Monitoring cerebral oxygenation of preterm infants using a neonatal specific sensor.

INTRODUCTION: Cerebral oxygenation (rcSO2) monitoring in preterm infants may identify periods of cerebral hypoxia or hyperoxia. We hypothesised that there was a relationship between rcSO2 values and short term outcome in infants of GA < 32weeks. METHODS: RcSO2 values were recorded for the first 48 h of life using an INVOS monitor with a neonatal sensor. The association between cranial ultrasound scan measured brain injury and rcSO2 was assessed. RESULTS: 120 infants were included. Sixty-nine percent (83) of infants had a normal outcome (no IVH, no PVL, and survival at 1 month); less than one-quarter, 22% (26), had low grade IVH 1 or 2 (moderate outcome); and 9% (11) of infants had a severe outcome (IVH ≥ 3, PVL or died before 1 month age). rcSO2 values were lower for infants GA < 28weeks when compared with those GA 28-32, p < 0.001. There was no difference in absolute rcSO2 values between the three outcome groups but a greater degree of cerebral hypoxia was associated with preterm infants who had low grade 1 or 2 IVH. CONCLUSION: Infants of GA < 28 weeks have lower cerebral oxygenation in the first 2 days of life. A greater degree of hypoxia was seen in infants with grade 1 or 2 haemorrhage. Normative ranges need to be gestation specific.

Auscultate, palpate and tap: time to re-evaluate.

AIM: To determine the accuracy of current methods of heart rate (HR) assessment. METHODS: All participants palpated a simulated pulsating umbilicus (UMB), listened to a tapping rate (TAP) and auscultated a simulated HR (AUSC). A simulated HR of 54, 88 and 128 beats per minute (bpm) was randomised for all methods. RESULTS: Twenty-nine healthcare staff participated in this study. Correct assessment of HR of 54 bpm as being within the 0-59 range occurred in 17.2% UMB, 17.2% TAP and 31% AUSC and was obtained in <10 seconds by 48.3%, 65.5% and 62.1%, respectively. A rate of 88 bpm was correctly assessed as within the 60-100 range in 82.8% UMB, 79.3% TAP and 79.3% AUSC and was obtained in <10 seconds by 55.2%, 58.6% and 55.2%, respectively. A rate of 128 bpm was identified as >100 bpm by 96.6% UMB, 93.1% TAP, and 93.1% AUSC and was obtained in <10 seconds by 51.7%, 55.2% and 62.1%, respectively. CONCLUSION: Current methods in assessing rates below 60 bpm are inaccurate and may overestimate HR. We recommend that these methods alone should not be relied upon in neonatal resuscitation and objective assessment of heart rate should be readily available at all newborn resuscitations.

Perfusion index in the preterm infant immediately after birth.

AIM: To evaluate PI in preterm infants during the first 10 min of life. DESIGN/METHODS: An observational study was conducted in the delivery room on preterm infants (less than 32 week gestation). PI values were obtained from a pre ductal saturation probe placed on the right wrist. Analysis was performed on the first 10 min of data to investigate the correlation of PI with gestational age, heart rate, blood pressure, and lactate values. RESULTS: 33 infants with a median gestational age of 29 wks (IQR, 26-30 wks) and median birth weight of 1205 g (IQR, 925-1520 g) were included for analysis. The overall median PI value for the first 10 min was 1.3 (IQR, 0.86-1.68). There was no significant correlation found between delivery room PI and gestational age(r=0.28, 95% CI: -0.09, 0.59), lactate levels (r=-0.25, 95% CI: -0.62, 0.18) and blood pressure values (r=-0.18, 95% CI: -0.46, 0.20). An average correlation value of r=-0.417 (95% CI: - 0.531, -0.253) was found between PI and heart rate values. There was no statistical difference between the median of the median PI value over the first 5 min of life compared to the second 5 min (p=0.22). Variability, as quantified by the IQR, was higher in the first 5 min compared to the second 5 min: median of 0.5(IQR, 0.27, 0.92) vs 0.2(IQR, 0.10, 0.30) (p<0.00). CONCLUSIONS: Delivery room PI values are easily obtained, however, have significant variability over the first 5 min of life and may add little to delivery room assessment.

Quantitative or qualitative carbon dioxide monitoring for manual ventilation: a mannequin study.

AIM: To compare the effectiveness of an in-line EtCO2 detector (DET) and a quantitative EtCO2 detector (CAP), both attached to a t-piece resuscitator, during PPV via a face mask. METHODS: Paediatric trainees were randomly assigned to determine the method of PPV they commenced with (No device (ND), DET or CAP). Participants used each method for 2 min. Participants were video-recorded to determine the amount of effective ventilations delivered with each method. RESULTS: Twenty-three paediatric trainees provided a total of 6035 ventilations, and 91.2% were deemed effective. The percentages of median effective ventilations with the ND, the DET and the CAP were 91.0%, 93.0% and 94.0%, respectively. Fourteen (61%) of the trainees indicated a preference for the DET method, 8 (35%) for the CAP method, and 1 (4%) of the trainees indicated a preference for the ND method. Capnography was the most effective method per patient. CONCLUSION: There was no adverse effect with the addition of EtCO2 detectors. Trainees favoured methods of EtCO2 monitoring during ventilation. The NeoStat device was the preferred device by the majority. The greatest efficacy was achieved with the capnography device. Capnography may enhance face mask ventilation.

A review of carbon dioxide monitoring in preterm newborns in the delivery room.

INTRODUCTION: The physiologic adaptation to extra uterine life during the immediate neonatal period is unique. Many newborns require assistance in this adaptive process. Recent evidence now supports titrating oxygen to guide resuscitation but no guidance is provided on utilizing exhaled CO2 measurements. AIM: To review the current evidence relating to the use of CO2 monitoring in preterm newborns in the delivery room. METHODS: Search was performed using the Cochrane Central Register of Controlled Trials, MEDLINE (1966-2014) and PREMEDLINE, EMBASE (1980-2014), CINAHL (1982-2014), Web of Science (1975-2014) and the Oxford Database of Perinatal Trials. RESULTS: The search revealed 21 articles relating to CO2 detection, either quantitative or qualitative, in the newborn infant. The majority of these were observational studies, eight relating to CO2 detection as a means of confirming correct endotracheal tube placement in the newborn infant. The other indication is for mask ventilation, and there is one randomized control trial and four observational studies of CO2 detection during mask ventilation. The overall recommendation for CO2 detection for both clinical uses in the delivery suite is level B. DISCUSSION: CO2 detection may be of particular benefit for preterm infants in the delivery suite. However there is a need for further research into CO2 detection, in particular capnography, as a means of confirming effective PPV in neonatal resuscitation.

Efficacy and user preference of two CO2 detectors in an infant mannequin randomized crossover trial.

Assessment of effective ventilation in neonatal mask ventilation can be difficult. This study aims to determine whether manual ventilation with a T-piece resuscitator containing an inline CO2 detector (either a Pedi-Cap® CO2 detector or a Neo-StatCO2