Factors that impact second attempt success for neonatal intubation following first attempt failure: a report from the National Emergency Airway Registry for Neonates.

OBJECTIVE: To determine the factors associated with second attempt success and the risk of adverse events following a failed first attempt at neonatal tracheal intubation. DESIGN: Retrospective analysis of prospectively collected data on intubations performed in the neonatal intensive care unit (NICU) and delivery room from the National Emergency Airway Registry for Neonates (NEAR4NEOS). SETTING: Eighteen academic NICUs in NEAR4NEOS. PATIENTS: Neonates requiring two or more attempts at intubation between October 2014 and December 2021. MAIN OUTCOME MEASURES: The primary outcome was successful intubation on the second attempt, with severe tracheal intubation-associated events (TIAEs) or severe desaturation (≥20% decline in oxygen saturation) being secondary outcomes. Multivariate regression examined the associations between these outcomes and patient characteristics and changes in intubation practice. RESULTS: 5805 of 13 126 (44%) encounters required two or more intubation attempts, with 3156 (54%) successful on the second attempt. Second attempt success was more likely with changes in any of the following: intubator (OR 1.80, 95% CI 1.56 to 2.07), stylet use (OR 1.65, 95% CI 1.36 to 2.01) or endotracheal tube (ETT) size (OR 2.11, 95% CI 1.74 to 2.56). Changes in stylet use were associated with a reduced chance of severe desaturation (OR 0.74, 95% CI 0.61 to 0.90), but changes in intubator, laryngoscope type or ETT size were not; no changes in intubator or equipment were associated with severe TIAEs. CONCLUSIONS: Successful neonatal intubation on a second attempt was more likely with a change in intubator, stylet use or ETT size.

Underimmunization of very low birth weight infants at discharge from the neonatal intensive care unit.

OBJECTIVE: To quantify immunization status among premature infants discharged from neonatal intensive care units (NICUs), and identify risk factors for underimmunization. STUDY DESIGN: We performed a cohort study of infants <33 weeks gestation discharged home between 2011 and 2020 from 241 NICUs. Using multivariable logistic regression, we examined the association between risk factors and underimmunization at discharge, defined as <1 dose of 5 vaccine types when discharged at 60-119 days of age and <2 doses when discharged at 120-179 days of age. RESULTS: Of 30,766 infants discharged at 60-119 days of age, 14% were underimmunized. Among 4358 infants discharged at 120-179 days of age, 53% were underimmunized. For infants discharged at 60-119 days of age, ventilator support within 30 days of discharge was associated with underimmunization. Having a surgical procedure was associated with underimmunization in both groups. CONCLUSION: A large proportion of premature infants discharged from the NICU are underimmunized.

Associations between family presence and neonatal intubation outcomes: a report from the National Emergency Airway Registry for Neonates: NEAR4NEOS.

OBJECTIVE: Describe the current practice of family presence during neonatal tracheal intubations (TIs) across neonatal intensive care units (NICUs) and examine the association with outcomes. DESIGN: Retrospective analysis of TIs performed in NICUs participating in the National Emergency Airway Registry for Neonates (NEAR4NEOS). SETTING: Thirteen academic NICUs. PATIENTS: Infants undergoing TI between October 2014 and December 2017. MAIN OUTCOME MEASURES: Association of family presence with TI processes and outcomes including first attempt success (primary outcome), success within two attempts, adverse TI-associated events (TIAEs) and severe oxygen desaturation ≥20% from baseline. RESULTS: Of the 2570 TIs, 242 (9.4%) had family presence, which varied by site (median 3.6%, range 0%-33%; p<0.01). Family member was more often present for older infants and those with chronic respiratory failure. Fewer TIs were performed by residents when family was present (FP 10% vs no FP 18%, p=0.041). Among TIs with family presence versus without family presence, the first attempt success rate was 55% vs 49% (p=0.062), success within two attempts was 74% vs 66% (p=0.014), adverse TIAEs were 18% vs 20% (p=0.62) and severe oxygen desaturation was 49% vs 52%, (p=0.40). In multivariate analyses, there was no independent association between family presence and intubation success, adverse TIAEs or severe oxygen desaturation. CONCLUSION: Family are present in less than 10% of TIs, with variation across NICUs. Even after controlling for important patient, provider and site factors, there were no significant associations between family presence and intubation success, adverse TIAEs or severe oxygen desaturation.

Incidence, impact and indicators of difficult intubations in the neonatal intensive care unit: a report from the National Emergency Airway Registry for Neonates.

OBJECTIVE: To determine the incidence, indicators and clinical impact of difficult tracheal intubations in the neonatal intensive care unit (NICU). DESIGN: Retrospective review of prospectively collected data on intubations performed in the NICU from the National Emergency Airway Registry for Neonates. SETTING: Ten academic NICUs. PATIENTS: Neonates intubated in the NICU at each of the sites between October 2014 and March 2017. MAIN OUTCOME MEASURES: Difficult intubation was defined as one requiring three or more attempts by a non-resident provider. Patient (age, weight and bedside predictors of difficult intubation), practice (intubation method and medications used), provider (training level and profession) and outcome data (intubation attempts, adverse events and oxygen desaturations) were collected for each intubation. RESULTS: Out of 2009 tracheal intubations, 276 (14%) met the definition of difficult intubation. Difficult intubations were more common in neonates <32 weeks, <1500 g. The difficult intubation group had a 4.9 odds ratio (OR) for experiencing an adverse event and a 4.2 OR for severe oxygen desaturation. Bedside screening tests of difficult intubation lacked sensitivity (receiver operator curve 0.47-0.53). CONCLUSIONS: Difficult intubations are common in the NICU and are associated with adverse event and severe oxygen desaturation. Difficult intubations occur more commonly in small preterm infants. The occurrence of a difficult intubation in other neonates is hard to predict due to the lack of sensitivity of bedside screening tests.

Neonatal Intubation Practice and Outcomes: An International Registry Study.

BACKGROUND AND OBJECTIVES: Neonatal tracheal intubation is a critical but potentially dangerous procedure. We sought to characterize intubation practice and outcomes in the NICU and delivery room (DR) settings and to identify potentially modifiable factors to improve neonatal intubation safety. METHODS: We developed the National Emergency Airway Registry for Neonates and collected standardized data for patients, providers, practices, and outcomes of neonatal intubation. Safety outcomes included adverse tracheal intubation-associated events (TIAEs) and severe oxygen desaturation (≥20% decline in oxygen saturation). We examined the relationship between intubation characteristics and adverse events with univariable tests and multivariable logistic regression. RESULTS: We captured 2009 NICU intubations and 598 DR intubations from 10 centers. Pediatric residents attempted 15% of NICU and 2% of DR intubations. In the NICU, the first attempt success rate was 49%, adverse TIAE rate was 18%, and severe desaturation rate was 48%. In the DR, 46% of intubations were successful on the first attempt, with 17% TIAE rate and 31% severe desaturation rate. Site-specific TIAE rates ranged from 9% to 50% (P < .001), and severe desaturation rates ranged from 29% to 69% (P = .001). Practices independently associated with reduced TIAEs in the NICU included video laryngoscope (adjusted odds ratio 0.46, 95% confidence interval 0.28-0.73) and paralytic premedication (adjusted odds ratio 0.38, 95% confidence interval 0.25-0.57). CONCLUSIONS: We implemented a novel multisite neonatal intubation registry and identified potentially modifiable factors associated with adverse events. Our results will inform future interventional studies to improve neonatal intubation safety.

Congenital Mesoblastic Nephroma Presenting With Refractory Hypertension in a Premature Neonate: A Case Study.

The most common nonencapsulated solid renal tumor in the neonatal period is congenital mesoblastic nephroma. Mesoblastic nephroma is a solid lesion originating within or extending from the renal parenchyma. These tumors proliferate rapidly, typically within 3-6 months after birth. Mesoblastic nephromas are stratified by classification as either classical (benign) or atypical (malignant); masses composed of both benign and malignant cells are also reported. The hallmark clinical manifestation of mesoblastic nephroma is a palpable abdominal mass, which may be accompanied by hypertension, hypercalcemia, hematuria, and polyuria. Differentiating between benign and malignant renal tumors is essential to invoke a timely, evidence-based management and treatment plan. With appropriate surgical intervention in a timely manner, prognosis is excellent and mesoblastic nephroma is considered curable. We present a case involving a premature infant with congenital mesoblastic nephroma with discussion of embryology, pathophysiology, diagnostic, management, and prognostic implications for the neonate and family.

Effect of Peer-to-Peer Nurse-Physician Collaboration on Attitudes Toward the Nurse-Physician Relationship.

The goal of this study was to pilot a novel peer-to-peer nurse-physician collaboration program and assess for changes in attitudes toward collaboration among a group of newly licensed nurses and resident physicians (n = 39). The program included large group meetings, with discussion of key concepts related to interprofessional collaboration. In unit-based teams, the registered nurses and physicians developed a quality improvement project to meet a need on their unit. Creating learning activities like this program enable nursing professional development specialists to promote interprofessional collaboration and learning.

Development of a Health Professions Education Research-Specific Institutional Review Board Template.

PROBLEM: Health professions education (HPE) has become a core component of the mission of academic health centers (AHCs) nationwide. The volume of HPE research projects being reviewed has increased, presenting new challenges for institutional review boards (IRBs). As HPE research becomes increasingly sophisticated in its design and methods, IRBs and researchers alike have a duty to better understand its unique characteristics. Researchers must be better able to conceptualize and describe their research to IRBs, and IRBs should be able to provide timely review and assure protection of research subjects (or participants). APPROACH: The creation of HPE research-specific IRB templates may be one way to improve the interactions between education researchers and IRBs. This report describes the development and early implementation of an HPE research-specific IRB template at Duke University from 2013 to 2014. OUTCOMES: Early adopters have noted increased ease of preparation and submission, while IRB staff have reported improved proposal clarity and more attention to protecting learners as research participants. Focus during educational or training sessions about the new template has shifted-from merely a description of the new submission process to a more comprehensive education series that includes discussion of regulatory definitions, examination of case studies, and opportunity for audience feedback. NEXT STEPS: Continued collection of quantitative and qualitative data regarding the implementation of this IRB template will help its developers more precisely describe its effects on HPE research projects. Formalizing and streamlining the interactions between HPE researchers and IRBs is an important goal for all AHCs.

Adverse Events After Routine Immunization of Extremely Low-Birth-Weight Infants.

IMPORTANCE: Immunization of extremely low-birth-weight (ELBW) infants in the neonatal intensive care unit (NICU) is associated with adverse events, including fever and apnea or bradycardia, in the immediate postimmunization period. These adverse events present a diagnostic dilemma for physicians, leading to the potential for immunization delay and sepsis evaluations. OBJECTIVE: To compare the incidence of sepsis evaluations, need for increased respiratory support, intubation, seizures, and death among immunized ELBW infants in the 3 days before and after immunization. DESIGN, SETTING, AND PARTICIPANTS: In this multicenter retrospective cohort study, we studied 13,926 ELBW infants born at 28 weeks' gestation or less who were discharged from January 1, 2007, through December 31, 2012, from 348 NICUs managed by the Pediatrix Medical Group. EXPOSURES: At least one immunization between the ages of 53 and 110 days. MAIN OUTCOMES AND MEASURES: Incidence of sepsis evaluations, need for increased respiratory support, intubation, seizures, and death. RESULTS: Most of the 13,926 infants (91.2%) received 3 or more immunizations. The incidence of sepsis evaluations increased from 5.4 per 1000 patient-days in the preimmunization period to 19.3 per 1000 patient-days in the postimmunization period (adjusted rate ratio [ARR], 3.7; 95% CI, 3.2-4.4). The need for increased respiratory support increased from 6.6 per 1000 patient-days in the preimmunization period to 14.0 per 1000 patient-days in the postimmunization period (ARR, 2.1; 95% CI, 1.9-2.5), and intubation increased from 2.0 per 1000 patient-days to 3.6 per 1000 patient-days (ARR, 1.7; 95% CI, 1.3-2.2). The postimmunization incidence of adverse events was similar across immunization types, including combination vaccines when compared with single-dose vaccines. Infants who were born at 23 to 24 weeks' gestation had a higher risk of sepsis evaluation and intubation after immunization. A prior history of sepsis was associated with higher risk of sepsis evaluation after immunization. CONCLUSIONS AND RELEVANCE: All ELBW infants in the NICU had an increased incidence of sepsis evaluations and increased respiratory support and intubation after routine immunization. Our findings provide no evidence to suggest that physicians should not use combination vaccines in ELBW infants. Further studies are needed to determine whether timing or spacing of immunization administrations confers risk for the developing adverse events and whether a prior history of sepsis confers risk for an altered immune response in ELBW infants.

Predicting neonatal intubation competency in trainees.

BACKGROUND AND OBJECTIVES: Pediatric residency training programs are graduating residents who are not competent in neonatal intubation, a vital skill needed for any pediatrician involved in delivery room resuscitations. However, a precise definition of competency during training is lacking. The objective of this study was to more precisely define the trajectory toward competency in neonatal intubation for pediatric residents, as a framework for later evaluating complementary training tools. METHODS: This is a retrospective single-center observational study of resident-performed neonatal intubations at Duke University Medical Center between 2005 and 2013. Using a Bayesian statistical model, intubation competency was defined when the resident attained a 75% likelihood of intubating their next patient successfully. RESULTS: A total of 477 unique intubation attempts by 105 residents were analyzed. The path to proficiency was defined by a categorical or milestone learning event after which all learners move toward competency in a similar manner. In our cohort, 4 cumulative successes were needed to achieve competency. Only 24 of 105 (23%) achieved competency during the study period. Residents who failed their first 2 opportunities, compared with those successful on their first 2 opportunities, needed nearly double the intubation exposure to achieve competency. CONCLUSIONS: Bayesian statistics may be useful to more precisely describe neonatal intubation competency in residents. Achieving competency in neonatal intubation appears to be a categorical or milestone learning event whose timing varies between residents. The current educational environment does not provide adequate procedural exposure to achieve competency for most residents.

Specificity of DNA-binding by the FAX-1 and NHR-67 nuclear receptors of Caenorhabditis elegans is partially mediated via a subclass-specific P-box residue.

BACKGROUND: The nuclear receptors of the NR2E class play important roles in pattern formation and nervous system development. Based on a phylogenetic analysis of DNA-binding domains, we define two conserved groups of orthologous NR2E genes: the NR2E1 subclass, which includes C. elegans nhr-67, Drosophila tailless and dissatisfaction, and vertebrate Tlx (NR2E2, NR2E4, NR2E1), and the NR2E3 subclass, which includes C. elegans fax-1 and vertebrate PNR (NR2E5, NR2E3). PNR and Tll nuclear receptors have been shown to bind the hexamer half-site AAGTCA, instead of the hexamer AGGTCA recognized by most other nuclear receptors, suggesting unique DNA-binding properties for NR2E class members. RESULTS: We show that NR2E3 subclass member FAX-1, unlike NHR-67 and other NR2E1 subclass members, binds to hexamer half-sites with relaxed specificity: it will bind hexamers with the sequence ANGTCA, although it prefers a purine to a pyrimidine at the second position. We use site-directed mutagenesis to demonstrate that the difference between FAX-1 and NHR-67 binding preference is partially mediated by a conserved subclass-specific asparagine or aspartate residue at position 19 of the DNA-binding domain. This amino acid position is part of the "P box" that plays a critical role in defining binding site specificity and has been shown to make hydrogen-bond contacts to the second position of the hexamer in co-crystal structures for other nuclear receptors. The relaxed specificity allows FAX-1 to bind a much larger repertoire of half-sites than NHR-67. While NR2E1 class proteins bind both monomeric and dimeric sites, the NR2E3 class proteins bind only dimeric sites. The presence of a single strong site adjacent to a very weak site allows dimeric FAX-1 binding, further increasing the number of dimeric binding sites to which FAX-1 may bind in vivo. CONCLUSION: These findings identify subclass-specific DNA-binding specificities and dimerization properties for the NR2E1 and NR2E3 subclasses. For the NR2E1 protein NHR-67, Asp-19 permits binding to AAGTCA half-sites, while Asn-19 permits binding to AGGTCA half-sites. The apparent conservation of DNA-binding properties between vertebrate and nematode NR2E receptors allows for the possibility of evolutionarily-conserved regulatory patterns.