Laryngeal mask airway in neonatal stabilization and transport: a retrospective study.

Laryngeal mask airway (LMA) may be considered by health caregivers of level I-II hospitals for neonatal resuscitation and stabilization before and during interhospital care, but literature provides little information on this aspect. This study reviewed the use of LMA during stabilization and transport in a large series of neonates. This is a retrospective study evaluating the use of LMA in infants who underwent emergency transport by the Eastern Veneto Neonatal Emergency Transport Service between January 2003 and December 2021. All data were obtained from transport registry, transport forms, and hospital charts. In total, 64/3252 transferred neonates (2%) received positive pressure ventilation with an LMA, with increasing trend over time (p = 0.001). Most of these neonates were transferred after birth (97%), due to a respiratory or neurologic disease (95%). LMA was used before the transport (n = 60), during the transport (n = 1), or both (n = 3). No device-related adverse effects were recorded. Sixty-one neonates (95%) survived and were discharged/transferred from the receiving center. CONCLUSION: In a large series of transferred neonates, LMA use during stabilization and transport was rare but increasing over time, and showed some heterogeneity among referring centers. In our series, LMA was safe and lifesaving in "cannot intubate, cannot oxygenate" situations. Future prospective, multicenter research may provide detailed insights on LMA use in neonates needing postnatal transport. WHAT IS KNOWN: • A supraglottic airway device may be used as an alternative to face mask and endotracheal tube during neonatal resuscitation. • The laryngeal mask may be considered by health caregivers of low-level hospitals with limited exposure on airway management, but literature provides little information on this aspect. WHAT IS NEW: • In a large series of transferred neonates, laryngeal mask use was rare but increasing over time, and showed some heterogeneity among referring centers. • The laryngeal mask was safe and lifesaving in "cannot intubate, cannot oxygenate" situations.

Trends in neonatal emergency transport in the last two decades.

Although maternal antenatal transfer is the preferred option, some infants inevitably need urgent transport to a tertiary neonatal care facility after birth. This study aimed to investigate trends over time in patient characteristics and respiratory management in a large series of neonatal emergency transfers, in order to provide health caregivers an up-to-date profile of such patients and their therapeutic needs. Trends in patient characteristics and respiratory management were evaluated in 3337 transfers by the Eastern Veneto Neonatal Emergency Transport Service in 2000-2019. Joinpoint regression analysis was performed to evaluate trends and to estimate annual percentage changes (APCs). Proportions of preterm neonates increased (APC2000-2012 2.25%), then decreased (APC2012-2019 - 6.04%). Transfers at birth increased (APC2000-2013 2.69%), then decreased (APC2013-2019 - 5.76%). Proportion of neonates with cardiac and surgical diseases declined (APCs2000-2019 - 6.82% and - 3.32%), while proportion of neonates with neurologic diseases increased (APC2000-2019 8.62%). Use of nasal-continuous-positive-airway-pressure (APC2000-2019 9.72%) and high-flow-nasal-cannula (APC2007-2019 58.51%) at call, and nasal-continuous-positive-airway-pressure (APC2000-2019 13.87%) and nasal-intermittent-mandatory-ventilation (APC2000-2019 32.46%) during transfer increased. Mechanical ventilation during transfer decreased (APC2014-2019 - 10.77%). Use of oxygen concentrations at 21% increased at call and during transfer (APCs 2000-2019 2.24% and 2.44%), while oxygen concentrations above 40% decreased at call and during transfer (APCs 2000-2019 - 3.93% and - 5.12%).Conclusion: Our findings revealed a shift toward a more "gentle" approach and the reduced use of oxygen in respiratory management. Equipment and team expertise should meet the requirements of such changing patients and their therapeutic needs. What is Known: • Although antenatal transfer is the preferred option, some infants inevitably need urgent transport to a tertiary neonatal care facility after birth. • Trend studies investigating cohort information with appropriate statistical methods represent useful instruments to detect changes over time. What is New: • Our findings revealed marked changes in patient characteristics and respiratory management in a large series of neonatal emergency transfers during the last two decades. • Equipment and team expertise should meet the requirements of such changing patients and their therapeutic needs.

Time needed to intubate and suction a manikin prior to instituting positive pressure ventilation: a simulation trial.

Tracheal suctioning in non-vigorous newborn delivered through meconium-stained amniotic fluid (MSAF) is supposed to delay initiation of positive pressure ventilation (PPV), but the magnitude of such delay is unknown. To compare the time of PPV initiation when performing immediate laryngoscopy with intubation and suctioning vs. performing immediate PPV without intubation in a manikin model. Randomized controlled crossover (AB/BA) trial comparing PPV initiation with or without endotracheal suctioning in a manikin model of non-vigorous neonates born through MSAF. Participants were 20 neonatologists and 20 pediatric residents trained in advanced airway management. Timing of PPV initiation was longer with vs. without endotracheal suctioning in both pediatric residents (mean difference 13 s, 95% confidence interval 8 to 18 s; p < 0.0001) and neonatologists (mean difference 12 s, 95% confidence interval 8 to 16 s; p < 0.0001). The difference in timing of PPV initiation was similar between pediatric residents and neonatologists (mean difference - 1 s, 95% confidence interval - 7 to 6 s; p = 0.85).Conclusions: Performing immediate laryngoscopy with intubation and suctioning was associated with longer-but not clinically relevant-time of initiation of PPV compared with immediate PPV without intubation in a manikin model. While suggesting negligible delay in starting PPV, further studies in a clinical setting are warranted.Registration: clinicaltrial.gov NCT04076189. What is Known: • Management of the non-vigorous newborn delivered through meconium-stained amniotic fluid remains still controversial. • Tracheal suctioning in non-vigorous newborn delivered through meconium-stained amniotic fluid is supposed to delay initiation of positive pressure ventilation, but the magnitude of such delay is unknown. What is New: • Performing immediate ventilation without intubation was associated with shorter-but not clinically relevant-time of initiation of ventilation compared to immediate laryngoscopy with intubation and suctioning in a manikin model. • Further studies in a clinical setting are warranted.

HandS ECMO: Preliminary Experience With "Hub and Spoke" Model in Neonates With Meconium Aspiration Syndrome.

We aim to evaluate clinical outcomes of emergent extracorporeal membrane oxygenation (ECMO) implantation in newborns with life-threatening meconium aspiration syndrome (MAS) in peripheral hospitals with Hub and Spoke (HandS) setting. We retrospectively reviewed all neonates presenting with MAS, with no other comorbidities, treated with HandS ECMO, in peripheral hospitals. Team activation time (TAT) was described as the time from first alerting call to ECMO support initiation. From May 2014 to December 2016, 4 patients met our inclusion criteria. In addition, 2 cases occurred on the same day, requiring a second simultaneous HandS ECMO team activation. All patients were younger than 8 days of life (1, 1, 4, and 7), with a mean BSA 0.21 ± 0.03m2 , and TAT of 203, 265, 320, and 340 min. One patient presented ventricular fibrillation after priming administration. Veno-arterial ECMO was established in all patients after uneventful surgical neck vessels cannulation (right carotid artery and jugular vein). Mean time from skin incision to ECMO initiation was 19 ± 1.4 min. Mean length of ECMO support was 2.75 ± 1.3 days. All patients were weaned off support without complications. At a mean follow up of 20.5 ± 7.8 months, all patients are alive, with no medications, normal somatic growth, and neuropsychological development. MAS is a life-threatening condition that can be successfully managed with ECMO support. A highly trained multidisciplinary HandS ECMO team is crucial for the successful management of these severely ill newborns in peripheral hospitals.

Time Perception during Neonatal Resuscitation.

OBJECTIVE: To assess the accuracy of time perception during a simulated complex neonatal resuscitation. STUDY DESIGN: Participants in 5 neonatal resuscitation program courses were directly involved in a complex simulation scenario. They were asked to assume the role of team leader, assistant 1, or assistant 2. At the end of the scenario, each participant completed a questionnaire on perceived time intervals for key resuscitation interventions. During the scenario, actual times were documented by an external observer and video recorded for later review. In addition, participants were asked to evaluate their self-perceived level of stress and preparation. RESULTS: Health care providers (68 physicians and 40 nurses) were involved in 36 scenarios. Perceived time intervals for the initiation of key resuscitation interventions were shorter than the actual time intervals, regardless of the participant's role in the scenario. Self-assessed levels of stress and preparation did not influence time perception. CONCLUSIONS: Health care providers underestimate the passage of time, irrespective of their role in a simulated complex neonatal resuscitation. Participant's self-assessed levels of stress and preparation were not related to the accuracy of their time perception. These findings highlight the importance of assigning a dedicated individual to document interventions and the passage of time during a neonatal resuscitation.

Supreme Laryngeal Mask Airway versus Face Mask during Neonatal Resuscitation: A Randomized Controlled Trial.

OBJECTIVE: To assess the effectiveness of supreme laryngeal mask airway (SLMA) over face mask ventilation for preventing need for endotracheal intubation at birth. STUDY DESIGN: We report a prospective, randomized, parallel 1:1, unblinded, controlled trial. After a short-term educational intervention on SLMA use, infants ≥34-week gestation and/or expected birth weight ≥1500 g requiring positive pressure ventilation (PPV) at birth were randomized to resuscitation by SLMA or face mask. The primary outcome was the success rate of the resuscitation devices (SLMA or face mask) defined as the achievement of an effective PPV preventing the need for endotracheal intubation. RESULTS: We enrolled 142 patients (71 in SLMA and 71 in face mask group, respectively). Successful resuscitation rate was significantly higher with the SLMA compared with face mask ventilation (91.5% vs 78.9%; P = .03). Apgar score at 5 minutes was significantly higher in SLMA than in face mask group (P = .02). Neonatal intensive care unit admission rate was significantly lower in SLMA than in face mask group (P = .02). No complications related to the procedure occurred. CONCLUSIONS: In newborns with gestational age ≥34 weeks and/or expected birth weight ≥1500 g needing PPV at birth, the SLMA is more effective than face mask to prevent endotracheal intubation. The SLMA is effective in clinical practice after a short-term educational intervention. TRIAL REGISTRATION: Registered with ClinicalTrials.gov: NCT01963936.

Total body polyethylene wraps for preventing hypothermia in preterm infants: a randomized trial.

OBJECTIVE: To evaluate whether a polyethylene total body wrapping (covering both the body and head) is more effective than conventional treatment (covering up to the shoulders) in reducing perinatal thermal losses in very preterm infants. STUDY DESIGN: This was a multicenter, prospective, randomized, parallel 1:1, unblinded, controlled trial of infants<29 weeks' gestation age, comprising two study groups: experimental group (total body group; both the body and head covered with a polyethylene occlusive bag, with the face uncovered) and control group (only the body, up to the shoulders, covered with a polyethylene occlusive bag). The primary outcome was axillary temperature on neonatal intensive care unit admission immediately after wrap removal. RESULTS: One hundred randomly allocated infants (50 in the total body group and 50 controls) completed the study. Mean axillary temperature on neonatal intensive care unit admission was similar in the two groups (36.5±0.6°C total body vs 36.4±0.8°C controls; P=.53). The rate of moderate hypothermia (temperature<36°C) was 12% in the total body group and 20% in the control group (P=.41). Three subjects in each group (6.0%) had an axillary temperature>37.5°C on admission, and one subject in control group had an axillary temperature>38°C. CONCLUSION: Total body wrapping is comparable with covering the body up to the shoulders in preventing postnatal thermal losses in very preterm infants.

Delivery room management of extremely low birthweight infants shows marked geographical variations in Italy.

AIM: To evaluate any geographical variations in practice and adherence to international guidelines for early delivery room management of extremely low birthweight (ELBW) infants in the North, Centre and South of Italy. METHODS: A questionnaire was sent to all 107 directors of Italian level III centres between April and August 2012. RESULTS: There was a 92% (n = 98) response rate. A polyethylene bag/wrap was used by 54 centres (55.1%), with the highest rate in Northern Italy (77.5%) and the lowest rate in Southern (37.7%) areas. In Northern regions, one centre (2.5%) said it used oxygen concentrations >40% to initiate positive pressure ventilation in ELBW infants. These proportions were higher in the Central (14.3%) and Southern (16.2%) areas. A T-piece device for positive pressure ventilation was more frequently available in the Northern (95%) units than in those in the Central (66.7%) and Southern (69.4%) regions. A median of 13% (IQR: 5%-30%) of ELBW infants received chest compressions at birth in Italy: 5%, 18% and 22% in Northern, Central and Southern units, respectively. CONCLUSION: In Italy, delivery room management of ELBW infants showed marked geographical variations. Implementation of national training programmes could increase adherence to the guidelines and reduce such discordance.

A Simulation Competition on Neonatal Resuscitation as a New Educational Tool for Pediatric Residents.

BACKGROUND: Training programs on resuscitation have been developed using simulation-based learning to build skills, strengthen cognitive strategies, and improve team performance. This is especially important for residency programs where reduced working hours and high numbers of residents can reduce the educational opportunities during the residency, with lower exposure to practical procedures and prolonged length of training. Within this context, gamification has gained popularity in teaching and learning activities. This report describes the implementation of a competition format in the context of newborn resuscitation and participants' perceptions of the educational experience. METHODS: Thirty-one teams of three Italian pediatric residents participated in a 3-day simulation competition on neonatal resuscitation. The event included an introductory lecture, familiarization time, and competition time in a tournament-like structure using high-fidelity simulation stations. Each match was evaluated by experts in neonatal resuscitation and followed by a debriefing. The scenarios and debriefings of simulation station #1 were live broadcasted in the central auditorium where teams not currently competing could observe. At the end of the event, participants received an online survey regarding their perceptions of the educational experience. RESULTS: 81/93 (87%) participants completed the survey. Training before the event mostly included reviewing protocols and textbooks. Low-fidelity manikins were the most available simulation tools at the residency programs. Overall, the participants were satisfied with the event and appreciated the live broadcast of scenarios and debriefings in the auditorium. Most participants felt that the event improved their knowledge and self-confidence and stimulated them to be more involved in high-fidelity simulations. Suggested areas of improvement included more time for familiarization and improved communication between judges and participants during the debriefing. CONCLUSIONS: Participants appreciated the simulation competition. They self-perceived the educational impact of the event and felt that it improved their knowledge and self-confidence. Our findings suggest areas of improvements for further editions and may serve as an educational model for other institutions.

Surfactant Treatment of Late Preterm Infants during Emergency Transport: A Retrospective, Observational Study.

BACKGROUND: In late preterm infants born in nontertiary hospitals, the occurrence of respiratory distress syndrome requires postnatal transport. This study aimed to investigate the impact of the timing of surfactant administration in late preterm infants needing postnatal transport. METHODS: This is a retrospective study evaluating surfactant administration in late preterm infants during emergency transports by the Eastern Veneto Neonatal Emergency Transport Service between January 2005 and December 2019. The outcome measures included short-term clinical complications, stabilization time, oxygen concentration, duration of mechanical ventilation and noninvasive respiratory support, length of hospital stay, bronchopulmonary dysplasia, intraventricular hemorrhage, and sepsis. RESULTS: Surfactant was administered to 155/303 neonates (51.1%) at 3 different time points: at a referring hospital (50 neonates), when the transport team arrived (25 neonates), or at a referral hospital (80 neonates). Stabilization time was longer in neonates receiving surfactant by the transport team (adjusted mean difference 17 min, 95% confidence interval, 4-29 min; p = 0.01). Decrease in oxygen concentrations during the transport was larger in neonates receiving surfactant at a referring hospital (adjusted mean difference -11%, 95% confidence interval, -15 to -3%; p = 0.01). The other outcome measures were not statistically different according to the timing of surfactant administration. CONCLUSIONS: In late preterm infants with respiratory distress needing postnatal transfer, stabilization time was longer when the first surfactant was administered by the transport team, but such delay did not affect safety and clinical outcomes.

The "Hub and Spoke" (HandS) ECMO for "Resuscitating" Neonates with Respiratory Life-Threatening Conditions.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) implantation for neonates with severe cardiorespiratory life-threatening conditions is highly effective. However, since ECMO is a high-risk and complex therapy, this treatment is usually performed in centers with proven expertise. METHODS: A retrospective review of neonates, from January 2014 to January 2020, presenting with life-threatening conditions and treated by means of Hub and Spoke (HandS) ECMO in peripheral (spoke) hospitals. Data were retrieved from our internal ECMO registry. Protocols and checklists were revised and shared with all spoke hospitals located in North-Eastern Italy. RESULTS: Eleven neonates receiving maximal respiratory and cardiovascular support at a spoke hospital underwent HandS ECMO management. All but three patients were affected by life-threatening meconium aspiration syndrome (MAS). The median ECMO support duration and hospitalization were four (range 2-32) and 30 days (range 8-50), respectively. All but two patients (with congenital diaphragmatic hernia), were weaned off ECMO and discharged home. At a mean follow up of 33.7 ± 29.2 months, all survivors were alive and well, without medications, and normal somatic growth. All but one had normal neuropsychological development. CONCLUSION: HandS ECMO model for neonates with life-threatening conditions is effective and successful. A specialized multidisciplinary team and close cooperation between Hub and Spoke centers are essential for success.

Trends in respiratory management of transferred very preterm infants in the last two decades.

BACKGROUND: Among infants needing urgent transfer after birth, very preterm infants are a high-risk sub-group requiring special attention. This study aimed to assess trends in early respiratory management in a large series of very preterm infants undergoing postnatal transfer. METHODS: Trends in patient characteristics and early respiratory management were assessed in 798 very preterm infants who were transferred by the Eastern Veneto Neonatal Emergency Transport Service in 2000-2019. Trends were analyzed using joinpoint regression analysis and summarized as annual percentage changes (APCs). RESULTS: Proportion of neonates with birth weight less than 1 kg decreased from 33% to 16% (APC -3.82%). Use of nasal-continuous-positive-airway pressure increased (at call: APC 15.39%; during transfer: APC 15.60%), while use of self-inflating bag (at call: APC -12.09%), oxygen therapy (at call: APC -13.00%; during transfer: APC -23.77%) and mechanical ventilation (at call: APC -2.71%; during transfer: APC -2.99%) decreased. Use of oxygen concentrations at 21% increased (at call: APC 6.26%; during transfer: APC 7.14%), while oxygen concentrations above 40% decreased (at call: APC -5.73%; at transfer APC -8.89%). Surfactant administration at call increased (APC 3%-10%), while surfactant administration when arriving at referring hospital remained around 7-11% (APC 2.55%). CONCLUSION: Relevant trends toward "gentle" approaches in early respiratory management of very preterm infants undergoing postnatal transfer occurred during the last twenty years. In addition, the proportion of transferred extremely low birth weight infants halved. Clinicians and stakeholders should consider such information when allocating assets to both hospitals and transfer services and planning regional perinatal programs.

Thermal management with and without servo-controlled system in preterm infants immediately after birth: a multicentre, randomised controlled study.

BACKGROUND: The thermal servo-controlled systems are routinely used in neonatal intensive care units (NICUs) to accurately manage patient temperature, but their role during the immediate postnatal phase has not been previously assessed. OBJECTIVE: To compare two modalities of thermal management (with and without the use of a servo-controlled system) immediately after birth. STUDY DESIGN AND SETTING: Multicentre, unblinded, randomised trial conducted 15 Italian tertiary hospitals. PARTICIPANTS: Infants with estimated birth weight <1500 g and/or gestational age <30+6 weeks. INTERVENTION: Thermal management with or without a thermal servo-controlled system during stabilisation in the delivery room. PRIMARY OUTCOME: Proportion of normothermia at NICU admission (axillary temperature 36.5°C-37.5°C). RESULTS: At NICU admission, normothermia was achieved in 89/225 neonates (39.6%) with the thermal servo-controlled system and 95/225 neonates (42.2%) without the thermal servo-controlled system (risk ratio 0.94, 95% CI 0.75 to 1.17). Thermal servo-controlled system was associated with increased mild hypothermia (36°C-36.4°C) (risk ratio 1.48, 95% CI 1.09 to 2.01). CONCLUSIONS: In very low birthweight infants, thermal management with the servo-controlled system conferred no advantage in maintaining normothermia at NICU admission, while it was associated with increased mild hypothermia. Thermal management of preterm infants immediately after birth remains a challenge. TRIAL REGISTRATION NUMBER: NCT03844204.

Heat loss prevention in very preterm infants in delivery rooms: a prospective, randomized, controlled trial of polyethylene caps.

OBJECTIVE: To evaluate in preterm infants whether polyethylene caps prevent heat loss after delivery better than polyethylene occlusive wrapping and conventional drying. STUDY DESIGN: This was a prospective, randomized, controlled trial of infants <29 weeks' gestation including 3 study groups: (1) experimental group in which the heads of patients were covered with a polyethylene cap; (2) polyethylene occlusive skin wrap group; and (3) control group in which infants were dried. Axillary temperatures were compared at the time of admission to the neonatal intensive care unit (NICU) immediately after cap and wrap removal and 1 hour later. RESULTS: The 96 infants randomly assigned (32 covered with caps, 32 wrapped, 32 control) completed the study. Mean axillary temperature on NICU admission was similar in the cap group (36.1 degrees C +/- 0.8 degrees C) and wrap group (35.8 degrees C +/- 0.9 degrees C), and temperatures on admission to the NICU were significantly higher than in the control group (35.3 degrees C +/- 0.8 degrees C; P < .01). Infants covered with polyethylene caps (43%) and placed in polyethylene bags (62%) were less likely to have a temperature <36.4 degrees C on admission to the NICU than control infants (90%). In the cap group, temperature 1 hour after admission was significantly higher than in the control group. CONCLUSIONS: For very preterm infants, polyethylene caps are comparable with polyethylene occlusive skin wrapping to prevent heat loss after delivery. Both these methods are more effective than conventional treatment.

Neonatal Resuscitation Where the Mother Has a Suspected or Confirmed Novel Coronavirus (SARS-CoV-2) Infection: Suggestion for a Pragmatic Action Plan.

Coronavirus disease 2019 (COVID-19), caused by the novel SARS-CoV-2 virus, is rapidly spreading across the world. As the number of infections increases, those of infected pregnant women and children will rise as well. Controversy exists whether COVID-19 can be transmitted in utero and lead to disease in the newborn. As this chance cannot be ruled out, strict instructions for the management of mothers and newborn infants are mandatory. This perspective aims to be a practical support tool for the planning of delivery and neonatal resuscitation of infants born by mothers with suspected or confirmed COVID-19 infection.

Knowledge and practical performance gained by Iraqi residents after participation to a neonatal resuscitation program course.

AIM: Neonatal resuscitation program (NRP) course is effective in improving knowledge in participants coming from developed as well as developing countries; however, its impact on practical performances has not been yet formally evaluated in participants coming from developing countries. We evaluate the knowledge and the performance on clinical simulations gained by Iraqi residents following participation in the NRP course. METHODS: A 71-item questionnaire derived from the standard test contained in the American Heart Association and American Academy of Pediatrics Neonatal Resuscitation Manual was administered to participants before and after the course. All participants were tested with a final Mega code (Mega code A scenario-NRP textbook) to evaluate their performance on clinical simulations. RESULTS: Twenty-six obstetrical and 2 pediatric residents participated in the NRP course, respectively. The percentages of correct answers significantly improved from before (52 +/- 14%) to immediately after the course (85 +/- 7%); p < 0.001. Mean score obtained at the final Mega code was 68 +/- 8%. Four out of 28 (14%) participants reached the minimum score required for passing the exam (80%). CONCLUSION: Residents coming from a developing country (Iraq) significantly improved their knowledge attainment following participation in the NRP course; however, their performance on clinical simulations was unsatisfactory, suggesting that this aspect needs to be improved.

Oxygen supplementation in the delivery room: T-piece resuscitator cap open or occluded?

OBJECTIVE: Updated neonatal resuscitation guidelines for free-flow oxygen administration with a T-piece resuscitator recommend higher gas flow and an open T-piece cap. We aimed to determine the effect of gas inflow rate and cap occlusion on oxygen delivery through a T-piece resuscitator. STUDY DESIGN: Using a NeoPuff™ T-piece, oxygen inflow was randomly adjusted from 4 to 10 liters per minute (LPM). Gas outflow and oxygen concentration were measured with the T-piece cap open and occluded. Data were analyzed with repeated measures 2-way ANOVA. RESULT: Gas outflow was significantly decreased with the T-piece cap open compared with occluded at each inflow rate (p < 0.001). There was no difference in oxygen concentration of the outflow gas. CONCLUSION: Gas flow from the T-piece is affected by the inflow rate and cap occlusion but oxygen concentration is not. To deliver 5 LPM of free-flow oxygen with the cap open, a minimum of 8 LPM gas inflow is required.