Endotracheal Intubation in Neonates: A Prospective Study of Adverse Safety Events in 162 Infants.

OBJECTIVE: To determine the rate of adverse events associated with endotracheal intubation in newborns and modifiable factors contributing to these events. STUDY DESIGN: We conducted a prospective, observational study in a 100-bed, academic, level IV neonatal intensive care unit from September 2013 through June 2014. We collected data on intubations using standardized data collection instruments with validation by medical record review. Intubations in the delivery or operating rooms were excluded. The primary outcome was an intubation with any adverse event. Adverse events were defined and tracked prospectively as nonsevere or severe. We measured clinical variables including number of attempts to successful intubation and intubation urgency (elective, urgent, or emergent). We used logistic regression models to estimate the association of these variables with adverse events. RESULTS: During the study period, 304 intubations occurred in 178 infants. Data were available for 273 intubations (90%) in 162 patients. Adverse events occurred in 107 (39%) intubations with nonsevere and severe events in 96 (35%) and 24 (8.8%) intubations, respectively. Increasing number of intubation attempts (OR 2.1, 95% CI, 1.6-2.6) and emergent intubations (OR 4.7, 95% CI, 1.7-13) were predictors of adverse events. The primary cause of emergent intubations was unplanned extubation (62%). CONCLUSIONS: Adverse events are common in the neonatal intensive care unit, occurring in 4 of 10 intubations. The odds of an adverse event doubled with increasing number of attempts and quadrupled in the emergent setting. Quality improvement efforts to address these factors are needed to improve patient safety.

In tropical lowland rain forests monocots have tougher leaves than dicots, and include a new kind of tough leaf.

BACKGROUND AND AIMS: There has been little previous work on the toughness of the laminae of monocots in tropical lowland rain forest (TLRF) despite the potential importance of greater toughness in inhibiting herbivory by invertebrates. Of 15 monocot families with >100 species in TLRF, eight have notably high densities of fibres in the lamina so that high values for toughness are expected. METHODS: In north-eastern Australia punch strength was determined with a penetrometer for both immature leaves (approx. 30 % final area on average) and fully expanded, fully toughened leaves. In Singapore and Panama, fracture toughness was determined with an automated scissors apparatus using fully toughened leaves only. KEY RESULTS: In Australia punch strength was, on average, 7x greater in shade-tolerant monocots than in neighbouring dicots at the immature stage, and 3x greater at the mature stage. In Singapore, shade-tolerant monocots had, on average, 1.3x higher values for fracture toughness than neighbouring dicots. In Panama, both shade-tolerant and gap-demanding monocots were tested; they did not differ in fracture toughness. The monocots had markedly higher values than the dicots whether shade-tolerant or gap-demanding species were considered. CONCLUSIONS: It is predicted that monocots will be found to experience lower rates of herbivory by invertebrates than dicots. The tough monocot leaves include both stiff leaves containing relatively little water at saturation (e.g. palms), and leaves which lack stiffness, are rich in water at saturation and roll readily during dry weather or even in bright sun around midday (e.g. gingers, heliconias and marants). Monocot leaves also show that it is possible for leaves to be notably tough throughout the expansion phase of development, something never recorded for dicots. The need to broaden the botanist's mental picture of a 'tough leaf' is emphasized.