Targeted Neonatal Echocardiography in the Management of Neonatal Pulmonary Hypertension.

Pulmonary hypertension (PH) in neonates, originating from a range of disease states with heterogeneous underlying pathophysiology, is associated with significant morbidity and mortality. Although the final common pathway is a state of high right ventricular afterload leading to compromised cardiac output, multiple hemodynamic phenotypes exist in acute and chronic PH, for which cardiorespiratory treatment strategies differ. Comprehensive appraisal of pulmonary pressure, pulmonary vascular resistance, cardiac function, pulmonary and systemic blood flow, and extrapulmonary shunts facilitates delivery of individualized cardiovascular therapies in affected newborns.

Rapid cycle deliberate practice to improve airway skills and performance of trainees in a pediatric emergency department.

Objective: The study objective was to determine the effect of a rapid cycle deliberate practice (RCDP) program on simulated and actual airway skills by pediatric emergency medicine (PEM) fellows. Methods: We designed and implemented a 12-month RCDP airway skills curriculum for PEM fellows at an academic pediatric institution. The curriculum was designed using airway training literature, RCDP principals, and internal quality assurance airway video review program. Simulation training scenarios increased in complexity throughout the curriculum. PEM fellows participated in monthly sessions. Two PEM faculty facilitated the sessions, utilizing a step-by-step objective structured clinical evaluation (OSCE)-style tool for each scenario. Data were collected for all four levels of the Kirkpatrick Model of Training Evaluation-participant response (reaction, pre-post session survey), skills performance in the simulation setting (learning, pre-post OSCE), skills performance for actual patients (behavior, video review), and patient outcomes (results, video review). Results: During the study period (August 2021 to June 2022), 13 PEM fellows participated in 112 sessions (mean nine sessions per fellow). PEM fellows reported improved comfort in all domains of airway management, including intubation performance. Participant OSCE scores improved posttraining (pretraining median score for trainees 57 [IQR 57-59], posttraining median 61 [IQR 61-62], p = 0.0005). Over the 12 months, PEM fellows performed 45 intubation attempts in the pediatric emergency department (median patient age 4 years [IQR 1-9 years]). Compared to a 5-year historical cohort, participants had higher first-pass success (87% vs. 71%, p = 0.028) and shorter attempt duration (22 s vs. 29 s, p = 0.018). There was no significant difference in the frequency of oxyhemoglobin desaturation in the training period versus the historical period (7% vs. 15%, p = 0.231). Conclusions: At multiple levels of educational outcomes, including participant behavior and patient outcomes, an RCDP program was associated with improved airway skills and performance of PEM fellows.

Structured Callouts, the Shared Mental Model, and Teamwork: A Video-Based Study in a Pediatric Emergency Department.

OBJECTIVES: The shared mental model is essential to high-quality resuscitations. A structured callout (SCO) is often performed to establish the shared mental model, but the literature on SCOs is limited. The objectives of this study are to describe performance of SCOs during pediatric medical emergencies and to determine whether a SCO is associated with better teamwork. METHODS: This was a retrospective study in the resuscitation area of an academic pediatric emergency department, where performance of a SCO is a standard expectation. Only medical or nontrauma patients were eligible for inclusion. Data collection was performed by structured video review by 2 observers and verified by a third blinded observer. A SCO was defined as team leader (Pediatric Emergency Medicine fellow or faculty physician) verbalization of at least 1 element of the patient history/examination or an assessment of patient physiology and 1 element of the diagnostic or therapeutic plan. We independently measured teamwork using the Teamwork Emergency Assessment Measure (TEAM) tool. RESULTS: We reviewed 60 patient encounters from the pediatric emergency department resuscitation area between April 2018 and June 2020. Median patient age was 6 years; the team leader was a Pediatric Emergency Medicine fellow in 55% of encounters. The physician team leader performed a SCO in 38 (63%) of patient encounters. The TEAM scores were collected for 46 encounters. Mean TEAM score (SD) was 42.3 (1.7) in patients with a SCO compared with 40.0 (3.0) in those without a SCO ( P = 0.007). CONCLUSIONS: Performance of a SCO was associated with better teamwork, but the difference was of unclear clinical significance.

Improving Pediatric Procedural Skills for EMS Clinicians: A Longitudinal Simulation-Based Curriculum with Novel, Remote, First-Person-View Video-Based Outcome Measurement.

OBJECTIVE: Emergency medical services (EMS) clinicians are expected to provide expert care to all patients, but face obstacles in maintaining skillsets required in the care of critically ill or injured children. The objectives of this study were to describe and assess the effectiveness of a pediatric-focused, simulation-based, procedural training program for EMS clinicians, delivered on-site by a pediatric simulation education team. We also describe a novel, remote, asynchronous performance outcome measurement system using first-person-view video review. METHODS: This was a prospective study of simulation-based training and procedural outcomes. The study population involved EMS clinicians at three fire-based EMS agencies stratified as urban, suburban, and rural sites. The primary outcome was performance of intraosseous catheterization (IO), bag-valve-mask ventilation (BVM), and supraglottic device placement (SGD), measured across three time points. Secondary outcomes were identification of differences across EMS agencies and participant survey responses. RESULTS: We obtained video data from 122 clinicians, totaling 561 videos, with survey response rates of 89.0-91.3%. Pre-intervention scores were high: least-square means (95% confident-intervals) 9.5 (8.9, 10.2) for IO; 9.6 (9.3, 9.9) for BVM; and 11.6 (10.9, 12.2) for SGD. There was significant improvement post-intervention: 11.5 (10.7, 12.3) for IO; 11.0 (10.7, 11.4) for BVM; and 13.6 (12.8, 14.4) for SGD. Improvement was maintained at follow-up after a median of 9.5 months: 10.5 (9.8, 11.2) for IO; 10.2 (9.9, 10.6) for BVM; and 12.4 (11.7, 13.1) for SGD. There were no statistical differences between sites. Of survey respondents, half had not cared for a critically ill or injured child in at least a year, the vast majority had not had hands-on pediatric training in over 6 months, and the majority felt that training should occur at least every 6 months. CONCLUSIONS: Our pediatric-focused, simulation-based procedural training program was associated with improvement and maintenance of high-baseline procedural performance for EMS clinicians over the study period. Findings were consistent across sites. Remote assessment was feasible. Participant surveys emphasized a desire for more pediatric-focused training and highlighted the low frequency of clinical exposure to procedures potentially needed in the care of critically ill or injured pediatric patients.

Tolerability and Acceptability of Autonomous Immersive Virtual Reality Incorporating Digital Twin Technology for Mass Training in Healthcare.

INTRODUCTION: As part of onboarding and systems testing for a clinical expansion, immersive virtual reality (VR) incorporating digital twin technology was used. While digital twin technology has been leveraged by industry, its use in health care has been limited with no prior application for onboarding or training. The tolerability and acceptability of immersive VR for use by a large population of healthcare staff were unknown. METHODS: A prospective, observational study of an autonomous immersive VR onboarding experience to a new clinical space was conducted from May to September 2021. Participants were healthcare staff from several critical care and acute care units. Primary outcomes were tolerance and acceptability measured by reported adverse effects and degree of immersion. Secondary outcomes were attitudes toward the efficacy of VR compared with standard onboarding experiences. RESULTS: A total of 1522 healthcare staff participated. Rates of adverse effects were low and those with prior VR experience were more likely to report no adverse effects. Odds of reporting immersion were high across all demographic groups, though decreased with increasing age. The preference for VR over low-fidelity methods was high across all demographics; however, preferences were mixed when compared with traditional simulation and real-time clinical care. CONCLUSIONS: Large-scale VR onboarding is feasible, tolerable, and acceptable to a diverse population of healthcare staff when using digital twin technology. This study also represents the largest VR onboarding experience to date and may address preconceived notions that VR-based training in health care is not ready for widespread adoption.

High-risk criteria for the physiologically difficult paediatric airway: A multicenter, observational study to generate validity evidence.

BACKGROUND: Single-center studies have identified risk factors for peri-intubation cardiac arrest in the emergency department (ED). The study objective was to generate validity evidence from a more diverse, multicenter cohort of patients. METHODS: We completed a retrospective cohort study of 1200 paediatric patients who underwent tracheal intubation in eight academic paediatric EDs (150 per ED). The exposure variables were 6 previously studied high-risk criteria for peri-intubation arrest: (1) persistent hypoxemia despite supplemental oxygen, (2) persistent hypotension, (3) concern for cardiac dysfunction, (4) post-return of spontaneous circulation (ROSC), (5) severe metabolic acidosis (pH < 7.1), and (6) status asthmaticus. The primary outcome was peri-intubation cardiac arrest. Secondary outcomes included extracorporeal membrane oxygenation (ECMO) cannulation and in-hospital mortality. We compared all outcomes between patients that met one or more versus no high-risk criteria, using generalized linear mixed models. RESULTS: Of the 1,200 paediatric patients, 332 (27.7%) met at least one of 6 high-risk criteria. Of these, 29 (8.7%) suffered peri-intubation arrest compared to zero arrests in patients meeting none of the criteria. On adjusted analysis, meeting at least one high-risk criterion was associated with all 3 outcomes - peri-intubation arrest (AOR 75.7, 95% CI 9.7-592.6), ECMO (AOR 7.1, 95% CI 2.3-22.3) and mortality (AOR 3.4, 95% 1.9-6.2). Four of 6 criteria were independently associated with peri-intubation arrest: persistent hypoxemia despite supplemental oxygen, persistent hypotension, concern for cardiac dysfunction, and post-ROSC. CONCLUSIONS: In a multicenter study, we confirmed that meeting at least one high-risk criterion was associated with paediatric peri-intubation cardiac arrest and patient mortality.

Do Case Reports and Case Series Generate Clinical Discoveries About Preeclampsia? A Systematic Review.

Background: Preeclampsia is a leading cause of maternal and perinatal mortality and morbidity. The management of preeclampsia has not changed much in more than two decades, and its aetiology is still not fully understood. Case reports and case series have traditionally been used to communicate new knowledge about existing conditions. Whether this is true for preeclampsia is not known. Objective: To determine whether recent case reports or case series have generated new knowledge and clinical discoveries about preeclampsia. Methods: A detailed search strategy was developed in consultation with a medical librarian. Two bibliographic databases were searched through Ovid: Embase and MEDLINE. We selected case reports or case series published between 2015 and 2020, comprising pregnant persons diagnosed with hypertensive disorders of pregnancy, including preeclampsia. Two reviewers independently screened all publications. One reviewer extracted data from included studies, while another conducted a quality check of extracted data. We developed a codebook to guide our data extraction and outcomes assessment. The quality of each report was determined based on Joanna Briggs Institute (JBI) critical appraisal checklist for case reports and case series. Results: We included 104 case reports and three case series, together comprising 118 pregnancies. A severe presentation or complication of preeclampsia was reported in 81% of pregnancies, and 84% had a positive maternal outcome, free of death or persistent complications. Only 8% of the case reports were deemed to be of high quality, and 53.8% of moderate quality; none of the case series were of high quality. A total of 26 of the 107 publications (24.3%) included a novel clinical discovery as a central theme. Conclusion: Over two-thirds of recent case reports and case series about preeclampsia do not appear to present new knowledge or discoveries about preeclampsia, and most are of low quality.

The Importance of Median Glossoepiglottic Fold Engagement on Laryngeal View and Tracheal Intubation Success in Children.

STUDY OBJECTIVE: Our study objective was to determine if the location of laryngoscope blade tip placement is associated with clinically important tracheal intubation outcomes in a pediatric emergency department. METHODS: We conducted a video-based observational study of pediatric emergency department patients undergoing tracheal intubation with standard geometry Macintosh and Miller video laryngoscope blades (Storz C-MAC, Karl Storz). Our main exposures were direct lifting of the epiglottis versus blade tip placement within the vallecula and median glossoepiglottic fold engagement versus not when the blade tip was placed in the vallecula. Our main outcomes were glottic visualization and procedural success. We compared measures of glottic visualization between successful and unsuccessful attempts using generalized linear mixed models. RESULTS: Proceduralists placed the blade tip in the vallecula (indirectly lifting the epiglottis) during 123 (71.9%) of 171 attempts. When compared with indirectly lifting the epiglottis, directly lifting the epiglottis was associated with improved visualization-by percentage of glottic opening (POGO) (adjusted odds ratio [AOR], 11.0; 95% confidence interval [CI], 5.1 to 23.6) and modified Cormack-Lehane (AOR, 21.5; 95% CI, 6.6 to 69.9). When in the vallecula, engagement of the median glossoepiglottic fold was associated with improved POGO (AOR, 3.6; 95% CI, 1.9 to 6.8), modified Cormack-Lehane (AOR, 3.9; 95% CI, 1.1 to 14.1), and success (AOR, 9.9; 95% CI, 2.3 to 43.7). CONCLUSIONS: Emergency tracheal intubation can be performed in children at a high level by directly or indirectly lifting the epiglottis. If indirectly lifting the epiglottis, median glossoepiglottic fold engagement is helpful in maximizing glottic visualization and procedural success.

Making a move: Using simulation to identify latent safety threats before the care of injured patients in a new physical space.

BACKGROUND: In today's rapidly changing health care environment, hospitals are expanding into newly built spaces. Preserving patient safety by identifying latent safety threats (LSTs) in advance of opening a new physical space is key to continued excellent care. At our level 1 pediatric trauma center, the hospital undertook a 5-year project to build a critical care tower, including a new emergency department with five trauma bays. To allow for identification and mitigation of LSTs before opening, we performed simulation-based clinical systems testing. METHODS: Eight simulation scenarios were developed, based on actual patient presentations, incorporating a variety of injury patterns. Scenarios included workflow and movement from the helipad and squad entrance as well as to radiology, the operating room, and the pediatric intensive care unit. A multiple resuscitation scenario was also designed to test the use of all five bays simultaneously. Multidisciplinary high-fidelity simulations were conducted in the new tower. Key trauma and emergency department stakeholders facilitated all sessions, using a structured framework for systems integration debriefing framework and failure mode and effect analysis to identify and prioritize LSTs, respectively. RESULTS: Eight sessions were conducted for 2 months. A total of 201 staff participated, including trauma surgeons, respiratory therapists, nurses, emergency physicians, x-ray technicians, pharmacists, emergency medical services, and operating room staff. In total, 118 LSTs (average of 14.8/session) were identified. Latent safety threats were categorized. An action plan for mitigation was developed after applying failure mode and effects analysis prioritization scores (based on severity, probability, and ease of detection). CONCLUSION: Systems-focused trauma simulations identified a large number of LSTs before the opening of a new critical care building. Identification of LSTs is feasible and facilitates mitigation before actual patient care begins, improving patient safety. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Fraction of Expired Oxygen as a Measure of Preoxygenation Prior to Rapid Sequence Intubation in the Pediatric Emergency Department.

BACKGROUND: Pulse oximetry (SpO2) is a flawed measure of adequacy of preoxygenation prior to intubation. The fraction of expired oxygen (FeO2) is a promising but understudied alternative. OBJECTIVE: To investigate FeO2 as a measure of preoxygenation prior to intubation in a pediatric emergency department. METHODS: We conducted a prospective, observational study of patients 18 and younger. We collected data using video review, and FeO2 was measured via inline sampling. The main outcomes were FeO2 and SpO2 at the start of preoxygenation, end of preoxygenation/start of intubation attempt, and the end of intubation attempt. We compared FeO2 and SpO2 at the end of preoxygenation for patients with and without oxyhemoglobin desaturation. RESULTS: We enrolled 85 of 88 eligible patients during the 14-month study period. FeO2 data were available at the start of preoxygenation for 53 of 85 patients (62%), and for the end of preoxygenation for 59 of 85 patients (69%). Median FeO2 at the start and end of preoxygenation was 90% (interquartile range [IQR] 88, 92) and 90% (IQR 88, 92). Median SpO2 at the start and end of preoxygenation was 100% (IQR 100, 100). There were 11 episodes of desaturation, with median FeO2 at the start of intubation attempt of 89.5 (IQR 54.5, 91.5) and median SpO2 of 100 (IQR 99, 100). Patients who did not have a desaturation event had a median FeO2 of 90.0 (IQR 88.0, 92.0). CONCLUSIONS: Measuring FeO2 during rapid sequence intubation is challenging with feasibility limitations, but may be a more discriminatory metric of adequate preoxygenation.

Emergency Department Visits Before Sudden Unexpected Infant Death: A Touchpoint for Unsafe Sleep Reduction.

OBJECTIVES: Unsafe sleep remains a leading cause of preventable sudden unexpected infant death (SUID). Infants frequently visit emergency departments (EDs), but the frequency of visits before SUID is unknown. The objective of this study was to determine how often SUID infants visited a pediatric ED or urgent care (UC) before death. METHODS: We performed a retrospective study of infant deaths in the county of a large, academic pediatric institution. We linked institutional records with coroner reports and death scene investigations. We excluded deaths associated with childbirth, prematurity, injury, or underlying medical condition. We characterized all SUID infants, focusing on unsafe sleep factors detailed in the medical record and scene reports. The main outcome was ED/UC visit(s) before the visit for SUID. RESULTS: Seventy-three of 122 infant deaths met inclusion criteria for SUID over 76 months (April 2014-July 2020). Median age at death was 87 days (IQR 58, 137); 68 (93%) died before 6 months-of-age. Twenty infants (27%) had an ED/UC visit before SUID; mean visits for these infants were 1.7 (SD 0.8). Median days between the last ED/UC visit and SUID was 39; five infants visited the ED/UC within 2 weeks of SUID. Most visits were for minor medical conditions. All 73 SUID infants had at least one unsafe sleep factor; 88% had ≥2 and 56% ≥3. CONCLUSIONS: Many SUID infants visited a pediatric ED/UC before death, and unsafe sleep factors were found in every case. Early infancy ED/UC visits may present an opportunity for targeted prevention efforts.

Don't Hold Your Breath-A Video-Based Study of Procedural Intervals During Pediatric Rapid Sequence Intubation.

OBJECTIVE: Develop a framework for data collection to determine the contributions of both laryngoscopy and tube delivery intervals to the apneic period in unsuccessful and successful attempts among patients undergoing rapid sequence intubation (RSI) in a pediatric emergency department (PED). DESIGN: This was a retrospective, observational study of RSI. SETTING: An academic PED. PATIENTS: A consecutive sample of all intubations attempts of first provider physicians performing RSI in the shock trauma suite over a 10-month period in 2018-2019. MEASUREMENT AND MAIN RESULTS: Data were collected by structured video review. The main outcome was the duration of the laryngoscopy and tube delivery intervals per attempt. We compared interval duration between successful and unsuccessful attempts, adjusting for age, accounting for repeated measures, and clustering by provider. There were 69 patients with 89 total intubation attempts. Sixty-three patients were successfully intubated by the first provider (91%). Pediatric emergency medicine fellows performed 54% of the attempts. The median duration of the apneic period per attempt was longer in unsuccessful attempts (57 vs 44 seconds; median of difference, -10.5; 95% confidence interval [CI], -17.0 to -4.0). The duration of laryngoscopy was similar (18 vs 13 seconds; median of difference, -3.5; 95% CI, -8.0 to 1.0), but tube delivery was longer in unsuccessful attempts (25.5 vs. 11 seconds; median of difference, -12.5; 95% CI, -17.0 to -4.0). These results did not change when adjusting for age or clustering by provider. CONCLUSIONS: We successfully developed a specific, time-based framework for the contributors to prolonged apnea in RSI. Prolonged tube delivery accounted for more of the apneic period. Future studies and improvement should focus on problems during tube delivery in the PED.

Video Laryngoscope Screen Visualization and Tracheal Intubation Performance: A Video-Based Study in a Pediatric Emergency Department.

STUDY OBJECTIVE: Our study objectives were to describe patterns of video laryngoscope screen visualization during tracheal intubation in a pediatric emergency department (ED) and to determine their associations with procedural performance. METHODS: We conducted a prospective, observational, video-based study of pediatric ED patients undergoing tracheal intubation with a standard geometry video laryngoscope (Storz C-MAC; Karl Storz, Tuttlingen, Germany). Our primary exposure was video screen visualization patterns, measured by the percentage of each attempt spent viewing the screen and the number of times the proceduralist changed their gaze between the patient and screen (gaze switches). Our primary outcome was first-pass success. We compared measures of screen visualization between successful and unsuccessful first attempts using a generalized linear mixed model. RESULTS: From December 2019 to October 2021, we collected data on 153 patients. The first-pass success rate was 79.1%. Proceduralists viewed the video screen during 80.4% of attempts; the median percentage of each attempt spent viewing the video screen was 42.1% (interquartile range 8.7% to 65.5%). The median number of gaze switches per attempt was 3 (interquartile range 1 to 6, maximum 22). The percentage of each attempt spent viewing the video screen was not associated with success (adjusted odds ratio 1.00, 95% confidence interval 0.93 to 1.08); additional gaze switches were associated with a lower likelihood of success (adjusted odds ratio 0.80, 95% confidence interval 0.71 to 0.90). CONCLUSION: We found wide variation in how proceduralists viewed the video laryngoscope screen during intubations in a pediatric ED. We illustrate the application of 2 objective screen visualization measures to quantify and understand how clinicians actually use video laryngoscopy.

Sustained Improvement in the Performance of Rapid Sequence Intubation Five Years after a Quality Improvement Initiative.

Many quality improvement interventions do not lead to sustained improvement, and the sustainability of healthcare interventions remains understudied. We conducted a time-series analysis to determine whether improvements in the safety of rapid sequence intubation (RSI) in our academic pediatric emergency department were sustained 5 years after a quality improvement initiative. METHODS: There were 3 study periods: baseline (April 2009-March 2010), improvement (July 2012-December 2013), and operational (January 2014-December 2018). All patients undergoing RSI were eligible. We collected data using a structured video review. We compared key processes and outcomes with statistical process control charts. RESULTS: We collected data for 615 of 643 (96%) patient encounters with RSI performed: 114 baseline (12 months), 105 improvement (18 months), and 396 operational (60 months). Key characteristics were similar, including patient age. Statistical process control charts indicated sustained improvement of all 6 key processes and the primary outcome measure (oxyhemoglobin desaturation) throughout the 5-year operational period. CONCLUSIONS: Improvements in RSI safety were sustained 5 years after a successful improvement initiative, with further improvement seen in several key processes. Further research is needed to elucidate the factors contributing to sustainability.

PEMCRC anaphylaxis study protocol: a multicentre cohort study to derive and validate clinical decision models for the emergency department management of children with anaphylaxis.

INTRODUCTION: There remain significant knowledge gaps about the management and outcomes of children with anaphylaxis. These gaps have led to practice variation regarding decisions to hospitalise children and length of observation periods following treatment with epinephrine. The objectives of this multicentre study are to (1) determine the prevalence of and risk factors for severe, persistent, refractory and biphasic anaphylaxis, as well as persistent and biphasic non-anaphylactic reactions; (2) derive and validate prediction models for emergency department (ED) discharge; and (3) determine data-driven lengths of ED and inpatient observation prior to discharge to home based on initial reaction severity. METHODS AND ANALYSIS: The study is being conducted through the Pediatric Emergency Medicine Collaborative Research Committee (PEMCRC). Children 6 months to less than 18 years of age presenting to 30 participating EDs for anaphylaxis from October 2015 to December 2019 will be eligible. The primary outcomes for each objective are (1) severe, persistent, refractory or biphasic anaphylaxis, as well as persistent or biphasic non-anaphylactic reactions; (2) safe ED discharge, defined as no receipt of acute anaphylaxis medications or hypotension beyond 4 hours from first administered dose of epinephrine; and (3) time from first to last administered dose of epinephrine and vasopressor cessation. Analyses for each objective include (1) descriptive statistics to estimate prevalence and generalised estimating equations that will be used to investigate risk factors for anaphylaxis outcomes, (2) least absolute shrinkage and selection operator regression and binary recursive partitioning to derive and validate prediction models of children who may be candidates for safe ED discharge, and (3) Kaplan-Meier analyses to assess timing from first to last epinephrine doses and vasopressor cessation based on initial reaction severity. ETHICS AND DISSEMINATION: All sites will obtain institutional review board approval; results will be published in peer-reviewed journals and disseminated via traditional and social media, blogs and online education platforms.

Improving diagnostic accuracy in neonates with left heart obstruction in a transport setting.

AIM: Differentiating left heart obstruction (LHO) from other severe illness in the neonatal period is challenging, and important for guiding clinical management. The aim of this study was to identify factors distinguishing LHO from non-LHO in neonates. METHODS: A retrospective, cohort study of neonates referred to the Newborn and Paediatric Emergency Transport Service, New South Wales, with suspected LHO during the epoch 1996-2016. RESULTS: A total of 273 neonates were included; 240 with confirmed LHO. Administration of prostaglandin E1 to infants with a structurally normal heart was not associated with impaired acid-base or oxygenation status. Pre-transport diagnostic accuracy of LHO was 74.4%; sensitivity 84.5%, positive predictive value 86.0%. On multivariable logistic regression, hepatomegaly (odds ratio 2.54; 95% confidence interval 1.05-6.16) was associated with confirmed LHO. CONCLUSIONS: A low threshold for prostaglandin E1 infusion should be maintained in infants with suspected LHO. Hepatomegaly is associated with a diagnosis of LHO and may be more useful than other parameters in predicting the condition.

Use of vasopressin in neonatal hypertrophic obstructive cardiomyopathy: case series.

OBJECTIVE: To determine the effect of vasopressin on arterial blood pressure in infants with neonatal hypertrophic obstructive cardiomyopathy (HOCM). STUDY DESIGN: Retrospective case study in Neonatal ICU involving six infants; five born to mothers with diabetes mellitus (mean gestational age 37.5 ± 0.9 weeks). Vasopressin infusion was started at a mean dose of 0.3 ± 0.2 mU/kg/min. RESULT: Initiation of vasopressin was followed by improved mean (p = 0.004), systolic (p = 0.028), and diastolic (p = 0.009) arterial pressure within 2 h. Heart rate (p = 0.025) and oxygen requirement (p = 0.021) also declined after initiation. Serum sodium declined initially and recovered by 72 h (p = 0.017). CONCLUSION: Although there is limited experience with vasopressin use in neonatal HOCM, our case series suggests it may be beneficial for improving systemic hypotension and stabilization of hemodynamics. The potential for hyponatremia is high, necessitating careful fluid/electrolyte management. A prospective randomized trial is necessary to confirm safety and efficacy of vasopressin treatment in neonatal HOCM.