Effects of an extubation readiness test protocol at a tertiary care fully outborn neonatal intensive care unit.

BACKGROUND AND OBJECTIVES: Extubation readiness testing (ERT) in the Neonatal Intensive Care Unit (NICU) is highly variable and lacking standardized criteria. To address this gap, an evidence-based, inter-professionally developed ERT protocol was implemented to assess effectiveness on extubation failure within 72 h and on duration of intubation (DOI). METHODS: A longitudinal retrospective chart review in a level III, fully outborn NICU, of intubated infants admitted 1-year prior (Group 1), and 1 year after implementation (Group 2). Patients were extubated if they passed a 2-stage ERT protocol (3 min continuous positive airway pressure (CPAP) followed by 7 min CPAP + pressure support). Descriptive, comparative statistics, and univariate and multiple logistic regression were completed on all patients and a ≤32 6/7 weeks subgroup (intubated at day-of-life 1); p < 0.05 is considered significant. RESULTS: All patients (n = 589 (n = 294 Group 1, n = 295 Group 2)) were included (preterm, intubated day of life one subgroup: n = 42 Group 1, n = 38 Group 2). For all patients, extubation failure decreased significantly from 9.9% to 4.1% (p = 0.006); Group 1 patients were 2.42 times more likely to experience extubation failure compared with Group 2. Extubation failure in the preterm subgroup decreased from 21.7% to 2.6% (p = 0.01); Group 1 patients were 10.71 times more likely to experience extubation failure. Median DOI was similar in both groups for all patients and in the preterm subgroup. CONCLUSIONS: A unique two-stage ERT protocol was effective at reducing extubation failure rate, without increasing DOI, largely in preterm infants. The evidence-based, interprofessionally developed ERT protocol and its integration into the NICU culture largely contributed to its success.

A Stewardship Program to Optimize the Use of Inhaled Nitric Oxide in Pediatric Critical Care.

PURPOSE: Inhaled nitric oxide (iNO) is a pulmonary vasodilator that is approved for use in term and near-term neonates with hypoxic respiratory failure associated with evidence of pulmonary hypertension. However, it is commonly used in infants and children to treat a variety of other cardiopulmonary diseases associated with pulmonary hypertension and hypoxic respiratory failure. In critically ill children, iNO therapy may be continued for a prolonged period, and this increases the risk for adverse consequences including toxicity and unnecessary costs. We implemented an iNO Stewardship Program with the aim of improving adherence to guidelines and reducing unnecessary iNO utilization. METHODS: Between April 1, 2011, and March 31, 2015, a before and after cohort study was conducted at The Hospital for Sick Children. Prospective iNO usage and outcome variables in the poststewardship period were examined. RESULTS: Patient characteristics and outcomes were similar before and after stewardship implementation. The number of iNO therapy courses were also similar in the before and after period. Inhaled nitric oxide utilization in the pediatric intensive care unit and the cardiac critical care unit decreased from 15 765 hours in the prestewardship period (April 2011 to March 2013) to 10 342 hours in the poststewardship period (April 2013 to March 2015), with significant improvement in adherence to the iNO guideline and a small decrease in expenditure (3%). CONCLUSION: Implementation of the iNO Stewardship was successful at reducing overall iNO utilization. This quality improvement initiative helped us optimize practice and subsequently expand the methodology to inform the clinical indication for iNO.

Impact of Stewardship on Inhaled Nitric Oxide Utilization in a Neonatal ICU.

OBJECTIVES: Inhaled nitric oxide (iNO) remains the "gold standard" therapy for hypoxemic respiratory failure in newborns. Despite good quality evidence to guide iNO use in this population, we observed considerable practice variation, particularly in timing and rate of weaning. To promote evidence-based practice, we launched an iNO stewardship program in April 2013. Our objective was to determine whether iNO stewardship led to changes in iNO utilization and weaning. METHODS: We conducted a quality improvement project in an outborn quaternary NICU, targeting improved iNO guideline compliance. We compared patterns of iNO utilization between 2 cohorts: prestewardship (April 2011-March 2013; retrospective data collection) and poststewardship (April 2013-March 2015; prospective data collection). RESULTS: Eighty-seven neonates received 88 courses of iNO in the 2 years prestewardship, and 64 neonates received 64 courses of iNO in the 2 years poststewardship. There were no significant differences (P > .05) in patient demographics, in the proportion of patients receiving iNO "off-label," in proportion initiated at the referring hospital, or in outcomes (death or extracorporeal membrane oxygenation). There were significant (P < .05) reductions in median total hours on iNO per patient (47 vs 20; P < .001), in iNO hours per patient from maximum dose to initial wean (28 vs 9; P < .01), and in hours from initial wean to discontinuation (14 vs 8; P < .05). CONCLUSIONS: The introduction of iNO stewardship was associated with improved adherence to evidence-based guidelines and an overall reduction in total and per-patient iNO use.

Is It Time to Review Guidelines for ETT Positioning in the NICU? SCEPTIC-Survey of Challenges Encountered in Placement of Endotracheal Tubes in Canadian NICUs.

Objectives. To examine current opinions and practices regarding endotracheal tube placement across several Canadian Neonatal Intensive Care Units. Design. Clinical directors from Canadian Neonatal Network affiliated NICUs and Neonatal-Perinatal Programs across Canada were invited via email to participate in and disseminate the online survey to staff neonatologists, neonatal fellows, respiratory therapists, and nurse practitioners. Result. There is wide variability in the beliefs and practices related to ETT placement. The majority use "weight +6" formula and "aim to black line" on ETT at vocal cords to estimate the depth of an oral ETT and reported estimation as challenging in ELBW infants. The majority agreed that mid-trachea is an ideal ETT tip position; however their preferred position on chest X-ray varied. Many believe that ETT positioning could be improved with more precise ETT markings. Conclusion. Further research should focus on developing more effective guidelines for ETT tip placement in the ELBW infants.

Vasopressin improves survival compared with epinephrine in a neonatal piglet model of asphyxial cardiac arrest.

BACKGROUND: Epinephrine is a component of all resuscitation algorithms. Vasopressin is a pulmonary vasodilator and systemic vasopressor. We investigated the effect of epinephrine vs. vasopressin on survival and hemodynamics after neonatal porcine cardiac arrest (CA). METHODS: A 4-min asphyxial CA was induced, after which cardiopulmonary resuscitation (CPR) was commenced. Animals were randomized to low- (LDE: 0.01 mg/kg) or high-dose epinephrine (HDE: 0.03 mg/kg), low- (LDV: 0.2 U/kg) or high-dose vasopressin (HDV: 0.4 U/kg), or control (saline). Clinical and echocardiography indexes were monitored. RESULTS: Sixty-nine animals were randomized. Survival was greater in HDV (n = 8 (89%); P < 0.05 ANOVA) vs. control (n = 7 (43%)) and LDE (n = 5 (36%)) but not vs. HDE (n = 7 (64%)) or LDV (n = 6 (75%)). Animals resuscitated with LDE required more shocks (2.5 (interquartile range: 2-6); P < 0.05) and higher doses of energy (15 J (interquartile range: 10-20); P < 0.05). Left ventricular output was comparable between groups, but a greater increase in superior vena caval flow was seen after HDV (P < 0.001 vs. control, LDE, and HDE). Plasma troponin was greatest in the HDE group (P < 0.05 vs. control and HDV). CONCLUSION: Vasopressin results in improved survival, lower postresuscitation troponin, and less hemodynamic compromise after CA in newborn piglets. Vasopressin may be a candidate for testing in human neonates.

Nasal high-frequency oscillation for lung carbon dioxide clearance in the newborn.

BACKGROUND: Noninvasive ventilation has been used increasingly in recent years to minimize the duration of endotracheal mechanical ventilation in neonates due to its association with lung injury. Nasal high-frequency oscillation (nHFO) is a relatively new noninvasive modality but evidence for its use is limited. OBJECTIVE: The goal of this study was to compare the CO2 clearance efficacy of nHFO and noninvasive positive pressure ventilation (NIPPV) in a neonatal lung model. DESIGN/METHODS: A newborn mannequin with dimensions and anatomy similar to a term infant was utilized. It was connected to a commercially available neonatal mechanical ventilator using a manufacturer-provided nasal adaptor. Various modes of noninvasive ventilation were compared as CO2 clearance was measured at the oropharynx by an end-tidal CO2 analyzer following the addition of a known amount of CO2 into the lung. Measurements were obtained at two different lung compliances using nHFO and compared with nCMV and nasal continuous positive airway pressure (nCPAP) as a control. Pressures near the nasal adaptor and the larynx were simultaneously measured with in-line pressure transducers. RESULTS: Whereas no CO2 elimination was observed under nCPAP, its clearance with nHFO was 3-fold greater as compared to NIPPV. On nHFO, CO2 clearance was inversely proportional to frequency and maximal at 6 and 8 Hz. At a lower lung compliance, CO2 clearance was significantly higher at 6 Hz as compared to 10 Hz. During nHFO set to deliver a MAP of 10.0, we documented pressures of 7.2 ± 0.3 at the nasal adaptor and only 2.3 ± 0.3 cm H2O at the larynx. CONCLUSIONS: Nasal HFO is effective and superior to NIPPV at lung CO2 elimination in a newborn mannequin model. The use of nHFO as the preferred mode of noninvasive ventilation warrants further clinical studies.