Amplitude-Integrated Electroencephalography: A Readily Available Tool for Neonatologists.

Hypoxic-ischemic encephalopathy (HIE) is a common condition occurring at birth, impairing central nervous system function. Therapeutic hypothermia is beneficial for suspected HIE as it reduces mortality and disability in survivors but not for other types of encephalopathy (e.g., metabolic). Amplitude-integrated electroencephalography (aEEG) complements limited resource Neonatal Intensive Care Units as a screening tool that can provide information regarding the degree of encephalopathy and electrographic seizures. Patients with HIE are at increased risk for seizures, which are subclinical in half of the cases. The aEEG emphasizes electroencephalographic amplitude differences, whereas continuous video electroencephalography (cEEG) provides a high-resolution picture of cerebral electrical activity, making it the most accurate method for detecting subclinical seizures. Still, its interpretation demands extensive training beyond the scope of neonatologists. Any infant in whom aEEG is suspicious for seizures should undergo cEEG to confirm the findings because even very low-amplitude artifacts might be misdiagnosed as seizures. We report a case and review the utility of aEEG in detecting subclinical seizures in neonates with HIE during therapeutic hypothermia while cEEG is not available.

Ventriculoperitoneal Shunt Tap Task Trainer: A Technical Report.

This technical report describes the creation of a model of an infant with a ventriculoperitoneal shunt (VPS). This model is authentic, assembled easily, and reusable which allows for pediatric and neurosurgical practitioners to gain experience in performing VPS taps. Learning objectives have been provided to guide task training.

Neonatal Transport Ventilation: Simulation to Improve Knowledge and Skills.

Introduction: Neonatal transport is a frequent activity in most tertiary and regional perinatal centers. Neonatal transport teams serve as mobile intensive care units and are equipped with specialized incubators that have built-in ventilators that can provide several levels of support. In our institution, we aim to educate all neonatal transport providers, including neonatal-perinatal fellows, neonatal intensive care unit-dedicated advanced practice providers, and neonatal intensive care unit-dedicated registered respiratory therapists, on transport ventilation management and troubleshooting, utilizing simulation to optimize patient care during transport. Methods: We developed scenarios based on the equipment used at our institution: an AirBorne Voyager transport incubator with a built-in Crossvent 2i+ infant ventilator, AirBorne TXP-2D high-frequency ventilator, and AeroNOx inhaled nitric oxide system (International Biomedical). Equipment and troubleshooting knowledge were assessed via knowledge tests prior to and at intervals after simulation scenario completion. We performed paired t tests to analyze change in test scores at each time point postsimulation compared to presimulation. Facilitated debriefing and a survey elicited feedback on learner confidence and comfort. Results: Ten learners participated in the simulations and completed the knowledge assessments. At all postsimulation time points, mean knowledge scores showed statistically significant improvements compared to presimulation scores. Feedback from learners on confidence in their skills and comfort with the equipment was positive. Discussion: Neonatal transport team ventilator knowledge and troubleshooting skills have improved after instituting this semiannual simulation training.

Pericardiocentesis Simulation Model: Low Cost, Easy to Assemble, Effective Task Trainer.

Pericardial effusion is a potentially lethal condition. If it is discovered early, it can be treated by pericardiocentesis under controlled condition with imaging by experienced care providers. If it is diagnosed at a later stage with clinical compromise, then an emergent procedure might be necessary. Since it is encountered infrequently, many providers may have little or no experience in managing the condition and performing a life-saving pericardiocentesis. This is a technical report that describes the creation of a neonatal model for pericardiocentesis. This is a high-fidelity, low-cost model that is simple to create. Materials that are inexpensive and easy to obtain are utilized to make the model. Neonatal care providers, including residents, fellows, nurse practitioners, physician assistants, and attendings, can practice with this model. In some medical centers, an echocardiogram or bedside ultrasound is available to guide needle insertion; however, practicing the procedure on a model provides valuable experience. This model is designed to teach the performance of unguided pericardiocentesis without the use of simultaneous imaging. Included with this technical report are a supply list, a checklist, and a suggested scenario that can be used in association with this model. In this article, we have discussed our own experience and described lessons learned about training neonatal care providers in pericardiocentesis.

Neonatal Hydrops Simulation Model: A Technical Report.

This technical report describes the creation of a model of a newborn with hydrops fetalis (HF). This model is easy to assemble, quite authentic and reusable allowing for many neonatal intensive care providers to practice rare, life-saving procedures. Learning objectives and a critical action checklist have been included to guide the simulation and add additional complexity to the scenario, if desired.

Incidence of Complications Associated with Parenteral Nutrition in Preterm Infants < 32 Weeks with a Mixed Oil Lipid Emulsion vs a Soybean Oil Lipid Emulsion in a Level IV Neonatal Intensive Care Unit.

BACKGROUND: Parenteral nutrition (PN) is crucial for the improvement of long-term outcomes in very low birth weight (VLBW) neonates. Lipid injectable emulsions are a key component of PN, as they contain essential fatty acids and provide energy critical for brain growth. Prolonged administration increases risk of intestinal failure-associated liver disease, including cholestasis, and other complications. METHODS: This is a retrospective, quasi-experimental cohort study of 215 VLBW neonates. The primary outcome was a change in direct bilirubin concentration. Secondary outcomes included change in total bilirubin concentration and incidences of cholestasis and other disease states associated with PN and prematurity. Cholestasis was defined as direct bilirubin ≥ 1.0 mg/dL with total bilirubin < 5.0 mg/dL or direct bilirubin > 20% of total bilirubin with total bilirubin > 5.0 mg/dL. RESULTS: Change in direct bilirubin concentration was not different between groups. Incidence of cholestasis was not different between groups per charted diagnosis or per study definition. Non-stage-0 retinopathy of prematurity, bronchopulmonary dysplasia, sepsis, and necrotizing enterocolitis were all lower in the mixed oil lipid emulsion group, which remained significant after adjustment for differences in gestational age, birth weight, and PN duration. CONCLUSIONS: Although mixed oil lipid emulsion was not found to be associated with a lower risk of cholestasis, it may decrease risks of other disease states associated with PN therapy.

Respiratory outcomes after neonatal prone versus supine positioning following scheduled cesarean delivery: a randomized trial.

BACKGROUND: Prone positioning is a common practice after vaginal birth promoting skin to skin contact and has been associated with improved oxygenation in mechanically ventilated neonates in the recent analysis. Neonates of women not in labor delivered via C-section are at increased risk of respiratory distress; it is unclear whether vigorous neonates without a need of resuscitation would benefit from prone positioning immediately after birth. OBJECTIVE: To determine whether prone positioning of vigorous term neonates for the first 5 min after scheduled cesarean delivery will decrease the incidence of respiratory distress and therapeutic interventions, characterized by the frequency and duration of respiratory support (RS). DESIGN/METHODS: In a single center, randomized parallel clinical trial, vigorous term neonates delivered via scheduled cesarean delivery were positioned prone or supine and their heart rate, oxygen saturation and signs of respiratory distress were recorded at 1-min intervals for the first 5 min. Infants not reaching target oxygen saturations suggested by the neonatal resuscitation guidelines received RS via Neopuff in supine position; respiratory support was discontinued once oxygen saturation targets were met and infant was free of respiratory symptoms. Primary outcomes measured were frequency and duration of RS, secondary outcomes were admission to the NICU for respiratory distress, length of stay, heart rate and oxygen saturation during the initial 5 min of life. RESULTS: Two hundred twenty-five neonates in prone and 231 in supine position completed the study out of 500 randomized subjects. Frequency of RS (31 versus 30%, p = .93), mean RS duration (4.08 versus 4.39 min; p = .71), frequency of admission to the NICU (5% in both groups; p = .95) and mean length of stay (0.14 versus 0.28 days; p = .42) were similar between the prone and supine groups. The supine cohort had higher initial oxygen saturation (p = .02) as well as heart rate (p = .004). CONCLUSIONS: Prone or supine positioning of term neonates after scheduled cesarean delivery resulted in comparable respiratory outcomes including the need for resuscitation in the first minutes of life.

Exchange Transfusion Simulation Models: A Technical Report.

This technical report describes the creation of two exchange transfusion models in the newborn. These are low cost, easy to assemble, authentic, and realistic task trainers that provide the opportunity for neonatal providers to practice this rare, life-saving procedure. A critical action checklist is included to guide the simulated procedure. Also included is a suggested clinical scenario with optional complications and variations.

Meningomyelocele Simulation Model: Pre-surgical Management-Technical Report.

This technical report describes the creation of a myelomeningocele model of a newborn baby. This is a simple, low-cost, and easy-to-assemble model that allows the medical team to practice the delivery room management of a newborn with myelomeningocele. The report includes scenarios and a suggested checklist with which the model can be employed.

Noise Reduction in the Neonatal Intensive Care Unit: A Quality Improvement Initiative.

Exogenous noise has deleterious effects on the developing fetus and infant. The aim of this quality improvement project was to lower the mean ambient noise level within a level IV neonatal intensive care unit (NICU) by 10% from the baseline in one year. Multiple noise reduction strategies were tested through Plan-Do-Study-Act cycles based on the Institute for Healthcare Improvement model for improvement. Strategies targeted environmental and behavioral modifications. Noise levels were recorded continuously; means and peaks were calculated. The mean noise level decreased from 62.4 dB to 56.1 dB, and peak noise level decreased from 115 dB to 76 dB within 12 months. Day shift noise level decreased by 7.7 dB; night shift noise level decreased by 4.9 dB from baseline. Targeted education, behavioral, and environmental modifications decreased the noise level in the NICU as per the study aim. To create a change in culture, constant dialogue between the project champions and the NICU staff is necessary.