Premedication practices for tracheal intubation in neonates transported by French medical transport teams: a prospective observational study.

OBJECTIVES: Premedication practices for neonatal tracheal intubations have not yet been described for neonatal transport teams. Our objective is to describe the use of sedation/analgesia (SA) for tracheal intubations and to assess its tolerance in neonates transported by medical transport teams in France. SETTING: This prospective observational study was part of the EPIPPAIN 2 project and collected around-the-clock data on SA practices in neonates intubated by all five paediatric medical transport teams of the Paris region during a 2-month period. Intubations were classified as emergent, semiemergent and non-emergent. Sedation level and conditions of intubation were assessed with the Tonus, Reactivity, Awareness and Conditions of intubation to Help in Endotracheal intubation Assessment (TRACHEA score). The scores range from 0 to 10 representing an increasing ladder from adequate to inadequate sedation, and from excellent to very poor conditions of intubation. PARTICIPANTS: 40 neonates intubated in 28 different centres. RESULTS: The mean (SD) age was 34.9 (3.9) weeks, and 62.5% were intubated in the delivery room. 30/40 (75%) of intubations were performed with the use of SA. In 18/30 (60.0%) intubations performed with SA, the drug regimen was the association of sufentanil and midazolam. Atropine was given in 19/40 intubations. From the 16, 21 and 3 intubations classified as emergent, semiemergent and non-emergent, respectively, 8 (50%), 19 (90.5%) and 3 (100%) were performed with SA premedication. 79.3% of intubations performed with SA had TRACHEA scores of 3 or less. 22/40 (55%) infants had at least one of the following adverse events: muscle rigidity, bradycardia below 100/min, desaturation below 80% and nose or pharynx-larynx bleeding. 7/24 (29.2%) of those who had only one attempt presented at least one of these adverse events compared with 15/16 (93.8%) of those who needed two or more attempts (p<0.001). CONCLUSION: SA premedication is largely feasible for tracheal intubations performed in neonates transported by medical transport teams including intubations judged as emergent or semiemergent. TRIAL REGISTRATION NUMBER: NCT01346813; Results.

Correction: Passive hypothermia (≥35 - <36°C) during transport of newborns with hypoxic-ischaemic encephalopathy.

[This corrects the article DOI: 10.1371/journal.pone.0170100.].

Passive hypothermia (≥35 - <36°C) during transport of newborns with hypoxic-ischaemic encephalopathy.

BACKGROUND: Hypothermia initiated in the first six hours of life in term infants with hypoxic ischemic encephalopathy reduces the risk of death and severe neurological sequelae. Our study's principal objective was to evaluate transport predictors potentially influencing arrival in NICU (Neonatal Intensive Care Unit) at a temperature ≥35-<36°C. METHODOLOGY/PRINCIPAL FINDINGS: A multi-centric, prospective cohort study was conducted during 18 months by the three Neonatal Transport Teams and 13 NICUs. Newborns were selected for inclusion according to biological and clinical criteria before transport using passive hypothermia using a target temperature of ≥35-<36°C. Data on 120 of 126 inclusions were available for analysis. Thirty-three percent of the children arrived in NICU with the target temperature of ≥35-<36°C. The mean temperature for the whole group of infants on arrival in NICU was 35.4°C (34.3-36.5). The median age of all infants on arrival in NICU was 3h03min [2h25min-3h56min]. Three infants arrived in NICU with a temperature of <33°C and eleven with a temperature ≥37°C. Adrenaline during resuscitation was associated with a lower mean temperature on arrival in NICU. CONCLUSIONS/SIGNIFICANCE: Our strategy using ≥35-<36°C passive hypothermia combined with short transport times had little effect on temperature after the arrival of Neonatal Transport Team although did reduce numbers of infants arriving in NICU in deep hypothermia. For those infants where hypothermia was discontinued in NICU our strategy facilitated re-warming. Re-adjustment to a lower target temperature to ≥34.5-<35.5°C may reduce the proportion of infants with high/normothermic temperatures.

Case-control study of respiratory dynamic compliance in mechanically ventilated near-term newborns in a pre-hospital setting.

PURPOSE: To determine the threshold value between normal or decreased dynamic compliance (Cdyn) in ventilated near-term newborns. METHODS: A case control study was performed during pediatric transport. Controls were newborns without pulmonary disease (group 1; n = 30) and cases were newborns with respiratory distress syndrome, the paradigm of decreased Cdyn (group 2; n = 30). All consecutive newborns of more than 34 weeks' gestation and less than 5 days of life, intubated and ventilated with Babylog 8,000 plus (Dräger, Lübeck, Germany) were included from February 2008 to June 2010. Newborns were assigned to groups 1, 2, or 3 (other patients with disease where the compliance is not easily predictable) by two physicians, using predefined criteria. Cdyn was as measured by the ventilator in spontaneous mandatory ventilation mode with less than 15% leaks. RESULTS: One hundred and twelve newborns were included in the study. In the multivariate analysis, the groups of diseases and height were statistically associated with Cdyn (p < 0.001). The receiver operating characteristic curve of Cdyn corrected for height constructed with group 1 and 2 newborns yielded a cutoff value of 2.02 mL/mbar/m with a sensitivity of 100% (95% confidence interval [100-100%]) and a specificity of 96% (95% confidence interval [90-100%]) to differentiate between group 1 and 2 newborns. CONCLUSION: Ventilator-measured dynamic compliance can differentiate normal and decreased compliance in near-term newborns of more than 34 weeks' gestation in the clinical setting.

Out-of-hospital emergency medicine in pediatric patients: prevalence and management of pain.

INTRODUCTION: Much less is known about pain prevalence in pediatric patients in an out-of-hospital than emergency department setting. The purpose of this study was to determine pain prevalence in children in a prehospital emergency setting and to identify the factors associated with pain relief. MATERIALS AND METHODS: This prospective cohort study in consecutive patients 15 years or younger was conducted by 5 mobile intensive care units working 24/7 (January-December 2005). The presence of pain, its intensity, and alleviation by the administration of analgesics were recorded. RESULTS: A total of 258 of 433 pediatric patients were included, of whom 96 were suffering from acute pain (37%; 95% confidence interval [CI], 31-43) that was intense to severe in 67% of cases. Trauma was the only factor significantly associated with acute pain (odds ratio, 818; 95% CI, 153-4376). Overall, 92% of the children in pain received at least one analgesic drug; 41% received a combination of drugs. Opioid administration was significantly associated with intense to severe pain (odds ratio, 7; 95% CI, 2-25). On arrival at hospital, 67% of the children were still in pain; but 84% had experienced some pain relief regardless of their sex, age, or disorder. CONCLUSION: In a prehospital emergency setting, more than a third of children experience acute pain with a high prevalence of intense to severe pain. Scoring pain in children, and especially in the newborn, is beleaguered by a lack of suitable scales. Despite this, it was possible to treat 90% of children in pain and provide relief in 80% of cases.