T-piece resuscitator or self-inflating bag during neonatal resuscitation: a scoping review.

BACKGROUND: To identify the evidence for administering positive pressure ventilation (PPV) to infants at birth by either T-piece resuscitator (TPR) or self-inflating bag (SIB), and to determine whether a full systematic review (SR) is warranted. METHODS: Guided by the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for scoping reviews, eligible studies included peer-reviewed human studies, prospectively or retrospectively comparing a TPR vs. SIB for administering PPV at birth. Databases searched were OVID Medline, PubMed, Embase and the Cochrane Central Register of Controlled Trials. Review Manager software was used for the data analysis. RESULTS: Following electronic literature search and review, data from four eligible studies (3 RCT and 1 observational study), enrolling a total of 2889 patients, were included. Studies differed regarding the investigated populations, reported outcomes and came from different geographical areas. In particular for preterm infants, use of TPR for providing PPV may improve survival, result in fewer intubations at birth and decrease the incidence of bronchopulmonary dysplasia. CONCLUSIONS: This scoping review identified two new studies with substantive new evidence, pointing towards improved survival, decreased bronchopulmonary dysplasia and fewer intubations at birth, in particular among preterm infants treated with TPR. Full SR of the literature is advised. IMPACT: This scoping review identified studies comparing TPR vs. SIB for respiratory support of newborn infants previously not included in the International Liaison Committee on Resuscitation (ILCOR) recommendations. Our review found substantive new evidence highlighting that device choice may impact the outcomes of compromised newborn infants'. This scoping review stipulates the need for full SR and updated meta-analysis of studies investigating supportive equipment for stabilizing infants at birth in order to inform ILCOR treatment recommendations.

Monitoring heart rate in the delivery room.

Resuscitation algorithms and guidelines highlight the importance of heart rate (HR) in determining interventions and assessing their effect. However, the actual HR values used are historical based upon normal physiology, and HR at birth may be affected by mode of delivery and timing of cord clamping as well as respiratory status and condition at delivery. Furthermore, the most accurate and effective ways to assess and monitor HR in the newborn infant are only now becoming established. This article examines the importance of HR values and the most widely used methods of estimation as well as some newer modalities which are being developed.

Effects of a course in neonatal resuscitation--evaluation of an educational intervention on the standard of neonatal resuscitation.

BACKGROUND: Appropriate assessment and resuscitation is an important part of neonatal care provided during the first minutes of life. Midwifery and junior medical staff are often in the frontline of neonatal resuscitation. Appropriate education and training of midwifery staff is therefore essential if the standard of care delivered to babies in the delivery suite is to be improved and maintained. Evaluation of any such educational interventions is necessary to assess their effectiveness. AIM: To assess the effect of a course in neonatal resuscitation introduced in 1995 aimed at midwifery staff, on the standard of care provided to babies immediately after birth. Prior to this, training in neonatal resuscitation was largely theoretical. METHODS: Naturalistic design observational study conducted in a maternity unit with a tertiary neonatal intensive care unit in the North of England. We compared two groups of babies born before and after the course was introduced. Use of naloxone in the delivery suite and appropriateness of its use, and temperature on admission to neonatal intensive care unit were used as proxy markers for standard of care and compared in the two groups. We also looked at the use of mask intermittent positive pressure ventilation (IPPV) and tracheal intubation in the delivery suite. RESULTS: Use of naloxone fell dramatically from 13.2% of all babies born in 1994 to 0.5% in 2003. Inappropriate use of naloxone before other resuscitation measures were initiated declined from 75% of babies given naloxone in 1994 to 10% in 2003. The incidence of hypothermia (<35 degrees C) on admission to neonatal unit declined from 9% of all admissions to 2.3% in 2003. There was a trend towards increased use of mask ventilation in the delivery suite with a corresponding trend towards less tracheal intubation. CONCLUSION: We have shown that the intervention has been related temporally to an improvement in the quality of care delivered by midwifery staff to newborn babies. Practical courses in neonatal resuscitation can contribute to improvements in the quality of care provided to babies immediately after birth. These courses are more effective than theoretical teaching alone.

Two microsomal-associated iron-binding proteins observed in rat small intestinal cells during iron absorption.

Acrylamide gel electrophoresis of microsomal protein obtained from rat small intestinal mucosal cells, after an injection of [3H]leucine, demonstrated increased quantities of two soluble iron-binding proteins during iron absorption, one with a high molecular weight (about 400 000) and the other of intermediate molecular weight (80 000). Both proteins were present in a ribosomal-enriched sub-fraction obtained during purification of the microsomal membrane but were not identified among the purified membrane proteins.

Some properties of 5-hydroxytryptamine receptors in the hindquarters of the rat.

1 The rat hindquarter preparation, as described, responds with reproducible vasoconstriction to noradrenaline and tryptamines. 2 The receptors involved in these responses are distinct. 3 Evidence of heterogeneity of tryptamine receptors was not obtained. 4 The 5-hydroxytryptamine (5-HT) antagonists, methysergide and cyproheptadine, although very potent, displayed antagonism of a non-competitive type whereas a series of phenothiazines and phentolamine displayed competitive antagonism against 5-HT. 5 For the phenothiazines the order of increasing potency was promazine less than chlorpromazine less than triflupromazine.

Statistical comparison of the fibrometer and the Electra 600 for prothrombin time determination.

Determinations of prothrombin time with the semiautomatic fibrometer and with a more automated machine (Electra 600) were compared in regard to reproducibility, accuracy, and speed. Prothrombin times determined for replicate samples with the two machines showed a correlation coefficient of 0.98, but the Electra 600 sensed the clot 0.5 seconds before the fibrometer. The overall coefficients of variation for multiple tests in the normal therapeutic and elevated ranges of prothrombin time were 3.5% for the fibrometer and 2.0% for the Electra 600. The average technician working time was 60% shorter with the fully automated machine than with fibrometer. It is concluded that the automated machine was more accurate and more rapid in determining prothrombin time.

Diagnosis of infected modified Blalock-Taussig shunt by computed tomography.

Accurate localization of infection after pediatric cardiac operation is essential for correct decisions regarding treatment. We report a case of infection and endocarditis of a Blalock-Taussig shunt. Localization by computed tomography led to successful surgical intervention.

Evidence for purinergic transmission in mouse bladder and for modulation of responses to electrical stimulation by 5-hydroxytryptamine.

Electrical stimulation (ES) contracted superfused mouse bladder, and 10(-7) M tetrodotoxin (TTX) abolished the twitches without impairing responses to acetylcholine (ACh) or beta,gamma-methylene ATP. ES acted largely through nerves which were not cholinergic, adrenergic or histaminergic. They may be purinergic because the bladder was contracted by stable analogues of ATP, and after desensitisation by a high concentration of alpha,beta-methylene ATP the response to ES was selectively reduced. 5-Hydroxytryptamine (5-HT) at 0.03-3 X 10(-6) M and tetraethylammonium (TEA) at 0.1-10 X 10(-3) M potentiated responses to ES, on average by 64% and 182%. Pempidine had no effect on responses to ES. The action of TEA was different from that of 5-HT; potentiation of responses was greater than could be produced by 5-HT, and whereas 5-HT did not increase responses to ACh, TEA markedly increased twitch tensions. The mode of action of 5-HT is not clear.

Stimulation of mucus output from rat colon in vivo.

Sodium chloride (155 mM) and N-acetyl cysteine (6 mM) were recirculated through the colons of anaesthetized rats. Mucus accumulated in the perfusion fluid which was changed at intervals to allow mucus output to be estimated by measurement of hexose. The output of mucus could be stimulated by intravenous administration of the cholinergic drugs carbachol and bethanechol; this effect was inhibited by atropine. Mucus output could also be stimulated by intravenous 5-hydroxytryptamine. This was not a muscarinic cholinergic effect because atropine did not prevent it. Neither did methysergide inhibit it; but chlorpromazine did. Precursors of 5-hydroxytryptamine, 5-hydroxytryptophan and L-tryptophan, also stimulated mucus output if given in high dosage. The results suggest that in this preparation mucus output can be stimulated by two distinct mechanisms, one cholinergic, the other involving 5-hydroxytryptamine and perhaps 5-hydroxytryptophan.

On the nature of the receptor mediating the action of 5-hydroxytryptamine in potentiating responses of the mouse urinary bladder strip to electrical stimulation.

Superfused mouse bladder strip responded to electrical stimulation (ES) by twitch contractions. These contractions were potentiated by 5-hydroxytryptamine (5-HT; 0.03-3.0 microM). Three tryptamine analogues were tested for their ability to potentiate the responses to ES and their relative activities were compared with values in the literature. 5-Carboxamidotryptamine was more potent than 5-HT, N-omega-methyl 5-HT was about equipotent, and alpha-methyl 5-HT was much less potent. Exogenous noradrenaline did not reduce the effect of 5-HT, although it reduced the response of the tissue to ES. The maximum increase in tissue tension evoked by 5-HT was unaltered by phentolamine (1 microM) or bretylium (25 microM). These results show that 5-HT did not act on the bladder by inhibiting the release of catecholamines from intrinsic nerves. The effect of 5-HT proved very resistant to attempts to block it with conventional 5-HT antagonists. Several antagonists were studied including ketanserin, methysergide, methiothepin, and MDL 72222 but even at concentrations as high as 1 microM none of them exhibited any marked inhibitory effect against the action of 5-HT. At 10 microM some compounds showed activity, but none abolished the effect except methiothepin - and its action was not surmountable by increasing the concentration of 5-HT. Thus the effect of 5-HT on the bladder was not mediated by 5-HT receptors of types 'M', 'D' or 5-HT2.(ABSTRACT TRUNCATED AT 250 WORDS)

Paediatric basic life support: a practical assessment.

Current European Resuscitation Council (ERC) guidelines for paediatric basic life support advocate delivery of 20 cycles/min at a compression rate of 100/min and a compression:ventilation ratio of 5:1 (Resuscitation 1997;34:115-27; Resuscitation 1998;37(2):97-100). We have evaluated whether cardiopulmonary resuscitation (CPR) can be delivered at this rate by hospital providers. We recruited 24 rescuers, all of whom had successfully completed a training course in paediatric life support. Each was asked to perform single rescuer CPR on a Resusci-Junior mannequin (Laerdal, Kent, UK) for 5 min, following the current ERC guidelines. Compressions and ventilations were recorded in real time by inductance plethysmography. Maintenance of the 5:1 ratio was ensured by investigator observation. Cycles of CPR in the first and fifth minutes of resuscitation were counted. The average duration of compression, ventilation and 'transfer time' spent between these two activities was calculated as a percentage of the average duration of a cycle of CPR. All 24 rescuers completed 5 min of resuscitation. Twenty-three of 24 were unable to deliver 20 cycles of CPR in either the first minute (range 8-27; median 11; interquartile range (IQR) 10-13.75) or in the fifth minute (8-26; 11.5; 10-13.75). The median (IQR) duration of a cycle of CPR was 5 s in the first and fifth minutes. Transfer time comprised 30% of total cycle time. In this study, over 95% of single rescuers trained in paediatric life support were unable to deliver 20 cycles of CPR/min. The guidelines make no allowance for time spent moving between compression and ventilation activity. Future consensus statements should take account of this transfer time. Any changes in recommendations should obviously be prospectively audited with Utstein-style reporting and studies of practicability.

Neonatal resuscitation--a practical assessment.

Current European neonatal resuscitation guidelines (Zideman et al. Resuscitation 1998;37:103-110) advocate cardiopulmonary resuscitation (CPR) at 120 compressions per minute in a ratio of 3:1. This is commonly interpreted as a net rate, thus requiring delivery of 40 breaths per minute, which is the upper end of the range of 30-40 breaths per minute suggested in the guidelines. At least one other interpretation is available, but the correct one is not specified. No studies have evaluated whether the rates inferred by the guidelines can be achieved. This study assesses the ability of trained hospital providers to fulfil these criteria in a simulated arrest scenario. A group of anaesthetists, paediatricians, midwives and neonatal nurses was asked to perform CPR either as single rescuers or in pairs, for 5 min, following European Resuscitation Council guidelines. Breaths and compressions delivered were measured by inductance plethysmography. The number of breaths delivered in the first and fifth minute of the scenario were measured, as well as the quality of delivered breaths. Of 33 single resuscitators, none were able to deliver 40 breaths per minute in either the first minute (range 11-34; median 20; interquartile range 14-26) or the fifth (13-35; 19; 15.25-26.5). Of 18 pairs of rescuers, four achieved 40 breaths per minute in the first minute (24-45; 33.5; 29.75-38.25) but only three of 17 were able to sustain this to the fifth minute (21-48; 35; 30.5 39). One pair did not complete 5 min of resuscitation. Single rescuers were unable to achieve the rate of CPR suggested by current guidelines. Only 22% of paired rescuers were able to achieve this standard in the first minute, falling to less than 20% by the fifth minute. We recommend modifying the guidelines to make them unambiguous and practicable, with the emphasis shifted onto the quality of compressions and ventilations, rather than quantity.

European Resuscitation Council Guidelines 2000 for Newly Born Life Support. A statement from the Paediatric Life Support Working Group and approved by the Executive Committee of the European Resuscitation Council.

The European Resuscitation Council (ERC) last issued guidelines for the resuscitation of the newly born infant in 1999 [1]. This was an "Advisory Statement" of the International Liaison Committee on Resuscitation (ILCOR). Following this, the American Heart Association and the Neonatal Resuscitation Programme Steering Committee of the American Academy of Paediatrics and representatives of the World Health Organisation, together with representatives from ILCOR, undertook a series of evidence-based evaluations of the science of resuscitation which culminated in the publication of "Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care" in August 2000 [2,3]. The Paediatric Life Support Working Party of the European Resuscitation Council has considered this document and the supporting scientific literature and presents the ERC Newly Born Guidelines in this paper. Readers will find few changes to the ILCOR Advisory Statement recommendations as the new evidence that has emerged since its publication in 1999 has been confirmatory of the ILCOR recommendations.

Measurement of urine output by weighing nappies.

The effect of humidity on measurement of neonatal urine output was assessed by weighing nappies in a clinically relevant context. Saline was used as dummy urine, on modern nappies in incubators at various humidity settings. In at least some additional humidity, no clinically relevant evaporative loss occurred.

Premedication before intubation in UK neonatal units.

AIMS: To establish the extent and type of premedication used before intubation in neonatal units in the United Kingdom. METHODS: A structured telephone survey was conducted of 241 eligible units. Units were subdivided into those that routinely intubated and ventilated babies (routine group) and those that transferred intubated and ventilated babies (transfer group). RESULTS: Of the units contacted, 239 (99%) participated. Only 88/239 (37%) gave any sedation before intubating on the unit and only 34/239 (14%) had a written policy covering this. Morphine was used most commonly (66%), with other opioids and benzodiazepines used less frequently. Of the 88 units using sedation, 19 (22%) also used paralysis. Suxamethonium was given by 10/19 (53%) but only half of these combined it with atropine. Drug doses varied by factors of up to 200, even for commonly used drugs. CONCLUSION: Most UK neonatal units do not sedate babies before intubating, despite evidence of physiological and practical benefits. Only a minority have written guidelines, which prohibits auditing of practice.

Prevalence and clinical significance of cardiac murmurs in neonates.

AIM: To determine the prevalence and clinical significance of murmurs detected during routine neonatal examination. METHODS: In a two year prospective study, 7204 newborn babies underwent routine examination by senior house officers. All those with murmurs underwent echocardiographic examination. All babies presenting later in infancy were also identified, to ascertain the total prevalence of congenital heart disease in infancy. RESULTS: Murmurs were detected in 46 babies (0.6%) of whom 25 had a cardiac malformation. The most common diagnosis was a ventricular septal defect, although four babies had asymptomatic left heart outflow obstruction. A further 32 infants from the same birth cohort had a normal neonatal examination but were found to have a cardiac malformation before 12 months of age. CONCLUSIONS: The neonatal examination detects only 44% of cardiac malformations which present in infancy. If a murmur is heard there is a 54% chance of there being an underlying cardiac malformation. Parents and professionals should be aware that a normal neonatal examination does not preclude a clinically significant cardiac malformation. The detection of a murmur should prompt early referral to a paediatric cardiologist for diagnosis or appropriate reassurance.

Examination for cardiac malformations at six weeks of age.

AIM: To attempt to define the prevalence and significance of murmurs detected on routine clinical examination at six to eight weeks. METHODS: A retrospective review of the results of routine clinical examination of a cohort of 6 to 8 week old babies resident in Newcastle upon Tyne, was carried out in two 12 month periods. All cardiac defects diagnosed in infancy in the same cohort were ascertained. RESULTS: 7132 babies were eligible for routine examination; 83% of these were examined. Murmurs were heard in 47 of 5395 babies and in 11 of 25 referred for evaluation congenital heart disease was found. The six to eight week examination led to diagnosis of 11 of 35 cases (31%) of congenital heart disease in the study population. CONCLUSIONS: Nearly one baby in 100 had a murmur on routine examination at six to eight weeks. Nearly half of those with murmurs who were referred had a structural cardiovascular malformation.

Presentation of obstructive left heart malformations in infancy.

This study documents the presentation of acutely life threatening congenital heart disease in infancy in order to assess the performance of screening examinations soon after birth and at 6 weeks of age. All cases of obstructive left heart malformations presenting in infancy in one health region from 1987-91 were analysed retrospectively. Altogether, 120 infants presented with either hypoplastic left heart syndrome, interruption of the aortic arch, coarctation of the aorta, or aortic valve stenosis. Twelve became symptomatic or died within 24 hours. Thirty four had an abnormal neonatal examination, eight of whom were referred. Six more became symptomatic before discharge. Ninety four babies went home, 51 developed heart failure before 6 weeks, and another seven died without diagnosis. Twenty five of 36 (69%) reaching 6 weeks without diagnosis had a second examination which was abnormal in 17. Two babies died undiagnosed after 6 weeks and the other 18 presented at up to 11 months of age. The neonatal and 6 week examinations perform poorly as screening tests for congenital heart disease. A normal neonatal examination does not exclude life threatening congenital heart disease.