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Lacquiere D, Smith J, Bhanderi N, Lockie F, Pickles J, Steere M, Craven J, Mazur S. Early experience in use of videolaryngoscopy by a neonatal pre-hospital and retrieval service. Emerg Med Australas 2024; 36:476-478. [PMID: 38290834 DOI: 10.1111/1742-6723.14374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Accepted: 01/01/2024] [Indexed: 02/01/2024]
Abstract
OBJECTIVE To describe initial experience with use of the Glidescope Go videolaryngoscope by an Australian neonatal pre-hospital and retrieval service. METHODS We conducted a 31-month retrospective review of an airway registry for neonates intubated by MedSTAR Kids clinicians. RESULTS Twenty-two patients were intubated using the Glidescope Go, compared with 50 using direct laryngoscopy. First-pass success was 17/22 (77.3%) with the Glidescope Go and 38/50 (76%) with direct laryngoscopy. Complications occurred in 7/22 (32%) and 8/50 (16%), respectively. CONCLUSIONS On initial review of this practice change, videolaryngoscopy allows neonatal tracheal intubation with a comparable success rate to direct laryngoscopy in a pre-hospital and retrieval setting.
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Affiliation(s)
- David Lacquiere
- South Australian Ambulance Service MedSTAR, Adelaide, South Australia, Australia
- Pulse Anaesthetics, Adelaide, South Australia, Australia
| | - Jacob Smith
- Emergency Department, Ninewells Hospital, Dundee, UK
| | - Neel Bhanderi
- South Australian Ambulance Service MedSTAR, Adelaide, South Australia, Australia
- Emergency Department, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Francis Lockie
- South Australian Ambulance Service MedSTAR, Adelaide, South Australia, Australia
- Paediatric Emergency Department, Women and Children's Hospital, Adelaide, South Australia, Australia
| | - Jacintha Pickles
- South Australian Ambulance Service MedSTAR, Adelaide, South Australia, Australia
| | - Mardi Steere
- Paediatric Emergency Department, Women and Children's Hospital, Adelaide, South Australia, Australia
- Royal Flying Doctor Service SA/NT, Adelaide, South Australia, Australia
| | - John Craven
- Emergency Department, Mount Barker District Soldiers Memorial Hospital, Mount Barker, South Australia, Australia
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Stefan Mazur
- South Australian Ambulance Service MedSTAR, Adelaide, South Australia, Australia
- Emergency Department, Royal Adelaide Hospital, Adelaide, South Australia, Australia
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Geraghty LE, Dunne EA, Ní Chathasaigh CM, Vellinga A, Adams NC, O'Currain EM, McCarthy LK, O'Donnell CPF. Video versus Direct Laryngoscopy for Urgent Intubation of Newborn Infants. N Engl J Med 2024; 390:1885-1894. [PMID: 38709215 DOI: 10.1056/nejmoa2402785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/07/2024]
Abstract
BACKGROUND Repeated attempts at endotracheal intubation are associated with increased adverse events in neonates. When clinicians view the airway directly with a laryngoscope, fewer than half of first attempts are successful. The use of a video laryngoscope, which has a camera at the tip of the blade that displays a view of the airway on a screen, has been associated with a greater percentage of successful intubations on the first attempt than the use of direct laryngoscopy in adults and children. The effect of video laryngoscopy among neonates is uncertain. METHODS In this single-center trial, we randomly assigned neonates of any gestational age who were undergoing intubation in the delivery room or neonatal intensive care unit (NICU) to the video-laryngoscopy group or the direct-laryngoscopy group. Randomization was stratified according to gestational age (<32 weeks or ≥32 weeks). The primary outcome was successful intubation on the first attempt, as determined by exhaled carbon dioxide detection. RESULTS Data were analyzed for 214 of the 226 neonates who were enrolled in the trial, 63 (29%) of whom were intubated in the delivery room and 151 (71%) in the NICU. Successful intubation on the first attempt occurred in 79 of the 107 patients (74%; 95% confidence interval [CI], 66 to 82) in the video-laryngoscopy group and in 48 of the 107 patients (45%; 95% CI, 35 to 54) in the direct-laryngoscopy group (P<0.001). The median number of attempts to achieve successful intubation was 1 (95% CI, 1 to 1) in the video-laryngoscopy group and 2 (95% CI, 1 to 2) in the direct-laryngoscopy group. The median lowest oxygen saturation during intubation was 74% (95% CI, 65 to 78) in the video-laryngoscopy group and 68% (95% CI, 62 to 74) in the direct-laryngoscopy group; the lowest heart rate was 153 beats per minute (95% CI, 148 to 158) and 148 (95% CI, 140 to 156), respectively. CONCLUSIONS Among neonates undergoing urgent endotracheal intubation, video laryngoscopy resulted in a greater number of successful intubations on the first attempt than direct laryngoscopy. (Funded by the National Maternity Hospital Foundation; VODE ClinicalTrials.gov number, NCT04994652.).
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Affiliation(s)
- Lucy E Geraghty
- From the Departments of Neonatology (L.E.G., E.A.D., C.M.N.C., E.M.O., L.K.M., C.P.F.O.) and Radiology (N.C.A.), National Maternity Hospital, and the School of Medicine (L.E.G., C.M.N.C., E.M.O., L.K.M., C.P.F.O.) and the Centre for Support and Training in Analysis and Research (CSTAR), School of Public Health, Physiotherapy, and Sports Science (A.V.), University College Dublin - both in Dublin
| | - Emma A Dunne
- From the Departments of Neonatology (L.E.G., E.A.D., C.M.N.C., E.M.O., L.K.M., C.P.F.O.) and Radiology (N.C.A.), National Maternity Hospital, and the School of Medicine (L.E.G., C.M.N.C., E.M.O., L.K.M., C.P.F.O.) and the Centre for Support and Training in Analysis and Research (CSTAR), School of Public Health, Physiotherapy, and Sports Science (A.V.), University College Dublin - both in Dublin
| | - Caitríona M Ní Chathasaigh
- From the Departments of Neonatology (L.E.G., E.A.D., C.M.N.C., E.M.O., L.K.M., C.P.F.O.) and Radiology (N.C.A.), National Maternity Hospital, and the School of Medicine (L.E.G., C.M.N.C., E.M.O., L.K.M., C.P.F.O.) and the Centre for Support and Training in Analysis and Research (CSTAR), School of Public Health, Physiotherapy, and Sports Science (A.V.), University College Dublin - both in Dublin
| | - Akke Vellinga
- From the Departments of Neonatology (L.E.G., E.A.D., C.M.N.C., E.M.O., L.K.M., C.P.F.O.) and Radiology (N.C.A.), National Maternity Hospital, and the School of Medicine (L.E.G., C.M.N.C., E.M.O., L.K.M., C.P.F.O.) and the Centre for Support and Training in Analysis and Research (CSTAR), School of Public Health, Physiotherapy, and Sports Science (A.V.), University College Dublin - both in Dublin
| | - Niamh C Adams
- From the Departments of Neonatology (L.E.G., E.A.D., C.M.N.C., E.M.O., L.K.M., C.P.F.O.) and Radiology (N.C.A.), National Maternity Hospital, and the School of Medicine (L.E.G., C.M.N.C., E.M.O., L.K.M., C.P.F.O.) and the Centre for Support and Training in Analysis and Research (CSTAR), School of Public Health, Physiotherapy, and Sports Science (A.V.), University College Dublin - both in Dublin
| | - Eoin M O'Currain
- From the Departments of Neonatology (L.E.G., E.A.D., C.M.N.C., E.M.O., L.K.M., C.P.F.O.) and Radiology (N.C.A.), National Maternity Hospital, and the School of Medicine (L.E.G., C.M.N.C., E.M.O., L.K.M., C.P.F.O.) and the Centre for Support and Training in Analysis and Research (CSTAR), School of Public Health, Physiotherapy, and Sports Science (A.V.), University College Dublin - both in Dublin
| | - Lisa K McCarthy
- From the Departments of Neonatology (L.E.G., E.A.D., C.M.N.C., E.M.O., L.K.M., C.P.F.O.) and Radiology (N.C.A.), National Maternity Hospital, and the School of Medicine (L.E.G., C.M.N.C., E.M.O., L.K.M., C.P.F.O.) and the Centre for Support and Training in Analysis and Research (CSTAR), School of Public Health, Physiotherapy, and Sports Science (A.V.), University College Dublin - both in Dublin
| | - Colm P F O'Donnell
- From the Departments of Neonatology (L.E.G., E.A.D., C.M.N.C., E.M.O., L.K.M., C.P.F.O.) and Radiology (N.C.A.), National Maternity Hospital, and the School of Medicine (L.E.G., C.M.N.C., E.M.O., L.K.M., C.P.F.O.) and the Centre for Support and Training in Analysis and Research (CSTAR), School of Public Health, Physiotherapy, and Sports Science (A.V.), University College Dublin - both in Dublin
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Solanki S, Dogra S, Gupta PK, Peters NJ, Malik MA, Mahajan JK. Randomized controlled trial to evaluate the rate of successful neonatal endotracheal intubation performed with a stylet versus without a stylet. Paediatr Anaesth 2024; 34:448-453. [PMID: 38305632 DOI: 10.1111/pan.14845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 12/20/2023] [Accepted: 01/09/2024] [Indexed: 02/03/2024]
Abstract
INTRODUCTION Neonates in intensive care units often require endotracheal intubation and mechanical ventilation. During this intubation procedure, a stylet is frequently used along with an endotracheal tube. Despite the widespread use of a stylet, it is still not known whether its use increases the intubation success rate. This study examined the association between stylet use and the intubation success rate in surgical neonates. METHODOLOGY This single-center study was conducted between December 2021 and December 2022 in the Neonatal surgical intensive care unit of a tertiary care center in Northern India. Infants were randomized to have the endotracheal intubation procedure performed using either an endotracheal tube alone or with a stylet. The primary outcome of the study was to assess the successful first-attempt neonatal endotracheal intubation rate with and without using a stylet. Apart from the rate of successful intubation, the duration of the intubation and complications during the intubation procedures as measured by bradycardia, desaturation episodes, and local trauma were also recorded. Both groups were thus compared on above mentioned outcomes. RESULTS The total number of neonates enrolled were 200, and the overall success rate (81% in the stylet group vs. 73% in the non-stylet group) was not statistically significant. Intubation time was however less, when stylet was used (16.2 ± 4.3 vs. 17.5 ± 5.0 s, p = .046). When the endotracheal tube size was 3 or less, the success rate was substantially higher in the stylet group (80%) than the non-stylet group (63%), p = .03. No statistical difference was recorded for bleeding and local trauma, though the esophageal intubation rate was higher when intubation was attempted without the stylet. CONCLUSION Endotracheal intubation using a stylet did not significantly improve the success rate of the procedure, however, intubation time significantly varied between groups and in different conditions. The rigidity and curvature provided by the stylet may facilitate the process of intubation when smaller caliber endotracheal tubes are used.
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Affiliation(s)
| | - Shivani Dogra
- Department of Paediatric Surgery, PGIMER, Chandigarh, India
| | - Pramod K Gupta
- Department of Paediatric Surgery, PGIMER, Chandigarh, India
| | - Nitin J Peters
- Department of Paediatric Surgery, PGIMER, Chandigarh, India
| | - Muneer A Malik
- Department of Paediatric Surgery, PGIMER, Chandigarh, India
| | - J K Mahajan
- Department of Paediatric Surgery, PGIMER, Chandigarh, India
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Song ES, Jeon GW. Updates in neonatal resuscitation: routine use of laryngeal masks as an alternative to face masks. Clin Exp Pediatr 2024; 67:240-246. [PMID: 37448129 PMCID: PMC11065637 DOI: 10.3345/cep.2023.00619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 05/17/2023] [Accepted: 07/10/2023] [Indexed: 07/15/2023] Open
Abstract
Although positive-pressure ventilation (PPV) has traditionally been performed using a face mask in neonatal resuscitation, face mask ventilation for delivering PPV has a high failure rate due to mask leaks, airway obstruction, or gastric inflation. Furthermore, face mask ventilation is compromised during chest compressions. Endotracheal intubation in neonates requires a high skill level, with a first-attempt success rate of <50%. Laryngeal masks can transfer positive pressure more effectively even during chest compressions, resulting in a lower PPV failure rate compared to that of face masks in neonatal resuscitation. In addition, inserting a laryngeal mask is easier and more accessible than endotracheal intubation, and mortality rates do not differ between the 2 methods. Therefore, in neonatal resuscitation, laryngeal masks are recommended in infants with gestational age >34 weeks and/or with a birth weight >2 kg, in cases of unsuccessful face mask ventilation (as a primary airway device) or endotracheal intubation (as a secondary airway device, alternative airway). In other words, laryngeal masks are recommended when endotracheal intubation fails as well as when PPV cannot be achieved. Although laryngeal masks are commonly used in anesthetized pediatric patients, they are infrequently used in neonatal resuscitation due to limited experience, a preference for endotracheal tubes, or a lack of awareness among the healthcare providers. Thus, healthcare providers must be aware of the usefulness of laryngeal masks in depressed neonates requiring PPV or endotracheal intubation, which can promptly resuscitate these infants and improve their outcomes, resulting in decreased morbidity and mortality rates.
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Affiliation(s)
- Eun Song Song
- Department of Pediatrics, Chonnam National University Medical School, Gwangju, Korea
| | - Ga Won Jeon
- Department of Pediatrics, Inha University Hospital, Inha University College of Medicine, Incheon, Korea
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Lee DT, Bruno CJ, Sharifi M, Shabanova V, Johnston LC. Assessing Barriers to Utilization of Premedication for Neonatal Intubation Based on the Theoretical Domains Framework. Am J Perinatol 2024; 41:e1163-e1171. [PMID: 36646097 DOI: 10.1055/s-0042-1760449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
OBJECTIVE This study aimed to identify barriers and facilitators of premedication utilization for nonemergent neonatal intubations (NIs) in a level IV neonatal intensive care unit (NICU). STUDY DESIGN Between November 2018 and January 2019, multidisciplinary providers at a level IV NICU were invited to participate in an anonymous, electronic survey based on Theoretical Domains Framework to identify influences on utilization of evidence-based recommendations for NI premedication. RESULTS Of 186 surveys distributed, 84 (45%) providers responded. Most agreed with premedication use in the following domains: professional role/identity (86%), emotions (79%), skills (72%), optimism (71%), and memory, attention, and decision process (71%). Domains with less agreement include social influences (42%), knowledge (57%), intention (60%), belief about capabilities (63%), and behavior regulation (64%). Additional barriers include environmental context and resources, and beliefs about consequences. CONCLUSION Several factors influence premedication use for nonemergent NI and may serve as facilitators and/or barriers. Efforts to address barriers should incorporate a multidisciplinary approach to improve patient outcomes and decrease procedure-related pain. KEY POINTS · Premedication for NIs can optimize conditions and decrease rates of tracheal intubation adverse events but there is significant international and institutional variation for premedication use for NI.. · Guided by implementation science methods, the Theoretical Domains Framework was utilized to construct a novel assessment tool to determine potential barriers to and facilitators of the use of premedication for NI.. · Several factors influence premedication for nonemergent NI..
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Affiliation(s)
- Dianne T Lee
- Department of Pediatrics, Children's Mercy Kansas City Hospital, Kansas City, Missouri
| | - Christie J Bruno
- Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut
| | - Mona Sharifi
- Department of Pediatrics, Center for Implementation Science, Yale University School of Medicine, New Haven, Connecticut
| | - Veronika Shabanova
- Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut
| | - Lindsay C Johnston
- Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut
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Sugiura T, Urushibata R, Fukaya S, Shioda T, Fukuoka T, Iwata O. Dependence of Successful Airway Management in Neonatal Simulation Manikins on the Type of Supraglottic Airway Device and Providers' Backgrounds. CHILDREN (BASEL, SWITZERLAND) 2024; 11:530. [PMID: 38790524 PMCID: PMC11119467 DOI: 10.3390/children11050530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Revised: 04/24/2024] [Accepted: 04/25/2024] [Indexed: 05/26/2024]
Abstract
Supraglottic airway devices such as laryngeal masks and i-gels are useful for airway management. The i-gel is a relatively new device that replaces the air-inflated cuff of the laryngeal mask with a gel-filled cuff. It remains unclear which device is more effective for neonatal resuscitation. We aimed to evaluate the dependence of successful airway management in neonatal simulators on the device type and providers' backgrounds. Ninety-one healthcare providers performed four attempts at airway management using a laryngeal mask and i-gel in two types of neonatal manikins. The dependence of successful insertions within 16.7 s (75th percentile of all successful insertions) on the device type and providers' specialty, years of healthcare service, and completion of the neonatal resuscitation training course was assessed. Successful insertion (p = 0.001) and insertion time (p = 0.003) were associated with using the i-gel vs. laryngeal mask. The providers' backgrounds were not associated with the outcome. Using the i-gel was associated with more successful airway management than laryngeal masks using neonatal manikins. Considering the limited effect of the provider's specialty and experience, using the i-gel as the first-choice device in neonatal resuscitation may be advantageous. Prospective studies are warranted to compare these devices in the clinical setting.
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Affiliation(s)
- Takahiro Sugiura
- Department of Pediatrics and Neonatology, Toyohashi Municipal Hospital, 50 Aza Hakken Nishi, Aotake-cho, Toyohashi 441-8570, Japan;
- Department of Pediatrics and Neonatology, Shizuoka Saiseikai General Hospital, Shizuoka 422-8527, Japan; (R.U.); (T.S.); (T.F.)
| | - Rei Urushibata
- Department of Pediatrics and Neonatology, Shizuoka Saiseikai General Hospital, Shizuoka 422-8527, Japan; (R.U.); (T.S.); (T.F.)
- Department of Pediatrics, Hamamatsu University School of Medicine, Hamamatsu 431-3192, Japan
| | - Satoko Fukaya
- Center for Human Development and Family Science, Department of Pediatrics and Neonatology, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho, Nagoya 467-8601, Japan;
| | - Tsutomu Shioda
- Department of Pediatrics and Neonatology, Shizuoka Saiseikai General Hospital, Shizuoka 422-8527, Japan; (R.U.); (T.S.); (T.F.)
| | - Tetsuya Fukuoka
- Department of Pediatrics and Neonatology, Shizuoka Saiseikai General Hospital, Shizuoka 422-8527, Japan; (R.U.); (T.S.); (T.F.)
| | - Osuke Iwata
- Department of Pediatrics and Neonatology, Toyohashi Municipal Hospital, 50 Aza Hakken Nishi, Aotake-cho, Toyohashi 441-8570, Japan;
- Center for Human Development and Family Science, Department of Pediatrics and Neonatology, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho, Nagoya 467-8601, Japan;
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Peebles PJ, Jensen EA, Herrick HM, Wildenhain PJ, Rumpel J, Moussa A, Singh N, Abou Mehrem A, Quek BH, Wagner M, Pouppirt NR, Glass KM, Tingay DG, Hodgson KA, O’Shea JE, Sawyer T, Brei BK, Jung P, Unrau J, Kim JH, Barry J, DeMeo S, Johnston LC, Nishisaki A, Foglia EE. Endotracheal Tube Size Adjustments Within Seven Days of Neonatal Intubation. Pediatrics 2024; 153:e2023062925. [PMID: 38469643 PMCID: PMC10979295 DOI: 10.1542/peds.2023-062925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/08/2023] [Indexed: 03/13/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Neonatal endotracheal tube (ETT) size recommendations are based on limited evidence. We sought to determine data-driven weight-based ETT sizes for infants undergoing tracheal intubation and to compare these with Neonatal Resuscitation Program (NRP) recommendations. METHODS Retrospective multicenter cohort study from an international airway registry. We evaluated ETT size changes (downsizing to a smaller ETT during the procedure or upsizing to a larger ETT within 7 days) and risk of procedural adverse outcomes associated with first-attempt ETT size selection when stratifying the cohort into 200 g subgroups. RESULTS Of 7293 intubations assessed, the initial ETT was downsized in 5.0% of encounters and upsized within 7 days in 1.5%. ETT downsizing was most common when NRP-recommended sizes were attempted in the following weight subgroups: 1000 to 1199 g with a 3.0 mm (12.6%) and 2000 to 2199 g with a 3.5 mm (17.1%). For infants in these 2 weight subgroups, selection of ETTs 0.5 mm smaller than NRP recommendations was independently associated with lower odds of adverse outcomes compared with NRP-recommended sizes. Among infants weighing 1000 to 1199 g: any tracheal intubation associated event, 20.8% with 2.5 mm versus 21.9% with 3.0 mm (adjusted OR [aOR] 0.62, 95% confidence interval [CI] 0.41-0.94); severe oxygen desaturation, 35.2% with 2.5 mm vs 52.9% with 3.0 mm (aOR 0.53, 95% CI 0.38-0.75). Among infants weighing 2000 to 2199 g: severe oxygen desaturation, 41% with 3.0 mm versus 56% with 3.5mm (aOR 0.55, 95% CI 0.34-0.89). CONCLUSIONS For infants weighing 1000 to 1199 g and 2000 to 2199 g, the recommended ETT size was frequently downsized during the procedure, whereas 0.5 mm smaller ETT sizes were associated with fewer adverse events and were rarely upsized.
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Affiliation(s)
- Patrick J. Peebles
- Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Erik A. Jensen
- Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | | | - Jennifer Rumpel
- Univeristy of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Ahmed Moussa
- Centre Hospitalier Universitaire Sainte-Justine, Université de Montréal, Montréal, Canada
| | - Neetu Singh
- Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | | | | | | | | | | | - David G. Tingay
- Neonatal Research, Murdoch Children’s Research Institute, Melbourne, Australia; Royal Children’s, Melbourne, Australia; Department of Paediatrics, University of Melbourne, Australia
| | | | | | | | | | - Philipp Jung
- University Hospital Schleswig Holstein, Campus Lübeck, Lübeck, Germany
| | - Jennifer Unrau
- Alberta Children’s Hospital, University of Calgary, Alberta, Canada
| | - Jae H. Kim
- Perinatal Institute, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - James Barry
- University of Colorado School of Medicine, Aurora, Colorado
| | | | | | - Akira Nishisaki
- Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
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Guthrie SO, Roberts KD. Less invasive surfactant administration methods: Who, what and how. J Perinatol 2024; 44:472-477. [PMID: 37737494 DOI: 10.1038/s41372-023-01778-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 08/14/2023] [Accepted: 09/12/2023] [Indexed: 09/23/2023]
Abstract
Surfactant administration via an endotracheal tube (ETT) has been the standard of care for infants with respiratory distress syndrome for decades. As non-invasive ventilation has become commonplace in the NICU, methods for administering surfactant without use of an ETT have been developed. These methods include thin catheter techniques (LISA, MIST), aerosolization/ nebulization, and surfactant administration through laryngeal (LMA) or supraglottic airways (SALSA). This review will describe these methods and discuss considerations and implementation into clinical practice.
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Affiliation(s)
- S O Guthrie
- Department of Pediatrics, Division of Neonatology, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - K D Roberts
- Department of Pediatrics, Division of Neonatology, University of Minnesota, Minneapolis, MN, USA.
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9
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Byrne BJ, Kapadia V. Improving Accuracy for Initial Endotracheal Tube Size Selection for Newborns. Pediatrics 2024; 153:e2023064843. [PMID: 38469641 DOI: 10.1542/peds.2023-064843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/24/2024] [Indexed: 03/13/2024] Open
Affiliation(s)
- Bobbi J Byrne
- Division of Neonatal Perinatal Medicine, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana
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Maglio S, Cavallin F, Sala C, Bua B, Villani PE, Menciassi A, Tognarelli S, Trevisanuto D. Neonatal intubation: what are we doing? Eur J Pediatr 2024; 183:1811-1817. [PMID: 38260994 PMCID: PMC11001655 DOI: 10.1007/s00431-023-05418-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 12/28/2023] [Accepted: 12/30/2023] [Indexed: 01/24/2024]
Abstract
How and when the forces are applied during neonatal intubation are currently unknown. This study investigated the pattern of the applied forces by using sensorized laryngoscopes during the intubation process in a neonatal manikin. Nine users of direct laryngoscope and nine users of straight-blade video laryngoscope were included in a neonatal manikin study. During each procedure, relevant forces were measured using a force epiglottis sensor that was placed on the distal surface of the blade. The pattern of the applied forces could be divided into three sections. With the direct laryngoscope, the first section showed either a quick rise of the force or a discontinuous rise with several peaks; after reaching the maximum force, there was a sort of plateau followed by a quick drop of the applied forces. With the video laryngoscope, the first section showed a quick rise of the force; after reaching the maximum force, there was an irregular and heterogeneous plateau, followed by heterogeneous decreases of the applied forces. Moreover, less forces were recorded when using the video laryngoscope. Conclusions: This neonatal manikin study identified three sections in the diagram of the forces applied during intubation, which likely mirrored the three main phases of intubation. Overall, the pattern of each section showed some differences in relation to the laryngoscope (direct or video) that was used during the procedure. These findings may provide useful insights for improving the understanding of the procedure. What is Known: • Neonatal intubation is a life-saving procedure that requires a skilled operator and may cause direct trauma to the tissues and precipitate adverse reactions. • Intubation with a videolaryngoscope requires less force than with a direct laryngoscope, but how and when the forces are applied during the whole neonatal intubation procedure are currently unknown. What is New: • Forces applied to the epiglottis during intubation can be divided into three sections: (i) an initial increase, (ii) a sort of plateau, and (iii) a decrease. • The pattern of each section shows some differences in relation to the laryngoscope (direct or videolaryngoscope) that is used during the procedure.
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Affiliation(s)
- Sabina Maglio
- The BioRobotics Institute, Scuola Superiore Sant'Anna, Pisa, Italy
- Department of Excellence in Robotics & AI, Scuola Superiore Sant'Anna, Pisa, Italy
| | | | - Chiara Sala
- Department of Pediatric Anesthesia and Intensive Care "V. Buzzi" Children's Hospital, University of Milan, Milan, Italy
| | - Benedetta Bua
- Department of Women and Children Health, University Hospital of Padua, Via Giustiniani, 3, 35128, Padua, Italy
| | - Paolo Ernesto Villani
- Department of Woman's and Child's Health, Poliambulanza Hospital, Fondazione Poliambulanza, Brescia, Italy
| | - Arianna Menciassi
- The BioRobotics Institute, Scuola Superiore Sant'Anna, Pisa, Italy
- Department of Excellence in Robotics & AI, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Selene Tognarelli
- The BioRobotics Institute, Scuola Superiore Sant'Anna, Pisa, Italy
- Department of Excellence in Robotics & AI, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Daniele Trevisanuto
- Department of Women and Children Health, University Hospital of Padua, Via Giustiniani, 3, 35128, Padua, Italy.
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11
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Coelho LP, Couto TB. Can video laryngoscopy and supplemental oxygen redefine pediatric, infant and neonatal tracheal intubation standards? Transl Pediatr 2024; 13:508-512. [PMID: 38590366 PMCID: PMC10998985 DOI: 10.21037/tp-23-530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 02/05/2024] [Indexed: 04/10/2024] Open
Affiliation(s)
- Laila Pinto Coelho
- Postgraduate Medical Education Department, University of São Paulo Faculty of Medicine, São Paulo, Brazil
| | - Thomaz Bittencourt Couto
- Pediatric Emergency Department, Instituto da Criança do Hospital das Clínicas, Children’s Hospital, University of São Paulo Faculty of Medicine, São Paulo, Brazil
- Simulation Center, Hospital Israelita Albert Einstein, São Paulo, Brazil
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12
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Matlock DN, Ratcliffe SJ, Courtney SE, Kirpalani H, Firestone K, Stein H, Dysart K, Warren K, Goldstein MR, Lund KC, Natarajan A, Demissie E, Foglia EE. The Diaphragmatic Initiated Ventilatory Assist (DIVA) trial: study protocol for a randomized controlled trial comparing rates of extubation failure in extremely premature infants undergoing extubation to non-invasive neurally adjusted ventilatory assist versus non-synchronized nasal intermittent positive pressure ventilation. Trials 2024; 25:201. [PMID: 38509583 PMCID: PMC10953115 DOI: 10.1186/s13063-024-08038-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 03/06/2024] [Indexed: 03/22/2024] Open
Abstract
BACKGROUND Invasive mechanical ventilation contributes to bronchopulmonary dysplasia (BPD), the most common complication of prematurity and the leading respiratory cause of childhood morbidity. Non-invasive ventilation (NIV) may limit invasive ventilation exposure and can be either synchronized or non-synchronized (NS). Pooled data suggest synchronized forms may be superior. Non-invasive neurally adjusted ventilatory assist (NIV-NAVA) delivers NIV synchronized to the neural signal for breathing, which is detected with a specialized catheter. The DIVA (Diaphragmatic Initiated Ventilatory Assist) trial aims to determine in infants born 240/7-276/7 weeks' gestation undergoing extubation whether NIV-NAVA compared to non-synchronized nasal intermittent positive pressure ventilation (NS-NIPPV) reduces the incidence of extubation failure within 5 days of extubation. METHODS This is a prospective, unblinded, pragmatic, multicenter phase III randomized clinical trial. Inclusion criteria are preterm infants 24-276/7 weeks gestational age who were intubated within the first 7 days of life for at least 12 h and are undergoing extubation in the first 28 postnatal days. All sites will enter an initial run-in phase, where all infants are allocated to NIV-NAVA, and an independent technical committee assesses site performance. Subsequently, all enrolled infants are randomized to NIV-NAVA or NS-NIPPV at extubation. The primary outcome is extubation failure within 5 days of extubation, defined as any of the following: (1) rise in FiO2 at least 20% from pre-extubation for > 2 h, (2) pH ≤ 7.20 or pCO2 ≥ 70 mmHg; (3) > 1 apnea requiring positive pressure ventilation (PPV) or ≥ 6 apneas requiring stimulation within 6 h; (4) emergent intubation for cardiovascular instability or surgery. Our sample size of 478 provides 90% power to detect a 15% absolute reduction in the primary outcome. Enrolled infants will be followed for safety and secondary outcomes through 36 weeks' postmenstrual age, discharge, death, or transfer. DISCUSSION The DIVA trial is the first large multicenter trial designed to assess the impact of NIV-NAVA on relevant clinical outcomes for preterm infants. The DIVA trial design incorporates input from clinical NAVA experts and includes innovative features, such as a run-in phase, to ensure consistent technical performance across sites. TRIAL REGISTRATION www. CLINICALTRIALS gov , trial identifier NCT05446272 , registered July 6, 2022.
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Affiliation(s)
- David N Matlock
- University of Arkansas for Medical Sciences, 4301 W. Markham St., Slot 512-5B, Little Rock, AR, 72205, USA.
- University of Arkansas for Medical Sciences, Little Rock, AR, USA.
| | | | | | - Haresh Kirpalani
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- McMaster University, Hamilton, ON, Canada
| | | | | | - Kevin Dysart
- Nemours Children's Health Wilmington, Philadelphia, PA, USA
| | - Karen Warren
- The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | | | | | - Aruna Natarajan
- National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Ejigayehu Demissie
- National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Elizabeth E Foglia
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- The Children's Hospital of Philadelphia, Philadelphia, PA, USA
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13
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Foglia EE, Shah BA, DeShea L, Lander K, Kamath-Rayne BD, Herrick HM, Zaichkin J, Lee S, Bonafide C, Song C, Hallford G, Lee HC, Kapadia V, Leone T, Josephsen J, Gupta A, Strand ML, Beasley WH, Szyld E. Laryngeal mask use during neonatal resuscitation at birth: A United States-based survey of neonatal resuscitation program providers and instructors. Resusc Plus 2024; 17:100515. [PMID: 38094660 PMCID: PMC10716019 DOI: 10.1016/j.resplu.2023.100515] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 11/13/2023] [Accepted: 11/15/2023] [Indexed: 04/11/2024] Open
Abstract
Aim Neonatal resuscitation guidelines promote the laryngeal mask (LM) interface for positive pressure ventilation (PPV), but little is known about how the LM is used among Neonatal Resuscitation Program (NRP) Providers and Instructors. The study aim was to characterize the training, experience, confidence, and perspectives of NRP Providers and Instructors regarding LM use during neonatal resuscitation at birth. Methods A voluntary anonymous survey was emailed to all NRP Providers and Instructors. Survey items addressed training, experience, confidence, and barriers for LM use during resuscitation. Associations between respondent characteristics and outcomes of both LM experience and confidence were assessed using logistic regression. Results Between 11/7/22-12/12/22, there were 5,809 survey respondents: 68% were NRP Providers, 55% were nurses, and 87% worked in a hospital setting. Of these, 12% had ever placed a LM during newborn resuscitation, and 25% felt very or completely confident using a LM. In logistic regression, clinical or simulated hands-on training, NRP Instructor role, professional role, and practice setting were all associated with both LM experience and confidence.The three most frequently identified barriers to LM use were insufficient experience (46%), preference for other interfaces (25%), and failure to consider the LM during resuscitation (21%). One-third (33%) reported that LMs are not available where they resuscitate newborns. Conclusion Few NRP providers and instructors use the LM during neonatal resuscitation. Strategies to increase LM use include hands-on clinical training, outreach promoting the advantages of the LM compared to other interfaces, and improving availability of the LM in delivery settings.
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Affiliation(s)
- Elizabeth E. Foglia
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, PA, United States
| | - Birju A. Shah
- Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
| | - Lise DeShea
- Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
| | - Kathryn Lander
- Global Child Health and Life Support, American Academy of Pediatrics, Itasca, IL, United States
| | - Beena D. Kamath-Rayne
- Global Child Health and Life Support, American Academy of Pediatrics, Itasca, IL, United States
| | - Heidi M. Herrick
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, PA, United States
| | | | - Sura Lee
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, PA, United States
| | - Christopher Bonafide
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, PA, United States
| | - Clara Song
- Southern California Permanente Medical Group, Anaheim, CA, United States
| | - Gene Hallford
- Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
| | - Henry C. Lee
- Division of Neonatology, University of California San Diego School of Medicine, La Jolla, CA, United States
| | - Vishal Kapadia
- Division of Neonatology, Department of Pediatrics, UT Southwestern, Dallas, TX, United States
| | - Tina Leone
- Division of Neonatology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, United States
| | - Justin Josephsen
- Division of Neonatology, Saint Louis University School of Medicine, St. Louis, MO, United States
| | - Arun Gupta
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, United States
| | - Marya L. Strand
- Division of Neonatology, Saint Louis University School of Medicine, St. Louis, MO, United States
| | - William H. Beasley
- Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
| | - Edgardo Szyld
- Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
| | - for the American Academy of Pediatrics Delivery Room Intervention, Evaluation DRIVE Network
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, PA, United States
- Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
- Global Child Health and Life Support, American Academy of Pediatrics, Itasca, IL, United States
- Positive Pressure, PLLC, Shelton, WA, United States
- Southern California Permanente Medical Group, Anaheim, CA, United States
- Division of Neonatology, University of California San Diego School of Medicine, La Jolla, CA, United States
- Division of Neonatology, Department of Pediatrics, UT Southwestern, Dallas, TX, United States
- Division of Neonatology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, United States
- Division of Neonatology, Saint Louis University School of Medicine, St. Louis, MO, United States
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, United States
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14
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Stein ML, Sarmiento Argüello LA, Staffa SJ, Heunis J, Egbuta C, Flynn SG, Khan SA, Sabato S, Taicher BM, Chiao F, Bosenberg A, Lee AC, Adams HD, von Ungern-Sternberg BS, Park RS, Peyton JM, Olomu PN, Hunyady AI, Garcia-Marcinkiewicz A, Fiadjoe JE, Kovatsis PG. Airway management in the paediatric difficult intubation registry: a propensity score matched analysis of outcomes over time. EClinicalMedicine 2024; 69:102461. [PMID: 38374968 PMCID: PMC10875248 DOI: 10.1016/j.eclinm.2024.102461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 01/16/2024] [Accepted: 01/17/2024] [Indexed: 02/21/2024] Open
Abstract
Background The Paediatric Difficult Intubation Collaborative identified multiple attempts and persistence with direct laryngoscopy as risk factors for complications in children with difficult tracheal intubations and subsequently engaged in initiatives to reduce repeated attempts and persistence with direct laryngoscopy in children. We hypothesised these efforts would lead to fewer attempts, fewer direct laryngoscopy attempts and decrease complications. Methods Paediatric patients less than 18 years of age with difficult direct laryngoscopy were enrolled in the Paediatric Difficult Intubation Registry. We define patients with difficult direct laryngoscopy as those in whom (1) an attending or consultant obtained a Cormack Lehane Grade 3 or 4 view on direct laryngoscopy, (2) limited mouth opening makes direct laryngoscopy impossible, (3) direct laryngoscopy failed in the preceding 6 months, and (4) direct laryngoscopy was deferred due to perceived risk of harm or poor chance of success. We used a 5:1 propensity score match to compare an early cohort from the initial Paediatric Difficult Intubation Registry analysis (August 6, 2012-January 31, 2015, 785 patients, 13 centres) and a current cohort from the Registry (March 4, 2017-March 31, 2023, 3925 patients, 43 centres). The primary outcome was first attempt success rate between cohorts. Success was defined as confirmed endotracheal intubation and assessed by the treating clinician. Secondary outcomes were eventual success rate, number of attempts at intubation, number of attempts with direct laryngoscopy, the incidence of persistence with direct laryngoscopy, use of supplemental oxygen, all complications, and severe complications. Findings First-attempt success rate was higher in the current cohort (42% vs 32%, OR 1.5 95% CI 1.3-1.8, p < 0.001). In the current cohort, there were fewer attempts (2.2 current vs 2.7 early, regression coefficient -0.5 95% CI -0.6 to -0.4, p < 0.001), fewer attempts with direct laryngoscopy (0.6 current vs 1.0 early, regression coefficient -0.4 95% CI -0.4 to 0.3, p < 0.001), and reduced persistence with direct laryngoscopy beyond two attempts (7.3% current vs 14.1% early, OR 0.5 95% CI 0.4-0.6, p < 0.001). Overall complication rates were similar between cohorts (19% current vs 20% early). Severe complications decreased to 1.8% in the current cohort from 3.2% in the early cohort (OR 0.55 95% CI 0.35-0.87, p = 0.011). Cardiac arrests decreased to 0.8% in the current cohort from 1.8% in the early cohort. We identified persistence with direct laryngoscopy as a potentially modifiable factor associated with severe complications. Interpretation In the current cohort, children with difficult tracheal intubations underwent fewer intubation attempts, fewer attempts with direct laryngoscopy, and had a nearly 50% reduction in severe complications. As persistence with direct laryngoscopy continues to be associated with severe complications, efforts to limit direct laryngoscopy and promote rapid transition to advanced techniques may enhance patient safety. Funding None.
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Affiliation(s)
- Mary Lyn Stein
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital and Harvard Medical School, Boston, MA, USA
| | | | - Steven J. Staffa
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Julia Heunis
- Department of Pediatrics, Boston Children’s Hospital, Department of Anesthesiology, Perioperative, and Pain Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| | - Chinyere Egbuta
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Stephen G. Flynn
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Sabina A. Khan
- Department of Anesthesiology, UTHealth - McGovern Medical School, Houston, TX, USA
| | - Stefano Sabato
- Department of Anaesthesia and Pain Management, Royal Children’s Hospital, and Anaesthesia Research Group, Murdoch Children’s Research Institute, Parkville, Australia
| | - Brad M. Taicher
- Department of Anesthesiology, Duke University Hospital, Durham, NC, USA
| | - Franklin Chiao
- Department of Anesthesiology, Westchester Medical Center, Valhalla, NY, USA
| | - Adrian Bosenberg
- Department of Anesthesiology and Pain Medicine, Seattle Children’s Hospital, University of Washington, Seattle, WA, USA
| | - Angela C. Lee
- Division of Anesthesiology, Pain and Perioperative Medicine, Children’s National Hospital, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - H. Daniel Adams
- Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Britta S. von Ungern-Sternberg
- Department of Anaesthesia and Pain Medicine, Perth Children’s Hospital, Institute for Paediatric Perioperative Excellence, Division of Emergency Medicine, Anaesthesia and Pain Medicine, The University of Western Australia, Perioperative Medicine Team, Perioperative Care Program, and Telethon Kids Institute, Perth, Australia
| | - Raymond S. Park
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital and Harvard Medical School, Boston, MA, USA
| | - James M. Peyton
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Patrick N. Olomu
- Department of Pediatric Anesthesiology and Pain Management, Children’s Health System of Texas, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Agnes I. Hunyady
- Department of Anesthesiology and Pain Medicine, Seattle Children’s Hospital, University of Washington, Seattle, WA, USA
| | - Annery Garcia-Marcinkiewicz
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - John E. Fiadjoe
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Pete G. Kovatsis
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital and Harvard Medical School, Boston, MA, USA
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15
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Johnson MD, Tingay DG, Perkins EJ, Sett A, Devsam B, Douglas E, Charlton JK, Wildenhain P, Rumpel J, Wagner M, Nadkarni V, Johnston L, Herrick HM, Hartman T, Glass K, Jung P, DeMeo SD, Shay R, Kim JH, Unrau J, Moussa A, Nishisaki A, Foglia EE. Factors that impact second attempt success for neonatal intubation following first attempt failure: a report from the National Emergency Airway Registry for Neonates. Arch Dis Child Fetal Neonatal Ed 2024:fetalneonatal-2023-326501. [PMID: 38418208 DOI: 10.1136/archdischild-2023-326501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 02/21/2024] [Indexed: 03/01/2024]
Abstract
OBJECTIVE To determine the factors associated with second attempt success and the risk of adverse events following a failed first attempt at neonatal tracheal intubation. DESIGN Retrospective analysis of prospectively collected data on intubations performed in the neonatal intensive care unit (NICU) and delivery room from the National Emergency Airway Registry for Neonates (NEAR4NEOS). SETTING Eighteen academic NICUs in NEAR4NEOS. PATIENTS Neonates requiring two or more attempts at intubation between October 2014 and December 2021. MAIN OUTCOME MEASURES The primary outcome was successful intubation on the second attempt, with severe tracheal intubation-associated events (TIAEs) or severe desaturation (≥20% decline in oxygen saturation) being secondary outcomes. Multivariate regression examined the associations between these outcomes and patient characteristics and changes in intubation practice. RESULTS 5805 of 13 126 (44%) encounters required two or more intubation attempts, with 3156 (54%) successful on the second attempt. Second attempt success was more likely with changes in any of the following: intubator (OR 1.80, 95% CI 1.56 to 2.07), stylet use (OR 1.65, 95% CI 1.36 to 2.01) or endotracheal tube (ETT) size (OR 2.11, 95% CI 1.74 to 2.56). Changes in stylet use were associated with a reduced chance of severe desaturation (OR 0.74, 95% CI 0.61 to 0.90), but changes in intubator, laryngoscope type or ETT size were not; no changes in intubator or equipment were associated with severe TIAEs. CONCLUSIONS Successful neonatal intubation on a second attempt was more likely with a change in intubator, stylet use or ETT size.
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Affiliation(s)
- Mitchell David Johnson
- Neonatal Medicine, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
- Neonatal Research, Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - David Gerald Tingay
- Neonatal Medicine, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
- Neonatal Research, Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Elizabeth J Perkins
- Neonatal Research, Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Arun Sett
- Neonatal Research, Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Newborn Services, Western Health, St Albans, Victoria, Australia
| | - Bianca Devsam
- Neonatal Medicine, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
- Neonatal Research, Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Ellen Douglas
- Neonatal Research, Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Julia K Charlton
- Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
- Division of Neonatology, British Columbia Women's Hospital and Health Centre, Vancouver, British Columbia, Canada
| | - Paul Wildenhain
- The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Jennifer Rumpel
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Michael Wagner
- Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Department of Pediatrics, Medical University Vienna, Vienna, Austria
| | - Vinay Nadkarni
- Department of Anesthesiology, Critical Care, and Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Lindsay Johnston
- Department of Pediatrics, Yale University, New Haven, Connecticut, USA
| | - Heidi M Herrick
- Division of Neonatology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Tyler Hartman
- Department of Pediatrics, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Kristen Glass
- Department of Pediatrics, Penn State Health Children's Hospital/Penn State College of Medicine, Hershey, Pennsylvania, USA
| | - Philipp Jung
- Department of Pediatrics, University Hospital Schleswig-Holstein, Luebeck, Germany
| | - Stephen D DeMeo
- Division of Neonatology, WakeMed Health and Hospitals, Raleigh, North Carolina, USA
| | - Rebecca Shay
- Department of Pediatrics, Division of Neonatology, University of Colorado, Aurora, Colorado, USA
| | - Jae H Kim
- Perinatal Institute, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Jennifer Unrau
- Newborn Critical Care, Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Ahmed Moussa
- Division of Neonatology, Department of Pediatrics, Centre Hospitalier Universitaire Sainte-Justine, Montreal, Quebec, Canada
- CHU Sainte-Justine Research Centre, Université de Montréal, Montreal, Quebec, Canada
| | - Akira Nishisaki
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Elizabeth E Foglia
- Division of Neonatology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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16
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Bisesi SA, Stauber SD, Hutchinson DJ, Acquisto NM. Current Practices and Safety of Medication Use During Pediatric Rapid Sequence Intubation. J Pediatr Pharmacol Ther 2024; 29:66-75. [PMID: 38332961 PMCID: PMC10849688 DOI: 10.5863/1551-6776-29.1.66] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 06/22/2023] [Indexed: 02/10/2024]
Abstract
OBJECTIVES This study aimed to characterize medication-related practices during and immediately -following rapid sequence intubation (RSI) in pediatric care units across the United States and to evaluate adverse drug events. METHODS This was a multicenter, observational study of medication practices surrounding intubation in pediatric and neonatal intensive care unit (NICU) and emergency department patients across the United States. RESULTS A total of 172 patients from 13 geographically diverse institutions were included. Overall, 24%, 69%, and 50% received preinduction, induction, and neuromuscular blockade, respectively. Induction and neuromuscular blocking agent (NMBA) use was low in NICU patients (52% and 23%, respectively), whereas nearly all patients intubated outside of the NICU received both (98% and 95%, respectively). NICU patients who received RSI medications were older and weighed more. Despite infrequent use of atropine (21%), only 3 patients developed bradycardia after RSI. Of the 119 patients who received an induction agent, fentanyl (67%) and midazolam (34%) were administered most frequently. Hypotension and hypertension occurred in 23% and 24% of patients, respectively, but were not associated with a single induction agent. Etomidate use was low and not associated with development of adrenal insufficiency. Rocuronium was the most used NMBA (78%). Succinylcholine use was low (11%) and administered despite hyperkalemia in 2 patients. Postintubation sedation and analgesia were not used or inadequate based on timing of initiation in many patients who received a non-depolarizing NMBA. CONCLUSIONS Medication practices surrounding pediatric RSI vary across the United States and may be influenced by patient location, age, and weight.
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Affiliation(s)
- Sarah A Bisesi
- Department of Pharmacy (SAB), University of Rochester Medical Center, Rochester, NY
| | - Sierra D Stauber
- Department of Pharmacy (SDS), University of Rochester Medical Center, Rochester, NY
| | - David J Hutchinson
- Department of Pharmacy Practice and Education (DJH), St. John Fisher University, Wegmans School of Pharmacy, Rochester, NY
| | - Nicole M Acquisto
- Departments of Pharmacy and Emergency Medicine (NMA), University of Rochester Medical Center, Rochester, NY
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17
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Fuchs A, Koepp G, Huber M, Aebli J, Afshari A, Bonfiglio R, Greif R, Lusardi AC, Romero CS, von Gernler M, Disma N, Riva T. Apnoeic oxygenation during paediatric tracheal intubation: a systematic review and meta-analysis. Br J Anaesth 2024; 132:392-406. [PMID: 38030551 DOI: 10.1016/j.bja.2023.10.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 10/03/2023] [Accepted: 10/24/2023] [Indexed: 12/01/2023] Open
Abstract
BACKGROUND Supplemental oxygen administration by apnoeic oxygenation during laryngoscopy for tracheal intubation is intended to prolong safe apnoea time, reduce the risk of hypoxaemia, and increase the success rate of first-attempt tracheal intubation under general anaesthesia. This systematic review examined the efficacy and effectiveness of apnoeic oxygenation during tracheal intubation in children. METHODS This systematic review and meta-analysis included randomised controlled trials and non-randomised studies in paediatric patients requiring tracheal intubation, evaluating apnoeic oxygenation by any method compared with patients without apnoeic oxygenation. Searched databases were MEDLINE, Embase, Cochrane Library, CINAHL, ClinicalTrials.gov, International Clinical Trials Registry Platform (ICTRP), Scopus, and Web of Science from inception to March 22, 2023. Data extraction and risk of bias assessment followed the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) recommendation. RESULTS After initial selection of 40 708 articles, 15 studies summarising 9802 children were included (10 randomised controlled trials, four pre-post studies, one prospective observational study) published between 1988 and 2023. Eight randomised controlled trials were included for meta-analysis (n=1070 children; 803 from operating theatres, 267 from neonatal intensive care units). Apnoeic oxygenation increased intubation first-pass success with no physiological instability (risk ratio [RR] 1.27, 95% confidence interval [CI] 1.03-1.57, P=0.04, I2=0), higher oxygen saturation during intubation (mean difference 3.6%, 95% CI 0.8-6.5%, P=0.02, I2=63%), and decreased incidence of hypoxaemia (RR 0.24, 95% CI 0.17-0.33, P<0.01, I2=51%) compared with no supplementary oxygen administration. CONCLUSION This systematic review with meta-analysis confirms that apnoeic oxygenation during tracheal intubation of children significantly increases first-pass intubation success rate. Furthermore, apnoeic oxygenation enables stable physiological conditions by maintaining oxygen saturation within the normal range. CLINICAL TRIAL REGISTRATION Protocol registered prospectively on PROSPERO (registration number: CRD42022369000) on December 2, 2022.
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Affiliation(s)
- Alexander Fuchs
- Department of Anaesthesiology and Pain Medicine, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland; Unit for Research in Anaesthesia, IRCCS Istituto Giannina Gaslini, Genoa, Italy.
| | - Gabriela Koepp
- Department of Anaesthesiology and Pain Medicine, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
| | - Markus Huber
- Department of Anaesthesiology and Pain Medicine, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
| | - Jonas Aebli
- Department of Anaesthesiology and Pain Medicine, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
| | - Arash Afshari
- Department of Paediatric And Obstetric Anesthesia, Juliane Marie Centre, Rigshospitalet, University of Copenhagen, Institute of Clinical Medicine, Copenhagen, Denmark
| | - Rachele Bonfiglio
- Unit for Research in Anaesthesia, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Robert Greif
- School of Medicine, Sigmund Freud University Vienna, Vienna, Austria; University of Bern, Bern, Switzerland
| | - Andrea C Lusardi
- Unit for Research in Anaesthesia, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Carolina S Romero
- Anesthesia, Critical Care and Pain Department, Hospital General Universitario De Valencia, Research Methods Department, Universidad Europea de Valencia, Valencia, Spain
| | | | - Nicola Disma
- Unit for Research in Anaesthesia, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Thomas Riva
- Department of Anaesthesiology and Pain Medicine, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
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18
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Wanous AA, Brown R, Rudser KD, Roberts KD. Comparison of laryngeal mask airway and endotracheal tube placement in neonates. J Perinatol 2024; 44:239-243. [PMID: 37919512 DOI: 10.1038/s41372-023-01818-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 10/10/2023] [Accepted: 10/23/2023] [Indexed: 11/04/2023]
Abstract
OBJECTIVE We hypothesize that the time, number of attempts, and physiologic stability of placement of an LMA would be superior compared to ETT. STUDY DESIGN Videotape and physiologic parameters of LMA (n = 36) and ETT (n = 31) placement procedures for infants 28-36 weeks gestation were reviewed. RESULTS Duration of attempts (32 vs 66 s, p < 0.001) and mean total airway insertion time (88 vs 153 s, p = 0.06) was shorter for LMA compared to ETT. Mean number of attempts for successful placement was fewer for LMA (1.5 vs 1.9, p = 0.11). Physiologic parameters remained near baseline in both groups despite very different degrees of premedication. CONCLUSION Placement of an LMA required less time and fewer number of attempts compared to ETT. Physiologic stability of an LMA was maintained without the use of an analgesic and muscle relaxant. Use of an LMA is a favorable alternative to ETT placement for surfactant delivery in neonates. TRIAL REGISTRATION NCT01116921.
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Affiliation(s)
- Amanda A Wanous
- University of Minnesota Medical School, University of Minnesota, Minneapolis, MN, USA
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA, USA
| | - Roland Brown
- Division of Biostatistics, University of Minnesota, Minneapolis, MN, USA
| | - Kyle D Rudser
- Division of Biostatistics, University of Minnesota, Minneapolis, MN, USA
| | - Kari D Roberts
- Department of Pediatrics, University of Minnesota Masonic Children's Hospital, Minneapolis, MN, USA.
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19
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Chen DY, Devsam B, Sett A, Perkins EJ, Johnson MD, Tingay DG. Factors that determine first intubation attempt success in high-risk neonates. Pediatr Res 2024; 95:729-735. [PMID: 37777605 PMCID: PMC10899101 DOI: 10.1038/s41390-023-02831-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 08/17/2023] [Accepted: 09/19/2023] [Indexed: 10/02/2023]
Abstract
BACKGROUND Approximately 50% of all neonatal endotracheal intubation attempts are unsuccessful and associated with airway injury and cardiorespiratory instability. The aim of this study was to describe intubation practice at a high-risk Neonatal Intensive Care Unit (NICU) and identify factors associated with successful intubation at the first attempt. METHODS Retrospective cohort study of all infants requiring intubation within the Royal Children's Hospital NICU over three years. Data was collected from the National Emergency Airway Registry for Neonates (NEAR4NEOS). Outcomes were number of attempts, level of operator training, equipment used, difficult airway grade, and clinical factors. Univariate and multivariate analysis were performed to determine factors independently associated with first attempt success. RESULTS Three hundred and sixty intubation courses, with 538 attempts, were identified. Two hundred and twenty-five (62.5%) were successful on first attempt, with similar rates at subsequent attempts. On multivariate analysis, increasing operator seniority increased the chance of first attempt success. Higher glottic airway grades were associated with lower chance of first attempt success, but neither a known difficult airway nor use of a stylet were associated with first attempt success. CONCLUSION In a NICU with a high rate of difficult airways, operator experience rather than equipment was the greatest determinant of intubation success. IMPACT Neonatal intubation is a high-risk lifesaving procedure, and this is the first report of intubation practices at a quaternary surgical NICU that provides regional referral services for complex medical and surgical admissions. Our results showed that increasing operator seniority and lower glottic airway grades were associated with increased first attempt intubation success rates, while factors such as gestational age, weight, stylet use, and known history of difficult airway were not. Operator factors rather than equipment factors were the greatest determinants of first attempt success, highlighting the importance of team selection for neonatal intubations in a high-risk cohort of infants.
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Affiliation(s)
- Donna Y Chen
- Neonatal Research, Murdoch Children's Research Institute, Parkville, VIC, Australia.
- Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia.
| | - Bianca Devsam
- Neonatal Research, Murdoch Children's Research Institute, Parkville, VIC, Australia
- Neonatology, The Royal Children's Hospital, Parkville, VIC, Australia
- Department of Nursing, Melbourne School of Health Sciences, University of Melbourne, Melbourne, VIC, Australia
| | - Arun Sett
- Neonatal Research, Murdoch Children's Research Institute, Parkville, VIC, Australia
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, VIC, Australia
- Newborn Services, Joan Kirner Women's and Children's, Western Health, Melbourne, VIC, Australia
| | - Elizabeth J Perkins
- Neonatal Research, Murdoch Children's Research Institute, Parkville, VIC, Australia
- Neonatology, The Royal Children's Hospital, Parkville, VIC, Australia
| | - Mitchell D Johnson
- Neonatal Research, Murdoch Children's Research Institute, Parkville, VIC, Australia
- Neonatology, The Royal Children's Hospital, Parkville, VIC, Australia
| | - David G Tingay
- Neonatal Research, Murdoch Children's Research Institute, Parkville, VIC, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia
- Neonatology, The Royal Children's Hospital, Parkville, VIC, Australia
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20
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Ali MA, Raju MP, Miller G, Vora N, Beeram M, Raju V, Shetty A, Govande V, Nguyen N, Chiruvolu A. Pre-Medications for Non-Emergency Tracheal Intubation in the United States Neonatal Intensive Care Units. Cureus 2024; 16:e53512. [PMID: 38440038 PMCID: PMC10911687 DOI: 10.7759/cureus.53512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/03/2024] [Indexed: 03/06/2024] Open
Abstract
BACKGROUND Premedication in neonates undergoing elective intubation effectively minimizes the negative physiological events of bradycardia, systemic hypertension, intracranial hypertension, and hypoxia. Premedication decreases procedure-related pain and discomfort. This study aimed to evaluate the current practice of pre-intubation medications for non-emergent intubations in preterm and term neonates in the United States. STUDY DESIGN A cross-sectional survey (Appendix) was sent via e-mail to all level 3 and 4 Neonatal Intensive Care Units (NICUs) of the Organization of Neonatal Perinatal Medicine Training Program Directors (ONTPD), NICU directors with pediatric residency only, and Baylor Scott and White Health, Mednax, and Envision health services systems. RESULTS Of 170 responses, 41% (69/168) routinely premedicate, 38% (64/168) premedicate under specific circumstances, and 21% (35/168) do not administer any routine pre-intubation medications. Only 46% (77/168) of units had a written policy. The most frequently used drugs were fentanyl (68%, 116/170), atropine (39%, 66/170), midazolam (38%, 64/170), and morphine (26%, 45/170). 21% (36/170) used a two-drug combination, and 38% (64/170) used a three-drug combination. The most commonly used two-drug combination was atropine and fentanyl, and the most common three-drug combination was atropine, fentanyl, and a paralytic agent. CONCLUSION Despite the well-documented benefits of premedication for NICU intubations, as aligned with AAP recommendations, the US lags behind other nations, with stagnant rates since 2006. This disparity persists despite a rise in written policies, which exhibit significant content variations. The authors advocate for the adoption of standardized, AAP-aligned policies across all NICUs in the US. Continued research is vital to monitor the progress of this crucial practice and address any underlying barriers to implementation.
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Affiliation(s)
- Mahmoud A Ali
- Pediatrics/Neonatology, West Virginia University, Morgantown, USA
- Neonatology, Baylor Scott & White Health, Temple, USA
| | | | - Greg Miller
- Neonatology, Baylor Scott & White Health, Temple, USA
| | - Niraj Vora
- Neonatology, Baylor Scott & White Health, Temple, USA
| | | | - Venkata Raju
- Neonatology, Baylor Scott & White Health, Temple, USA
| | - Ashith Shetty
- Neonatology, Baylor Scott & White Health, Temple, USA
| | | | - Nguyen Nguyen
- Pediatrics, Baylor Scott & White Health, Temple, USA
| | - Arpitha Chiruvolu
- Neonatology, Baylor University Medical Center, Dallas, USA
- Neonatology, Pediatrix Medical Group, Dallas, USA
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21
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Belting C, Rüegger CM, Waldmann AD, Bassler D, Gaertner VD. Rescue nasopharyngeal tube for preterm infants non-responsive to initial ventilation after birth. Pediatr Res 2024:10.1038/s41390-024-03033-6. [PMID: 38273117 DOI: 10.1038/s41390-024-03033-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Revised: 11/29/2023] [Accepted: 12/29/2023] [Indexed: 01/27/2024]
Abstract
BACKGROUND Physiological changes during the insertion of a rescue nasopharyngeal tube (NPT) after birth are unclear. METHODS Observational study of very preterm infants in the delivery room. Data were extracted at predefined timepoints starting with first facemask placement after birth until 5 min after insertion of NPT. End-expiratory lung impedance (EELI), heart rate (HR) and SpO2/FiO2-ratio were analysed over time. Changes during the same time span of NIPPV via facemask and NIPPV via NPT were compared. RESULTS Overall, 1154 inflations in 15 infants were analysed. After NPT insertion, EELI increased significantly [0.33 AU/kg (0.19-0.57), p < 0.001]. Compared with the mask period, changes in EELI were not significantly larger during the NPT period [median difference (IQR) = 0.14 AU/kg (-0.14-0.53); p = 0.12]. Insertion of the NPT was associated with significant improvement in HR [52 (33-96); p = 0.001] and SpO2/FiO2-ratio [161 (69-169); p < 0.001] not observed during the mask period. CONCLUSIONS In very preterm infants non-responsive to initial facemask ventilation after birth, insertion of an NPT resulted in a considerable increase in EELI. This additional gain in lung volume was associated with an immediate improvement in clinical parameters. The use of a NPT may prevent intubation in selected non-responsive infants. IMPACT After birth, a nasopharyngeal tube may be considered as a rescue airway in newborn infants non-responsive to initial positive pressure ventilation via facemask. Although it is widely used among clinicians, its effect on lung volumes and physiological parameters remains unclear. Insertion of a rescue NPT resulted in a considerable increase in lung volume but this was not significantly larger than during facemask ventilation. However, insertion of a rescue NPT was associated with a significant and clinically important improvement in heart rate and oxygenation. This study highlights the importance of individual strategies in preterm resuscitation and introduces the NPT as a valid option.
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Affiliation(s)
- Carina Belting
- Newborn Research, Department of Neonatology, University Hospital and University of Zürich, Zürich, Switzerland
- Department of Pediatric Intensive Care and Neonatology, Children's Hospital of Eastern Switzerland, St. Gallen, Switzerland
| | - Christoph M Rüegger
- Newborn Research, Department of Neonatology, University Hospital and University of Zürich, Zürich, Switzerland
| | - Andreas D Waldmann
- Department of Anaesthesiology and Intensive Care Medicine, Rostock University Medical Centre, Rostock, Germany
| | - Dirk Bassler
- Newborn Research, Department of Neonatology, University Hospital and University of Zürich, Zürich, Switzerland
| | - Vincent D Gaertner
- Newborn Research, Department of Neonatology, University Hospital and University of Zürich, Zürich, Switzerland.
- Division of Neonatology, Dr von Hauner Children's Hospital, Ludwig-Maximilians-Universität München, Munich, Germany.
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22
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Dominick CL, Blanke BN, Simmons EM, Traynor DM, Fowler M, Nishisaki A, Napolitano N. Outcomes of Unplanned Extubations in a Large Children's Hospital. Respir Care 2024; 69:184-190. [PMID: 38164617 PMCID: PMC10898459 DOI: 10.4187/respcare.10904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Abstract
BACKGROUND Unplanned extubation (UE) is defined as unintentional dislodgement of an endotracheal tube (ETT) from the trachea. UEs can lead to instability, cardiac arrest, and may require emergent tracheal re-intubation. As part of our hospital-wide quality improvement (QI) work, a multidisciplinary committee reviewed all UEs to determine contributing factors and evaluation of clinical outcomes to develop QI interventions aimed to minimize UEs. The objective was to investigate occurrence, contributing factors, and clinical outcomes of UEs in the pediatric ICU (PICU), cardiac ICU (CICU), and neonatal ICU (NICU) in a large academic children's hospital. We hypothesized that these would be substantially different across 3 ICUs. METHODS A single-center retrospective review of UEs in the PICU, CICU, and NICU was recorded in a prospective database for the last 5 y. Consensus-based standardized operational definitions were developed to capture contributing factors and adverse events associated with UEs. Data were extracted through electronic medical records by 3 respiratory therapists and local Virtual Pediatric Systems (VPS) database. Consistency of data extraction and classification were evaluated. RESULTS From January 2016-December 2021, 408 UEs in 339 subjects were reported: PICU 52 (13%), CICU 31 (7%), and NICU 325 (80%). The median (interquartile range) of age and weight was 2.0 (0-4.0) months and 5.3 (3.0-8.0) kg. Many UE events were not witnessed (54%). Common contributing factors were routine nursing care (no. = 70, 18%), ETT retaping (no. = 62, 16%), and being held (no. = 15, 3.9%). The most common adverse events with UE were desaturation < 80% (33%) and bradycardia (22.8%). Cardiac arrest occurred in 12%. Sixty-seven percent of UEs resulted in re-intubation within 72 h. The proportion of re-intubation across 3 units was significantly different: PICU 62%, CICU 35%, NICU 71%, P < .001. CONCLUSIONS UEs occurred commonly in a large academic children's hospital. Whereas UE was associated with adverse events, re-intubation rates within 72 h were < 70% and variable across the units.
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Affiliation(s)
- Cheryl L Dominick
- Department of Respiratory Care, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
| | - Brooke N Blanke
- Department of Respiratory Care, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Emily M Simmons
- Department of Respiratory Care, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Danielle M Traynor
- Critical Care Center for Evidence and Outcomes, Pediatric Intensive Care Unit, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Madeline Fowler
- College of Nursing and Health Professionals, Drexel University, Philadelphia, Pennsylvania
| | - Akira Nishisaki
- Division of Anesthesia and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Natalie Napolitano
- Department of Respiratory Care, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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23
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Disma N, Asai T, Cools E, Cronin A, Engelhardt T, Fiadjoe J, Fuchs A, Garcia-Marcinkiewicz A, Habre W, Heath C, Johansen M, Kaufmann J, Kleine-Brueggeney M, Kovatsis PG, Kranke P, Lusardi AC, Matava C, Peyton J, Riva T, Romero CS, von Ungern-Sternberg B, Veyckemans F, Afshari A. Airway management in neonates and infants: European Society of Anaesthesiology and Intensive Care and British Journal of Anaesthesia joint guidelines. Br J Anaesth 2024; 132:124-144. [PMID: 38065762 DOI: 10.1016/j.bja.2023.08.040] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Accepted: 08/30/2023] [Indexed: 01/05/2024] Open
Abstract
Airway management is required during general anaesthesia and is essential for life-threatening conditions such as cardiopulmonary resuscitation. Evidence from recent trials indicates a high incidence of critical events during airway management, especially in neonates or infants. It is important to define the optimal techniques and strategies for airway management in these groups. In this joint European Society of Anaesthesiology and Intensive Care (ESAIC) and British Journal of Anaesthesia (BJA) guideline on airway management in neonates and infants, we present aggregated and evidence-based recommendations to assist clinicians in providing safe and effective medical care. We identified seven main areas of interest for airway management: i) preoperative assessment and preparation; ii) medications; iii) techniques and algorithms; iv) identification and treatment of difficult airways; v) confirmation of tracheal intubation; vi) tracheal extubation, and vii) human factors. Based on these areas, Population, Intervention, Comparison, Outcomes (PICO) questions were derived that guided a structured literature search. GRADE (Grading of Recommendations, Assessment, Development and Evaluation) methodology was used to formulate the recommendations based on those studies included with consideration of their methodological quality (strong '1' or weak '2' recommendation with high 'A', medium 'B' or low 'C' quality of evidence). In summary, we recommend: 1. Use medical history and physical examination to predict difficult airway management (1C). 2. Ensure adequate level of sedation or general anaesthesia during airway management (1B). 3. Administer neuromuscular blocker before tracheal intubation when spontaneous breathing is not necessary (1C). 4. Use a videolaryngoscope with an age-adapted standard blade as first choice for tracheal intubation (1B). 5. Apply apnoeic oxygenation during tracheal intubation in neonates (1B). 6. Consider a supraglottic airway for rescue oxygenation and ventilation when tracheal intubation fails (1B). 7. Limit the number of tracheal intubation attempts (1C). 8. Use a stylet to reinforce and preshape tracheal tubes when hyperangulated videolaryngoscope blades are used and when the larynx is anatomically anterior (1C). 9. Verify intubation is successful with clinical assessment and end-tidal CO2 waveform (1C). 10. Apply high-flow nasal oxygenation, continuous positive airway pressure or nasal intermittent positive pressure ventilation for postextubation respiratory support, when appropriate (1B).
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Affiliation(s)
- Nicola Disma
- Unit for Research in Anaesthesia, IRCCS Istituto Giannina Gaslini, Genoa, Italy.
| | - Takashi Asai
- Department of Anesthesiology, Dokkyo Medical University Koshigaya Hospital, Koshigaya, Saitama, Japan
| | - Evelien Cools
- Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | | | - Thomas Engelhardt
- Department of Anaesthesia, Montreal Children's Hospital, McGill University Health Centre, Montréal, QC, Canada
| | - John Fiadjoe
- Department of Anaesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Alexander Fuchs
- Unit for Research in Anaesthesia, IRCCS Istituto Giannina Gaslini, Genoa, Italy; Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Annery Garcia-Marcinkiewicz
- Department of Anaesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Walid Habre
- Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | - Chloe Heath
- Department of Anaesthesia and Pain Management, Starship Children's Hospital, Auckland, New Zealand; Perioperative Medicine Team, Perioperative Care Program, Telethon Kids Institute, Perth, WA, Australia
| | - Mathias Johansen
- Department of Anaesthesia, Montreal Children's Hospital, McGill University Health Centre, Montréal, QC, Canada
| | - Jost Kaufmann
- Department for Pediatric Anesthesia, Children's Hospital Cologne, Cologne, Germany; Faculty for Health, University of Witten/Herdecke, Witten, Germany
| | - Maren Kleine-Brueggeney
- Department of Cardiac Anaesthesiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité (DHZC) and Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Pete G Kovatsis
- Department of Anaesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Peter Kranke
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Würzburg, Würzburg, Germany
| | - Andrea C Lusardi
- Unit for Research in Anaesthesia, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Clyde Matava
- Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, Toronto, ON, Canada
| | - James Peyton
- Department of Anaesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Thomas Riva
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Carolina S Romero
- Department of Anesthesia and Critical Care, Consorcio Hospital General Universitario de Valencia, Methodology Department, Universidad Europea de Valencia, Valencia, Spain
| | - Britta von Ungern-Sternberg
- Perioperative Medicine Team, Perioperative Care Program, Telethon Kids Institute, Perth, WA, Australia; Department of Anaesthesia and Pain Management, Perth Children's Hospital, Perth, WA, Australia; Division of Emergency Medicine, Anaesthesia and Pain Medicine, Medical School, The University of Western Australia, Perth, WA, Australia
| | | | - Arash Afshari
- Department of Paediatric and Obstetric Anaesthesia, Copenhagen University Hospital, Rigshospitalet & Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
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24
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Mani S, Rawat M. Less Invasive Surfactant Administration: A Viewpoint. Am J Perinatol 2024; 41:211-227. [PMID: 36539205 PMCID: PMC10791155 DOI: 10.1055/a-2001-9139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 12/12/2022] [Indexed: 02/17/2023]
Abstract
The standard of care in treating respiratory distress syndrome in preterm infants is respiratory support with nasal continuous positive airway pressure or a combination of continuous positive airway pressure and exogenous surfactant replacement. Endotracheal intubation, the conventional method for surfactant administration, is an invasive procedure associated with procedural and mechanical ventilation complications. The INSURE (intubation, surfactant administration, and extubation soon after) technique is an accepted method aimed at reducing the short-term complications and long-term morbidities related to mechanical ventilation but does not eliminate risks associated with endotracheal intubation and mechanical ventilation. Alternative methods of surfactant delivery that can overcome the problems associated with the INSURE technique are surfactant through a laryngeal mask, surfactant through a thin intratracheal catheter, and aerosolized surfactant delivered using nebulizers. The three alternative methods of surfactant delivery studied in the last two decades have advantages and limitations. More than a dozen randomized controlled trials have aimed to study the benefits of the three alternative techniques of surfactant delivery compared with INSURE as the control arm, with promising results in terms of reduction in mortality, need for mechanical ventilation, and bronchopulmonary dysplasia. The need to find a less invasive surfactant administration technique is a clinically relevant problem. Before broader adoption in routine clinical practice, the most beneficial technique among the three alternative strategies should be identified. This review aims to summarize the current evidence for using the three alternative techniques of surfactant administration in neonates, compare the three techniques, highlight the knowledge gaps, and suggest future directions. KEY POINTS: · The need to find a less invasive alternative method of surfactant delivery is a clinically relevant problem.. · Clinical trials that have studied alternative surfactant delivery methods have shown promising results but are inconclusive for broader adoption into clinical practice.. · Future studies should explore novel clinical trial methodologies and select clinically significant long term outcomes for comparison..
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Affiliation(s)
- Srinivasan Mani
- Department of Pediatrics, University of Toledo, Toledo, Ohio
| | - Munmun Rawat
- Department of Pediatrics, University at Buffalo, Buffalo, New York
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25
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Disma N, Asai T, Cools E, Cronin A, Engelhardt T, Fiadjoe J, Fuchs A, Garcia-Marcinkiewicz A, Habre W, Heath C, Johansen M, Kaufmann J, Kleine-Brueggeney M, Kovatsis PG, Kranke P, Lusardi AC, Matava C, Peyton J, Riva T, Romero CS, von Ungern-Sternberg B, Veyckemans F, Afshari A. Airway management in neonates and infants: European Society of Anaesthesiology and Intensive Care and British Journal of Anaesthesia joint guidelines. Eur J Anaesthesiol 2024; 41:3-23. [PMID: 38018248 PMCID: PMC10720842 DOI: 10.1097/eja.0000000000001928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2023]
Abstract
Airway management is required during general anaesthesia and is essential for life-threatening conditions such as cardiopulmonary resuscitation. Evidence from recent trials indicates a high incidence of critical events during airway management, especially in neonates or infants. It is important to define the optimal techniques and strategies for airway management in these groups. In this joint European Society of Anaesthesiology and Intensive Care (ESAIC) and British Journal of Anaesthesia (BJA) guideline on airway management in neonates and infants, we present aggregated and evidence-based recommendations to assist clinicians in providing safe and effective medical care. We identified seven main areas of interest for airway management: i) preoperative assessment and preparation; ii) medications; iii) techniques and algorithms; iv) identification and treatment of difficult airways; v) confirmation of tracheal intubation; vi) tracheal extubation, and vii) human factors. Based on these areas, Population, Intervention, Comparison, Outcomes (PICO) questions were derived that guided a structured literature search. GRADE (Grading of Recommendations, Assessment, Development and Evaluation) methodology was used to formulate the recommendations based on those studies included with consideration of their methodological quality (strong '1' or weak '2' recommendation with high 'A', medium 'B' or low 'C' quality of evidence). In summary, we recommend: 1. Use medical history and physical examination to predict difficult airway management (1С). 2. Ensure adequate level of sedation or general anaesthesia during airway management (1B). 3. Administer neuromuscular blocker before tracheal intubation when spontaneous breathing is not necessary (1С). 4. Use a videolaryngoscope with an age-adapted standard blade as first choice for tracheal intubation (1B). 5. Apply apnoeic oxygenation during tracheal intubation in neonates (1B). 6. Consider a supraglottic airway for rescue oxygenation and ventilation when tracheal intubation fails (1B). 7. Limit the number of tracheal intubation attempts (1C). 8. Use a stylet to reinforce and preshape tracheal tubes when hyperangulated videolaryngoscope blades are used and when the larynx is anatomically anterior (1C). 9. Verify intubation is successful with clinical assessment and end-tidal CO 2 waveform (1C). 10. Apply high-flow nasal oxygenation, continuous positive airway pressure or nasal intermittent positive pressure ventilation for postextubation respiratory support, when appropriate (1B).
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Affiliation(s)
- Nicola Disma
- From the Unit for Research in Anaesthesia, IRCCS Istituto Giannina Gaslini, Genoa, Italy (ND, AF, ACL), Department of Anesthesiology, Dokkyo Medical University Koshigaya Hospital, Koshigaya, Saitama, Japan (TA), Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals and University of Geneva, Geneva, Switzerland (EC, WH), Medical Library, Boston Children's Hospital, Boston, MA, USA (AC), Department of Anaesthesia, Montreal Children's Hospital, McGill University Health Centre, Montréal, QC, Canada (TE, MJ), Department of Anaesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA (JF, PGK, JP), Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland (AF, TR), Department of Anaesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA (AG-M), Department of Anaesthesia and Pain Management, Starship Children's Hospital, Auckland, New Zealand (CH), Perioperative Medicine Team, Perioperative Care Program, Telethon Kids Institute, Perth, WA, Australia (CH, BvU-S), Department for Pediatric Anesthesia, Children's Hospital Cologne, Cologne, Germany (JK), Faculty for Health, University of Witten/Herdecke, Witten, Germany (JK), Department of Cardiac Anaesthesiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité (DHZC) and Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany (MK-B), Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Würzburg, Würzburg, Germany (PK), Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, Toronto, ON, Canada (CM), Department of Anesthesia and Critical Care, Consorcio Hospital General Universitario de Valencia, Methodology Department, Universidad Europea de Valencia, Valencia, Spain (CSR), Department of Anaesthesia and Pain Management, Perth Children's Hospital, Perth, WA, Australia (BvU-S), Division of Emergency Medicine, Anaesthesia and Pain Medicine, Medical School, The University of Western Australia, Perth, WA, Australia (BvU-S), Faculty of Medicine, UCLouvain, Brussels, Belgium (FV), Department of Paediatric and Obstetric Anaesthesia, Copenhagen University Hospital, Rigshospitalet & Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark (AA)
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Neches SK, DeMartino C, Shay R. Pharmacologic Adjuncts for Neonatal Tracheal Intubation: The Evidence Behind Premedication. Neoreviews 2023; 24:e783-e796. [PMID: 38036442 DOI: 10.1542/neo.24-12-e783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Abstract
Premedication such as analgesia, sedation, vagolytics, and paralytics may improve neonatal tracheal intubation success, reduce intubation-associated adverse events, and create optimal conditions for performing this high-risk and challenging procedure. Although rapid sequence induction including a paralytic agent has been adopted for intubations in pediatric and adult critical care, neonatal clinical practice varies. This review aims to summarize details of common classes of neonatal intubation premedication including indications for use, medication route, dosage, potential adverse effects in term and preterm infants, and reversal agents. In addition, this review shares the literature on national and international practice variations; explores evidence in support of establishing premedication guidelines; and discusses unique circumstances in which premedication use has not been established, such as during catheter-based or minimally invasive surfactant delivery. With increasing survival of extremely preterm infants, clear guidance for premedication use in this population will be necessary, particularly considering potential short- and long-term side effects of procedural sedation on the developing brain.
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Affiliation(s)
- Sara K Neches
- Department of Pediatrics, Division of Neonatology, University of Washington School of Medicine and Seattle Children's Hospital, Seattle, WA
| | - Cassandra DeMartino
- Department of Pediatrics, Division of Neonatology, Yale New Haven Hospital, New Haven, CT
| | - Rebecca Shay
- Department of Pediatrics, Division of Neonatology, University of Colorado School of Medicine and Children's Hospital of Colorado, Denver, CO
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27
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Marc-Aurele K, Branche T, Adams A, Feister J, Boyle K, Scala M. Recommendations for creating a collaborative NICU environment to support teamwork and trainee education. J Perinatol 2023; 43:1520-1525. [PMID: 37620402 DOI: 10.1038/s41372-023-01756-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 06/26/2023] [Accepted: 08/14/2023] [Indexed: 08/26/2023]
Abstract
In a 2022 survey, a majority of neonatology program directors reported regular conflict between neonatal-perinatal fellows and frontline providers (FLPs) (i.e., neonatal nurse practitioners (NNPs), neonatal physician assistants (PAs), and neonatal hospitalists). This paper reviews recommendations of a multidisciplinary workgroup for creating a more collaborative unit environment that supports teamwork and education. The self-study framework is a helpful tool to identify specific pressure points at individual institutions. Implementing clear guidelines for procedural distribution and role clarification are often critical interventions. FLPs and Pediatric Physician Trainees may benefit from conflict management coaching and communication training. At the same time, we recommend that respective leaders support a psychologically safe environment for team members to feel safe to solve problems on their own. Going forward, more work is important to optimize teamwork in the setting of anticipated staffing shortages, limitations to resident neonatology exposure, changes in training requirements, and ongoing development of the FLP role.
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Affiliation(s)
| | - Tonia Branche
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Aaron Adams
- Duke University School of Medicine, Durham, NC, USA
| | - John Feister
- Stanford University School of Medicine, Stanford, CA, USA
| | - Kristine Boyle
- Lucile Packard Children's Hospital Stanford, Stanford, CA, USA
| | - Melissa Scala
- Stanford University School of Medicine, Stanford, CA, USA.
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Mockler S, Metelmann C, Metelmann B, Thies KC. Prevalence and severity of pediatric emergencies in a German helicopter emergency service: implications for training and service configuration. Eur J Pediatr 2023; 182:5057-5065. [PMID: 37656240 PMCID: PMC10640406 DOI: 10.1007/s00431-023-05178-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 08/15/2023] [Accepted: 08/23/2023] [Indexed: 09/02/2023]
Abstract
This study primarily aims to determine the frequency of life-threatening conditions among pediatric patients served by the DRF, a German helicopter emergency service (HEMS) provider. It also seeks to explore the necessity of invasive procedures in this population, discussing the implications for HEMS crew training and service configuration based on current literature. We analyzed the mission registry from 31 DRF helicopter bases in Germany, focusing on 7954 children aged 10 or younger over a 5-year period (2014-2018). Out of 7954 identified children (6.2% of all primary missions), 2081 (26.2%) had critical conditions. Endotracheal intubation was needed in 6.5% of cases, while alternative airway management methods were rare (n = 14). Half of the children required intravenous access, and 3.6% needed intraosseous access. Thoracostomy thoracentesis and sonography were only performed in isolated cases. Conclusions: Critically ill or injured children are infrequent in German HEMS operations. Our findings suggest that the likelihood of HEMS teams encountering such cases is remarkably low. Besides endotracheal intubation, life-saving invasive procedures are seldom necessary. Consequently, we conclude that on-the-job training and mission experience alone are insufficient for acquiring and maintaining the competencies needed to care for critically ill or injured children. What is Known: • Pediatric emergencies are relatively rare in the prehospital setting, but their incidence is higher in helicopter emergency medical services (HEMS) compared to ground-based emergency services. What is New: • On average, HEMS doctors in Germany encounter a critically ill or injured child approximately every 1.5 years in their practice, establish an IV or IO access in infants or toddlers every 2 years, and intubate an infant every 46 years. • This low frequency highlights the insufficiency of on-the-job training alone to develop and maintain pediatric skills among HEMS crews. Specific interdisciplinary training for HEMS crews is needed to ensure effective care for critically unwell pediatric patients.
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Affiliation(s)
- Stefan Mockler
- Department of Anesthesiology, University Hospital Greifswald, Sauerbruchstr, 17475, Greifswald, Germany.
| | - Camilla Metelmann
- Department of Anesthesiology, University Hospital Greifswald, Sauerbruchstr, 17475, Greifswald, Germany
| | - Bibiana Metelmann
- Department of Anesthesiology, University Hospital Greifswald, Sauerbruchstr, 17475, Greifswald, Germany
| | - Karl Christian Thies
- Department of Anaesthesiology and Critical Care, EvKB, OWL University Medical Center, Campus Bielefeld Bethel, Burgsteig 13, 33617, Bielefeld, Germany
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29
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Herrick HM, O'Reilly MA, Foglia EE. Success rates and adverse events during neonatal intubation: Lessons learned from an international registry. Semin Fetal Neonatal Med 2023; 28:101482. [PMID: 38000925 PMCID: PMC10842734 DOI: 10.1016/j.siny.2023.101482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2023]
Abstract
Neonatal endotracheal intubation is a challenging procedure with suboptimal success and adverse event rates. Systematically tracking intubation outcomes is imperative to understand both universal and site-specific barriers to intubation success and safety. The National Emergency Airway Registry for Neonates (NEAR4NEOS) is an international registry designed to improve neonatal intubation practice and outcomes that includes over 17,000 intubations across 23 international sites as of 2023. Methods to improve intubation safety and success include appropriately matching the intubation provider and situation and increasing adoption of evidence-based practices such as muscle relaxant premedication and video laryngoscope, and potentially new interventions such as procedural oxygenation.
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Affiliation(s)
- Heidi M Herrick
- Division of Neonatology, Department of Pediatrics, The Children's Hospital of Philadelphia, 3401 Civic Center Blvd, 2nd Floor, Philadelphia, PA, 19104, USA; Division of Neonatology, Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, 8th Floor Ravdin, 3400 Spruce St, PA, 19104, Philadelphia, Pennsylvania, USA.
| | - Mackenzie A O'Reilly
- Division of Neonatology, Department of Pediatrics, The Children's Hospital of Philadelphia, 3401 Civic Center Blvd, 2nd Floor, Philadelphia, PA, 19104, USA; Division of Neonatology, Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, 8th Floor Ravdin, 3400 Spruce St, PA, 19104, Philadelphia, Pennsylvania, USA.
| | - Elizabeth E Foglia
- Division of Neonatology, Department of Pediatrics, The Children's Hospital of Philadelphia, 3401 Civic Center Blvd, 2nd Floor, Philadelphia, PA, 19104, USA; Division of Neonatology, Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, 8th Floor Ravdin, 3400 Spruce St, PA, 19104, Philadelphia, Pennsylvania, USA.
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Abstract
'Apnoeic oxygenation' describes the diffusion of oxygen across the alveolar-capillary interface in the absence of tidal respiration. Apnoeic oxygenation requires a patent airway, the diffusion of oxygen to the alveoli, and cardiopulmonary circulation. Apnoeic oxygenation has varied applications in adult medicine including facilitating tubeless anaesthesia or improving oxygenation when a difficult airway is known or anticipated. In the paediatric population, apnoeic oxygenation prolongs the time to oxygen desaturation, facilitating intubation. This application has gained attention in neonatal intensive care where intubation remains a challenging procedure. Difficulties are related to the infant's size and decreased respiratory reserve. In addition, policy changes have led to limited opportunities for operators to gain proficiency. Until recently, evidence of benefit of apnoeic oxygenation in the neonatal population came from a small number of infants recruited to paediatric studies. Evidence specific to neonates is emerging and suggests apnoeic oxygenation may increase intubation success and limit physiological instability during the procedure. The best way to deliver oxygen to facilitate apnoeic oxygenation remains an important question.
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Affiliation(s)
- Elizabeth K Baker
- Newborn Research Centre, Royal Women's Hospital, Victoria, Australia, Level 7, 20 Flemington Rd, Parkville, Victoria, 3052, Australia; Department of Obstetrics, Gynaecology and Newborn Health, University of Melbourne, Parkivlle, Victoria, Australia.
| | - Peter G Davis
- Newborn Research Centre, Royal Women's Hospital, Victoria, Australia, Level 7, 20 Flemington Rd, Parkville, Victoria, 3052, Australia; Department of Obstetrics, Gynaecology and Newborn Health, University of Melbourne, Parkivlle, Victoria, Australia; Murdoch Children's Research Institute, Parkville, Victoria, Australia.
| | - Kate A Hodgson
- Newborn Research Centre, Royal Women's Hospital, Victoria, Australia, Level 7, 20 Flemington Rd, Parkville, Victoria, 3052, Australia; Department of Obstetrics, Gynaecology and Newborn Health, University of Melbourne, Parkivlle, Victoria, Australia.
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Shah BA, Foulks A, Lapadula MC, McCoy M, Hallford G, Bedwell S, DeShea L, Szyld E. Laryngeal Mask Use in the Neonatal Population: A Survey of Practice Providers at a Regional Tertiary Care Center in the United States. Am J Perinatol 2023; 40:1551-1557. [PMID: 34729719 DOI: 10.1055/s-0041-1736662] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate the level of training, awareness, experience, and confidence of neonatal practice providers in the use of laryngeal mask (LM), and to identify the barriers in its implementation in the neonatal population. STUDY DESIGN Descriptive observational study utilizing an anonymous online questionnaire among healthcare providers at the Oklahoma Children's Hospital who routinely respond to newborn deliveries and have been trained in the Neonatal Resuscitation Program (NRP). Participants included physicians, trainees, nurse practitioners, nurses, and respiratory therapists. RESULTS Ninety-five participants completed the survey (27.5% response rate). The sample consisted of 77 NRP providers (81%), 11 instructors (12%), and 7 instructor mentors (7%). Among 72 respondents who had undergone LM training, 51 (54%) had hands-on manikin practice, 4 (4%) watched the American Academy of Pediatrics (AAP) NRP educational video, and 17 (18%) did both. Nurses (39 out of 46) were more likely to have completed LM training than were physicians (31 out of 47). With only 11 (12%) participants having ever placed a LM in a newly born infant, the median confidence for LM placement during neonatal resuscitation was 37 on a 0 to 100 scale. Frequently reported barriers for LM use in neonates were limited experience (81%), insufficient training (59%), preference for endotracheal tube (57%), and lack of awareness (56%). CONCLUSION While the majority of the neonatal practice providers were trained in LM placement, only a few had ever placed one in a live newborn, with a low degree of confidence overall. Future practice improvement should incorporate ongoing interdisciplinary LM education, availability of LM in the labor and delivery units, and promotion of awareness of LM as an alternative airway. KEY POINTS · LM is underutilized as an alternative airway.. · Insufficient experience and training limit LM use.. · Providers confidence with LM placement is low..
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Affiliation(s)
- Birju A Shah
- Neonatal-Perinatal Medicine, Oklahoma Children's Hospital, OU Health, Oklahoma City, Oklahoma
- Pediatrics, College of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Arlen Foulks
- Neonatal-Perinatal Medicine, Oklahoma Children's Hospital, OU Health, Oklahoma City, Oklahoma
- Pediatrics, College of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Maria C Lapadula
- Pediatrics, College of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Mike McCoy
- Neonatal-Perinatal Medicine, Oklahoma Children's Hospital, OU Health, Oklahoma City, Oklahoma
| | - Gene Hallford
- Pediatrics, College of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Susan Bedwell
- Neonatal-Perinatal Medicine, Oklahoma Children's Hospital, OU Health, Oklahoma City, Oklahoma
- Fran and Earl Ziegler College of Nursing, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Lise DeShea
- Pediatrics, College of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Edgardo Szyld
- Neonatal-Perinatal Medicine, Oklahoma Children's Hospital, OU Health, Oklahoma City, Oklahoma
- Pediatrics, College of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
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32
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Roberts CT, O'Shea JE. Alternatives to neonatal intubation. Semin Fetal Neonatal Med 2023; 28:101488. [PMID: 38000926 DOI: 10.1016/j.siny.2023.101488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2023]
Abstract
Opportunities to learn and maintain competence in neonatal intubation have decreased. As many clinicians providing care to the newborn infant are not skilled in intubation, alternative strategies are critical. Most preterm infants breathe spontaneously, and require stabilisation rather than resuscitation at birth. Use of tactile stimulation, deferred cord clamping, and avoidance of hypoxia can help optimise breathing for these infants. Nasal devices appear a promising alternative to the face mask for early provision of respiratory support. In term and near-term infants, supraglottic airways may be the most effective initial approach to resuscitation. Use of supraglottic airways during resuscitation can be taught to a range of providers, and may reduce need for intubation. While face mask ventilation is an important skill, it is challenging to perform effectively. Identification of the best approach to training the use of these devices during neonatal resuscitation remains an important priority.
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Affiliation(s)
- Calum T Roberts
- Department of Paediatrics, Monash University, Melbourne, VIC, Australia; The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia; Monash Newborn, Monash Children's Hospital, Melbourne, VIC, Australia.
| | - Joyce E O'Shea
- Department of Paediatrics, Royal Hospital for Sick Children, Glasgow, Scotland, United Kingdom
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Walterspiel JN. Design and Superior Performance of a New Endotracheal Tube to Avoid the Asphyxiation of Premature Infants. Cureus 2023; 15:e47655. [PMID: 38021521 PMCID: PMC10679846 DOI: 10.7759/cureus.47655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/25/2023] [Indexed: 12/01/2023] Open
Abstract
Background Neonatal endotracheal intubation attempts often fail, with failures typically attributable to unintended esophageal intubation, with asphyxia, brief or prolonged, as the consequence. Standard-of-care neonatal endotracheal tubes have changed little over recent decades, even as the gestational age of neonates thought eligible for resuscitation and intensive care has decreased. Methods A new neonatal endotracheal tube was patterned after the soft steering mechanism of a two-string fishing line trocar. The new tube remains patent throughout the intubation for air movement and CO2 detection and allows for a finger on the intubator's hand to stiffen, curve, and elevate the tip of the tube over the epiglottis and into the trachea without occluding the vision through a laryngoscope. This tube's engineering principles were studied prospectively in a controlled open-label pilot study in premature infants. Infants were observed during 12 intubations in a one-to-one comparison with standard practice. Results The new design in comparison to a conventional neonatal endotracheal tube (CNETT) was found to be superior. The average intubation time (mean 36.6 sec, median 30 sec) was shorter (mean 44.6 sec, median 45 sec) in the new design. Intubation attempts were fewer (0 vs. 3), and unintended esophageal intubations were also fewer (0 vs. 4). Conclusion Tracheal intubation of premature infants with the new soft-steering mechanism endotracheal tube was associated with less asphyxia, fewer intubation attempts, and fewer esophageal intubations.
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Affiliation(s)
- Juan N Walterspiel
- Pediatrics, Independent Medical Contractor, LocumTenens, Menlo Park, USA
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34
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Sawyer T, Yamada N, Umoren R. The difficult neonatal airway. Semin Fetal Neonatal Med 2023; 28:101484. [PMID: 38000927 DOI: 10.1016/j.siny.2023.101484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2023]
Abstract
Airway management is one of the most crucial aspects of neonatal care. The occurrence of a difficult airway is more common in neonates than in any other age group, and any neonatal intubation can develop into a difficult airway scenario. Understanding the intricacies of the difficult neonatal airway is paramount for healthcare professionals involved in the care of newborns. This chapter explores the multifaceted aspects of the difficult neonatal airway. We begin with a review of the definition and incidence of difficult airway in the neonate. Then, we explore factors contributing to a difficult neonatal airway. We next examine diagnostic considerations specific to the difficult neonatal airway, including prenatal imaging. Finally, we review management strategies. The importance of a multidisciplinary team approach and the role of communication and collaboration in achieving optimal outcomes are emphasized.
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Affiliation(s)
- Taylor Sawyer
- Division of Neonatology, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA.
| | - Nicole Yamada
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University, Palo Alto, California, USA
| | - Rachel Umoren
- Division of Neonatology, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
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35
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Abstract
Endotracheal intubation is a life-saving procedure for many newborns. Historically, it has been achieved by obtaining an airway view through the mouth via direct laryngoscopy. It is a skill that takes time and practice to achieve proficiency. Increasing evidence for the benefit of videolaryngoscopy in adults and the new development of technology has allowed videolaryngoscopy to become a reality in neonatal care. Studies have examined its use as both a technique to improve intubation safety and success, and as a training tool for those learning the skill in this vulnerable population. We present the current evidence for videolaryngoscopy in neonates in different settings where intubation may be required, in addition to exploring the challenges and practicalities of implementing this technique into clinical practice.
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Affiliation(s)
- Sandy Kirolos
- Neonatal unit, Chelsea & Westminster Hospital, 369 Fulham Road, London, SW10 9NH, UK.
| | - Gemma Edwards
- Neonatal unit, Princess Royal Maternity Hospital, 16 Alexandra Parade, Glasgow, G31 2ER, UK.
| | - Joyce O'Shea
- Neonatal unit, Royal Hospital for Children, 1345 Govan Road, Glasgow, G51 4TF, UK. Joyce.O'
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36
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Lategan I, Durand D, Harrison M, Nakwa F, Van Wyk L, Velaphi S, Horn A, Kali G, Soll R, Ehret D, Zar H, Tooke L. A multicentre neonatal interventional randomised controlled trial of nebulized surfactant for preterm infants with respiratory distress: Neo-INSPIRe trial protocol. BMC Pediatr 2023; 23:472. [PMID: 37726758 PMCID: PMC10507916 DOI: 10.1186/s12887-023-04296-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 09/07/2023] [Indexed: 09/21/2023] Open
Abstract
INTRODUCTION Respiratory distress syndrome in preterm infants is an important cause of morbidity and mortality. Less invasive methods of surfactant administration, along with the use of continuous positive airway pressure (CPAP), have improved outcomes of preterm infants. Aerosolized surfactant can be given without the need for airway instrumentation and may be employed in areas where these skills are scarce. Recent trials from high-resourced countries utilising aerosolized surfactant have had a low quality of evidence and varying outcomes. METHODS AND ANALYSIS The Neo-INSPIRe trial is an unblinded, multicentre, randomised trial of a novel aerosolized surfactant drug/device combination. Inclusion criteria include preterm infants of 27-34+6 weeks' gestational age who weigh 900-1999g and who require CPAP with a fraction of inspired oxygen (FiO2) of 0.25-0.35 in the first 2-24 h of age. Infants are randomised 1:1 to control (CPAP alone) or intervention (CPAP with aerosolized surfactant). The primary outcome is the need for intratracheal bolus surfactant instillation within 72 h of age. Secondary outcomes include the incidence of reaching failure criteria (persistent FiO2 of > 0.40, severe apnoea or severe work of breathing), the need for and duration of ventilation and respiratory support, bronchopulmonary dysplasia and selected co-morbidities of prematurity. Assuming a 40% relative risk reduction to reduce the proportion of infants requiring intratracheal bolus surfactant from 45 to 27%, the study will aim to enrol 232 infants for the study to have a power of 80% to detect a significant difference with a type 1 error of 0.05. ETHICS AND DISSEMINATION Ethical approval has been granted by the relevant human research ethics committees at University of Cape Town (HREC 681/2022), University of the Witwatersrand HREC (221112) and Stellenbosch University (M23/02/004). TRIAL REGISTRATION PACTR202307490670785.
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Affiliation(s)
- Ilse Lategan
- Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
| | | | - Michael Harrison
- Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
- Groote Schuur Hospital Neonatal Unit, Neonatal Department, Groote Schuur Hospital, Old Main Building, Cape Town, South Africa
| | - Firdose Nakwa
- Department of Paediatrics and Child Health, University of the Witwatersrand, Johannesburg, South Africa
- Chris Hani Baragwanath Hospital Neonatal Unit, Johannesburg, South Africa
| | - Lizelle Van Wyk
- Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
- Tygerberg Hospital Neonatal Unit, Cape Town, South Africa
| | - Sithembiso Velaphi
- Department of Paediatrics and Child Health, University of the Witwatersrand, Johannesburg, South Africa
- Chris Hani Baragwanath Hospital Neonatal Unit, Johannesburg, South Africa
| | - Alan Horn
- Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
- Groote Schuur Hospital Neonatal Unit, Neonatal Department, Groote Schuur Hospital, Old Main Building, Cape Town, South Africa
| | - Gugu Kali
- Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
- Tygerberg Hospital Neonatal Unit, Cape Town, South Africa
| | - Roger Soll
- Vermont Oxford Network, Burlington, VT, USA
- University of Vermont Larner College of Medicine, Pediatrics, Burlington, VT, USA
| | - Danielle Ehret
- Vermont Oxford Network, Burlington, VT, USA
- University of Vermont Larner College of Medicine, Pediatrics, Burlington, VT, USA
| | - Heather Zar
- Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
- Unit on Child and Adolescent Health, South African Medical Research Council, Cape Town, South Africa
| | - Lloyd Tooke
- Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa.
- Groote Schuur Hospital Neonatal Unit, Neonatal Department, Groote Schuur Hospital, Old Main Building, Cape Town, South Africa.
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Huang Y, Zhao J, Hua X, Luo K, Shi Y, Lin Z, Tang J, Feng Z, Mu D. Guidelines for high-flow nasal cannula oxygen therapy in neonates (2022). J Evid Based Med 2023; 16:394-413. [PMID: 37674304 DOI: 10.1111/jebm.12546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 08/16/2023] [Indexed: 09/08/2023]
Abstract
High-flow nasal cannula (HFNC) oxygen therapy, which is important in noninvasive respiratory support, is increasingly being used in critically ill neonates with respiratory failure because it is comfortable, easy to setup, and has a low incidence of nasal trauma. The advantages, indications, and risks of HFNC have been the focus of research in recent years, resulting in the development of the application. Based on current evidence, we developed guidelines for HFNC in neonates using the Grading of Recommendations Assessment, Development and Evaluation (GRADE). The guidelines were formulated after extensive consultations with neonatologists, respiratory therapists, nurse specialists, and evidence-based medicine experts. We have proposed 24 recommendations for 9 key questions. The guidelines aim to be a source of evidence and reference of HFNC oxygen therapy in clinical practice, and so that more neonates and their families will benefit from HFNC.
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Affiliation(s)
- Yi Huang
- Department of Neonatology, West China Second University Hospital, Sichuan University, Chengdu, P.R. China
| | - Jing Zhao
- Department of Neonatology, West China Second University Hospital, Sichuan University, Chengdu, P.R. China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Chengdu, P.R. China
| | - Xintian Hua
- Department of Neonatology, West China Second University Hospital, Sichuan University, Chengdu, P.R. China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Chengdu, P.R. China
| | - Keren Luo
- Department of Neonatology, West China Second University Hospital, Sichuan University, Chengdu, P.R. China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Chengdu, P.R. China
| | - Yuan Shi
- Department of Neonatology, Children's Hospital of Chongqing Medical University, Chongqing, P.R. China
| | - Zhenlang Lin
- Department of Neonatology, The Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, P.R. China
| | - Jun Tang
- Department of Neonatology, West China Second University Hospital, Sichuan University, Chengdu, P.R. China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Chengdu, P.R. China
| | - Zhichun Feng
- Department of Neonatology, Faculty of Pediatrics, Chinese PLA General Hospital, Beijing, P.R. China
| | - Dezhi Mu
- Department of Neonatology, West China Second University Hospital, Sichuan University, Chengdu, P.R. China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Chengdu, P.R. China
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Neches SK, Brei BK, Umoren R, Gray MM, Nishisaki A, Foglia EE, Sawyer T. Association of full premedication on tracheal intubation outcomes in the neonatal intensive care unit: an observational cohort study. J Perinatol 2023; 43:1007-1014. [PMID: 36801956 DOI: 10.1038/s41372-023-01632-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 02/01/2023] [Accepted: 02/06/2023] [Indexed: 02/20/2023]
Abstract
OBJECTIVE Evaluate the association of short-term tracheal intubation (TI) outcomes with premedication in the NICU. STUDY DESIGN Observational single-center cohort study comparing TIs with full premedication (opiate analgesia and vagolytic and paralytic), partial premedication, and no premedication. The primary outcome is adverse TI associated events (TIAEs) in intubations with full premedication compared to those with partial or no premedication. Secondary outcomes included change in heart rate and first attempt TI success. RESULTS 352 encounters in 253 infants (median gestation 28 weeks, birth weight 1100 g) were analyzed. TI with full premedication was associated with fewer TIAEs aOR 0.26 (95%CI 0.1-0.6) compared with no premedication, and higher first attempt success aOR 2.7 (95%CI 1.3-4.5) compared with partial premedication after adjusting for patient and provider characteristics. CONCLUSION The use of full premedication for neonatal TI, including an opiate, vagolytic, and paralytic, is associated with fewer adverse events compared with no and partial premedication.
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Affiliation(s)
- Sara K Neches
- University of Washington School of Medicine and Seattle Children's Hospital, Department of Pediatrics, Division of Neonatology, Seattle, WA, USA.
| | - Brianna K Brei
- University of Nebraska Medical Center, Department of Pediatrics, Division of Neonatology, Omaha, NE, USA
| | - Rachel Umoren
- University of Washington School of Medicine and Seattle Children's Hospital, Department of Pediatrics, Division of Neonatology, Seattle, WA, USA
| | - Megan M Gray
- University of Washington School of Medicine and Seattle Children's Hospital, Department of Pediatrics, Division of Neonatology, Seattle, WA, USA
| | - Akira Nishisaki
- Children's Hospital of Philadelphia. Department of Anesthesiology and Critical Care Medicine, Philadelphia, PA, USA
| | - Elizabeth E Foglia
- Children's Hospital of Philadelphia. Department of Pediatrics, Division of Neonatology, Philadelphia, PA, USA
| | - Taylor Sawyer
- University of Washington School of Medicine and Seattle Children's Hospital, Department of Pediatrics, Division of Neonatology, Seattle, WA, USA
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Hojnicki M, Zapata HA, Kaluarachchi DC, Fort P, Minton S, Albert G, Ross A, Wilding GE, Guthrie SO. Predictors of successful treatment of respiratory distress with aerosolized calfactant. J Perinatol 2023; 43:991-997. [PMID: 37433969 DOI: 10.1038/s41372-023-01722-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Revised: 06/14/2023] [Accepted: 07/05/2023] [Indexed: 07/13/2023]
Abstract
INTRODUCTION Predictors for successful aerosolized surfactant treatment are not well defined. OBJECTIVE To identify predictors for successful treatment in the AERO-02 trial and the AERO-03 expanded access program. METHODS Neonates receiving nasal continuous positive airway pressure (NCPAP) at the time of first aerosolized calfactant administration were included in this analysis. Associations between demographic and clinical predictors to need for intubation were examined using univariate testing and multivariate logistic regression analyses. RESULTS Three hundred and eighty infants were included in the study. Overall, 24% required rescue by intubation. Multivariate modeling revealed that the predictors of successful treatment were a gestational age ≥31 weeks, a respiratory severity score (RSS) of <1.9, and <2 previous aerosol treatments. CONCLUSION Gestational age, number of aerosols, and RSS are predictive of successful treatment. These criteria will help select patients most likely to benefit from aerosolized surfactant.
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Affiliation(s)
- Michelle Hojnicki
- Johns Hopkins All Children's Hospital, Maternal, Fetal and Neonatal Institute, St. Petersburg, FL, USA
| | - Henry A Zapata
- Department of Pediatrics, Division of Neonatology and Newborn Nursery, University of Wisconsin-Madison, Madison, WI, USA
| | - Dinushan C Kaluarachchi
- Department of Pediatrics, Division of Neonatology and Newborn Nursery, University of Wisconsin-Madison, Madison, WI, USA
| | - Prem Fort
- Johns Hopkins All Children's Hospital, Maternal, Fetal and Neonatal Institute, St. Petersburg, FL, USA
- Department of Pediatrics, Division of Neonatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | | | - Ann Ross
- Department of Neonatology, K Hovnanian Children's Hospital, Hackensack Meridian Health, Neptune, NJ, USA
| | - Gregory E Wilding
- Department of Biostatistics, University at Buffalo, Buffalo, NY, USA
| | - Scott O Guthrie
- Department of Pediatrics, Division of Neonatology, Vanderbilt University School of Medicine, Nashville, TN, USA.
- Jackson-Madison County General Hospital, Jackson, TN, USA.
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Glenn T, Fischer L, Markowski A, Carr CB, Malay S, Hibbs AM. Complicated Intubations are Associated with Bronchopulmonary Dysplasia in Very Low Birth Weight Infants. Am J Perinatol 2023; 40:1245-1252. [PMID: 34500482 PMCID: PMC9239052 DOI: 10.1055/s-0041-1736130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE This study aimed to evaluate the association between desaturation <60% (severe desaturation) during intubation and a total number of intubation attempts in the first week of life in very low birth weight (VLBW) infants with adverse long-term outcomes including bronchopulmonary dysplasia (BPD) and severe periventricular/intraventricular hemorrhage grade 3 or 4 (PIVH). STUDY DESIGN A retrospective chart review was performed on VLBW infants intubated in the neonatal intensive care unit during the first week of life between January 2017 and July 2020. Descriptive tables were generated for two outcomes including BPD and PIVH. Multivariable logistic regression was performed for each outcome including significant predictors that differed between groups with a p-value of <0.2. RESULTS A total of 146 patients were included. Patients with BPD or PIVH had a lower gestational age, and patients with BPD had a lower BW. Patients with BPD had a greater number of intubation attempts in the first week of life (4 vs. 3, p < 0.001). In multivariable logistic regression controlling for confounding variables, the odds developing BPD were higher for patients with increased cumulative number of intubation attempts in the first week of life (odds ratio [OR]: 1.29, 95% confidence interval [CI]: 1.03-1.62, p = 0.029). Post hoc analyses revealed increased odds of developing BPD with increased number of intubation encounters in the first week of life (OR: 2.20, 95% CI: 1.04-4.82, p = 0.043). In this post hoc analysis including intubation encounters in the model; desaturation <60% during intubation in the first week of life was associated with increased odds of developing BPD (OR: 2.35, 95% CI: 1.02-5.63, p = 0.048). CONCLUSION The odds of developing BPD for VLBW infants were higher with increased intubation attempts and intubation encounters. In a post hoc analysis, the odds of developing BPD were also higher with desaturation during intubation. Further research is needed to determine mechanisms of the relationship between complicated intubations and the development of BPD. KEY POINTS · Neonatal intubations often require multiple attempts.. · Neonates frequently desaturate during intubation.. · Intubation attempts are positively associated with BPD.. · Severe desaturation may be positively associated with BPD..
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Affiliation(s)
- Tara Glenn
- Division of Neonatology, Department of Pediatrics, UH Rainbow Babies and Children’s Hospital, Cleveland, OH
- Case Western Reserve University School of Medicine, Cleveland, OH
| | - Linnea Fischer
- Case Western Reserve University School of Medicine, Cleveland, OH
| | - Ashley Markowski
- Division of Neonatology, Department of Pediatrics, UH Rainbow Babies and Children’s Hospital, Cleveland, OH
| | - Cara Beth Carr
- Division of Neonatology, Department of Pediatrics, UH Rainbow Babies and Children’s Hospital, Cleveland, OH
| | - Sindhoosha Malay
- Case Western Reserve University School of Medicine, Cleveland, OH
| | - Anna Maria Hibbs
- Division of Neonatology, Department of Pediatrics, UH Rainbow Babies and Children’s Hospital, Cleveland, OH
- Case Western Reserve University School of Medicine, Cleveland, OH
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Lemyre B, Deguise MO, Benson P, Kirpalani H, Ekhaguere OA, Davis PG. Early nasal intermittent positive pressure ventilation (NIPPV) versus early nasal continuous positive airway pressure (NCPAP) for preterm infants. Cochrane Database Syst Rev 2023; 7:CD005384. [PMID: 37466143 PMCID: PMC10355255 DOI: 10.1002/14651858.cd005384.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Abstract
BACKGROUND Nasal continuous positive airway pressure (NCPAP) is a strategy to maintain positive airway pressure throughout the respiratory cycle through the application of a bias flow of respiratory gas to an apparatus attached to the nose. Early treatment with NCPAP is associated with decreased risk of mechanical ventilation exposure and might reduce chronic lung disease. Nasal intermittent positive pressure ventilation (NIPPV) is a form of noninvasive ventilation delivered through the same nasal interface during which patients are exposed to short inflations, along with background end-expiratory pressure. OBJECTIVES To examine the risks and benefits of early (within the first six hours after birth) NIPPV versus early NCPAP for preterm infants at risk of or with respiratory distress syndrome (RDS). Primary endpoints are respiratory failure and the need for intubated ventilatory support during the first week of life. Secondary endpoints include the incidence of mortality, chronic lung disease (CLD) (oxygen therapy at 36 weeks' postmenstrual age), pneumothorax, duration of respiratory support, duration of oxygen therapy, and intraventricular hemorrhage (IVH). SEARCH METHODS Searches were conducted in January 2023 in CENTRAL, MEDLINE, Embase, Web of Science, and Dissertation Abstracts. The reference lists of related systematic reviews and of studies selected for inclusion were also searched. SELECTION CRITERIA We considered all randomized and quasi-randomized controlled trials. Eligible studies compared NIPPV versus NCPAP treatment, starting within six hours after birth in preterm infants (< 37 weeks' gestational age (GA)). DATA COLLECTION AND ANALYSIS We collected and analyzed data using the recommendations of the Cochrane Neonatal Review Group. MAIN RESULTS We included 17 trials, enrolling 1958 infants in this review. NIPPV likely reduces the rate of respiratory failure (risk ratio (RR) 0.65, 95% confidence interval (CI) 0.54 to 0.78; risk difference (RD) -0.08, 95% CI -0.12 to -0.05; 17 RCTs, 1958 infants; moderate-certainty evidence) and needing endotracheal tube ventilation (RR 0.67, 95% CI 0.56 to 0.81; RD -0.07, 95% CI -0.11 to -0.04; 16 RCTs; 1848 infants; moderate-certainty evidence) amongst infants treated with early NIPPV compared with early NCPAP. The meta-analysis demonstrated that NIPPV may reduce the risk of developing CLD compared to CPAP (RR 0.70, 95% CI 0.52 to 0.92; 12 RCTs, 1284 infants; low-certainty evidence) slightly. NIPPV may result in little to no difference in mortality (RR 0.82, 95% CI 0.62 to 1.10; 17 RCTs; 1958 infants; I2 of 0%; low-certainty evidence), the incidence of pneumothorax (RR 0.92, 95% CI 0.60 to 1.41; 16 RCTs; 1674 infants; I2 of 0%; low-certainty evidence), and rates of severe IVH (RR 0.98, 95% CI 0.53 to 1.79; 8 RCTs; 977 infants; I2 of 0%; low-certainty evidence). AUTHORS' CONCLUSIONS When applied within six hours after birth, NIPPV likely reduces the risk of respiratory failure and the need for intubation and endotracheal tube ventilation in very preterm infants (GA 28 weeks and above) with respiratory distress syndrome or at risk for RDS. It may also decrease the rate of CLD slightly. However, most trials enrolled infants with a gestational age of approximately 28 to 32 weeks with an overall mean gestational age of around 30 weeks. As such, the results of this review may not apply to extremely preterm infants that are most at risk of needing mechanical ventilation or developing CLD. Additional studies are needed to confirm these results and to assess the safety of NIPPV compared with NCPAP alone in a larger patient population.
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Affiliation(s)
- Brigitte Lemyre
- Division of Neonatology, Children's Hospital of Eastern Ontario, Ottawa, Canada
| | - Marc-Olivier Deguise
- Dept. of Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, Canada
- Faculty of Medicine, University of Ottawa, Ottawa, Canada
| | - Paige Benson
- Faculty of Medicine, University of Ottawa, Ottawa, Canada
| | | | - Osayame A Ekhaguere
- Division of Neonatal-Perinatal Medicine, Indiana University, Indianapolis, Indiana, USA
| | - Peter G Davis
- Newborn Research Centre, The Royal Women's Hospital, Parkville, Australia
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Roberts K, Wanous A, Brown R, Rudser K. Comparison of Laryngeal Mask Airway and Endotracheal Tube Placement in Neonates. RESEARCH SQUARE 2023:rs.3.rs-3136331. [PMID: 37503152 PMCID: PMC10371080 DOI: 10.21203/rs.3.rs-3136331/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/29/2023]
Abstract
Objective We hypothesize that the time, number of attempts and physiologic stability of placement of an LMA would be superior compared to ETT. Study Design Videotape and physiologic parameters of LMA (n = 36) and ETT (n = 31) placement procedures for infants 28-36 weeks gestation were reviewed. Results Duration of attempts (32 vs 66 sec, p < 0.001) and mean total procedure time (88 vs 153 sec, p = 0.06) was shorter for LMA compared to ETT. Mean number of attempts for successful placement was fewer for LMA (1.5 vs 1.9, p = 0.11). Physiologic parameters remained near baseline in both groups despite very different degrees of premedication. Conclusion Placement of an LMA required less time and fewer number of attempts compared to ETT. Physiologic stability of an LMA was maintained without the use of an analgesic and muscle relaxant. Use of an LMA is a favorable alternative to ETT placement for surfactant delivery in neonates. Trial registration NCT01116921.
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Robin B, Soghier LM, Vachharajani A, Moussa A. Laryngeal Mask Airway Clinical Use and Training: A Survey of North American Neonatal Health Care Professionals. Am J Perinatol 2023. [PMID: 37429322 DOI: 10.1055/s-0043-1771017] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/12/2023]
Abstract
OBJECTIVE The aim of this study was to explore North American neonatal health care professionals' (HCPs) experience, confidence, skill, and training with the laryngeal mask airway (LMA). STUDY DESIGN This was a cross-sectional survey. RESULTS The survey was completed by 2,159 HCPs from Canada and the United States. Seventy nine percent had no clinical experience with the LMA, and less than 20% considered the LMA an alternative to endotracheal intubation (EI). The majority had received LMA training; however, 28% of registered nurses, 18% of respiratory therapists, 17% of physicians, and 12% of midwives had never inserted an LMA in a mannequin. Less than a quarter of respondents agreed that the current biennial Neonatal Resuscitation Program instruction paradigm is sufficient for LMA training. All groups reported low confidence and skill with LMA insertion, and compared with all other groups, the respiratory therapists had the highest reported confidence and skill. CONCLUSION This survey study, which is the first of its kind to include midwives, demonstrates that neonatal HCPs lack experience, confidence, skill, and training with the LMA, rarely use the device, and in general, do not consider the LMA as an alternative to EI. These findings contribute to, and support the findings of previous smaller studies, and in conjunction with the diminishing opportunities for EI, highlight the need for programs to emphasize the importance of the LMA for neonatal airway management and prioritize regular LMA training, with focus that parallels the importance placed on the skills of EI and mask ventilation. KEY POINTS · Lack of training for laryngeal mask airway use in neonatal resuscitation.. · Neonatal health care professionals rarely use the laryngeal mask airway as an alternate airway device.. · Neonatal health care professionals lack confidence and skill with the laryngeal mask airway..
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Affiliation(s)
- Beverley Robin
- Department of Pediatrics, Rush University Medical Center; Chicago, Illinois
| | - Lamia M Soghier
- Department of Neonatology, Children's National Hospital, The George Washington University School of Medicine and Health Sciences; Washington, District of Columbia
| | | | - Ahmed Moussa
- Department of Pediatrics, CHU Sainte-Justine, University of Montreal, Montreal, Quebec, Canada
- CHU Sainte-Justine Research Center, University of Montreal, Montreal, Quebec, Canada
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Pichler K, Kuehne B, Dekker J, Stummer S, Giordano V, Berger A, Kribs A, Klebermass-Schrehof K. Assessment of Comfort during Less Invasive Surfactant Administration in Very Preterm Infants: A Multicenter Study. Neonatology 2023; 120:473-481. [PMID: 37311430 PMCID: PMC10614453 DOI: 10.1159/000530333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 03/10/2023] [Indexed: 06/15/2023]
Abstract
INTRODUCTION This study was set up to investigate if and to what extent non-pharmacological analgesia is able to provide comfort to very preterm infants (VPI) during less invasive surfactant administration (LISA). METHODS This was a prospective non-randomized multicenter observational study performed in level IV NICUs. Inborn VPI with a gestational age between 220/7 and 316/7 weeks, signs of respiratory distress syndrome, and the need for surfactant replacement were included. Non-pharmacological analgesia was performed in all infants during LISA. In case of failure of the first LISA attempt, additional analgosedation could be administered. COMFORTneo scores during LISA were assessed. RESULTS 113 VPI with a mean gestational age of 27 weeks (+/- 2.3 weeks) and mean birth weight of 946 g (+/- 33 g) were included. LISA was successful at the first laryngoscopy attempt in 81%. COMFORTneo scores were highest during laryngoscopy. At this time point, non-pharmacological analgesia provided adequate comfort in 61% of the infants. 74.4% of lower gestational aged infants (i.e., 220-266 weeks) were within the comfort zone during laryngoscopy compared to 51.6% of higher gestational aged infants (i.e., 270-320 weeks) (p = 0.016). The time point of surfactant administration did not influence the COMFORTneo scores during the LISA procedure. CONCLUSION Non-pharmacological analgesia provided comfort in as much as 61% of the included VPI during LISA. Further research is needed to both develop strategies to identify infants who, despite receiving non-pharmacological analgesia, are at high risk for experiencing discomfort during LISA and define patient-tailored dosage and choice of analgosedative drugs.
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Affiliation(s)
- Karin Pichler
- Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Department of Pediatrics, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria,
| | - Benjamin Kuehne
- Division of Neonatology, Department of Paediatrics, University of Cologne, Cologne, Germany
| | - Janneke Dekker
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Sophie Stummer
- Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Department of Pediatrics, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Vito Giordano
- Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Department of Pediatrics, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Angelika Berger
- Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Department of Pediatrics, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Angela Kribs
- Division of Neonatology, Department of Paediatrics, University of Cologne, Cologne, Germany
| | - Katrin Klebermass-Schrehof
- Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Department of Pediatrics, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
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Van Der Veeken E, Manley BJ, Owen L, Kamlin O, Roberts C, Newman S, Francis K, Donath S, Davis P, Cuzzilla R, Hodgson KA. Cerebral Oxygenation during Neonatal Intubation with Nasal High Flow: A Sub-Study of the SHINE Randomized Trial. Neonatology 2023; 120:458-464. [PMID: 37231978 DOI: 10.1159/000529870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 02/22/2023] [Indexed: 05/27/2023]
Abstract
INTRODUCTION Nasal high flow (nHF) improves the likelihood of successful neonatal intubation on the first attempt without physiological instability. The effect of nHF on cerebral oxygenation is unknown. The aim of this study was to compare cerebral oxygenation during endotracheal intubation in neonates receiving nHF and those receiving standard care. METHODS A sub-study of a multicentre randomized trial of nHF during neonatal endotracheal intubation. A subset of infants had near-infrared spectroscopy (NIRS) monitoring. Eligible infants were randomly assigned to nHF or standard care during the first intubation attempt. NIRS sensors provided continuous regional cerebral oxygen saturation (rScO2) monitoring. The procedure was video recorded, and peripheral oxygen saturation and rScO2 data were extracted at 2-second intervals. The primary outcome was the average difference in rScO2 from baseline during the first intubation attempt. Secondary outcomes included average rScO2 and rate of change of rScO2. RESULTS Nineteen intubations were analyzed (11 nHF; 8 standard care). Median (interquartile range [IQR]) postmenstrual age was 27 (26.5-29) weeks, and weight was 828 (716-1,135) g. Median change in rScO2 from baseline was -1.5% (-5.3 to 0.0) in the nHF group and -9.4% (-19.6 to -4.5) in the standard care group. rScO2 fell more slowly in infants managed with nHF compared with standard care: median (IQR) rScO2 change -0.08 (-0.13 to 0.00) % per second and -0.36 (-0.66 to -0.22) % per second, respectively. CONCLUSIONS In this small sub-study, regional cerebral oxygen saturation was more stable in neonates who received nHF during intubation compared with standard care.
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Affiliation(s)
- Ellyn Van Der Veeken
- Newborn Research, The Royal Women's Hospital, Melbourne, Victoria, Australia
- Department of Obstetrics and Gynaecology, The University of Melbourne, Parkville, Victoria, Australia
| | - Brett James Manley
- Newborn Research, The Royal Women's Hospital, Melbourne, Victoria, Australia
- Department of Obstetrics and Gynaecology, The University of Melbourne, Parkville, Victoria, Australia
- Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Louise Owen
- Newborn Research, The Royal Women's Hospital, Melbourne, Victoria, Australia
- Department of Obstetrics and Gynaecology, The University of Melbourne, Parkville, Victoria, Australia
- Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Omar Kamlin
- Newborn Research, The Royal Women's Hospital, Melbourne, Victoria, Australia
- Department of Obstetrics and Gynaecology, The University of Melbourne, Parkville, Victoria, Australia
- Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Calum Roberts
- Monash Newborn, Monash Children's Hospital, Melbourne, Victoria, Australia
- Department of Paediatrics, Monash University, Melbourne, Victoria, Australia
- The Ritchie Centre, Hudson Institute of Medical Research, VIC, Melbourne, Australia
| | - Sophie Newman
- Department of Neonatal Medicine, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Kate Francis
- Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Department of Paediatrics, The University of Melbourne, Parkville, Victoria, Australia
| | - Susan Donath
- Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Department of Paediatrics, The University of Melbourne, Parkville, Victoria, Australia
| | - Peter Davis
- Newborn Research, The Royal Women's Hospital, Melbourne, Victoria, Australia
- Department of Obstetrics and Gynaecology, The University of Melbourne, Parkville, Victoria, Australia
- Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Rocco Cuzzilla
- Newborn Research, The Royal Women's Hospital, Melbourne, Victoria, Australia
| | - Kate Alison Hodgson
- Newborn Research, The Royal Women's Hospital, Melbourne, Victoria, Australia
- Department of Obstetrics and Gynaecology, The University of Melbourne, Parkville, Victoria, Australia
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Cavallin F, Margarita T, Bua B, Beltrame F, Pasta E, Villani PE, Trevisanuto D. Rigid versus soft catheter for less invasive surfactant administration: A crossover randomized controlled manikin trial. Pediatr Pulmonol 2023. [PMID: 37154505 DOI: 10.1002/ppul.26458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 04/01/2023] [Accepted: 04/27/2023] [Indexed: 05/10/2023]
Abstract
BACKGROUND We compared surfactant administration with a rigid versus soft catheter in a manikin simulating an extremely preterm infant. METHODS Randomized controlled crossover (AB/BA) trial. Fifty tertiary hospital consultants and pediatric residents. The primary outcome was the time of device positioning. The secondary outcomes were the success of the first attempt, the number of attempts, and the participant's opinion. RESULTS Median time of device positioning was 19 s (interquartile range [IQR]: 15-25) with rigid catheter and 40 s (IQR: 28-66) with soft catheter (p < 0.0001). Success at first attempt was 92% with rigid catheter and 74% with soft catheter (p = 0.01). Median number of attempts was 1 (IQR: 1-1) with rigid catheter and 1 (IQR: 1-2) with soft catheter (p = 0.009). Participants found the rigid catheter easier to use (p < 0.0001). CONCLUSIONS In a preterm manikin model, using a rigid catheter for less invasive surfactant administration was quicker and easier to use than a soft catheter.
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Affiliation(s)
| | - Teresa Margarita
- Department of Woman's and Child's Health, University Hospital of Padua, Padua, Italy
| | - Benedetta Bua
- Department of Woman's and Child's Health, University Hospital of Padua, Padua, Italy
| | - Francesca Beltrame
- Department of Woman's and Child's Health, University Hospital of Padua, Padua, Italy
| | | | | | - Daniele Trevisanuto
- Department of Woman's and Child's Health, University Hospital of Padua, Padua, Italy
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Fleishhacker ZJ, Bennion DM, Manaligod J, Kacmarynski D, Ropp BY, Kanotra S. Quality Improvement of Pediatric Airway Emergency Carts: Standardization, Streamlining, and Simulation. Cureus 2023; 15:e39727. [PMID: 37398737 PMCID: PMC10310310 DOI: 10.7759/cureus.39727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/30/2023] [Indexed: 07/04/2023] Open
Abstract
Objective Pediatric airway emergencies are amongst the most tenuous scenarios faced by on-call providers, requiring quick access to the appropriate equipment and a timely response. In the present study, we report on the testing and improvement of pediatric airway carts at our institution. The primary objective was to optimize our pediatric airway emergency carts to improve response times. Secondarily, we aimed to implement a training scenario to improve providers' familiarity and confidence in attaining and assembling equipment. Methods Surveys of airway cart configuration at our hospital and others were used to identify differences. Volunteer otolaryngology physicians were tasked with responding to a mock scenario using an existing cart or one modified based on the survey. Outcomes included (1) time to arrival of the provider with the appropriate equipment, (2) time from arrival to complete assembly of equipment, and (3) time for re-assembly of the equipment. Results The survey revealed differences in cart equipment and location. The inclusion of a flexible bronchoscope and a video tower, as well as the placement of the carts directly within the ICU, resulted in improved time to arrival by an average of 181 seconds, and improved equipment assembly time by an average of 85 seconds. Discussion Standardization of pediatric airway equipment on the cart and location near critically ill patients improved response efficiency. Simulation led to improved confidence and reduced reaction time among providers at all levels of experience. Conclusion The present study provides an example for the optimization of airway carts, which can be adapted by healthcare systems to their local milieu.
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Affiliation(s)
- Zachary J Fleishhacker
- Otolaryngology - Head and Neck Surgery, University of Iowa Hospitals and Clinics, Iowa City, USA
| | - Douglas M Bennion
- Otolaryngology - Head and Neck Surgery, University of Iowa Hospitals and Clinics, Iowa City, USA
| | - Jose Manaligod
- Otolaryngology - Head and Neck Surgery, University of Iowa Hospitals and Clinics, Iowa City, USA
| | - Deborah Kacmarynski
- Otolaryngology - Head and Neck Surgery, University of Iowa Hospitals and Clinics, Iowa City, USA
| | - Bonita Y Ropp
- Nursing, University of Iowa Hospitals and Clinics, Iowa City, USA
| | - Sohit Kanotra
- Otolaryngology - Head and Neck Surgery, University of Iowa Hospitals and Clinics, Iowa City, USA
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Herrick HM, O'Reilly M, Lee S, Wildenhain P, Napolitano N, Shults J, Nishisaki A, Foglia EE. Providing Oxygen during Intubation in the NICU Trial (POINT): study protocol for a randomised controlled trial in the neonatal intensive care unit in the USA. BMJ Open 2023; 13:e073400. [PMID: 37055198 PMCID: PMC10106049 DOI: 10.1136/bmjopen-2023-073400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 03/28/2023] [Indexed: 04/15/2023] Open
Abstract
INTRODUCTION Nearly half of neonatal intubations are complicated by severe desaturation (≥20% decline in pulse oximetry saturation (SpO2)). Apnoeic oxygenation prevents or delays desaturation during intubation in adults and older children. Emerging data show mixed results for apnoeic oxygenation using high-flow nasal cannula (NC) during neonatal intubation. The study objective is to determine among infants ≥28 weeks' corrected gestational age (cGA) who undergo intubation in the neonatal intensive care unit (NICU) whether apnoeic oxygenation with a regular low-flow NC, compared with standard of care (no additional respiratory support), reduces the magnitude of SpO2 decline during intubation. METHODS AND ANALYSIS This is a multicentre, prospective, unblinded, pilot randomised controlled trial in infants ≥28 weeks' cGA who undergo premedicated (including paralytic) intubation in the NICU. The trial will recruit 120 infants, 10 in the run-in phase and 110 in the randomisation phase, at two tertiary care hospitals. Parental consent will be obtained for eligible patients prior to intubation. Patients will be randomised to 6 L NC 100% oxygen versus standard of care (no respiratory support) at time of intubation. The primary outcome is magnitude of oxygen desaturation during intubation. Secondary outcomes include additional efficacy, safety and feasibility outcomes. Ascertainment of the primary outcome is performed blinded to intervention arm. Intention-to-treat analyses will be conducted to compare outcomes between treatment arms. Two planned subgroup analyses will explore the influence of first provider intubation competence and patients' baseline lung disease using pre-intubation respiratory support as a proxy. ETHICS AND DISSEMINATION The Institutional Review Boards at the Children's Hospital of Philadelphia and the University of Pennsylvania have approved the study. Upon completion of the trial, we intend to submit our primary results to a peer review forum after which we plan to publish our results in a peer-reviewed paediatric journal. TRIAL REGISTRATION NUMBER ClinicalTrials.gov Registry (NCT05451953).
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Affiliation(s)
- Heidi M Herrick
- Pediatrics, Division of Neonatology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Mackenzie O'Reilly
- Pediatrics, Division of Neonatology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Sura Lee
- Pediatrics, Division of Neonatology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Paul Wildenhain
- Pediatrics, Division of Neonatology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Natalie Napolitano
- Respiratory Therapy, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Justine Shults
- Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Biostatistics, Epidemiology, and Informatics, Division of Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Akira Nishisaki
- Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Anesthesiology and Critical Care Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Elizabeth E Foglia
- Pediatrics, Division of Neonatology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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49
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Miller KA, Prieto MM, Wing R, Goldman MP, Polikoff LA, Nishisaki A, Nagler J. Development of a paediatric airway management checklist for the emergency department: a modified Delphi approach. Emerg Med J 2023; 40:287-292. [PMID: 36788006 DOI: 10.1136/emermed-2022-212758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 02/03/2023] [Indexed: 02/16/2023]
Abstract
BACKGROUND Airway management checklists have improved paediatric patient safety in some clinical settings, but consensus on the appropriate components to include on a checklist for paediatric tracheal intubation in the ED is lacking. METHODS A multidisciplinary panel of 14 experts in airway management within and outside of paediatric emergency medicine participated in a modified Delphi approach to develop consensus on the appropriate components for a paediatric airway management checklist for the ED. Panel members reviewed, modified and added to the components from the National Emergency Airway Registry for Children airway safety checklist for paediatric intensive care units using a 9-point appropriateness scale. Components with a median score of 7.0-9.0 and a 25th percentile score ≥7.0 achieved consensus for inclusion. A priori, the modified Delphi method was limited to a maximum of two rounds for consensus on essential components and one additional round for checklist creation. RESULTS All experts participated in both rounds. Consensus was achieved on 22 components. Twelve were original candidate items and 10 were newly suggested or modified items. Consensus components included the following categories: patient assessment and plan (5 items), patient preparation (5 items), pharmacy (2 items), equipment (7 items) and personnel (3 items). The components were formatted into a 17-item clinically usable checklist. CONCLUSIONS Using the modified Delphi method, consensus was established among airway management experts around essential components for an airway management checklist intended for paediatric tracheal intubation in the ED.
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Affiliation(s)
- Kelsey A Miller
- Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Monica M Prieto
- Department of Pediatrics - Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Robyn Wing
- Department of Emergency Medicine - Pediatric Emergency Medicine, Hasbro Children's Hospital, Providence, Rhode Island, USA
| | - Michael P Goldman
- Departments of Pediatrics and Emergency Medicine, Yale-New Haven Children's Hospital, New Haven, Connecticut, USA
| | - Lee A Polikoff
- Department of Pediatrics, Hasbro Children's Hospital, Providence, Rhode Island, USA
| | - Akira Nishisaki
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Joshua Nagler
- Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
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50
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Kessler L, Gröpel P, Aichner H, Aspalter G, Kuster L, Schmölzer GM, Berger A, Wagner M, Simma B. Eye-tracking during simulated endotracheal newborn intubation: a prospective, observational multi-center study. Pediatr Res 2023:10.1038/s41390-023-02561-x. [PMID: 36932183 DOI: 10.1038/s41390-023-02561-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Revised: 02/14/2023] [Accepted: 02/27/2023] [Indexed: 03/19/2023]
Abstract
BACKGROUND The aim was to assess health care providers' (HCPs) visual attention (VA) by using eye-tracking glasses during a simulated neonatal intubation. METHODS HCPs from three pediatric and neonatal departments (Feldkirch and Vienna, Austria, and Edmonton, Canada) completed a simulated neonatal intubation scenario while wearing eye-tracking glasses (Tobii Pro Glasses 2®, Tobii, Stockholm, Sweden) to record their VA. Main outcomes included duration of intubation, success rate, and VA. We further compared orotracheal and nasotracheal intubations. RESULTS 30 participants were included. 50% completed the intubation within 30 s (M = 35.40, SD = 16.01). Mostly nasotracheal intubations exceeded the limit. Experience was an important factor in reducing intubation time. VA differed between more and less experienced HCPs as well as between orotracheal and nasotracheal intubations. Participants also focused on different areas of interest (AOIs) depending on the intubator's experience. More experience was associated with a higher situational awareness (SA) and fewer distractions, which, however, did not transfer to significantly better intubation performance. CONCLUSION Half of the intubations exceeded the recommended time limit. Differences in intubation duration depending on type of intubation were revealed. VA differed between HCPs with different levels of experience and depended on duration and type of intubation. IMPACT Simulated neonatal intubation duration differs between orotracheal and nasotracheal intubation. Visual attention during simulated neonatal intubation shows differences depending on intubation duration, intubator experience, type of intubation, and level of distraction. Intubator experience is a vital parameter for reducing intubation duration and improving intubator focus on task-relevant stimuli.
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Affiliation(s)
- Lisa Kessler
- Department of Pediatrics, Academic Teaching Hospital, Landeskrankenhaus Feldkirch, Feldkirch, Austria. .,Pediatric Simulation Center, Academic Teaching Hospital, Landeskrankenhaus Feldkirch, Feldkirch, Austria. .,Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Department of Pediatrics, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria. .,Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, AB, Canada. .,Department of Pediatrics, University of Alberta, Edmonton, AB, Canada.
| | - Peter Gröpel
- Division of Sport Psychology, Department of Sport Science, University of Vienna, Vienna, Austria
| | - Heidi Aichner
- Department of Pediatrics, Academic Teaching Hospital, Landeskrankenhaus Feldkirch, Feldkirch, Austria.,Pediatric Simulation Center, Academic Teaching Hospital, Landeskrankenhaus Feldkirch, Feldkirch, Austria
| | - Gerhard Aspalter
- Department of Pediatrics, Academic Teaching Hospital, Landeskrankenhaus Feldkirch, Feldkirch, Austria.,Pediatric Simulation Center, Academic Teaching Hospital, Landeskrankenhaus Feldkirch, Feldkirch, Austria
| | - Lucas Kuster
- Pediatric Simulation Center, Academic Teaching Hospital, Landeskrankenhaus Feldkirch, Feldkirch, Austria
| | - Georg M Schmölzer
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, AB, Canada.,Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Angelika Berger
- Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Department of Pediatrics, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Michael Wagner
- Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Department of Pediatrics, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Burkhard Simma
- Department of Pediatrics, Academic Teaching Hospital, Landeskrankenhaus Feldkirch, Feldkirch, Austria.,Pediatric Simulation Center, Academic Teaching Hospital, Landeskrankenhaus Feldkirch, Feldkirch, Austria
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