Targeted neonatal echocardiography services: need for standardized training and quality assurance

OBJECTIVES

Targeted neonatal echocardiography refers to a focused assessment of myocardial performance and hemodynamics directed by a specific clinical question. It has become the standard of care in many parts of the world, but practice is variable, and there has been a lack of standardized training and evaluation to date. Targeted neonatal echocardiography was first introduced to Canada in 2006. The purpose of this study was to examine the characteristics of targeted neonatal echocardiography practice and training methods in Canadian neonatal intensive care units (NICUs).

METHODS

A total of 142 Canadian neonatologists were invited to participate in an online survey, which was conducted in September 2010. The survey consisted of questions related to the availability of targeted neonatal echocardiography, clinical indications, benefits and risks, and training methods.

RESULTS

The overall survey response rate was 65%. Forty-eight respondents (34%) indicated that targeted neonatal echocardiography was available in their units, and the program was introduced within the preceding 1 to 5 years. In centers where it was unavailable, lack of on-site echocardiography expertise was cited as the major barrier to implementation. The most common indications for targeted neonatal echocardiography included evaluation of a hemodynamically significant ductus arteriosus, systemic or pulmonary blood flow, and response to cardiovascular treatments. Only 27% of respondents, working in centers where targeted neonatal echocardiography existed, actually performed the studies themselves; most individuals completed 11 to 20 studies per month. Almost half of the respondents said that training was available in their institutions, but methods of training and evaluation were inconsistent. Eighty-seven percent of respondents reported no formalized process for assessment of ongoing competency after the initial training period.

CONCLUSIONS

Targeted neonatal echocardiography is becoming more widely available and is gaining acceptance in Canadian NICUs. Although training is provided in many institutions, the process is not well established, and formal evaluation is rarely performed. This study emphasizes the need for development of standards for formalized training, evaluation, and quality assurance.

2023 American Heart Association and American Academy of Pediatrics Focused Update on Neonatal Resuscitation: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

This 2023 focused update to the neonatal resuscitation guidelines is based on 4 systematic reviews recently completed under the direction of the International Liaison Committee on Resuscitation Neonatal Life Support Task Force. Systematic reviewers and content experts from this task force performed comprehensive reviews of the scientific literature on umbilical cord management in preterm, late preterm, and term newborn infants, and the optimal devices and interfaces used for administering positive-pressure ventilation during resuscitation of newborn infants. These recommendations provide new guidance on the use of intact umbilical cord milking, device selection for administering positive-pressure ventilation, and an additional primary interface for administering positive-pressure ventilation.

Tactile Stimulation in Newborn Infants With Inadequate Respiration at Birth: A Systematic Review

CONTEXT

For many years the International Liaison Committee on Resuscitation has recommended the use of tactile stimulation for initial management of infants born with inadequate respiratory effort at birth without systematically examining its effectiveness.

OBJECTIVE

Systematic review to compare the effectiveness of tactile stimulation with routine handling in newly born term and preterm infants.

DATA SOURCES

Medline, Embase, Cochrane CENTRAL, along with clinical trial registries.

STUDY SELECTION

Randomized and non-randomized studies were included based on predetermined criteria.

DATA EXTRACTION

Data were extracted independently by authors. Risk of Bias in Nonrandomized Studies of Interventions (ROBINS-I) was used to assess risk of bias in non-randomized studies. Grading of Recommendations, Assessment, Development and Evaluations (GRADE) was used to assess the certainty of evidence.

RESULTS

Among 2455 unique articles identified, 2 observational studies were eligible and qualitatively summarized. Because one of the studies was at critical risk of bias, only the other study including 243 preterm infants on continuous positive airway pressure with clinical indications for tactile stimulation was analyzed. It showed a reduction in tracheal intubation in infants receiving tactile stimulation compared with no tactile stimulation (12 of 164 vs 14 of 79, risk ratio of 0.41 [95% confidence interval 0.20 to 0.85]); however, the certainty of evidence was very low.

LIMITATIONS

The available data were limited and only from observational studies.

CONCLUSIONS

A potential benefit of tactile stimulation was identified but was limited by the very low certainty of evidence. More research is suggested to evaluate the effectiveness as well as the optimal type and duration of tactile stimulation.

Survey of practices in relation to chronic pulmonary hypertension in neonates in the Canadian Neonatal Network and the National Institute of Child Health and Human Development Neonatal Research Network

Current knowledge gaps pertaining to diagnosis and management of neonatal chronic pulmonary hypertension (cPH) may result in significant variability in clinical practice. The objective of the study is to understand cPH management practices in neonatal intensive care units affiliated with the Canadian Neonatal Network (CNN) and National Institute of Child Health and Human Development Neonatal Research Network (NRN). A 32-question survey seeking practice details for cPH evaluation, diagnostic criteria, conservative measures, pharmacotherapeutics, and follow-up was e-mailed to a designated physician at each center. Responses were described as frequency (percentage) and compared between CNN and NRN, where appropriate. Overall response rate was 67% (CNN 20/28 (71%), NRN 9/15 (60%)). While 8 (28%) centers had standardized management protocols, 17 (59%) routinely evaluate high-risk patients; moderate-severe chronic lung disease being the commonest indication. While interventricular septal flattening on echocardiography was the commonest listed diagnostic criterion, several adjunctive indices were also identified. Asymptomatic neonates with cPH were managed expectantly (routine care) in 50% of sites, and using various conservative measures in others. Pulmonary vasodilators were prescribed for symptomatic cases, with 60% of sites using them early (86% reporting any use). Seventy-five percent of sites use inhaled nitric oxide and sildenafil citrate as first- and second-line agents, respectively. Use of standard protocols, cardiac catheterization, and conservative measures for asymptomatic cases was more common in NRN units (p < 0.05). While there is relative homogeneity in patient identification and diagnostic criteria used for neonatal cPH, significant interunit inconsistencies still exists in routine evaluation, use of additional investigations, management of asymptomatic cases, frequency and type of conservative measures, and choice of pulmonary vasodilators.

Update for Canadian NRP providers: A case-based review

The International Liaison Committee on Resuscitation (ILCOR) Neonatal Task Force reviews available resuscitation science every 5 years and develops guidelines which are integrated into educational programs such as the Neonatal Resuscitation Program (NRP). The most recent ILCOR Neonatal Task Force consensus guidelines were published in October 2015. The Canadian Paediatric Society's NRP Steering Committee has reviewed ILCOR guidelines alongside the 7th edition (2016) NRP materials. Using a case-based approach, this practice point highlights the main changes relating to the delivery of NRP, within the Canadian context.

Management of bronchiolitis: current practices in Ireland

To establish current practice for hospital-based treatment of uncomplicated respiratory syncytial virus (RSV) infection in the Republic of Ireland. A questionnaire was sent to all consultant general paediatricians in the Republic of Ireland. The questionnaire described a clinical scenario and this was followed by a list of management questions. The scenario was of a 3-month-old infant with uncomplicated but moderately severe RSV infection requiring hospitalization. Seventy-three questionnaires were sent. 63/73 (86%) of the questionnaires were returned. With respect to management of this case almost all (61/63) the paediatricians felt that oxygen therapy was necessary (oxygen saturation described in the case was 90%). With respect to bronchodilator therapy, ipratropium bromide (38/63--60%) was chosen much more frequently than salbutamol (15/63--24%). Chest physiotherapy would have been prescribed by 8/63--13% of paediatricians. Oral steroids were infrequently chosen (1/63--2%) but nebulised steroids were selected in 7/63 (11%) cases. The routine use of RSV monoclonal antibody, palivizumab, for RSV prophylaxis was reported by 49% (31/63) of paediatricians. Prematurity with bronchopulmonary dysplasia was considered an indication for its administration by all of these but only 23% considered prematurity alone to be an indication. The management of infants with RSV bronchiolitis varies greatly among consultant paediatricians in Ireland. Evidence based guidelines may be of value in establishing a more uniform national treatment approach.

Modes of death in neonatal intensive care units

With the ever-increasing availability of aggressive medical treatment and technical support, neonatologists are offered an increasing ability to prolong life. While "end-of-life" decisions within NICUs have been studied internationally, there is limited data available for Ireland. Through the auspices of the Irish Faculty of Paediatrics 2002 Neonatal Mortality Ouestionnaire, decisions made around the time of death in Irish Neonatal Intensive Care Units were examined. The overall response rate to the questionnaire was 96% (n=25). One hundred and eighty seven deaths were reported for 2002. Information pertaining to the mode of death was available in 53% of cases. Seventy seven percent of those paediatricians who answered this question, reported either withdrawing or withholding treatment in babies thought to have a hopeless outcome, with the greatest proportion of these deaths occurring in premature infants (n=30) and babies with congenital defects (n=40).

2023 American Heart Association and American Academy of Pediatrics Focused Update on Neonatal Resuscitation: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

This 2023 focused update to the neonatal resuscitation guidelines is based on 4 systematic reviews recently completed under the direction of the International Liaison Committee on Resuscitation Neonatal Life Support Task Force. Systematic reviewers and content experts from this task force performed comprehensive reviews of the scientific literature on umbilical cord management in preterm, late preterm, and term newborn infants, and the optimal devices and interfaces used for administering positive-pressure ventilation during resuscitation of newborn infants. These recommendations provide new guidance on the use of intact umbilical cord milking, device selection for administering positive-pressure ventilation, and an additional primary interface for administering positive-pressure ventilation.

The effect of ethanol on cerebral glycogen levels in the chick embryo

Ethanol (10 to 50 micro-liters/egg) was injected into the albumen of the 13 day chick embryo. The control solution and ethanol carrier was bacteriostatic saline (0.1 ml). The KOH-alcohol-Anthrone colorimetric method was used for glycogen determination. Ethanol at 20 or 30 mul/egg lowered the mean cerebral glycogen (p less than 0.05). Higher dosages elevated cerebral glycogen over the same time period (p less than 0.05). The glycogen-depleting effect of 20 mul/egg and the glycogen increasing effect of 40 mul/egg were maintained through 168 hours of ethanol exposure (20 days incubation).

2024 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces

This is the eighth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations; a more comprehensive review was done in 2020. This latest summary addresses the most recent published resuscitation evidence reviewed by the International Liaison Committee on Resuscitation task force science experts. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the quality of the evidence, using Grading of Recommendations Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections. In addition, the task forces list priority knowledge gaps for further research.

Use of Simulation in Canadian Neonatal-Perinatal Medicine Training Programs

Introduction Simulation is used for the delivery of education and on occasion assessment. Before such a tool is used routinely in neonatal training programs across Canada, a need assessment is required to determine its current usage by accredited training programs. Our aim was to characterize the type of simulation modalities used and the perceived simulation-based training needs in Canadian neonatal-perinatal medicine (NPM) training programs. Methods A 22-item and 13-item online descriptive survey was sent to all NPM program directors and fellows in Canada, respectively. The survey was modeled on a previously validated tool by Johnston, et al. and responses were collected over 30 days. Results In total, eight (63%) program directors and 24 (28%) fellows completed the survey, with all respondents indicating that simulation is being used. Both lab-based and in situ simulations are occurring, with a range of simulation modalities employed to primarily teach resuscitation, procedural and communication skills. Fellows indicated that simulation should also be used to also teach other important topics, including disease-specific management, crisis resource management, and prevention of medical error. Five (63%) programs have faculty with formal simulation training and four (50%) programs have at least one faculty involved in simulation research. Conclusion Simulation is widely used in Canadian NPM training programs, with program directors and fellows identifying this as an important tool. Simulation can be used to teach a range of skills, but programs need to align their curriculum with both training objectives and learner needs. There is an opportunity for faculty development and increased simulation research.

When I say … active learning

If 'active learning' means 'anything other than passive', does it really have much meaning at all? The authors offer suggestions regarding how we might better conceptualize the term 'active learning' moving forward.

Predictors of successful trial off continuous positive airway pressure and high flow nasal cannula in preterm infants <30 weeks' gestation: A retrospective study

OBJECTIVES

To identify the predictors of successful first trial off nasal continuous positive airway pressure (nCPAP).

METHODS

A retrospective cohort study of infants ≤29 weeks' gestation who required nCPAP for >24 h was conducted. Logistic regression was used to detect predictors for successful trial off nCPAP. Statistical analysis was performed using the SAS software.

RESULTS

A total of 727 infants were included in the analysis. Infants who were successful in their first trial off nCPAP (n = 313) were of higher gestational age (GA) and birth weight (BW), as well as a higher proportion of female infants, compared with those who were not successful (p < 0.01). When stratified by GA, a negative correlation was noted between GA and postmenstrual age at successful trial off nCPAP or high flow nasal cannula (HFNC) (r = 0.45, p < 0.01). Logistic regression analysis showed that GA (odds ratio [OR] 1.13, 95% confidence interval [CI] [1.03-1.24], p = 0.01) and percentage of time spent with an oxygen saturation over 89% in the 24 h preceding the trial off nCPAP (OR 1.08, 95% CI [1.05-1.11], p = 0.00) were independent predictors for successful trial off nCPAP.

CONCLUSION

Successful trial off nCPAP or HFNC in preterm infants is significantly associated with higher GA, BW, female gender, and the specific oxygen saturation histogram in the preceding 24-h period.

2024 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces

This is the eighth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations; a more comprehensive review was done in 2020. This latest summary addresses the most recent published resuscitation evidence reviewed by the International Liaison Committee on Resuscitation task force science experts. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the quality of the evidence, using Grading of Recommendations Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections. In addition, the task forces list priority knowledge gaps for further research.

Accuracy of 7-8-9 Rule: Neonatal Endotracheal Intubation

DOI: http://dx.doi.org/10.3126/jnps.v32i1.5759  J. Nepal Paediatr. Soc. Vol.32(1) 2012 93