Rescuer Exertion and Fatigue Using Two-Thumb vs. Two-Finger Method During Simulated Neonatal Cardiopulmonary Resuscitation.

Background: Rescuer fatigue during neonatal CPR can affect CPR quality leading to reduced cerebral and myocardial perfusion. Aim: To investigate rescuer fatigue during simulated neonatal CPR using both objective (heart rate and cardiac output) and subjective measures. Methods: A randomized crossover manikin study performed. Nineteen doctors working in neonatology were randomized to (a) two-thumb term, (b) two-finger term, (c) two-thumb preterm, or (d) two-finger preterm group. Cardiac output and heart rate were measured with a non-invasive cardiac output monitor. A Likert scale assessed participants' level of perceived exertion. Results: In the preterm group, the mean change in HR from rest to 5 min in the TT group was 11.58 bpm (SD 6.22) vs. 9.94 bpm (SD 8.48), (p-value 0.36). There was no difference in change in CO, 2.10 (SD 1.15) in the TT group vs. 1.39 (SD 1.63) in TF group (p value 0.23). There was no difference in BORG RPE rating. In the term group, the mean change in HR from rest to 5 min was 15 bpm (SD 8.40) in TT group and 13 bpm (SD 7.86) in TF group, (p-value 0.416). The median change in CO from rest to 5 min was 1.50 (0.78 to 2.42 IQR) in TT group vs. 1.60 (0.65 to 3.0 IQR) in TF group. Conclusion: Providing chest compressions is associated with an increase in both heart rate and cardiac output. We did not identify difference between objective and subjective measures of fatigue between either technique in a preterm or term model.

Perceptions of webcams in the neonatal intensive care unit: here's looking at you kid!

INTRODUCTION: Many tertiary neonatal units employ a restricted visiting policy. Webcams have previously been implemented in the neonatal unit setting in several countries. OBJECTIVES: This study aims to determine the views from parents, physicians, and nursing staff before implementation of a webcam system. METHODS: A questionnaire-based study. RESULTS: There were 101 responses. Parental computer usage was 83%. The majority of parents indicated that they would use the webcam system. Parents felt that a webcam system would reduce stress. Members of the nursing staff were most concerned about privacy risks (68%), compared with parents who were confident in the security of these systems (92%, p-value < 0.001). Seventy two percent of nurses felt that a webcam system would increase the stress levels of staff as compared with less than 20% of the physicians (p-value < 0.001). DISCUSSION: The majority of parents who completed the questionnaire have positive attitudes toward implementation of a webcam system in the NICU. Education of health care staff is required before implementation.

Perfusion index in the very preterm infant.

AIM: Perfusion Index (PI) is a quantifiable measurement of peripheral perfusion and may be a useful adjunct to the assessment of circulatory status in the newborn. (i) To assess reproducibility of PI and (ii) To determine whether there is a difference between simultaneously obtained limb measurements of PI in newborns <32 weeks GA in the transitional period. METHODS: Perfusion Index was measured in newborns <32 weeks during the first 48 h of life. To examine reproducibility, the pulse oximetry probe was replaced on the same limb consecutively by the same operator. Upper and lower limbs were then simultaneously evaluated over a 5-min period. Heart rate, blood pressure, birth weight, ventilation requirement, inotrope use, lactate, PCO2 and CRIB-II score were also recorded. RESULTS: Thirty infants were assessed. Intraclass correlation coefficient for reproducibility in the same limb was high (r value = 0.982 p < 0.001). Measurements obtained in the right upper limb were consistently higher than either lower limb. The median (IQR) PI for the entire cohort was 0.70 (0.29-1.35). No correlation existed between gestational age, birth weight, CRIB scores, systolic and diastolic blood pressure, mean blood pressure and median PI values. CONCLUSION: Perfusion Index measurement is reproducible, and values are highest in the right upper limb. Wide differences between right upper and lower limb readings are most likely related to transitional circulatory changes.

In vitro comparison of neonatal suction catheters using simulated 'pea soup' meconium.

BACKGROUND: A variety of suction catheters (type, size and design) are recommended for oropharyngeal suctioning of meconium during newborn resuscitation, but it is not known which performs best. In this study we compared different sizes of soft catheters, the Yankauer (YK) and the portable bulb syringe (BS), in suctioning a solution of varying viscosity. METHODS: Simulated meconium (SM) was made using commercial canned pea soup in two strengths, full-strength thick-particulate (TP) and 50% strained soup diluted with water, that is, thin-non-particulate (TnP), with saline as a control. A 20 ml aliquot of solution was suctioned over 5 s with each device using an electrical suction pump set at two different pressures, 100 and 150 mm Hg (21 kpa). In addition, the negative pressure of five BSs was measured in order to compare generated pressures with the alternative devices. RESULTS: The YK and BS suctioned almost 100% of saline, while the 6F and 8F catheters suctioned 50% and 75% saline, respectively. The YK suctioned 100% of TnP, saline and 30% of TP. At reduced suction pressures (100 and 50 mm Hg) the YK also suctioned all TnP. The 12F and 14F catheters suctioned a minimal amount of TP, whereas YK was the most efficient, suctioning 30% of TP. The mean negative pressure generated with five BSs was 78 and 71 mm Hg by a male and female operator, respectively. CONCLUSIONS: The YK and BS outperform the catheters in suctioning SM. The YK is the best for TP, but all devices perform poorly in suctioning fluid of this consistency.

T-piece gas flow palpation as a clinical indicator of endotracheal intubation in neonates.

We aimed to determine if providers could detect simulated spontaneous respirations of an intubated neonate by palpating gas flow changes at the positive end expiratory pressure valve of a T-piece resuscitation device in an in vitro setting. We also aimed to demonstrate whether the sensitivity of this methodology was related to the exhaled tidal volumes and/or the gas flow settings on the resuscitation device. A T-piece resuscitator (Neopuff®) circuit was connected to a neonatal silicon test lung. Expiratory tidal volumes of 5, 10 and 15 ml were provided via the test lung, with the Neopuff® set at gas flow rates of 5, 10 and 15 L/min. Physician volunteers were asked to identify whether they could detect expiratory gas from the test lung at the circuit T-piece with the volar surface of their wrist, at different tidal volumes and gas flows. Ten doctors detected 315 of 450 expirations; 95, 73 and 42 % of tidal volumes of 15, 10 and 5 ml, respectively, were detected with an overall positive predictive value of 98.7 %. Detection of exhalations was similar at different gas flow rates for each tidal volume. No exhalations were detected at zero gas flow. We concluded that T-piece gas flow palpation may be a useful and previously unreported clinical sign, which may help to reassure clinicians that they have successfully intubated the trachea. As with any clinical sign, it should not be considered in isolation but within the context of the clinical picture.

Smartphone technology enhances newborn intubation knowledge and performance amongst paediatric trainees.

OBJECTIVE: Smartphones are widely used by physicians, but their effectiveness in improving teaching of clinical skills is not known. The aim of this study was to determine if pre procedural use of a smartphone neonatal intubation instructional application (NeoTube) improves trainee knowledge and enhances procedural skills performance in newborn intubation. DESIGN: Neonatal Resuscitation Program certified trainees in paediatrics and neonatology completed a knowledge based questionnaire on neonatal intubation, and were recorded intubating a term newborn manikin model. They then used the NeoTube iPhone application for 15 min, before completing the questionnaire and intubation again. Video recordings were later reviewed by two independent assessors, blinded to whether it was pre or post NeoTube use. RESULTS: 20 paediatric trainees (12 fellows and 8 residents) participated in this study. Comparing pre and post-viewing of the application, Questionnaire Scores (median (range)) increased from 18.5 (8-28) to 31 (24-35) (P<0.001), with calculation scores increasing from 6 (0-11) to 11 (6-12) (P<0.001), Skill Scores increased from 11 (9-15) to 12.5 (9-16) (P=0.016), and the duration of intubation attempt decreased from 39 to 31 s (P=0.044) following utilisation of the application. There was a significant positive correlation with duration of specialist training for procedure performance post viewing, but not pre viewing of the application. CONCLUSIONS: Bedside use of smartphones can enhance both knowledge of newborn intubation and improves procedural performance, including reducing the time to successfully intubate. Smartphones may have a useful role in bringing procedural skills training closer to the bedside.

Comparison of the T-piece resuscitator with other neonatal manual ventilation devices: a qualitative review.

AIM: To review the literature surrounding various aspects of T-piece resuscitator use, with particular emphasis on the evidence comparing the device to other manual ventilation devices in neonatal resuscitation. DATA SOURCES: The Medline, EMBASE, Cochrane databases were searched in April 2011. Ongoing trials were identified using www.clinicaltrials.gov and www.controlled-trials.com. Additional studies from reference lists of eligible articles were considered. All studies including T-piece resuscitator use were eligible for inclusion. RESULTS: Thirty studies were included. There were two randomised controlled trials in newborn infants comparing the devices, one of which addressed short and intermediate term morbidity and mortality outcomes and found no difference between the T-piece resuscitator and self inflating bag. From manikin studies, advantages to the T-piece resuscitator include the delivery of inflating pressures closer to predetermined target pressures with least variation, the ability to provide prolonged inflation breaths and more consistent tidal volumes. Disadvantages include a technically more difficult setup, more time required to adjust pressures during resuscitation, a larger mask leak and less ability to detect changes in compliance. CONCLUSIONS: There is a need for appropriately designed randomised controlled trials in neonates to highlight the efficacy of one device over another. Until these are performed, healthcare providers should be appropriately trained in the use of the device available in their departments, and be aware of its own limitations.

A disappearing neonatal skin lesion.

A preterm baby girl was noted at birth to have a firm, raised, non-tender skin lesion located over her right hip. She developed three similar smaller lesions on her ear, buttock and right knee. All lesions had resolved by 2 months of age.

The Neopuff's PEEP valve is flow sensitive.

AIM: The current recommendation in setting up the Neopuff is to use a gas flow of 5-15 L/min. We investigated if the sensitivity of the positive end expiratory pressure (PEEP) valve varies at different flow rates within this range. METHODS: Five Neopuffs were set up to provide a PEEP of 5 cm H(2) O. The number of clockwise revolutions to complete occlusion of the PEEP valve and the mean and range of pressures at each quarter clockwise revolution were recorded at gas flow rates between 5 and 15 L/min. RESULTS: At 5, 10 and 15 L/min, 0.5, 1.7 and 3.4 full clockwise rotations were required to completely occlude the PEEP valve, and pressures rose from 5 to 11.4, 18.4 and 21.5 cm H(2) O, respectively. At a flow rate of 5 L/min, half a rotation of the PEEP dial resulted in a rise in PEEP from 5 to 11.4cm H(2) O. At 10 L/min, half a rotation resulted in a rise from 5 to 7.7cm H(2) O, and at 15 L/min PEEP rose from 5 to 6.8cm H(2) O. CONCLUSION: Users of the Neopuff should be aware that the PEEP valve is more sensitive at lower flow rates and that half a rotation of the dial at 5 L/min gas flow can more than double the PEEP.