Randomised trial of estimating oral endotracheal tube insertion depth in newborns using weight or vocal cord guide

BACKGROUND

When intubating newborns, clinicians aim to position the endotracheal tube (ETT) tip in the midtrachea. The depth to which ETTs should be inserted is often estimated using the infant's weight. ETTs are frequently incorrectly positioned in newborns, most often inserted too far. Using the vocal cord guide (a mark at the distal end of the ETT) to guide insertion depth has been recommended.

OBJECTIVE

To determine whether estimating ETT insertion depth using the vocal cord guide rather than weight results in more correctly positioned ETT tips.

DESIGN

Single-centre randomised controlled trial.

SETTING

Level III neonatal intensive care unit (NICU) at a university maternity hospital (National Maternity Hospital, Dublin, Ireland).

PATIENTS

Newborn infants without congenital anomalies intubated in the NICU.

INTERVENTIONS

Participants were randomised to have ETT insertion depth estimated using weight [insertion depth (cm) = weight (kg) +6] or vocal cord guide.

MAIN OUTCOME MEASURE

Correct ETT position, that is, tip between the upper border of the first thoracic vertebra (T1) and the lower border of the second thoracic vertebra (T2) on a chest X-ray as determined by one paediatric radiologist masked to group assignment.

RESULTS

136 participants were randomised. The proportion of correctly positioned ETTs was similar in both groups (weight 30/69 (44%) vs vocal cord guide 27/67 (40%), p=0.731). Most incorrectly positioned ETT (69/79, 87%) were too low.

CONCLUSION

Estimating ETT insertion depth using the vocal cord guide did not result in more correctly positioned ETT tips.

TRIAL REGISTRATION NUMBER

ISRCTN39654846.

Recent developments in the surgical management of paediatric epilepsy

Among the 1% of children affected by epilepsy, failure of pharmacological therapy and early age of seizure onset can lead to worse long-term cognitive outcomes, mental health disorders and impaired functional status. Surgical management often improves functional and cognitive outcomes in children with medically refractory epilepsy, especially when seizure remission is achieved. However, surgery remains underused in children with drug-resistant epilepsy, creating a large treatment gap. Several recent innovations have led to considerable improvement in surgical technique, including the recent development of minimally invasive diagnostic and therapeutic techniques such as stereotactic EEG, transcranial magnetic stimulation, MRI-guided laser ablation, as well as novel paradigms of neurostimulation. This article discusses the current landscape of surgical innovation in the management of paediatric epilepsy, leading to a paradigm shift towards minimally invasive therapy and closing the treatment gap in children suffering from drug-resistant seizures.

A Clinical Procedures Course for Medical Students

INTRODUCTION

Doctors perform many clinical procedures throughout their careers. It is important for students to learn these procedures in a nonthreatening environment. This clinical procedures course introduces students to several basic diagnostic and therapeutic procedures, both invasive and noninvasive. These include managing pediatric and adult airways, starting intravenous lines, inserting arterial and central lines, inserting Foley catheters and nasogastric tubes, and performing lumbar punctures and paracentesis.

METHODS

Small-group teaching is used to achieve these objectives; over the course of 4 weeks, the medical students meet once a week for 4 hours. Each meeting includes teaching and demonstrations of the procedures by faculty instructors and residents. This is followed by practice of the procedures on mannequin simulators and partial task trainers by the students. Feedback is then given to the students by the instructors.

RESULTS

Based on conversations during the feedback sessions, the students feel that the materials used in the course are helpful in learning these clinical procedures.

DISCUSSION

The medical students feel that the course familiarizes them with clinical procedures they may be asked to perform on patients during their clinical rotations and postgraduate training.

Neonatal lumbar puncture: are clinical landmarks accurate?

BACKGROUND

The intercristal line (ICL), defined by the superior aspect of the iliac crest, is used to clinically identify the entry point for lumbar puncture (LP) in neonates. Accepted practice is to insert the needle at the L3/4 or L4/5 intervertebral space.

AIM

To investigate the vertebral level crossed by the ICL as determined by manual palpation and the ability of manual palpation to reliably identify a specified intervertebral space.

METHOD

A total of 30 term neonates were recruited. Paediatricians identified and marked the ICL and the intervertebral space above, with babies in left lateral position. The anatomical positions of both points and the end of the conus medullaris were confirmed using ultrasonography.

RESULTS

The ICL was marked from L2/3 to L5/S1. In 25 babies (83%), the ICL was identified at the desired vertebral level between L3/4 and L4/5. The intervertebral space above this line was marked between L1/2 to L4/5. The potential site for LP was identified higher than intended in 11 cases (36%). The end of the conus medullaris ranged from L1 to L3 terminating at L2 or lower in 11 cases (36%).

CONCLUSIONS

There are wide variations in the positions of the ICL and potential LP site. Using the ICL to guide LP does not appear to be accurate, raising the possibility of potential spinal cord damage.

Inguinal hernia repair in premature infants: more questions than answers

This review shows that there are many single institution studies reviewing outcomes of premature infants with IH. However, the numbers of patients in these studies are often small and most studies were retrospective, therefore, these studies were subject to the limitations inherent to observational studies for identifying best treatment methods. Nevertheless, the studies show that risks are high in this population and that outcomes may vary with the timing of repair. There have been calls for multicentre randomised trials comparing early versus later IH repair from all over the world and for a very long time. Yet, despite the frequency of IH repair in premature infants, this issue remains unstudied in a high-quality manner. A large, multicentre randomised trial is currently underway to address the effect of timing on the short-term and long-term safety and efficacy of IH repair in this population so that we may be able to deliver safe surgical care to this vulnerable population.

Topical anaesthetics: what's new?

Topical anaesthetics, often used by anaesthetists, dentists and dermatologists, have increasingly been recognised for their utility in paediatrics. With topical anaesthetics, the 'ouchless' paediatric practice becomes an achievable goal. The primary drawback to their use is the length of time for anaesthetic effect, but planning ahead and making use of newer formulations and adjuncts can overcome this barrier. This update will review topical anaesthetic formulations available, adjuncts to reduce the time to anaesthesia, adverse effects, common indications and products on the horizon.

Implantable cardioverter-defibrillators in children

Implantable cardioverter-defibrillators (ICD) have become an integral component in the management of children with life-threatening cardiac arrhythmias complicating a variety of different inherited and congenital cardiovascular conditions. Implantation often requires novel approaches and configurations to overcome the size and anatomic limitations posed by many children needing ICDs. While their use has undoubtedly saved many lives, ICD use may be associated with significant morbidity, so detailed case selection and individualised postimplant programming is critical.

Change in practice after the Surfactant, Positive Pressure and Oxygenation Randomised Trial

OBJECTIVE

To test the hypothesis that the proportion of endotracheal intubation (ETI) in the delivery room (DR) decreased in Neonatal Research Network (NRN) centres after the National Institute of Child Health and Human Development NRN Surfactant, Positive Pressure, and Oxygenation Randomised Trial (SUPPORT).

DESIGN

Retrospective cohort study using the prospective NRN generic database.

SETTING

Eleven centres that participated in the SUPPORT trial and remained part of the NRN. Preterm neonates 24(0/7)-27(6/7) weeks' gestational age enrolled in the SUPPORT trial were randomised to: (1) DR continuous positive airway pressure or DR ETI with early surfactant administration; and (2) oxygen saturation targets of 85-89% or 91-95%. The prior NRN feasibility trial had assessed the feasibility of randomisation to continuous positive airway pressure versus ETI.

PATIENTS

Infants 24(0/7)-27(6/7) weeks' gestational age, excluding infants with syndromes or major malformations and those on comfort care only.

MAIN OUTCOME MEASURE

Proportion of DR ETI.

RESULTS

The proportion of DR ETI decreased significantly in the group of infants from centres that had not participated in the feasibility trial (91% before vs 75% after SUPPORT, adjusted relative risk 0.86, 95% CI 0.83-0.89, p<0.0001) but not in the group of infants from the other centres, where the proportion of ETI was already lower prior to initiation of the SUPPORT trial (61% before vs 58% after SUPPORT, adjusted relative risk 0.96, 95% CI 0.89 to 1.05, p=0.40).

CONCLUSION

This study shows that DR ETI changed after SUPPORT only in NRN centres that had not participated in a similar trial.

TRIAL REGISTRATION NUMBER

NCT00063063 (GDB) and NCT00233324 (SUPPORT).

Headache after lumbar puncture: randomised crossover trial of 22-gauge versus 25-gauge needles

OBJECTIVES

To compare the frequency of headache and the procedure time following lumbar puncture (LP) using a 25-gauge needle compared to a 22-gauge needle.

DESIGN

4-period crossover blinded randomised controlled trial.

SETTING

Oncology unit, Royal Children's Hospital, Melbourne.

PATIENTS

Children aged 4-15 years at enrolment having LPs as part of their treatment for leukaemia.

INTERVENTIONS

Each child was allocated a random sequence of four LPs, two with a 22-gauge and two with a 25-gauge needle.

OUTCOME MEASURES

The presence of post-LP headache. Secondary outcomes included the presence of any headache, procedure time and impact of headache on the family.

RESULTS

Data on 341 procedures in 93 randomised children were analysed. There was little difference in the incidence of post-LP headache between the two needle sizes (22-gauge 7.2%, 95% CI 3.8 to 12.2; 25-gauge 4.6%, 95% CI 2.0 to 8.9, p=0.3) or in the incidence of any headache (22-gauge 18% 95% CI 12.5 to 24.6; 25-gauge 15%, 95% CI 10.0 to 21.1, p=0.4). Use of the 25-gauge needle was associated with longer procedure times. The incidence of post-LP headache showed little evidence of an age effect (OR =1.1, 95% CI 0.98 to 1.3) and was higher in girls than in boys (11% vs 3%, respectively, OR=3.3, 95% CI 1.3 to 8.4, p=0.014). Fifty-five per cent of families with a child with a post-LP headache assessed the overall functional impact as moderate or severe.

CONCLUSIONS

There was little difference in the occurrence of post-LP headache or any headache between procedures carried out using the 22-gauge or 25-gauge needles. Depending on the circumstances of the procedure and the experience of the operator, either gauge may be appropriate for an LP in a child.

Infantile haemangiomas and quality of life

OBJECTIVE

To determine the quality of life (QOL) and self-esteem of children with infantile haemangiomas using objective measures.

DESIGN

Twenty-one children, 5-8 years old, with a diagnosis of head or neck haemangioma measuring 2 cm or more, were compared with 22 children with no history of haemangioma.

SETTING

A tertiary medical centre in the north of Israel.

INTERVENTIONS

Demographic and clinical details were collected, followed by two questionnaires-Paediatric Quality of Life Inventory (PedsQL) and Harter pictorial scale of Perceived Competence and Social Acceptance for young children-answered by children and parents of the two groups.

MAIN OUTCOME MEASURES

QOL and self-esteem of the children in the two groups.

RESULTS

There were no significant differences in QOL indices or self-perception scores between children with and without haemangioma (86.6±10.3 vs 80.1±15.07, p=0.23 and 3.62±0.2 vs 3.72±0.21, p=0.17, respectively). Interestingly, parents of children with haemangioma reported higher QOL of their children than parents of children without haemangioma (86.4±9.6 vs 77.1±14.9, p<0.03). Likewise, a positive correlation between parents' scored PedsQL and children's scored PedsQL was found (0.56, p=0.008).

CONCLUSIONS

The findings raise a question about aggressive as opposed to more conservative treatment, especially in the era of propranolol.