Anne Ades

Echocardiographic Evaluation of Umbilical Venous Catheter Placement

OBJECTIVE: To compare techniques for guiding and confirming placement of umbilical venous catheters (UVCs) using two-dimensional echocardiography.STUDY DESIGN: Fifty-three newborns admitted to our neonatal intensive care unit who required an UVC or who were transferred within 24 hours of UVC placement at a referring hospital were studied. UVC position was assessed by antero-posterior (AP) chest radiography (CXR), lateral CXR, and oxygenation data. The accuracy of the above techniques was compared to echocardiography with saline contrast injection.RESULTS: Echocardiography revealed that UVCs were located ideally at the right atrial/inferior vena cava junction in only 12 (23%) of 53 patients. Twenty-four (45%) were incorrectly positioned in the left atrium. The sensitivity and specificity of AP CXR in evaluating inappropriate UVC position were 32% and 89%, respectively. Lateral CXR and thoracic level on AP CXR did not predict accurately catheter position. UVC pO2 data were not useful in excluding left atrial placement.CONCLUSION: Current methods to determine insertion length and confirm location of UVCs are not adequate. Echocardiography should be considered to confirm correct placement of UVCs.

Learn, see, practice, prove, do, maintain: an evidence-based pedagogical framework for procedural skill training in medicine.

Acquisition of competency in procedural skills is a fundamental goal of medical training. In this Perspective, the authors propose an evidence-based pedagogical framework for procedural skill training. The framework was developed based on a review of the literature using a critical synthesis approach and builds on earlier models of procedural skill training in medicine. The authors begin by describing the fundamentals of procedural skill development. Then, a six-step pedagogical framework for procedural skills training is presented: Learn, See, Practice, Prove, Do, and Maintain. In this framework, procedural skill training begins with the learner acquiring requisite cognitive knowledge through didactic education (Learn) and observation of the procedure (See). The learner then progresses to the stage of psychomotor skill acquisition and is allowed to deliberately practice the procedure on a simulator (Practice). Simulation-based mastery learning is employed to allow the trainee to prove competency prior to performing the procedure on a patient (Prove). Once competency is demonstrated on a simulator, the trainee is allowed to perform the procedure on patients with direct supervision, until he or she can be entrusted to perform the procedure independently (Do). Maintenance of the skill is ensured through continued clinical practice, supplemented by simulation-based training as needed (Maintain). Evidence in support of each component of the framework is presented. Implementation of the proposed framework presents a paradigm shift in procedural skill training. However, the authors believe that adoption of the framework will improve procedural skill training and patient safety.

Proficiency and Retention of Neonatal Resuscitation Skills by Pediatric Residents

BACKGROUND: The basic knowledge and skill base to resuscitate a newborn infant is taught in the Neonatal Resuscitation Program (NRP). We hypothesize that caregivers will perform below current acceptable standards before the recertification period of two years. METHODS: This is a prospective descriptive study evaluating performance of pediatric residents’ NRP knowledge and skills over time. NRP scores are used as baseline data. Follow‐up is performed before the residents first NICU rotation. Differences in the mean scores are analyzed for degree of retention. Subset score analysis is also performed. RESULTS: Eighty-eight subjects completed both evaluations. Knowledge scores maintained close to passing throughout the academic year. Subset evaluation revealed significant deficits within the intubation lesson. Alarming deficits were seen in skills evaluation starting at initial NRP certification with 39.1% residents having failing scores. Mean scores were below passing for every group on follow-up testing. Subgroup analysis of skills revealed deficits in the initial phases of resuscitation (lessons 1–3). CONCLUSIONS: Deterioration of skills is seen shortly after training. It appears that knowledge is generally better retained. Discrepancies between areas of knowledge and skill deterioration indicate that proficiency in one does not necessarily indicate proficiency of the other.

Evaluation of the Neonatal Resuscitation Program's recommended chest compression depth using computerized tomography imaging

BACKGROUND Neonatal Resuscitation Program (NRP) guidelines recommend chest compression depths of 1/3 the anterior-posterior (AP) chest depth. Appropriateness of this recommendation has not been rigorously assessed. OBJECTIVE To compare the efficacy and safety of neonatal chest compression depths of 1/4, 1/3, and 1/2 AP chest depth during cardiopulmonary resuscitation. DESIGN/METHODS Anterior-posterior internal and external chest depth, heart dimensions, and non-cardiac thoracic tissue depth were measured from neonatal chest CTs. Using these measurements, residual internal chest depth, the remaining depth of the chest between the sternum and spine after external compression, was calculated for compression depths of 1/4, 1/3 and 1/2 anterior-posterior chest depth. Compression sufficient to compress the chest to <10mm of residual internal chest depth was defined as over-compression. Using a mathematic model, an estimated ejection fraction (EF) was calculated for each chest compression depth. Compression inadequate to obtain a predicted 50% EF was defined as under-compression. Descriptive statistics, Fishers exact test and Students t-test were used to analyze data, where appropriate. RESULTS Fifty-four neonatal chest CT scans were evaluated. Estimated chest compression induced EF increased incrementally with increasing chest compression depth (EF was 51+/-3% with 1/4 AP chest depth vs 69+/-3% with 1/3 AP chest depth, and 106% with 1/2 AP chest depth, p<0.001). Under-compression was predicted in 29/54 patients with 1/4 AP compression depth, but none of the patients with 1/3 or 1/2 AP compression depth, p<0.001. Over-compression, or lack of adequate residual chest depth, was predicted in 49/54 patients with 1/2 AP compression depth, but none of the patients with 1/4 or 1/3 AP compression depth, p<0.001. CONCLUSIONS Mathematical modeling based upon neonatal chest CT scan dimensions suggests that current NRP chest compression recommendations of 1/3 AP chest depth should be more effective than 1/4 compression depth, and safer than 1/2 AP compression depth.

Videolaryngoscopy Versus Direct Laryngoscopy in Simulated Pediatric Intubation

STUDY OBJECTIVE We determine whether videolaryngoscopy results in a higher prevalence of first-attempt intubation success and improved glottic visualization than direct laryngoscopy when performed by pediatric emergency medicine providers in simulated patients. METHODS This was a cross-sectional study at a single institution. Fellows and faculty in pediatric emergency medicine were invited to participate. Each subject performed intubations on 3 simulators (newborn, infant, adult), using a videolaryngoscope; each simulator was intubated by each subject with and without use of video. Primary outcome was first-attempt intubation success; secondary outcome was percentage of glottic opening score (POGO). RESULTS Twenty-six participants performed 156 intubations; complete data were available for 148 intubations. First-attempt success in the neonate was 88%; in the infant, 79%; and in the adult, 60%. In the adult simulator, videolaryngoscopy use showed a first-attempt success in 81% of subjects compared with 39% with direct laryngoscopy (difference 43%; 95% confidence interval [CI] 18% to 67%). There was no difference in first-attempt success rates between videolaryngoscopy and direct laryngoscopy in the newborn or infant simulators. Videolaryngoscopy use led to increased POGO scores in all 3 simulators, with a difference of 25% (95% CI 2% to 48%) in newborn simulators, 23% (95% CI 2% to 48%) in infant simulators, and 42% (95% CI 18% to 66%) in adult simulators. CONCLUSION Videolaryngoscopy was associated with greater first-attempt success during intubation by pediatric emergency physicians on an adult simulator. POGO score was significantly improved in all 3 simulators with videolaryngoscopy.

Impact of Mode of Delivery on Markers of Perinatal Hemodynamics in Infants with Hypoplastic Left Heart Syndrome

OBJECTIVE To determine whether the mode of delivery of infants prenatally diagnosed with hypoplastic left heart syndrome (HLHS) affects markers of perinatal hemodynamics. STUDY DESIGN A retrospective review of patients diagnosed prenatally with HLHS and delivered within our institution was undertaken. Arterial blood gases, echocardiographic data, and markers of end organ function were compared based on route of delivery. RESULTS A total of 79 infants with HLHS were enrolled between January 2002 and December 2008. The infants delivered by elective cesarian delivery (CD) had younger gestational age compared with those delivered by vaginal delivery (VD) or by urgent CD/operative VD. Those delivered by elective CD had lower pH and higher partial pressure of CO(2) on arterial cord blood gas analysis. There were no differences in partial pressure of O(2) and base deficit among the 3 study groups. One-minute and 5-minute Apgar scores, markers of end organ function, echocardiographic parameters, length of hospitalization, and survival to discharge were similar among the groups. CONCLUSIONS Overall, newborns with a prenatal diagnosis of HLHS transitioned well to extrauterine life without significant acidosis regardless of the mode of delivery. Delivery of newborns with HLHS by elective CD did not demonstrate any hemodynamic advantage over VD in our cohort of patients.

Preterm Infants With Congenital Heart Disease and Bronchopulmonary Dysplasia: Postoperative Course and Outcome After Cardiac Surgery

Objective. Success in treatment of premature infants has resulted in increased numbers of neonates who have bronchopulmonary dysplasia (BPD) and require surgical palliation or repair of congenital heart disease (CHD). We sought to investigate the impact of BPD on children with CHD after heart surgery. Methods. This was a retrospective, multicenter study of patients who had BPD, defined as being oxygen dependent at 28 days of age with radiographic changes, and CHD and had cardiac surgery (excluding arterial duct ligation) between January 1991 and January 2002. Forty-three infants underwent a total of 52 cardiac operations. The median gestational age at birth was 28 weeks (range: 23–35 weeks), birth weight was 1460 g (range: 431–2500 g), and age at surgery was 2.7 months (range: 1.0–11.6 months). Diagnoses included left-to-right shunts (n = 15), conotruncal abnormalities (n = 13), arch obstruction (n = 6), univentricular hearts (n = 4), semilunar valve obstruction (n = 3), Shone syndrome (n = 1), and cor triatriatum (n = 1). Results. Thirty-day survival was 84% with 6 early and 6 late postoperative deaths. Survival to hospital discharge was 68%. There was 50% mortality for patients with univentricular hearts and severe BPD. The median duration of preoperative ventilation was 76 days (range: 2–244 days) and of postoperative ventilation was 15 days (range: 1–141 days). The median duration of cardiac ICU stay was 7.5 days (range: 1–30 days) and of hospital stay was 115 days (range: 35–475 days). Current pulmonary status includes on room air (n = 14), O2 at home (n = 4), and ventilated at home (n = 4) or in hospital (n = 4), and 5 patients were lost to follow-up. Conclusions. BPD has significant implications for children who have CHD and undergo cardiac surgery, leading to prolonged ICU and hospital stays, although most survivors are not O2 dependent. Postoperative mortality was highest among patients with univentricular hearts and severe BPD. Optimal timing of surgery and strategies to improve outcome remains to be delineated.

Factors Associated with Adverse Events during Tracheal Intubation in the NICU

Background: The incidence of adverse tracheal intubation-associated events (TIAEs) and associated patient, practice, and intubator characteristics in the neonatal intensive care unit (NICU) setting are unknown. Objectives: To determine the incidence of adverse TIAEs and to identify factors associated with TIAEs in the NICU. Methods: Single-site prospective observational cohort study of infants who were intubated in a level 4 referral NICU between September 1, 2011 and November 30, 2013. A standardized pediatric airway registry was implemented to document patient, practice, and intubator characteristics and outcomes of intubation encounters. The primary outcome was adverse TIAEs. Results: Adverse TIAEs occurred in 153 of 701 (22%) tracheal intubation encounters. Factors that were independently associated with lower incidence of TIAEs in logistic regression included attending physician (vs. resident; odds ratio (OR) 0.4, 95% CI: 0.16, 0.98) and use of paralytic medication (OR 0.45, 95% CI: 0.25, 0.81). Severe oxygen desaturations (≥20% decrease in oxygen saturation) occurred in 51.1% of encounters and were more common in tracheal intubations performed by residents (62.8%), compared to fellows (43.2%) or attendings (47.5%; p = 0.008). Conclusions: Adverse TIAEs and severe oxygen desaturation events are common in the NICU setting. Modifiable risk factors associated with TIAEs identified include intubator training level and use of paralytic medications.

Neonatal-perinatal medicine fellow procedural experience and competency determination: results of a national survey.

Objective:Ensuring that neonatal–perinatal medicine (NPM) fellows attain competency in performing neonatal procedures is a requirement of training-competent neonatologists.Study Design:A survey of NPM fellows was performed to determine the procedural experience of current fellows, investigate techniques used to track procedural experience and examine the methods programs use to verify procedural competency.Results:One hundred and sixty-three fellows in 57 accredited training programs responded to the survey. Reported number of procedures provide contemporary normative data on procedural experience during training. The majority of fellows reported using an online reporting system to track experience. The most common technique to verify procedural competency was supervised practice until an arbitrary number of procedures had been performed.Conclusions:NPM fellow procedural experience increases significantly for most, but not all, procedures duration training. We speculate that supplemental simulation training for rare neonatal procedures would help ensure the competency of graduating NPM fellows. Experience alone is insufficient to verify competency. Further work on the accurate tracking of experience and verification of procedural competency is needed.

Improving neonatal intubation safety: A journey of a thousand miles

Neonatal intubation is one of the most common procedures performed by neonatologists, however, the procedure is difficult and high risk. Neonates who endure the procedure often experience adverse events, including bradycardia and severe oxygen desaturations. Because of low first attempt success rates, neonates are often subjected to multiple intubation attempts before the endotracheal tube is successfully placed. These factors conspire to make intubation one of the most dangerous procedures in neonatal medicine. In this commentary we review key elements in the journey to improve neonatal intubation safety. We begin with a review of intubation success rates and complications. Then, we discuss the importance of intubation training. Next, we examine quality improvement efforts and patient safety research to improve neonatal intubation safety. Finally, we evaluate new tools which may improve success rates, and decrease complications during neonatal intubation.