Introducing a novel respiratory function monitor for neonatal resuscitation training.

Background: A respiratory function monitor (RFM) gives immediate feedback, allowing clinicians to adjust face mask ventilation to correct leak or inappropriate tidal volumes. We audited the satisfaction of clinicians with a neonatal resuscitation training package, incorporating a novel RFM. Methods: This was a mixed-methods study conducted at The Royal Women's Hospital, Melbourne, Australia. Clinicians were approached to complete a neonatal resuscitation training session. Participants watched a training video, then provided ventilation to term and preterm manikins first without, and then with, the RFM. Clinicians completed a survey after the session and undertook a follow-up session three months later. The primary outcome was participant satisfaction with the RFM. Secondary outcomes included participants' self-assessment of face mask leak and tidal volumes when using the RFM. Results: Fifty clinicians completed both the initial and follow-up session. Participants reported high levels of satisfaction with the RFM for both term and preterm manikins: on a scale from 0, meaning "not at all", and 100, meaning "yes, for all resuscitations", the median response (interquartile range, IQR) was 82 (74-94) vs 81.5 (69-94.5). Levels of satisfaction were similar for less experienced and more experienced clinicians: median (IQR) 83 (77-93) vs 81 (71.5-95) respectively. When using the monitor, clinicians accurately self-assessed that they achieved leak below 30% and tidal volumes within the target range at least 80% of the time. Conclusion: Clinicians of all experience levels had a high level of satisfaction with a training package including a novel RFM.

Advanced analyses of physiological signals in the neonatal intensive care unit.

Management and monitoring of infants within the neonatal intensive care unit represents a unique challenge. It involves an array of life-threatening diseases, procedures with potentially lifelong impacts, co-morbidities associated with preterm birth and risk of infection from prolonged exposure to the hospital environment. With the integration of monitoring systems and increasing accessibility of high-resolution data, there is a growing interest in the utility of advanced data analyses in predictive monitoring and characterising patterns of disease. Such analyses may offer an opportunity to identify infants at high risk of certain conditions and to detect the onset of disease prior to manifestation of clinical signs. This allows caregivers more time to respond and mitigate any abnormal or potentially fatal changes. We review techniques for variability analysis as they have been or have the potential to be applied to neonatal intensive care, the disease conditions in which they have been tested, and technical as well as clinical challenges relevant to their application.

Ventilator-delivered mask ventilation compared with three standard methods of mask ventilation in a manikin model.

BACKGROUND: Little is known regarding the variations in effective ventilation during bag and mask resuscitation with standard methods compared with that delivered by ventilator-delivered mask ventilation (VDMV). AIM: To measure the variations in delivered airway pressure, tidal volume (TV), minute ventilation (MV) and inspiratory time during a 3-min period of mask ventilation comparing VDMV with three commonly used hand-delivered methods of bag and mask ventilation: Laerdal self-inflating bag (SIB); anaesthetic bag and T-piece Neopuff. METHODS: A modified resuscitation manikin was used to measure variation in mechanical ventilation during 3-min periods of mask ventilation. Thirty-six experienced practitioners gave positive pressure mask ventilation targeting acceptable chest wall movement with a rate of 60 inflations/min and when pressures could be targeted or set, a peak inspiratory pressure (PIP) of 18 cm water, positive end-expiratory pressure (PEEP) of 5 cm water, for 3 min with each of the four mask ventilation methods. Each mode was randomly sequenced. RESULTS: A total of 21 136 inflations were recorded and analysed. VDMV achieved PIP and PEEP closest to that targeted and significantly lower variation in all measured parameters (p<0.001) other than with PIP. SIB delivered TV and MV over twice that delivered by VDMV and Neopuff. CONCLUSION: During 3-min periods of mask ventilation on a manikin, VDMV produced the least variation in delivered ventilation. SIB produced wide variation and unacceptably high TV and MV in experienced hands.

Mask leak in one-person mask ventilation compared to two-person in newborn infant manikin study.

AIM: To compare a new two-person method (four hands) of delivering mask ventilation with a standard one-person method using the Laerdal self-inflating bag (SIB) and the Neopuff (NP) infant resuscitator in a manikin model. BACKGROUND: Recent studies of simulated neonatal resuscitation using bag and mask ventilation techniques have shown facemask leak levels of 55-57% in expert hands. METHODS: 48 participants were randomly paired and instructed to give mask ventilation for a 2-min period as single-person resuscitators, then as two-person paired resuscitators at set pressures for NP and set parameters for SIB. Airway pressure, flow, inspiratory tidal volume, expiratory tidal volume and mask leak were recorded. RESULTS: A total of 21 578 inflations were recorded and analysed. For SIB, mask leak was greater (11.5%) with single-person compared to two-person (5.4%; mean difference 6.1%, 95% CI 1.5 to 10.7, p<0.01). For NP, mask leak was greater for single-person (22.2%) compared to two-person (9.1%; mean difference 13.1% 95% CI 3.6 to 22.6, p<0.01). For single-person mask ventilation, mask leak was greater with NP (22.2%) compared to SIB (11.5%; mean difference 10.7%, 95% CI 1.4 to 19.7, p<0.01). For two-person mask ventilation, mask leak was greater for NP (9.1%) compared to SIB (5.4%; mean difference 3.7%, 95% CI 0.1 to 6.4, p<0.05). CONCLUSIONS: Two-person mask ventilation technique reduces mask leak by approximately 50% compared to the standard one-person mask ventilation method. NP mask ventilation has higher mask leak than Laerdal SIB for both single- and two-person technique mask ventilation.

Does caffeine impair cerebral oxygenation and blood flow velocity in preterm infants?

AIM: The aim of the study is to assess the effects of an intravenous 10 mg/kg loading dose of caffeine base in cerebral oxygenation, cerebral Doppler blood flow velocity and cardiac output in preterm infants. METHODS: Preterm neonates <34 weeks gestation were investigated at 1 and 4 h following the loading dose of caffeine using Doppler cerebral sonography, cardiac echocardiography and cerebral spatially resolved near-infrared spectroscopy. RESULTS: Forty infants were studied with a mean gestational age (mean ± standard deviation) of 27.7 (±2.5) weeks, birth weight of 1155 (±431) g and a postnatal age of 2.8 (±2.2) days. Mean Anterior Cerebral Artery peak and time average mean blood flow velocity fell significantly by 14% and 17.7%, respectively at 1 h post-caffeine loading dose, which recovered partially by 4 h. Cerebral Tissue Oxygenation Index fell from pre-dose levels by 9.5% at 1 h with partial recovery to 4.9% reduced at 4 h post-dose. There were no significant changes in left or right ventricular output, transcutaneous oxygen saturation, transcutaneous PCO(2) or total vascular resistance. CONCLUSIONS: A loading dose of 10 mg/kg caffeine base resulted in significant reduction at 1 h post-dose in cerebral oxygenation and cerebral blood flow velocity with partial recovery at 4 h.

Spontaneous preterm birth of liveborn infants in women at low risk in Australia over 10 years: a population-based study.

OBJECTIVES: To describe a 10-year trend in preterm birth. DESIGN: Population-based study. SETTING: Australia. POPULATION: All women who gave birth during 1994-03. METHODS: The proportion of spontaneous preterm births (greater than or equal to 22 weeks of gestation and less than 37 completed weeks of gestation) was calculated by dividing the number of women who had a live spontaneous preterm birth (excluding elective caesarean section and induction of labour) by the total number of women who had a live birth after spontaneous onset of labour (excluding elective caesarean section and induction of labour). This method was repeated for the selected population of women at low risk. MAIN OUTCOME MEASURE: Preterm birth rates among the overall population of women; preterm birth among all women with a spontaneous onset of labour; and preterm birth in a selected population of women who were either primiparous or multiparous, non-Indigenous; aged 20-40 years and who gave birth to a live singleton baby after the spontaneous onset of labour. RESULTS: Over the 10-year study period, the proportion of all women having a live preterm birth in Australia increased by 12.1% (from 5.9% in 1994 to 6.6% in 2003). Among women with a spontaneous onset of labour, there was an increase of 18.3% (from 5.7 to 6.7%). Among the selected population of low-risk women after the spontaneous onset of labour, the rate increased by 10.7% (from 5.6 to 6.2%) among first time mothers and by 19.2% (4.4-5.2%) among selected multiparous women. CONCLUSIONS: Over the 10-year period of 1994-03, the rate of spontaneous preterm birth among low-risk women having a live singleton birth has risen in Australia.

A new method for rapid measurement of lactate in fetal and neonatal blood.

A prospective trial to determine the accuracy and precision of the Boehringer Mannheim Accusport handheld lactate meter in measuring plasma lactate levels in umbilical cord blood and neonatal blood microsamples was performed in the labour ward and the neonatal intensive care unit of the NepeanHospital. Specimens were collected from the umbilical artery of 160 consecutive deliveries covering gestations from 26 to 42 weeks, and from 110 umbilical artery catheters covering a range of gestations from 26 to 41 weeks. Serum was also obtained from an exchange transfusion for coefficient of variation analysis. Blood was simultaneously tested for lactic acid concentration on the Boehringer Mannheim (BM) Accusport held lactate meter and the Radiometer ABL 625 blood-gas machine. Clinical data from the mother and baby were recorded together with the full blood-gas analysis for comparison with the lactate measures. Coefficients of variation for the BM Accusport lactate meter were established by a further 120 samples of plasma lactate at 6 concentrations from 1 to 20 mmol/L. The stability of measurements with the BM lactate meter over a wide range of temperatures was ascertained by repeated sampling of known concentrations of plasma lactate from 0.5 degrees C to 37 degrees C. The BM Accusport lactate meter was found to be accurate from 1 mmol/L to 20 mmol/L with a Passing Bablok regression line y = 0.004 + 0.915 x (95% CI of slope of 0.889 to 0.946 and intercept -0.138 to 0.094) for whole blood, and y = 0.200 + 1.000 x (95% CI of slope 0.989 to 1.018 and intercept 0.080 to 0.222) for plasma. Between run coefficient of variation (CV) was calculated to be 1.23% to 5.53% over the clinically significant range (2.2-19.3 mmol/L). The BM lactate meter was accurate from 5 to 37 degrees C. At 0.5 degrees C the BM lactate meter significantly underestimated the plasma lactate concentration. There was no significant effect of haematocrit (41.5 to 62%), gestation, or operator on the accuracy of the BM lactate meter. The Accusport handheld lactate meter is an accurate, commercially available, method of measuring plasma lactate levels in only 60 seconds at the point-of-care. It requires only 15 microL of blood and is significantly cheaper than other assay methods. The BM lactate meter is well suited to assess lactic acidaemia of fetal scalp and neonatal blood samples to help quantify hypoxic stress in the perinatal period.

Family support, financial needs, and health care needs of rural elderly in China: a field study.

This study examined family support, financial needs, and health care needs of 100 elderly persons in a rural county in China. Data revealed that immediate family members helped elderly persons with activities of daily living and instrumental activities of daily living, and that adult children also provided financial assistance to most of the elderly. However, only eight percent of the elderly persons reported that they had adequate financial resources. In the four villages surveyed, collective health care systems had collapsed in the early 1980's. Due to high costs of health care and the absence of government support, almost two thirds of the elderly persons had unmet needs for health care. In addition, elderly persons who reported poor health were more likely to have unmet financial and health care needs.

Health care and family support systems of functionally impaired rural elderly men and women in Terengganu, Malaysia.

This article examines the health and social support systems of a small survey sample of rural, low-income, functionally impaired elderly persons in the state of Terengganu, Malaysia. Increases in the number and proportion of the elderly are a growing concern, especially in rural areas where there are indications that traditional care givers (daughters) for the elderly are migrating to urban areas. The out-migration patterns in this survey, however, were less than expected. In general, the needs of the respondents are being met by multiple in-kind assistance from adult children, spouses, relatives, friends and neighbors bolstered by free government health care and cash assistance programs. The survey does raise serious concerns regarding the utilization of health care facilities by women, the negative impact of detrimental myths about aging, and the need for more visiting nurses and mobile clinics.

World developments and trends in social security.

A survey of developments in the social security systems of more than 125 countries from 1971 to 1975 found that most programs are undergoing significant growth. This pattern is reflected primarily by the adoption of additional programs and new provisions designed to raise benefit levels, provide flexibility in retirement practices, expand coverage, and cope with demographic changes, inflationary trends, and growing costs. The new measures tend to extend the role of social security programs through providing a greater proportion of the population with more comprehensive protection and setting higher benefit rates to replace income lost because of old age, disability, sickness, work injury, unemployment, or death.