Cerebral and peripheral tissue oxygenation in stable neonates: Absent influence of cardiac function.

AIM: Cardiac function is a major factor for tissue perfusion and therefore may affect the tissue oxygen saturation. Aim was to analyse possible associations between cardiac function parameters and cerebral and peripheral tissue oxygenation in neonates on the first day after birth. METHODS: For the present study, we analysed secondary outcome parameters of a previously performed prospective single centre observational study. The prospective study was conducted at the Medical University of Graz, Austria between September 2011 and June 2013. We included preterm and term neonates who were admitted to the neonatal intensive care unit and in whom simultaneous near-infrared spectroscopy measurements and echocardiography were obtained on the first day after birth. Cardiac function parameters were correlated to cerebral and peripheral tissue oxygen saturation and cerebral and peripheral fractional tissue oxygen extraction at the time of echocardiography. RESULTS: A total of 60 neonates of whom 47 were preterm and 13 were term (median gestational age: 34; IQR 33-35 weeks, mean birth weight: 2276 ± 774 grams) were included. There were no statistically significant correlations between cardiac function parameters and regional tissue oxygenation parameters. CONCLUSION: In the present study, we found no correlation between regional tissue oxygenation and parameters of cardiac function in cardio-circulatory stable neonates on the first day after birth.

Sustained decrease in latent safety threats through regular interprofessional in situ simulation training of neonatal emergencies.

Simulation training at trainees' actual workplace offers benefits over traditional simulation-based team training. We prospectively investigated whether regular in situ simulation training of neonatal emergencies in an interprofessional and interdisciplinary team could be used to identify and rectify latent safety threats (LSTs).For this purpose, we conducted 1-day in situ simulation trainings at the Department of Gynaecology and Obstetrics, Feldbach, Austria, targeting anaesthesiologists, obstetricians, midwives, nurses and consultant paediatricians. Using published criteria for categorising LSTs, we collected LSTs, either recognised by trainers or training participants, categorised them qualitatively (medication, equipment, resource/system) and based on their potential for harm, discussed them with training participants, and reported them to hospital leadership.We conducted 13 trainings between June 2015 and April 2023, identifying 67 LSTs, most in the category of equipment (42/67, 62.7%), followed by resource/system (14/67, 20.9%) and medication (11/67, 16.4%). Sixty-one (91.0%) of the LSTs could be rectified by the next training. We observed a significant negative correlation between the number of delivered trainings and the frequency of identified LSTs (Pearson correlation coefficient r= -0,684, p=0.01).While we identified a higher number of LSTs in comparison to previously published studies, regular in situ simulation training of neonatal emergencies over a period of almost 8 years positively impacted patient safety, as the majority of LSTs was rectified by the next training. Even more important, the decrease in LSTs with the increasing number of delivered in situ simulation trainings underlines the sustained effect of this educational intervention.

Impact of Carbon Dioxide on Cerebral Oxygenation and Vital Parameters in Stable Preterm and Term Infants Immediately after Birth.

INTRODUCTION: Carbon dioxide (pCO2) induces changes in the tone of cerebral vessels. The aim of the present study was to evaluate the impact of pCO2 on cerebral regional tissue oxygen saturation (crSO2), cerebral fractional tissue oxygen extraction (cFTOE), and cerebral tissue oxygen extraction (cTOE), measured with near-infrared spectroscopy (NIRS), in preterm and term infants 15 min after birth. METHODS: Post hoc analyses of secondary outcome parameters of prospective observational studies were performed. Stable preterm and term infants with cerebral NIRS monitoring (INVOS 5100C) until minute 15 after birth and a blood gas analysis, performed between minutes 14-18 after birth, were included. Heart rate (HR) and arterial oxygen saturation (SpO2) were recorded. pCO2 was correlated with crSO2, cFTOE, cTOE, SpO2, HR, and partial pressure of oxygen (pO2). RESULTS: Eleven preterm infants with a median (IQR) gestational age of 34.8 (32.7-36.1) weeks were analyzed. Mean ± SD pCO2 was 53.5 ± 4.2 mm Hg. At minute 15 after birth, crSO2 was 82.6 (74.3-91.3)%, cFTOE 0.15 ± 0.09, cTOE 14.6 ± 8.4%, SpO2 97.4 ± 2.1%, and HR 152 (136-167) bpm. pCO2 correlated negatively with crSO2 (p = 0.012) and positively with cFTOE (p = 0.035) and cTOE (p = 0.037). Eighty-four term infants with a gestational age of 39.0 (38.5-38.9) weeks were analyzed. pCO2 was 53.5 ± 6.3 mm Hg. At minute 15 after birth, crSO2 was 84.4 (80.8-85.1)%, cFTOE 0.14 ± 0.08, cTOE 13.6 ± 7.9%, SpO2 96.5 ± 2.6%, and HR 155 (153-163) bpm. pCO2 did only negatively correlate with pO2 (p = 0.034) in term infants. CONCLUSION: In preterm infants, higher pCO2 was associated with lower crSO2 and higher cFTOE/cTOE. In term infants, no associations were observed. The present findings suggest that the vasodilatative effect of pCO2 is less pronounced in preterm infants during immediate postnatal transition.

Does physiological-based cord clamping improve cerebral tissue oxygenation and perfusion in healthy term neonates? - A randomized controlled trial.

Objectives: To evaluate cerebral tissue oxygenation index (cTOI) during neonatal transition in a group of healthy full-term neonates receiving either a physiological-based approach of deferred cord clamping (CC) after the onset of stable regular breathing (PBCC group) or a standard approach of time-based CC < 1 min (control group). Secondary aim was to evaluate changes in cerebral blood volume (ΔCBV), peripheral arterial oxygen saturation (SpO2) and heart rate (HR) in those neonates. Materials and Methods: We conducted a randomized controlled trial (clinicaltrials.gov: NCT02763436) including vaginally delivered healthy full-term neonates. Continuous measurements of cTOI and ΔCBV using near-infrared spectroscopy, and of SpO2 and HR using pulse oximetry were performed within the first 15 min after birth. Data of each minute of the PBCC group were compared to those of the control group. Results: A total of 71 full-term neonates (PBCC: n = 35, control: n = 36) with a mean (SD) gestational age of 40.0 (1.0) weeks and a birth weight of 3,479 (424) grams were included. Median (IQR) time of CC was 275 (197-345) seconds and 58 (35-86) seconds in the PBCC and control group, respectively (p < 0.001). There were no significant differences between the two groups regarding cTOI (p = 0.319), ΔCBV (p = 0.814), SpO2 (p = 0.322) and HR (p = 0.878) during the first 15 min after birth. Conclusion: There were no significant differences in the course of cTOI as well as ΔCBV, SpO2 and HR during the first 15 min after birth in a group of healthy full-term neonates, who received either deferred CC after the onset of stable regular breathing or standard CC < 1 min. Thus, deferring CC ≥ 1 min following a physiological-based approach offers no benefits regarding cerebral tissue oxygenation and perfusion after uncomplicated vaginal delivery compared to a time-based CC approach.

Increased Risk for Cerebral Hypoxia During Immediate Neonatal Transition After Birth in Term Neonates Delivered by Caesarean Section With Prenatal Tobacco Exposure.

Introduction: Maternal tobacco smoking during pregnancy is a global health problem leading to an increased risk for fetal and neonatal morbidities. So far, there are no data of the potential impact of maternal smoking during pregnancy on the most vulnerable period after birth - the immediate postnatal transition. The aim of the present study was therefore, to compare cerebral oxygenation during immediate postnatal transition in term neonates with and without prenatal tobacco exposure. Methods: Included in this post-hoc analysis were healthy term neonates, with measurements of cerebral oxygenation (INVOS 5100C) during the first 15 min after birth, and for whom information on maternal smoking behavior during pregnancy was available. Neonates with prenatal tobacco exposure (smoking group) were matched 1:1 according to gestational age (±1 week), birth weight (±100 grams) and hematocrit (±5 %) to neonates without (non-smoking group). Cerebral regional tissue oxygen saturation (crSO2), cerebral fractional tissue oxygen extraction (cFTOE), arterial oxygen saturation (SpO2) and heart rate (HR) within the first 15 min after birth were compared between the two groups. Results: Twelve neonates in the smoking group with a median (IQR) gestational age of 39.1 (38.8-39.3) weeks and a birth weight of 3,155 (2,970-3,472) grams were compared to 12 neonates in the non-smoking group with 39.1 (38.7-39.2) weeks and 3,134 (2,963-3,465) grams. In the smoking group, crSO2 was significantly lower and cFTOE significantly higher until min 5 after birth. HR was significantly higher in the smoking group in min 3 after birth. Beyond this period, there were no significant differences between the two groups. Conclusion: Cerebral oxygenation within the first 5 min after birth was compromised in neonates with prenatal tobacco exposure. This observation suggests a higher risk for cerebral hypoxia immediately after birth due to fetal tobacco exposure.

Successful Postnatal Cardiopulmonary Resuscitation Due to Defibrillation.

An asphyxiated term neonate required postnatal resuscitation. After six minutes of cardio-pulmonary resuscitation (CPR) and two doses of epinephrine, spontaneous circulation returned, but was shortly followed by ventricular fibrillation. CPR and administration of magnesium, calcium gluconate, and sodium bicarbonate did not improve the neonate's condition. A counter shock of five Joule was delivered and the cardiac rhythm immediately converted to sinus rhythm. The neonate was transferred to the neonatal intensive care unit and received post-resuscitation care. Due to prolonged QTc and subsequently suspected long-QT syndrome propranolol treatment was initiated. The neonate was discharged home on day 14 without neurological sequelae.

Fetal Inflammatory Response Syndrome and Cerebral Oxygenation During Immediate Postnatal Transition in Preterm Neonates.

Introduction: Fetal inflammatory response syndrome (FIRS), defined as elevated umbilical cord blood interleukin-6 (IL-6) values > 11 pg/ml, is associated with an increased risk of neonatal morbidity and mortality. The primary aim of the present study was to evaluate a potential influence of FIRS on cerebral oxygen saturation (crSO2) and fractional tissue oxygen extraction (cFTOE) during immediate postnatal transition in preterm neonates. The secondary aim was to analyze the potential influence of FIRS on cerebral injury and mortality. Methods: Secondary outcome parameters of prospective observational studies were analyzed. Preterm neonates with measured IL-6 values from umbilical cord blood and cerebral near-infrared spectroscopy (NIRS) measurements during immediate transition after birth were included. Preterm neonates with FIRS (FIRS group) were matched 1:1 for gestational age (± 1 week) to preterm neonates without FIRS (non-FIRS group). crSO2, cFTOE, arterial oxygen saturation (SpO2), heart rate (HR), and fraction of inspired oxygen (FiO2) were compared between both groups. In addition, cerebral injury and mortality were compared between both groups. Results: A total of 46 preterm neonates were included. Twenty-three neonates in the FIRS group [median gestational age 32.1 (IQR 30.3-33.0) weeks; median IL-6 19.7 (IQR 12.2-37.0) pg/ml] were compared to 23 neonates in the non-FIRS group [gestational age: 32.0 (30.4-33.1) weeks; IL-6: 5.4 (3.0-6.7) pg/ml]. cFTOE showed significantly lower values within the first 4 min and a trend toward lower values in minute 5 after birth in the FIRS group. There were no significant differences in crSO2 within the first 15 min after birth between the two groups. SpO2 was significantly lower in minutes 5 and 6 and HR was significantly lower in minutes 2 and 4 after birth in the FIRS group compared to the non-FIRS group. Survival without cerebral injury was similar in both groups. Conclusion: In preterm neonates with FIRS the crSO2 was similar despite significantly lower cFTOE values during the first minutes after birth. This observation may be a result of compromised oxygen consumption and delivery in the first minutes after birth in neonates with FIRS.

Medical students and research: Is there a current discrepancy between education and demands?

This article refers to a correspondence letter recently published in The Lancet, describing successful student-led research initiatives in Latin America, which were introduced because of low support from universities and governments. As a final-year medical student with keen interest in science, the topic of student engagement in research activities caught my interest. Literature shows that while junior doctors are required to perform research on their own and face intense pressure to publish, formal training in principles of research and scientific writing is often neglected by medical schools. This contrast is worrying, as the progression of the medical profession and the quality of patient care depend on high-quality research and on future generations of physician-scientists being both enthusiastic and competent. Hence, this article summarizes suggestions to increase both students' research proficiency and participation in scientific activities, and offers a critical view on this important topic, as medical schools without curricular research education and without active student integration should urgently consider revising their policies.

Are medical schools hesitant to teach undergraduate students teaching skills? A medical student's critical view.

Junior medical staff provides a large proportion of undergraduate student education. However, despite increasing numbers of resident-as-teacher training programs, junior doctors may still not be sufficiently prepared to teach medical students. Hence, medical schools should consider implementing formal teaching skills training into undergraduate curricula.