Impact of neonatal pain and opiate administration in animal models: A meta-analysis concerning pain threshold

BACKGROUND AND AIM

Neonatal intensive care treatment, including frequently performed painful procedures and administration of analgesic drugs, can have different effects on the neurodevelopment. This systematic review and meta-analysis aimed to investigate the influence of pain, opiate administration, and pre-emptive opiate administration on pain threshold in animal studies in rodents, which had a brain development corresponding to preterm and term infants.

METHODS

A systematic literature search of electronic data bases including CENTRAL (OVID), CINAHL (EBSCO), Embase.com, Medline (OVID), Web of Science, and PsycInfo (OVID) was conducted. A total of 42 studies examining the effect of pain (n = 38), opiate administration (n = 9), and opiate administration prior to a painful event (n = 5) in rodents were included in this analysis.

RESULTS

The results revealed that pain (g = 0.42, 95%CI 0.16-0.67, p = 0.001) increased pain threshold leading to hypoalgesia. Pre-emptive opiate administration had the opposite effect, lowering pain threshold, when compared to pain without prior treatment (g = -1.79, 95%CI -2.71-0.86, p = 0.0001). Differences were found in the meta regression for type of stimulus (thermal: g = 0.66, 95%CI 0.26-1.07, p = 0.001; vs. mechanical: g = 0.13, 95%CI -0.98-1.25, p = 0.81) and gestational age (b = -1.85, SE = 0.82, p = 0.027). In addition, meta regression indicated an association between higher pain thresholds and the amount of cumulative pain events (b = 0.06, SE = 0.03, p = 0.05) as well as severity of pain events (b = 0.94, SE = 0.28, p = 0.001).

CONCLUSION

Neonatal exposure to pain results in higher pain thresholds. However, caution is warranted in extrapolating these findings directly to premature infants. Further research is warranted to validate similar effects in clinical contexts and inform evidence-based practices in neonatal care.

[The unconscious child]

Acute disturbance of consciousness in a child is a potentially life-threatening condition. There are a variety of possible causes - traumatic, infectious, toxic, metabolic/endocrine, cardio-circulatory - to name a few. The history often provides important clues to narrow down the differential diagnoses. The recognition of reversible causes and a structured diagnostic process are life-saving in an emergency.

Impact of probe-induced abdominal compression on two-dimensional shear wave elastography measurement of split liver transplants in children

PURPOSE

To evaluate the effect of probe-induced abdominal compression of split liver transplants (SLT) in children on 2D-shear wave elastography (SWE) values.

MATERIALS AND METHODS

Data from 11 children (4.7 ± 4.8 years) who had undergone SLT and SWE were evaluated retrospectively. Elastograms were obtained with probes placed in an epigastric, midline position on the abdominal wall, with no and slight compression, using convex and linear transducers. For each identically positioned probe and condition, 12 serial elastograms were obtained and the SLT diameter was measured. Liver stiffness and degree of SLT compression were compared.

RESULTS

Slight probe pressure resulted in SLT compression, with a shorter distance between the cutis and the posterior margin of the liver transplant than in the measurement with no pressure (curved array, 5.0 ± 1.1 vs. 5.9 ± 1.3 cm, mean compression 15 %± 8 %; linear array, 4.7 ± 0.9 vs. 5.3 ± 1.0 cm, mean compression 12 %± 8 %; both p < 0.0001). The median liver stiffness was significantly greater with slight pressure than with no pressure (curved transducer, 13.38 ± 3.0 vs. 7.02 ± 1.7 kPa, p < 0.0001; linear transducer, 18.53 ± 7.1 vs. 9.03 ± 1.5 kPa, p = 0.0003).

CONCLUSION

Slight abdominal compression can significantly increase SWE values in children with left-lateral SLT. To obtain meaningful results and reduce operator dependency in free-hand examinations, probe pressure must be controlled carefully.

KEY POINTS

· Probe-induced compression can increase elastography values in split liver transplants in children. · In free-hand examination, probe pressure must be controlled carefully. · Pressure loading can be determined indirectly by the anteroposterior transplant diameter.

CITATION FORMAT

· Groth M, Fischer L, Herden U et al. Impact of probe-induced abdominal compression on two-dimensional shear wave elastography measurement of split liver transplants in children. Fortschr Röntgenstr 2023; 195: 905 - 912.

Perceived stress of mothers and fathers on two NICUs before and during the SARS-CoV-2 pandemic

Parents of very low birth weight (VLBW) infants in a neonatal intensive care unit experienced additional stress during the SARS-CoV-2 pandemic due to the related restrictions in hospital visiting policies. Our study aimed to compare parents' burdens before and during the pandemic. This survey included 121 parents of 76 VLBW infants in two European Level IV perinatal centers before and during the pandemic. We performed standardized parent questionnaires with mothers and fathers separately to evaluate their emotional stress and well-being. The pandemic worsened the emotional well-being of parents of VLBW infants, particularly of mothers. During the pandemic, mothers reported significantly higher state anxiety levels (48.9 vs. 42.9, p = 0.026) and hampered bonding with the child (6.3 vs. 5.2, 0 = 0.003) than before. In addition, mothers felt more personally restricted than fathers (6.1 vs. 5.2, p = 0.003). Fathers experienced lower levels of stress than mothers; they were equally burdened before and during the pandemic. Restrictions in visiting policies for families of VLBW infants during the SARS-CoV-2 pandemic have a significant negative impact on parental stress and should therefore be applied cautiously.

The impact of pandemic restrictive visiting policies on infant wellbeing in a NICU

BACKGROUND

Given the countrywide lockdown in the first pandemic period and the respective Hospital restrictive policies, we aimed to investigate if the SARS-COV-2 pandemic was associated to a reduced parental presence in the NICU and in which form this had an impact on infant wellbeing.

METHODS

Retrospective cohort study about altered NICUs parental presence (measured by number of visits and kangaroo care time) due to pandemic restrictive policies and its impact on infant wellbeing (measured through The Neonatal Pain Agitation and Sedation scale and nurses' descriptive documentation).

RESULTS

Presence of both parents at the same time was significantly lower during pandemic. Contrary, maternal presence only and total kangaroo-care time were higher within the pandemic (163.36 ± 94.07 vs 122.71 ± 64.03; p = 0.000). Lower NPASS values were documented during the lookdown (1.28 ± 1.7 vs 1.78 ± 2.2; p = 0.000).

CONCLUSION

Data collected through the pandemic confirm the importance of parental presence for infants' wellbeing in a NICU setting.

IMPACT

Parental support is an extremely important aspect for infants hospitalized in an intensive care unit. Their presence was limited in many NICUs worldwide during the SARS-COV-2 pandemic. This study confirm the importance of parental presence for infants' wellbeing also in a pandemic situation. Our results support a family-centered newborn individualized developmental care approach in the NICU.

Pilot study of an interprofessional pediatric mechanical ventilation educational initiative in two intensive care units

INTRODUCTION

Inappropriate ventilator settings, non-adherence to a lung-protective ventilation strategy, and inadequate patient monitoring during mechanical ventilation can potentially expose critically ill children to additional risks. We set out to improve team theoretical knowledge and practical skills regarding pediatric mechanical ventilation and to increase compliance with treatment goals.

METHODS

An educational initiative was conducted from August 2019 to July 2021 in a neonatal and pediatric intensive care unit of the University Children's Hospital, Hamburg-Eppendorf, Germany. We tested baseline theoretical knowledge using a multiple choice theory test (TT) and practical skills using a practical skill test (PST), consisting of four sequential Objective Structured Clinical Examinations of physicians and nurses. We then implemented an educational bundle that included video self-training, checklists, pocket cards, and reevaluated team performance. Ventilators and monitor settings were randomly checked in all ventilated patients. We used a process control chart and a mixed-effects model to analyze the primary outcome.

RESULTS

A total of 47 nurses and 20 physicians underwent assessment both before and after the implementation of the initiative using TT. Additionally, 34 nurses and 20 physicians were evaluated using the PST component of the initiative. The findings revealed a significant improvement in staff performance for both TT and PST (TT: 80% [confidence interval (CI): 77.2-82.9] vs. 86% [CI: 83.1-88.0]; PST: 73% [CI: 69.7-75.5] vs. 95% [CI: 93.8-97.1]). Additionally, there was a notable increase in self-confidence among participants, and compliance with mechanical ventilation treatment goals also saw a substantial rise, increasing from 87.8% to 94.5%.

DISCUSSION

Implementing a pediatric mechanical ventilation education bundle improved theoretical knowledge and practical skills among interprofessional pediatric intensive care staff and increased treatment goal compliance in ventilated children.

Pain and neurodevelopmental outcomes of infants born very preterm

AIM

To investigate the impact of the level of pain experienced by infants born preterm on neurodevelopmental outcomes during their stay in a neonatal intensive care unit.

METHOD

In this retrospective data analysis we included all surviving infants born preterm with a gestational age between 23 and 32 weeks from 2011 to 2015, who were assessed using the Neonatal Pain, Agitation, and Sedation Scale and examined at 1 year of age using the Bayley Scales of Infant Development. We excluded all infants who had suffered severe neurological morbidities and undergone surgical interventions.

RESULTS

A total of 196 infants born preterm were included in the analyses: 105 in the 'no pain group' and 91 in the 'pain group'. Significant differences between the groups were detected for both mental and motor development (p = 0.003, 95% confidence interval [CI] 2.23-10.92; p = 0.025, 95% CI 0.64-9.78). The results remained significant after controlling for other important medical conditions (p = 0.001, 95% CI -19.65 to -5.40; p = 0.010, 95% CI -16.18 to -2.29).

INTERPRETATION

Neonatal pain exposure was associated with altered neurodevelopmental outcomes of infants born very preterm at a corrected age of 12 months. This observation highlights the importance of adequate pain management to reduce the risk of poor neurodevelopmental outcomes in these vulnerable patients.

Recommendations for endotracheal tube insertion depths in children

BACKGROUND

Endotracheal tube (ETT) malposition is frequent in paediatric intubation. The current recommendations for ETT insertion depths are based on formulae that hold various limitations. This study aimed to develop age-based, weight-based and height-based curve charts and tables for ETT insertion depth recommendations in children.

METHODS

In this retrospective single-centre study, we determined the individual optimal ETT insertion depths in paediatric patients by evaluating postintubation radiographic images. Age-based, weight-based and height-based ETT insertion depth recommendations were developed using regression analysis. We compared the insertion depths predicted by the models with previously published formulae.

RESULTS

Intubations of 167 children (0-17.9 years) were analysed. Best-fit curves generated with logistic regression analysis revealed R2 values between 0.784 and 0.880. The insertion depths predicted by the models corresponded well with published age-based and height-based formulae. However, they demonstrated the unsuitability of weight-related linear formulae to predict ETT depth in children.

CONCLUSION

The recommendations developed in this study facilitate a fast and accurate determination of recommended ETT insertion depths in children. Our recommendations provide greater accuracy than previously published formulae and demonstrate that weight-related linear formulae are unsuitable for predicting ETT depth in children.

Recommendations for Peripherally Inserted Central Catheter Insertion Depths in Neonates

OBJECTIVE

Malposition of peripherally inserted central catheters (PICCs) is common. Recommendations for PICC insertion depths are scarce and comprise complex equations. This study aimed to develop diagrams and tables for the recommendation of PICC insertion depths in neonates based on anthropometric parameters.

STUDY DESIGN

In this retrospective single-center study, the individual optimal PICC insertion depths were correlated with body weight, length, and head circumference. Using linear regression analysis, line charts and tables for the recommendation of PICC insertion depth were generated and compared with previously published recommendations.

RESULT

PICC insertion depths of 204 infants (gestational age at PICC installation: 24.0-44.9 weeks) with 131 (64%) PICC in the upper extremities and 73 (36%) in the lower extremities were analyzed. Linear logistic regression models revealed R2 values between 0.387 and 0.884.

CONCLUSION

The charts and table developed in this study enable a fast and accurate determination of recommended PICC insertion depths in neonates.

Living in a box: Understanding acoustic parameters in the NICU environment

Background

In the last years, a significant body of scientific literature was dedicated to the noisy environment preterm-born infants experience during their admission to Neonatal Intensive Care Units (NICUs). Nonetheless, specific data on sound characteristics within and outside the incubator are missing. Therefore, this study aimed to shed light on noise level and sound characteristics within the incubator, considering the following domain: environmental noise, incubator handling, and respiratory support.

Methods

The study was performed at the Pediatric Simulation Center at the Medical University of Vienna. Evaluation of noise levels inside and outside the incubator was performed using current signal analysis libraries and toolboxes, and differences between dB_A and dB_SPL values for the same acoustic noises were investigated. Noise level results were furthermore classed within previously reported sound levels derived from a literature survey. In addition, sound characteristics were evaluated by means of more than 70 temporal, spectral, and modulatory timbre features.

Results

Our results show high noise levels related to various real-life situations within the NICU environment. Differences have been observed between A weighted (dB_A) and unweighted (dB_SPL) values for the same acoustic stimulus. Sonically, the incubator showed a dampening effect on sounds (less high frequency components, less brightness/sharpness, less roughness, and noisiness). However, a strong tonal booming component was noticeable, caused by the resonance inside the incubator cavity. Measurements and a numerical model identified a resonance of the incubator at 97 Hz and a reinforcement of the sound components in this range of up to 28 dB.

Conclusion

Sound characteristics, the strong low-frequency incubator resonance, and levels in dB_SPL should be at the forefront of both the development and promotion of incubators when helping to preserve the hearing of premature infants.

Therapeutic Management of COVID-19 in a Pediatric Patient with Neurodegenerative CLN2 Disease and ICV-Enzyme Replacement Therapy: A Case Report

The 12 years old male patient presented here suffers from neuronal ceroid lipofuscinoses 2 (CLN2) (MIM# 204500) and receives intracerebroventricular enzyme replacement therapy (ICV-ERT) every 14 days. After the emergence of the coronavirus disease 2019 (COVID-19) pandemic, routine care of children and adolescents with rare chronic diseases has become challenging. Although, in general, children do not develop severe COVID-19, when severe acute respiratory syndrome coronavirus 2 infection was detected by polymerase chain reaction-screening examination in our CLN2 patient before hospital admission for ICV-ERT, he was regarded to be at risk. Upon diagnosis, the patient developed respiratory deterioration symptoms and was admitted to our pediatric intensive care unit to receive oxygen, remdesivir, and steroids. As far as we know, this is the first CLN2 patient receiving intraventricular enzyme therapy with COVID-19 who required intensive care treatment and specific therapy.

Discriminant properties of the Behavioral Pain Scale for assessment of procedural pain-related distress in ventilated children

OBJECTIVES

Children hospitalized in a pediatric intensive care unit (PICU) are frequently exposed to distressing and painful medical procedures and interventions. There is a lack of clinical scales to measure procedural pain-related distress in ventilated children. The Behavioral Pain Scale (BPS) was initially developed to detect procedural pain in critically ill adults. This study aims to assess the BPS's discriminant properties for measuring procedural pain-related distress in ventilated pediatric patients incorporating two instruments validated for pediatric patients.

METHODS

This prospective exploratory study was performed with ventilated children admitted to the interdisciplinary 14-bed PICU of the University Children's Hospital, University Medical Center Hamburg-Eppendorf, Germany. The nurse in charge and an independent observer simultaneously assessed the patients using German versions of the BPS, the COMFORT-B scale (CBS), and the modified Face, Legs, Activity, Cry, Consolability (mFLACC) scale immediately before and during endotracheal suctioning.

RESULTS

We analyzed 170 parallel assessments in n=34 ventilated children. Patients were (mean ± SD) 9.5 ± 4.8 years old. Internal consistency for the BPS was excellent (α=0.93). We found a high rater agreement for all clinical scales (BPS: k=0.73, CBS: k=0.80, mFLACC: k=0.71). Strong correlations were identified between BPS and CBS (r=0.89) and BPS and mFLACC (r=0.79). The BPS cutoff values showed likewise excellent results (area under the curve CBS >16: 0.97; mFLACC >2: 0.91).

CONCLUSIONS

In our population of ventilated children, the BPS was well suited to detect procedural pain-related distress compared with two validated pain scales. Further extensive validation studies should follow to support our findings.

Versorgung und Reanimation des reifen Neugeborenen nach der Geburt

Die volle Reanimation eines Neugeborenen mit Beatmungen, Thoraxkompressionen und der Gabe von Medikamenten ist ein äußerst seltenes Ereignis, das selbst neonatologische Teams immer wieder vor Herausforderungen stellt. Gerade in diesen seltenen und häufig dramatischen Situationen ist schnelles und umsichtiges Handeln im Team gefragt. Dabei ist die effektivste und meist einzig notwendige Maßnahme für die erfolgreiche Versorgung eines nicht spontan atmenden Neugeborenen eine suffiziente Maskenbeatmung. Wird diese effektiv durchgeführt, sind beim Neugeborenen in den seltensten Fällen tatsächlich Thoraxkompressionen notwendig. Im März 2021 wurde vom European Resuscitation Council (ERC) die neue Leitlinie zur Reanimation von Neugeborenen publiziert. Auf Basis dieser Leitlinie beschreibt der vorliegende Beitrag detailliert den im Algorithmus der Versorgung und Reanimation von reifen Neugeborenen dargestellten Handlungsablauf. Er richtet sich damit einerseits insbesondere an NichtneonatologInnen, die für die Versorgung v. a. von reifen Neugeborenen nach der Geburt verantwortlich sind. Andererseits soll er auch jenen zur Unterstützung dienen, die medizinisches Personal in der Versorgung von lebensbedrohten Neugeborenen trainieren und den Algorithmus der Neugeborenenreanimation als didaktisches Konzept vermitteln.

The consequences of neonatal pain, stress and opiate administration in animal models: An extensive meta-analysis concerning neuronal cell death, motor and behavioral outcomes

This systematic review and meta-analysis aimed to investigate the association of neonatal exposure to pain, stress, opiate administration alone, as well as opiate administration prior to a painful procedure on neuronal cell death, motor, and behavioral outcomes in rodents. In total, 36 studies investigating the effect of pain (n = 18), stress (n = 15), opiate administration (n = 13), as well as opiate administration prior to a painful event (n = 7) in rodents were included in our meta-analysis. The results showed a large effect of pain (g = 1.37, 95% CI 1.00-1.74, p < .001) on neuronal cell death. Moreover, higher number of neonatal pain events were significantly associated with increased neuronal cell death, increased anxiety (b = -1.18, SE = 0.43, p = .006), and depressant-like behavior (b = 1.74, SE = 0.51, p = .027) in rodents. Both opiates and pain had no impact on motor function (g = 0.26, 95% CI 0.18-0.70, p = .248).

Thyroid function, thyroid antibodies and early postnatal development in neonates of mothers with thyroid disorders

BACKGROUND

Thyroid dysfunction during pregnancy is relatively common and can cause obstetric complications and significantly influence fetal development.

AIMS

We aimed to evaluate postnatal clinical and laboratory characteristics in the first days of life in infants born to mothers with a thyroid disorder.

STUDY DESIGN AND SUBJECTS

We conducted a retrospective single-center study with neonates born between January 2010 and May 2020. Early laboratory parameters and clinical findings in neonates of mothers with different maternal thyroid disorders were analysed.

RESULTS

We included 314 newborns of mothers with Hashimoto's thyroiditis, 171 with non-Hashimoto's hypothyroidism, 42 with Graves' disease, 12 with non-Graves' hyperthyroidism, and 190 neonates born to mothers without thyroid dysfunction. No demographic, clinical, and laboratory differences were observed between neonates from mothers with a thyroid disorder and healthy mothers. FT3 and fT4 correlated positively with gestational age (p < 0.001; p < 0.001) and negatively with maximum postnatal weight loss (p = 0.043; p < 0.001). High fT3 values were associated with lower maximum bilirubin levels (p = 0.020).

CONCLUSION

Despite an increased morbidity risk due to the transplacental exposure to maternal antibodies, most neonates born to mothers with thyroid disorders show normal postnatal development and thyroid function tests during the first days of life.

Estimation of Optimal Nasotracheal Tube Insertion Depth in Neonates Based on Fetal Biometric Measurements

BACKGROUND

Current recommendations for neonatal endotracheal tube (ETT) insertion depths require the knowledge of anthropometric measurements, which are not immediately available in the delivery room setting.

OBJECTIVE

This study aimed to develop recommendations based on prenatally available fetal biometric measurements.

METHODS

In this retrospective study, the optimal ETT depths for nasotracheal insertion were correlated with fetal demographic and biometric data. Using linear regression analysis, diagrams with best-fit lines and tables for the recommendation of ETT insertion depth based on the prenatally available data were generated.

RESULTS

We analyzed optimal nasotracheal ETT insertion depth in 98 neonates (gestational age range: 23.7-42.0 weeks). Linear regression analysis revealed high correlations between fetal measurements and the optimal ETT insertion depth (R2 = 0.712-0.837).

CONCLUSION

We provide recommendations for neonatal nasotracheal ETT insertion depths based on prenatally available data with the potential to facilitate rapid and accurate intubation of neonates.

Teaching fiberoptic-assisted tracheoscopy in very low birth weight infants: A randomized controlled simulator study

OBJECTIVE

We developed a fiberoptic-assisted tracheoscopy (FAST) method to avoid direct laryngoscopy during surfactant replacement therapy and compared two training approaches on a very low birth weight (VLBW) infant simulator.

DESIGN

This prospective randomized controlled study was conducted at the Department of Neonatology and Pediatric Intensive Care Medicine of the University Medical Center Hamburg-Eppendorf, Germany.

PARTICIPANTS

We recruited physicians, trainees, students, and nurses without prior experience in endoscopic techniques.

INTERVENTIONS

Participants were assigned randomly to a group that received instructions according to Peyton's Four-Step Approach and a control group that received standard bedside teaching only.

MAIN OUTCOME MEASURES

Primary endpoints were the total and the component times required to place the bronchoscope and the method success.

RESULTS

We recruited 186 participants. Compared with the control group, the Peyton group had a lower mean (±standard deviation) FAST completion time (33.2 ± 27.5 s vs. 79.5 ± 47.9 s, p < 0.001; d = 1.12) and a higher FAST success rate (95% vs. 84%, p = 0.036, V = 0.18).

CONCLUSION

After standardized training, the vast majority of novices completed FAST successfully. Peyton's four-step approach resulted in faster and more successful performance than standardized training.

Anatomic accuracy, physiologic characteristics, and fidelity of very low birth weight infant airway simulators

BACKGROUND

Medical simulation training requires realistic simulators with high fidelity. This prospective multi-center study investigated anatomic precision, physiologic characteristics, and fidelity of four commercially available very low birth weight infant simulators.

METHODS

We measured airway angles and distances in the simulators Premature AirwayPaul (SIMCharacters), Premature Anne (Laerdal Medical), Premie HAL S2209 (Gaumard), and Preterm Baby (Lifecast Body Simulation) using computer tomography and compared these to human cadavers of premature stillbirths. The simulators' physiologic characteristics were tested, and highly experienced experts rated their physical and functional fidelity.

RESULTS

The airway angles corresponded to those of the reference cadavers in three simulators. The nasal inlet to glottis distance and the mouth aperture to glottis distance were only accurate in one simulator. All simulators had airway resistances up to 20 times higher and compliances up to 19 times lower than published reference values. Fifty-six highly experienced experts gave three simulators (Premature AirwayPaul: 5.1 ± 1.0, Premature Anne 4.9 ± 1.1, Preterm Baby 5.0 ± 1.0) good overall ratings and one simulator (Premie HAL S2209: 2.8 ± 1.0) an unfavorable rating.

CONCLUSION

The simulator physiology deviated significantly from preterm infants' reference values concerning resistance and compliance, potentially promoting a wrong ventilation technique.

IMPACT

Very low birth weight infant simulators showed physiological properties far deviating from corresponding patient reference values. Only ventilation with very high peak pressure achieved tidal volumes in the simulators, as aimed at in very low birth weight infants, potentially promoting a wrong ventilation technique. Compared to very low birth weight infant cadavers, most tested simulators accurately reproduced the anatomic angular relationships, but their airway dimensions were relatively too large for the represented body. The more professional experience the experts had, the lower they rated the very low birth weight infant simulators.

Audio Feature Analysis for Acoustic Pain Detection in Term Newborns

INTRODUCTION

Crying newborns signal a need or discomfort as part of the innate communication system. Exposure to pain is related to infants' unfavorable neurodevelopmental outcomes. There is a tremendous need for more objective methods to assess neonatal pain. An audio analysis of acoustic utterances could provide specific information on the patient's pain level.

METHODS

We analyzed 67 videos of 33 term-born newborns recorded during a planned capillary blood sample, including the stimuli, non-noxious thermal stimulus, short noxious stimulus, and prolonged unpleasant stimulus, between December 2020 and March 2021. Two expert raters evaluated the infants' pain responses using the Neonatal Facial Coding System (NFCS). The mean values of 123 timbre features of the recorded audio data were analyzed by using specific toolboxes and libraries from the following programming environments: MIRtoolbox (MATLAB), MiningSuite (MATLAB), Essentia (Python), AudioCommons timbral models (Python), and Librosa (Python).

RESULTS

The NFCS values were significantly higher during the short noxious stimulus (p < 0.001) and prolonged unpleasant stimulus (p < 0.001) than during the non-noxious thermal stimulus, whereas NFCS values during the short noxious stimulus and prolonged unpleasant stimulus were similar (p = 0.79). Brightness, roughness, percussive energy, and attack times were identified as the features having the highest impact on the NFCS.

CONCLUSION

This hypothesis-generating study identified several salient acoustic features highly associated with pain responses in term newborns. Our analysis is an encouraging starting point for the targeted analysis of pain-specific acoustic features of neonatal cries and vocalizations from the perspective of real-time acoustic processing.

Recommendations for nasotracheal tube insertion depths in neonates

BACKGROUND

Endotracheal tube (ETT) malposition is common in neonatal intubation. Recommendations for ETT insertion depths predominantly address orotracheal intubation. The aim of this study was to develop gestational age-, weight-, and length-based curve charts and tables for nasotracheal ETT insertion depth recommendations in neonates.

METHOD

In this retrospective single-center study, the individual optimal ETT insertion depths in neonates were determined by evaluating postintubation radiographic images. Gestational age-, weight-, and length-based best-fit curves and tables were generated using regression analysis to calculate related ETT insertion depths. The insertion depths predicted by the models were compared with previously published recommendations.

RESULTS

We analyzed intubations of 178 neonates (gestational age range at intubation: 23.7-43.0 weeks). Applying sigmoidal logistic regression models, curves, and tables revealed R ² values between 0.766 and 0.837. The insertion depths predicted by the models revealed certain deviations when compared with four previously published recommendations for nasotracheal ETT depth estimation in neonates.

CONCLUSION

The charts and tables developed in this study enable a fast and accurate determination of recommended nasotracheal ETT insertion depths in neonates.

Improved Less Invasive Surfactant Administration Success in Preterm Infants after Procedure Standardization

Less invasive surfactant administration (LISA) has been introduced at our tertiary Level IV perinatal center since 2016 with an unsatisfactory success rate, which we attributed to an inconsistent, non-standardized approach and ambiguous patient inclusion criteria. This study aimed to improve the LISA success rate to at least 75% within 12 months by implementing a highly standardized LISA approach combined with team training. The Plan Do Study Act method of quality improvement was used for this initiative. Baseline assessment included a review of patient medical records 12 months before the intervention regarding patient characteristics, method success rate, respiratory, and adverse outcomes. A multi-professional team developed a standardized LISA approach and a training program including an educational film, checklists, pocket cards, and team briefings. Twenty-one preterm infants received LISA before and 24 after the intervention. The mean LISA success rate improved from 62% before the intervention to 92% (p = 0.029) after the intervention. Implementing a highly standardized LISA approach and multi-professional team training significantly improved the methods’ success rate.

Iatrogenic Blood Loss in Very Low Birth Weight Infants and Transfusion of Packed Red Blood Cells in a Tertiary Care Neonatal Intensive Care Unit

An adequate blood volume is important for neonatal adaptation. The study objective was to quantify the cumulative iatrogenic blood loss in very low birth weight (VLBW) infants by blood sampling and the necessity of packed red cell transfusions from birth to discharge from the hospital. In total, 132 consecutive VLBW infants were treated in 2019 and 2020 with a median birth weight of 1180 g (range 370–1495 g) and a median length of stay of 54 days (range 0–154 days) were included. During the initial four weeks of life, the median absolute amount of blood sampling was 16.5 mL (IQR 12.3–21.1 mL), sampling volume was different with 14.0 mL (IQR 12.1–16.2 mL) for non-transfused infants and 21.6 mL (IQR 17.5–29.4 mL) for transfused infants. During the entire length of stay, 31.8% of the patients had at least one transfusion. In a generalized logistic regression model, the cumulative amount of blood sampling (p < 0.01) and lower hematocrit at birth (p = 0.02) were independent predictors for the necessity of blood transfusion. Therefore, optimized patient blood management in VLBW neonates should include sparse blood sampling to avoid iatrogenic blood loss.

Impact of Propofol Bolus Administration on the Nociceptive Flexion Reflex Threshold and Bispectral Index in Children—A Case Series

We analyzed the impact of propofol administration during continuous sedation and analgesia on the nociceptive flexion reflex threshold (NFRT) and Bispectral Index (BIS) in ventilated children. We examined patients who received propofol before planned endotracheal suctioning. Patients were clinically assessed using the modified Face, Legs, Activity, Cry, Consolability (mFLACC) scale and COMFORT-B (Comfort Behavior) scale. We continuously recorded the NFRT and BIS. We recorded 23 propofol administrations in eight patients with an average age of 8.6 ± 3.5 years. The median (minimum-maximum) scores for the mFLACC scale and COMFORT-B scale were 0 (0–5) and 6 (6–17), respectively, before the bolus. The administration of a weight-adjusted propofol bolus of 1.03 ± 0.31 mg/kg resulted in an increase in NFRT and burst-suppression ratio; BIS and electromyogram values decreased. Changes from baseline (95% CI) after propofol bolus administration were BIS −23.9 (−30.8 to −17.1), EMG -10.5 dB (−13.3 to −7.7), SR 14.8 % (5.6 to 24.0) and NFRT 13.6 mA (5.5 to 21.7). Further studies are needed to determine whether sedated children may benefit from objective pain and sedation monitoring with BIS and NFRT.

[Effects of Obstetric Analgesia with Systemic Opioids on the Newborn - A Review]

INTRODUCTION

Three-quarters of all women receive analgesia during labor. There are regional and systemic analgesia procedures available. In this review, we investigate the impact of obstetric analgesia using systemic opioids on neonatal outcomes.

METHODS

We searched the PubMed and Cochrane Library databases using the following search terms: "meptazinol", "meptide", "analgesia", "painkiller", "pain reliever", "obstetrics", "labor", "labour", "delivery", "neonate", "newborn", "child", "baby", "infant", "fetus", "fetal", "opioid" and "opiate" as well as performed an additional MeSH Terms search in PubMed.

RESULTS

Of 355 potentially relevant studies, we included 23 studies in this review. The studies varied widely in quality, sample size, and outcome criteria. Neonatal outcome was often only a secondary endpoint. Rarely were significant differences related to neonatal outcome reported between the different systemic opioids or compared with control groups. Twelve studies compared neonatal APGAR scores between treatment groups, with ten (83%) of these studies showing no differences.

DISCUSSION/OUTLOOK

In summary, we assess the evidence as limited and ambiguous as to whether systemic obstetric opioid therapy negatively affects the newborn. Studies regarding the long-term outcome of the newborns are lacking. A statement regarding the necessity of postnatal monitoring of newborns after maternal obstetric opioid therapy cannot be concluded. Further studies, ideally with a prospective study design and control group, should be considered.

Long-term impact of systematic pain and sedation management on cognitive, motor, and behavioral outcomes of extremely preterm infants at preschool age

BACKGROUND

Providing optimal pain relief is a challenging task when caring for premature infants. The aim of this study was to compare the long-term cognitive, motor, and behavioral outcomes of preterm infants before and after the implementation of a pain and sedation protocol. In addition, we investigated whether the increased opiate administration resulting after the implementation process had an impact on these outcomes.

METHODS

Cognitive outcomes were evaluated using the Kaufman Assessment Battery for Children (KABC), neuromotor examinations were based on Amiel-Tison, and behavioral outcomes were assessed using the parent-reported Child Behavior Checklist (CBCL).

RESULTS

One hundred extremely preterm infants were included in the study (control group, n = 53; intervention group, n = 47). No significant differences were found in cognitive and motor outcomes at preschool age. However, every increase in the cumulative opiate exposure for each 100 mg/kg was weakly significantly associated with a higher risk for autism spectrum features (adjusted odds ratio (aOR) = 1.822, 95% confidence interval (CI) [1.231-2.697]; P = 0.03) and withdrawn behavior (aOR = 1.822, 95% CI [1.231-2.697]; P = 0.03) at preschool age.

CONCLUSION

Increased neonatal cumulative opiate exposure did not alter cognitive and motor outcomes but may represent a risk factor for autism spectrum and withdrawn behavior at preschool age.

IMPACT

The implementation of a protocol for the management of pain and sedation in preterm infants resulted in increased cumulative opiate exposure. Our study adds further evidence that increased neonatal opiate exposure did  not alter cognitive and motor outcomes but may yield a potential risk factor for autism spectrum disorders and withdrawn behavior at preschool age. A vigilant use of opiates is recommended. Further studies are needed looking for novel pain management strategies and drugs providing optimal pain relief with minimal neurotoxicity.

Whole-Exome Sequencing in Critically Ill Neonates and Infants: Diagnostic Yield and Predictability of Monogenic Diagnosis

INTRODUCTION

Monogenic diseases play an important role in critically ill neonates and infants treated in the intensive care unit. This study aimed to determine the diagnostic yield of whole-exome sequencing (WES) for monogenic diseases and identify phenotypes more likely associated with a genetic etiology.

METHODS

From March 2017 to 2020, a comprehensive diagnostic workup including WES in a single academic center was performed in 61 unrelated, critically ill neonates and infants with an unknown underlying disease within the first year of life. We conducted 59 trio-WES, 1 duo-WES, and 1 single-WES analyses. Symptoms were classified according to the Human Phenotype Ontology.

RESULTS

The overall molecular genetic diagnostic rate within our cohort was 46% (28/61) and 50% (15/30) in the subgroup of preterm neonates. Identifying the genetic cause of disease facilitates individualized management in the majority of patients. A positive or negative predictive power of specific clinical features for a genetic diagnosis could not be observed.

CONCLUSION

WES is a powerful noninvasive diagnostic tool in critically ill neonates and infants with a high diagnostic rate. We recommend initiating WES as early as possible due to the impact on management and family counseling. Recommendations regarding the clinical utility of WES in critically ill neonates and infants should not be based on the phenotype alone. Here, we present a clinical workflow for the application of WES for critically ill neonates and infants in an interdisciplinary setting.

Intravesical monitoring of intra-abdominal pressure after renal transplantation in children: A safety and feasibility study

IAH after RTX can threaten graft viability. This study aimed to assess the feasibility and safety of longitudinal IAP measurements as an IAH screening method in children after RTX. A cohort of eight children with a mean ± SD [range] age 9.6 ± 6.2 [2-17] years who underwent RTX and 18 control patients were evaluated between May 2017 and February 2018. We compared longitudinal IAP measurements using a Foley manometer to other clinical monitoring data. In total, 29 IAP measurements were performed in RTX patients and 121 in controls. The mean post-operative IAP was 7.4 ± 4.3 [1-16] mm Hg following RTX and 8.1 ± 3.7 [1-19] mm Hg in controls. We noted IAH in 9 (31%) of 29 IAP measurements after RTX and in 41 (34%) of 121 IAP measurements in controls. No graft dysfunction occurred in RTX patients despite elevated IAP values. The mean ± SD [range] time expenditure for IAP measurement was 2.1 ± 0.4 [0.6-3.2] minutes. No severe complications occurred during the IAP measurements. Analysis of longitudinal IAP measurements demonstrated that IAP measurement is safe and feasible in children recovering from renal transplantation in the PICU.

From structural modalities in perinatal medicine to the frequency of preterm birth

Preterm birth is a global health problem that affects 11% of all live births: it remains a significant cause of death and an important cause of long-term loss of human potential among survivors all around the world. In the last decade, many developed countries have seen an increase in the rate of infants born preterm. Various theoretical and practical concepts have been discussed that aim to optimize the perinatal care of preterm infants and their mothers. These include the definition of hospitals with different levels of care, the regionalization of care, the creation of large care units with high case numbers, and a high level of expertise. This review article focuses on the connection between health care structures and different aspects of preterm birth. Furthermore, this review article highlights the fact that preterm birth is a heterogeneous syndrome with many underlying pathologies and that the causality for a large number of cases remains unexplained. There is still a significant knowledge gap concerning the actual drivers of spontaneous preterm birth, and future research particularly in parturition immunology as well as genetics of prematurity will be essential to identify new targets for therapy.

A prospective observational trial evaluating factors predictive of accurate endotracheal tube positioning in neonates and small infants

BACKGROUND

There is a high incidence of endotracheal tube malposition in neonates and small infants. Yet, verification of accurate endotracheal tube location via radiographic imaging involves radiation exposure.

AIMS

This study aimed to identify demographic and clinical parameters associated with accurate endotracheal tube positioning.

METHODS

We conducted a prospective single-center study with term and preterm neonates and small infants between January 2018 and November 2019. We investigated correlations between ten variables and accurate endotracheal tube position.

RESULTS

One hundred and sixty eight nasal intubations in 139 patients (weight 390-5000 g) were analyzed. An accurate tube position was confirmed by radiographic imaging in 71.4% of the intubations. The endotracheal tube was high in 8.3% and low in 20.2% of the cases. Male gender was the only variable that significantly correlated with an accurate endotracheal tube position (OR 2.5; 95% CI: 1.3, 5.0; P = .010).

CONCLUSION

So far, no parameter has proven to be able to predict accurate endotracheal tube position in neonates reliably. These findings emphasize the indispensability of postintubation imaging in neonates and small infants.

[How well are patients informed on the websites of German university breast centres about the possibilities of breast reconstruction?]

INTRODUCTION

In recent decades, the internet has become one of the most important sources of information for patients. How substantial are the possibilities to find out about breast reconstruction on the homepages of university hospitals in Germany? Is there information about plastic surgery with its spectrum of modern reconstructive possibilities?

METHODS

A total of 35 homepages of university breast centres in Germany was analysed for the indication of cooperation with a plastic surgeon or a department for plastic surgery and their links, with information on reconstructive possibilities such as implant reconstruction, autologous soft tissue reconstruction with pedicled and free flaps as well as lipofilling.

RESULTS

A plastic surgeon or a cooperating department is mentioned on 49 % of the homepages. Of those homepages, 20 % contain a direct link. 91 % of the homepages describe the possibility of breast reconstruction in general, 80 % of the websites the use of autologous tissue. In 51 % of the cases, a free tissue transfer is mentioned, whereas only 23 % describe the procedures like DIEP flap, TMG, or I-GAP in more detail. Only two centres use detailed illustrations. Six websites (17 %) describe reconstruction by pedicled TRAM flap only. Breast reconstruction with a silicone implant is mentioned on 71 % of the websites. The possibility of lipofilling is discussed in 31 %.

DISCUSSION

About half of the websites of university breast centres do not show any cooperation with a plastic surgeon. There are significant gaps in the information on free tissue transfer for breast reconstruction.

Indoor Climate and Air Quality in a Neonatal Intensive Care Unit

INTRODUCTION AND OBJECTIVE

The skin and respiratory system of premature neonates are in permanent contact with indoor room air. We longitudinally analyzed the room air climate and quality in neonatal intensive care inside and outside an incubator.

METHODS

Sampling was performed in 2 patient rooms and inside a neonatal incubator (Caleo, Draeger Medical, Lübeck, Germany) over 6 weeks with 5-min resolution resulting in 12,090 samples (U-Monitor, U-Earth Biotech, London, UK). Temperature, humidity, and air pollutants, including particulate matter (<1 μm [PM1] and <2.5 μm [PM2.5]), volatile organic compounds (VOC), and odorous gases (OG), were recorded. Room air parameters were analyzed using time series analysis. A linear regression model was used to check for statistically significant linear trends. Statistical analysis was performed using decompensation of time series analysis and spectral analysis by fast Fourier transformation.

RESULTS

The indoor climate target values of the ward's central ventilation system for temperature and humidity were not always met. Room air parameters (PM, VOC, and OG) showed significant daytime-dependent fluctuations with different oscillation frequencies per day. The daily mean (first quartile - third quartile) concentrations of PM2.5 were significantly higher inside the incubator compared to the surrounding ambient air (2,158 [1,948-2,298] pcs/L vs. 2,018 [1,852-2,058] pcs/L; p < 0.001). OG were significantly lower inside the incubator compared to ambient air. VOC levels inside the incubator were substantially higher during the first 5 days of the observation period compared to VOC levels in the surrounding ambient air.

CONCLUSIONS

The indoor climate of neonatal intensive care units should be monitored in real time to detect deviations from target parameters quickly. In our neonatal intensive care unit, indoor air quality fluctuated significantly depending on the time of day. We highly suspect that air pollutants are carried into the direct patient environment by visitors and medical staff. The incubator does not protect against PM and VOC exposure but reduces exposure to OG. Cleaning procedures may lead to substantially higher concentrations of VOC inside the incubator and may represent a potentially harmful factor for premature infants.

Pain and Sedation Scales for Neonatal and Pediatric Patients in a Preverbal Stage of Development: A Systematic Review

IMPORTANCE

Because children in a preverbal stage of development are unable to voice their feelings, they completely depend on their caregiving team for the interpretation and management of their pain and discomfort. Thus, accurately validated scales to assess pain and sedation levels are crucial.

OBJECTIVE

To provide clinicians a complete overview on the validity and reliability of the existing pain and sedation scales for different target populations (preterm infants, term infants, and toddlers) and in different clinical contexts.

EVIDENCE REVIEW

BIOSIS Previews, Cumulative Index to Nursing and Allied Health Literature, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Embase, MEDLINE, PsycCRITIQUES, PsycINFO, PSYNDEXplus Literature and Audiovisual Media, and PSYNDEXplus Tests were the databases screened from their inception to August 2018. All studies examining the validity or reliability of a given pain or sedation scale for patients in a preverbal stage of development were included in this systematic review. Those scales that were tested for at least construct validity, internal consistency, and interrater reliability were subsequently scored using the consensus-based standards for the selection of health measurement instruments (COSMIN) checklist.

FINDINGS

In total, 89 validation articles comprising 65 scales were included. Fifty-seven scales (88%) were useful for assessing pain, 13 scales (20%) for assessing sedation, and 4 scales (6%) for assessing both conditions. Forty-two (65%) were behavioral scales, and 23 (35%) were multidimensional scales. Eleven scales (17%) were validated for infants on mechanical ventilation. Thirty-seven scales (57%) were validated for preterm infants, 24 scales (37%) for term and preterm infants, 7 scales (11%) for term-born children, 7 scales (11%) for preterm infants, term infants, and toddlers, and 17 scales (26%) for term infants and toddlers. Twenty-eight scales (43%) considered construct validity, internal consistency, and interrater reliability.

CONCLUSIONS AND RELEVANCE

Clinicians should consider using scales that are validated for at least construct validity, internal consistency, and interrater reliability, combining this information with the population of interest and the construct the scale is intended to measure.

Monitoring intra-abdominal pressure after liver transplantation in children

IAH after LTX can impair perfusion and threaten graft viability. This study aimed to assess the feasibility of longitudinal IAP measurements as an IAH screening method in children after LTX. A cohort of 23 children with a mean age (range) 3.1 (3 months-14 years) who underwent LTX between May 2017 and February 2018 were evaluated retrospectively. Longitudinal IAP measurements were compared to bedside Doppler US monitoring data. In total, 425 IAP measurements and 257 US examinations were performed. The mean ± SD (range) time expenditure for IAP measurement was 1.9 ± 0.4 (0.5-3.2) minutes. The mean post-operative IAP was 7.9 ± 3.6 (1-25) mm Hg. IAH (IAP ≥ 10 mm Hg) was noted in 102 (24%) of 257 measurements. Agitation had a significant impact on IAP (estimate: 9.3 mm Hg, CI: 6.72-11.97, P < .01). In patients with TAC, IAP was increased (6.7 ± 2.1 vs 8.7 ± 3.1 mm Hg, P = .02) while peak portal venous velocities decreased (38 ± 27 vs 26 ± 22 cm/s, P = .03) after patch reduction. An abdominal compartment syndrome with severely impaired vascular flow was noted in one patient. Episodes of elevated IAP were noted in a large proportion of patients, underscoring the need for IAP monitoring in pediatric liver transplant recipients. The safety and low time expenditure associated with IAP measurement could be included easily into standard nursing procedures for these patients.

Excessive Seizure Clusters in an Otherwise Well-Controlled Epilepsy as a Possible Hallmark of Untreated Vitamin B6-Responsive Epilepsy due to a Homozygous PLPBP Missense Variant

Recently, mutations in the PLPBP gene were described as a novel cause for vitamin B6-responsive epilepsy. We report the outcome in case of a male adolescent with a novel homozygous missense variant in PLPBP who was never treated with pyridoxine until the age of 16 years. He presented with only mild cognitive impairment and an early-onset, well-controlled epilepsy. In our patient, excessive seizure clusters and anxiety states occurred intermittently, suggesting that the combination might be a hallmark in untreated patients. Thus, mutations in PLPBP should be addressed even in adolescent patients with only mild learning disabilities and relatively good seizure control over the years.

The power of N-PASS, aEEG, and BIS in detecting different levels of sedation in neonates: A preliminary study

BACKGROUND

Sedatives are essential drugs in every intensive care unit in order to ensure the patient's optimal level of comfort. Avoiding conditions of over- and under-sedation is a challenge in a neonatal intensive care setting. Drug administration could be optimized by the concomitant use of objective methods to assess the level of sedation.

AIMS

We aimed to look at the ability of different methods (Neonatal Pain, Agitation and Sedation Scale, amplitude-integrated Electroencephalogram, and Bispectral Index), and their combination, in detecting different level of sedation.

METHODS

Twenty-seven neonates among whom 17 were receiving sedatives with or without opiate analgesics were monitored using the Neonatal Pain, Agitation and Sedation Scale, the amplitude-integrated Electroencephalogram, and the Bispectral Index. According to the expert opinion of two trained neonatologists, patients were categorized into three groups: no, light, and deep sedation. Four hours of simultaneous assessment of the Neonatal Pain, Agitation and Sedation Scale scores, Burdjalov scores (to summarize the amplitude-integrated Electroencephalogram trace), and Bispectral Index values were considered for the comparative analysis across these groups.

RESULTS

All three methods could differentiate patients who were not sedated from those who were deeply sedated: median score 12 and 9, respectively, (95% CI of difference = 1.99-5.99, P = 0.001) for the amplitude-integrated Electroencephalogram Burdjalov score; median 1 and -5, respectively, (95% CI of difference = 2.99-8.00, P = 0.001) for the Neonatal Pain, Agitation and Sedation Scale; and median 48 and 37, respectively, (CI of difference = 1.77-22.00, P = 0.043) for the Bispectral Index. However none of them, used alone, was able to differentiate light and deep sedation: median score 10 and 9, respectively, for the amplitude-integrated Electroencephalogram Burdjalov score; median -2 and -5, respectively, for the Neonatal Pain, Agitation and Sedation Scale; and median 48 and 37, respectively, for the Bispectral Index. Only the amplitude-integrated Electroencephalogram and the Neonatal Pain, Agitation and Sedation Scale were able to differentiate between the conditions of no sedation and light sedation. Also, according to the area under the curves values, the combination of the Neonatal Pain, Agitation and Sedation Scale with the Burdjalov score derived from the amplitude-integrated Electroencephalogram showed the best accuracy in differentiating light and deep sedation.

CONCLUSION

While none of the three methods alone was able to precisely differentiate between different levels of sedation, we suggest that using a combination of amplitude-integrated Electroencephalogram and Neonatal Pain, Agitation and Sedation Scale can be useful to distinguish between light and deep sedation in neonatal patients.

Effect of increased opiate exposure on three years neurodevelopmental outcome in extremely preterm infants

BACKGROUND

International guidelines recommend the use of item based scales for the assessment of pain and sedation. In our previous study, the implementation of the Neonatal Pain Agitation and Sedation Scale (N-PASS), and the associated systematic assessment and treatment of pain and sedation reduced pain and over-sedation in our intervention group, but lead to a significant increase of individual opiate exposure. This increased opiate exposure was not associated with impaired motor and mental development at one year of age. As one-year follow-up is not necessarily representative for future outcomes, we retested our sample at three years of age.

METHODS

Fifty-three patients after (intervention group) and 61 before implementation (control group) of the N-PASS and the Vienna Protocol for the Management of Neonatal Pain and Sedation (VPNPS), were compared for motor, mental and behavioural development at three-years follow-up using the Bayley Scales of Infant Development.

RESULTS

Cumulative opiate exposure was not associated with mental (p = .31) and motor (p = .20) problems when controlling for other important medical conditions, but was associated to lower behavioural scores (p = .007). No statistically significant differences were found with regard to mental (p = .65), psychomotor (p = .12) and behavioural (p = .61) development before and after the implementation of the N-PASS and the VPNPS.

CONCLUSION

Implementing a neonatal pain and sedation protocol increased opiate exposure without affecting neurodevelopmental outcome at three-years of age.

Arterial catheterisation in neonates can result in severe ischaemic complications but does not impair long-term extremity function

AIM

We evaluated the incidence of arterial catheterisation and analysed the risk factors and the extent and outcome of ischaemic complications in neonates.

METHODS

This was a retrospective cohort study of 1506 neonates admitted to two, ten-bed neonatal intensive care units (NICUs) at the Medical University of Vienna, Austria, between 1 January 2011 and 31 December 2014. Medical charts, daily reports and photo documentation were reviewed for arterial catheterisation and ischaemic complications. Patients with severe ischaemic complications were followed up to evaluate extremity function, scaring and cosmetic results.

RESULTS

There were 542 arterial catheterisations in 485 patients, including 275 born below 28 weeks, which resulted in severe complications in 19 of 485 (4%) patients. Three died before follow-up. Patients with complications had a significantly lower birthweight, lower postmenstrual age and higher rates of intracranial haemorrhage, retinopathy of prematurity and necrotising enterocolitis. They had also undergone multiple arterial catheterisations more often, needed longer inotropic support and had longer NICU stays than patients without complications. Extremity function was unimpaired in ten of 16 patients with severe ischaemic complications.

CONCLUSION

Severe ischaemic complications in neonates following arterial catheterisation were rare events, but could cause devastating damage. Most patients didn't show impaired extremity function at follow-up.

Are All Amplitude-Integrated Electroencephalogram Systems Equal?

BACKGROUND

Filter and peak detection algorithms implemented in amplitude-integrated electroencephalogram (aEEG) systems are not standardized. New aEEG systems are continuously enriching the market and clinicians are faced with different aEEG devices whose tracings may vary.

OBJECTIVES

The aim of this work was to determine the role of different aEEG systems on quantitative measurements of the aEEG.

METHODS

In this observational study, a single-channel aEEG recording (Olympic CFM 6000) with corresponding EEG signal was obtained from 32 infants at a gestational age of 36-44 weeks. The signals were split into 334 episodes of 4 h. New aEEG tracings were generated using the NicoletOne Reader Software and aEEG emulations with varying filter profiles and peak detection settings. The aEEG amplitude margins and automated annotation of continuous normal voltage (CNV) were compared.

RESULTS

The output of the Olympic and the NicoletOne systems are very similar but not identical; the Spearman rank correlations of the aEEG amplitude margins exceeded 0.9 and the differences in the lower and upper amplitude margins were 1.55 μV (SD 1.47) and -2.12 μV (SD 1.44) on average (n = 309), respectively. The aEEG emulation showed that the differences between the output of the Olympic and the NicoletOne system could be primarily ascribed to the peak detection algorithm. The differences in output can affect automated analyses with agreement rates in CNV detection of 76% (n = 32, positive) and 92% (n = 32, negative) when comparing the Olympic to the NicoletOne outputs.

CONCLUSIONS

Commercial aEEG systems have similar but not identical outputs. Care is advised when interpreting automated aEEG classifications across different devices.

Neurological sequelae of healthcare-associated sepsis in very-low-birthweight infants: Umbrella review and evidence-based outcome tree

Sepsis is a frequent cause of death in very-low-birthweight infants and often results in neurological impairment. Its attributable risk of sequelae has not been systematically assessed. To establish an outcome tree for mapping the burden of neonatal sepsis, we performed systematic literature searches to identify systematic reviews addressing sequelae of neonatal sepsis. We included cohort studies and performed meta-analyses of attributable risks. Evidence quality was assessed using GRADE. Two systematic reviews met inclusion criteria. The first included nine cohort studies with 5,620 participants and five outcomes (neurodevelopmental impairment, cerebral palsy, vision impairment, hearing impairment, death). Pooled risk differences varied between 4% (95% confidence interval (CI):2-10) and 13% (95% CI:5-20). From the second review we analysed four studies with 472 infants. Positive predictive value of neurodevelopmental impairment for later cognitive impairment ranged between 67% (95% CI:22-96) and 83% (95% CI:36-100). Neonatal sepsis increases risk of permanent neurological impairment. Effect size varies by outcome, with evidence quality being low to very low. Data were used to construct an outcome tree for neonatal sepsis. Attributable risk estimates for sequelae following neonatal sepsis are suitable for burden estimation and may serve as outcome parameters in interventional studies.

The implementation of systematic pain and sedation management has no impact on outcome in extremely preterm infants

AIM

This study compared the short-term and neurodevelopmental outcomes of extremely preterm infants before and after the implementation of a protocol to manage neonatal pain and sedation.

METHODS

Our study cohort comprised 140 extremely preterm infants from two neonatal intensive care units. We retrospectively analysed opiate exposure, time on mechanical ventilation, inotropic support, nutritional aspects and growth 12 months before (controls) vs 12 months after (intervention) the implementation of the Vienna Protocol for Neonatal Pain and Sedation. Infants were evaluated at the corrected age of 12 months using the Bayley Scales of Infant Development - Second Edition.

RESULTS

After the protocol was implemented, the cumulative opiate dose increased from a baseline of 15 mg/kg ± 41 to 89 mg/kg ± 228 morphine equivalents. Time on mechanical ventilation, inotropic support, length of parenteral nutrition, growth, length of stay and in-hospital morbidity were similar before and after the implementation, with no differences between the groups in mental, motor and behavioural development at the one-year follow-up. However, opiate exposure was a possible risk factor for lower behaviour rating scores (estimate = -0.04; p = 0.006). [Correction added on 23 February 2016, after online publication: In the preceding sentences, the cumulative opiate dose as well as the estimate value for the behavioral rating scale were previously incorrect and have been amended in this current version.]

CONCLUSION

Implementing a neonatal pain and sedation protocol increased opiate exposure, but had no effect on the in-hospital and neurodevelopmental outcomes of extremely preterm infants.

Bispectral index and lower margin amplitude of the amplitude-integrated electroencephalogram in neonates

BACKGROUND

The lower margin amplitude (LMA) of the amplitude-integrated electroencephalogram (aEEG) is suppressed in neonates during deep sedation, a feature that is attributed to the bispectral index (BIS) in adults.

OBJECTIVE

We compare the BIS and the LMA of the aEEG in neonates.

METHODS

Thirty neurologically healthy neonates between 37 and 44 weeks postmenstrual age were included in this study. Twenty patients received sedoanalgesic therapy for various reasons. BIS and aEEG recordings were performed simultaneously. The digital data were imported in the numerical software environment Matlab®. The LMA of the aEEG was computed on a 1-min time scale and synchronized with the BIS data. The correlation between the time-dependent variables BIS and LMA was estimated using the Spearman rank correlation index.

RESULTS

The median correlation between BIS and LMA was 0.3. Inclusion of recordings of high signal quality only into analysis improved the median correlation index to 0.6.

CONCLUSIONS

We found a light-to-moderate correlation between BIS and LMA in our study cohort and a good correlation in the subgroup with high signal quality.

An instructional video enhanced bag-mask ventilation quality during simulated newborn resuscitation

AIM

Approximately 20% of newborns infants need respiratory support at birth. This study evaluated whether video-based education could improve quality of positive pressure ventilation (PPV) performed by inexperienced staff during neonatal resuscitation.

METHODS

Fourth-year medical students were randomly paired and instructed to give PPV to a modified manikin as single-person resuscitators and as two-person-paired resuscitators using either an air cushion rim mask or a round mask before and after watching a self-instructional video. Airway pressure, gas flow, tidal volume and mask leak were recorded. PPV performance quality was analysed using video recording.

RESULTS

Mask leak was lower during one-person ventilation when using the air cushion rim mask (56 ± 16%) compared to the round mask (71 ± 19%). Round mask leak during one-person ventilation was significantly lower when using the two point top hold in contrast to the 'o.k.' rim hold (before training: 63 ± 22% vs. 72 ± 18%, after training: 57 ± 17% vs. 77 ± 12%). Watching a self-instructional video improved performance quality scores of both correct head positioning, and the quality of airway manoeuvres compared to baseline, however mask leak was not significantly reduced.

CONCLUSION

A self-instructional video significantly improved bag mask PPV performance in inexperienced providers but did not improve mask leak in a model of neonatal resuscitation.

The Neonatal Pain, Agitation and Sedation Scale reliably detected oversedation but failed to differentiate between other sedation levels

AIM

The aim of this study was to analyse the sedation subscale of the Neonatal Pain, Agitation and Sedation Scale (N-PASS), because the N-PASS has only been validated for the assessment of acute and prolonged pain.

METHODS

The nurses' expert opinion regarding the level of sedation of the study patients was used as reference scale. Paired assessments of both the N-PASS sedation subscale and the nurses' expert opinion were performed in 50 sedated neonates from 23 to 44 weeks of postmenstrual age.

RESULTS

A total set of 503 paired observations was included into analysis. The median N-PASS sedation subscale scores were significantly different for the three nurses' expert opinion categories, with minus eight for oversedation, minus two for adequate sedation and zero for undersedation (p < 0.0001). Interobserver agreement for the N-PASS sedation subscale was excellent - linearly weighted Cohen's Kappa was 0.93 - as was the internal consistency of 0.88, estimated by a Cronbach's alpha. The internal consistency increased to 0.90 if the vital sign item of the subscale was deleted.

CONCLUSION

The N-PASS sedation subscale reliably detected oversedation, but failed to differentiate between adequate and undersedation. We therefore recommend using additional methods to ensure adequate assessment of sedation in neonates.