Postnatal Steroids Use for Bronchopulmonary Dysplasia in a Quaternary Care NICU.

OBJECTIVE: Intercenter variation and trends in postnatal steroids (PNS) use among preterm infants for prevention or treatment of bronchopulmonary dysplasia (BPD) is known. Understanding intracenter PNS use patterns facilitate implementation of center-specific change interventions to optimize outcomes.This study aimed to (i) quantify the proportion of infants who received PNS, and describe the timing, type, trends over time, regimen used, and deviations, and (2) describe the clinical characteristics and unadjusted outcomes of infants who received PNS. STUDY DESIGN: This was a cohort study in a quaternary neonatal intensive care unit including infants born at less than 33 weeks, and who received PNS for prevention or treatment of BPD between 2011 and 2021. Following data were included: proportion of babies who received PNS; type of PNS; age at initiation and duration; trends over time; deviation from published regimen; morbidity, mortality, and cointerventions. RESULTS: One hundred and eighty four infants (8% of <33 week' infants) received PNS. The median (interquartile range [IQR]) gestational age and birth weight were 25 (24-26) weeks and 720 (625-841) grams, respectively. The median (IQR) day of initiation and duration of PNS use were 29 (19-38) and 10 (10-22) days, respectively. One hundred and fifty-seven (85%) infants received dexamethasone (DX) and 22 (12%) received hydrocortisone as the first PNS course, and 71 (39%) infants received multiple courses. The proportion of infants receiving PNS remained unchanged, but the cumulative median dose received for BPD per patient increased by 56%. Nearly one-third of cumulative PNS dose came from PNS used for non-BPD indications. Forty-six percent infants had a deviation from published regimen (±20% deviation in duration or ±10% deviation in dose). Survival, survival without major morbidity, moderate-to-severe BPD, and technology dependence at discharge were 87, 2, 91, and 67%, respectively. CONCLUSION: Increased variation in PNS use, deviation from published regimen, and concurrent PNS exposure from non-BPD indication offer insights into implementing interventions to improve processes. KEY POINTS: · In this quaternary NICU, 8% of infants born before 33 weeks were administered postnatal steroids (PNS).. · The percentage of infants given PNS remained stable; however, the cumulative dose per patient for BPD rose.. · The study identified targeted interventions to minimize clinical practice variations at the center..

Association of 24-Hour In-house Neonatologist Coverage with Outcomes of Extremely Preterm Infants.

OBJECTIVE: This study aimed to assess if 24-hour in-house neonatologist (NN) coverage is associated with delivery room (DR) resuscitation/stabilization and outcomes among inborn infants <29 weeks' gestational age (GA). STUDY DESIGN: Survey-linked cohort study of 2,476 inborn infants of 23 to 28 weeks' gestation, admitted between 2014 and 2015 to Canadian Neonatal Network Level-3 neonatal intensive care units (NICUs) with a maternity unit. Exposures were classified using survey responses based on the most senior provider offering 24-hour in-house coverage: NN, fellow, and no NN/fellow. Primary outcome was death and/or major morbidity (bronchopulmonary dysplasia, severe neurological injury, late-onset sepsis, necrotizing enterocolitis, and retinopathy of prematurity). Multivariable logistic regression analysis was used to assess the association between exposures and outcomes and adjust for confounders. RESULTS: Among the 28 participating NICUs, most senior providers ensuring 24-hour in-house coverage were NN (32%, 9/28), fellows (39%, 11/28), and no NN/fellow (29%, 8/28). No NN/fellow coverage and 24-hour fellow coverage were associated with higher odds of infants receiving DR chest compressions/epinephrine compared with 24-hour NN coverage (adjusted odds ratio [aOR] = 4.72, 95% confidence interval [CI]: 2.12-10.6 and aOR = 3.33, 95% CI: 1.44-7.70, respectively). Rates of mortality/major morbidity did not differ significantly among the three groups: NN, 63% (249/395 infants); fellow, 64% (1092/1700 infants); no NN/fellow, 70% (266/381 infants). CONCLUSION: 24-hour in-house NN coverage was associated with lower rates of DR chest compressions/epinephrine. There was no difference in neonatal outcomes based on type of coverage; however, further studies are needed as ecological fallacy cannot be ruled out. KEY POINTS: · Lower rates of DR cardiopulmonary resuscitation with 24h in-house NN coverage. · The type of 24h in-house coverage was not associated with mortality and/or major morbidity.. · High-volume centers more often have 24h in-house neonatal fellow coverage.

Designing behavioral interventions using the capability-opportunity-motivation-behavior model and the theoretical domains framework to optimize oxygen saturation maintenance by NICU providers.

Objective: Despite evidence-based guidelines, SpO2 maintenance-related practices of care providers remain inconsistent. Our aim was to evaluate the impact of interprofessional learning workshops, bedside coaching, and neonatal intensive care unit (NICU) level enablers on targeted behavioral change of NICU staff, focusing on SpO2 maintenance. Methods: NICU is a specialized area of the hospital with sophisticated monitors where multidisciplinary staff provide round-the-clock care for sick and preterm infants. As a subset of a quality improvement project to improve SpO2 maintenance and reduce desaturation events, three targeted evidence-based staff behaviors were deemed as important based on established capability-opportunity-motivation-behavior and theoretical domains framework models: setting SpO2 alarm limits, using SpO2 alarm management algorithms, and reporting daily summaries of SpO2 during rounds. We conducted interprofessional workshops, provided bedside coaching, and altered unit NICU processes (guidelines, automated SpO2 histogram printouts, defined staff standard work) and measured demonstrable changes in staff reaction, learning, and behaviors by direct observation of behaviors and survey questionnaires. Results: Two hundred and seventy-five (87%) and 210 (80%) of NICU staff attended workshops and received bedside coaching, respectively. The proportion of staff expressing satisfaction with workshop and bedside coaching was 85% and 82%, respectively. The proportion of staff reporting improvement in their knowledge and confidence related to SpO2 maintenance increased significantly following the workshop. Targeted behaviors related to SpO2 maintenance like setting appropriate alarm limits, adhering to SpO2 management algorithm, and reporting daily SpO2 summaries during rounds increased from 80% to 96%, 0% to 64%, and 20% to 70%, respectively. Conclusion: Focused behavioral change interventions aimed at improving staff capability, opportunity, and motivation resulted in a demonstrable change in targeted staff behaviors related to SpO2 maintenance. Further research is needed to establish ways of optimizing intended staff behaviors while implementing care bundles in a given setting.

Corrigendum to: Refining evidence-based retinopathy of prematurity screening guidelines: The SCREENROP study.

[This corrects the article DOI: 10.1093/pch/pxz085.].

Development and Validation of Early Warning Criteria to Identify Escalated Care Events in Neonatal Intensive Care Unit Patients.

OBJECTIVE: This study aimed to identify and validate the diagnostic utility of a set of clinical and laboratory criteria (early warning criteria [EWC]) that portend a clinical deterioration event (escalated care event [ECE]) in neonatal intensive care unit (NICU) patients. STUDY DESIGN: Using the RAND appropriateness method, we first established a consensus on seven ECE, that is, events that require additional monitoring, treatment, or stay in the NICU or that were associated with morbidity. We then established consensus on EWC that could portend an ECE from an initial set of 32 potential EWC items to a final set of 10 items. The occurrence and nonoccurrence of EWC and ECE were prospectively identified and tracked over 9 weeks. RESULTS: Among 170 NICU patients studied (2,502 patient-days), the frequency of an EWC was 53 per 1,000 patient-days. Of these patients, 41% had an EWC and 16% had an ECE. An EWC was followed by an ECE within 72 hours, 37% of the time, and within a median time interval of 113 minutes. The sensitivity, specificity, positive predictive values, and negative predictive values of EWC in identifying an ECE were 0.96, 0.69, 0.37, and 0.99, respectively. CONCLUSION: A simple bedside NICU-specific EWC identifies neonates likely to develop ECEs in the NICU.

Refining evidence-based retinopathy of prematurity screening guidelines: The SCREENROP study.

PURPOSE: Retinopathy of prematurity (ROP) is a potentially blinding condition affecting premature infants for which less than 10% of babies undergoing screening require treatment. This study assessed and validated predictors of developing clinically significant ROP (type 2 or worse) and ROP requiring treatment. DESIGN: Nationwide retrospective cohort study. METHODS: This study included infants born between January 2014 and June 2016, admitted to level 3 neonatal intensive care units across Canada who underwent ROP screening. Data were derived from the Canadian Neonatal Network database. Predefined ≥ 1% risk for clinically significant retinopathy or prematurity and ROP requiring treatment was set as threshold for screening. Thirty-two potential predictors were analyzed, to identify and validate the most important ones for predicting clinically significant ROP. The predictors were determined on a derivation cohort and tested on a validation cohort. Multivariable logistic regression modeling was used for analysis. RESULTS: Using a sample of 4,888 babies and analyzing 32 potential predictors, capturing babies with ≥1% risk of developing clinically significant ROP equated to screening babies with birth weight (BW) <1,300 g or gestational age (GA) <30 weeks while capturing babies with ≥1% risk of requiring ROP treatment equated to screening babies with BW <1,200 g or GA <29 weeks. CONCLUSIONS: The Canadian ROP screening criteria can be modified to screen babies with BW <1,200 g or GA <30 weeks. Using these criteria, babies requiring treatment would be identified while reducing the number of babies screened unnecessarily.

Outcomes of Neonates With Complex Medical Needs.

BACKGROUND: Children with complex medical needs (CMN) are high healthcare resource utilizers, have varying underlying diagnoses, and experience repeated hospitalizations. Outcomes on neonatal intensive care (NICU) patients with CMN are unknown. PURPOSE: The primary aim is to describe the clinical profile, resource use, prevalence, and both in-hospital and postdischarge outcomes of neonates with CMN. The secondary aim is to assess the feasibility of sustaining the use of the neonatal complex care team (NCCT). METHODS: A retrospective cohort study was conducted after implementing a new model of care for neonates with CMN in the NICU. All neonates born between January 2013 and December 2016 and who met the criteria for CMN and were cared for by the NCCT were included. RESULTS: One hundred forty-seven neonates with a mean (standard deviation) gestational age of 34 (5) weeks were included. The major underlying diagnoses were genetic/chromosomal abnormalities (48%), extreme prematurity (26%), neurological abnormality (12%), and congenital anomalies (11%). Interventions received included mechanical ventilation (69%), parenteral nutrition (68%), and technology dependency at discharge (91%). Mortality was 3% before discharge and 17% after discharge. Postdischarge hospital attendances included emergency department visits (44%) and inpatient admissions (58%), which involved pediatric intensive care unit admissions (26%). IMPLICATIONS FOR PRACTICE: Neonates with CMN have multiple comorbidities, high resource needs, significant postdischarge mortality, and rehospitalization rates. These cohorts of NICU patients can be identified early during their NICU course and serve as targets for implementing innovative care models to meet their unique needs. IMPLICATIONS FOR RESEARCH: Future studies should explore the feasibility of implementing innovative care models and their potential impact on patient outcomes and cost-effectiveness.

Antibiotics for neonates born through meconium-stained amniotic fluid.

BACKGROUND: Approximately 1 in 10 pregnancies is affected by meconium passage at delivery, which can result in meconium aspiration syndrome (MAS). MAS can cause respiratory complications and, very rarely, death. Antibiotics have been prescribed for neonates exposed to meconium in amniotic fluid, with the intention of preventing infection due to potential bacterial contaminants. OBJECTIVES: We conducted this review to assess the efficacy and safety of antibiotics for:1. prevention of infection, morbidity, and mortality among infants born through meconium-stained amniotic fluid (MSAF) who are asymptomatic at birth; and2. prevention of infection, morbidity, and mortality among infants born through MSAF who have signs and symptoms compatible with meconium aspiration syndrome (MAS). SEARCH METHODS: We performed a literature search using the following databases: MEDLINE (1966 to July 2016); Embase (1980 to July 2016); the Cumulative Index to Nursing and Allied Health Literature (CINAHL; 1982 to July 2016); and the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 7) in the Cochrane Library. We also searched clinical trials databases, conference proceedings, and reference lists of retrieved articles. SELECTION CRITERIA: We included randomised and quasi-randomised controlled trials that compared antibiotics administered via any route versus placebo or no treatment for prevention of infection among neonates exposed to MSAF, or who developed MAS. We excluded cohort, case control, and any other non-randomised studies and applied no language restrictions. We included studies of term and preterm infants, and we included studies examining use of any antibacterial antibiotics. We included studies that reported on any outcomes of interest. DATA COLLECTION AND ANALYSIS: We assessed the methodological quality of included trials by reviewing information provided in study reports and obtained by personal communication with study authors. We extracted data on relevant outcomes, estimated effect size, and reported values as risk ratios (RRs), risk differences (RDs), and mean differences (MDs), as appropriate. We conducted subgroup analyses for treatment of MAS and for prophylaxis (asymptomatic neonates exposed to meconium). MAIN RESULTS: Four randomised controlled studies including a total of 695 participants were eligible for inclusion. Three studies evaluated neonates with MAS, and one study assessed asymptomatic neonates exposed to meconium in amniotic fluid. These studies exhibited varying degrees of methodological rigour: Two studies were at low risk of bias, and two were at unclear risk. We graded evidence derived from these studies as low quality. We downgraded overall evidence owing to the large number of participants lost to follow-up in one trial, the small sample sizes of all trials, and unclear methodological details provided for two trials.The primary outcome was risk of early- and late-onset neonatal sepsis. Antibiotics did not decrease the risk of sepsis in neonates with a diagnosis of MAS (RR 1.54, 95% confidence interval (CI) 0.27 to 8.96; RD 0.00, 95% CI -0.02 to 0.03; 445 participants, three studies; I² = 0%) nor in asymptomatic neonates exposed to meconium in amniotic fluid (RR 0.76, 95% CI 0.25 to 2.34; RD -0.01, 95% CI -0.07 to 0.04; 250 participants, one study; I² = 0%). Results show no significant differences in mortality or duration of stay in hospital between groups given antibiotics and control groups of symptomatic and asymptomatic neonates. One study in asymptomatic neonates reported a significant reduction in duration of mechanical ventilation for the control group compared with the antibiotic group (MD 0.26, 95% CI 0.15 to 0.37; 250 participants, one study; I² = 0%). AUTHORS' CONCLUSIONS: Upon review of available evidence, we found no differences in infection rates following antibiotic treatment among neonates born through meconium-stained fluid and those with meconium aspiration syndrome. The overall quality of evidence is low owing to the small number of included studies. Well-controlled studies of adequate power are needed.

Survey of noninvasive respiratory support practices in Canadian neonatal intensive care units.

AIM: To evaluate practice variation with respect to noninvasive respiratory support (NRS) use across Canadian neonatal intensive care units (NICUs). METHODS: A web-based survey was sent to all site investigators of the 30 level 3 NICUs participating in the Canadian Neonatal Network. The survey inquired about the use of five commonly described NRS modes. In addition, the presence and adherence to local guidelines were ascertained. Descriptive analyses were performed to identify variations in practice. RESULTS: In total, 28 (93%) of the 30 tertiary NICUs responded to the survey. Continuous positive airway pressure (CPAP) was employed universally (100%). High-flow nasal cannula (HFNC) was used in 89% of NICUs, biphasic CPAP in 79% and nasal intermittent positive pressure ventilation (NIPPV) in 54%, and nasal high-frequency ventilation was used in 18% of units. Only 61% of all NRS use was guided by local policies, with the lowest being for HFNC (36%). There was a wide range of settings employed and interfaces used for all NRS modes. CONCLUSION: There are significant practice variations in NRS use across Canadian NICUs. Further research is needed to evaluate the significance in relation to pulmonary outcomes to determine optimal NRS strategies.

Introduction of microsystems in a level 3 neonatal intensive care unit-an interprofessional approach.

BACKGROUND: Growth of neonatal intensive care units in number and size has raised questions towards ability to maintain continuity and quality of care. Structural organization of intensive care units is known as a key element for maintaining the quality of care of these fragile patients. The reconstruction of megaunits of intensive care to smaller care units within a single operational service might help with provision of safe and effective care. METHODS/DESIGN: The clinical team and patient distribution lay out, admission and discharge criteria and interdisciplinary round model was reorganized to follow the microstructure philosophy. A working group met weekly to formulate the implementation planning, to review the adaptation and adjustment process and to ascertain the quality of implementation following the initiation of the microsystem model. DISCUSSION: In depth examination of microsystem model of care in this study, provides systematic evaluation of this model on variable aspects of health care. The individual projects of this trial can be source of solid evidence for guidance of future decisions on optimized model of care for the critically ill newborns. TRIAL REGISTRATION: ClinicalTrial.gov, NCT02912780 . Retrospectively registered on 22 September 2016.

Trends and Variations in the Use of Inhaled Nitric Oxide in Preterm Infants in Canadian Neonatal Intensive Care Units.

Objective To determine the proportion of infants who receive inhaled nitric oxide (iNO), and to characterize the variations in its use by gestational age (GA) and center in infants <34 weeks' gestation. Design Retrospective analysis was performed in infants born at <34 weeks' gestation and admitted to neonatal intensive care units participating in the Canadian Neonatal Network between January 2010 and December 2013. Results Of 19,525 infants, 831 (4.2%) received iNO. A total of 369 infants (44%) received iNO during the first 2 days after birth. The proportion of neonates who received iNO in the 22 to 25, 26 to 29, and 30 to 33 weeks' GA groups was 16.1, 6.0, and 1.3%, respectively. Infants in whom iNO was initiated in the first 2 days of age received it for a shorter duration (median, 3 days; interquartile range [IQR], 2-5) as compared with those who started after 2 days (median, 5 days; IQR, 2-11). The use of iNO varied by center, ranging from 0 to 15.5% (p < 0.001). Conclusion Out of every 25 infants born at <34 weeks' gestation in Canada received iNO, with the highest rate of use in infants born at lower gestation. Further research to identify reasoning, efficacy, and safety of iNO in preterm infants is warranted.

Impact of interprofessional education on noninvasive ventilation in a tertiary neonatal intensive care unit.

OBJECTIVE: To evaluate the impact and effectiveness of an experiential interprofessional education workshop on noninvasive ventilation (NIV) in the setting of a neonatal intensive care unit. METHODS: In the present cross-sectional study, a full-day workshop, consisting of didactic and hands-on components, was developed to assess knowledge and perceptions, and to disseminate the latest evidence and practical aspects of NIV use. All health care professionals (HCPs) were asked to participate. Pre- and post-participation questionnaires and knowledge tests were used to assess the effectiveness of knowledge transfer, and to seek participants' reflections on the utility of the workshop. RESULTS: Among 214 participants, 206 (96%) and 195 (91%) completed the pre- and post-participation questionnaires, respectively. The majority agreed (14%) or strongly agreed (75%) that NIV education was important for their role. Participants scored their perceived comfort with NIV following the workshop highly (median 5 [interquartile range (IQR) 1]) on a five-point Likert scale and 96% would recommend it to a colleague. Median knowledge scores on NIV, assessed as percent correct responses, increased from 74% (IQR 16) to 86% (IQR 11) (P<0.05). CONCLUSIONS: A focused, context-specific workshop helped improve understanding and comfort among HCPs while reducing misconceptions about NIV. Further research to assess optimal delivery of NIV education and impact on patient outcomes is required.

Les effets d'une formation interprofessionnelle sur la ventilation non invasive dans une unité de soins intensifs néonatals de niveau tertiaire. OBJECTIF: Évaluer les effets et l'efficacité d'un atelier expérimental de formation interprofessionnelle sur la ventilation non invasive (VNI) dans une unité de soins intensifs néonatals. MÉTHODOLOGIE: Dans la présente étude transversale, les chercheurs ont créé un atelier d'une journée comportant des volets magistraux et pratiques pour évaluer les connaissances et les perceptions et pour faire connaître les données probantes les plus récentes et les aspects pratiques de la VNI. Ils ont invité tous les professionnels de la santé (PdS) à y participer. Ils ont utilisé des questionnaires avant et après la participation et des tests de connaissances pour évaluer l'efficacité de l'application du savoir et pour obtenir les réflexions des participants sur l'utilité de l'atelier. RÉSULTATS: Parmi les 214 participants, 206 (96 %) et 195 (91 %) ont rempli le questionnaire avant et après la participation, respectivement. La majorité étaient d'accord (14 %) ou tout à fait d'accord (75 %) pour affirmer que la formation sur la VNI était importante dans leur rôle. Les participants avaient une perception élevée de leur aisance à l'égard de la VNI après la formation (médiane 5 [plage interquartile (PIQ) 1]) sur une échelle de Likert de cinq points, et 96 % l'auraient recommandée à un collègue. Les indices de connaissances médians sur la VNI, évalués selon le pourcentage de bonnes réponses, sont passés de 74 % (PIQ 16) à 86 % (PIQ 11) (P<0,05). CONCLUSIONS: Un atelier ciblé et adapté au milieu a contribué à accroître la compréhension et l'aisance des PdS tout en réduisant les idées fausses quant à la VNI. D'autres recherches s'imposent pour évaluer la prestation optimale de la formation sur la VNI et les effets sur les résultats cliniques des patients.

Current practice of neonatal resuscitation documentation in North America: a multi-center retrospective chart review.

BACKGROUND: To determine the comprehensiveness of neonatal resuscitation documentation and to determine the association of various patient, provider and institutional factors with completeness of neonatal documentation. METHODS: Multi-center retrospective chart review of a sequential sample of very low birth weight infants born in 2013. The description of resuscitation in each infant's record was evaluated for the presence of 29 Resuscitation Data Items and assigned a Number of items documented per record. Covariates associated with this Assessment were identified. RESULTS: Charts of 263 infants were reviewed. The mean gestational age was 28.4 weeks, and the mean birth weight 1050 g. Of the infants, 69 % were singletons, and 74 % were delivered by Cesarean section. A mean of 13.2 (SD 3.5) of the 29 Resuscitation Data Items were registered for each birth. Items most frequently present were; review of obstetric history (98 %), Apgar scores (96 %), oxygen use (77 %), suctioning (71 %), and stimulation (62 %). In our model adjusted for measured covariates, the institution was significantly associated with documentation. CONCLUSIONS: Neonatal resuscitation documentation is not standardized and has significant variation. Variation in documentation was mostly dependent on institutional factors, not infant or provider characteristics. Understanding this variation may lead to efforts to standardize documentation of neonatal resuscitation.

Macrolides do not affect the incidence of moderate and severe bronchopulmonary dysplasia in symptomatic ureaplasma-positive infants.

AIM: The aim of this study was to compare the incidence of bronchopulmonary dysplasia (BPD) in symptomatic ureaplasma-positive treated preterm infants and asymptomatic preterm infants not tested or treated for ureaplasma. METHODS: A retrospective matched cohort study was conducted in a tertiary, neonatal unit between January 2007 and December 2012. Infants ≤29 completed weeks with signs and symptoms suggesting ureaplasma pneumonia who received macrolides comprised the study group. Infants ≤29 weeks without signs and symptoms not tested or treated with macrolides were the controls. Infants were mandatorily matched for gestational age ± one week or birthweight ± 100 grams. RESULTS: There were 31 infants in the study group and 62 in the control group. The baseline demographic data of both groups were similar on the whole. The incidence of moderate and severe BPD, defined by oxygen dependency or the need for continuous positive airway pressure at 36 weeks of postconceptual age, was 45.2% in the study group and 40.3% in the controls (p = 0.65). There was no significant difference in morbidities or mortality between the groups. CONCLUSION: A selective approach of treating symptomatic ureaplasma-positive preterm infants with macrolides did not affect the incidence of moderate and severe BPD.

Compression force on the upper jaw during neonatal intubation: mannequin study.

AIM: Neonatal intubation is a technically challenging procedure, and pressure-related injuries to surrounding structures have been reported. The primary objective of this study was to determine the pressure exerted on the upper jaw during tracheal intubation using a neonatal mannequin. METHOD: Multidisciplinary care providers working at a neonatal intensive care unit were requested to intubate a neonatal mannequin using the standard laryngoscope and 3.0-mm (internal diameter) endotracheal tube. Compression force exerted was measured by using pressure-sensitive film taped on the upper jaw before every intubation attempt. Pressure, area under pressure and time taken to intubate were compared between the different types of health-care professionals. RESULTS: Thirty care providers intubated the mannequin three times each. Pressure impressions were observed on the developer film after every intubation attempt (n = 90). The mean pressure exerted during intubation across all health-care providers was 568 kPa (SD 78). The mean area placed under pressure was 142 mm(2) (SD 45), and the mean time taken for intubation was 14.7 s (SD 4.3). There was no difference in pressure exerted on the upper jaw between frequent and less frequent intubators. It was found that pressure greater than 400 kPa was inadvertently applied on the upper jaw during neonatal intubation, far exceeding the 250 kPa shown to cause tissue injury in animal models. CONCLUSION: The upper jaw is exposed to a significant compression force during intubation. Although such exposure is brief, it has the potential to cause tissue injury. Contact of the laryngoscope blade with the upper jaw occurred in all intubation attempts with the currently used design of laryngoscope.

Prophylactic indomethacin worsens short-term respiratory outcomes in extremely low-birth-weight infants.

OBJECTIVE: To compare the effects of prophylactic indomethacin versus expectant management on short-term respiratory outcomes in extremely low-birth-weight (ELBW) infants. METHODS: This was a retrospective cohort study of ELBW infants with gestational age less than 28 weeks, born at a level III neonatal intensive care unit from 2004 to 2009. Patients were grouped based on whether they received prophylactic indomethacin or expectant treatment. The key outcome was the cumulative number of days of mechanical ventilation. Other outcomes were cumulative number of days supplemental oxygen and continuous positive airway pressure (CPAP) were required; duration of hospital stay; mortality; and other morbidities such as necrotizing enterocolitis and intraventricular hemorrhage. Multivariable linear regression was performed with treatment group and seven covariates, defined a priori, as predictor variables and cumulative number of days of mechanical ventilation as the outcome. RESULTS: There were 144 infants in the prophylaxis group and 221 infants in the expectant treatment group. At baseline, the Score for Neonatal Acute Physiology-Perinatal Extension, incidence of respiratory distress syndrome, and usage of antenatal corticosteroids were significantly higher in the prophylaxis group. The cumulative number of days of mechanical ventilation, supplemental oxygen, and CPAP were significantly higher in the prophylaxis group. On multivariable linear regression, after adjusting for confounders, use of prophylactic indomethacin (unstandardized ß coefficient = 12.4; 95% confidence interval [CI]: 6.6, 18.1; p < 0.001), birth weight (ß = -0.025; 95% CI: -0.05, -0.001; p = 0.043), and gestation (ß = -4.5; 95% CI: -7.24, -1.8; p = 0.001) were the independent predictors of cumulative number of days of mechanical ventilation. CONCLUSION: ELBW infants who received prophylactic indomethacin had significantly longer cumulative number of days of mechanical ventilation, supplemental oxygen, and CPAP. Prophylactic indomethacin is an independent predictor of cumulative number of days of mechanical ventilation.

Pharmacology of milrinone in neonates with persistent pulmonary hypertension of the newborn and suboptimal response to inhaled nitric oxide.

OBJECTIVES: Persistent pulmonary hypertension of the newborn is a common problem with significant morbidity and mortality. Inhaled nitric oxide is the standard care, but up to 40% of neonates are nonresponders. Milrinone is a phosphodiesterase III inhibitor which increases the bioavailability of cyclic adenosine monophosphate and has been shown to improve pulmonary hemodynamics in animal experimental models. The primary objective was to investigate the pharmacological profile of milrinone in persistent pulmonary hypertension of the newborn. Secondary objectives were to delineate short-term outcomes and safety profile. SUBJECTS AND METHODS: An open label study of milrinone in neonates with persistent pulmonary hypertension of the newborn was conducted. Patients received an intravenous loading dose of milrinone (50 µg/kg) over 60 mins followed by a maintenance infusion (0.33-0.99 µg/kg/min) for 24-72 hrs. Physiologic indices of cardiorespiratory stability and details of cointerventions were recorded. Serial blood milrinone levels were collected after the bolus, following initiation of the maintenance infusion to determine steady state levels, and following discontinuation of the drug to determine clearance. Echocardiography was performed before and after (1, 12 hrs) milrinone initiation. INTERVENTIONS: Milrinone. MEASUREMENTS AND MAIN RESULTS: Eleven neonates with a diagnosis of persistent pulmonary hypertension of the newborn who met eligibility criteria were studied. The median (SD) gestational age and weight at birth were 39.2 ± 1.3 wks and 3481 ± 603 g. The mean (± sd) half-life, total body clearance, volume of distribution, and steady state concentration of milrinone were 4.1 ± 1.1 hrs, 0.11 ± 0.01 L/kg/hr, 0.56 ± 0.19 L/kg, and 290.9 ± 77.7 ng/mL. The initiation of milrinone led to an improvement in PaO2 (p = 0.002) and a sustained reduction in FIO2 (p < 0.001), oxygenation index (p < 0.001), mean airway pressure (p = 0.03), and inhaled nitric oxide dose (p < 0.001). Although a transient reduction in systolic arterial pressure (p < 0.001) was seen following the bolus, there was overall improvement in base deficit (p = 0.01) and plasma lactate (p = 0.04) with a trend towards lower inotrope score. Serial echocardiography revealed lower pulmonary artery pressure, improved right and left ventricular output, and reduced bidirectional or right-left shunting (p < 0.05) after milrinone treatment. CONCLUSIONS: The pharmacokinetics of milrinone in persistent pulmonary hypertension of the newborn is consistent with published data. The administration of intravenous milrinone led to better oxygenation and improvements in pulmonary and systemic hemodynamics in patients with suboptimal response to inhaled nitric oxide. These data support the need for a randomized controlled trial in neonates.

Care Bundle to Improve Oxygen Maintenance and Events.

Prolonged periods spent outside the target range of oxygen saturation (SpO2) in preterm infants, along with frequent desaturation events, predispose them to retinopathy of prematurity (ROP) and long-term neurodevelopmental impairment. The primary aim of this study was to increase the mean time spent within the target SpO2 range (WTR) by 10% and to reduce the frequency of desaturation events by 5 events per patient day, respectively, within 18 months of implementing a care bundle. Methods: This study was completed in a 46-bed neonatal intensive care unit (NICU), involving 246 staff members and led by a quality improvement team. The change interventions included implementing new practice guidelines, reviewing daily summaries of SpO2 maintenance, daily infant wellness assessment, standardizing workflow, and responding to SpO2 alarms. In addition, we collected staff satisfaction and compliance with change interventions, resource use, and morbidity and mortality data at discharge. Results: The mean time spent WTR increased from 65.3% to 75.3%, and the frequency of desaturation events decreased from 25.1 to 16.5 events per patient day, respectively, with a higher magnitude of benefit in infants on days with supplemental oxygen. Postimplementation, the duration of high-frequency ventilation and supplemental oxygen were lower, but morbidity and mortality rates were similar. Staff satisfaction with training workshops, coaching, use of the infant wellness assessment tool, and SpO2 alarm management algorithms were 74%, 82%, 80%, and 74%, respectively. Conclusion: Implementing a care bundle to improve oxygen maintenance and reduce desaturation events increased the time spent WTR and reduced the frequency of desaturation events.

Understanding what patients and physicians need to improve their decision-making about antenatal corticosteroids in late preterm gestation: a qualitative framework analysis.

BACKGROUND: It is unclear whether the benefits of administration of antenatal corticosteroids in late preterm gestation outweigh its harms. We sought to understand whether patients and physicians need increased support to decide whether to administer antenatal corticosteroids in late preterm gestation, and their informational needs and preferences for decision-making roles related to this intervention; we also wanted to know if creation of a decision-support tool would be useful. METHODS: We conducted individual, semistructured interviews with pregnant people, obstetricians and pediatricians in Vancouver, Canada, in 2019. Using a qualitative framework analysis method, we coded, charted and interpreted interview transcripts into categories that formed an analytical framework. RESULTS: We included 20 pregnant participants, 10 obstetricians and 10 pediatricians. We organized codes into the following categories: informational needs to decide whether to administer antenatal corticosteroids; preferences for decision-making roles regarding this treatment; the need for support to make this treatment decision; and the preferred format and content of a decision-support tool. Pregnant participants wanted to be involved in decision-making about antenatal corticosteroids in late preterm gestation. They wanted information on the medication, respiratory distress, hypoglycemia, parent-neonate bonding and long-term neurodevelopment. There was variation in physician counselling practices, and in how patients and physicians perceived the balance of treatment harms and benefits. Responses suggested a decision-support tool may be useful. Participants desired clear descriptions of risk magnitude and uncertainty. INTERPRETATION: Pregnant people and physicians would likely benefit from increased support to consider the harms and benefits of antenatal corticosteroids in late preterm gestation. Creation of a decision-support tool may be useful.

Variation in the management of persistent pulmonary hypertension of the newborn: a survey of physicians in Canada, Australia, and New Zealand.

BACKGROUND: Despite advances in management of persistent pulmonary hypertension of the newborn (PPHN), the risk of mortality and adverse neurological sequelae remains high. Characterizing variation in practices is a crucial step toward improved patient outcome. OBJECTIVE: Evaluate intensive care practices in Canada and the Australia-New Zealand region (AUS-NZ). METHODS: A prospective cross-sectional online survey of neonatologists was conducted. A 35-item questionnaire was developed, validated, and piloted to collect information on diagnosis, inhaled nitric oxide (iNO) practices, alternative vasodilators or cardiotropes, and echocardiography. Variation among survey respondents as well as intergroup comparison was performed. RESULTS: Data were collected from 217 respondents. Echocardiography and arterial blood gas were the most common diagnostic tests to assess the severity of PPHN. iNO administration is more frequently scrutinized in Canada (36% versus 10% [AUS-NZ], p < 0.001). Canadian physicians reported higher use of intravenous milrinone (p < 0.001), vasopressin (p = 0.02), and inhaled prostacyclin (p = 0.02), but lower use of sildenafil (p = 0.01) for refractory pulmonary hypertension. A greater proportion of neonatologists in AUS-NZ were trained to perform echocardiography (p < 0.001) to optimize treatment decisions. CONCLUSION: Wide variation exists in the management of PPHN. There is a need to provide more guidance regarding principles of management in PPHN, while recognizing the dynamic nature of cardiopulmonary physiology in individual patients.