Video laryngoscopy-assisted less-invasive surfactant administration quality improvement initiative.

OBJECTIVE: To describe the use of quality improvement methodology in transitioning from delivery of surfactant by INSURE (INtubation-SURfactant administration-Extubation) to video laryngoscope-assisted LISA (less-invasive surfactant administration) for infants with respiratory distress syndrome (RDS) receiving non-invasive ventilatory support. SETTING: Two large neonatal intensive care units (NICUs) at Northwell Health (New Hyde Park, New York, USA). STUDY POPULATION: Infants with RDS receiving continuous positive airway pressure in the NICU and eligible for surfactant administration. RESULTS: LISA was initiated in our NICUs in January 2021, after extensive guideline development, education programmes, hands-on training and provider credentialing. Our Specific, Measurable, Achievable, Relevant and Timely aim was to deliver surfactant by LISA for 65% of total doses by 31 December 2021. This goal was achieved within 1 month of go-live. In total, 115 infants received at least one dose of surfactant during the year. Of those, 79 (69%) received it via LISA and 36 (31%) via INSURE. Two Plan-Do-Study-Act cycles contributed to improved adherence to guidelines on timely surfactant administration and both written and video documentation. CONCLUSIONS: Safe and effective introduction of LISA with the use of video laryngoscopy is achievable with careful planning, clear clinical guidelines, adequate hands-on training and comprehensive safety and quality control.

Structured Neonatal Point-of-Care Ultrasound Training Program.

OBJECTIVE: Point-of-care ultrasound (POC US) has been increasingly used by intensive care physicians. Growing use of POC US necessitates defining distinct clinical indications for its application, as well as structured POC US training programs. Homogeneous approach to POC US education combined with rigorous quality assurance should further enable POC US to become standard-of-care clinical tool. This study aimed to present the first, innovative, and structured POC US program in neonatal-perinatal medicine field. In addition, we reviewed the availability of the POC US training programs across different medical specialties. STUDY DESIGN: Available English-language publications on POC US training programs in general and neonatal-perinatal medicine were reviewed in this study. DISCUSSION: Mounting body of evidence suggests improved procedural completion rates, as well as clinical decision making with the use of POC US. However, limited research supported the existence of structured, comprehensive POC US programs. It was recognized that medical institutions need to develop syllabuses, teach, and credential increasing number of health care professionals in the use of POC US. We defined intuitive educational strategy that encompasses POC US clinical indications, educational curriculum, scanning protocols, competence evaluation, and finally credentialing process. In addition, we offered description of the imaging quality assurance, as well as POC US coding, and reimbursement. CONCLUSION: Future efforts need to be dedicated to the ongoing development of neonatal POC US as a clinical instrument. It should allow for eventual paradigm change and improved effectiveness in management of critically ill neonates.

Determination of optimal endotracheal tube tip depth from the gum in neonates by X-ray and ultrasound.

Background/objective: Proper placement of endotracheal tube (ETT) in the midtrachea is essential. Initial depth of placement of oral ETT from the lips is commonly estimated based on weight ("7-8-9 rule"), gestational age, or nasal-tragus distance. However, these measurements can be altered by superficial factors and the mobility of the lips relative to the airway, so the upper alveolar ridge (gum) may provide a superior landmark. Also, confirmation of ETT tip position by point of care ultrasound (POC-US) is noninvasive and may enable localization of the ETT tip in real time. The objective of this study is to define optimal initial ETT depth from the gum in infants relative to weight, and to compare the efficacy of POC-US with standard chest X-ray (CXR) for confirming ETT tip position.Methods: Neonates requiring oral intubation were enrolled. At the time of CXR that were obtained for clinical indications, the position of the ETT at both the lip and gum were recorded. "Optimal" ETT placement in midtrachea (from lip and gum) was calculated based on the observed measurements and the distance of the ETT tip from the carina on CXR. Linear regression was used to model ideal placement of ETT, as a function of weight. POC-US was performed using a 10 MHz cardiac probe and high parasternal view. Distance from the ETT bevel to the superior aspect of the right pulmonary artery, which is at the level of carina, was measured using electronic calipers.Results: Infants were recruited at a median age of 3 days (n = 75), weight 1300 g, and corrected gestational age 31.6 ± 5.8 weeks. The regression equation for optimal placement from the gum (in cm) was 5.21 + 1.03 × weight (kg). Using estimates of 5 or 5.5 cm + weight (kg) to the gum yielded accuracy similar or superior to the 7-8-9 rule to the lip. Most of the variability in ideal placement of ETT tip from the gum was determined by weight (R2 = 0.83). The difference between optimal placement using lip and gum was 0.51 ± 0.24 cm. ETT location by POC-US (n = 40) was in substantial agreement with CXR (intraclass correlation coefficient 0.95, 95% CI: 0.92, 0.98).Conclusions: Marking oral ETT placement to the gum is feasible, with optimal depth of about 5.2 cm + weight (kg), across all weight categories. POC-US can be used for rapid confirmation of continued ideal ETT tip location, with accuracy similar to CXR. Further studies will be needed to determine whether marking ETT depth to the gum or using POC-US achieves the goal of decreased complications of ETT misplacement or displacement.

Gene expression profile of endotoxin-stimulated leukocytes of the term new born: control of cytokine gene expression by interleukin-10.

INTRODUCTION: Increasing evidence now supports the association between the fetal inflammatory response syndrome (FIRS) with the pathogenesis of preterm labor, intraventricular hemorrhage and bronchopulmonary dysplasia. Polymorphonuclear leukocyte (PMNs) and mononuclear cell (MONOs) infiltration of the placenta is associated with these disorders. The aim of this study was to reveal cell-specific differences in gene expression and cytokine release in response to endotoxin that would elucidate inflammatory control mechanisms in the newly born. METHODS: PMNs and MONOs were separately isolated from the same cord blood sample. A genome-wide microarray screened for gene expression and related pathways at 4 h of LPS stimulation (n = 5). RT-qPCR and ELISA were performed for selected cytokines at 4 h and 18 h of LPS stimulation. RESULTS: Compared to PMNs, MONOs had a greater diversity and more robust gene expression that included pro-inflammatory (PI) cytokines, chemokines and growth factors at 4 h. Only MONOs had genes changing expression (all up regulated including interleukin-10) that were clustered in the JAK/STAT pathway. Pre-incubation with IL-10 antibody, for LPS-stimulated MONOs, led to up regulated PI and IL-10 gene expression and release of PI cytokines after 4 h. DISCUSSION: The present study suggests a dominant role of MONO gene expression in control of the fetal inflammatory response syndrome at 4 hrs of LPS stimulation. LPS-stimulated MONOs but not PMNs of the newborn have the ability to inhibit PI cytokine gene expression by latent IL-10 release.