Bin Huey Quek
- Neonatology, KK Women's and Children's Hospital, Singapore, Singapore
| | - Ayman Abou Mehrem
- Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Jeanne Zenge
- Department of Pediatrics, Section of Neonatology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Justine Shults
- Children's Hospital of Philadelphia, Ambler, Pennsylvania, USA
| | - Vinay Nadkarni
- Department of Anesthesiology, Critical Care, and Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Jae Kim
- Perinatal Institute, Cincinnati, Ohio, USA
| | - Neetu Singh
- Pediatrics, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Alicia Tisnic
- Alberta Children's Hospital, Alberta, Alberta, Canada
| | - Elizabeth Foglia
- Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Akira Nishisaki
- Department of Anesthesiology, Critical Care, and Pediatrics, University of Pennsylvania School of Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | | |
Collapse
|
37
|
Tippmann S, Haan M, Winter J, Mühler AK, Schmitz K, Schönfeld M, Brado L, Mahmoudpour SH, Mildenberger E, Kidszun A. Adverse Events and Unsuccessful Intubation Attempts Are Frequent During Neonatal Nasotracheal Intubations. Front Pediatr 2021; 9:675238. [PMID: 34046376 PMCID: PMC8144442 DOI: 10.3389/fped.2021.675238] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 04/16/2021] [Indexed: 01/11/2023] Open
Abstract
Background: Intubation of neonates is difficult and hazardous. Factors associated with procedure-related adverse events and unsuccessful intubation attempts are insufficiently evaluated, especially during neonatal nasotracheal intubations. Objective: Aim of this study was to determine the frequency of tracheal intubation-associated events (TIAEs) during neonatal nasotracheal intubations and to identify factors associated with TIAEs and unsuccessful intubation attempts in our neonatal unit. Methods: This was a prospective, single-site, observational study from May 2017 to November 2019, performed at a tertiary care neonatal intensive care unit in a German academic teaching hospital. All endotracheal intubation encounters performed by the neonatal team were recorded. Results: Two hundred and fifty-eight consecutive intubation encounters in 197 patients were analyzed. One hundred and forty-eight (57.4%) intubation encounters were associated with at least one TIAE. Intubation inexperience (<10 intubation encounters) (OR = 2.15; 95% CI, 1.257-3.685) and equipment problems (OR = 3.43; 95% CI, 1.12-10.52) were predictive of TIAEs. Intubation at first attempt (OR = 0.10; 95% CI, 0.06-0.19) and videolaryngoscopy (OR = 0.47; 96% CI, 0.25-0.860) were predictive of intubation encounters without TIAEs. The first intubation attempt was commonly done by pediatric residents (67.8%). A median of two attempts were performed until successful intubation. Restricted laryngoscopic view (OR = 3.07; 95% CI, 2.08-4.53; Cormack-Lehane grade 2 vs. grade 1), intubation by pediatric residents when compared to neonatologists (OR = 1.74; 95% CI, 1.265-2.41) and support by less experienced neonatal nurses (OR = 1.60; 95% CI, 1.04-2.46) were associated with unsuccessful intubation attempts. Conclusions: In our unit, TIAEs and unsuccessful intubation attempts occurred frequently during neonatal nasotracheal intubations. To improve success rates, quality improvement und further research should target interprofessional education and training, equipment problems and videolaryngoscopy.
Collapse
Affiliation(s)
- Susanne Tippmann
- Division of Neonatology, Department of Pediatrics, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Martin Haan
- Division of Neonatology, Department of Pediatrics, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Julia Winter
- Division of Neonatology, Department of Pediatrics, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Ann-Kathrin Mühler
- Division of Neonatology, Department of Pediatrics, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Katharina Schmitz
- Division of Neonatology, Department of Pediatrics, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Mascha Schönfeld
- Division of Neonatology, Department of Pediatrics, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Luise Brado
- Division of Neonatology, Department of Pediatrics, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Seyed Hamidreza Mahmoudpour
- Division of Medical Biostatistics and Bioinformatics, Institute of Medical Biostatistics, Epidemiology and Informatics, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Eva Mildenberger
- Division of Neonatology, Department of Pediatrics, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - André Kidszun
- Division of Neonatology, Department of Pediatrics, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany.,Division of Neonatology, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| |
Collapse
|
38
|
Bhattacharjee I, Das A, Collin M, Aly H. Predicting outcomes of mechanically ventilated premature infants using respiratory severity score. J Matern Fetal Neonatal Med 2020; 35:4620-4627. [PMID: 33280479 DOI: 10.1080/14767058.2020.1858277] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Extremely low birth weight (ELBW) infants have significant morbidities and higher mortality. The major morbidities are bronchopulmonary dysplasia (BPD), intraventricular hemorrhage (IVH) and retinopathy of prematurity (ROP). Release of proinflammatory cytokines has been implicated in the development of systemic inflammation that contributes to BPD aND ROP. Also, cumulative oxygen exposure in the first 3 days of life and use of mechanical ventilation was associated with 3-fold increase in severe IVH. Therefore, early ventilation and oxygenation may contribute significantly to morbidities in ELBW infants. Respiratory severity score (RSS), a product of Mean airway pressure (MAP) and FiO2, is a steady-state noninvasive assessment tool useful in infants to monitor the severity of respiratory failure. We used RSS, in the first 3 days of life of ELBW infants, to predict neonatal morbidities and mortality. STUDY DESIGN In a single-center retrospective cohort study in an urban setting, convenience sampling of ELBW infants meeting the study criteria who were mechanically ventilated at birth for the first 3 days of life were included. Time-weighted average RSS was plotted on receiver-operating characteristic (ROC) curve in the first 3 days of life to predict outcomes. Sensitivity, specificity, positive predictive value, negative predictive value and likelihood ratios were calculated. RESULTS A total of 69 infants qualified for the study. RSS in the first 3 days significantly predicted the composite outcome of death, ROP, IVH or BPD with an area under the curve (AUC) of 0.82 (p < 0.001). Individually, RSS predicted death, severe ROP and IVH with an AUC of 0.86, 0.77 and 0.71 respectively; but did not predict severe BPD (AUC 0.61). RSS was more sensitive and specific than each of its component; FiO2 and MAP. Weighted RSS in the first 3 days had high-negative predictive value of 98.1% for death between 7 days and 36 weeks, 94.6% for ROP and 91.7% for IVH. CONCLUSIONS This study is the first to show that RSS in the first 3 days of life is a good predictor of composite neonatal outcomes: severe IVH, BPD, ROP, or mortality. Early RSS had a high positive predictive value for the composite outcome of morbidities/mortality and a high specificity for mortality, ROP, and IVH individually.
Collapse
Affiliation(s)
| | - Anirudha Das
- Department of Neonatology, Cleveland Clinic Children's Hospital, Cleveland, OH, USA
| | - Marc Collin
- Department of Neonatology, MetroHealth Medical Center, Cleveland, OH, USA
| | - Hany Aly
- Department of Neonatology, Cleveland Clinic Children's Hospital, Cleveland, OH, USA
| |
Collapse
|
39
|
Cummings JJ, Gerday E, Minton S, Katheria A, Albert G, Flores-Torres J, Famuyide M, Lampland A, Guthrie S, Kuehn D, Weitkamp JH, Fort P, Abu Jawdeh EG, Ryan RM, Martin GC, Swanson JR, Mulrooney N, Eyal F, Gerstmann D, Kumar P, Wilding GE, Egan EA. Aerosolized Calfactant for Newborns With Respiratory Distress: A Randomized Trial. Pediatrics 2020; 146:peds.2019-3967. [PMID: 33060258 DOI: 10.1542/peds.2019-3967] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/11/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Exogenous surfactants to treat respiratory distress syndrome (RDS) are approved for tracheal instillation only; this requires intubation, often followed by positive pressure ventilation to promote distribution. Aerosol delivery offers a safer alternative, but clinical studies have had mixed results. We hypothesized that efficient aerosolization of a surfactant with low viscosity, early in the course of RDS, could reduce the need for intubation and instillation of liquid surfactant. METHODS A prospective, multicenter, randomized, unblinded comparison trial of aerosolized calfactant (Infasurf) in newborns with signs of RDS that required noninvasive respiratory support. Calfactant was aerosolized by using a Solarys nebulizer modified with a pacifier adapter; 6 mL/kg (210 mg phospholipid/kg body weight) were delivered directly into the mouth. Infants in the aerosol group received up to 3 treatments, at least 4 hours apart. Infants in the control group received usual care, determined by providers. Infants were intubated and given instilled surfactant for persistent or worsening respiratory distress, at their providers' discretion. RESULTS Among 22 NICUs, 457 infants were enrolled; gestation 23 to 41 (median 33) weeks and birth weight 595 to 4802 (median 1960) grams. In total, 230 infants were randomly assigned to aerosol; 225 received 334 treatments, starting at a median of 5 hours. The rates of intubation for surfactant instillation were 26% in the aerosol group and 50% in the usual care group (P < .0001). Respiratory outcomes up to 28 days of age were no different. CONCLUSIONS In newborns with early, mild to moderate respiratory distress, aerosolized calfactant at a dose of 210 mg phospholipid/kg body weight reduced intubation and surfactant instillation by nearly one-half.
Collapse
Affiliation(s)
| | - Erick Gerday
- Utah Valley Regional Medical Center, Provo, Utah
| | | | - Anup Katheria
- Sharp Mary Birch Hospital for Women and Newborns, San Diego, California
| | | | | | - Mobolaji Famuyide
- Department of Pediatrics, University of Mississippi, Oxford, Mississippi
| | | | - Scott Guthrie
- Jackson-Madison County General Hospital, Jackson, Tennessee
| | - Devon Kuehn
- East Carolina University and Vidant Medical Center, Greenville, North Carolina
| | | | - Prem Fort
- Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | | | - Rita M Ryan
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina
| | | | | | | | - Fabien Eyal
- University of South Alabama Children's and Women's Hospital, Mobile, Alabama
| | | | - Praveen Kumar
- Order of St. Francis Children's Hospital of Illinois, Peoria, Illinois
| | - Greg E Wilding
- Department of Biostatistics, University at Buffalo, Buffalo, New York; and
| | | | | |
Collapse
|
40
|
Halling C, Raymond T, Brown LS, Ades A, Foglia EE, Allen E, Wyckoff MH. Neonatal delivery room CPR: An analysis of the Get with the Guidelines®-Resuscitation Registry. Resuscitation 2020; 158:236-242. [PMID: 33080368 DOI: 10.1016/j.resuscitation.2020.10.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 09/29/2020] [Accepted: 10/05/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND Cardiopulmonary resuscitation (CPR) in the delivery room (DR) after birth is rare. We hypothesized that factors related to maternal, delivery, infant and resuscitation event characteristics associated with outcomes could be identified. We also hypothesized there would be substantial variation from the Neonatal Resuscitation Program (NRP) algorithm. METHODS Retrospective review of all neonates receiving chest compressions in the DR from the AHA Get With The Guidelines-Resuscitation registry from 2001 to 2014. The primary outcome was return of spontaneous circulation (ROSC) in the DR. Secondary outcome was survival to hospital discharge. Descriptive statistics were used to characterize data. Odds ratios with confidence intervals were calculated as appropriate to compare survivors and non-survivors. RESULTS There were 1153 neonates who received chest compressions in the DR. ROSC was achieved in 968 (84%) newborns and 761 (66%) survived to hospital discharge. Fifty-one percent of the cohort received chest compressions without medications. Cardiac compressions were initiated within the first minute of life in 76% of the events, and prior to endotracheal intubation in 79% of the events. In univariate analysis, factors such as prematurity, number of endotracheal intubation attempts, increased time to first adrenaline dose, and CPR duration were associated with decreased odds of ROSC in the DR. Longer CPR duration was associated with decreased odds of ROSC in multivariate analysis. CONCLUSION In this cohort of infants receiving chest compressions following delivery, recognizable pre-birth risk factors as well as resuscitation interventions associated with increased and decreased odds of achieving ROSC were identified. Chest compressions were frequently initiated in the first minute of the event and often prior to endotracheal intubation. Further investigations should focus on methods to decrease time to critical resuscitation interventions, such as successful endotracheal intubation and administration of the first dose of adrenaline, in order to improve DR-CPR outcomes.
Collapse
Affiliation(s)
- Cecilie Halling
- Division of Neonatology, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH, USA.
| | - Tia Raymond
- Division of Cardiac Critical Care, Department of Pediatrics, Medical City Children's Hospital, Dallas, TX, USA
| | | | - Anne Ades
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, USA
| | - Elizabeth E Foglia
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, USA
| | - Emilie Allen
- Mountain View College, Nursing Faculty, Dallas, TX, USA
| | - Myra H Wyckoff
- Division of Neonatal Perinatal Medicine, Department of Pediatrics, University of Texas Southwestern, Dallas, TX, USA
| | | |
Collapse
|
41
|
Parodi A, De Angelis LC, Re M, Raffa S, Malova M, Rossi A, Severino M, Tortora D, Morana G, Calevo MG, Brisigotti MP, Buffelli F, Fulcheri E, Ramenghi LA. Placental Pathology Findings and the Risk of Intraventricular and Cerebellar Hemorrhage in Preterm Neonates. Front Neurol 2020; 11:761. [PMID: 32922347 PMCID: PMC7456995 DOI: 10.3389/fneur.2020.00761] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Accepted: 06/19/2020] [Indexed: 11/13/2022] Open
Abstract
Placental pathology as a predisposing factor to intraventricular hemorrhage remains a matter of debate, and its contribution to cerebellar hemorrhage development is still largely unexplored. Our study aimed to assess placental and perinatal risk factors for intraventricular and cerebellar hemorrhages in preterm infants. This retrospective cohort study included very low-birth weight infants born at the Gaslini Children's Hospital between January 2012 and October 2016 who underwent brain magnetic resonance with susceptibility-weighted imaging at term-equivalent age and whose placenta was analyzed according to the Amsterdam Placental Workshop Group Consensus Statement. Of the 286 neonates included, 68 (23.8%) had intraventricular hemorrhage (all grades) and 48 (16.8%) had a cerebellar hemorrhage (all grades). After correction for gestational age, chorioamnionitis involving the maternal side of the placenta was found to be an independent risk factor for developing intraventricular hemorrhage, whereas there was no association between maternal and fetal inflammatory response and cerebellar hemorrhage. Among perinatal factors, we found that intraventricular hemorrhage was significantly associated with cerebellar hemorrhage (odds ratio [OR], 8.14), mechanical ventilation within the first 72 h (OR, 2.67), and patent ductus arteriosus requiring treatment (OR, 2.6), whereas cesarean section emerged as a protective factor (OR, 0.26). Inotropic support within 72 h after birth (OR, 5.24) and intraventricular hemorrhage (OR, 6.38) were independent risk factors for cerebellar hemorrhage, whereas higher gestational age was a protective factor (OR, 0.76). Assessing placental pathology may help in understanding mechanisms leading to intraventricular hemorrhage, although its possible role in predicting cerebellar bleeding needs further evaluation.
Collapse
Affiliation(s)
- Alessandro Parodi
- Neonatal Intensive Care Unit, Department Mother and Child, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Laura Costanza De Angelis
- Neonatal Intensive Care Unit, Department Mother and Child, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Martina Re
- Neonatal Intensive Care Unit, Department Mother and Child, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Sarah Raffa
- Neonatal Intensive Care Unit, Department Mother and Child, IRCCS Istituto Giannina Gaslini, Genoa, Italy.,Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genoa, Genoa, Italy
| | - Mariya Malova
- Neonatal Intensive Care Unit, Department Mother and Child, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Andrea Rossi
- Neuroradiology Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy.,Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
| | | | - Domenico Tortora
- Neuroradiology Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Giovanni Morana
- Neuroradiology Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Maria Grazia Calevo
- Epidemiology and Biostatistics Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Maria Pia Brisigotti
- Gynaecologic and Fetal-Perinatal Pathology Centre, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Francesca Buffelli
- Gynaecologic and Fetal-Perinatal Pathology Centre, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Ezio Fulcheri
- Gynaecologic and Fetal-Perinatal Pathology Centre, IRCCS Istituto Giannina Gaslini, Genoa, Italy.,Division of Pathology, Department of Surgical Sciences (DISC), University of Genoa, Genoa, Italy
| | - Luca Antonio Ramenghi
- Neonatal Intensive Care Unit, Department Mother and Child, IRCCS Istituto Giannina Gaslini, Genoa, Italy.,Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genoa, Genoa, Italy
| |
Collapse
|
42
|
Gray MM, Edwards EM, Ehret DEY, Brei BK, Greenberg LT, Umoren RA, Ringer S, Horbar J. Resuscitation Opportunities for Fellows of Very Low Birth Weight Infants in the Vermont Oxford Network. Pediatrics 2020; 146:peds.2019-3641. [PMID: 32532791 DOI: 10.1542/peds.2019-3641] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/22/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Neonatal-perinatal medicine (NPM) fellowship programs must provide adequate delivery room (DR) experience to ensure that physicians can independently provide neonatal resuscitation to very low birth weight (VLBW) infants. The availability of learning opportunities is unknown. METHODS The number of VLBW (≤1500 g) and extremely low birth weight (ELBW) (<1000 g) deliveries, uses of continuous positive airway pressure, intubation, chest compressions, and epinephrine over 3 years at accredited civilian NPM fellowship program delivery hospitals were determined from the Vermont Oxford Network from 2012 to 2017. Using Poisson distributions, we estimated the expected probabilities of fellows experiencing a given number of cases over 3 years at each program. RESULTS Of the 94 NPM fellowships, 86 programs with 115 delivery hospitals and 62 699 VLBW deliveries (28 703 ELBW) were included. During a 3-year fellowship, the mean number of deliveries per fellow ranged from 14 to 214 (median: 60) for VLBWs and 7 to 107 (median: 27) for ELBWs. One-half of fellows were expected to see ≤23 ELBW deliveries and 52 VLBW deliveries, 24 instances of continuous positive airway pressure, 23 intubations, 2 instances of chest compressions, and 1 treatment with epinephrine. CONCLUSIONS The number of opportunities available to fellows for managing VLBW and ELBW infants in the DR is highly variable among programs. Fellows' exposure to key, high-risk DR procedures such as cardiopulmonary resuscitation is low at all programs. Fellowship programs should track fellow exposure to neonatal resuscitations in the DR and integrate supplemental learning opportunities. Given the low numbers, the number of new and existing NPM programs should be considered.
Collapse
Affiliation(s)
- Megan M Gray
- Division of Neonatology, Department of Pediatrics, School of Medicine, University of Washington and Seattle Children's Hospital, Seattle, Washington;
| | - Erika M Edwards
- Department of Pediatrics, The Robert Larner, M.D. College of Medicine and.,Vermont Oxford Network, Burlington, Vermont; and.,Department of Mathematics and Statistics, College of Engineering and Mathematical Sciences, University of Vermont, Burlington, Vermont
| | - Danielle E Y Ehret
- Department of Pediatrics, The Robert Larner, M.D. College of Medicine and.,Vermont Oxford Network, Burlington, Vermont; and
| | - Brianna K Brei
- Division of Neonatology, Department of Pediatrics, School of Medicine, University of Washington and Seattle Children's Hospital, Seattle, Washington
| | | | - Rachel A Umoren
- Division of Neonatology, Department of Pediatrics, School of Medicine, University of Washington and Seattle Children's Hospital, Seattle, Washington
| | - Steven Ringer
- Division of Neonatology, Department of Pediatrics, Children's Hospital at Dartmouth-Hitchcock and Department of Pediatrics, Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire
| | - Jeffrey Horbar
- Department of Pediatrics, The Robert Larner, M.D. College of Medicine and.,Vermont Oxford Network, Burlington, Vermont; and
| |
Collapse
|
43
|
Law BHY, Schmölzer GM. Analysis of visual attention and team communications during neonatal endotracheal intubations using eye-tracking: An observational study. Resuscitation 2020; 153:176-182. [PMID: 32580005 DOI: 10.1016/j.resuscitation.2020.06.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 06/08/2020] [Accepted: 06/10/2020] [Indexed: 01/06/2023]
Abstract
PURPOSE Eye-tracking can be used to analyse visual attention (VA) of health care providers during clinical tasks. No study has examined eye-tracking during neonatal endotracheal intubation. We aimed to examine VA and team communications during endotracheal intubation using eye-tracking in the Neonatal Intensive Care Unit. METHODS Twenty-seven video-recordings were obtained using eye-tracking glasses worn by intubators during endotracheal intubation of stable neonates. Videos were analysed to obtain i) intubation duration and success, ii) areas of interest (AOIs), iii) duration spent on each AOI, iv) types and frequency of gaze-shifts between AOIs, and v) monitor looking behaviour, and vi) team communications of vital signs and verbal medication orders. RESULTS Twenty-four videos were of acceptable quality and analysed. Median attempt duration was 44.7 s. Success rate was 79%. Overall, 50% of VA was directed at the infant, with 23% of VA directed at equipment. There were 415 gaze-shifts types and 0.55 gaze-shifts/sec. Intubators glanced at the monitor spontaneously and rarely reported vital signs afterwards. Language used to communicate vital signs and medication orders varied. CONCLUSION During neonatal intubations, 50% of VA was directed away from the infant. Team communications were non-standard. Eye-tracking can be used to analyse human performance during neonatal resuscitation.
Collapse
Affiliation(s)
- Brenda Hiu Yan Law
- Centre for the Studies of Asphyxia and Resuscitation, Royal Alexandra Hospital, Edmonton, Canada; Department of Pediatrics, University of Alberta, Edmonton, Canada.
| | - Georg M Schmölzer
- Centre for the Studies of Asphyxia and Resuscitation, Royal Alexandra Hospital, Edmonton, Canada; Department of Pediatrics, University of Alberta, Edmonton, Canada
| |
Collapse
|
44
|
Affiliation(s)
- Taylor Sawyer
- Department of Pediatrics, Division of Neonatology, and
| | - Kaalan Johnson
- Department of Otolaryngology, Division of Pediatric Otolaryngology-Head and Neck Surgery, University of Washington School of Medicine and Seattle Children's Hospital, Seattle, WA
| |
Collapse
|
45
|
Yeo KT, Thomas R, Chow SS, Bolisetty S, Haslam R, Tarnow-Mordi W, Lui K. Improving incidence trends of severe intraventricular haemorrhages in preterm infants <32 weeks gestation: a cohort study. Arch Dis Child Fetal Neonatal Ed 2020; 105:145-150. [PMID: 31201252 DOI: 10.1136/archdischild-2018-316664] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Revised: 05/08/2019] [Accepted: 05/14/2019] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To describe the trend and risk factors for severe intraventricular haemorrhage (IVH) among infants <32 weeks gestation. DESIGN Population-based cohort study. SETTING Australia and New Zealand. PATIENTS All preterm infants <32 weeks gestation in the Australian and New Zealand Neonatal Network (ANZNN) from 1995 to 2012. INTERVENTIONS Comparison of IVH incidence between 6-year epochs. MAIN OUTCOME MEASURES Overall IVH and severe IVH incidence. RESULTS A total of 60 068 infants were included, and overall survival to discharge increased from 89% to 93% over the three epochs. As the percentage of infants with IVH decreased from 23.6% to 21.3% and 21.4% (p<0.001) from epoch 1 to 3, respectively, fewer survivors had severe IVH (4.0%, 3.3% and 2.8%, respectively, p<0.001). Over time, there were fewer antenatal complications, higher antenatal steroid usage and more caesarean-section births. Fewer infants were intubated at birth, had low 5 min Apgar score, had sepsis or pneumothorax needing drainage. Adjusted for perinatal confounders, there was significant reduction in odds of severe IVH from epoch 1 to 3 (adjusted OR (AOR) 0.8, 95% CI 0.7 to 0.9). Factors associated with development of severe IVH include no antenatal steroids (AOR 1.7, 95% CI 1.5 to 1.9), male (AOR 1.3, 95% CI 1.2 to 1.4), 5 min Apgar score <7 (AOR 2.0, 95% CI 1.9 to 2.2), intubated at birth (AOR 2.0, 95% CI 1.8 to 2.2), extremely low gestational age (AOR 4.0, 95% CI 3.7 to 4.4), outborn (AOR 1.6, 95% CI 1.5 to 1.8) and vaginal delivery (AOR 1.4, 95% CI 1.3 to 1.6). CONCLUSIONS Along with increased survival among infants born <32 weeks gestation, the incidence of severe IVH has decreased over the 18 years, especially in the most recent period. This coincided with reduction in rates of risk factors for severe IVH development.
Collapse
Affiliation(s)
- Kee Thai Yeo
- Department of Newborn Care, Royal Hospital for Women, Randwick, New South Wales, Australia.,Department of Neonatology, KK Women's and Children's Hospital, Singapore
| | - Reji Thomas
- Department of Newborn Care, Royal Hospital for Women, Randwick, New South Wales, Australia.,Mount Gambier Hospital, Mount Gambier, South Australia, Australia
| | - Sharon Sw Chow
- National Perinatal Epidemiology and Statistics Unit, Centre for Big Data Research in Health, University of New South Wales, Sydney, New South Wales, Australia.,School of Women's & Children's Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Srinivas Bolisetty
- Department of Newborn Care, Royal Hospital for Women, Randwick, New South Wales, Australia.,School of Women's & Children's Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Ross Haslam
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - William Tarnow-Mordi
- National Health & Medical Research Council Trials Centre, University of Sydney, Sydney, New South Wales, Australia
| | - Kei Lui
- Department of Newborn Care, Royal Hospital for Women, Randwick, New South Wales, Australia.,School of Women's & Children's Health, University of New South Wales, Sydney, New South Wales, Australia
| | | |
Collapse
|
46
|
Nasef N, Rashed HM, Aly H. Practical aspects on the use of non-invasive respiratory support in preterm infants. Int J Pediatr Adolesc Med 2020; 7:19-25. [PMID: 32373698 PMCID: PMC7193067 DOI: 10.1016/j.ijpam.2020.02.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Preterm infants frequently present with respiratory insufficiency requiring respiratory assistance. Invasive mechanical ventilation has been associated with several short and long term complications. Therefore, the practice of early use of non-invasive ventilation has been adopted. Nasal CPAP proved efficacy as an initial therapy for preterm infants. Non-invasive positive pressure ventilation is an alternative used to mitigate CPAP failure in infants with apnea or increased work of breathing. High flow nasal cannula gained popularity primarily due to the ease of its use, despite multiple prominent trials that demonstrated its inferiority. Bi-level positive airway pressure and neurally adjusted non-invasive ventilatory are used in infants with apnea and increased work of breathing. The effectiveness of non invasive ventilation tools can be augmented by having a proper protocol for initiation, weaning, skin care, positioning, and developmental care during their application.
Collapse
Affiliation(s)
- Nehad Nasef
- Neonatal Intensive Care Unit, Mansora University Children's Hospital, Mansoura, Egypt.,Department of Pediatrics, Faculty of Medicine, University of Mansoura, Egypt
| | - Hend Me Rashed
- School of Medicine, University of Sheffield, Sheffield, United Kingdom
| | - Hany Aly
- Department of Neonatology, Cleveland Clinic Children's, Cleveland, OH, USA
| |
Collapse
|
47
|
Tippmann S, Kidszun A. Adequate analgesia and sedation should be given to neonates during non-emergency endotracheal intubation. Acta Paediatr 2020; 109:17-19. [PMID: 31452275 DOI: 10.1111/apa.14987] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 08/13/2019] [Accepted: 08/23/2019] [Indexed: 01/22/2023]
Affiliation(s)
- Susanne Tippmann
- Department of Neonatology, Medical Centre of the Johannes Gutenberg University, Mainz, Germany
| | - André Kidszun
- Department of Neonatology, Medical Centre of the Johannes Gutenberg University, Mainz, Germany
| |
Collapse
|
48
|
Alotaibi WSM, Alsaif NS, Ahmed IA, Mahmoud AF, Ali K, Hammad A, Aldibasi OS, Alsaif SA. Reduction of severe intraventricular hemorrhage, a tertiary single-center experience: incidence trends, associated risk factors, and hospital policy. Childs Nerv Syst 2020; 36:2971-2979. [PMID: 32367164 PMCID: PMC7649152 DOI: 10.1007/s00381-020-04621-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Accepted: 04/13/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To determine the incidence, trends, maternal and neonatal risk factors of severe intraventricular hemorrhage (IVH) among infants born 24-32 weeks and/or < 1500 g, and to evaluate the impact of changing of hospital policies and unit clinical practice on the IVH incidence. STUDY DESIGN Retrospective chart review of preterm infants with a gestational age (GA) of 24-326 weeks and/or weight of < 1500 g born at King Abdulaziz Medical City-Riyadh (KAMC-R), Saudi Arabia, from 2016 to 2018. Multivariate logistic regression model was constructed to determine the probability of developing severe IVH and identify associations with maternal and neonatal risk factors. RESULTS Among 640 infants, the overall incidence of severe IVH was 6.4% (41 infants), and its rate decreased significantly, from 9.4% in 2016 to 4.5% and 5% in 2017 and 2018 (p = 0.044). Multivariate analysis revealed that caesarian section delivery decreased the risk of severe IVH in GA group 24-27 weeks (p = 0.045). Furthermore use of inotropes (p = 0.0004) and surfactant (p = 0.0003) increased the risk of severe IVH. Despite increasing use of inotropes (p = 0.024), surfactant therapy (p = 0.034), and need for delivery room intubation (p = 0.015), there was a significant reduction in the incidence of severe IVH following the change in unit clinical practice and hospital policy (p = 0.007). CONCLUSION Cesarean section was associated with decreased all grades of IVH and severe IVH, while use of inotropes was associated with increased severe IVH. The changes in hospital and unit policy were correlated with decreased IVH during the study period.
Collapse
Affiliation(s)
| | - Nada S. Alsaif
- King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Ibrahim A. Ahmed
- King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia ,Neonatal Intensive Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Aly Farouk Mahmoud
- Neonatal Intensive Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Kamal Ali
- Neonatal Intensive Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Abdullah Hammad
- Medical Imaging Department, Pediatric Radiology, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Omar S. Aldibasi
- King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia ,Department of Bioinformatics and Biostatistics, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Saif A. Alsaif
- King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia ,Neonatal Intensive Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| |
Collapse
|
49
|
Abstract
Advances in neonatology have led to unprecedented improvements in neonatal survival such that those born as early as 22 weeks of gestation now have some chance of survival, and over 70% of those born at 24 weeks of gestation survive. Up to 50% of infants born extremely preterm develop poor outcomes involving long-term neurodevelopmental impairments affecting cognition and learning, or motor problems such as cerebral palsy. Poor outcomes arise because the preterm brain is vulnerable both to direct injury (by events such as intracerebral hemorrhage, infection, and/or hypoxia), or indirect injury due to disruption of normal development. This neonatal brain injury and/or dysmaturation is called "encephalopathy of prematurity". Current and future strategies to improve outcomes in this population include prevention of preterm birth, and pre-, peri-, and postnatal approaches to protect the developing brain. This review will describe mechanisms of preterm brain injury, and current and upcoming therapies in the antepartum and postnatal period to improve preterm encephalopathy.
Collapse
Affiliation(s)
- Pratik Parikh
- Department of Pediatrics, Division of Neonatology, University of Washington, Seattle, WA.
| | - Sandra E Juul
- Department of Pediatrics, Division of Neonatology, University of Washington, Seattle, WA.
| |
Collapse
|
50
|
Abstract
Fetal to neonatal transition after birth is a complex, well-coordinated process involving multiple organ systems. Any significant derangement in this process increases the risk of death and other adverse outcomes, underlying the importance of continuous monitoring to promptly detect and correct these derangements by effective resuscitative support. In recent years, there has been increasing efforts to move from subjective and discontinuous monitoring to more objective and continuous monitoring of different physiological parameters. Some of them like pulse oximetry for arterial oxygen saturation and electrocardiography for heart rate monitoring are now part of resuscitation guidelines whereas others like respiratory function monitoring, near infrared spectroscopy, or amplitude integrated electroencephalography are being evaluated. In this review, we describe some of the physiological parameters that can be monitored during delivery room emergencies and review the evidence for some of the monitoring technologies currently being evaluated.
Collapse
Affiliation(s)
- Deepak Jain
- University of Miami Miller School of Medicine, United States
| | | |
Collapse
|