Objective
Determine whether higher targeted oxygen levels are associated with reduced incidence of pulmonary hypertension (PH) and elevated pulmonary vascular resistance (PVR) in extremely premature ...infants.
Study design
Retrospective chart review of 252 extremely preterm infants (<29 weeks), who underwent echocardiogram prior to discharge. PH rates were compared during periods (June 2012‐May 2015 and June 2015‐April 2016) when lower (88‐92%) or higher (90‐95%) oxygen saturation targets were used. PH was determined on echocardiography. The ratio of pulmonary artery acceleration time to right ventricular ejection time was computed, with values <0.31 indicative of elevated PVR. Survival analysis compared the effects of oxygen saturation group on development/resolution of PH and elevated PVR.
Results
The higher saturation group had significantly lower risk of developing PH (hazard ratio (HR) = 0.50, 95%CI 0.26‐0.95; P = 0.03) or elevated PVR (HR = 0.55, 95%CI 0.38‐0.81; P = 0.002), compared to the lower oxygen saturation group. Median time to PH development was significantly shorter in the lower saturation group than in the higher saturation group (5 days vs 12 days; P = 0.02), as was time to development of elevated PVR (4 days vs 6 days; P < 0.001). Duration of PH (P = 0.12) and elevated PVR (P = 0.86) did not differ significantly between groups. Cumulative incidence of PH (P = 0.04) and elevated PVR (P = 0.01) at 36 weeks post‐menstrual age was significantly lower in the high saturation group compared to the lower saturation group.
Conclusion
Higher targeted oxygen saturation was associated with reduced risk of PH or elevated PVR in extremely preterm infants compared to lower oxygen saturation target.
Appropriate tools are essential to support a clinician's decision to refer very preterm infants to developmental resources. Streamlining the use of developmental assessment or screening tools to make ...clinical decisions offers an alternative methodology to help to choose the most effective way to assess this very high-risk population.
To examine the influence of the Ages and Stages Questionnaire-3rd edition (ASQ3) and the Bayley Scales of Infant Development-3rd edition (Bayley-III) scores within a clinically-based decision-making process.
This retrospective cohort study includes children born at less than 29 weeks gestation who had completed both psychologist-administered Bayley-III and physician-observed ASQ3 assessments at 18 months corrected age. Theoretical referral decisions (TRDs) based on each assessment results were formulated, using cut-off scores between the lower first and second standard deviation values and below the lower second standard deviation values. TRDs to refer to developmental resources were evaluated in light of the multidisciplinary team's actual final integrated decisions (FID).
Complete data was available for 67 children. The ASQ3 and the Bayley-III had similar predictive value for the FID, with comparable kappa values. Comparisons of the physicians' and psychologists' TRDs with the FIDs demonstrated that the ASQ3 in conjunction with the medical and socio-familial findings predicted 93% of referral decisions.
Taking into consideration potential methodological biases, the results suggest that either ASQ3 or Bayley-III, along with socio-environmental, medical and neurological assessment, are sufficient to guide the majority of clinicians' decisions regarding referral for specialty services. This retrospective study suggests that the physician-supervised ASQ3 may be sufficient to assess children who had been extremely preterm infants for referral purposes. The findings need to be confirmed in a larger, well-designed prospective study to minimize and account for potential sources of bias.
Sudden unexpected clinical deterioration or cardiorespiratory instability is common in neonates and is often referred as a “crashing” neonate. The established resuscitation guidelines provide an ...excellent framework to stabilize and evaluate these infants, but it is primarily based upon clinical assessment only. However, clinical assessment in sick neonates is limited in identifying underlying pathophysiology. The Crashing Neonate Protocol (CNP), utilizing point-of-care ultrasound (POCUS), is specifically designed for use in neonatal emergencies. It can be applied both in term and pre-term neonates in the neonatal intensive care unit (NICU). The proposed protocol involves a stepwise systematic assessment with basic ultrasound views which can be easily learnt and reproduced with focused structured training on the use of portable ultrasonography (similar to the FAST and BLUE protocols in adult clinical practice). We conducted a literature review of the evidence-based use of POCUS in neonatal practice. We then applied stepwise voting process with a modified DELPHI strategy (electronic voting) utilizing an international expert group to prioritize recommendations. We also conducted an international survey among a group of neonatologists practicing POCUS. The lead expert authors identified a specific list of recommendations to be included in the proposed CNP. This protocol involves pre-defined steps focused on identifying the underlying etiology of clinical instability and assessing the response to intervention.
Conclusion
: To conclude, the newly proposed POCUS-based CNP should be used as an adjunct to the current recommendations for neonatal resuscitation and not replace them, especially in infants unresponsive to standard resuscitation steps, or where the underlying cause of deterioration remains unclear.
What is known?
• Point-of-care ultrasound (POCUS) is helpful in evaluation of the underlying pathophysiologic mechanisms in sick infants.
What is new?
• The Crashing Neonate Protocol (CNP) is proposed as an adjunct to the current recommendations for neonatal resuscitation, with pre-defined steps focused on gaining information regarding the underlying pathophysiology in unexplained “crashing” neonates.
• The proposed CNP can help in targeting specific and early therapy based upon the underlying pathophysiology, and it allows assessment of the response to intervention(s) in a timely fashion.
Accurate interpretations of neonatal cranial ultrasound (CUS) studies are essential skills for physicians in neonatal intensive care units (NICUs) in order to properly diagnose and manage brain ...injury. However, these skills are not formally taught to pediatric and neonatal-perinatal medicine (NPM) trainees in Canada. Therefore, our study describes the design, implementation, and evaluation of a new web-based learning (WBL) module that focuses on teaching these skills.
Trainees' needs assessment survey, sent to all NPM and pediatrics trainees (n = 62), concluded that most of them feel uncomfortable with their ability to interpret CUS, highlighting the need for a new educational intervention. The needs assessment informed the development of the WBL module, which we evaluated using questionnaires and pre-and post-testing methods to measure participants' satisfaction, knowledge gain, skills development, and behaviour changes. Only trainees rotating through the NICU over 6 months (n = 23) were invited to participate in all the evaluation steps. We used the ADDIE instructional design model as a framework for this project.
Respondents were very satisfied with the module, and their baseline knowledge increased significantly after studying and engaging with the module. The post-test score was 76% (p < 0.001) compared to the pre-test mean score of 42%. Tests for CUS interpretation skills assessment showed that 49% of pre-test answers were incorrect compared to 8% in the post-test (p < 0.001). Seventy-eight percent of trainees (n = 18) responded to a survey conducted a year after implementation, and 78% of the respondents (n = 14) reported that they still used these skills and shared this knowledge with junior trainees.
A WBL module for teaching neonatal CUS interpretation considerably improved trainees' knowledge and enhanced their skills in interpreting neonatal CUS.
Objectives
Despite increased evidence that point-of-care ultrasound (POCUS) has the potential to improve patient care in many clinical areas, the extent of use and training in POCUS in Canadian ...neonatal intensive care units (NICUs) has not been described in the literature. In this study, we aimed to explore the extent to which POCUS is being used and the need for a formal curriculum with defined POCUS competencies in the field of Neonatal-Perinatal Medicine (NPM).
Methods
We sent a cross-sectional electronic survey to all NPM program directors and fellows in Canada. All 13 Canadian NPM programs were invited to participate. Data were analyzed using descriptive statistics and qualitative content analysis.
Results
The response rate was 69% (
n
= 9) from program directors (PDs) and 29% (
n
= 25) from NPM fellows. Most respondents indicated regular use of POCUS in clinical practice and ready access to a portable ultrasound machine. The most common use for POCUS was targeted assessment of patent ductus arteriosus (PDA) and persistent pulmonary hypertension (PPHN). Only six PDs reported that POCUS skills are taught to trainees in their centers and only two PDs reported that a structured program existed. Barriers to POCUS structured training include a lack of trained personnel as well as insufficient time in the busy NPM curriculum.
Conclusion
POCUS is widely used in Canadian NICUs. However, a formal curriculum and assessment of competencies in this area of neonatal clinical care are lacking.
Abstract
Background
Recent clinical practice changes in neonatal care resulted in higher, narrower oxygen saturation target ranges for preterm infants. The effect of targeting higher or lower oxygen ...saturations on respiratory outcomes of preterm infants and duration of hospitalization has not been extensively reviewed in the context of current care, but could have significant implications.
Methods
A multicentre retrospective cohort of 145 preterm infants was conducted; 105 had lower oxygen saturation targets (88 to 92%), 40 had higher targets (90 to 95%). The primary outcome was bronchopulmonary dysplasia (BPD). Secondary outcomes included duration of invasive/noninvasive respiratory support, oxygen therapy, and hospitalization. The primary outcome was compared using Fisher’s exact test. Secondary outcomes were evaluated with survival analysis and Wilcoxon rank sum test.
Results
The difference in incidence of BPD in the lower (N=56, 53.3%) and higher saturation groups (N=14, 35.0%) was not statistically significant (relative risk RR=0.66 0.41, 1.04, P=0.06). The difference in duration of mechanical ventilation in the lower (median 7.8 days, interquartile range IQR 3.7 to 15.9) and higher saturation groups (median 4.5, IQR 1.9 to 12.3) approached statistical significance (P=0.05). There were no statistically significant differences in the durations of other respiratory supports or hospital stay between the two groups.
Conclusions
The results of this study approached statistical significance and suggest that higher, narrower oxygen saturation targets may result in a clinically important reduction in BPD incidence and duration of mechanical ventilation. These results require validation in a larger sample to refine optimal targets.
Objective: Premenstrual syndrome (PMS) is a very prevalent condition that affects premenopausal women and can result in monthly debilitating emotional and physical symptoms. The objective of this ...systematic review was to determine which predictive factors were associated with an increased amount of bias in non-randomized studies (NRSs) of PMS.
Materials and methods: A search of the EMBASE and Medline electronic databases was completed from January 1, 2010 to December 2021. The methodological quality of the included studies was independently evaluated and critically appraised using the Risk of Bias in Non-Randomized Studies - of Interventions (ROBINS-1) tool. Associations of different factors with the risk of bias levels were assessed using a univariate logistic regression. Odds ratio and 95% confidence interval (CI) were reported.
Results: Of the 1668 studies, 38 were determined to be eligible for inclusion. The ROBINS-1 tool identified that 12 studies were of low/moderate risk of bias (31.6%) and 26 were of serious/critical risk (68.4%). Evidence of relationships between the ROBINS-1 score and impact factor (OR=0.20; 95% CI, 0.07 to 0.57; p= 0.003) and number of authors (OR=0.65; 95% CI, 0.43 to 0.99; p= 0.046) were identified, whereas no relationships were found with the number of citations, the sample size, the funding type, or the conflict-of-interest statement.
Conclusion: The systematic review concludes that the methodological rigor of non-randomized studies of PMS can vary, with fewer authors and a lower impact factor showing evidence of association with a decreased quality of evidence.
Abstract
Neonatal herpes simplex virus (NHSV) infections are associated with significant morbidity and mortality. Numerous factors influence the transmission of HSV infection to newborns; however, ...immersion in water during labor has received very little attention as a possible risk factor despite the increasing popularity of water births. We report a case of disseminated NHSV type 1 infection, possibly acquired during a water birth. The purpose of this report is to alert healthcare providers to this potential route of transmission and to highlight the importance of screening guidelines for HSV before a water birth. Furthermore, it is essential to consider NHSV infection in any febrile infant who is not responding to standard empirical antibiotic management, even in the absence of herpetic lesions.
: Point of Care Ultrasound (POCUS) is an important tool in pediatric emergency medicine. In neonatal intensive care medicine ultrasound is often used to evaluate the brains of sick neonates. In ...theory, POCUS could be used in the ED in young children to evaluate the brain for abnormal pathology.
: To examine the ability of PEM faculty to use brain POCUS to identify clinically significant brain injuries in children with head injuries and/or abnormal neurological exams, and generate sensitivity and specificity of brain POCUS in assessing such findings.
: This study used a convenience sample of patients seen in a tertiary care pediatric centre who required a CT head. A team of physicians who were trained at a workshop for brain POCUS were on call to perform the POCUS while being blinded to the results of the CT.
21 children were enrolled in the study. Five (24%) of the patients had a CT that was positive for intracranial bleeds. Of the 5 patients with a positive CT, 3 had a brain POCUS scan that was also positive. The two false negative brain POCUS scans were on patients with small bleeds (no surgical intervention required) on CT, as reported by radiology. The sensitivity of brain POCUS was 60% (CI 15% - 95%) with a specificity of 94% (CI 70%-100%). The diagnostic accuracy of brain POCUS was 86% (CI 64% - 97%).
This small proof of concept study shows that brain POCUS is an imaging modality with reasonable sensitivity and specificity in identifying intracranial pathologies that are present on CT. Its use may be most beneficial to expedite definitive imaging and subspeciality involvement.
ObjectiveTo examine the influence of timing of initiation of therapeutic hypothermia (TH) on brain injury on MRI and on neurodevelopmental outcomes at 18 months.DesignRetrospective cohort ...study.SettingTertiary neonatal intensive care unit in Ontario, Canada.PatientsNinety-one patients with hypoxic ischaemic encephalopathy (HIE) were included, 54 in the early TH group and 37 in the late TH group.InterventionWhole-body hypothermia administered for 72 hours, initiated either before 3 hours of life (early TH) or between 3 and 6 hours of life (late TH).Main outcome measuresBrain injury on MRI after TH (assessed by two neuroradiologists), and neurodevelopmental outcomes at 18 months old.ResultsTH was initiated at a median time of 1.4 hours (early TH) and 4.4 hours (late TH). Sixty-four neonates (early TH=36, late TH=28) survived and completed neurodevelopmental assessment at 18 months. Neonates in the early TH group received more extensive resuscitation than neonates in the late TH group (p=0.0008). No difference was observed between the two groups in the pattern or severity of brain injury on MRI, or in the neurodevelopmental outcomes at 18 months. The non-survivors (n=16) had lower Apgar scores at 10 min, more extensive resuscitation, suffered from more severe HIE and had significantly more abnormal cerebral function monitoring.ConclusionIn this retrospective cohort study, TH initiated early was associated neither with a difference in brain injury on MRI nor better neurodevelopmental outcomes at 18 months.
PDF
