Use of Initial Endotracheal versus Intravenous Epinephrine During Neonatal Cardiopulmonary Resuscitation in the Delivery Room: Review of a National Database

OBJECTIVE

To assess whether initial epinephrine administration by endotracheal tube (ET) in newly born infants receiving chest compressions and epinephrine in the delivery room is associated with lower rates of return of spontaneous circulation (ROSC) compared with newborns receiving initial intravenous (IV) epinephrine.

STUDY DESIGN

We conducted a retrospective review of neonates receiving chest compressions and epinephrine in the delivery room (DR) from the AHA Get With The Guidelines®-Resuscitation registry from October 2013 through July 2020. Neonates were classified according to initial route of epinephrine (ET versus IV). The primary outcome of interest was ROSC in the DR.

RESULTS

408 infants met inclusion criteria; of these, 281 (68.9%) received initial ET epinephrine and 127 (31.1%) received initial IV epinephrine. The initial ET epinephrine group included those infants who also received subsequent IV epinephrine when ET epinephrine failed to achieve ROSC. Comparing initial ET with initial IV epinephrine, ROSC was achieved in 70.1% vs. 58.3% (adjusted risk difference (aRD) = 10.02, [95% CI 0.05, 19.99]). ROSC was achieved in 58.3% with IV epinephrine alone, and 47.0% with ET epinephrine alone with 40.0% receiving subsequent IV epinephrine.

CONCLUSION

This study suggests that initial use of ET epinephrine is reasonable during DR resuscitation as there were higher rates of ROSC compared with initial IV epinephrine administration. However, administration of IV epinephrine should not be delayed in those infants not responding to initial ET epinephrine, as almost half of infants who received initial ET epinephrine subsequently received IV epinephrine prior to achieving ROSC.

Endotracheal Tube Size Adjustments Within Seven Days of Neonatal Intubation

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.

Delivery Room Resuscitation of Infants with Congenital Diaphragmatic Hernia: Lessons Learned through Video Review

INTRODUCTION

Delivery room (DR) interventions for infants with congenital diaphragmatic hernia (CDH) are not well described. This study sought to describe timing and order of DR interventions and identify system factors impacting CDH DR resuscitations using a human factors framework.

METHODS

Single center observational study of video recorded CDH DR resuscitations documenting timing and order of interventions. The team used the Systems Engineering Initiative for Patient Safety (SEIPS) model to identify system factors impacting DR resuscitations and time to invasive ventilation.

RESULTS

We analyzed 31 video recorded CDH resuscitations. We observed variability in timing and order of resuscitation tasks. The 'Internal Environment' and 'Tasks' components of the SEIPS model were prominent factors affecting resuscitation efficiency; significant room and bed spatial constraints exist, and nurses have a significant task burden. Additionally, endotracheal tube preparation was a prominent barrier to timely invasive ventilation.

CONCLUSION

Video review revealed variation in event timing and order during CDH resuscitations. Standardization of room set-up, equipment, and event order and reallocation of tasks facilitate more efficient intubation and ventilation, representing targets for CDH DR improvement initiatives. This work emphasizes the utility of rigorous human factors review to identify areas for improvement during DR resuscitation.

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

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.

Laryngeal mask use during neonatal resuscitation at birth: A United States-based survey of neonatal resuscitation program providers and instructors

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.

Randomized Controlled Trials of Pulmonary Vasodilator Therapy Adjunctive to Inhaled Nitric Oxide for Persistent Pulmonary Hypertension of the Newborn: A Systematic Review

Inhaled nitric oxide (iNO) is a pulmonary vasodilator considered standard of care to treat persistent pulmonary hypertension of the newborn. However, not all infants respond to iNO. The authors performed a systematic review to examine methodology, outcomes, and challenges of randomized controlled trials testing pulmonary vasodilator medications adjunctive to iNO. The 5 trials identified showed heterogeneity in eligibility criteria and outcomes assessed. No trial achieved recruitment goals, limiting conclusions regarding efficacy, safety, and pharmacology. Trial design consensus and alternative methodologic strategies such as deferred consent, real-world controls, nonrandomized database assessments, and Bayesian statistical approaches are needed.

Factors that impact second attempt success for neonatal intubation following first attempt failure: a report from the National Emergency Airway Registry for Neonates

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.

2023 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces

The International Liaison Committee on Resuscitation engages in a continuous review of new, peer-reviewed, published cardiopulmonary resuscitation and first aid science. Draft Consensus on Science With Treatment Recommendations are posted online throughout the year, and this annual summary provides more concise versions of the final Consensus on Science With Treatment Recommendations from all task forces for the year. Topics addressed by systematic reviews this year include resuscitation of cardiac arrest from drowning, extracorporeal cardiopulmonary resuscitation for adults and children, calcium during cardiac arrest, double sequential defibrillation, neuroprognostication after cardiac arrest for adults and children, maintaining normal temperature after preterm birth, heart rate monitoring methods for diagnostics in neonates, detection of exhaled carbon dioxide in neonates, family presence during resuscitation of adults, and a stepwise approach to resuscitation skills training. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the quality of the evidence, using Grading of Recommendations Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections. In addition, the task forces list priority knowledge gaps for further research. Additional topics are addressed with scoping reviews and evidence updates.

2023 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces

The International Liaison Committee on Resuscitation engages in a continuous review of new, peer-reviewed, published cardiopulmonary resuscitation and first aid science. Draft Consensus on Science With Treatment Recommendations are posted online throughout the year, and this annual summary provides more concise versions of the final Consensus on Science With Treatment Recommendations from all task forces for the year. Topics addressed by systematic reviews this year include resuscitation of cardiac arrest from drowning, extracorporeal cardiopulmonary resuscitation for adults and children, calcium during cardiac arrest, double sequential defibrillation, neuroprognostication after cardiac arrest for adults and children, maintaining normal temperature after preterm birth, heart rate monitoring methods for diagnostics in neonates, detection of exhaled carbon dioxide in neonates, family presence during resuscitation of adults, and a stepwise approach to resuscitation skills training. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the quality of the evidence, using Grading of Recommendations Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections. In addition, the task forces list priority knowledge gaps for further research. Additional topics are addressed with scoping reviews and evidence updates.

Success rates and adverse events during neonatal intubation: Lessons learned from an international registry

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.

Respiratory function after birth in infants with congenital diaphragmatic hernia

OBJECTIVE

To characterise the transitional pulmonary physiology of infants with congenital diaphragmatic hernia (CDH) using measures of expiratory tidal volume (TV) and end-tidal carbon dioxide (ETCO2).

DESIGN

Prospective single-centre observational study.

SETTING

Quaternary neonatal intensive care unit.

PATIENTS

Infants with an antenatal diagnosis of CDH born at the Children's Hospital of Philadelphia.

INTERVENTIONS

TV and ETCO2 were simultaneously recorded using a respiratory function monitor (RFM) during invasive positive pressure ventilation immediately after birth.

MAIN OUTCOME MEASURES

TV per birth weight and ETCO2 values were summarised for each minute after birth. Subgroups of interest were defined by liver position (thoracic vs abdominal) and extracorporeal membrane oxygenation (ECMO) treatment.

RESULTS

RFM data were available for 50 infants from intubation until a median (IQR) of 9 (7-14) min after birth. TV and ETCO2 values increased for the first 10 min after birth, but intersubject values were heterogeneous. TVs were overall lower and ETCO2 values higher in infants with an intrathoracic liver and infants who were ultimately treated with ECMO. On hospital discharge, survival was 88% (n=43) and 34% (n=17) of infants were treated with ECMO.

CONCLUSION

Respiratory function immediately after birth is heterogeneous for infants with CDH. Lung aeration, as evidenced by expired TV and ETCO2, appears to be ongoing throughout the first 10 min after birth during invasive positive pressure ventilation. Close attention to expired TV and ETCO2 levels by 10 min after birth may provide an opportunity to optimise and individualise ventilatory support for this high-risk population.

Association of full premedication on tracheal intubation outcomes in the neonatal intensive care unit: an observational cohort study

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.

Exposure to umbilical cord management approaches and death or neurodevelopmental impairment at 22-26 months' corrected age after extremely preterm birth

OBJECTIVE

To compare death or severe neurodevelopmental impairment (NDI) at 22-26 months' corrected age (CA) among extremely preterm infants following exposure to different forms of umbilical cord management.

DESIGN

Retrospective study.

SETTING

Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network registry.

PATIENTS

Infants born <27 weeks' gestation in 2016-2018 without severe congenital anomalies who received active treatment after birth and underwent neurodevelopmental assessments between 22 and 26 months' CA.

EXPOSURES

Immediate cord clamping (ICC), delayed cord clamping (DCC) or umbilical cord milking (UCM).

MAIN OUTCOMES AND MEASURE

Primary composite outcome of death or severe NDI at 22-26 months' CA, defined as severe cerebral palsy, Bayley-III cognitive/motor composite score <70, bilateral deafness or blindness; individual components were examined as secondary outcomes. Multivariable regression examined associations, adjusting for risk factors identified a priori and potential confounders. Mediation analysis explored the effect of severe intraventricular haemorrhage (IVH) on the exposure-outcome relationship.

RESULTS

Among 1900 infants, 64.1% were exposed to ICC, 27.8% to DCC and 8.1% to UCM. Compared with ICC-exposed infants, DCC-exposed infants had lower odds of death or severe NDI (adjusted OR 0.64, 95% CI 0.50 to 0.83). No statistically significant differences were observed when comparing UCM with either ICC or DCC, or between secondary outcomes across groups. Association between cord management and the primary outcome was not mediated by severe IVH.

CONCLUSION

Compared with ICC, DCC exposure was associated with lower death or severe NDI at 22-26 months' CA among extremely preterm infants, which was not mediated by severe IVH.

Evaluating the Accuracy of Pulse Oximetry in Children According to Race

This cross-sectional study investigates the association between race and pulse oximeter accuracy in children in the US.

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

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).

Use of ventilation/perfusion mismatch to guide individualised CPAP level selection in preterm infants: a feasibility trial

OBJECTIVE

To measure within-subject changes in ventilation/perfusion (V'/Q') mismatch in response to a protocol of individualised nasal continuous positive airway pressure (CPAP) level selection.

DESIGN

Single-arm, non-randomised, feasibility trial.

SETTING

Three centres in the Children's Hospital of Philadelphia neonatal care network.

PATIENTS

Twelve preterm infants of postmenstrual age 27-35 weeks, postnatal age >24 hours, and receiving a fraction of inspired oxygen (FiO₂) >0.25 on CPAP of 4-7 cm H₂O.

INTERVENTIONS

We applied a protocol of stepwise CPAP level changes, with the overall direction and magnitude guided by individual responses in V'/Q' mismatch, as determined by the degree of right shift (kilopascals, kPa) in a non-invasive gas exchange model. Best CPAP level was defined as the final pressure level at which V'/Q' improved by more than 5%.

MAIN OUTCOME MEASURES

Within-subject change in V'/Q' mismatch between baseline and best CPAP levels.

RESULTS

There was a median (IQR) within-subject reduction in V'/Q' mismatch of 1.2 (0-3.2) kPa between baseline and best CPAP levels, p=0.02. Best CPAP was observed at a median (range) absolute level of 7 (5-8) cm H₂O.

CONCLUSIONS

Non-invasive measures of V'/Q' mismatch may be a useful approach for identifying individualised CPAP levels in preterm infants. The results of our feasibility study should be interpreted cautiously and replication in larger studies evaluating the impact of this approach on clinical outcomes is needed.

TRIAL REGISTRATION NUMBER

NCT02983825.

2022 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces

This is the sixth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. This summary addresses the most recently published resuscitation evidence reviewed by International Liaison Committee on Resuscitation Task Force science experts. Topics covered by systematic reviews include cardiopulmonary resuscitation during transport; approach to resuscitation after drowning; passive ventilation; minimizing pauses during cardiopulmonary resuscitation; temperature management after cardiac arrest; use of diagnostic point-of-care ultrasound during cardiac arrest; use of vasopressin and corticosteroids during cardiac arrest; coronary angiography after cardiac arrest; public-access defibrillation devices for children; pediatric early warning systems; maintaining normal temperature immediately after birth; suctioning of amniotic fluid at birth; tactile stimulation for resuscitation immediately after birth; use of continuous positive airway pressure for respiratory distress at term birth; respiratory and heart rate monitoring in the delivery room; supraglottic airway use in neonates; prearrest prediction of in-hospital cardiac arrest mortality; basic life support training for likely rescuers of high-risk populations; effect of resuscitation team training; blended learning for life support training; training and recertification for resuscitation instructors; and recovery position for maintenance of breathing and prevention of cardiac arrest. Members from 6 task forces have assessed, discussed, and debated the quality of the evidence using Grading of Recommendations Assessment, Development, and Evaluation criteria and generated consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections, and priority knowledge gaps for future research are listed.

Recommended Guideline for Uniform Reporting of Neonatal Resuscitation: The Neonatal Utstein Style

Clinical research on neonatal resuscitation has accelerated over recent decades. However, an important methodologic limitation is that there are no standardized definitions or reporting guidelines for neonatal resuscitation clinical studies. To address this, the International Liaison Committee on Resuscitation Neonatal Life Support Task Force established a working group to develop the first Utstein-style reporting guideline for neonatal resuscitation. The working group modeled this approach on previous Utstein-style guidelines for other populations. This reporting guideline focuses on resuscitation of newborns immediately after birth for respiratory failure, bradycardia, severe bradycardia, or cardiac arrest. We identified 7 relevant domains: setting, patient, antepartum, birth/preresuscitation, resuscitation process, postresuscitation process, and outcomes. Within each domain, relevant data elements were identified as core versus supplemental. Core data elements should be collected and reported for all neonatal resuscitation studies, while supplemental data elements may be collected and reported using standard definitions when possible. The Neonatal Utstein template includes both core and supplemental elements across the 7 domains, and the associated Data Table provides detailed information and reporting standards for each data element. The Neonatal Utstein reporting guideline is anticipated to assist investigators engaged in neonatal resuscitation research by standardizing data definitions. The guideline will facilitate data pooling in meta-analyses, enhancing the strength of neonatal resuscitation treatment recommendations and subsequent guidelines.

Resuscitators' opinions on using a respiratory function monitor during neonatal resuscitation

AIM

The aim of this study was to assess the resuscitators' opinions of the usefulness and clinical value of using a respiratory function monitor (RFM) when resuscitating extremely preterm infants with positive pressure ventilation.

METHODS

The link to an online survey was sent to 106 resuscitators from six countries who were involved in a multicentre trial that compared the percentage of inflations within a predefined target range with and without the RFM. The resuscitators were asked to assess the usefulness and clinical value of the RFM. The survey was online for 4 months after the trial ended in May 2019.

RESULTS

The survey was completed by 74 (70%) resuscitators of which 99% considered the RFM to be helpful during neonatal resuscitation and 92% indicated that it influenced their decision-making. The majority (76%) indicated that using the RFM improved their practice and made resuscitation more effective, even when the RFM was not available. Inadequate training was the key issue that limited the effectiveness of the RFM: 45% felt insufficiently trained, and 78% felt more training in using and interpreting the RFM would have been beneficial.

CONCLUSION

Resuscitators considered the RFM to be helpful to guide neonatal resuscitation, but sufficient training was required to achieve the maximum benefit.

2022 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces

This is the sixth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. This summary addresses the most recently published resuscitation evidence reviewed by International Liaison Committee on Resuscitation Task Force science experts. Topics covered by systematic reviews include cardiopulmonary resuscitation during transport; approach to resuscitation after drowning; passive ventilation; minimizing pauses during cardiopulmonary resuscitation; temperature management after cardiac arrest; use of diagnostic point-of-care ultrasound during cardiac arrest; use of vasopressin and corticosteroids during cardiac arrest; coronary angiography after cardiac arrest; public-access defibrillation devices for children; pediatric early warning systems; maintaining normal temperature immediately after birth; suctioning of amniotic fluid at birth; tactile stimulation for resuscitation immediately after birth; use of continuous positive airway pressure for respiratory distress at term birth; respiratory and heart rate monitoring in the delivery room; supraglottic airway use in neonates; prearrest prediction of in-hospital cardiac arrest mortality; basic life support training for likely rescuers of high-risk populations; effect of resuscitation team training; blended learning for life support training; training and recertification for resuscitation instructors; and recovery position for maintenance of breathing and prevention of cardiac arrest. Members from 6 task forces have assessed, discussed, and debated the quality of the evidence using Grading of Recommendations Assessment, Development, and Evaluation criteria and generated consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections, and priority knowledge gaps for future research are listed.

2022 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces

This is the sixth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. This summary addresses the most recently published resuscitation evidence reviewed by International Liaison Committee on Resuscitation Task Force science experts. Topics covered by systematic reviews include cardiopulmonary resuscitation during transport; approach to resuscitation after drowning; passive ventilation; minimising pauses during cardiopulmonary resuscitation; temperature management after cardiac arrest; use of diagnostic point-of-care ultrasound during cardiac arrest; use of vasopressin and corticosteroids during cardiac arrest; coronary angiography after cardiac arrest; public-access defibrillation devices for children; pediatric early warning systems; maintaining normal temperature immediately after birth; suctioning of amniotic fluid at birth; tactile stimulation for resuscitation immediately after birth; use of continuous positive airway pressure for respiratory distress at term birth; respiratory and heart rate monitoring in the delivery room; supraglottic airway use in neonates; prearrest prediction of in-hospital cardiac arrest mortality; basic life support training for likely rescuers of high-risk populations; effect of resuscitation team training; blended learning for life support training; training and recertification for resuscitation instructors; and recovery position for maintenance of breathing and prevention of cardiac arrest. Members from 6 task forces have assessed, discussed, and debated the quality of the evidence using Grading of Recommendations Assessment, Development, and Evaluation criteria and generated consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections, and priority knowledge gaps for future research are listed.

Perinatal management: Lessons learned from the neonatal research network

Recent contributions of the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network (NRN) regarding obstetrical perinatal interventions and neonatal delivery room practices include the following: the impact of multiple antepartum factors including maternal diabetes, hypertension, obesity and mode of delivery on outcomes of extremely preterm newborns, effects of delayed delivery interval for extremely preterm multiples, effects of antenatal steroids on preterm newborn outcomes and the impact of antenatal magnesium sulfate therapy on neurodevelopmental outcomes for extremely preterm infants. NRN studies also contribute important evidence for neonatal delivery room resuscitation guidelines including umbilical cord management and maintenance of euthermia immediately after birth. The updated NRN outcome calculator helps better counsel families regarding possible outcomes for the most immature newborns if resuscitation is attempted at birth. Thus, the NRN provides substantial information regarding effects of perinatal management on newborn infants.

Positive pressure ventilation at birth

OBJECTIVE

To review the current state of the art of positive pressure ventilation (PPV) during resuscitation FINDINGS: The frequency of PPV during delivery room resuscitation varies across settings and gestational age subgroups. Goal targets and parameters for delivery room PPV remain undefined. The T-piece resuscitator provides the most consistent pressures during PPV and may improve clinical outcomes. The laryngeal mask may be an important alternative interface for PPV, but more data are needed to identify the optimal role of the supraglottic airway during PPV. No objective monitors of PPV have conclusively demonstrated improved outcomes to date.

CONCLUSION

More information, including real-world data from population-based studies, is needed to provide data-driven guidelines for positive pressure ventilation during neonatal transition after birth.

Learning with digital recording and video review of delivery room resuscitation

Digital recording and video review of delivery room resuscitations is a proven useful tool to evaluate neonatal resuscitation program (NRP) technical and non-technical skills. It is also valuable for research, quality improvement, and individual and group learning. Digital recording and video review programs are growing in number, and planning and implementation of digital recording requires careful thought. Consideration of technology requirements, policy implementation, and stakeholder involvement is essential to implement a successful digital recording and video review program. Video review can then be applied for individual and team-based learning. An approach to sustainability and on-going quality review of the program are key components critical to success.

Variation and Temporal Trends in Delivery Room Management of Moderate and Late Preterm Infants

BACKGROUND

Although delivery room (DR) intervention decreases with increasing gestational age (GA), little is known about DR management of moderate and late preterm (MLP) infants.

METHODS

Using the Vermont Oxford Network database of all NICU admissions, we examined the receipt of DR interventions including supplemental oxygen, positive pressure ventilation, continuous positive airway pressure, endotracheal tube ventilation, chest compressions, epinephrine, and surfactant among MLP infants (30 to 36 weeks') without congenital anomalies born from 2011 to 2020. Pneumothorax was examined as a potential resuscitation-associated complication. Intervention frequency was assessed at the infant- and hospital-level, stratified by GA and over time.

RESULTS

Overall, 55.3% of 616 110 infants (median GA: 34 weeks) from 483 Vermont Oxford Network centers received any DR intervention. Any DR intervention frequency decreased from 89.7% at 30 weeks to 44.2% at 36 weeks. From 2011 to 2020, there was an increase in the provision of continuous positive airway pressure (17.9% to 47.8%, P ≤.001) and positive pressure ventilation (22.9% to 24.9%, P ≤.001) and a decrease in endotracheal tube ventilation (6.9% to 4.0% P ≤.001), surfactant administration (3.5% to 1.3%, P ≤.001), and pneumothorax (1.9% to 1.6%, P ≤.001). Hospital rates of any DR intervention varied (median 54%, interquartile range 47% to 62%), though the frequency was similar across hospitals with different NICU capabilities after adjustment.

CONCLUSIONS

The DR management of MLP infants varies at the individual- and hospital-level and is changing over time. These findings illustrate the differing interpretation of resuscitation guidelines and emphasize the need to study MLP infants to improve evidence-based DR care.

Perinatal COVID-19 maternal and neonatal outcomes at two academic birth hospitals

OBJECTIVE

Describe 1-month outcomes among newborns of persons with perinatal COVID-19.

STUDY DESIGN

Prospective observational study of pregnant persons who tested positive for SARS-CoV-2 between 14 days before and 3 days after delivery and their newborns, from 3/2020 to 3/2021 at two urban high-risk academic hospitals. Phone interviews were conducted to determine 1-month newborn outcomes.

RESULTS

Among 9748 pregnant persons, 209 (2.1%) tested positive for perinatal SARS-CoV-2. Symptomatically infected persons were more likely to have a preterm delivery due to worsening maternal condition and their newborns were more likely to test positive for SARS-CoV-2 compared with asymptomatic persons. Six of 191 (3.1%) infants tested were positive for SARS-CoV-2; none had attributable illness before discharge. Of 169 eligible families, 132 (78.1%) participated in post-discharge interviews; none reported their newborn tested positive for SARS-CoV-2 by 1 month of age.

CONCLUSION

Symptomatic perinatal COVID-19 had a substantial effect on maternal health but no apparent short-term effect on newborns.

Does videolaryngoscopy improve tracheal intubation first attempt success in the NICUs? A report from the NEAR4NEOS

OBJECTIVE

We hypothesized that videolaryngoscope use for tracheal intubations would differ across NICUs, be associated with higher first attempt success and lower adverse events.

STUDY DESIGN

Data from the National Emergency Airway Registry for Neonates (01/2015 to 12/2017) included intubation with direct laryngoscope or videolaryngoscope. Primary outcome was first attempt success. Secondary outcomes were adverse tracheal intubation associated events and severe desaturation.

RESULTS

Of 2730 encounters (13 NICUs), 626 (23%) utilized a videolaryngoscope (3% to 64% per site). Videolaryngoscope use was associated with higher first attempt success (p < 0.001), lower adverse tracheal intubation associated events (p < 0.001), but no difference in severe desaturation. After adjustment, videolaryngoscope use was not associated with higher first attempt success (OR:1.18, p = 0.136), but was associated with lower tracheal intubation associated events (OR:0.45, p < 0.001).

CONCLUSION

Videolaryngoscope use is variable, not independently associated with higher first attempt success but associated with fewer tracheal intubation associated events.

Sustained Inflation Versus Intermittent Positive Pressure Ventilation for Preterm Infants at Birth: Respiratory Function and Vital Sign Measurements

OBJECTIVE

To characterize respiratory function monitor (RFM) measurements of sustained inflations and intermittent positive pressure ventilation (IPPV) delivered noninvasively to infants in the Sustained Aeration of Infant Lungs (SAIL) trial and to compare vital sign measurements between treatment arms.

STUDY DESIGN

We analyzed RFM data from SAIL participants at 5 trial sites. We assessed tidal volumes, rates of airway obstruction, and mask leak among infants allocated to sustained inflations and IPPV, and we compared pulse rate and oxygen saturation measurements between treatment groups.

RESULTS

Among 70 SAIL participants (36 sustained inflations, 34 IPPV) with RFM measurements, 40 (57%) were spontaneously breathing prior to the randomized intervention. The median expiratory tidal volume of sustained inflations administered was 5.3 mL/kg (IQR 1.1-9.2). Significant mask leak occurred in 15% and airway obstruction occurred during 17% of sustained inflations. Among 34 control infants, the median expiratory tidal volume of IPPV inflations was 4.3 mL/kg (IQR 1.3-6.6). Mask leak was present in 3%, and airway obstruction was present in 17% of IPPV inflations. There were no significant differences in pulse rate or oxygen saturation measurements between groups at any point during resuscitation.

CONCLUSION

Expiratory tidal volumes of sustained inflations and IPPV inflations administered in the SAIL trial were highly variable in both treatment arms. Vital sign values were similar between groups throughout resuscitation. Sustained inflation as operationalized in the SAIL trial was not superior to IPPV to promote lung aeration after birth in this study subgroup.

TRIAL REGISTRATION

Clinicaltrials.gov: NCT02139800.

2021 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Neonatal Life Support; Education, Implementation, and Teams; First Aid Task Forces; and the COVID-19 Working Group

The International Liaison Committee on Resuscitation initiated a continuous review of new, peer-reviewed published cardiopulmonary resuscitation science. This is the fifth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations; a more comprehensive review was done in 2020. This latest summary addresses the most recently published resuscitation evidence reviewed by International Liaison Committee on Resuscitation task force science experts. Topics covered by systematic reviews in this summary include resuscitation topics of video-based dispatch systems; head-up cardiopulmonary resuscitation; early coronary angiography after return of spontaneous circulation; cardiopulmonary resuscitation in the prone patient; cord management at birth for preterm and term infants; devices for administering positive-pressure ventilation at birth; family presence during neonatal resuscitation; self-directed, digitally based basic life support education and training in adults and children; coronavirus disease 2019 infection risk to rescuers from patients in cardiac arrest; and first aid topics, including cooling with water for thermal burns, oral rehydration for exertional dehydration, pediatric tourniquet use, and methods of tick removal. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the quality of the evidence, according to the Grading of Recommendations Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations or good practice statements. Insights into the deliberations of the task forces are provided in Justification and Evidence-to-Decision Framework Highlights sections. In addition, the task forces listed priority knowledge gaps for further research.

2021 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations

The International Liaison Committee on Resuscitation initiated a continuous review of new, peer-reviewed published cardiopulmonary resuscitation science. This is the fifth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations; a more comprehensive review was done in 2020. This latest summary addresses the most recently published resuscitation evidence reviewed by International Liaison Committee on Resuscitation task force science experts. Topics covered by systematic reviews in this summary include resuscitation topics of video-based dispatch systems; head-up cardiopulmonary resuscitation; early coronary angiography after return of spontaneous circulation; cardiopulmonary resuscitation in the prone patient; cord management at birth for preterm and term infants; devices for administering positive-pressure ventilation at birth; family presence during neonatal resuscitation; self-directed, digitally based basic life support education and training in adults and children; coronavirus disease 2019 infection risk to rescuers from patients in cardiac arrest; and first aid topics, including cooling with water for thermal burns, oral rehydration for exertional dehydration, pediatric tourniquet use, and methods of tick removal. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the quality of the evidence, according to the Grading of Recommendations Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations or good practice statements. Insights into the deliberations of the task forces are provided in Justification and Evidence-to-Decision Framework Highlights sections. In addition, the task forces listed priority knowledge gaps for further research.

Birth Volume and Geographic Distribution of US Hospitals With Obstetric Services From 2010 to 2018

IMPORTANCE

Timely access to clinically appropriate obstetric services is critical to the provision of high-quality perinatal care.

OBJECTIVE

To examine the geographic distribution, proximity, and urban adjacency of US obstetric hospitals by annual birth volume.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective population-based cohort study identified US hospitals with obstetric services using the American Hospital Association (AHA) Annual Survey of Hospitals and Centers for Medicare & Medicaid provider of services data from 2010 to 2018. Obstetric hospitals with 10 or more births per year were included in the study. Data analysis was performed from November 6, 2020, to April 5, 2021.

EXPOSURE

Hospital birth volume, defined by annual birth volume categories of 10 to 500, 501 to 1000, 1001 to 2000, and more than 2000 births.

MAIN OUTCOMES AND MEASURES

Outcomes assessed by birth volume category were percentage of births (from annual AHA data), number of hospitals, geographic distribution of hospitals among states, proximity between obstetric hospitals, and urban adjacency defined by urban influence codes, which classify counties by population size and adjacency to a metropolitan area.

RESULTS

The study included 26 900 hospital-years of data from 3207 distinct US hospitals with obstetric services, reflecting 34 054 951 associated births. Most infants (19 327 487 [56.8%]) were born in hospitals with more than 2000 births/y, and 2 528 259 (7.4%) were born in low-volume (10-500 births/y) hospitals. More than one-third of obstetric hospitals (37.4%; 10 064 hospital-years) were low volume. A total of 46 states had obstetric hospitals in all volume categories. Among low-volume hospitals, 18.9% (1904 hospital-years) were not within 30 miles of any other obstetric hospital and 23.9% (2400 hospital-years) were within 30 miles of a hospital with more than 2000 deliveries/y. Isolated hospitals (those without another obstetric hospital within 30 miles) were more frequently low volume, with 58.4% (1112 hospital-years) located in noncore rural areas.

CONCLUSIONS AND RELEVANCE

In this cohort study, marked variations were found in birth volume, geographic distribution, proximity, and urban adjacency among US obstetric hospitals from 2010 to 2018. The findings related to geographic isolation and rural-urban distribution of low-volume obstetric hospitals suggest the need to balance proximity with volume to optimize effective referral and access to high-quality perinatal care.

Reducing Severe Tracheal Intubation Events Through an Individualized Airway Bundle

BACKGROUND

Neonatal tracheal intubation (TI) is a high-risk procedure associated with adverse safety events. In our newborn and infant ICU, we measure adverse tracheal intubation-associated events (TIAEs) as part of our participation in National Emergency Airway Registry for Neonates, a neonatal airway registry. We aimed to decrease overall TIAEs by 10% in 12 months.

METHODS

A quality improvement team developed an individualized approach to intubation using an Airway Bundle (AB) for patients at risk for TI. Plan-do-study-act cycles included AB creation, simulation, unit roll out, interprofessional education, team competitions, and adjusting AB location. Outcome measure was monthly rate of TIAEs (overall and severe). Process measures were AB initiation, AB use at intubation, video laryngoscope (VL) use, and paralytic use. Balancing measure was inadvertent administration of TI premedication. We used statistical process control charts.

RESULTS

Data collection from November 2016 to August 2020 included 1182 intubations. Monthly intubations ranged from 12 to 41. Initial overall TIAE rate was 0.093 per intubation encounter, increased to 0.172, and then decreased to 0.089. System stability improved over time. Severe TIAE rate decreased from 0.047 to 0.016 in June 2019. AB initiation improved from 70% to 90%, and AB use at intubation improved from 18% to 55%. VL use improved from 86% to 97%. Paralytic use was 83% and did not change. The balancing measure of inadvertent TI medication administration occurred once.

CONCLUSIONS

We demonstrated a significant decrease in the rate of severe TIAEs through the implementation of an AB. Next steps include increasing use of AB at intubation.

Epidemiology and outcomes of infants after cardiopulmonary resuscitation in the neonatal or pediatric intensive care unit from a national registry

AIM

Cardiopulmonary resuscitation (CPR) in hospitalized infants is a relatively uncommon but high-risk event associated with mortality. The study objective was to identify factors associated with mortality and survival among infants who receive CPR in the neonatal intensive care unit (NICU) or pediatric intensive care unit (PICU).

METHODS

Retrospective observational study of infants with an index CPR event in the NICU or PICU between 1/1/06 and 12/31/18 in the American Heart Association's Get With The Guidelines-Resuscitation registry. Associations between patient, event, unit, and hospital factors and the primary outcome, mortality prior to discharge, were examined using multivariable logistic regression.

RESULTS

Among 3521 infants who received CPR, 2080 (59%) died before discharge, with 25% mortality during CPR and 40% within 24 h. Mortality prior to discharge occurred in 65% and 47% of cases in the NICU and PICU, respectively. Factors most strongly independently associated with pre-discharge mortality were vasoactive agent before CPR (adjusted odds ratio (aOR): 2.77, 95% confidence interval (CI) 2.15-3.58), initial pulseless condition (aOR: 2.38, 95% CI 1.46-3.86) or development of pulselessness (aOR: 2.36, 95% CI 1.78-3.12), and NICU location compared with PICU (aOR: 3.85, 95% CI 2.86-5.19). Endotracheal intubation during CPR was associated with decreased odds of pre-discharge mortality (aOR: 0.40, 95% CI 0.33-0.49).

CONCLUSION

Infants who receive CPR in the intensive care unit experience high mortality rates; identifiable patient, event, and unit factors increase the odds of mortality. Further investigation should explore the association between unit type, resuscitation processes, and mortality.

Intubation Competence During Neonatal Fellowship Training

OBJECTIVES

To characterize neonatal-perinatal medicine fellows' progression toward neonatal intubation procedural competence during fellowship training.

METHODS

Multi-center cohort study of neonatal intubation encounters performed by neonatal-perinatal medicine fellows between 2014 through 2018 at North American academic centers in the National Emergency Airway Registry for Neonates. Cumulative sum analysis was used to characterize progression of individual fellows' intubation competence, defined by an 80% overall success rate within 2 intubation attempts. We employed multivariable analysis to assess the independent impact of advancing quarter of fellowship training on intubation success.

RESULTS

There were 2297 intubation encounters performed by 92 fellows in 8 hospitals. Of these, 1766 (77%) were successful within 2 attempts. Of the 40 fellows assessed from the start of training, 18 (45%) achieved procedural competence, and 12 (30%) exceeded the deficiency threshold. Among fellows who achieved competence, the number of intubations to meet this threshold was variable, with an absolute range of 8 to 46 procedures. After adjusting for patient and practice characteristics, advancing quarter of training was independently associated with an increased odds of successful intubation (adjusted odds ratio: 1.10; 95% confidence interval 1.07-1.14).

CONCLUSIONS

The number of neonatal intubations required to achieve procedural competence is variable, and overall intubation competence rates are modest. Although repetition leads to skill acquisition for many trainees, some learners may require adjunctive educational strategies. An individualized approach to assess trainees' progression toward intubation competence is warranted.

Associations between family presence and neonatal intubation outcomes: a report from the National Emergency Airway Registry for Neonates: NEAR4NEOS

OBJECTIVE

Describe the current practice of family presence during neonatal tracheal intubations (TIs) across neonatal intensive care units (NICUs) and examine the association with outcomes.

DESIGN

Retrospective analysis of TIs performed in NICUs participating in the National Emergency Airway Registry for Neonates (NEAR4NEOS).

SETTING

Thirteen academic NICUs.

PATIENTS

Infants undergoing TI between October 2014 and December 2017.

MAIN OUTCOME MEASURES

Association of family presence with TI processes and outcomes including first attempt success (primary outcome), success within two attempts, adverse TI-associated events (TIAEs) and severe oxygen desaturation ≥20% from baseline.

RESULTS

Of the 2570 TIs, 242 (9.4%) had family presence, which varied by site (median 3.6%, range 0%-33%; p<0.01). Family member was more often present for older infants and those with chronic respiratory failure. Fewer TIs were performed by residents when family was present (FP 10% vs no FP 18%, p=0.041). Among TIs with family presence versus without family presence, the first attempt success rate was 55% vs 49% (p=0.062), success within two attempts was 74% vs 66% (p=0.014), adverse TIAEs were 18% vs 20% (p=0.62) and severe oxygen desaturation was 49% vs 52%, (p=0.40). In multivariate analyses, there was no independent association between family presence and intubation success, adverse TIAEs or severe oxygen desaturation.

CONCLUSION

Family are present in less than 10% of TIs, with variation across NICUs. Even after controlling for important patient, provider and site factors, there were no significant associations between family presence and intubation success, adverse TIAEs or severe oxygen desaturation.

Umbilical Cord Milking vs Delayed Cord Clamping and Associations with In-Hospital Outcomes among Extremely Premature Infants

OBJECTIVE

To compare in-hospital outcomes after umbilical cord milking vs delayed cord clamping among infants <29 weeks of gestation.

STUDY DESIGN

Multicenter retrospective study of infants born <29 weeks of gestation from 2016 to 2018 without congenital anomalies who received active treatment at delivery and were exposed to umbilical cord milking or delayed cord clamping. The primary outcome was mortality or severe (grade III or IV) intraventricular hemorrhage (IVH) by 36 weeks of postmenstrual age (PMA). Secondary outcomes assessed at 36 weeks of PMA were mortality, severe IVH, any IVH or mortality, and a composite of mortality or major morbidity. Outcomes were assessed using multivariable regression, incorporating mortality risk factors identified a priori, confounders, and center. A prespecified, exploratory analysis evaluated severe IVH in 2 gestational age strata, 22-24^6/7 and 25-28^6/7 weeks.

RESULTS

Among 1834 infants, 23.6% were exposed to umbilical cord milking and 76.4% to delayed cord clamping. The primary outcome, mortality or severe IVH, occurred in 21.1% of infants: 28.3% exposed to umbilical cord milking and 19.1% exposed to delayed cord clamping, with an aOR that was similar between groups (aOR 1.45, 95% CI 0.93, 2.26). Infants exposed to umbilical cord milking had higher odds of severe IVH (19.8% umbilical cord milking vs 11.8% delayed cord clamping, aOR 1.70 95% CI 1.20, 2.43), as did the 25-28^6/7 week stratum (14.8% umbilical cord milking vs 7.4% delayed cord clamping, aOR 1.89 95% CI 1.22, 2.95). Other secondary outcomes were similar between groups.

CONCLUSIONS

This analysis of extremely preterm infants suggests that delayed cord clamping is the preferred practice for placental transfusion, as umbilical cord milking exposure was associated with an increase in the adverse outcome of severe IVH.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT00063063.

Placental transfusion and short-term outcomes among extremely preterm infants

OBJECTIVE

To compare short-term outcomes after placental transfusion (delayed cord clamping (DCC) or umbilical cord milking (UCM)) versus immediate cord clamping among extremely preterm infants.

DESIGN

Retrospective study.

SETTING

The Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network registry.

PATIENTS

Infants born <29 weeks' gestation in 2016 or 2017 without congenital anomalies who received active treatment after delivery.

INTERVENTION/EXPOSURE

DCC or UCM.

MAIN OUTCOME MEASURES

Primary outcomes: (1) composite of mortality or major morbidity by 36 weeks' postmenstrual age (PMA); (2) mortality by 36 weeks PMA and (3) composite of major morbidities by 36 weeks' PMA. Secondary composite outcomes: (1) any grade intraventricular haemorrhage or mortality by 36 weeks' PMA and (2) hypotension treatment in the first 24 postnatal hours or mortality in the first 12 postnatal hours. Outcomes were assessed using multivariable regression, adjusting for mortality risk factors identified a priori, significant confounders and centre as a random effect.

RESULTS

Among 3116 infants, 40% were exposed to placental transfusion, which was not associated with the primary composite outcome of mortality or major morbidity by 36 weeks' PMA (adjusted OR (aOR) 1.26, 95% CI 0.95 to 1.66). However, exposure was associated with decreased mortality by 36 weeks' PMA (aOR 0.71, 95% CI 0.55 to 0.92) and decreased hypotension treatment in first 24 postnatal hours (aOR 0.66, 95% CI 0.53 to 0.82).

CONCLUSION

In this extremely preterm infant cohort, exposure to placental transfusion was not associated with the composite outcome of mortality or major morbidity, though there was a reduction in mortality by 36 weeks' PMA.

TRIAL REGISTRATION NUMBER

NCT00063063.

Team Stress and Adverse Events during Neonatal Tracheal Intubations: A Report from NEAR4NEOS

OBJECTIVE

This study aimed to examine the association between team stress level and adverse tracheal intubation (TI)-associated events during neonatal intubations.

STUDY DESIGN

TIs from 10 academic neonatal intensive care units were analyzed. Team stress level was rated immediately after TI using a 7-point Likert scale (1 = high stress). Associations among team stress, adverse TI-associated events, and TI characteristics were evaluated.

RESULT

In this study, 208 of 2,009 TIs (10%) had high stress levels (score < 4). Oxygenation failure, hemodynamic instability, and family presence were associated with high stress level. Video laryngoscopy and premedication were associated with lower stress levels. High stress level TIs were associated with adverse TI-associated event rates (31 vs. 16%, p < 0.001), which remained significant after adjusting for potential confounders including patient, provider, and practice factors associated with high stress (odds ratio: 1.90, 96% confidence interval: 1.36-2.67, p < 0.001).

CONCLUSION

High team stress levels during TI were more frequently reported among TIs with adverse events.

Corrective steps to enhance ventilation in the delivery room

OBJECTIVE

The clinical impact of ventilation corrective steps for delivery room positive pressure ventilation (PPV) is not well studied. We aimed to characterise the performance and effect of ventilation corrective steps (MRSOPA (Mask adjustment, Reposition airway, Suction mouth and nose, Open mouth, Pressure increase and Alternative airway)) during delivery room resuscitation of preterm infants.

DESIGN

Prospective observational study of delivery room PPV using video and respiratory function monitor recordings.

SETTING

Tertiary academic delivery hospital.

PATIENTS

Preterm infants <32 weeks gestation.

MAIN OUTCOME MEASURE

Mean exhaled tidal volume (Vte) of PPV inflations before and after MRSOPA interventions, categorised as inadequate (<4 mL/kg); appropriate (4-8 mL/kg), or excessive (>8 mL/kg). Secondary outcomes were leak (>30%) and obstruction (Vte <1 mL/kg), and infant heart rate.

RESULTS

There were 41 corrective interventions in 30 infants, with a median duration of 15 (IQR 7-29) s. The most frequent intervention was a combination of Mask/Reposition and Suction/Open. Mean Vte was inadequate before 16/41 interventions and became adequate following 6/16. Mean Vte became excessive after 6/41 interventions. Mask leak, present before 13/41 interventions, was unchanged after 4 and resolved after 9. Obstruction was present before five interventions and was subsequently resolved only once. MRSOPA interventions introduced leak in two cases and led to obstruction in one case. The heart rate was <100 beats per minute before 31 interventions and rose to >100 beats per minute after 14/31 of these.

CONCLUSIONS

Ventilation correction interventions improve tidal volume delivery in some cases, but lead to ineffective or excessive tidal volumes in others. Mask leak and obstruction can be induced by MRSOPA manoeuvres.

Provider visual attention on a respiratory function monitor during neonatal resuscitation

BACKGROUND

A respiratory function monitor (RFM) provides real-time positive pressure ventilation feedback. Whether providers use RFM during neonatal resuscitation is unknown.

METHODS

Ancillary study to the MONITOR(NCT03256578) randomised controlled trial. Neonatal resuscitation leaders at two centres wore eye-tracking glasses, and visual attention (VA) patterns were compared between RFM-visible and RFM-masked groups.

RESULTS

14 resuscitations (6 RFM-visible, 8 RFM-masked) were analysed. The median total gaze duration on the RFM was significantly higher with a visible RFM (29% vs 1%, p<0.01), while median total gaze duration on other physical objects was significantly lower with a visible RFM (3% vs 8%, p=0.02). Median total gaze duration on the infant was lower with RFM visible, although not statistically significantly (29% vs 46%, p=0.05).

CONCLUSION

Providers' VA patterns differed during neonatal resuscitation when the RFM was visible, emphasising the importance of studying the impact of additional delivery room technology on providers' behaviour.

Neonatal delivery room CPR: An analysis of the Get with the Guidelines®-Resuscitation Registry

BACKGROUND

Cardiopulmonary resuscitation (CPR) in the delivery room (DR) after birth is rare. We hypothesized that factors related to maternal, delivery, infant and resuscitation event characteristics associated with outcomes could be identified. We also hypothesized there would be substantial variation from the Neonatal Resuscitation Program (NRP) algorithm.

METHODS

Retrospective review of all neonates receiving chest compressions in the DR from the AHA Get With The Guidelines-Resuscitation registry from 2001 to 2014. The primary outcome was return of spontaneous circulation (ROSC) in the DR. Secondary outcome was survival to hospital discharge. Descriptive statistics were used to characterize data. Odds ratios with confidence intervals were calculated as appropriate to compare survivors and non-survivors.

RESULTS

There were 1153 neonates who received chest compressions in the DR. ROSC was achieved in 968 (84%) newborns and 761 (66%) survived to hospital discharge. Fifty-one percent of the cohort received chest compressions without medications. Cardiac compressions were initiated within the first minute of life in 76% of the events, and prior to endotracheal intubation in 79% of the events. In univariate analysis, factors such as prematurity, number of endotracheal intubation attempts, increased time to first adrenaline dose, and CPR duration were associated with decreased odds of ROSC in the DR. Longer CPR duration was associated with decreased odds of ROSC in multivariate analysis.

CONCLUSION

In this cohort of infants receiving chest compressions following delivery, recognizable pre-birth risk factors as well as resuscitation interventions associated with increased and decreased odds of achieving ROSC were identified. Chest compressions were frequently initiated in the first minute of the event and often prior to endotracheal intubation. Further investigations should focus on methods to decrease time to critical resuscitation interventions, such as successful endotracheal intubation and administration of the first dose of adrenaline, in order to improve DR-CPR outcomes.

Duration of Resuscitation at Birth, Mortality, and Neurodevelopment: A Systematic Review

CONTEXT

The International Liaison Committee on Resuscitation Neonatal Life Support Task Force reviewed evidence for the duration of cardiopulmonary resuscitation (CPR) for newborns immediately after birth.

OBJECTIVE

To summarize evidence for ongoing CPR on the outcomes of survival, neurodevelopment, and the composite of survival without moderate or severe neurodevelopmental impairment (NDI).

DATA SOURCES

Medline, Embase, Evidence-Based Medicine Reviews, Cumulative Index to Nursing and Allied Health Literature, and Scientific Electronic Library Online were searched between inception and February 29, 2020.

STUDY SELECTION

Two independent reviewers selected studies of newborns with at least 10 minutes of asystole, bradycardia, or pulseless electrical activity for which CPR is indicated.

DATA EXTRACTION

Two independent reviewers extracted data and appraised the risk of bias.

RESULTS

In 16 eligible studies, researchers reported outcomes of 579 newborns born between 1982 and 2017. Within individual studies, 2% to 100% of infants survived to last follow-up (hospital discharge through 12 years). Summarized across studies, 237 of 579 (40.9%) newborns survived to last follow-up. In 13 studies, researchers reported neurodevelopmental outcomes of 277 newborns. Of these, 30 of 277 (10.8%) survived without moderate or severe impairment, and 240 of 277 (87%) met the composite outcome of death or NDI (191 died and 49 survived with moderate or severe impairment).

LIMITATIONS

There was very low certainty of evidence because of risk of bias and inconsistency.

CONCLUSIONS

Infants with ongoing CPR at 10 minutes after birth are at high risk for mortality and neurodisability, but survival without moderate or severe NDI is possible. One specified duration of CPR is unlikely to uniformly predict survival or survival without neuroimpairment.

Deferred consent for delivery room studies: the providers' perspective

OBJECTIVE

To gain insight into neonatal care providers' perceptions of deferred consent for delivery room (DR) studies in actual scenarios.

METHODS

We conducted semistructured interviews with 46 neonatal intensive care unit (NICU) staff members of the Leiden University Medical Center (the Netherlands) and the Hospital of the University of Pennsylvania (USA). At the time interviews were conducted, both NICUs conducted the same DR studies, but differed in their consent approaches. Interviews were audio-recorded, transcribed and analysed using the qualitative data analysis software Atlas.ti V.7.0.

RESULTS

Although providers reported to regard the prospective consent approach as the most preferable consent approach, they acknowledged that a deferred consent approach is needed for high-quality DR management. However, providers reported concerns about parental autonomy, approaching parents for consent and ethical review of study protocols that include a deferred consent approach. Providers furthermore differed in perceived appropriateness of a deferred consent approach for the studies that were being conducted at their NICUs. Providers with first-hand experience with deferred consent reported positive experiences that they attributed to appropriate communication and timing of approaching parents for consent.

CONCLUSION

Insight into providers' perceptions of deferred consent for DR studies in actual scenarios suggests that a deferred consent approach is considered acceptable, but that actual usage of the approach for DR studies can be improved on.

Impact of flow disruptions in the delivery room

AIM

Flow disruptions (FDs) are deviations from the progression of care that compromise safety and efficiency of a specific process. The study aim was to identify the impact of FDs during neonatal resuscitation and determine their association with key process and outcome measures.

METHODS

Prospective observational study of video recorded delivery room resuscitations of neonates <32 weeks gestational age. FDs were classified using an adaptation of Wiegmann's FD tool. The primary outcome was target oxygenation saturation achievement at 5 min. Secondary outcomes included achieving target saturation at 10 min, time to positive pressure ventilation for initially apnoeic/bradycardic neonates, time to electrocardiogram signal, time to pulse oximetry signal, and time to stable airway. Multivariable logistic regression assessed association between FDs and achieving target saturations adjusting for gestational age and leader. Associations between FDs and time to event outcomes were assessed using Cox proportional hazards models.

RESULTS

Between 10/2017-7/2018, 32 videos were included. A mean of 52.6 FDs (standard deviation 17.9) occurred per resuscitation. Extraneous FDs were the most common FDs. FDs were associated with an adjusted odds ratio of 0.92 (95% confidence interval [CI] 0.80-1.05) of achieving target saturation at 5 min and 0.94 (95% CI 0.84-1.05) at 10 min. There was no significant evidence to show FDs were associated with time to event outcomes.

CONCLUSIONS

FDs occurred frequently during neonatal resuscitation. Measuring FDs is a feasible method to assess the impact of human factors in the delivery room and identify modifiable factors and practices to improve patient care.