Does videolaryngoscopy improve tracheal intubation first attempt success in the NICUs? A report from the NEAR4NEOS.

OBJECTIVE: We hypothesized that videolaryngoscope use for tracheal intubations would differ across NICUs, be associated with higher first attempt success and lower adverse events. STUDY DESIGN: Data from the National Emergency Airway Registry for Neonates (01/2015 to 12/2017) included intubation with direct laryngoscope or videolaryngoscope. Primary outcome was first attempt success. Secondary outcomes were adverse tracheal intubation associated events and severe desaturation. RESULTS: Of 2730 encounters (13 NICUs), 626 (23%) utilized a videolaryngoscope (3% to 64% per site). Videolaryngoscope use was associated with higher first attempt success (p < 0.001), lower adverse tracheal intubation associated events (p < 0.001), but no difference in severe desaturation. After adjustment, videolaryngoscope use was not associated with higher first attempt success (OR:1.18, p = 0.136), but was associated with lower tracheal intubation associated events (OR:0.45, p < 0.001). CONCLUSION: Videolaryngoscope use is variable, not independently associated with higher first attempt success but associated with fewer tracheal intubation associated events.

Resuscitation 2020: Proceedings From the NeoHeart 2020 International Conference.

Resuscitation guidelines are developed and revised by medical societies throughout the world. These guidelines are increasingly based on evidence from preclinical and clinical research. The International Liaison Committee on Resuscitation reviews evidence for each resuscitation practice and provides summary consensus statements that inform resuscitation guideline committees. A similar process is used for different populations including neonatal, pediatric, and adult resuscitation. The NeoHeart 2020 Conference brought together experts in resuscitation to discuss recent evidence and guidelines for resuscitation practices. This review summarizes the main focus of discussion from this symposium.

Team Stress and Adverse Events during Neonatal Tracheal Intubations: A Report from NEAR4NEOS.

OBJECTIVE: This study aimed to examine the association between team stress level and adverse tracheal intubation (TI)-associated events during neonatal intubations. STUDY DESIGN: TIs from 10 academic neonatal intensive care units were analyzed. Team stress level was rated immediately after TI using a 7-point Likert scale (1 = high stress). Associations among team stress, adverse TI-associated events, and TI characteristics were evaluated. RESULT: In this study, 208 of 2,009 TIs (10%) had high stress levels (score < 4). Oxygenation failure, hemodynamic instability, and family presence were associated with high stress level. Video laryngoscopy and premedication were associated with lower stress levels. High stress level TIs were associated with adverse TI-associated event rates (31 vs. 16%, p < 0.001), which remained significant after adjusting for potential confounders including patient, provider, and practice factors associated with high stress (odds ratio: 1.90, 96% confidence interval: 1.36-2.67, p < 0.001). CONCLUSION: High team stress levels during TI were more frequently reported among TIs with adverse events.

Therapeutic Plasma Exchange in Neonatal Septic Shock: A Retrospective Cohort Study.

OBJECTIVE: This study aimed to examine the use of therapeutic plasma exchange (TPE) as adjunctive therapy in neonatal septic shock. STUDY DESIGN: This retrospective cohort study was performed on a convenience sample of neonates in a quaternary children's hospital between January 2018 and February 2019. RESULTS: We identified three neonates with septic shock who received TPE. Two neonates had adenovirus sepsis, and one had group B streptococcal sepsis. All neonates were on extracorporeal life support (ECLS) when TPE was started. The median duration of TPE was 6 days (interquartile range [IQR]: 3-15), with a median of four cycles (IQR: 3-5). Lactate levels decreased significantly after TPE (median before TPE: 5.4 mmol/L [IQR: 2.4-6.1] vs. median after TPE: 1.2 mmol/L [IQR: 1.0-5.8]; p < 0.001). Platelet levels did not change (median before TPE: 73,000/mm3 [IQR: 49,000-100,000] vs. median after TPE: 80,000/mm3 (IQR: 62,000-108,000); p = 0.2). Organ failure indices improved after TPE in two of the three neonates. Hypocalcemia was seen in all cases despite prophylactic calcium infusions. One neonate died, and two survived to ICU discharge. CONCLUSION: TPE can be safely performed in neonates with septic shock. TPE may have a role as an adjunctive therapy in neonates with septic shock requiring ECLS.

Expanding phenotype with severe midline brain anomalies and missense variant supports a causal role for FOXA2 in 20p11.2 deletion syndrome.

Rare individuals with 20p11.2 proximal deletions have been previously reported, with a variable phenotype that includes heterotaxy, biliary atresia, midline brain defects associated with panhypopituitarism, intellectual disability, scoliosis, and seizures. Deletions have ranged in size from 277 kb to 11.96 Mb. We describe a newborn with a de novo 2.7 Mb deletion of 20p11.22p11.21 that partially overlaps previously reported deletions and encompasses FOXA2. Her clinical findings further expand the 20p11.2 deletion phenotype to include severe midline cranial and intracranial defects such as aqueductal stenosis with hydrocephalus, mesencephalosynapsis with diencephalic-mesencephalic junction dysplasia, and pyriform aperture stenosis. We also report one individual with a missense variant in FOXA2 who had abnormal glucose homeostasis, panhypopituitarism, and endodermal organ dysfunction. Together, these findings support the critical role of FOXA2 in panhypopituitarism and midline defects.

Neonatal Intubation Competency Assessment Tool: Development and Validation.

BACKGROUND: Neonatal tracheal intubation (NTI) is an important clinical skill. Suboptimal performance is associated with patient harm. Simulation training can improve NTI performance. Improving performance requires an objective assessment of competency. Competency assessment tools need strong evidence of validity. We hypothesized that an NTI competency assessment tool with multisource validity evidence could be developed and be used for formative and summative assessment during simulation-based training. METHODS: An NTI assessment tool was developed based on a literature review. The tool was refined through 2 rounds of a modified Delphi process involving 12 subject-matter experts. The final tool included a 22-item checklist, a global skills assessment, and an entrustable professional activity (EPA) level. The validity of the checklist was assessed by having 4 blinded reviewers score 23 videos of health care providers intubating a neonatal simulator. RESULTS: The checklist items had good internal consistency (overall α = 0.79). Checklist scores were greater for providers at greater training levels and with more NTI experience. Checklist scores correlated with global skills assessment (ρ = 0.85; P < .05), EPA levels (ρ = 0.87; P < .05), percent glottic exposure (r = 0.59; P < .05), and Cormack-Lehane scores (ρ = 0.95; P < .05). Checklist scores reliably predicted EPA levels. CONCLUSIONS: We developed an NTI competency assessment tool with multisource validity evidence. The tool was able to discriminate NTI performance based on experience. The tool can be used during simulation-based NTI training to provide formative and summative assessment and can aid with entrustment decisions.

Generalized arterial calcification of infancy associated with meconium peritonitis: a case report and review of the literature.

Generalized arterial calcification of infancy (GACI) is a rare genetic disorder consisting of diffuse arterial calcification and intimal proliferation. The disease typically results in progressive arterial stenosis and frequently leads to death from myocardial ischemia by 6 months of life. Affected infants are usually diagnosed before birth or in the neonatal period with symptoms of congestive heart failure. Therapy with bisphosphonate has been used to treat the condition, but with inconsistent results. The disease is associated with mutations in ENPP1 in the majority of the cases. Here we report a unique case of GACI associated with in utero meconium peritonitis and without coding region mutations of the ENPP1 gene. GACI should be considered in the differential diagnosis in infants presenting with arterial calcifications and congenital anomalies of the gastrointestinal tract.