Optimal human and system performance during neonatal resuscitation.

Performance in the delivery of care to sick neonates in need of resuscitation has long been defined primarily in terms of the extent of the knowledge possessed and hands-on skill demonstrated by physicians and other healthcare professionals. This definition of performance in neonatal resuscitation is limited by its focus solely on the human beings delivering care and a perceived set of the requisite skills to do so. This manuscript will expand the definition of performance to include all of the skill sets that humans must use to resuscitate newborns as well as the often complex systems in which those humans operate while delivering that care. It will also highlight how the principles of human factors and ergonomics can be used to enhance human and system performance during patient care. Finally, it will describe the role of simulation and debriefing in the assessment of human and system performance.

Effects of delivery room quality improvement on premature infant outcomes.

OBJECTIVE: Delivery room management interventions have been successfully implemented via collaborative quality improvement (QI) projects. However, it is unknown whether these successes translate to reductions in neonatal morbidity and mortality. STUDY DESIGN: This was a prospective pre-post intervention study of three nonrandomized hospital groups within the California Perinatal Quality Care Collaborative. A collaborative QI model (Collaborative QI) was compared with a single-site QI model (NICU QI) and a non-participant population when implementing evidence-based delivery room practices. The intervention period was between June 2011 and May 2012. Infants born with gestational age between 22 weeks 0 days and 29 weeks 6 days and birth weight ⩽1500 g were included. Outcomes were mortality and select morbidities (bronchopulmonary dysplasia (BPD), intraventricular hemorrhage (IVH), retinopathy of prematurity (ROP) and necrotizing enterocolitis (NEC)). Outcomes were compared between the baseline (January 2010 to May 2011) and post-intervention period (June 2012 to May 2013) within each comparison group. RESULTS: Ninety-five hospitals were included with 4222 infants in the baseline period and 4186 infants in the post-intervention period. The Collaborative QI group had significantly reduced odds of developing BPD post-intervention (odds ratio (OR) 0.8, 95% confidence interval (CI) 0.65 to 0.99) or composite BPD-death (OR 0.83, 95% CI 0.69 to 1.00). In both the Collaborative QI and non-participants there were also reductions in IVH, severe IVH, composite severe IVH-death, severe ROP and composite severe ROP-death. CONCLUSION: Hospitals dedicated to improving delivery room practices can impact neonatal outcomes.

Post-event debriefings during neonatal care: why are we not doing them, and how can we start?

Post-event debriefings are a foundational behavior of high performing teams. Despite the inherent value of post-event debriefings, the frequency with which they are used in neonatal care is extremely low. If post-event debriefings are so beneficial, why aren't they conducted more frequently? The reasons are many, but solutions are available. In this report, we provide practical advice on conducting post-event debriefing in neonatal care. In addition, we examine the perceived barriers to conducting post-event debriefings, and offer strategies to overcome them. Finally, we consider opportunities to foster a culture change within neonatal care which integrates debriefing as standard daily work. By establishing a safety culture in neonatal care that encourages and facilitates effective post-event debriefings, patient safety can be enhanced and clinical outcomes can be improved.

The advantages of prenatal consultation by a neonatologist.

The neonatologist can be a valuable source of information for the pregnant woman and her partner faced with making difficult decisions. In specific clinical situations, a focused, thorough consultation by a neonatologist provides benefits for the parents, their child, the physicians, and the health care delivery system as a whole. Members of the perinatal team should act to facilitate early neonatal consultation in order to ease the transition from the obstetric to the neonatal team after delivery.

Who's teaching neonatal resuscitation to housestaff? Results of a national survey.

OBJECTIVE: This study was designed to investigate current patterns of training in neonatal resuscitation in US residency programs in general pediatrics. METHODS: A questionnaire was mailed to the chief residents and directors of all US residency programs in general pediatrics to determine who provides supervision and teaching of neonatal resuscitation in the delivery room and neonatal intensive care unit. This questionnaire also inquired as to the use within these residency programs of standardized resuscitation training courses such as Pediatric Advanced Life Support and Neonatal Resuscitation Program. RESULTS: Residents in their third and second years of training are most often cited as responsible for supervision and teaching of neonatal resuscitation in the delivery room, whereas attending neonatologists are cited most frequently as being responsible for these tasks in the neonatal intensive care unit. Pediatric Advanced Life Support is required by virtually all US residency programs, followed in frequency by Neonatal Resuscitation Program and Advanced Cardiac Life Support. CONCLUSIONS: Because those in training collectively provide much of the supervision and teaching of neonatal resuscitation, vigilance is required so that appropriate resuscitation skills are developed and maintained. Objective performance markers may be useful in assessing competency in caring for sick newborns.neonatal resuscitation, delivery room, Neonatal Resuscitation Program, Pediatric Advanced Life Support, Advanced Cardiac Life Support.

Time for a new paradigm in pediatric medical education: teaching neonatal resuscitation in a simulated delivery room environment.

OBJECTIVES: Acquisition and maintenance of the skills necessary for successful resuscitation of the neonate are typically accomplished by a combination of completion of standardized training courses using textbooks, videotape, and manikins together with active participation in the resuscitation of human neonates in the real delivery room. We developed a simulation-based training program in neonatal resuscitation (NeoSim) to bridge the gap between textbook and real life and to assess trainee satisfaction with the elements of this program. METHODS: Thirty-eight subjects (physicians and nurses) participated in 1 of 9 full-day NeoSim programs combining didactic instruction with active, hands-on participation in intensive scenarios involving life-like neonatal and maternal manikins and real medical equipment. Subjects were asked to complete an extensive evaluation of all elements of the program on its conclusion. RESULTS: The subjects expressed high levels of satisfaction with nearly all aspects of this novel program. Responses to open-ended questions were especially enthusiastic in describing the realistic nature of simulation-based training. The major limitation of the program was the lack of fidelity of the neonatal manikin to a human neonate. CONCLUSION: Realistic simulation-based training in neonatal resuscitation is possible using current technology, is well received by trainees, and offers benefits not inherent in traditional paradigms of medical education.

Secondary infection presenting as recurrent pulmonary hypertension.

Primary infection in the neonate, especially group B streptococcal infection, has long been recognized as a cause of persistent pulmonary hypertension of the newborn (PPHN), sometimes requiring treatment with inhaled nitric oxide (iNO) and extracorporeal membrane oxygenation (ECMO). However, secondary nosocomial infections in the neonatal period have not been widely reported as a cause of severe recurrent pulmonary hypertension (PHTN). We now present two cases of secondary infection in the neonate leading to significant PHTN. In both cases, the infants presented with PPHN soon after birth, requiring transfer to a level 3 neonatal intensive care unit and treatment with high-frequency oscillatory ventilation and iNO. After successful resolution of the initial PPHN, including extubation to nasal cannula, both infants developed signs of severe recurrent PHTN, leading to reintubation, high-frequency oscillatory ventilation and iNO therapy, and consideration of ECMO. In both cases, blood cultures taken at the time of recurrence of PHTN returned positive, one for Staphylococcus epidermidis, the other for methicillin-resistant Staphylococcus aureus. These unusual cases present the possibility of severe recurrent PHTN requiring iNO or ECMO in the setting of secondary infection. We speculate that these infants, although extubated after their first episodes of PHTN, were at risk for recurrence of PHTN due to continued pulmonary vascular reactivity.

Salvage laparotomy for failure of peritoneal drainage in necrotizing enterocolitis in infants with extremely low birth weight.

BACKGROUND/PURPOSE: Peritoneal drainage is a temporizing procedure for infants with extremely low birth weight (ELBW) who have perforated necrotizing enterocolitis (NEC). "Salvage" laparotomy is advocated when patients worsen after drainage. Some patients have survived with intact gastrointestinal functional after drainage alone. The purpose of this study is to determine if these salvage laparotomies are beneficial. METHODS: The authors reviewed the records of ELBW infants treated at Stanford University with perforated NEC from 1993 through 1998. Data collected included demographic makeup, type of operation, survival rate, postoperative complications, length of stay (LOS), and cost. RESULTS: The authors treated 26 patients, 9 with laparotomy and 17 with peritoneal drainage. The peritoneal drainage group had lower birth weight and more comorbid conditions. Survival rate was similar between laparotomy and drainage: 55.6% versus 41.2%. Four patients in the drainage group underwent salvage laparotomy for perceived clinical deterioration. All of these patients died. The clinical status of patients who had salvage laparotomy and died was similar to those who did not and lived. Seven of 13 patients treated with drainage followed only by supportive care and antibiotics survived. Cost and LOS for patients undergoing salvage laparotomy were much greater than for nonsurviving patients undergoing only peritoneal drainage: 84 +/- 20 days and $660,000 compared with 34 +/- 11 days and $306,000. CONCLUSIONS: Both primary peritoneal drainage and laparotomy should be considered primary therapy for perforated NEC. Patients undergoing peritoneal drainage typically experience clinical deterioration after operation. In this limited experience, salvage laparotomy did not appear beneficial.

Neonatal hypoglycemia, part II: pathophysiology and therapy.

Contemporary research is elucidating both the molecular mechanisms of hypoglycemia-induced neuronal injury and its corresponding clinical manifestations. Recognizing and screening those neonates at highest risk of hypoglycemia-induced injury is an important skill for all physicians responsible for the care of newborns. Appropriate therapy, consisting of either oral or intravenous glucose, should never be delayed while one is awaiting laboratory confirmation of a "low" glucose level.

The value of neurophysiologic approaches in the anticipation and evaluation of neonatal hypoglycemia.

The association of low blood glucose with central nervous system (CNS) injury was first described in 1937 by Hartmann and Jaudon. In the early 60 years since publication of these observations the effects of hypoglycemia upon the brain remain poorly understood. Technology capable of accurately determining plasma glucose concentrations has been developed. Investigators have sought to establish critical values below which glucose levels should not be allowed to fall. Despite these efforts the definitive level of glucose capable of producing brain injury in any particular patient remains unknown. Glucose homeostasis within the neonatal CNS represents a dynamic process consisting of many interrelated variables including gestational and chronologic age, genotype, relative health, blood flow, metabolic rate and availability of other suitable substrates. New technique for assessing the glucose delivery: consumption ratio and directly monitoring the cellular consequences of glucose deprivation within discrete regions of the brain will help to answer the question 'How long is too low and how long is too long?'

Neonatal hypoglycemia, Part I: Background and definition.

Hypoglycemia in the neonate remains a common problem. The association of low blood glucose concentrations and abnormal development has prompted extensive research into the anticipation, evaluation, and treatment of neonatal hypoglycemia. Glucose homeostasis in the fetus and neonate is a developmentally regulated dynamic process involving a number of intricate physiologic mechanisms. In addition, the determination of glucose concentrations is dependent upon both the type of tissue analyzed and the limitations of the specific method employed. The complexity of glucose metabolism makes it difficult to precisely define "normal" and "abnormal" glucose levels in preterm and term neonates.

The OOPS procedure (operation on placental support): in utero airway management of the fetus with prenatally diagnosed tracheal obstruction.

Tracheal obstruction of the newborn caused by cervical masses such as teratomas and cystic hygromas can result in a profound hypoxic insult and even death, owing to an inability to establish an adequate airway after birth. Prenatal sonographic diagnosis of these congenital anomalies permits (1) anticipation of an airway problem at the time of delivery and (2) formulation of an algorithm for airway management while oxygen delivery to the baby is maintained through the placental circulation. This is the report of a fetus in whom a large anterior cervical cystic hygroma was detected by prenatal ultrasonography. A multidisciplinary management team was assembled, and an algorithm for airway management was developed. Elective cesarean delivery of the fetal head and thorax, under conditions of uterine tocolysis, permitted a controlled evaluation of the airway and endotracheal intubation while oxygen supply to the infant was maintained through the placenta. The baby remained intubated, and 2 days later underwent subtotal excision of the cervical cystic hygroma. Pharmacological maintenance of the feto-placental circulation after hysterotomy is an invaluable adjunct to airway management of the neonate with prenatally diagnosed tracheal obstruction.

Altered rhombomere-specific gene expression and hyoid bone differentiation in the mouse segmentation mutant, kreisler (kr).

Rhombomeres appear transiently in the vertebrate hindbrain shortly after neurulation and are thought to represent embryologic compartments in which the expression of different combinations of genes leads to segment-specific differentiation of the developing hindbrain, the cranial ganglia, and the branchial arches. To determine the extent to which gene expression is related to the formation of visible rhombomere boundaries, we have examined, by in situ hybridization, the expression of five rhombomere-specific genes in mouse embryos homozygous for the kreisler (kr) mutation, in which rhombomeres 4-7 are replaced by a smooth morphologically unsegmented neural tube. Using molecular probes specific for Hoxb-1 (Hox-2.9), Hoxb-3 (Hox-2.7), Hoxb-4 (Hox-2.6), Krox-20, or Fgf-3 (Int-2), we found that the kr mutation affects the expression of all the genes we examined, but, surprisingly, the altered patterns of expression are not restricted to that portion of the mutant hindbrain which is morphologically abnormal. Rostral expression boundaries of Hoxb-3 and Hoxb-4 are displaced from their normal positions at r4/5 and r6/7 to the approximate positions of r3/4 and r4/5, respectively. The expression domains of Krox-20 and Fgf-3 are also displaced in a rostral direction and the intensity of Fgf-3 hybridization is greatly reduced. The expression domain of Hoxb-1 is affected differently from the other genes in kr/kr embryos; its rostral boundary at r3/4 is intact but the caudal boundary is displaced from its normal location at r4/5 to the approximate position of r5/6. Because boundaries of gene expression for Hoxb-1 and Hoxb-4 are found in a region of the kr/kr hindbrain that lacks visible rhombomeres, establishment of regional identity, as reflected by differential gene expression, does not require overt segmentation. To investigate whether the altered patterns of gene expression we observed in the kr/kr embryonic hindbrain are associated with morphologic changes in the adult, we examined neural crest-derived tissues of the second and third branchial arches, which normally arise from rhombomeres 4 and 6, respectively. We found that the hyoid bone in kr/kr animals exhibited an accessory process on the greater horn (a third arch structure) most easily explained by ectopic development of a second arch structure (the hyoid lesser horn) in an area normally derived from the third arch.