Endotracheal tube manipulation during cardiopulmonary resuscitation in the neonatal intensive care unit.

OBJECTIVES: We sought to describe the approach to and impact of endotracheal tube (ETT) placement for cardiopulmonary resuscitation (CPR) occurring in the neonatal intensive care unit (NICU). STUDY DESIGN: A retrospective review of in-NICU CPR from 2012 to 2017 across ten NICUs in San Antonio, Texas. RESULTS: Of 209 CPR events, 22 (10.5%) patients required ETT placement at CPR onset, 23 (11%) had an existing ETT removed and replaced, and 8 (3.4%) both. We found no association between time without an ETT tube during CPR and time to return of spontaneous circulation (ROSC) or rate of ROSC. We found no documented use of a laryngeal mask airway during in-NICU CPR. CONCLUSIONS: For CPR occurring in the NICU, the achievement of ROSC or time to ROSC is not impacted by the need to place an initial AA at the onset of CPR in this contemporary cohort.

The Characteristics and Outcomes of Cardiopulmonary Resuscitation within the Neonatal Intensive Care Unit Based on Gestational Age and Unit Level of Care.

OBJECTIVES: This study aimed to describe the variation of in-neonatal intensive care unit (NICU) cardiopulmonary resuscitation (CPR) characteristics and outcomes across different gestational ages and levels of NICU care. STUDY DESIGN: This is a retrospective cohort study of in-NICU CPR events across 10 NICUs in San Antonio, TX from 2012 through 2017. RESULTS: We identified 140 patients experiencing a total of 210 in-NICU CPR events. CPR was performed in 0.23% of Level III and 0.85% of Level IV NICU admissions. Gestational age was inversely related to CPR incidence. The median age at in-NICU CPR was lower for preterm versus term infants (6 vs. 28 days, p = 0.002). With regression modeling, each added minute of chest compression decreased the odds of return to spontaneous circulation by 11%. CONCLUSION: In-NICU CPR incidence rises with decreasing gestational age and increasing level of NICU care. The rate of return of spontaneous circulation decreases significantly with increasing duration of chest compressions. Further study is needed to identify patient factors associated with adverse outcome.

Change in practice after the Surfactant, Positive Pressure and Oxygenation Randomised Trial.

OBJECTIVE: To test the hypothesis that the proportion of endotracheal intubation (ETI) in the delivery room (DR) decreased in Neonatal Research Network (NRN) centres after the National Institute of Child Health and Human Development NRN Surfactant, Positive Pressure, and Oxygenation Randomised Trial (SUPPORT). DESIGN: Retrospective cohort study using the prospective NRN generic database. SETTING: Eleven centres that participated in the SUPPORT trial and remained part of the NRN. Preterm neonates 24(0/7)-27(6/7) weeks' gestational age enrolled in the SUPPORT trial were randomised to: (1) DR continuous positive airway pressure or DR ETI with early surfactant administration; and (2) oxygen saturation targets of 85-89% or 91-95%. The prior NRN feasibility trial had assessed the feasibility of randomisation to continuous positive airway pressure versus ETI. PATIENTS: Infants 24(0/7)-27(6/7) weeks' gestational age, excluding infants with syndromes or major malformations and those on comfort care only. MAIN OUTCOME MEASURE: Proportion of DR ETI. RESULTS: The proportion of DR ETI decreased significantly in the group of infants from centres that had not participated in the feasibility trial (91% before vs 75% after SUPPORT, adjusted relative risk 0.86, 95% CI 0.83-0.89, p<0.0001) but not in the group of infants from the other centres, where the proportion of ETI was already lower prior to initiation of the SUPPORT trial (61% before vs 58% after SUPPORT, adjusted relative risk 0.96, 95% CI 0.89 to 1.05, p=0.40). CONCLUSION: This study shows that DR ETI changed after SUPPORT only in NRN centres that had not participated in a similar trial. TRIAL REGISTRATION NUMBER: NCT00063063 (GDB) and NCT00233324 (SUPPORT).

Change in care among nonenrolled patients during and after a randomized trial.

OBJECTIVE: Parkland Memorial Hospital (PMH) participated in Surfactant, Positive Pressure, and Oxygenation Randomized Trial (SUPPORT), an unblinded controlled trial, in which preterm neonates of 24(0/7) to 27(6/7) weeks' gestational age (GA) were randomized in the delivery room (DR) to endotracheal intubation or nasal continuous positive airway pressure. We hypothesized that DR intubation could change in nonenrolled patients at PMH and that the change would be larger than in comparable centers not participating in the trial. METHODS: The PMH Cohort included eligible but nonenrolled neonates of 24(0/7) to 27(6/7) weeks (primary) and noneligible neonates of 28 to 34(6/7) weeks (confirmatory). A subset (24(0/7)-29(6/7)weeks) of that cohort was compared with a contemporaneous cohort born in centers participating in the Vermont Oxford Network (VON). We used a Poisson regression model to obtain adjusted relative risks (RRs) of DR intubation (during/after SUPPORT versus before SUPPORT) for PMH and for VON along with the ratio of these RRs. RESULTS: In the PMH cohort (n = 3527), the proportion of DR intubation decreased during/after SUPPORT in the lower GA group (adjusted RR 0.76, 95% confidence interval [CI] 0.59-0.96) and the upper GA group (adjusted RR 0.57, 95% CI 0.46-0.70). Compared with the RR for DR intubation in VON, the RR at PMH was smaller in the lower (ratio of RR 0.76, 95% CI 0.65-0.87) and the upper GA group (ratio of RR 0.52, 95% CI 0.39-0.68). CONCLUSIONS: A center's participation in an unblinded randomized trial may affect process of care of nonenrolled patients.