Duration of intubation attempts during neonatal resuscitation

OBJECTIVE: Since the American Academy of Pediatrics Neonatal Resuscitation Program recommends that intubation should be completed in approximately 20 seconds, we measured the duration of neonatal intubation attempts by different operators, using video recordings of neonatal resuscitations. STUDY DESIGN: We used an ongoing quality improvement program to measure the duration of intubation attempts. RESULTS: The mean duration for the 50 successful intubations, including 6 for meconium, was 27.3 seconds compared with 29.8 seconds for unsuccessful attempts (not significant). Fifteen infants were successfully intubated on each of the first and second attempts, 10 on the third attempt, and 10 required more than 3 attempts. The mean duration of successful intubation was 31.9 seconds for PL-1's, 27.5 seconds for PL-2/3's, and 23.6 seconds for fellows. Overall intubations were more successful for a duration of 30 seconds or less compared with 20 seconds or less (72% vs 38%; chi(2)=10.3, P=.001). No infant decompensated between 20 and 30 seconds. Ten successful and 12 failed attempts took longer than 40 seconds. CONCLUSIONS: We recommend that a duration of 30 seconds is a reasonable guideline for neonatal intubation during resuscitation.     

Facilitation of neonatal nasotracheal intubation with premedication: a randomized controlled trial

OBJECTIVES: To determine if premedication reduces the time and number of attempts by junior medical staff to achieve nasotracheal intubation in neonates. The experimental design was a non-blinded randomized controlled pilot trial. The setting was a perinatal centre in a university teaching hospital. METHODS: Twenty infants (within the ranges of 25-40 weeks gestation, 650-3660 g and 1 h to 81 days of age) requiring semi-urgent intubation were randomized to either premedication with morphine, atropine and suxamethonium, or to awake intubation. RESULTS: There were no significant differences between the two groups in regard to prior intubation experience of the staff or infant weight or gestation. The intubation procedure, including intervening events, to completion was significantly faster in premedicated infants (median 60 s vs 595 s; P = 0.002) who were intubated at a younger postnatal age. It took twice as many attempts to intubate a conscious infant (median 2 vs 1; P = 0.010). There was a greater decrease in heart rate from the baseline in the unpremedicated group (mean 68 b.p.m. vs 29 b.p.m.; P = 0.017), but decreases in oxygen saturation were not different. Blood was observed in the oral and nasal passages after intubation in five of the awake infants and in one of the premedicated infants. CONCLUSIONS: The use of premedication reduces the total time and number of attempts taken to achieve successful nasotracheal intubation of neonates by junior medical staff under supervision.     

Proficiency and knowledge gained and retained by pediatric residents after neonatal resuscitation course

Background: In previous studies the efficacy of the Neonatal Resuscitation Program (NRP) was evaluated, demonstrating good retention of knowledge in the participants. The aim of the present study was to evaluate the knowledge and proficiency that pediatric residents gained and retained following NRP and to determine the necessity and timing of the refresher courses. Methods: The study consisted of 42 pediatric residents who were divided into three groups. Group 1 included pediatric residents who attended the course 1 year previously (n = 18); group 2, 6 months previously (n = 12); and group 3 included those residents who had not attended the NRP previously (n = 12). A written test consisting of 100 questions was applied, and endotracheal intubation skill on a neonatal manikin was evaluated. Results: The percentage of correct answers of participants in groups 1 and 2 decreased similarly during the 6 month and 1 year time period following previous courses. After the new NRP the correct answers increased significantly in groups 1 and 2. The duration of intubation attempt was 17.8 ± 6.0 s in group 1, 17.5 ± 1.5 s in group 2, and 22.3 ± 2.6 s in group 3 before the course and decreased after the course to 10.9 ± 2.0 s in group 1, 10.3 ± 1.5 s in group 2, and 11.7 ± 1.6 s in group 3. The knowledge missing after 6 months and 1 year were similar, while intubation skill decreased after 1 year following the course. Conclusions: Due to worsening of test findings at 6 months after NRP, and deterioration of performance of intubation 1 year after NRP, it is suggested that a refresher course may be required every year.     

Neonatal intubation: success of pediatric trainees

OBJECTIVES: To review the success of pediatric trainees for neonatal intubation over a 10-year interval at a single academic center. STUDY DESIGN: We reviewed a database of all neonatal intubations designed as a quality assurance process at our institution. Respiratory care practitioners recorded the number of attempts at the time of each procedure. Attempts were defined as each time a laryngoscope was placed in the baby's mouth. Success rates were calculated as the number of successful intubations divided by the attempts. RESULTS: From January 1992 through September 2002, 5051 successful intubations with 9190 attempts were performed by all practitioners. Pediatric residents intubated neonates successfully on 1676 occasions requiring 3719 attempts. The median success rates were 33% for pediatric level (PL)1 residents; 40% for PL2 and PL3 residents, and 68% for neonatal fellows ( P < .001). The success rates for residents who had more than 20 total attempts versus those who had fewer than 20 attempts were 49% versus 37% ( P < .001). CONCLUSIONS: Developing proficiency at intubation requires a significant amount of experience. Current pediatric residents at our institution have inadequate opportunity to achieve consistent success.     

新生儿选择性气管插管前阿托品与芬太尼联合应用插管成功率和安全性的随机对照研究

目的 评估新生儿选择性气管插管前阿托品和芬太尼联合应用的插管成功率和安全性。方法 选取2009年11月至2010年4月于南京医科大学附属南京儿童医院NICU行选择性气管插管的新生儿为研究对象,随机分为试验组和对照组。试验组于气管插管前先缓慢静脉推注5%葡萄糖2 mL+阿托品0.02 mg·kg-1,后缓慢静脉推注5%葡萄糖2 mL+芬太尼2~4 μg·kg-1;对照组于气管插管前先后缓慢静脉推注5%葡萄糖2 mL和5%葡萄糖2 mL。对研究对象和插管医生实施盲法。记录一次插管成功率、插管时间、平均插管次数、Goldberg评分、不良反应(胸壁僵直皮囊加压困难、SpO2<80%、HR<100·min-1、严重的心动过缓需要胸外按压及鼻腔或口腔出血)发生率、经头颅B超评估颅内出血的发生率和撤机时间。结果 研究期间62例新生儿入组,其中试验组30例,对照组32例。两组基线资料具可比性。两组患儿经鼻插管受阻改经口插管均为2例,余均经鼻插管。试验组的芬太尼平均用量为2.4 μg·kg-1。试验组一次插管成功率显著高于对照组,63.3%（19/30例） vs 31.3%（10/32例）,P=0.011。试验组平均插管时间显著低于对照组,（36±18）s vs （54±24）s,P=0.001。试验组平均插管次数显著低于对照组,（1.5±0.7）次 vs （2.0±0.8）次,P=0.005。试验组Goldberg评分显著低于对照组,（4.3±1.6）分 vs （6.8±1.8）分,P=0.000。两组不良反应发生率、撤机时间和颅内出血发生率差异均无统计学意义(均P>0.05)。结论 在新生儿选择性气管插管前联合应用阿托品与芬太尼,可提高一次插管成功率,缩短插管时间和插管次数,具有较好的安全性。     

Oxygen saturation trends immediately after birth

OBJECTIVE: To describe the changes in oxygen saturation (SpO2) in healthy infants during the first 10 minutes of life. STUDY DESIGN: In this observational study, infants > or = 35 weeks gestation at birth who did not require supplemental oxygen had continuous recordings taken of the preductal SpO2 over the first 10 minutes of life. RESULTS: A total of 115 infants were analyzed. On average, infants delivered by cesarean delivery had a 3% lower SpO2 than infants delivered by vaginal delivery (95% confidence interval [CI] = -5.8 to -0.7; P = .01). Infants born by cesarean delivery also took longer (risk ratio, 1.79) to reach a stable SpO2 > or = 85% (95% CI = 1.02 to 3.14; P = .04). At 5 minutes of age, median SpO2 values (interquartile range) were 87% (80% to 95%) for infants delivered vaginally and 81% (75% to 83%) for those delivered through cesarean section. The median SpO2 did not reach 90% until 8 minutes of age in either group. CONCLUSIONS: The process of transitioning to a normal postnatal oxygen saturation requires more than 5 minutes in healthy newborns breathing room air.     

Heat Loss Prevention (HeLP) in the delivery room: A randomized controlled trial of polyethylene occlusive skin wrapping in very preterm infants

OBJECTIVES: To determine if polyethylene occlusive skin wrapping of very preterm infants prevents heat loss after delivery better than conventional drying and to evaluate if any benefit is sustained after wrap removal. STUDY DESIGN: This was a randomized controlled trial of infants <28 weeks' gestation. The experimental group was wrapped from the neck down. Only the head was dried. Control infants were dried completely. Rectal temperatures were compared on admission to the neonatal intensive care unit immediately after wrap removal and 1 hour later. RESULTS: Of 55 infants randomly assigned (28 wrap, 27 control), 2 died in the delivery room and 53 completed the study. Wrapped infants had a higher mean rectal admission temperature, 36.5 degrees C (SD, 0.8 degrees C), compared with 35.6 degrees C (SD, 1.3 degrees C) in control infants ( P = .002). One hour later, mean rectal temperatures were similar in both groups (36.6 degrees C, SD, 0.7 degrees C vs 36.4 degrees C, SD, 0.9 degrees C, P = .4). Size at birth was an important determinant of heat loss: Mean rectal admission temperature increased by 0.21 degrees C (95% CI, 0.04 to 0.4) with each 100-g increase in birth weight. CONCLUSIONS: Polyethylene occlusive skin wrapping prevents rather than delays heat loss at delivery in very preterm infants.     

新生儿窒息复苏——当前需要纠正的概念误区

2011年我国发布了最新的“新生儿复苏指南”,不再习惯性称为“新生儿窒息复苏指南”,这种形式上的同国际接轨却蕴含着深刻的本质意义,将带来新生儿复苏的新思维、新行为,应从3个方面加以认识.一是当前国际上“新生儿窒息”的诊断十分严格,表明窒息是复苏后事件而非复苏前事件,复苏失败才有窒息,故不宜称窒息复苏;二是新生儿复苏流程图上显示从一出生到复苏完毕从来都不提窒息与否;三是如长期受“窒息复苏”错误概念桎梏,复苏行为则往往显得十分被动和应付,虽复苏方案与国外相同,但结果却一直不同.故转变观念,首先复苏,才有利于新生儿窒息病死率降至本可达到的国际水准.     

Isotonic versus hypotonic fluid supplementation in term neonates with severe hyperbilirubinemia - a double-blind, randomized, controlled trial

Aim: To compare the incidence of hyponatremia in full‐term neonates with severe hyperbilirubinemia, receiving intravenous fluid supplementation with 0.2% saline in 5% dextrose versus 0.9% saline in 5% dextrose, to prevent blood exchange transfusion (BET). Methods: In this double‐blind, randomized, controlled trial, full ‐ term newborns (≥37 weeks), appropriate for gestational age, with severe non‐haemolytic hyperbilirubinemia (serum bilirubin ≥ 20 mg/dL) were enrolled. Eligible neonates were randomized to receive either 0.2% saline in 5% dextrose (hypotonic fluid group) or 0.9% saline in 5% dextrose (isotonic fluid group) over 8 hrs, in addition to phototherapy. The primary outcome was proportion of neonates developing hyponatremia (serum Na < 135 mmol/L) after 8 h. Results: Forty‐two neonates were analysed in each group. Proportion of neonates developing hyponatremia after 8 h was higher in hypotonic fluid group as compared to isotonic fluid group (48.8% vs. 10.5%, p < 0.001). However, a larger proportion in isotonic fluid group developed hypernatremia (39.5% vs. 12.2%, p < 0.001). The rate of BET was similar in both groups. Conclusion: In full‐term neonates with severe hyperbilirubinemia, administration of hypotonic fluid to prevent BET was associated with a higher incidence of hyponatremia while isotonic fluid was associated with an increased incidence of hypernatremia.     

Home gardening improves dietary diversity,a cluster‐randomized controlled trial among Tanzanian women

Homestead food production (HFP) programmes improve the availability of vegetables by providing training in growing nutrient‐dense crops. In rural Tanzania, most foods consumed are carbohydrate‐rich staples with low micronutrient concentrations. This cluster‐randomized controlled trial investigated whether women growing home gardens have higher dietary diversity, household food security or probability of consuming nutrient‐rich food groups than women in a control group. We enrolled 1,006 women of reproductive age in 10 villages in Pwani Region in eastern Tanzania, split between intervention (INT) and control (CON) groups. INT received (a) agricultural training and inputs to promote HFP and dietary diversity and (b) nutrition and public health counselling from agricultural extension workers and community health workers. CON received standard services provided by agriculture and health workers. Results were analysed using linear regression models with propensity weighting adjusting for individual‐level confounders and differential loss to follow up. Women in INT consumed 0.50 (95% CI [0.20, 0.80], p = 0.001) more food groups per day than women in CON. Women in INT were also 14 percentage points (95% CI [6, 22], p = 0.001) more likely to consume at least five food groups per day, and INT households were 6 percentage points (95% CI [−13, 0], p = 0.059) less likely to experience moderate‐to‐severe food insecurity compared with CON. This home gardening intervention had positive effects on diet quality and food security after 1 year. Future research should explore whether impact is sustained over time as well as the effects of home garden interventions on additional measures of nutritional status.     

Routine neonatal postextubation chest physiotherapy: a randomized controlled trial

OBJECTIVE: To test the effects of a neonatal postextubation programme on the incidence of postextubation collapse and adverse outcomes. METHODS: A randomized controlled trial was carried out at the Mater Mothers' Hospital, Brisbane. Mechanically ventilated infants were randomized into one of two groups, physiotherapy group--which involved a regimen of chest wall percussion and oropharyngeal suctioning and control group - which involved suctioning without the percussion unless indicated. Chest X-rays were taken at 6 h and at 24 h postextubation. The primary outcome measure was postextubation collapse as determined by a paediatric radiologist blinded to the group allocation. RESULTS: One hundred and seventy-seven neonates were enrolled in the trial between 1997 and 1999. After an interim analysis, the trial was stopped early. No statistically significant difference was shown in the rate of postextubation collapse (15 of 87 (17.2%) physiotherapy group and 17 of 86 (19.8%) control group (P = 0.85)). No differences were shown between the groups in the number of apnoeic or bradycardic events, duration of requirement for supplemental oxygen or the need for re-intubation within 24 h postextubation. CONCLUSION: The results of this trial suggest that a routine neonatal postextubation chest physiotherapy programme for all infants is not indicated. There was no evidence that chest physiotherapy is associated with any adverse outcomes.