Management of oxygen saturation monitoring in preterm newborns in the NICU: the Italian picture

Laryngeal Mask for Minimally-invasive Surfactant Administration: A Narrative Review

The cornerstone of treatment for respiratory distress syndrome in preterm infants is surfactant administration, traditionally performed through an invasive procedure involving tracheal intubation and mechanical ventilation. Consequently, there has been a growing interest in exploring less invasive methods of surfactant delivery to mitigate the associated risks. Currently, several techniques are under evaluation, including intratracheal instillation using a thin catheter, aerosolized or nebulized administration, and guided administration by supraglottic airway devices. One such method is surfactant administration through laryngeal or supraglottic airway, which involves placing a laryngeal mask without the need for laryngoscopy and administering surfactant through the device. The simplicity of laryngeal mask insertion could potentially streamline the surfactant delivery process, eliminating the necessity for advanced skills. This narrative review aimed to assess the current evidence in the literature regarding the benefits and risks associated with surfactant administration through a laryngeal supraglottic airway.

Oxygen in the newborn period: Could the oxygen reserve index offer a new perspective?

Oxygen therapy has been one of the main challenges in neonatal intensive care units (NICU). The guidelines currently in use try to balance the burden of hypoxia and hyperoxia such as retinopathy of prematurity, bronchopulmonary dysplasia, and death. The goal of this paper is to review neonatal oxygenation and the impact of hyperoxia and hypoxia in neonatal outcomes as well as review the available literature concerning the use of Oxygen Reserve Index (ORiTM) in clinical practice and its potential in Neonatology, particularly in NICU. Pulse oximetry has been used to monitor oxygenation in newborns with the advantage of being a noninvasive and continuous parameter, however it has limitations in detecting hyperoxemic states due to the flattening of the hemoglobin dissociation curve. The ORiTM is a new parameter that has been used to detect moderate hyperoxia and, when used in addiction to spO2, could be helpful in both hypoxia and hyperoxia. Studies using this tool are mainly in the adult population, during anesthetic procedures with only a small number of studies being performed in pediatric context. Oxygen targets remain a major problem for neonatal population and regardless of the efforts made to establish a safe oxygenation range, a more individualized approach seems to be the more appropriate pathway. ORiTM monitoring could help defining how much oxygen is too much for each newborn. Despite its promising potential, ORiTM is still a recent technology that requires more studies to determine its true potential in clinical practice.

Monitoring SpO2: The Basics of Retinopathy of Prematurity (Back to Basics) and Targeting Oxygen Saturation

Oxygen (O2) is a drug frequently used in newborn care. Adverse effects of hypoxia are well known but the damaging effects of excess oxygen administration and oxidative stress have only been studied in the last 2 decades. Many negative effects have been described, including retinopathy of prematurity . Noninvasive pulse oximetry (SpO2) is useful to detect hypoxemia but requires careful evaluation and understanding of the frequently changing relationship between O2 and hemoglobin to prevent hyperoxemia. Intention to treat SpO2 ranges should be individualized for every newborn receiving supplemental O2, according to gestational age, post-natal age, and clinical condition.

Use and Efficacy of I-gel in Complicated Intubations in Newborn Infants: A Review of Case Reports in the Literature

INTRODUCTION

Current guidelines for neonatal resuscitation suggest the use of a laryngeal mask when ventilation with both facemask and endotracheal tube has failed in newborns weighing >2000 g or delivered ≥ 34 weeks of gestation age. Paediatric I-gel® is one of the latest supraglottic airway management devices suitable for children and newborns. I-gel® use was effective in guaranteeing adequate ventilation in patients with anatomic abnormalities in case of respiratory impairment or during surgical procedures after the induction of anaesthesia.

OBJECTIVE

The purpose of our review was to evaluate the use and efficacy of I-gel® in case of complicated intubations.

METHODS

In July 2023, two authors of this paper independently conducted searches of the MEDLINE, Web of Science, and Scopus databases without imposing any time constraints or other restrictions. Three case reports were included, each describing the use of I-gel® device in difficult intubations in newborns with anatomical abnormalities.

RESULTS

No difficulties were reported in the insertion of the device, which was placed even by inexperienced clinicians.

CONCLUSION

The data collected highlighted the possibility of using I-gel® not only as a rescue device after attempted and failed endotracheal placement but also as a first choice in selected patients. Studies on larger cohorts would be needed. Further research involving larger patient cohorts of multicentre NICUs is necessary to confirm the use of laryngeal masks in neonates weighing less than 2000 grams.

Determining an Optimal Oxygen Saturation Target Range Based on Neonatal Maturity: Demonstration of a Decision Tree Analytic

The utility of decision tree machine learning in exploring the interactions among the SpO2 target range, neonatal maturity, and oxemic-risk is demonstrated.

METHODS

This observational study used 3 years of paired age-SpO2-PaO2 data from a neonatal ICU. The CHAID decision tree method was used to explore the interaction of postmenstrual age (PMA) on the risk of extreme arterial oxygen levels at six different potential SpO2 target ranges (88-92%, 89-93%, 90-94%, 91-95%, 92-96% and 93-97%). Risk was calculated using a severity-weighted average of arterial oxygen outside the normal range for neonates (50-80 mmHg).

RESULTS

In total, 7500 paired data points within the potential target range envelope were analyzed. The two lowest target ranges were associated with the highest risk, and the ranges of 91-95% and 92-96% were associated with the lowest risk. There were shifts in the risk associated with PMA. All the target ranges showed the lowest risk at ≥42 weeks PMA. The lowest risk for preterm infants was within a target range of 92-96% with a PMA of ≤34 weeks.

CONCLUSIONS

This study demonstrates the utility of decision tree analytics. These results suggest that SpO2 target ranges that are different from typical range might reduce morbidity and mortality. Further research, including prospective randomized trials, is warranted.

SLAB51 Multi-Strain Probiotic Formula Increases Oxygenation in Oxygen-Treated Preterm Infants

Preterm infants are at risk of hypoxia and hyperoxia because of the immaturity of their respiratory and antioxidant systems, linked to increased morbidity and mortality. This study aimed to evaluate the efficacy of a single administration of the SLAB51 probiotic formula in improving oxygenation in respiratory distress syndrome (RDS)-affected premature babies, thus reducing their need for oxygen administration. Additionally, the capability of SLAB51 in activating the factor-erythroid 2-related factor (Nrf2) responsible for antioxidant responses was evaluated in vitro. In two groups of oxygen-treated preterm infants with similar SaO2 values, SLAB51 or a placebo was given. After two hours, the SLAB51-treated group showed a significant increase in SaO2 levels and the SaO2/FiO2 ratio, while the control group showed no changes. Significantly increased Nrf2 activation was observed in intestinal epithelial cells (IECs) exposed to SLAB51 lysates. In preterm infants, we confirmed the previously observed SLAB51's "oxygen-sparing effect", permitting an improvement in SaO2 levels. We also provided evidence of SLAB51's potential to enhance antioxidant responses, thus counteracting the detrimental effects of hyperoxia. Although further studies are needed to support our data, SLAB51 represents a promising approach to managing preterm infants requiring oxygen supplementation.

The Effect of Incubator Cover on Newborn Vital Signs: The Design of Repeated Measurements in Two Separate Groups with No Control Group

(1) Background: During their stays in neonatal intensive care units (NICU), newborns are exposed to many stimuli that disrupt their physiological indicators. The aim of this study was to investigate the impact of the light-dark cycle created with and without an incubator cover on the vital signs of term and preterm newborns. (2) Methods: A repeated measures design was used in the study utilizing two separate groups, without a control group. The study included 91 neonates hospitalized in a NICU (44 term and 47 preterm). With and without an incubator cover, the newborns' vital signs (heart rate (HR), respiratory rate (RR), oxygen saturation (SpO₂), and body temperature (BT)) were measured. Three separate measurements were taken. (3) Results: The mean age of the newborns was 37.0 weeks. There was no significant difference between the HR and RR medians of the term and preterms in the incubator undraped and clad measurements (p > 0.05). At the first measurement, the SpO₂ medians of the incubator-covered term and preterms were significantly higher than those of the incubator-covered term and preterms (p = 0.001). (4) Conclusions: The vital signs of the neonates demonstrated variable responses in the measurements when their incubators were covered vs. when they were not covered. However, more research on the effect of the light-dark cycle on their vital signs is required.

Oxygen for the Newborn: Friend or Foe?

Oxygen supplementation is widely used in neonatal care, however, it can also cause toxic effects if not used properly. Therefore, it appears crucial to find a balance in oxygen administration to avoid damage as a consequence of its insufficient or excessive use. Oxygen toxicity is mainly due to the production of oxygen radicals, molecules normally produced in humans and involved in a myriad of physiological reactions. In the neonatal period, an imbalance between oxidants and antioxidant defenses, the so-called oxidative stress, might occur, causing severe pathological consequences. In this review, we focus on the mechanisms of the production of oxygen radicals and their physiological functions in determining a set of diseases grouped together as "free radical diseases in the neonate". In addition, we describe the evolution of the oxygenation target recommendations during neonatal resuscitation and post-stabilization phases with the aim to define the best oxygen administration according to the newest evidence.

Melatonin in Newborn Infants Undergoing Surgery: A Pilot Study on Its Effects on Postoperative Oxidative Stress

Surgery is frequently associated with excessive oxidative stress. Melatonin acts as an antioxidant and transient melatonin deficiency has been described in neonatal surgical patients. This randomized, blinded, prospective pilot study tested the hypothesis that oral melatonin supplementation in newborn infants undergoing surgery is effective in reducing perioperative oxidative stress. A total of twenty-three newborn infants requiring surgery were enrolled: 10 received a single dose of oral melatonin 0.5 mg/kg in the morning, before surgery (MEL group), and 13 newborns served as the control group (untreated group). Plasma concentrations of melatonin, Non-Protein-Bound Iron (NPBI), Advanced Oxidation Protein Products (AOPP), and F2-Isoprostanes (F2-IsoPs) were measured. Both in the pre- and postoperative period, melatonin concentrations were significantly higher in the MEL group than in the untreated group (preoperative: 1265.50 ± 717.03 vs. 23.23 ± 17.71 pg/mL, p < 0.0001; postoperative: 1465.20 ± 538.38 vs. 56.47 ± 37.18 pg/mL, p < 0.0001). Melatonin significantly increased from the pre- to postoperative period in the untreated group (23.23 ± 17.71 vs. 56.47 ± 37.18 pg/mL; pg/mL p = 0.006). In the MEL group, the mean blood concentrations of NPBI, F2-IsoPs, and AOPP significantly decreased from the pre- to the postoperative period (4.69 ± 3.85 vs. 1.65 ± 1.18 micromol/dL, p = 0.049; 128.40 ± 92.30 vs. 50.25 ± 47.47 pg/mL, p = 0.037 and 65.18 ± 15.50 vs. 43.98 ± 17.92 micromol/dL, p = 0.022, respectively). Melatonin concentration increases physiologically from the pre- to the postoperative period, suggesting a defensive physiologic response to counteract oxidative stress. The administration of exogenous melatonin in newborn infants undergoing surgery reduces lipid and protein peroxidation in the postoperative period, showing a potential role in protecting babies from the deleterious consequences of oxidative stress.