Finding the most suitable puncture site for intraosseous access in term and preterm neonates: an ultrasound-based anatomical pilot study.

The purpose of this prospective ultrasound-based pilot study was to identify the most suitable tibial puncture site for intraosseous (IO) access in term and preterm neonates, describe tibial dimensions at this site, and provide anatomical landmarks for rapid localization. We measured the tibial dimensions and distances to anatomical landmarks at puncture sites A (proximal: 10 mm distal to the tibial tuberosity; distal: 10 mm proximal to the malleolus medialis) and B (chosen by palpation of the pediatrician), in 40 newborns in four weight groups (< 1000 g; 1000-2000 g, 2000-3000 g, and 3000-4000 g). Sites were rejected if they fell short of the assumed safety distance to the tibial growth plate of 10 mm. If both A and B were rejected, puncture site C was determined sonographically at the maximum tibial diameter while maintaining the safety distance. Puncture site A violated the safety distance in 53% and 85% (proximally and distally, respectively) and puncture site B in 38% and 33%. In newborns weighing 3000-4000 g, at median (IQR), the most suitable puncture site at the proximal tibia was 13.0 mm (12.0-15.8) distal to the tuberosity and 6.0 mm (4.0-8.0) medial to the anterior rim of the tibia. The median (IQR) diameters at this site were 8.3 mm (7.9-9.1) (transverse) and 9.2 mm (8.9-9.8) (anterior-posterior). The diameters increased significantly with increasing weight.  Conclusion: This study adds concise, practical information on the implementation of IO access in neonatal patients: the tibial dimensions in newborns in four different weight groups and initial data on anatomical landmarks to easily locate the IO puncture site. The results may help implement IO access in newborns more safely. What is Known: • Intraosseous access is a feasible option for emergency administration of vital drugs and fluids in newborns undergoing resuscitation when an umbilical venous catheter is impossible to place. • Severe complications of IO access due to malpositioned IO needles have been reported in neonates. What is New: • This study reports the most suitable tibial puncture sites for IO access and the tibial dimensions, in newborns of four weight groups. • The results can help to implement safe IO access in newborns.

The impact of extrauterine life on visual maturation in extremely preterm born infants.

BACKGROUND: Extrauterine life is an important factor when considering brain maturation. Few studies have investigated the development of visual evoked potentials (VEP) in extremely preterm infants, and only a minority have taken into consideration the impact of extrauterine life. The aim of this study was to assess the normal maturation of VEP in infants born prior to 29 weeks gestational age (GA) and to explore the potential influence of extrauterine life. METHODS: VEP were prospectively recorded in extremely preterm infants, and principal peaks (N0, N1, P1, N2, P2, N3) were identified. The mean of peak-time and percentages of peak appearances were assessed for three GA groups (23/24, 25/26, 27/28 weeks) and four subgroups of increasing postnatal age (PNA), up to 8 weeks after birth. RESULTS: A total of 163 VEP recordings in 38 preterm infants were analyzed. With increasing GA at birth, peak-times decreased. When comparing infants with equal GA but longer extrauterine life, those with the highest PNA demonstrated the shortest VEP peak-times. However, this effect was less present in infants born prior to 25 weeks GA. CONCLUSION: Provided that a certain maturational threshold is reached, extrauterine life appears to accelerate maturation of the visual system in preterm infants.

Duration to Establish an Emergency Vascular Access and How to Accelerate It: A Simulation-Based Study Performed in Real-Life Neonatal Resuscitation Rooms.

OBJECTIVES: To compare the duration to establish an umbilical venous catheter and an intraosseous access in real hospital delivery rooms and as a secondary aim to assess delaying factors during establishment and to provide recommendations to accelerate vascular access in neonatal resuscitation. DESIGN: Retrospective analysis of audio-video recorded neonatal simulation training. SETTINGS: Simulation training events in exact replications of actual delivery/resuscitation rooms of 16 hospitals with different levels of care (Austria and Germany). Equipment was prepared the same way as for real clinical events. SUBJECTS: Medical teams of four to five persons with birth-related background (midwives, nurses, neonatologists, and anesthesiologists) in a realistic team composition. INTERVENTIONS: Audio-video recorded mannequin-based simulated resuscitation of an asphyxiated newborn including the establishment of either umbilical venous catheter or intraosseous access. MEASUREMENTS AND MAIN RESULTS: The duration of access establishment (time from decision to first flush/aspiration), preparation (decision to start of procedure), and the procedure itself (start to first flush/aspiration) was significantly longer for umbilical venous catheter than for intraosseous access (overall duration 199 vs 86 s). Delaying factors for umbilical venous catheter establishment were mainly due to the complex approach itself, the multitude of equipment required, and uncertainties about necessary hygiene standards. Challenges in intraosseous access establishment were handling of the unfamiliar material and absence of an intraosseous access kit in the resuscitation room. There was no significant difference between the required duration for access establishment between large centers and small hospitals, but a trend was observed that duration for umbilical venous catheter was longer in small hospitals than in centers. Duration for intraosseous access was similar in both hospital types. CONCLUSIONS: Vascular access establishment in neonatal resuscitation could be accelerated by infrastructural improvements and specific training of medical teams. In simulated in situ neonatal resuscitation, intraosseous access is faster to establish than umbilical venous catheter. Future studies are required to assess efficacy and safety of both approaches in real resuscitation settings.

Neonatal simulation training decreases the incidence of chest compressions in term newborns.

AIM OF THE STUDY: To determine the effectiveness of a multidimensional neonatal simulation-based medical education training programme on direct and indirect patient outcome parameters. METHODS: This was a retrospective analytical study with a historical control group in a level II neonatal care unit (1,700 births per year). A multidimensional interdisciplinary training programme on neonatal resuscitation was implemented in 2015; pre-training (2012-2014) and post-training (2015-2019) eras were compared in terms of mortality (direct outcome) and the received intervention level immediately after birth (indirect outcome). Intervention levels were defined as follows: A) short-term non-invasive ventilation, B) prolonged non-invasive ventilation (>5 inflation breaths), C) chest compressions. RESULTS: Of 13,950 neonates born during the study period, 826 full-term newborns received one of the three intervention levels for adaptation after birth. A total of 284 (34.4%) patients received short-term non-invasive ventilation (A), 477 (57.8%) had prolonged ventilation (B), and 65 (7.9%) chest compressions (C), respectively. Comparing the pre- and post-training eras, there was no significant reduction in mortality, and no significant changes were found in groups A or B. However, the risk for chest compressions (group C) decreased significantly from 0.91% in the pre-training era to 0.20% in the post-training era (p < 0.001). CONCLUSION: Although there was no significant effect on neonatal mortality, regular interdisciplinary simulation training decreased the number of administered chest compressions immediately after birth. Further studies are needed to test indirect outcome-related parameters, such as frequency of chest compressions as a measure of effectiveness and impact of medical training.

Intraosseous access in neonates is feasible and safe - An analysis of a prospective nationwide surveillance study in Germany.

Background: This was a prospective surveillance study to investigate reports on the safety and frequency of use of intraosseous (IO) access in neonates. Methods: Over a two-year period, paediatric hospitals in Germany were asked to report all cases of IO access to the nationwide Surveillance Unit for Rare Paediatric Diseases (ESPED). Hospitals reporting a case submitted responses via an anonymised electronic questionnaire, providing details on indication, success rate, system used, location, duration to first successful IO access, complications, alternative access attempts and short-term outcome. We present a subset of data for IO use in infants of less than 28 days. Results: A total of 161 neonates (145 term and 16 preterm born infants) with 206 IO access attempts were reported. In 146 neonates (91%), IO access was successfully established, and success was achieved with the first attempt in 109 neonates (75%). There was no significant impact of gestational age or provider's educational level on success rates. In 71 infants with successful IO access (79%), the estimated duration of placement was less than 3 min. The proximal tibia was the predominant site used. A semiautomatic battery-driven device was used in 162 attempts (88%). The most often applied medications via IO access were crystalloid fluid and adrenaline. Potentially severe complications occurred in 9 patients (6%). Conclusion: Within this surveillance study, IO access in neonates was feasible and safe. IO access is an important alternative for vascular access in neonates.

A Novel Approach for More Effective Emergency Equipment Storage: The Task-Based Package-Organized Neonatal Emergency Backpack.

Objectives: To evaluate a new task-based package-organized (TPO) neonatal emergency backpack and to compare it to the classical (ABC- and material-based) backpack. Methods: Simulation-based assessment of time to retrieve equipment for three different tasks [intraosseous access (IO), intubation and adrenaline administration] using the TPO and the classical emergency backpack was compared. Results: Equipment retrieval times for the three tasks were assessed for 24 nurses (12 intermediate care, 12 intensive care) and were significantly faster in the TPO than in the classical backpack (IO 33 vs. 75 s, p < 0.001; intubation 53 vs. 70 s, p = 0,001; adrenaline 22 vs. 45 s, p < 0.001). The number of missing items was significantly lower using the TPO backpack for IO and adrenaline retrieval (IO 0,9 vs. 2,3 items, p < 00001, adrenaline 0.04 vs. 1, p < 0.001) but not for intubation equipment (0.9 vs. 1, not significant). The subjective rating of overall clearness was significantly higher for the TPO compared with the classical backpack (5,9 vs. 3,5, p < 0.001). Conclusion: Task-based package organization of neonatal emergency backpacks is feasible and might be superior to ABC-/material-oriented storage.

A Mixed-Lipid Emulsion Containing Fish Oil for the Parenteral Nutrition of Preterm Infants: No Impact on Visual Neuronal Conduction.

Fish oil is rich in omega-3 fatty acids and essential for neuronal myelination and maturation. The aim of this study was to investigate whether the use of a mixed-lipid emulsion composed of soybean oil, medium-chain triglycerides, olive oil, and fish oil (SMOF-LE) compared to a pure soybean oil-based lipid emulsion (S-LE) for parenteral nutrition had an impact on neuronal conduction in preterm infants. This study is a retrospective matched cohort study comparing preterm infants <1000 g who received SMOF-LE in comparison to S-LE for parenteral nutrition. Visual evoked potentials (VEPs) were assessed longitudinally from birth until discharge. The latencies of the evoked peaks N2 and P2 were analyzed. The analysis included 76 infants (SMOF-LE: n = 41 and S-LE: n = 35) with 344 VEP measurements (SMOF-LE: n= 191 and S-LE n = 153). Values of N2 and P2 were not significantly different between the SMOF-LE and S-LE groups. A possible better treatment effect in the SMOF-LE group was seen as a trend toward a shorter latency, indicating faster neural conduction at around term-equivalent age. Prospective trials and follow-up studies are necessary in order to evaluate the potential positive effect of SMOF-LE on neuronal conduction and visual pathway maturation.

Being Born Small for Gestational Age Influences Amplitude-Integrated Electroencephalography and Later Outcome in Preterm Infants.

BACKGROUND: The impact of growth restriction on perinatal morbidity is well known, but electroencephalographic (EEG) data on its influence are still scarce. OBJECTIVES: We aimed to analyze the influence of being born small for gestational age (SGA; defined as a birth weight <10th percentile) on the amplitude-integrated EEG (aEEG) score in the first 2 weeks of life in preterm infants born before 30 weeks of gestation, and its impact on later outcome. METHODS: aEEG data obtained within the first 2 weeks of life on preterm infants born SGA and before 30 weeks of gestational age (GA) were analyzed retrospectively using a combined score [including background activity, occurrence of sleep-wake cycles (SWC) and suspected seizure activity]. Neurodevelopmental outcome was evaluated at 24 months by means of the Bayley Scales of Infant Development II and a standardized neurological examination. RESULTS: One hundred and thirty-six patients were included (47 SGA and 89 controls). Infants with SGA had abnormal aEEG scores significantly more often (57 vs. 24%, p = 0.002) than infants born appropriate for gestational age (AGA). They also displayed SWC less frequently (65 vs. 96%, p = 0.001), were more likely to develop seizure activity (15 vs. 4%, p = 0.013) and had a normal neurodevelopmental outcome at the age of 2 years less frequently (36.2 vs. 59.6%, p = 0.02). CONCLUSION: Preterm infants born SGA and before 30 weeks of GA had less optimal scores on early aEEG and a poorer neurodevelopmental outcome at 24 months than the AGA controls.