Cerebral Oxygenation during Neonatal Intubation with Nasal High Flow: A Sub-Study of the SHINE Randomized Trial.

INTRODUCTION: Nasal high flow (nHF) improves the likelihood of successful neonatal intubation on the first attempt without physiological instability. The effect of nHF on cerebral oxygenation is unknown. The aim of this study was to compare cerebral oxygenation during endotracheal intubation in neonates receiving nHF and those receiving standard care. METHODS: A sub-study of a multicentre randomized trial of nHF during neonatal endotracheal intubation. A subset of infants had near-infrared spectroscopy (NIRS) monitoring. Eligible infants were randomly assigned to nHF or standard care during the first intubation attempt. NIRS sensors provided continuous regional cerebral oxygen saturation (rScO2) monitoring. The procedure was video recorded, and peripheral oxygen saturation and rScO2 data were extracted at 2-second intervals. The primary outcome was the average difference in rScO2 from baseline during the first intubation attempt. Secondary outcomes included average rScO2 and rate of change of rScO2. RESULTS: Nineteen intubations were analyzed (11 nHF; 8 standard care). Median (interquartile range [IQR]) postmenstrual age was 27 (26.5-29) weeks, and weight was 828 (716-1,135) g. Median change in rScO2 from baseline was -1.5% (-5.3 to 0.0) in the nHF group and -9.4% (-19.6 to -4.5) in the standard care group. rScO2 fell more slowly in infants managed with nHF compared with standard care: median (IQR) rScO2 change -0.08 (-0.13 to 0.00) % per second and -0.36 (-0.66 to -0.22) % per second, respectively. CONCLUSIONS: In this small sub-study, regional cerebral oxygen saturation was more stable in neonates who received nHF during intubation compared with standard care.

Outpatient parenteral antimicrobial therapy: how young is too young?

OBJECTIVE: To report the use, and assess the efficacy and outcomes of outpatient parenteral antimicrobial therapy (OPAT) in neonates (≤28 days of age), compared with older infants (1-12 months of age). DESIGN: A prospective 8-year observational study from September 2012 to September 2020. SETTING: The Hospital-in-the-Home (HITH) programme of the Royal Children's Hospital Melbourne. PATIENTS: Neonatal patients (≤28 days of age) were compared with older infants (1-12 months of age) receiving OPAT. INTERVENTIONS: Data were collected including demographics, diagnosis, type of venous access and antibiotic choice. MAIN OUTCOME MEASURES: Success of OPAT, antibiotic appropriateness, complications and readmission rate. RESULTS: There were 76 episodes for which neonates were admitted to HITH for OPAT, and 405 episodes for older infants. Meningitis was the most common diagnosis in both groups (59% and 35%, respectively); the most frequently prescribed antibiotic was ceftriaxone for both groups (61% and 49%). A positive bacterial culture was less frequent in neonates (38% vs 53%, p=0.02). Vascular access complication rate was 19% in neonates compared with 13% in older infants (p=0.2) with no central line-associated bloodstream infection in either group. Rates of appropriate antibiotic prescribing were similarly high between groups (93% vs 90%, p=0.3). The OPAT course was successfully completed in 74 of 74 (100%) neonates and 380 of 396 (96%) older infants (p=0.09). The unplanned readmission rate was low: 4 of 76 (5%) neonates and 27 of 405 (7%) older infants. CONCLUSIONS: OPAT is a safe and effective way of providing antibiotics to selected clinically stable neonatal patients. While appropriate antibiotic use was common, improvements can still be made.

Time to desaturation in preterm infants undergoing endotracheal intubation.

BACKGROUND: Neonatal endotracheal intubation is often associated with physiological instability. The Neonatal Resuscitation Program recommends a time-based limit (30 s) for intubation attempts in the delivery room, but there are limited physiological data to support recommendations in the neonatal intensive care unit (NICU). We aimed to determine the time to desaturation after ceasing spontaneous or assisted breathing in preterm infants undergoing elective endotracheal intubation in the NICU. METHODS: Observational study at The Royal Women's Hospital, Melbourne. A secondary analysis was performed of video recordings of neonates ≤32 weeks' postmenstrual age undergoing elective intubation. Infants received premedication including atropine, a sedative and muscle relaxant. Apnoeic oxygenation time (AOT) was defined as the time from the last positive pressure or spontaneous breath until desaturation (SpO2 <90%). RESULTS: Seventy-eight infants were included. The median (IQR) gestational age at birth was 27 (26-29) weeks and birth weight 946 (773-1216) g. All but five neonates desaturated to SpO2 <90% (73/78, 94%). The median (IQR) AOT was 22 (14-32) s. The median (IQR) time from ceasing positive pressure ventilation to desaturation <80% was 35 (24-44) s and to desaturation <60% was 56 (42-68) s. No episodes of bradycardia were seen. CONCLUSIONS: This is the first study to report AOT in preterm infants. During intubation of preterm infants in the NICU, desaturation occurs quickly after cessation of positive pressure ventilation. These data are important for the development of clinical guidelines for neonatal intubation. TRIAL REGISTRATION NUMBER: ACTRN12614000709640.

Gas flow in preterm infants treated with bubble CPAP: an observational study.

OBJECTIVE: To measure the nasal gas flow in infants treated with bubble continuous positive airway pressure (CPAP) and compare it with commonly used flows during nasal high flow (nHF) treatment. DESIGN: This is a prospective, single-centre study. Bubble CPAP pressure was measured at the nasal prongs. Set gas flow was reduced until bubbling in the water chamber just ceased. Set gas flow without bubbling then approximated flow entering the infant's nose ('delivered flow'). SETTING: Neonatal intensive care at The Royal Women's Hospital, Melbourne, Australia. PATIENTS: Clinically stable preterm infants receiving bubble CPAP therapy. MAIN OUTCOME MEASURE: Delivered flow (L/min) when bubbling stopped at a range of clinically set CPAP pressures (cm H2O). RESULTS: Forty-four infants were studied, with a mean (SD) gestational age at birth of 28.4 (2.2) weeks and birth weight of 1154 (419) g. At the time of the study, infants had a median (IQR) age of 4.5 (2-12) days and a mean (SD) weight of 1205 (407) g. Delivered flow ranged from 0.5 to 9.0 L/min, and increased with higher set CPAP pressures (median 3.5 L/min at CPAP 5 cm H2O vs 6.3 L/min at CPAP 8 cm H2O) and heavier weights (median 3.5 L/min in infants <1000 g vs 6.5 L/min for infants >1500 g). CONCLUSIONS: Nasal gas flows during bubble CPAP in preterm infants are similar to flows used during nHF and increase with higher set bubble CPAP pressures and in larger infants. Trial registration number ACTRN12619000197134.

Recurrent fevers in children: TRAPS for young players.

We present the case of an 11-month-old girl who presented with recurrent febrile episodes and was found to have tumour necrosis factor receptor-associated periodic syndrome due to a novel mutation in the TNFRSF1A gene. The concept of autoinflammatory diseases is discussed and the management of this condition reviewed.