Periventricular Leukomalacia Following Bowel Resection for Necrotizing Enterocolitis in a Premature Neonate

Necrotizing enterocolitis (NEC) and periventricular leukomalacia (PVL) are relatively common conditions in premature infants with low birth weight (VLBW). However, in the current literature, there are limited case reports of patients with concomitant NEC and PVL. We report a case of a premature female born at a gestational age of 25 weeks and five days who developed cystic intracranial lesions after emergent bowel resection due to NEC. Transcranial ultrasound and magnetic resonance imaging confirmed the presence of cystic PVL in the right middle cerebral artery distribution. Several observational studies note the association between spontaneous intestinal perforation, surgical NEC, and the presence of cystic PVL. When infants are unresponsive to medical management for NEC, exploratory laparotomy with resection of the necrotic or perforated intestine is indicated. However, infants treated surgically have poorer neurodevelopmental outcomes than those with medical therapy. Pathogenesis of neurodevelopmental impairment in preterm infants undergoing surgery involves dysfunctional cerebrovascular autoregulation (CAR), which is associated with harmful changes in cerebral perfusion that lead to neuronal injury. Ill preterm infants, such as those with NEC, cannot regulate cerebral perfusion appropriately, and impaired CAR may be present in more than half the preterm infants during laparotomy. Impaired CAR leads to poor cerebral perfusion that potentiates neuronal injury, such as PVL. This case also brings awareness to the need for adherence to screening practices for white matter injury in critical NICU patients through cost-effective transcranial ultrasound.

A Review on the Incidence and Related Risk Factors of Retinopathy of Prematurity Across Various Countries

Retinopathy of prematurity (ROP) is an ophthalmologic condition that is one of the leading causes of preventable childhood blindness. Due to the premature nature of blood vessels in preterm infants, retinal vessels are prone to damage. The incidence of ROP ranges with great variation across countries, and this study aims to identify the incidence and its related risk factors. A compilation of studies investigating the incidence of ROP was acquired through the PubMed and Google Scholar databases with a full free text in English filter set. All members of the study were involved in designating studies based on continent and arranging them into a table format. Following this, reasons for the variation in the incidence of ROP were investigated by individually assessing each study. The variation of an increased incidence of ROP seen in low-income countries (LICs) was most likely due to the availability of resources. As a preterm birth can give rise to further complications such as the development of sepsis, it is important to manage preterm birth with the utmost caution. Evidence has suggested that the two key variables in reducing the morbidity and mortality of ROP are the implementation of a screening and treatment protocol with controlled use of oxygen and the availability of resources in hospitals to adequately identify and manage ROP as early as possible. Through a comprehensive overview of the incidence of ROP, it is vital to review screening and treatment protocols in each hospital for ROP, which would aid in preventing its occurrence and initiating early treatment.

Simulated Umbilical Venous Catheter Placement Improves Resident Competence and Confidence

Background Pediatric ACGME (Accreditation Council for Graduate Medical Education) requirements include demonstrated competence in umbilical line placement. Given a waning number of these procedures clinically available to residents, new methods of procedural teaching must be employed. We developed a simulation-based strategy, using adult-learning principles, to teach umbilical venous catheter (UVC) placement to pediatric residents. We also determined whether procedural teaching via simulation increased confidence and competence among pediatric residents in performing the procedure. Methods Out of 23 first-year pediatric residents, eight participated in the study. Participants completed a survey evaluating their self-perceived competence and confidence in umbilical line placement. Their simulated umbilical line placement was assessed using a standardized checklist. Residents were then trained on simulated line placement in small groups by neonatologists. Six months later, residents completed a post-training survey and were assessed while placing simulated lines. Statistical analysis was completed using a paired t-test for parametric data, Wilcoxon signed-rank sum test for non-parametric data, and McNemar's chi-squared test for categorical data. Spearman's correlation was used for ordinal variables and Pearson's correlation was used for continuous variables. Results Nine PGY-1 (post-graduate year-1) residents completed the pre-training survey and simulation, while eight residents completed the post-training survey and simulation. There was an increase in resident confidence in placing umbilical lines six months after completion of the training session (p = 0.015) even though there was no difference in the number of umbilical lines that residents had placed in the intervening time. The residents performed a greater number of steps correctly after the training compared to their performance before the training (p=0.001). There was a statistically significant positive correlation between resident confidence and the number of steps performed correctly (rs(14)= 0.649, p = 0.006). There was no correlation between confidence and the number of umbilical lines placed on live subjects. Conclusion A teaching strategy that allows pediatric residents to struggle to perform UVC placement in a simulated setting, before receiving expert instruction, is effective at increasing their confidence and competence, even in the absence of exposure to human subjects.

Bag Valve Mask Ventilation as a Perceptual-Cognitive Skill

Objective This study used a high-fidelity infant mannequin to examine the relationship between the quality of bag valve mask ventilation (BVMV) and how providers of varying levels of experience use visual feedback (e.g., electronic vital signs) to guide their performance. Background BVMV is a common and critical procedure for managing pediatric respiratory emergencies. However, providers do not consistently deliver effective BVMV. Efforts to improve BVMV have ignored the question of how providers effectively use feedback often available during BVMV. Method Six expert and six novice respiratory therapists completed two simulations of an infant requiring BVMV. In one, the technology failed to display SpO₂, an important but somewhat redundant visual cue. Eye movements, verbal reports, and ventilation rate (in breaths per minute) were measured in each simulation. Results Regardless of SpO₂ availability, eye movements and verbal reports suggested that novices depended strongly on electronic vital signs and when SpO₂ was absent ventilated at a faster rate (exceeding the recommended range of ventilation rates) than when SpO₂ was present. Experts' ventilation rates were comparable and within the recommended range in both conditions. When SpO₂ was absent, experts emphasized information from direct observation of the patient that novices neglected. Conclusion Individual differences in the use of feedback during BVMV contribute to the quality of BVMV. This work bears on the theoretical discussions involving the use of automation and nontechnological cues to guide performance. Application These results have the potential to expand the current understanding of factors underlying effective BVMV with implications for training novice providers.

Novel Pulse Oximetry Sonifications for Neonatal Oxygen Saturation Monitoring: A Laboratory Study

OBJECTIVE

We aimed to test whether the use of novel pulse oximetry sounds (sonifications) better informs listeners when a neonate's oxygen saturation (SpO2) deviates from the recommended range.

BACKGROUND

Variable-pitch pulse oximeters do not accurately inform clinicians via sound alone when SpO2 is outside the target range of 90% to 95% for neonates on supplemental oxygen. Risk of blindness, organ damage, and death increase if SpO2 remains outside the target range. A more informative sonification may improve clinicians' ability to maintain the target range.

METHOD

In two desktop experiments, nonclinicians' ability to detect SpO2 range and direction of change was tested with novel versus conventional sonifications of simulated patient data. In Experiment 1, a "shoulder" sonification used larger pitch differences between adjacent saturation percentages for SpO2 values outside the target range. In Experiment 2, a "beacon" sonification used equal-appearing pitch differences, but when SpO2 was outside the target range, a fixed-pitch reference tone from the center of the target SpO2 range preceded every fourth pulse tone.

RESULTS

The beacon sonification improved range identification accuracy over the control display (85% vs. 60%; p < .001), but the shoulder sonification did not (55% vs. 52%).

CONCLUSION

The beacon provided a distinct auditory alert and reference that significantly improved nonclinical participants' ability to identify SpO2 range.

APPLICATION

Adding a beacon to the variable-pitch pulse oximeter sound may help clinicians identify when, and by how much, a neonate's SpO2 deviates from the target range, particularly during patient transport situations when auditory information becomes essential.