Complicated Intubations are Associated with Bronchopulmonary Dysplasia in Very Low Birth Weight Infants.

OBJECTIVE: This study aimed to evaluate the association between desaturation <60% (severe desaturation) during intubation and a total number of intubation attempts in the first week of life in very low birth weight (VLBW) infants with adverse long-term outcomes including bronchopulmonary dysplasia (BPD) and severe periventricular/intraventricular hemorrhage grade 3 or 4 (PIVH). STUDY DESIGN: A retrospective chart review was performed on VLBW infants intubated in the neonatal intensive care unit during the first week of life between January 2017 and July 2020. Descriptive tables were generated for two outcomes including BPD and PIVH. Multivariable logistic regression was performed for each outcome including significant predictors that differed between groups with a p-value of <0.2. RESULTS: A total of 146 patients were included. Patients with BPD or PIVH had a lower gestational age, and patients with BPD had a lower BW. Patients with BPD had a greater number of intubation attempts in the first week of life (4 vs. 3, p < 0.001). In multivariable logistic regression controlling for confounding variables, the odds developing BPD were higher for patients with increased cumulative number of intubation attempts in the first week of life (odds ratio [OR]: 1.29, 95% confidence interval [CI]: 1.03-1.62, p = 0.029). Post hoc analyses revealed increased odds of developing BPD with increased number of intubation encounters in the first week of life (OR: 2.20, 95% CI: 1.04-4.82, p = 0.043). In this post hoc analysis including intubation encounters in the model; desaturation <60% during intubation in the first week of life was associated with increased odds of developing BPD (OR: 2.35, 95% CI: 1.02-5.63, p = 0.048). CONCLUSION: The odds of developing BPD for VLBW infants were higher with increased intubation attempts and intubation encounters. In a post hoc analysis, the odds of developing BPD were also higher with desaturation during intubation. Further research is needed to determine mechanisms of the relationship between complicated intubations and the development of BPD. KEY POINTS: · Neonatal intubations often require multiple attempts.. · Neonates frequently desaturate during intubation.. · Intubation attempts are positively associated with BPD.. · Severe desaturation may be positively associated with BPD..

Improving thermoregulation in transported preterm infants: a quality improvement initiative.

OBJECTIVE: Increase the percentage of transported preterm or LBW infants with an admission temperature of 36.5-37.5 °C from 60 to 80% by December 2017. STUDY DESIGN: We used the Model for Improvement with Plan-Do-Study-Act (PDSA) cycles. Interventions focused on awareness of temperature control in preterm infants, adequate monitoring, and maintaining normothermia. Interventions consisted of standardizing isolette temperature, use of chemical warming pack and plastic wrap, and feedback. Data were plotted on a p-chart and grouped by month. RESULT: A total of 381 infants <37 weeks or <2.5 kg were transported from January 2016 to December 2019. At baseline 60% were admitted with a temperature within the range of 36.5-37.5 °C. Special cause variation was noted twice during the study period, initially to 80% in June 2018 and then to 96% in April 2019, without an increase in hyperthermia. CONCLUSION: Multidisciplinary quality improvement efforts improved normothermia in vulnerable transported infants to 96%.

Patient characteristics associated with complications during neonatal intubations.

INTRODUCTION: Complications of neonatal intubation are known to be increased with emergent intubations, increased number of attempts, unstable hemodynamics, or ventilation failure; and decreased with use of paralytic medication and videolaryngoscopy. Patient characteristics associated with complications are not well understood. DESIGN/METHODS: A retrospective cohort study was performed of neonates who underwent intubation between January 2017 and June 2019. Patient characteristics of infants with and without complications were compared. Complications included common adverse events and abnormal vital sign changes occurring during intubation. RESULTS: A total of 467 intubation encounters in 352 infants were included with median gestational age (GA) at birth of 29 weeks, postmenstrual age (PMA) 33 weeks at intubation, and median weight 1795 g. 41.5% of infants had complications and 58.5% of infants did not. Infants with complications compared to infants without had a median FiO2 of 0.50 versus 0.45 (p = .183), median GA at birth of 29 versus 31 weeks (p < .001), median PMA of 32 weeks versus 33.0 weeks (p = .352), median weight of 1540 g versus 1970g (p = .091), and median chronological age of 3 days versus 1 day (p = .001). Generalized Estimating Equations controlling for administration of paralytic indicated decreased complications in infants ≤21.5 days in chronological age (OR, 0.45; 95% CI, 0.30-0.69) and increased complications in infants ≤1565 g (OR, 1.52; 95% CI, 1.04-2.23). CONCLUSION: Patient characteristics associated with an increased rate of complications included chronological age and weight. Further study is needed to reduce complications.

Introducing Less-Invasive Surfactant Administration into a Level IV NICU: A Quality Improvement Initiative.

Less-invasive surfactant administration (LISA), a newer technique of delivering surfactant via a thin catheter, avoids mechanical ventilation. LISA has been widely adopted in Europe but less so in the US. Our goal was to increase the percentage of surfactant delivered via LISA from 0% to 51% by 12/2020. Project planning and literature review started 12/2019, and included a standardized equipment kit and simulation training sessions. We began Plan-Do-Study-Act (PDSA) cycles in 6/2020. Initial exclusions for LISA were gestational age (GA) <28 weeks (w) or ≥36 w, intubation in the delivery room, or PCO2 >70 if known; GA exclusion is now <25 w. From 6 to 12/2020, 97 patients received surfactant, 35 (36%) via LISA. When non-LISA-eligible patients were excluded, 35/42 (83%) received LISA successfully. There were only 2/37 patients for whom LISA was not able to be performed. Three LISA infants required mechanical ventilation in the first week of life. Sedation remained an initial challenge but improved when sucrose was used routinely. LISA was safely and successfully introduced in our NICU.

Decreasing Time from Decision to Intubation in Premedicated Neonates: A Quality Improvement Initiative.

Endotracheal intubation carries the risk of discomfort, decompensation, oral trauma, and endotracheal tube malposition. Treatment with premedications reduces complications, increases overall intubation safety, improves pain control, and improves first-pass success. However, time is frequently a barrier to administration. We aimed to decrease the decision-to-intubation time interval from a baseline of 40 minutes to less than 35 minutes over 6 months. METHODS: We used the Model for Improvement with multiple plan-do-study-act cycles to reduce the time from decision to successful intubation in nonemergent neonatal intubations. Key drivers were timely administration of medications, availability of skilled personnel and equipment, and efficient use of time. RESULTS: During this project, time from the decision to successful intubation decreased from a historical mean of 40 minutes to a new baseline of 27 minutes. This change represents a 33% decrease, with 80% of intubations occurring within 35 minutes. During this time, success rates remained stable, and medication errors and side effects did not increase. CONCLUSIONS: Standard processes to prepare and administer premedications decreased the time from decision to intubation without significant adverse effects, allowing the benefit of premedication administration in a safe and timely manner in nonemergent neonatal intubations.