A tiny baby intubation team improves endotracheal intubation success rate but decreases residents' training opportunities.

OBJECTIVE: To assess the educational and clinical impact of a tiny baby intubation team (TBIT). STUDY DESIGN: Retrospective study comparing endotracheal intubation (ETI) performed: pre-implementation of a TBIT (T1), 6 months post-implementation (T2), and 4 years post-implementation (T3). RESULTS: Post-implementation (T2), first-attempt success rate in tiny babies increased (44% T1; 59% T2, p = 0.04; 56% T3, p = NS) and the proportion of ETIs performed by residents decreased (53% T1; 37% T2, p = 0.001; 45% T3, p = NS). After an educational quality improvement intervention (prioritizing non-tiny baby ETIs to residents, systematic simulation training and ETI using videolaryngoscopy), in T3 residents' overall (67% T1; 60% T2, p = NS; 79% T3, p = 0.02) and non-tiny baby ETI success rate improved (72% T1; 60% T2, p = NS; 82% T3, p = 0.02). CONCLUSION: A TBIT improves success rate of ETIs in ELBW infants but decreases educational exposure of residents. Educational strategies may help maintain resident procedural competency without impacting on quality of care.

[Speaking about life and death in neonatology: How can communication with families be optimized?] / Parler de la vie et de la mort en néonatologie : comment optimiser la communication avec les parents ?

Technological progress and improved clinical knowledge have increased survival of neonates who would previously have died. Survival is sometimes accompanied by a risk of short- or long-term adverse outcomes, which may lead to complex decisions about withholding or withdrawing life-sustaining interventions. These decisions are among the most difficult decisions in pediatric practice. They also involve communicating with parents and are emotionally charged. Many articles examining end-of-life decisions in neonatology state the need for healthcare providers to be caring, compassionate, and human without offering clear, practical advice. In this article, the way in which neonates die and the ethical decision-making surrounding these decisions will be reviewed. Guidelines to reflect on the life trajectories of neonates will be offered, as well as recommendations to optimize communication with families during these difficult moments.

[Infusion of vasoactive drugs at low flow rate: effects of the syringe switch and syringe volume (experimental study)]. / Perfusion des médicaments vasoactifs à très faible débit : influence des modalités du relais et du volume des seringues (étude expérimentale).

OBJECTIVE: The flow rate of intravenous administration of vasoactive agents should be steady in order to prevent changes in hemodynamics. In the newborns, because the flow rate is often lower than 1mL/h, it is difficult to switch of the syringe. The aim of our study was to compare the variations of concentration of active substance delivered after a manual or an automatic switch off the syringe with three different volumes (10mL, 20mL and 50mL). MATERIALS AND METHODS: Glucose solution (10g/L) was used to simulate the administered substance. Saline was administered in "Y" simultaneously with the glucose solution through a catheter. The infused substance was collected at the tip of the catheter. The glucose concentration was measured at 15min-interval for 3hours. RESULTS: The manual switch of the syringe was associated with a significant alteration of the flow rate, lasting more than 15min. In contrast, the automatic switch of syringes was associated with no change of the flow rate, especially with small-volume syringes (10mL). CONCLUSION: In newborns, in order to prevent the change in flow rate of drugs after a switch of syringes, our results suggest the use of syringe-pump with built-in automatic switch and small-volume syringes.

[The long-term follow-up of patients with a congenital diaphragmatic hernia: review of the literature]. / Hernie de coupole diaphragmatique: devenir à long terme.

The increased survival rate reached in infants with congenital diaphragmatic hernia (CDH) has shown a concomitant increase in late morbidity. Many complications including pulmonary damage, cardiovascular disease, gastro-intestinal disease, failure to thrive, neurocognitive defects and musculoskeletal abnormalities have been described. Long-term pulmonary morbidity in CDH consists of obstructive and restrictive lung function impairments due to altered lung structure and prolonged ventilatory support. Long-term consequences of pulmonary hypertension are unknown. Gastro-esophageal reflux disease (GERD) is also an important contributor to overall morbidity. Failure to thrive may be caused by GERD, insufficient intake due to oral aversion and increased caloric requirements due to pulmonary morbidity. Neurological outcome is determined by an increased risk of perinatal and neonatal hypoxemia in the first days of life of CDH patients. Many studies have addressed the substantial impact of the health problems described above, on the overall well-being of CDH patients, but only a few studies focus on the health-related quality of life. Considering the scattered data indicating substantial morbidity in long-term survivors of CDH, follow-up studies that systematically assess long-term sequelae are needed. Based on such studies, a more focused approach for routine multidisciplinary follow-up programs could be established. It is the goal of the French Collaborative Network to promote exchange of knowledge, future research and development of treatment protocols.

[Congenital diaphragmatic hernia: respiratory and vascular outcomes]. / Hernie de coupole diaphragmatique : devenir respiratoire et vasculaire pulmonaire.

Congenital diaphragmatic hernia (CDH) is a life-threatening anomaly associated with a variable degree of pulmonary hypoplasia (PH) and persistent pulmonary hypertension (PPH). Despite remarkable advances in neonatal resuscitation and intensive care, and new postnatal treatment strategies, the rates of mortality and morbidity in the newborn with CDH remain high as the result of severe respiratory failure secondary to PH and PPH. Later, lung function assessments show obstructive and restrictive impairments due to altered lung structure and lung damage due to prolonged ventilatory support. The long-term consequences of pulmonary hypertension are unknown. Other problems include chronic pulmonary aspiration caused by gastro-oesophageal reflux and respiratory manifestations of allergy such as asthma or rhinitis. Finally, failure to thrive may be caused by increased caloric requirements due to pulmonary morbidity. Follow-up studies that systematically assess long-term sequelae are needed. Based on such studies, a more focused approach for routine multidisciplinary follow-up programs could be established. It is the goal of the French Collaborative Network to promote exchange of knowledge, future research and development of treatment protocols.

[Increased success rate in umbilical venous catheter positioning by posterior liver mobilization]. / Intérêt du refoulement hépatique pour repositionner un cathéter veineux ombilical « sous-hépatique ¼ dans la veine cave inférieure.

OBJECTIVE: To evaluate prospectively the benefit of posterior liver mobilization during umbilical venous catheterization to place the umbilical venous catheter (UVC) in the central position (inferior vena cava). PATIENTS AND METHODS: Sixty-five successive newborn infants admitted in 3 neonatal intensive care units who required a UVC were enrolled over a 4-month period. UVC positions were assessed by X-ray. UVCs were placed either in an adequate position (at the right atrial-inferior vena cava junction, indicating success) or inserted within the portal system (failure). In this case, the UVC was drawn back to the 3cm mark and then, an additional attempt to insert the UVC was made during lateroposterior liver mobilization by the operator's hand. The success and failure rates at 1st and 2nd attempts were evaluated and compared. Characteristics of the population and possible catheter-related complications were recorded. RESULTS: A total of 31 of 65 (55%) UVC insertions failed at the 1st attempt. Among these UVCs, 16 (52%) were correctly repositioned in the central position by hepatic mobilization. The success rate increased by 50% (p<0.05). No life-threatening complications were observed during the procedure. CONCLUSION: Hand liver mobilization during umbilical venous catheterization improves the rate of adequate insertion of the UVC into the inferior vena cava. It is a simple, quick, and safe procedure.

[Per and post-natal medical management of congenital diaphragmatic hernia]. / Prise en charge médicale per et post-natale de la hernie congénitale du diaphragme.

Congenital diaphragmatic hernia (CDH) is a 1 out of 3500 live-born malformation with persistent 30-40% mortality rate, related to severe pulmonary hypoplasia and hypertension. Better knowledge on the mechanisms inducing failure of adaptation at birth is a prerequisite for improving CDH prognosis. CDH is also associated with longterm morbidity, including prolonged respiratory failure, failure to growth, oral aversion, and scoliosis. Early prevention starting as soon as the first hours of life are required to reduced long term morbidity. The aims of the management are not only to reduce early mortality, related to persistent pulmonary hypertension, but also to prevent late morbidity.

[Management of severe respiratory failure in the newborn: indication of inhaled NO]. / Prise en charge de la détresse respiratoire sévère du nouveau-né: place du NO inhalé.

Severe respiratory failure results from large right to left shunting. In the newborn, both intrapulmonary and/or extrapulmonary shunting may cause severe respiratory failure. Right to left extrapulmonary shunting is associated with pulmonary hypertension (PPHN). Management depends on the main mechanism of the respiratory failure. Intrapulmonary shunting requires optimizing lung recrutment, whereas vascular recrutment is required to decrease extra-pulmonary shunting. Analysis of anamnesis, clinical examination, chest X-ray, and echocardiography allows distinguishing the mechanism of the respiratory failure. In case of PPHN, favorizing factors such as acidosis, stress, lung over distension, and polyglobuly should be treated. Inhaled NO is recommended in the treatment of PPHN after optimizing lung volume.