Factors associated with neonatal resuscitation knowledge and comfort across academic anesthesia institutions.

BACKGROUND: Neonatal resuscitation training is a requirement for all obstetric anesthesia fellows. However, while the majority of anesthesiologists who work on labor and delivery report having been involved in the resuscitation of a newborn, most do not have NRP training. OBJECTIVE: By studying a national cohort of anesthesiologists, our objective was to identify factors associated with knowledge and comfort with neonatal resuscitation and to inform decisions about neonatal resuscitation in obstetric anesthesia fellowship training. MATERIALS AND METHODS: After receiving exempt status, a survey assessing knowledge and comfort with neonatal resuscitation was sent to US academic institutions. Univariable and multiple variable regression analyses were performed to assess factors associated with knowledge and comfort. All statistical analyses were performed using R software (R version 3.4.3 [2017-11-30]; R Foundation for Statistical Computing, Vienna, Austria). RESULTS: Responses were received from 32 (84%) of 38 academic institutions that participated. A total of 245 surveys were collected from 20 December 2018 to 27 September 2019. The mean (standard deviation (SD)) percentage of correct knowledge answers in the cohort was 43.3% (22.6%). Knowledge scores were associated with obstetric anesthesia fellowship training, regularly working with infants, and current neonatal resuscitation program (NRP) training. The mean (SD) sum of comfort ratings from the individual questions was 49.9 (17.9). Comfort ratings were associated with pediatric anesthesia fellowship training, regularly working with infants, current NRP training, and having at least one year of general pediatrics residency training. CONCLUSIONS: Obstetric anesthesiologists have the knowledge but appear to lack the comfort to perform neonatal resuscitation. As obstetric anesthesiologists are sometimes involved in neonatal resuscitation, maintenance of certification is important in maintaining comfort with neonatal resuscitation if not regularly working with infants.

T Cell Transcriptomes Describe Patient Subtypes in Systemic Lupus Erythematosus.

BACKGROUND: T cells regulate the adaptive immune response and have altered function in autoimmunity. Systemic Lupus Erythematosus (SLE) has great diversity of presentation and treatment response. Peripheral blood component gene expression affords an efficient platform to investigate SLE immune dysfunction and help guide diagnostic biomarker development for patient stratification. METHODS: Gene expression in peripheral blood T cell samples for 14 SLE patients and 4 controls was analyzed by high depth sequencing. Unbiased clustering of genes and samples revealed novel patterns related to disease etiology. Functional annotation of these genes highlights pathways and protein domains involved in SLE manifestation. RESULTS: We found transcripts for hundreds of genes consistently altered in SLE T cell samples, for which DAVID analysis highlights induction of pathways related to mitochondria, nucleotide metabolism and DNA replication. Fewer genes had reduced mRNA expression, and these were linked to signaling, splicing and transcriptional activity. Gene signatures associated with the presence of dsDNA antibodies, low complement levels and nephritis were detected. T cell gene expression also indicates the presence of several patient subtypes, such as having only a minimal expression phenotype, male type, or severe with or without induction of genes related to membrane protein production. CONCLUSIONS: Unbiased transcriptome analysis of a peripheral blood component provides insight on autoimmune pathophysiology and patient variability. We present an open source workflow and richly annotated dataset to support investigation of T cell biology, develop biomarkers for patient stratification and perhaps help indicate a source of SLE immune dysfunction.

Babies in Distress: Malignant Hyperthermia in Infancy Explored.

There has been international debate on the infrequent occurrence of malignant hyperthermia in infants, where some reports state that this phenomenon does not exist in this age group; but the vast majority of studies counteract this argument. The proportion of documented cases in the infant population warrants a good review of cases and description of symptomatology observed with malignant hyperthermia in this cohort. It is paramount for clinicians of the pediatric population to recognize patients at risk of having a crisis, and to communicate this concern to the surgical/anesthetic team and also to be cognizant of the level of care necessary following a crisis.

An in vitro analysis of central venous drug delivery by continuous infusion: the effect of manifold design and port selection.

BACKGROUND: Central venous catheters are used extensively in anesthesia and critical care. Multiport manifolds allow for simultaneous administration of multiple medication infusions into a common central venous catheter lumen. The structures of such manifolds vary considerably. In this study, we quantitatively compared, in a laboratory model of continuous drug infusion, the drug delivery dynamics of a traditional stopcock manifold and a microinfusion manifold constructed to minimize dead volume. METHODS: A syringe pump infused a saline carrier solution at a low flow rate frequently used in an intensive care unit (10 mL/h) through a multiport manifold connected to the 16-gauge lumen of a standard 16-cm triple-lumen catheter. The model drug methylene blue (3 mL/h) joined the carrier flow at the first, second, or fourth stopcock of a traditional manifold or 1 of 2 positions in a microinfusion manifold, a new device designed to minimize dead volume. Effluent samples were collected every minute for quantitative spectrophotometric analysis of delivery onset and offset. RESULTS: Onset and offset times differed significantly among individual ports of the traditional 4-stopcock manifold. There was also a significant difference between the 2 ports of the microinfusion manifold, but this was less pronounced. Both ports of the microinfusion manifold yielded delivery dynamics that were similar to the most downstream port of the 4-stopcock manifold. There was good correlation between dynamic data and dead volume for each of the manifolds. CONCLUSIONS: Using a traditional stopcock manifold, port selection significantly affects drug delivery dynamics for continuous infusions. The findings provide quantitative support for the concept that the most critical infusion should join the system at the manifold port closest to the patient. Port selection was less important for the microinfusion manifold and dynamics were faster compared with the second and fourth ports of the stopcock manifold. The smaller dead volumes of the microinfusion manifold minimize unwanted delays in drug delivery onset and offset allowing more precise control over drug delivery by continuous infusion.

An analysis of drug delivery dynamics via a pediatric central venous infusion system: quantification of delays in achieving intended doses.

BACKGROUND: Pediatric patients frequently receive continuous infusions of drugs via central venous catheters in the intensive care unit and the operating room. This study characterized drug delivery profiles in a quantitative laboratory model of a standard pediatric central venous infusion system. METHODS: We evaluated drug delivery via a standard pediatric 8-cm, 4-F double-lumen catheter. One syringe pump infused normal saline as the carrier fluid through a limb of a Y-piece connected to the catheter's 22-gauge distal lumen. Through the other limb of the Y-piece, a second syringe pump infused methylene blue, the model drug, at a constant rate of 0.5 mL/h. The volume delivered was collected every minute for quantitative analysis. We compared 2 mL/h and 12 mL/h total flow rates to mimic volume delivery to a 3-kg infant, and priming of the Y-piece with the model drug, to mimic resumption of a stopped drug infusion, versus no priming, to mimic a new infusion. Drug pump system start-up performance was measured to estimate this factor's contribution to infusion onset profiles. RESULTS: When initiating a new infusion of the model drug, the time to steady-state delivery at the catheter's end varied significantly among the studied scenarios as measured by the time to reach half of the targeted dose (t(50)). Onset of delivery with a low total flow was much slower (t(50) = 23.5 +/- 2.1 min) than with the high flow rate (t(50) = 15.7 +/- 2.9 min). Priming the drug limb of the connecting Y-piece with methylene blue substantially shortened the time to steady state (low flow t(50) = 12.7 +/- 0.6 min, high flow t(50) = 5.2 +/- 0.8 min). Time to cessation of drug delivery to the end of the catheter after stopping the drug pump was substantially shorter using the high carrier flow rate (t(50) = 3 +/- 0.5 min) compared with the low carrier flow rate (t(50) = 11.6 +/- 0.8 min). Drug pump system start-up performance contributed to onset delay. CONCLUSIONS: Current infusion techniques in the pediatric care setting can result in significant, unrecognized, and potentially hazardous delays in achieving delivery of intended drug doses to the patient. Total flow rate, priming of the infusion system, the dead volume of the fluid path, and the start-up performance of the infusion pump system contribute to delays in achieving targeted rates of drug delivery.