Neonatal intubation: what are we doing?

How and when the forces are applied during neonatal intubation are currently unknown. This study investigated the pattern of the applied forces by using sensorized laryngoscopes during the intubation process in a neonatal manikin. Nine users of direct laryngoscope and nine users of straight-blade video laryngoscope were included in a neonatal manikin study. During each procedure, relevant forces were measured using a force epiglottis sensor that was placed on the distal surface of the blade. The pattern of the applied forces could be divided into three sections. With the direct laryngoscope, the first section showed either a quick rise of the force or a discontinuous rise with several peaks; after reaching the maximum force, there was a sort of plateau followed by a quick drop of the applied forces. With the video laryngoscope, the first section showed a quick rise of the force; after reaching the maximum force, there was an irregular and heterogeneous plateau, followed by heterogeneous decreases of the applied forces. Moreover, less forces were recorded when using the video laryngoscope.    Conclusions: This neonatal manikin study identified three sections in the diagram of the forces applied during intubation, which likely mirrored the three main phases of intubation. Overall, the pattern of each section showed some differences in relation to the laryngoscope (direct or video) that was used during the procedure. These findings may provide useful insights for improving the understanding of the procedure. What is Known: • Neonatal intubation is a life-saving procedure that requires a skilled operator and may cause direct trauma to the tissues and precipitate adverse reactions. • Intubation with a videolaryngoscope requires less force than with a direct laryngoscope, but how and when the forces are applied during the whole neonatal intubation procedure are currently unknown. What is New: • Forces applied to the epiglottis during intubation can be divided into three sections: (i) an initial increase, (ii) a sort of plateau, and (iii) a decrease. • The pattern of each section shows some differences in relation to the laryngoscope (direct or videolaryngoscope) that is used during the procedure.

A Simulation Competition on Neonatal Resuscitation as a New Educational Tool for Pediatric Residents.

BACKGROUND: Training programs on resuscitation have been developed using simulation-based learning to build skills, strengthen cognitive strategies, and improve team performance. This is especially important for residency programs where reduced working hours and high numbers of residents can reduce the educational opportunities during the residency, with lower exposure to practical procedures and prolonged length of training. Within this context, gamification has gained popularity in teaching and learning activities. This report describes the implementation of a competition format in the context of newborn resuscitation and participants' perceptions of the educational experience. METHODS: Thirty-one teams of three Italian pediatric residents participated in a 3-day simulation competition on neonatal resuscitation. The event included an introductory lecture, familiarization time, and competition time in a tournament-like structure using high-fidelity simulation stations. Each match was evaluated by experts in neonatal resuscitation and followed by a debriefing. The scenarios and debriefings of simulation station #1 were live broadcasted in the central auditorium where teams not currently competing could observe. At the end of the event, participants received an online survey regarding their perceptions of the educational experience. RESULTS: 81/93 (87%) participants completed the survey. Training before the event mostly included reviewing protocols and textbooks. Low-fidelity manikins were the most available simulation tools at the residency programs. Overall, the participants were satisfied with the event and appreciated the live broadcast of scenarios and debriefings in the auditorium. Most participants felt that the event improved their knowledge and self-confidence and stimulated them to be more involved in high-fidelity simulations. Suggested areas of improvement included more time for familiarization and improved communication between judges and participants during the debriefing. CONCLUSIONS: Participants appreciated the simulation competition. They self-perceived the educational impact of the event and felt that it improved their knowledge and self-confidence. Our findings suggest areas of improvements for further editions and may serve as an educational model for other institutions.

Rigid versus soft catheter for less invasive surfactant administration: A crossover randomized controlled manikin trial.

BACKGROUND: We compared surfactant administration with a rigid versus soft catheter in a manikin simulating an extremely preterm infant. METHODS: Randomized controlled crossover (AB/BA) trial. Fifty tertiary hospital consultants and pediatric residents. The primary outcome was the time of device positioning. The secondary outcomes were the success of the first attempt, the number of attempts, and the participant's opinion. RESULTS: Median time of device positioning was 19 s (interquartile range [IQR]: 15-25) with rigid catheter and 40 s (IQR: 28-66) with soft catheter (p < 0.0001). Success at first attempt was 92% with rigid catheter and 74% with soft catheter (p = 0.01). Median number of attempts was 1 (IQR: 1-1) with rigid catheter and 1 (IQR: 1-2) with soft catheter (p = 0.009). Participants found the rigid catheter easier to use (p < 0.0001). CONCLUSIONS: In a preterm manikin model, using a rigid catheter for less invasive surfactant administration was quicker and easier to use than a soft catheter.

Marked versus unmarked tip catheter for less invasive surfactant administration: A crossover randomised controlled manikin trial.

AIM: Less invasive surfactant administration is becoming increasingly popular, but health-care providers may experience some difficulties in achieving the correct positioning of the catheter in the trachea. We compared catheters with marked versus unmarked tips in terms of correct depth positioning in the trachea, total time, number of attempts and participant's opinion on using the device in a manikin model. METHODS: A randomised controlled crossover trial of surfactant administration with less invasive surfactant administration catheters with marked versus unmarked tip in a preterm infant manikin. Fifty tertiary hospital consultants and paediatric residents with previous experience in surfactant administration participated. The primary outcome measure was the positioning of the device at the correct depth in the trachea. The secondary outcome measures were the total time and the number of attempts for positioning the device in the trachea, and participant's opinion on using the device. RESULTS: Correct depth in the trachea was achieved by 38 (76%) and 28 (56%) participants using the catheters with marked and unmarked tip, respectively (P = 0.04). Median time of device positioning (P = 0.08) and number of attempts (P = 0.13) were not statistically different between the two catheters. Participants found the catheter with the marked tip easier to use (P = 0.007), especially concerning the insertion in the trachea (P = 0.04) and the positioning at the correct depth (P = 0.004). CONCLUSIONS: In a preterm manikin model, the marked tip catheter offered a higher chance of achieving the correct depth of the device in the trachea and was favoured by the participants.

Applied forces with direct versus indirect laryngoscopy in neonatal intubation: a randomized crossover mannequin study.

PURPOSE: In adult mannequins, videolaryngoscopy improves glottic visualization with lower force applied to upper airway tissues and reduced task workload compared with direct laryngoscopy. This trial compared oropharyngeal applied forces and subjective workload during direct vs indirect (video) laryngoscopy in a neonatal mannequin. METHODS: We conducted a randomized crossover trial of intubation with direct laryngoscopy, straight blade videolaryngoscopy, and hyperangulated videolaryngoscopy in a neonatal mannequin. Thirty neonatal/pediatric/anesthesiology consultants and residents participated. The primary outcome measure was the maximum peak force applied during intubation. Secondary outcome measures included the average peak force applied during intubation, time needed to intubate, and subjective workload. RESULTS: Direct laryngoscopy median forces on the epiglottis were 8.2 N maximum peak and 6.8 N average peak. Straight blade videolaryngoscopy median forces were 4.7 N maximum peak and 3.6 N average peak. Hyperangulated videolaryngoscopy median forces were 2.8 N maximum peak and 2.1 N average peak. The differences were significant between direct laryngoscopy and straight blade videolaryngoscopy, and between direct laryngoscopy and hyperangulated videolaryngoscopy. Significant differences were also found in the top 10th percentile forces on the epiglottis and palate, but not in the median forces on the palate. Time to intubation and subjective workload were comparable with videolaryngoscopy vs direct laryngoscopy. CONCLUSIONS: The lower force applied during videolaryngoscopy in a neonatal mannequin model suggests a possible benefit in reducing potential patient harm during intubation, but the clinical implications require assessment in future studies. REGISTRATION: ClinicalTrials.gov (NCT05197868); registered 20 January 2022.

RéSUMé: OBJECTIF: Sur les mannequins adultes, la vidéolaryngoscopie améliore la visualisation glottique avec une force plus faible appliquée aux tissus des voies aériennes supérieures et une charge de travail réduite par rapport à la laryngoscopie directe. Cette étude a comparé les forces appliquées sur la zone oropharyngée et la charge de travail subjective au cours d'une laryngoscopie directe vs indirecte (vidéolaryngoscopie) sur un mannequin néonatal. MéTHODE: Nous avons réalisé une étude randomisée croisée d'intubation par laryngoscopie directe, vidéolaryngoscopie à lame droite et vidéolaryngoscopie avec lame hyperangulée sur un mannequin néonatal. Trente spécialistes diplômés et résidents en néonatologie, en pédiatrie et en anesthésiologie y ont participé. Le critère d'évaluation principal était le pic de force maximal obtenu pendant l'intubation. Les critères d'évaluation secondaires comprenaient la force maximale moyenne appliquée pendant l'intubation, le temps nécessaire pour intuber et la charge de travail subjective. RéSULTATS: Les forces médianes appliquées sur l'épiglotte lors de la laryngoscopie directe étaient de 8,2 N pour le pic maximum et de 6,8 N pour le pic moyen. Les forces médianes appliquées lors de la vidéolaryngoscopie à lame droite étaient de 4,7 N pour le pic maximum et de 3,6 N pour le pic moyen. Les forces médianes appliquées lors de la vidéolaryngoscopie avec lame hyperangulée étaient de 2,8 N pour le pic maximum et de 2,1 N pour le pic moyen. Les différences étaient significatives entre la laryngoscopie directe et la vidéolaryngoscopie à lame droite, et entre la laryngoscopie directe et la vidéolaryngoscopie avec lame hyperangulée. Des différences significatives ont également été observées dans le 10e percentile supérieur des forces sur l'épiglotte et le palais, mais pas dans les forces médianes sur le palais. Le délai d'intubation et la charge de travail subjective étaient comparables entre la vidéolaryngoscopie et la laryngoscopie directe. CONCLUSION: La force plus faible appliquée lors de la vidéolaryngoscopie dans un modèle de mannequin néonatal suggère un avantage possible de réduction des lésions potentielles pour le patient pendant l'intubation, mais les implications cliniques doivent être évaluées dans des études futures. ENREGISTREMENT DE L'éTUDE: ClinicalTrials.gov (NCT05197868); enregistré le 20 janvier 2022.

Device positioning with LISA vs. INSURE: a crossover randomized controlled manikin trial.

OBJECTIVE: We aimed to compare time of device positioning, success of procedure and operator's opinion with LISA vs. INSURE in a manikin simulating an extremely low birthweight infant. METHODS: A randomized controlled crossover (AB/BA) trial of surfactant administration with LISA vs. INSURE in a preterm manikin. Forty-two tertiary hospital consultants and pediatric residents with previous experience with LISA and INSURE participated. The primary outcome measure was the time of device positioning. The secondary outcome measures were: success of the first attempt, number of attempts, correct depth, and participant's opinion on difficulty in using the device. RESULTS: Median time of device positioning was shorter with LISA vs. INSURE (median difference -8 s, 95% confidence interval -16 to -1 s; p = .04). Success at first attempt was 35/40 with LISA (83%) and 31/40 with INSURE (74%) (p = .42). Median number of attempts was 1 (IQR 1-1) with LISA and 1 (IQR 1-2) with INSURE (p = .08). Correct depth was achieved in 30/40 with LISA (71%) and 37/40 with INSURE (88%) (p = .12). Participants found LISA easier to insert in the trachea (p = .002) but INSURE easier to place at the correct depth (p = .008). Handling the device (p = .43), visualizing the glottis (p = .17) and overall difficulty in using the device (p = .13) were not statistically different. CONCLUSIONS: In a preterm manikin model, positioning a thin catheter (LISA) was quicker and easier than a tracheal tube (INSURE), but the magnitude of the difference was unlikely to be clinically relevant and the tracheal tube was easier to place at the correct depth. REGISTRATION: clinicaltrial.gov NCT04944108.

Treatment for Severe Malaria: Post-Artesunate Delayed Haemolysis and Neutropenia.

Parenteral artesunate (AS) is the WHO first-line treatment recommended in adults and children for severe malaria. Post-artesunate delayed haemolysis (PADH) is an uncommon adverse reaction to AS with a mechanism that is not fully understood, occurring in adults and children. Neutropenia is another possible finding after AS treatment, albeit rare. We present the case of a child who experienced both effects after treatment with AS for imported severe Falciparum malaria with very high parasitaemia. In addition, thirty-five paediatric cases of PADH, five cases of delayed anaemia without known haemolysis, and fourteen cases of neutropenia after artesunate treatment were identified from the literature review. PADH seems to be a dose-independent reaction and is not strongly related to hyperparasitaemia, although it is more frequent in this case. To date, the benefits of AS outweigh its potential side effects. However, haematological follow-up is mandatory to avoid possible complications from anaemia and neutropenia, especially in children treated with other contemporary drugs.

Impact of personal protective equipment on neonatal resuscitation procedures: a randomised, cross-over, simulation study.

BACKGROUND AND OBJECTIVE: Healthcare providers should use personal protective equipment (PPE) when performing aerosol-generating medical procedures during highly infectious respiratory pandemics. We aimed to compare the timing of neonatal resuscitation procedures in a manikin model with or without PPE for prevention of SARS-COVID-19 transmission. METHODS: A randomised controlled cross-over (AB/BA) trial of resuscitation with or without PPE in a neonatal resuscitation scenario. Forty-eight participants were divided in 12 consultant-nurse teams and 12 resident-nurse teams. The primary outcome measure was the time of positive pressure ventilation (PPV) initiation. The secondary outcome measures were duration of tracheal intubation procedure, time of initiation of chest compressions, correct use of PPE and discomfort/limitations using PPE. RESULTS: There were significant differences in timing of PPV initiation (consultant-nurse teams: mean difference (MD) 6.0 s, 95% CI 1.1 to 10.9 s; resident-nurse teams: MD 11.0 s, 95% CI 1.9 to 20.0 s), duration of tracheal intubation (consultant-nurse teams: MD 22.0 s, 95% CI 7.0 to 36.9 s; resident-nurse teams: MD 9.1 s, 95% CI 0.1 to 18.1 s) and chest compressions (consultant-nurse teams: MD 32.3 s, 95% CI 14.4 to 50.1 s; resident-nurse teams: MD 9.1 s, 95% CI 0.1 to 18.1 s). Twelve participants completed the dressing after entering the delivery room. PPE was associated with visual limitations (43/48 participants), discomfort in movements (42/48), limitations in communication (32/48) and thermal discomfort (29/48). CONCLUSIONS: In a manikin model, using PPE delayed neonatal resuscitation procedures with potential clinical impact. Healthcare workers reported limitations and discomfort when wearing PPE. TRIAL REGISTRATION NUMBER: NCT04666233.