Anand K. Rajani

Integration of early physiological responses predicts later illness severity in preterm infants.

Physiological parameters routinely and noninvasively collected in the first 3 hours of life can accurately predict morbidity in premature infants. Not All Preemies Are Alike Premature babies can be full of surprises. Although smaller and more premature babies generally experience more complications, the hospital course of individual infants can vary greatly. Preemies born the same size and at the same gestational age can have vastly different outcomes, ranging from death to healthy survival with minimal medical problems. Ideally, the infants who are likely to do well could stay in local hospitals where they are born, whereas their high-risk counterparts would be transferred to specialty referral centers for more aggressive treatment. Distinguishing these groups of patients has been the Holy Grail of neonatology for some time, however. Ranging from the old classic, the Apgar score, to the newest inventions such as SNAP, SNAPPE, and CRIB scores, these many different prediction methods attest to the difficulty of the task. Now, Saria et al. have developed a way to take advantage of the cardiorespiratory monitors that are ubiquitous in the neonatal intensive care unit and use routinely collected data to predict infants’ clinical outcomes more accurately than can be achieved with any of the scoring systems in use today. After infants are born prematurely, they are usually attached to a cardiorespiratory monitor within minutes of their delivery. The monitors continuously display and store each baby’s vital sign data, including heart rate, respiratory rate, and oxygen saturation. This continuous stream of vital sign data continues as each infant transfers from the delivery room to the neonatal intensive care unit, and then until the patient is discharged home, or longer as necessary. Saria et al. have found that physiologic data derived from routine monitoring in the first 3 hours of life can predict future outcomes. The authors used heart rate and respiratory rate, as well as variability in these parameters, and oxygen saturation and time of hypoxia in a computational model that was able to predict the patients’ risk of future morbidity. The model proved particularly accurate in predicting the risk of high morbidity due to infections and cardiopulmonary complications, even when these were not diagnosed until days or weeks later. PhysiScore, the new method developed by Saria et al. for assessing the prognosis of premature infants, is an important development given its improved specificity and sensitivity over preexisting scoring techniques. Moreover, it relies on readily accessible noninvasive data that are already routinely collected on all infants, and can be quickly calculated by computer as early as 3 hours into the infant’s life. PhysiScore is a timely and necessary invention and has the potential to optimize medical management for most premature infants. Physiological data are routinely recorded in intensive care, but their use for rapid assessment of illness severity or long-term morbidity prediction has been limited. We developed a physiological assessment score for preterm newborns, akin to an electronic Apgar score, based on standard signals recorded noninvasively on admission to a neonatal intensive care unit. We were able to accurately and reliably estimate the probability of an individual preterm infant’s risk of severe morbidity on the basis of noninvasive measurements. This prediction algorithm was developed with electronically captured physiological time series data from the first 3 hours of life in preterm infants (≤34 weeks gestation, birth weight ≤2000 g). Extraction and integration of the data with state-of-the-art machine learning methods produced a probability score for illness severity, the PhysiScore. PhysiScore was validated on 138 infants with the leave-one-out method to prospectively identify infants at risk of short- and long-term morbidity. PhysiScore provided higher accuracy prediction of overall morbidity (86% sensitive at 96% specificity) than other neonatal scoring systems, including the standard Apgar score. PhysiScore was particularly accurate at identifying infants with high morbidity related to specific complications (infection: 90% at 100%; cardiopulmonary: 96% at 100%). Physiological parameters, particularly short-term variability in respiratory and heart rates, contributed more to morbidity prediction than invasive laboratory studies. Our flexible methodology of individual risk prediction based on automated, rapid, noninvasive measurements can be easily applied to a range of prediction tasks to improve patient care and resource allocation.

The accuracy of human senses in the detection of neonatal heart rate during standardized simulated resuscitation: Implications for delivery of care, training and technology design

AIM Auscultation and palpation are recommended methods of determining heart rate (HR) during neonatal resuscitation. We hypothesized that: (a) detection of HR by auscultation or palpation will vary by more than ± 15BPM from actual HR; and (b) the inability to accurately determine HR will be associated with errors in management of the neonate during simulated resuscitation. SUBJECTS AND METHODS Using a prospective, randomized, controlled study design, 64 subjects participated in three simulated neonatal resuscitation scenarios. Subjects were randomized to technique used to determine HR (auscultation or palpation) and scenario order. Subjects verbalized their numeric assessment of HR at the onset of the scenario and after any intervention. Accuracy of HR determination and errors in resuscitation were recorded. Errors were classified as errors of omission (lack of appropriate interventions) or errors of commission (inappropriate interventions). Cochrans Q and chi square test were used to compare HR detection by method and across scenarios. RESULTS Errors in HR determination occurred in 26-48% of initial assessments and 26-52% of subsequent assessments overall. There were neither statistically significant differences in accuracy between the two techniques of HR assessment (auscultation vs palpation) nor across the three scenarios. Of the 90 errors in resuscitation, 43 (48%) occurred in association with errors in HR determination. CONCLUSIONS Determination of heart rate via auscultation and palpation by experienced healthcare professionals in a neonatal patient simulator with standardized cues is not reliable. Inaccuracy in HR determination is associated with errors of omission and commission. More reliable methods for HR assessment during neonatal resuscitation are required.

Comparison of Umbilical Venous and Intraosseous Access During Simulated Neonatal Resuscitation

OBJECTIVE: Emergent umbilical venous catheter (UVC) placement for persistent bradycardia in the delivery room is a rare occurrence that requires significant skill and involves space constraints. Placement of an intraosseous needle (ION) in neonates has been well described. The ION is already used in the pediatric population and is placed at an anatomic location distant from where chest compressions are performed. In this study we compared time to placement, errors in placement, and perceived ease of use for UVCs and IONs in a simulated delivery room. SUBJECTS AND METHODS: Forty health care providers were recruited. Subjects were shown an instructional video of both techniques and allowed to practice placement. Subjects participated in 2 simulated neonatal resuscitations requiring intravenous epinephrine. In 1 scenario they were required to place a UVC and in the other an ION. Scenarios were recorded for later analysis of placement time and error rate. Subjects were surveyed regarding the perceived level of difficulty of each technique. RESULTS: The average time required for ION placement was 46 seconds faster than for UVC placement (P < .001). There was no significant difference in the number of errors between UVC and ION placement or in perceived ease of use. CONCLUSIONS: In a simulated delivery room setting, ION placement can be performed more quickly than UVC insertion without any difference in technical error rate or perceived ease of use. ION insertion should be considered when rapid intravenous access is required in the neonate at the time of birth, especially by health care professionals who do not routinely place UVCs.

Delivery Room Management of the Newborn

Neonatal resuscitation is an attempt to facilitate the dynamic transition from fetal to neonatal physiology. This article outlines the current practices in delivery room management of the neonate. Developments in cardiopulmonary resuscitation techniques for term and preterm infants and advances in the areas of cerebral resuscitation and thermoregulation are reviewed. Resuscitation in special circumstances (such as the presence of congenital anomalies) are also covered. The importance of communication with other members of the health care team and the family is discussed. Finally, future trends in neonatal resuscitation are explored.

Using simulation to study difficult clinical issues: prenatal counseling at the threshold of viability across american and dutch cultures

Objective Prenatal counseling at the threshold of viability is a challenging yet critically important activity, and care guidelines differ across cultures. Studying how this task is performed in the actual clinical environment is extremely difficult. In this pilot study, we used simulation as a methodology with 2 aims as follows: first, to explore the use of simulation incorporating a standardized pregnant patient as an investigative methodology and, second, to determine similarities and differences in content and style of prenatal counseling between American and Dutch neonatologists. Methods We compared counseling practice between 11 American and 11 Dutch neonatologists, using a simulation-based investigative methodology. All subjects performed prenatal counseling with a simulated pregnant patient carrying a fetus at the limits of viability. The following elements of scenario design were standardized across all scenarios: layout of the physical environment, details of the maternal and fetal histories, questions and responses of the standardized pregnant patient, and the time allowed for consultation. Results American subjects typically presented several treatment options without bias, whereas Dutch subjects were more likely to explicitly advise a specific course of treatment (emphasis on partial life support). American subjects offered comfort care more frequently than the Dutch subjects and also discussed options for maximal life support more often than their Dutch colleagues. Conclusions Simulation is a useful research methodology for studying activities difficult to assess in the actual clinical environment such as prenatal counseling at the limits of viability. Dutch subjects were more directive in their approach than their American counterparts, offering fewer options for care and advocating for less invasive interventions. American subjects were more likely to offer a wider range of therapeutic options without providing a recommendation for any specific option.

Comparing the utility of a novel neonatal resuscitation cart with a generic code cart using simulation: a randomised, controlled, crossover trial

Objective To compare a novel neonatal resuscitation cart (NRC) to a generic code cart (GCC). Study design A prospective, randomised, controlled, crossover trial was performed to compare the utility of the NRC with the GCC during simulated deliveries of extremely low birthweight infants and infants with gastroschisis. Fifteen subjects participated. Mean times and accuracy of equipment and supply retrieval were compared for each scenario using the Wilcoxon test. Results Mean acquisition times for the NRC were always faster (by 58% to 74%) regardless of scenario (p<0.01). Accuracy of equipment selection did not differ. Ease of use was judged using a Likert scale (1=easiest to use; 5=most difficult), with mean score for NRC 1.1 and GCC 3.7 (p<0.0001). All subjects rated the NRC as easier to use. Conclusions The NRC was superior to the GCC in acquisition speed, supply selection and ease of use.

Newborn with Prenatally Diagnosed Choroidal Fissure Cyst and Panhypopituitarism and Review of the Literature

Little has been reported on fetal diagnosis of choroidal fissure cysts and prediction of the clinical complications that can result. We describe the case of a near-term male infant with prenatally diagnosed choroidal fissure cyst and bilateral clubfeet. His prolonged course in the neonatal intensive care nursery was marked by severe panhypopituitarism, late-onset diabetes insipidus, placement of a cystoperitoneal shunt, and episodes of sepsis. Postnatal genetic evaluation also revealed an interstitial deletion involving most of band 10q26.12 and the proximal half of band 10q26.13. The patient had multiple readmissions for medical and surgical indications and died at 6 months of age. This case represents the severe end of the spectrum of medical complications for children with choroidal fissure cysts. It highlights not only the importance of comprehensive evaluation and multidisciplinary management and counseling in such cases, but also the need for heightened vigilance in these patients.