Overnight staffing in Canadian neonatal and pediatric intensive care units.

Aim: Infants and children who require specialized medical attention are admitted to neonatal and pediatric intensive care units (ICUs) for continuous and closely supervised care. Overnight in-house physician coverage is frequently considered the ideal staffing model. It remains unclear how often this is achieved in both pediatric and neonatal ICUs in Canada. The aim of this study is to describe overnight in-house physician staffing in Canadian pediatric and level-3 neonatal ICUs (NICUs) in the pre-COVID-19 era. Methods: A national cross-sectional survey was conducted in 34 NICUs and 19 pediatric ICUs (PICUs). ICU directors or their delegates completed a 29-question survey describing overnight staffing by resident physicians, fellow physicians, nurse practitioners, and attending physicians. A comparative analysis was conducted between ICUs with and without in-house physicians. Results: We obtained responses from all 34 NICUs and 19 PICUs included in this study. A total of 44 ICUs (83%) with in-house overnight physician coverage provided advanced technologies, such as extracorporeal life support, and included all ICUs that catered to patients with cardiac, transplant, or trauma conditions. Residents provided the majority of overnight coverage, followed by the Critical Care Medicine fellows. An attending physician was in-house overnight in eight (15%) out of the 53 ICUs, seven of which were NICUs. Residents participating in rotations in the ICU would often have rotation durations of less than 6 weeks and were often responsible for providing care during shifts lasting 20-24 h. Conclusion: Most PICUs and level-3 NICUs in Canada have a dedicated in-house physician overnight. These physicians are mainly residents or fellows, but a notable variation exists in this arrangement. The potential effects on patient outcomes, resident learning, and physician satisfaction remain unclear and warrant further investigation.

Treatment of Neonatal Seizures: Comparison of Treatment Pathways From 11 Neonatal Intensive Care Units.

OBJECTIVE: Seizures are a common neonatal neurologic emergency. Many centers have developed pathways to optimize management. We evaluated neonatal seizure management pathways at level IV neonatal intensive care units (NICUs) in the United States to highlight areas of consensus and describe aspects of variability. METHODS: We conducted a descriptive analysis of 11 neonatal seizure management pathways from level IV NICUs that specialize in neonatal neurocritical care including guidelines for electroencephalography (EEG) monitoring, antiseizure medication (ASM) choice, timing, and dose. RESULTS: Study center NICUs had a median of 70 beds (interquartile range: 52-96). All sites had 24/7 conventional EEG initiation, monitoring, and review capability. Management pathways uniformly included prompt EEG confirmation of seizures. Most pathways included a provision for intravenous benzodiazepine administration if either EEG or loading of ASM was delayed. Phenobarbital 20 mg/kg IV was the first-line ASM in all pathways. Pathways included either fosphenytoin or levetiracetam as the second-line ASM with variable dosing. Third-line ASMs were most commonly fosphenytoin or levetiracetam, with alternatives including topiramate or lacosamide. All pathways provided escalation to continuous midazolam infusion with variable dosing for seizures refractory to initial medication trials. Three pathways also included lidocaine infusion. Nine pathways discussed ASM discontinuation after resolution of acute symptomatic seizures with variable timing. CONCLUSIONS: Despite a paucity of data from controlled trials regarding optimal neonatal seizure management, there are areas of broad agreement among institutional pathways. Areas of substantial heterogeneity that require further research include optimal second-line ASM, dosage, and timing of ASM discontinuation.

"Playing it SAFE in the NICU" SAFE-R: a targeted diagnostic ultrasound protocol for the suddenly decompensating infant in the NICU.

Rapid diagnosis of sudden, unexpected, and potentially fatal complications in the neonatal intensive care unit (NICU) is essential for the initiation of prompt and life-saving management. Point-of-care ultrasound (POCUS) protocols are widely used in adult emergency situations to diagnose and guide treatment, but none has been specifically developed for the neonate. We propose a targeted diagnostic ultrasound protocol for the suddenly decompensating infant in the NICU for rapid screening for the most common life-threatening complications needing immediate attention. We integrated current knowledge on the use of POCUS for diagnosis of the most critical neonatal complications into the "SAFE-R protocol" (Sonographic Assessment of liFe-threatening Emergencies - Revised). The ultrasound algorithm was evaluated at the bedside for suitability and ease of use. Main features of SAFE-R are the use of standardized ultrasound points and a simple one-probe rule-in/rule-out approach. The flowchart is designed by order of urgency and priority is given to treatable causes. Hence, ruling out cardiac tamponade is the first step in the decision tree, followed by pneumothorax, pleural effusion, then acute critical aortic occlusion, acute abdominal complications, and severe intraventricular hemorrhage.Conclusion: SAFE-R is the first ultrasound algorithm specifically conceived for use in the NICU to screen for the most common urgent neonatal complications leading to sudden deterioration, thereby providing critical information within minutes. The simplified and rapid approach is designed for the neonatologist and is easy to learn and quick to perform. What is Known: • The fields of neonatal and pediatric critical care are undergoing a transformation with the adoption of POCUS and the recent publication of the first international guidelines on POCUS for critically ill children and neonates. • Targeted emergency ultrasound protocols are widely used in adult emergency and critical care medicine, but specific and adapted ultrasound algorithms are lacking for the pediatric and neonatal population. What is New: • We propose the first targeted ultrasound protocol specifically designed for the suddenly decompensating infant in the NICU for rapid screening of the most common life-threatening complications needing immediate attention. • The SAFE-R ultrasound algorithm integrates current knowledge on ultrasound diagnosis of the most critical neonatal complications into a simple and easy-to-perform emergency scanning protocol aimed to guide initial management and resuscitation efforts.

Prolonged Continuous Monitoring of Regional Lung Function in Infants with Respiratory Failure.

Rationale: Electrical impedance tomography (EIT) allows instantaneous and continuous visualization of regional ventilation and changes in end-expiratory lung volume at the bedside. There is particular interest in using EIT for monitoring in critically ill neonates and young children with respiratory failure. Previous studies have focused only on short-term monitoring in small populations. The feasibility and safety of prolonged monitoring with EIT in neonates and young children have not been demonstrated yet. Objectives: To evaluate the feasibility and safety of long-term EIT monitoring in a routine clinical setting and to describe changes in ventilation distribution and homogeneity over time and with positioning in a multicenter cohort of neonates and young children with respiratory failure. Methods: At four European University hospitals, we conducted an observational study (NCT02962505) on 200 patients with postmenstrual ages (PMA) between 25 weeks and 36 months, at risk for or suffering from respiratory failure. Continuous EIT data were obtained using a novel textile 32-electrode interface and recorded at 48 images/s for up to 72 hours. Clinicians were blinded to EIT images during the recording. EIT parameters and the effects of body position on ventilation distribution were analyzed offline. Results: The average duration of EIT measurements was 53 ± 20 hours. Skin contact impedance was sufficient to allow image reconstruction for valid ventilation analysis during a median of 92% (interquartile range, 77-98%) of examination time. EIT examinations were well tolerated, with minor skin irritations (temporary redness or imprint) occurring in 10% of patients and no moderate or severe adverse events. Higher ventilation amplitude was found in the dorsal and right lung areas when compared with the ventral and left regions, respectively. Prone positioning resulted in an increase in the ventilation-related EIT signal in the dorsal hemithorax, indicating increased ventilation of the dorsal lung areas. Lateral positioning led to a redistribution of ventilation toward the dependent lung in preterm infants and to the nondependent lung in patients with PMA > 37 weeks. Conclusions: EIT allows continuous long-term monitoring of regional lung function in neonates and young children for up to 72 hours with minimal adverse effects. Our study confirmed the presence of posture-dependent changes in ventilation distribution and their dependency on PMA in a large patient cohort. Clinical trial registered with www.clinicaltrials.gov (NCT02962505).

APANICU 1.0: sistema automático para la valoración del dolor en las unidades de cuidados intensivos neonatales / APANICU 1.0: an automatic system for pain assessment at neonatal intensive care units

Objetivo: comprobar la conectividad del prototipo APANICU 1.0 (Automatic Pain Assessment in Neonatal Intensive Care Units) y el software de la unidad para valorar el dolor en neonatos, y determinar la concordancia en la valoración del dolor cuando se usa APANICU 1.0 frente a escalas validadas.Método: pilotaje del prototipo (APANICU) que combina y analiza parámetros conductuales y fisiológicos del neonato, adquiere datos del monitor de constantes y registra la actividad del bebé con cámara y micrófono, calculando una cifra de dolor en tiempo real. El estudio se realizó en la Unidad de Cuidados Intensivos Neonatales del Hospital Universitario Joan XXIII (Tarragona). Dos observadores (A y B) valoraron el dolor del neonato usando las escalas Premature Infant Pain Profile (PIPP) y Susan Givens Bell (SGB), simultáneamente al volcado de APANICU. Se valoró la concordancia intraobservador mediante el coeficiente de correlación intraclase y concordancia entre instrumentos mediante el coeficiente de correlación Rho de Sperman.Resultados: 11 neonatos, edad gestacional media (DE) 32 (7,23) semanas. Coeficiente de correlación intraclase (IC 95%) entre A y B con PIPP fue 0,516 (- 0,800; 0,870), con SGB fue 0,079 (- 2,422; 0,752). Coeficiente de correlación de Spearman entre PIPP (A) y APANICU fue -0,144 (p= 0,67); entre SGB (A) y APANICU fue 0,115 (p= 0,74); entre PIPP (B) y APANICU fue 0,435 (p= 0,18), entre SGB (B) y APANICU fue de 0,077(p= 0,82).Conclusión: APANICU 1.0 emite una cifra de dolor, pero necesita perfeccionarse, ya que los valores obtenidos no se correlacionaron adecuadamente. Se propone mejorar el software creando una versión 2.0.(AU)

Objective: to test the connectivity of the APANICU 1.0 (Automatic Pain Assessment in Neonatal Intensive Care Units) prototype and the software used in the unit to assess pain in newborns, and to determine the consistency in pain assessment when using APANICU 1.0 vs. validated scales.Method: pilot test of the prototype (APANICU) that combines and analyzes behavioral and physiological parameters of the newborn, obtains data from the vital signs monitor, and records the activity of the baby with camera and microphone, calculating a pain figure in real time. The study was conducted in the Neonatal Intensive Care Unit of the Hospital Universitario Joan XXIII (Tarragona). Two observers (A and B) assessed the pain of the newborn using the Premature Infant Pain Profile (PIPP) and Susan Givens Bell (SGB) scales, simultaneously with APANICU data dump. Consistency between observers was assessed through the coefficient of intra-class correlation, and consistency between instruments through the Spearman’s Rho coefficient of correlation.Results: eleven (11) newborns, with mean gestational age (SD): 32 (7.23) weeks. The coefficient of intra-class correlation (CI 95%) between A and B with PIPP was 0.516 (- 0.800; 0.870): and 0.079 (- 2.422; 0.752) with SGB. The Spearman’s Coefficient of Correlation between PIPP (A) and APANICU was -0.144 (p= 0.67); between SGB (A) and APANICU: 0.115 (p= 0.74); between PIPP (B) and APANICU: 0.435 (p= 0.18), and between SGB (B) and APANICU: 0.077 (p= 0.82).Conclusion: APANICU 1.0 issues a pain figure, but it needs improvement, because the values obtained were not adequately correlated. The proposal is to improve the software by creating a 2.0 version.(AU)

Clinical relevance of fetal hemodynamic monitoring: Perinatal implications.

Comprehensive assessment of fetal wellbeing involves monitoring of fetal growth, placental function, central venous pressure, and cardiac function. Ultrasound evaluation of the fetus using 2D, color Doppler, and pulse-wave Doppler techniques form the foundation of antenatal diagnosis of structural anomalies, rhythm abnormalities and altered fetal circulation. Accurate and timely prenatal identification of the fetus at risk is critical for appropriate parental counseling, antenatal diagnostic testing, consideration for fetal intervention, perinatal planning, and coordination of postnatal care delivery. Fetal hemodynamic monitoring and serial assessment are vital to ensuring fetal wellbeing, particularly in the setting of complex congenital anomalies. A complete hemodynamic evaluation of the fetus gives important information on the likelihood of a smooth postnatal transition and contributes to ensuring the best possible outcome for the neonate.

Physiology of the fetal and transitional circulation.

The fetal circulation is an entirely transient event, not replicated at any point in later life, and functionally distinct from the pediatric and adult circulations. Understanding of the physiology of the fetal circulation is vital for accurate interpretation of hemodynamic assessments in utero, but also for management of circulatory compromise in premature infants, who begin extrauterine life before the fetal circulation has finished its maturation. This review summarizes the key classical components of circulatory physiology, as well as some of the newer concepts of physiology that have been appreciated in recent years. The immature circulation has significantly altered function in all aspects of circulatory physiology. The mechanisms and significance of these differences are also discussed, as is the impact of these alterations on the circulatory transition of infants born prematurely.

Extracorporeal life support: updates and controversies.

The use of Extracorporeal Life Support (ECLS) in children and adults has markedly increased during the past few years with over 4000 patients placed on ECLS every year in over 200 centers. This article focuses on updates to the physiology and mechanics of ECLS with use of magnetically levitated centrifugal pumps, hollow-fiber gas-exchange devices, and bi-caval dual-lumen catheters. We also explore controversies in management including indications, cannulation approaches, renal replacement, monitoring of anticoagulation, early ambulation, and termination of ECLS. Finally, we present changes in the systems that provide ECLS including the single-provider model and regionalization of care.

Dimensionamento da dor durante a instalação do cateter central de inserção periférica em neonatos / Measuring pain in neonates during placement of central line catheter via peripheral insertion / Medida de la intensidad del dolor durante la instalación del catéter central de inserción periférica en neonatos

Objetivo: Dimensionar a dor durante a instalação do cateter central de inserção periférica, comparando o momento da punção venosa com a progressão do cateter. Métodos: Estudo descritivo exploratório com coleta prospectiva dos dados realizado na unidade neonatal de um hospital-escola de grande porte da cidade de São Paulo. Avaliou-se a resposta dolorosa ao procedimento de inserção do cateter em 28 neonatos utilizando-se a escala Premature Infant Pain Profile (PIPP) nas etapas de pré-punção (15 segundos), punção venosa (30 segundos) e progressão do cateter (30 segundos). Resultados: O escore PIPP maior ou igual a sete, indicativo de dor moderada a intensa, ocorreu em 13 RN (59,1 por cento) na primeira punção venosa e 10 RN (45,5 por cento) na progressão do cateter do grupo que não recebeu analgésico ou sedativo. Conclusão: Os resultados apontam para a necessidade de se adotar medidas analgésicas, uma vez que neonatos internados em unidade de terapia intensiva neonatal são freqüentemente submetidos a procedimentos invasivos e dolorosos.

Objective: To measure pain in neonates during placement of central line catheter via peripheral insertion by comparing pain at the moment of the introduction of the catheter and pain at the progression of the catheter. Methods: This was a descriptive exploratory study with 28 neonates from a large teaching hospital in Sao Paulo city. Data were collected with the Premature Infant Pain Profile (PIPP) 15 seconds prior the initial introduction of the catheter, during the initial introduction of the catheter (30 seconds), and during the progression of the catheter (30 seconds). Results: The majority of neonates (59.1 percent) had a score e" 7 on the PIPP, moderate to high pain intensity, during the initial introduction of the catheter. A greater number of neonates (45.5 percent) who did not receive analgesic or sedative medication had score e" 7 on the PIPP, moderate to high pain intensity, during the progression of the catheter. Conclusion: There is a need for adoption of use of analgesic medication in the neonatal unit, since neonates often undergo invasive and painful procedures.

Objetivo: Medir la intensidad del dolor durante la instalación del catéter central de inserción periférica, comparando el momento de la punción venosa con la progresión del catéter. Métodos: Estudio descriptivo exploratorio con recolección prospectiva de los datos realizado en la unidad neonatal de un hospital-escuela de gran porte de la ciudad de Sao Paulo. Se evaluó la respuesta dolorosa al procedimiento de inserción del catéter en 28 neonatos, utilizándose la escala Premature Infant Pain Profile (PIPP) en las etapas de pre-punción (15 segundos), punción venosa (30 segundos) y progresión del catéter (30 segundos). Resultados: El puntaje PIPP mayor o igual a siete, indicativo de dolor moderado a intenso ocurrió en 13 RN (59,1 por ciento) en la primera punción venosa y 10 RN (45,5 por ciento) en la progresión del catéter del grupo que no recibió analgésico o sedativo. Conclusión: Los resultados apuntan que es necesario adoptar medidas analgésicas, ya que los neonatos internados en la unidad de terapia intensiva neonatal son frecuentemente sometidos a procedimientos invasores y dolorosos.