Implication of Major Adverse Postoperative Events and Myocardial Injury on Disability and Survival: A Planned Subanalysis of the ENIGMA-II Trial.

BACKGROUND: Globally, >300 million patients have surgery annually, and ≤20% experience adverse postoperative events. We studied the impact of both cardiac and noncardiac adverse events on 1-year disability-free survival after noncardiac surgery. METHODS: We used the study cohort from the Evaluation of Nitrous oxide in Gas Mixture of Anesthesia (ENIGMA-II) trial, an international randomized trial of 6992 noncardiac surgical patients. All were ≥45 years of age and had moderate to high cardiac risk. The primary outcome was mortality within 1 postoperative year. We defined 4 separate types of postoperative adverse events. Major adverse cardiac events (MACEs) included myocardial infarction (MI), cardiac arrest, and myocardial revascularization with or without troponin elevation. MI was defined using the third Universal Definition and was blindly adjudicated. A second cohort consisted of patients with isolated troponin increases who did not meet the definition for MI. We also considered a cohort of patients who experienced major adverse postoperative events (MAPEs), including unplanned admission to intensive care, prolonged mechanical ventilation, wound infection, pulmonary embolism, and stroke. From this cohort, we identified a group without troponin elevation and another with troponin elevation that was not judged to be an MI. Multivariable Cox proportional hazard models for death at 1 year and assessments of proportionality of hazard functions were performed and expressed as an adjusted hazard ratio (aHR) and 95% confidence intervals (CIs). RESULTS: MACEs were observed in 469 patients, and another 754 patients had isolated troponin increases. MAPEs were observed in 631 patients. Compared with control patients, patients with a MACE were at increased risk of mortality (aHR, 3.36 [95% CI, 2.55-4.46]), similar to patients who suffered a MAPE without troponin elevation (n = 501) (aHR, 2.98 [95% CI, 2.26-3.92]). Patients who suffered a MAPE with troponin elevation but without MI had the highest risk of death (n = 116) (aHR, 4.29 [95% CI, 2.89-6.36]). These 4 types of adverse events similarly affected 1-year disability-free survival. CONCLUSIONS: MACEs and MAPEs occur at similar frequencies and affect survival to a similar degree. All 3 types of postoperative troponin elevation in this analysis were associated, to varying degrees, with increased risk of death and disability.

Minimally invasive fetal therapy for hydropic lung masses: three different approaches and review of the literature.

OBJECTIVE: To report three different antenatal therapeutic approaches for fetal lung masses associated with hydrops. METHODS: Three prospectively followed cases are described, and all 30 previously published minimally invasive cases of fetal therapy for hydropic lung masses are reviewed. RESULTS: Three hydropic fetuses with large intrathoracic lung masses presented at 17, 25 and 21 weeks of gestation, respectively. An aortic feeding vessel was identified in each case and thus a bronchopulmonary sequestration (BPS) was suspected. Under ultrasound guidance, the feeding vessel was successfully occluded with interstitial laser (Case 1), radiofrequency ablation (RFA) (Case 2) and thrombogenic coil embolization (Case 3). Complete (Cases 1 and 2) or partial (Case 3) resolution of the lung mass and hydrops was observed. A healthy infant was born at term after laser therapy (Case 1), and the involved lung lobe was resected on day 2 of postnatal life. In Case 2, hydrops resolved completely following RFA, but an iatrogenic congenital diaphragmatic hernia and abdominal wall defect became apparent 4 weeks later. The neonate died from sepsis following spontaneous preterm labor at 33 weeks. In Case 3, despite technical success in complete vascular occlusion with coils, a stillbirth ensued 2 days after embolization. CONCLUSIONS: The prognosis of large microcystic or echogenic fetal chest masses associated with hydrops is dismal. This has prompted attempts at treatment by open fetal surgery, with mixed results, high risk of premature labor and consequences for future pregnancies. We have demonstrated the possibility of improved outcome following ultrasound-guided laser ablation of the systemic arterial supply. Despite technical success, RFA and coil embolization led to procedure-related complications and need further evaluation.

Effects of exercise on lung lymph flow in sheep and goats during normoxia and hypoxia.

Vigorous exercise causes a marked increase in cardiac output with only a minimal increase in measureable pulmonary vascular pressures. These changes in pulmonary hemodynamics should affect lung water and solute movement. On nine occasions, we measured the effect of normoxic exercise on lung lymph flow in four sheep and two goats with chronic lymph fistulas (wt = 15-25 kg). In addition, lymph flow was also measured on five occasions in sheep during exercise at reduced barometric pressures (430 and 380 mmHg). During normobaria, the animals ran at 3-5 km/h with 0-10% elevation of the treadmill for 15 to 85 min. Exercise on average caused a 100% increase in cardiac output, a 140% increase in lung lymph flow, and a slight but significant reduction in lymph to plasma concentration ratio (l/p) for total protein and albumin (mol wt = 70,000). There was a significant linear correlation between lymph flow and cardiac output (r = 0.87, P less than 0.01). There was no change in l/p for IgG (mol wt = 150,000) or IgM (mol wt = 900,000) and no significant change in mean pulmonary arterial (Ppa) or mean left atrial (Pla) pressures. Transition from normobaria to hypobaria caused an increase in Ppa but no change in Pla, cardiac output, or lymph flow. Exercise during hypobaria caused increases in lymph flow that were qualitatively similar to changes observed during normobaric exercise: there was a 60% increase in cardiac output, a 90% increase in lymph flow, and an 11% reduction in l/p for total protein. There was no change in l/p for albumin, IgG, or IgM, and no further change in Ppa. The increased lymph flow during normoxic and hypobaric exercise is best explained by an increase in pulmonary vascular surface area for fluid and protein exchange. Our results suggest that the normal ovine lung has the potential to nearly triple the amount of perfused microvascular surface area. This speculation is relevant to the interpretation of lymph flow data from other experiments.

A low molecular weight heparin alters the fetal coagulation system in the pregnant sheep.

Standard heparin and a LMWH, CY222 do not cross the placenta nor alter fetal coagulation when injected into the pregnant ewe. We found that another LMWH, Pharmuka-10169 (PK-10169) alters fetal coagulation without crossing the placenta in the pregnant sheep. To characterize this anticoagulant we measured the in vitro and in vivo effects of 125I-PK-10169 in maternal and fetal plasmas following administration of PK-10169 to the mother or fetus. The fetal anticoagulant activity was not neutralizable by protamine sulphate and was attributable to the inhibition of thrombin but not factor Xa. In vitro, the fetal anticoagulant activity had properties similar to dermatan sulphate; both catalyzed the inhibition of thrombin but not factor Xa by sheep plasma; and neither was neutralizable by protamine sulphate. These effects were due to the enhanced neutralization of thrombin by heparin cofactor II. We conclude that PK-10169 does not cross the placenta, but does induce the release of an endogenous dermatan sulphate-like substance which alters fetal coagulation.

Prolonged low-dose dexamethasone treatment, in early gestation, does not alter blood pressure or renal function in adult sheep.

Low-dose dexamethasone treatment is used in pregnancies where the fetus is suspected to be at risk of congenital adrenal hyperplasia (CAH). In order to see if such treatment had long-term effects, pregnant ewes were treated with dexamethasone (20 micro g/kg maternal body weight) or saline from 25 to 45 days of gestation and blood pressure and renal function studied in offspring at 2 Years of age. There were 11 animals from dexamethasone treatment (six females and five males) and nine lambs from saline treatment (five females and four males). We aimed to study blood pressure and heart rate in the adult animals of both genders, and renal function only in the adult female animals. In both females and males, blood pressure and heart rate were similar between the two groups of animals. The excretion rates of sodium and potassium were similar between the two groups of animals. In addition, glomerular filtration rate was not different between the two groups of animals (112+/-11 ml/kg per h (S.E.M.) in saline-treated females vs 112+/-10 ml/kg per h in dexamethasone-treated females). There were no differences in body weight or weights of the kidney and heart between the treatments in both females and males. In conclusion, these results are reassuring for patients similarly exposed to prenatal dexamethasone treatment for CAH, as in our animal model no evidence of altered renal function or predisposition to adult hypertension was found.

Effect of increased surface tension and assisted ventilation on 99mTc-DTPA clearance.

Experiments were performed to determine the effects of conventional mechanical ventilation (CMV) and high-frequency oscillation (HFO) on the clearance of technetium-99m-labeled diethylenetriamine pentaacetate (99mTc-DTPA) from lungs with altered surface tension properties. A submicronic aerosol of 99mTc-DTPA was insufflated into the lungs of anesthetized, tracheotomized rabbits before and 1 h after the administration of the aerosolized detergent dioctyl sodium sulfosuccinate (OT). Rabbits were ventilated by one of four methods: 1) spontaneous breathing; 2) CMV at 12 cmH2O mean airway pressure (MAP); 3) HFO at 12 cmH2O MAP; 4) HFO at 16 cmH2O MAP. Administration of OT resulted in decreased arterial PO2 (PaO2), increased lung wet-to-dry weight ratios, and abnormal lung pressure-volume relationships, compatible with increased surface tension. 99mTc-DTPA clearance was accelerated after OT in all groups. The post-OT rate of clearance (k) was significantly faster (P less than 0.05) in the CMV at 12 cmH2O MAP [k = 7.57 +/- 0.71%/min (SE)] and HFO at 16 cmH2O MAP (k = 6.92 +/- 0.61%/min) groups than in the spontaneously breathing (k = 4.32 +/- 0.55%/min) and HFO at 12 cmH2O MAP (4.68 +/- 0.63%/min) groups. The clearance curves were biexponential in the former two groups. We conclude that pulmonary clearance of 99mTc-DTPA is accelerated in high surface tension pulmonary edema, and this effect is enhanced by both conventional ventilation and HFO at high mean airway pressure.

Tibial hemimelia and tetralogy of Fallot associated with first trimester exposure to amantadine.

Although amantadine hydrochloride has been extensively used for the prevention of influenza A2, few data exist regarding its safety in pregnancy. We report the outcome of a pregnancy during which the mother was treated with amantadine in the first trimester. The infant, born at 29 weeks gestation, has tetralogy of Fallot and tibial hemimelia. Follow-up of the four prospective cases known to date to the Motherisk Program in Toronto did not identify any abnormalities.

Fulminating haemophilus influenzae b meningitis.

Haemophilus influenzae type b (HIb) is the most common cause of bacterial meningitis in children with a mortality rate ranging from 1.6% to 14%. Most patients have a 2-3 day history of symptoms prior to admission. A few have fulminating disease with rapid neurological deterioration. Review of 191 cases of HIb meningitis revealed a mortality rate of 2.1% but all who died had fulminating meningitis (FM). Four of six patients with FM died. FM patients had symptoms for less than 24 hours before rapid neurological deterioration with increased ICP, seizures, coma and/or respiratory arrest. Review of 10 FM cases revealed that on admission, 5 had hypotension, 3 had thrombocytopenia, and 8 had coma. Typical CSF changes were seen in only 7. All fatal cases died within 24 hours. Brain swelling and tonsillar herniation were found at autopsy. SDS-PAGE outer membrane protein subtyping did not show one "killer strain". Animal and autopsy data suggest that diminished CSF outflow and cerebral edema contribute to increased ICP. To improve survival of FM patients, initial treatment must (1) decrease ICP below levels impairing cerebral perfusion, (2) maintain adequate ventilation and blood pressure, and include (3) LP when stable, (4) antibiotics, and (5) close monitoring. Utilizing these principles, two FM patients survived without major sequelae.

Concordance and precision of dual X-ray absorptiometry with a 10 s scan.

Development of dual energy X-ray absorptiometry (DXA) scanners with multidetector array technology has resulted in greatly shortened scanning times. The Hologic QDR-4500 includes an ultrafast (10 s) "turbo" scan mode recommended by the manufacturer for fast screening studies or as an aid to positioning the patient prior to scanning using the normal fast (30 s), medium (1 min) or high definition (2 min) modes. The suitability of the turbo mode for use in routine clinical studies was assessed by examining the concordance of bone mineral density (BMD) measurements obtained in this mode with measurements obtained using the three normal scanning modes. Studies in 151 female patients showed statistically significant discrepancies in four out of the six scan sites studied with systematic differences of 2.9% and 3.1% being observed for the posteroanterior (PA) spine and intertrochanteric region of the hip, respectively. In vivo precision for the 10 s scan found by performing duplicate measurements on 37 patients had a coefficient of variation of 1.3% for PA spine and 2.5% for femoral neck BMD. An investigation of the dependence of precision on body mass index (BMI) shows that the precision of spine and hip BMD was adversely affected with increasing BMI but the trend was statistically significant only in the spine. It was concluded that turbo mode scans are acceptable for routine clinical studies of the spine and hip but should not be used for longitudinal studies or patients with BMI greater than 30 kg m-2.

A comparison of a peripheral DXA system with conventional densitometry of the spine and femur.

Because of the perceived high cost of dual-energy X-ray absorptiometry (DXA) studies of the spine and femur, there is renewed interest in small, low-cost X-ray devices for scanning the peripheral skeleton. We have compared forearm bone mineral density (BMD) measurements (distal and ultradistal sites) performed on a DTX-200 (Osteometer MediTech, Hoersholm, Denmark) with spine (L1-L4) and femur (femoral neck and total hip sites) scans performed on a QDR-4500 (Hologic, Waltham, MA) in 172 white UK women aged 22-84 yr with a view to establishing differences caused by inconsistent reference ranges and different age-related changes in BMD. All BMDs were expressed as T-scores using the manufacturers' reference ranges for the forearm and spine, and the National Health and Nutrition Examination Survey (NHANES) ranges for the femur. Linear regression between peripheral and axial sites gave correlation coefficients r = 0.71-0.74 and roof mean standard errors (RMSE) 0.88-1.14 in T-score units. Subjects were divided into the following five age groups: <40 yr; 40-49 yr; 50-59 yr; 60-69 yr and >/=70 yr. A large systematic difference between distal and ultradistal T-scores (mean DeltaT = 0.59, SEM = 0.05) was found affecting all age groups. When the mean difference in T-score between each forearm site (distal, ultradistal) and each axial site (spine, femoral neck, total hip) was examined for premenopausal subjects (n = 58) the mean difference between forearm and axial T-score showed a consistent negative offset (DeltaT = -0.41 to -0.48) for the distal forearm site and a consistent positive offset (DeltaT = +0.30 to +0.37) for the ultradistal site. When interpreting results in postmenopausal women, age-related T-score changes in the forearm were in close agreement with the femoral neck region of exterest (ROI), but systematic differences were found between the forearm and the spine and total hip sites. The two forearm and three axial sites were compared to evaluate the number of postmenopausal subjects identified as osteoporotic on the basis of the World Health Organization (WHO) Study Group criteria (T-score <-2.5). Although forearm and spine T-scores identified approximately equal numbers of subjects as osteoporotic (distal 38/114; ultradistal 31/114; spine 30/114), the two femur sites identified fewer subjects as osteoporotic (femoral neck 25/114; total hip 16/114). The number for the total hip site was statistically significantly smaller than the spine and forearm sites.

Cardiomyopathy in adult Holstein Friesian cattle in Britain.

The clinical signs, pathology and breeding data of two cases of cardiomyopathy of an unusual kind in adult Holstein Friesian cattle in Britain are reported and compared with those in similar entities in Switzerland, Japan and Canada. The principal and primary lesions affect the heart and these produce secondary changes, particularly in the liver, and result in fatal congestive heart failure. The cardiac lesions consist of extensive myocyte vacuolation, endomysial and perimysial fibrosis and focal cardiac myocyte degeneration, atrophy and hypertrophy resulting in an extended range of myocyte size. Lesions affected all four heart chambers but were most severe in the ventricles. Vascular lesions, particularly moderate medial hypertrophy and intimal thickening of arterioles and arteries, occurred in heart, lung, kidney and lymph nodes. The liver showed severe fibrosis, chronic congestion and hepatocyte loss. There was a chronic multifocal nephritis. The cause is unknown, but the affected animals were full brother and sister and have a common ancestor in the male and female line five generations earlier.

Comparison of intradermal injections of bromodeoxyuridine and tritiated thymidine in the in vivo measurement of epidermal cell turnover time in goats.

Study of keratinisation defects such as seborrhoea may require investigation of epidermal cell kinetics in clinical cases. For this to be practically useful a safe, reliable and quick method is essential. This study compared epidermal cell kinetics in the goat following the use of intradermal injection of tritiated thymidine ([3H]TdR) and bromodeoxyuridine (BURD) to label S phase nuclei. Turnover time for goat epithelial cells was not significantly different for the two agents; 26.3 +/- 6.0 days for thymidine and 21.8 +/- 5.2 days for BURD. It was concluded that intradermal injection of BURD will be a suitable technique for investigating epidermal cell kinetics in vivo and could have applications in a clinical situation because it is quicker and safer than [3H]TdR.

Estimation of S phase duration in goat epidermis by an in vivo intradermal double labeling technique using bromodeoxyuridine and tritiated thymidine.

When studying skin diseases resulting from alterations in the rate of epidermal cell turnover it is useful to be able to quantify parts of the epidermal cell cycle. An in vivo intradermal technique is described which uses tritiated thymidine followed by bromodeoxyuridine to label cells in the S phase of the cell cycle. Combined autoradiographic and immunocytochemical techniques were used to quantify the flux of cells into and out of S phase. These results were then used to estimate the length of S phase. The technique was found to provide clear distinctive labelling of S phase nuclei with both reagents. This avoided many of the problems encountered with double labelling techniques using two radioactive labels. S phase was calculated to be 7.7 hours for goat skin.

Use of the forced oscillating airflow technique to measure the resistance of the equine upper airway: effects of laryngoventriculectomy and laryngoplasty.

Investigations were carried out to determine whether measurements of total respiratory resistance (TRR) made in resting animals could detect changes due to laryngeal hemiplegia. Control values of TRR were obtained in eight ponies and in six of these the measurements were repeated after division of the left recurrent laryngeal nerve in the mid-cervical region; two were retained as controls. A further set of measurements were made before two of the operated animals were subjected to left laryngoventriculectomy (Hobday operation). A laryngoplasty ('tie-back' operation) was performed on another two animals. Measurements of TRR were made at three-monthly intervals on all eight ponies for the next two years. Endoscopic examination of the larynx was carried out at the time of the measurements. All ponies showed a marked, but regular, variation in TRR over the two-year observation period. Nerve section was shown to be associated with an increase in TRR in five ponies. The Hobday operation decreased TRR in one animal and had no marked effect in the second. The tie-back operation was associated with a decreased TRR in one pony and an increase in the second. Autopsies were carried out on all six operated ponies and measurements of TRR and lower respiratory resistance (LRR) were made immediately before the animals were killed. Evidence of regeneration of the recurrent laryngeal nerve was seen in one of the ponies which underwent the Hobday operation. Histological evidence of regeneration was found in another pony.(ABSTRACT TRUNCATED AT 250 WORDS)

Growth restriction alters adult spatial memory and sensorimotor gating in a sex-specific manner.

In Western society, impaired uteroplacental blood flow is the major cause of human intrauterine growth restriction. Infants born small and who experience late childhood accelerated growth have an increased risk of developing adult diseases. Recent studies also suggest a link between birth weight and altered adult behavior, particularly relating to motor function, learning and memory, depression and schizophrenia. The aim of this study was to determine the relative influence of prenatal and postnatal growth restriction on adult behavioral outcomes in male and female rats. Uteroplacental insufficiency was induced in Wistar Kyoto rats by bilateral uterine vessel ligation on day 18 of gestation producing growth-restricted offspring (Restricted group). The Control group had sham surgery. Another group underwent sham surgery, with a reduction in litter size to five at birth equivalent to the Restricted litter size (Reduced Litter group). At 6 months of age, a series of behavioral tests were conducted in male and female offspring. Growth restriction did not impair motor function. In fact, Restricted and Reduced Litter males showed enhanced motor performance compared with Controls (P < 0.05). Spatial memory was greater in Restricted females only (P < 0.05). The Porsolts test was unremarkable, however, males exhibited more depressive-like behavior than females (P < 0.05). A reduction in sensorimotor gating function was identified in Reduced Litter males and females (P < 0.05). We have demonstrated that growth restriction and/or a poor lactational environment can affect adult rat behavior, particularly balance and coordination, memory and learning, and sensorimotor gating function, in a sex-specific manner.

Improved procedural performance following a simulation training session may not be transferable to the clinical environment.

OBJECTIVE: Neonatal intubation is a life-saving procedural skill required by pediatricians. Trainees receive insufficient clinical exposure to develop this competency. Traditional training comprises a Neonatal Resuscitation Program (NRP) complemented by clinical experience. More recently, simulation is being used in procedural skills training. The objective of this study is to examine the impact of a simulation session, which teaches the skill of neonatal intubation by comparing pre- and post-intervention performance, and examining transferability of skill acquisition to the clinical setting. STUDY DESIGN: First-year pediatric residents with NRP training, but no previous neonatal experience, attended a 2-h intubation education session conducted by two experienced respiratory therapists. Individual components of the skill were taught, followed by practice on a high-fidelity infant mannequin with concurrent feedback. Skills were assessed using a validated neonatal intubation checklist (CL) and a five-point global rating scale (GRS), pre- and immediately post-intervention, using the mannequin. Clinical intubations performed in the subsequent 8-week neonatal intensive-care unit (NICU) rotation were evaluated by documenting success rates, time taken to intubate, and CL and GRS scores. Performance was also compared with similar data collected on intubations performed by a historical cohort of first-year residents who did not receive the training intervention. Data were analyzed using descriptive statistics, Student's t-test and χ (2)-test as appropriate, and analysis of variance. RESULT: Thirteen residents participated in the educational session. Mean pre-intervention CL score was 65.4 ± 18% (s.d.) and GRS was 3 ± 0.7 (s.d.). Performance improved following the intervention with post-training CL score of 93 ± 5% (P<0.0001) and GRS of 3.92 ± 0.4 (P=0.0003). These trainees performed 40 intubations during their subsequent NICU rotation, with a success rate of 67.5% compared with 63.15% in the cohort group (NS). However, mean CL score for the study trainees during the NICU rotation was 64.6 ± 20%, significantly lower than their post-training CL score (P<0.001), and significantly lower than the historical cohort score of 82.5 ± 15.4% (P=0.001). In the intervention group, there were no significant differences between the pre-intervention and real-life CL scores of 65 ± 18% and 64.63 %, respectively, and the pre-intervention and real-life GRS of 3.0 ± 0.7 and 2.95 ± 0.86, respectively. CONCLUSION: Trainees showed significant improvement in intubation skills immediately post intervention, but this did not translate into improved-clinical performance, with performance returning to baseline. In fact, significantly higher CL scores were demonstrated by the cohort group. These data suggest that improved performance in the simulation environment may not be transferable to the clinical setting. They also support the evidence that although concurrent feedback may lead to improved performance immediately post training intervention, this does not result in improved skill retention overall.

Rupture of membranes before the age of viability and birth after the age of viability: comparison of outcomes in a matched cohort study.

OBJECTIVE: To compare composite adverse outcome rate of infants <32 weeks gestational age (GA) who were born after preterm premature rupture of membranes (PPROM) at previable gestation to those born without PPROM. STUDY DESIGN: Retrospective review of prospective collected data for infants discharged between 2004 and 2007 was conducted. Cases were infants with >7 days of PPROM that occurred before 24 weeks. Matched cohort consisted of infants born without PPROM (matched for GA, sex and admission date). Composite adverse outcome was assessed considering death or any of the following three severe morbidities (severe neurological injury, severe retinopathy of prematurity or chronic lung disease). RESULT: The 29 cases had higher mean severity of illness score compared with 74 matched infants. Mean duration of ROM was 45 vs 2 days and mean GA at the ROM was 21 vs 27 weeks, respectively. Logistic regression confirmed significantly higher risk of composite adverse outcome rates for cases (69 vs 47%; P=0.02, adjusted odds ratio 4.0, 95% CI 1.2, 13.6). CONCLUSION: The survival rate for infants born at <32 weeks following PPROM at previable age has improved significantly; however, these infants had a higher rate of adverse composite neonatal outcome.

Failure of pediatric and neonatal trainees to meet Canadian Neonatal Resuscitation Program standards for neonatal intubation.

OBJECTIVE: Neonatal intubation skills are initially taught through the Neonatal Resuscitation Program (NRP) and thereafter complemented by further practical clinical training. The aim of this study is to compare the ability of NRP trained individuals to successfully complete a neonatal intubation. STUDY DESIGN: A prospective observational study was performed at an inborn high-risk level 3 perinatal center. Participants were postgraduate years 1 and 3 pediatric residents, neonatal-perinatal medicine subspecialty residents and fellows, and neonatal intensive care unit (NICU) respiratory therapists (RTs) with earlier NRP training. Intubations were scored on a checklist as well as a global assessment scale. Characteristics of the intubation attempt were recorded for each patient. RESULT: Fifty neonatal intubations were assessed, of which 73% of the attempts were deemed successful. A higher proportion of endotracheal tubes were successfully placed by RTs (100%, P<0.05), compared with both NICU fellows (69%) and pediatric residents (63%). The overall mean time for successful neonatal intubation was 51+/-28 s, which is greater than twice the time currently recommended by the NRP and American Heart Association guidelines. Attempts by pediatric residents and NICU fellows were longer (P<0.05, analysis of variance) and received lower global assessment scale (P<0.05, analysis of variance) and checklist (P<0.05, analysis of variance) scores, when compared with RTs. CONCLUSION: The success rate and overall quality of neonatal intubations performed by neonatal and pediatric trainees in Canada did not meet NRP standards; in particular, the time taken to intubate by pediatric residents and neonatal fellows is concerning. Re-evaluation of training methods and the volume of formalized exposure to neonatal intubation in Canadian residency programs are required.