Adverse events associated with umbilical vascular catheters in the neonatal intensive care unit: A retrospective cohort study.

BACKGROUND: Umbilical catheters are commonly inserted in newborns in the neonatal intensive care unit (NICU) yet are associated with serious adverse events (AEs) such as malposition, migration, infection, thrombosis, hepatic complications, cardiac effusion, and cardiac tamponade. There is a need to determine the incidence and risk factors for AEs to inform safe practice. OBJECTIVES: The objective of this study was to determine the incidence and risk factors for AEs (all-cause and individual types) associated with umbilical venous catheters (UVCs) and umbilical arterial catheters (UACs) in the NICU. METHODS: A retrospective cohort study was conducted in an Australian level-VI NICU over a 3-year period. Any newborn who had both a UVC and UAC insertion attempt was included. RESULTS: There were 236 neonates who had 494 catheters (245 UVCs and 249 UACs). Of these, 71% of UVCs (95% confidence interval [CI]: 65.6-76.9%; incidence rate: 181.1-237.3 per 1000 catheter days) and 43.8% of UACs (95% CI: 38-50.5%; incidence rate: 102.0-146.3 per 1000 catheter days) were associated with an AE. The most common AE was malposition on first X-ray for UVCs (60.1%, 95% CI: 55.1-67.3) and UACs (32.6%, 95% CI: 26.8-39.6). A dwell time of ≥7 days was a significant predictor of UAC failure (incidence risk ratio: 1.5, 95% CI: 1.1-2.1, p = 0.006) and migration of the UVC (incidence risk ratio: 3.5, 95% CI: 1.0-11.5, p = 0.043). CONCLUSION: Adverse events related to insertion occurred in a relatively high percentage of umbilical catheters placed. Increased dwell time remains a significant risk factor for catheter migration and overall failure. Practice change and consideration of risk factors for both individual and overall AE risk are necessary to reduce complications.

Experience of sudden sensorineural hearing loss following a mild COVID-19 infection.

A woman in her 30s was referred to an otolaryngologist with an acute onset of aural fullness, noise sensitivity, unilateral sudden onset hearing loss, vertigo and tinnitus. She had a confirmed COVID-19 infection 5 weeks prior. A pure tone audiogram confirmed sensorineural hearing loss. MRI identified an empty sella of the pituitary gland and without an obvious cause for hearing loss. Oral prednisolone and betahistine were prescribed, and her audiovestibular symptoms slowly improved over the subsequent months. The patient continues to experience intermittent tinnitus.

Developmental pharmacokinetics of indomethacin in preterm neonates: Severely decreased drug clearance in the first week of life.

Indomethacin is used commonly in preterm neonates for the prevention of intracranial hemorrhage and closure of an abnormally open cardiac vessel. Due to biomedical advances, the infants who receive this drug in the neonatal intensive care unit setting have become younger, smaller, and less mature (more preterm) at the time of treatment. To develop a pharmacokinetics (PK) model to aid future dosing, we designed a prospective cohort study to characterize indomethacin PK in a dynamically changing patient population. A population PK base model was created using NONMEM, and a covariate model was developed in a primary development cohort and subsequently was tested for accuracy in a validation cohort. Postnatal age was a significant covariate for hepatic clearance (CLH ) and renal clearance (CLR ). The typical value of the total clearance (CL, the sum of CLR and CLH ) was 3.09 ml/h and expressed as CL/WTmedian  = 3.96 ml/h/kg, where WTmedian is the median body weight. The intersubject variability of CLR and CLH were 61% and 207%, respectively. The typical value of the volume of distribution Vp  = 366 ml (Vp /WTmedian  = 470 ml/kg), and its intersubject variability was 38.8%. Half-life was 82.1 h. Compared with more mature and older preterm populations studied previously, indomethacin CL is considerably lower in this contemporary population. Model-informed precision dosing incorporating important covariates other than weight alone offers an opportunity to individualize dosing in a susceptible patient undergoing rapid change.

Simultaneous quantification of trimethoprim metabolites in pediatric plasma.

The dual agent antibiotic, trimethoprim/sulfamethoxazole (TMP-SMX), has been prescribed to treat or prevent infections for over 50 years. However, there are no published validated analytical methods for the measurement of TMP metabolites in humans. We developed methodology enabling reliable quantification of TMP and 5 metabolites in human plasma. Chromatographic separation was achieved in less than 8 min using a biphenyl column. Analytes were detected in positive electrospray mode using a tandem Waters Xevo-TQ-XS mass spectrometer. Precision and accuracy values for all analytes were within 15% of nominal values during assay validation.

Risk factors for umbilical vascular catheter-related adverse events: A scoping review.

INTRODUCTION: Adverse events associated with umbilical catheters include malposition, bloodstream infections, thrombosis, tip migration, and extravasation, resulting in loss of vascular access and increased risk of morbidity and mortality. There is a need for greater understanding of risk factors associated with adverse events to inform safe practice. OBJECTIVES: The aim of the study was to summarise the existing evidence regarding risk factors for umbilical catheter-related adverse events to inform the undertaking of future research. REVIEW METHOD USED: A scoping review of peer-reviewed original research and theses was performed. DATA SOURCES: The US National Library of Medicine National Institutes of Health, Embase, EMcare, and ProQuest Dissertations and Theses were the data sources. REVIEW METHODS: Informed by the Joanna Briggs Institute Reviewer's Manual, all types of original research studies reporting adverse events published in English from 2009 to 2020 were eligible for inclusion. Studies where umbilical artery catheter and umbilical venous catheter data could not be extracted separately were excluded. RESULTS: Searching identified 1954 publications and theses, 1533 were excluded at screening, and 418 were assessed for eligibility at full text. A total of 89 studies met the inclusion criteria. A range of potential risk factors for umbilical arterial and venous catheters were identified. Longer dwell time and prematurity were associated with increased risk of bloodstream infection and thrombosis in cohort studies. Case studies detailed analogous factors such as insertion techniques and lack of catheter surveillance during dwell warrant further investigation. CONCLUSIONS: We identified a vast range of patient, device, and provider risk factors that warrant further investigation. There was a lack of large cohort studies and randomised controlled trials to demonstrate the significance of these risk factors. Improvement in methods to ensure correct catheter tip location and to detect adverse events early is essential. In addition, policy needs to be developed to guide clinicians in catheter surveillance measures to reduce the risk of adverse events.

Non-Contact Automatic Vital Signs Monitoring of Infants in a Neonatal Intensive Care Unit Based on Neural Networks.

Infants with fragile skin are patients who would benefit from non-contact vital sign monitoring due to the avoidance of potentially harmful adhesive electrodes and cables. Non-contact vital signs monitoring has been studied in clinical settings in recent decades. However, studies on infants in the Neonatal Intensive Care Unit (NICU) are still limited. Therefore, we conducted a single-center study to remotely monitor the heart rate (HR) and respiratory rate (RR) of seven infants in NICU using a digital camera. The region of interest (ROI) was automatically selected using a convolutional neural network and signal decomposition was used to minimize the noise artefacts. The experimental results have been validated with the reference data obtained from an ECG monitor. They showed a strong correlation using the Pearson correlation coefficients (PCC) of 0.9864 and 0.9453 for HR and RR, respectively, and a lower error rate with RMSE 2.23 beats/min and 2.69 breaths/min between measured data and reference data. A Bland-Altman analysis of the data also presented a close correlation between measured data and reference data for both HR and RR. Therefore, this technique may be applicable in clinical environments as an economical, non-contact, and easily deployable monitoring system, and it also represents a potential application in home health monitoring.

Adverse events associated with umbilical catheters: a systematic review and meta-analysis.

OBJECTIVE: To determine the incidence of adverse events (AEs) associated with umbilical catheters in the neonatal population. STUDY DESIGN: Systematic review and meta-analysis of observational studies and randomized controlled trials published between 2010 and 2020. RESULTS: In total 14,226 umbilical venous catheters (UVCs) and 4228 umbilical arterial catheters (UACs) were included. Overall, 13.4% of UVCs were associated with an AE (95% CI: 10.1-17.0) or 2.4 per 1000 catheter days (95% CI: 1.8-3.0). UACs had an AE rate of 9% (95% CI: 5.9-12.8) or 0.87 per 1000 catheter days (95% CI: 0.4-1.3). UVC malposition was the most common (41.7% [95% CI: 27.6-56.5]). Local injury from UAC taping was the most common AE in one study. CONCLUSIONS: Umbilical catheters have a high incidence of AEs. Research into accurate methods of tip verification, tip surveillance, and securement is required.

Nurse-initiated protocols in the emergency department management of pediatric oncology patients with fever and suspected neutropenia: a scoping review protocol.

OBJECTIVE: The objective of this review is to provide an overview of the existing evidence regarding nurse-initiated protocols in the emergency department management of pediatric oncology patients with fever and suspected neutropenia. INTRODUCTION: Febrile neutropenia in pediatric oncology patients poses a significant burden of increased morbidity and mortality. Prompt, efficient emergency care and rapid antibiotic administration within 60 minutes of presentation to hospital is required to prevent clinical deterioration and reduce rates of intensive care admission and mortality. Efficient emergency department care delivery is impacted by modern day challenges, such as increasing user-demand, limited resources, and lack of flow. In response to this, to expedite care provision, practice guidelines have been developed to include nurse-initiated protocols that guide nurses to initiate specific predetermined investigations and interventions for patients meeting certain criteria. Febrile neutropenic pediatric patients may be a specific group that can benefit from nurse-initiated protocols due to the time-critical nature of required care. INCLUSION CRITERIA: The scoping review will consider literature that reports on nurse-initiated protocols in the management of pediatric febrile oncology patients with suspected neutropenia in the emergency department setting. METHODS: JBI methodology for scoping reviews will guide the review process. English-language literature from 2000 to present will be searched in Embase, MEDLINE, Scopus, Emcare, CINAHL Plus, and gray literature in Google Scholar, Open Grey, and Theses Global. Critical appraisal will not be performed. A tabular and accompanying narrative summary of the information will present extracted evidence aligned to the review's objective and questions.

Noncontact Heart and Respiratory Rate Monitoring of Preterm Infants Based on a Computer Vision System: Protocol for a Method Comparison Study.

BACKGROUND: Biomedical research in the application of noncontact methods to measure heart rate (HR) and respiratory rate (RR) in the neonatal population has produced mixed results. This paper describes and discusses a protocol for conducting a method comparison study, which aims to determine the accuracy of a proposed noncontact computer vision system to detect HR and RR relative to the HR and RR obtained by 3-lead electrocardiogram (ECG) in preterm infants in the neonatal unit. OBJECTIVE: The aim of this preliminary study is to determine the accuracy of a proposed noncontact computer vision system to detect HR and RR relative to the HR and RR obtained by 3-lead ECG in preterm infants in the neonatal unit. METHODS: A single-center cross-sectional study was planned to be conducted in the neonatal unit at Flinders Medical Centre, South Australia, in May 2018. A total of 10 neonates and their ECG monitors will be filmed concurrently for 10 min using digital cameras. Advanced image processing techniques are to be applied later to determine their physiological data at 3 intervals. These data will then be compared with the ECG readings at the same points in time. RESULTS: Study enrolment began in May 2018. Results of this study were published in July 2019. CONCLUSIONS: The study will analyze the data obtained by the noncontact system in comparison to data obtained by ECG, identify factors that may influence data extraction and accuracy when filming infants, and provide recommendations for how this noncontact system may be implemented into clinical applications. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR1-10.2196/13400.

Non-contact heart and respiratory rate monitoring of preterm infants based on a computer vision system: a method comparison study.

BACKGROUND: Non-contact heart rate (HR) and respiratory rate (RR) monitoring is necessary for preterm infants due to the potential for the adhesive electrodes of conventional electrocardiogram (ECG) to cause damage to the epidermis. This study was performed to evaluate the agreement between HR and RR measurements of preterm infants using a non-contact computer vision system with comparison to measurements obtained by the ECG. METHODS: A single-centre, cross-sectional observational study was conducted in a Neonatal Unit. Ten infants and their ECG monitors were videoed using two Nikon cameras for 10 min. HR and RR measurements obtained from the non-contact system were extracted using advanced signal processing techniques and later compared to the ECG readings using Bland-Altman analysis. RESULTS: The non-contact system was able to detect an apnoea when the ECG determined movement as respirations. Although the mean bias between both methods was relatively low, the limits of agreement for HR were -8.3 to 17.4 beats per minute (b.p.m.) and for RR, -22 to 23.6 respirations per minute (r.p.m.). CONCLUSIONS: This study provides necessary data for improving algorithms to address confounding variables common to the neonatal population. Further studies investigating the robustness of the proposed system for premature infants are therefore required.

Nurses Providing End-of-Life Care for Infants and Their Families in the NICU: A Review of the Literature.

BACKGROUND: Nurses working in the neonatal intensive care unit (NICU) who care for dying infants and their families say they do not necessarily have the expertise or the specific training to provide quality end-of-life-care (EOLC). PURPOSE: The purpose of this review was to critically appraise the existing qualitative literature regarding nurses' experiences when caring for infants during end of life in the NICU and to identify barriers and enablers to provide quality EOLC. SEARCH STRATEGY: A literature search was conducted using CINAHL and OVID databases. Studies that explored nurses' experiences when caring for infants who were dying or when lifesaving care was withdrawn were retrieved and 15 studies were thematically analyzed. RESULTS: Five major themes emerged: advocating for the dying infant, building close relationships with the family, providing an appropriate care environment, nurses' emotional responses to dying or death, and professional inadequacy in EOLC. IMPLICATIONS FOR PRACTICE: Nurses face multiple challenges when providing EOLC including moral dilemmas and feelings of professional inadequacy. Avoidance was a common strategy used by nurses to cope with the stress associated with EOLC. Managers can foster quality EOLC by implementing education sessions about infant mortality, EOLC, advocacy, team communication, and self-care practices. IMPLICATIONS FOR RESEARCH: Research could evaluate the effectiveness of EOLC education sessions to build nurses' competence and confidence in advocacy and EOLC clinical skills.

Remote sensing of physiological signs using a machine vision system.

The aim of this work is to remotely measure heart rate (HR) and respiratory rate (RR) using a video camera from long range (> 50 m). The proposed system is based on imperceptible signals produced from blood circulation, including skin colour variations and head motion. As these signals are not visible to the naked eye and to preserve the signal strength in the video, we used an improved video magnification technique to enhance these invisible signals and detect the physiological activity within the subject. The software of the proposed system was built in a graphic user interface (GUI) environment to easily select a magnification system to use (colour or motion magnification) and measure the physiological signs independently. The measurements were performed on a set of 10 healthy subjects equipped with a finger pulse oximeter and respiratory belt transducer that were used as reference methods. The experimental results were statistically analysed by using the Bland-Altman method, Pearson's correlation coefficient, Spearman correlation coefficient, mean absolute error, and root mean squared error. The proposed system achieved high correlation even in the presence of movement artefacts, different skin tones, lighting conditions and distance from the camera. With acceptable performance and low computational complexity, the proposed system is a suitable candidate for homecare applications, security applications and mobile health devices.

Real Time Apnoea Monitoring of Children Using the Microsoft Kinect Sensor: A Pilot Study.

The objective of this study was to design a non-invasive system for the observation of respiratory rates and detection of apnoea using analysis of real time image sequences captured in any given sleep position and under any light conditions (even in dark environments). A Microsoft Kinect sensor was used to visualize the variations in the thorax and abdomen from the respiratory rhythm. These variations were magnified, analyzed and detected at a distance of 2.5 m from the subject. A modified motion magnification system and frame subtraction technique were used to identify breathing movements by detecting rapid motion areas in the magnified frame sequences. The experimental results on a set of video data from five subjects (3 h for each subject) showed that our monitoring system can accurately measure respiratory rate and therefore detect apnoea in infants and young children. The proposed system is feasible, accurate, safe and low computational complexity, making it an efficient alternative for non-contact home sleep monitoring systems and advancing health care applications.

Quantification of pravastatin acid, lactone and isomers in human plasma by UHPLC-MS/MS and its application to a pediatric pharmacokinetic study.

An ultra high pressure liquid chromatography-tandem mass spectrometric (UHPLC-MS/MS) method for the simultaneous quantitation of pravastatin and major metabolites, 3'α-hydroxy-pravastatin, pravalactone and 3'α-hydroxy-pravalactone, in human plasma has been developed and validated. Aliquots of (100µL) plasma in EDTA were diluted in pH 4.5 (0.1M buffer) to stabilize the analytes and subjected to hydrophilic lipophilic balance (HLB) solid phase extraction on 96 well µelution plates. Extracted samples were evaporated to dryness and reconstituted in pH 4.5 buffer. Chromatographic separation was performed on a Cortecs™ C18 column (2.1×100mm, 1.8µm), using gradient elution with a blend of acetonitrile and 10mM methylammonium acetate buffer (pH 4.5) at a flow rate of 0.4mL/min. Mass spectrometric detection was performed using multiple reaction monitoring (MRM) switching between positive/negative electrospay ionization (ESI). Pravastatin, 3'α-hydroxy-pravastatin, and internal standards [(2)H3]-pravastatin, and [(2)H3]-3'α-hydroxy-pravastatin were monitored in negative ESI mode at ion transitions m/z 423.2→321.1 and 426.2→321.1, respectively. Positive ESI mode was used for the detection of pravalactone, 3'α-hydroxy-pravalactone, and internal standards [(2)H3]-pravalactone, and [(2)H3]-3'α-hydroxy-pravalactone at ion transitions m/z 438.2→183.1 and 441.2→269.1 respectively. The method was linear for all analytes in the concentration range 0.5-200nM with intra- and inter-day precisions (as relative standard deviation) of ≤5.2% and accuracy (as relative error) of ≤8.0% at all quality control levels. The method was successfully applied to the investigation of pharmacokinetic properties of pravastatin and its metabolites in children after an oral dose of 20-40mg.