Colin Patrick Hawkes

Comparison of the T-piece resuscitator with other neonatal manual ventilation devices: A qualitative review

AIM To review the literature surrounding various aspects of T-piece resuscitator use, with particular emphasis on the evidence comparing the device to other manual ventilation devices in neonatal resuscitation. DATA SOURCES The Medline, EMBASE, Cochrane databases were searched in April 2011. Ongoing trials were identified using www.clinicaltrials.gov and www.controlled-trials.com. Additional studies from reference lists of eligible articles were considered. All studies including T-piece resuscitator use were eligible for inclusion. RESULTS Thirty studies were included. There were two randomised controlled trials in newborn infants comparing the devices, one of which addressed short and intermediate term morbidity and mortality outcomes and found no difference between the T-piece resuscitator and self inflating bag. From manikin studies, advantages to the T-piece resuscitator include the delivery of inflating pressures closer to predetermined target pressures with least variation, the ability to provide prolonged inflation breaths and more consistent tidal volumes. Disadvantages include a technically more difficult setup, more time required to adjust pressures during resuscitation, a larger mask leak and less ability to detect changes in compliance. CONCLUSIONS There is a need for appropriately designed randomised controlled trials in neonates to highlight the efficacy of one device over another. Until these are performed, healthcare providers should be appropriately trained in the use of the device available in their departments, and be aware of its own limitations.

N-Glycan Abnormalities in Children with Galactosemia

Galactose intoxication and over-restriction in galactosemia may affect glycosylation pathways and cause multisystem effects. In this study, we describe an applied hydrophilic interaction chromatography ultra-performance liquid chromatography high-throughput method to analyze whole serum and extracted IgG N-glycans with measurement of agalactosylated (G0), monogalactosylated (G1), and digalactosylated (G2) structures as a quantitative measure of galactose incorporation. This was applied to nine children with severe galactosemia (genotype Q188R/Q188R) and one child with a milder variant (genotype S135L/S135L). The profiles were also compared with those obtained from three age-matched children with PMM2-CDG (congenital disorder of glycosylation type Ia) and nine pediatric control samples. We have observed that severe N-glycan assembly defects correct in the neonate following dietary restriction of galactose. However, treated adult galactosemia patients continue to exhibit ongoing N-glycan processing defects. We have now applied informative galactose incorporation ratios as a method of studying the presence of N-glycan processing defects in children with galactosemia. We identified N-glycan processing defects present in galactosemia children from an early age. For G0/G1, G0/G2, and (G0/G1)/G2 ratios, the difference noted between galactosemia patients and controls was found to be statistically significant (p = 0.002, 0.01, and 0.006, respectively).

Smartphone technology enhances newborn intubation knowledge and performance amongst paediatric trainees

OBJECTIVE Smartphones are widely used by physicians, but their effectiveness in improving teaching of clinical skills is not known. The aim of this study was to determine if pre procedural use of a smartphone neonatal intubation instructional application (NeoTube) improves trainee knowledge and enhances procedural skills performance in newborn intubation. DESIGN Neonatal Resuscitation Program certified trainees in paediatrics and neonatology completed a knowledge based questionnaire on neonatal intubation, and were recorded intubating a term newborn manikin model. They then used the NeoTube iPhone application for 15 min, before completing the questionnaire and intubation again. Video recordings were later reviewed by two independent assessors, blinded to whether it was pre or post NeoTube use. RESULTS 20 paediatric trainees (12 fellows and 8 residents) participated in this study. Comparing pre and post-viewing of the application, Questionnaire Scores (median (range)) increased from 18.5 (8-28) to 31 (24-35) (P<0.001), with calculation scores increasing from 6 (0-11) to 11 (6-12) (P<0.001), Skill Scores increased from 11 (9-15) to 12.5 (9-16) (P=0.016), and the duration of intubation attempt decreased from 39 to 31 s (P=0.044) following utilisation of the application. There was a significant positive correlation with duration of specialist training for procedure performance post viewing, but not pre viewing of the application. CONCLUSIONS Bedside use of smartphones can enhance both knowledge of newborn intubation and improves procedural performance, including reducing the time to successfully intubate. Smartphones may have a useful role in bringing procedural skills training closer to the bedside.

Perfusion index in the very preterm infant

Perfusion Index (PI) is a quantifiable measurement of peripheral perfusion and may be a useful adjunct to the assessment of circulatory status in the newborn. (i) To assess reproducibility of PI and (ii) To determine whether there is a difference between simultaneously obtained limb measurements of PI in newborns <32 weeks GA in the transitional period.

Life and death decisions for incompetent patients: determining best interests--the Irish perspective.

Aims:  To determine whether healthcare providers apply the best interest principle equally to different resuscitation decisions.

Efficacy and user preference of two CO2 detectors in an infant mannequin randomized crossover trial.

Assessment of effective ventilation in neonatal mask ventilation can be difficult. This study aims to determine whether manual ventilation with a T-piece resuscitator containing an inline CO2 detector (either a Pedi-Cap® CO2 detector or a Neo-StatCO2 <Kg® CO2 detector connected to a facemask) facilitates effective positive pressure ventilation compared to no device in a mannequin study. Paediatric and neonatal trainees were randomly assigned to determine which method they began with (no device, Pedi-Cap or a Neo-Stat). The participants used each method for a period of 3 min. They were video-recorded to determine the amount of effective ventilations delivered and the overall percentage efficiency of each method. Efficacy of ventilation was determined by comparing the number of manual ventilations delivered with the number of times chest rise was observed in the video recording. There were 19 paediatric trainees who provided a total of 7,790 ventilations, and 93% were deemed effective. The percentage of effective ventilations with the T-piece resuscitator alone, the PediCap and the NeoStat were 90, 94 and 96%, respectively. The difference was greatest in the first minute (T-piece resuscitator alone 87.5%, PediCap 94%, NeoStat 96%). Two thirds preferred the Neo-Stat. The use of a CO2 detector improves positive pressure ventilation in a mannequin model, especially in the first minute of positive pressure ventilation. The Neo-Stat CO2 detector was the preferred device by the majority of the participants.

Using smart phone technology to teach neonatal endotracheal intubation (NeoTube): application development and uptake

Neonatal intubation is one of the core competencies of neonatal training. Training in neonatal intubation is commonly gained through direct supervision of novice trainees by experienced personnel and through simulation training using neonatal manikins. Experience in this procedure increases the likelihood of success and reduces the time taken to intubate (1,2). Reduced working hours, as well as changes in the indications for intubation at birth following meconium-stained amniotic fluid (3), and increased use of continuous positive airway pressure (CPAP) (4,5) have resulted in a decline in opportunities to learn neonatal intubation (1). Many infants who would previously have been intubated, received surfactant and commenced on mechanical ventilation are now being managed successfully with CPAP (4,5). In the setting of declining opportunity to learn this important, but challenging skill, trainers need to find alternative means of ensuring acquisition of this core competency. Theoretical knowledge is gained through textbooks, review articles and training courses such as the NRP. Practical sessions involving simulation are useful and commonly take place during neonatal resuscitation training days. The smart phone is a relatively new addition to the trainee’s learning repertoire, but smart phone applications have not previously been used to teach endotracheal intubation skills in neonatology. We describe the development, implementation and early usage of a new iPhone application, NeoTube, which was designed to assist novice and experienced users in acquiring the knowledge and skills required for neonatal endotracheal intubation. A medical team of two neonatal consultants (EMD and CAR), one neonatal registrar (CPH) and an information technology team (SH, BO’F and SW) collaborated on this project. The medical team was responsible for the content of the application as well as the structural layout. The information technology team was responsible for application design, programming and ensuring that the application met Apple’s requirements for applications. The project is described in the following five steps.

The Neopuff's PEEP valve is flow sensitive.

Aim:  The current recommendation in setting up the Neopuff is to use a gas flow of 5–15 L/min. We investigated if the sensitivity of the positive end expiratory pressure (PEEP) valve varies at different flow rates within this range.

In vitro comparison of neonatal suction catheters using simulated 'pea soup' meconium

Background A variety of suction catheters (type, size and design) are recommended for oropharyngeal suctioning of meconium during newborn resuscitation, but it is not known which performs best. In this study we compared different sizes of soft catheters, the Yankauer (YK) and the portable bulb syringe (BS), in suctioning a solution of varying viscosity. Methods Simulated meconium (SM) was made using commercial canned pea soup in two strengths, full-strength thick-particulate (TP) and 50% strained soup diluted with water, that is, thin-non-particulate (TnP), with saline as a control. A 20 ml aliquot of solution was suctioned over 5 s with each device using an electrical suction pump set at two different pressures, 100 and 150 mm Hg (21 kpa). In addition, the negative pressure of five BSs was measured in order to compare generated pressures with the alternative devices. Results The YK and BS suctioned almost 100% of saline, while the 6F and 8F catheters suctioned 50% and 75% saline, respectively. The YK suctioned 100% of TnP, saline and 30% of TP. At reduced suction pressures (100 and 50 mm Hg) the YK also suctioned all TnP. The 12F and 14F catheters suctioned a minimal amount of TP, whereas YK was the most efficient, suctioning 30% of TP. The mean negative pressure generated with five BSs was 78 and 71 mm Hg by a male and female operator, respectively. Conclusions The YK and BS outperform the catheters in suctioning SM. The YK is the best for TP, but all devices perform poorly in suctioning fluid of this consistency.

Doctors' knowledge of the acute management of Inborn Errors of Metabolism.

Inborn Errors of Metabolism (IEMs) are a group of heterogenous disorders which individually are rare, but collectively affect up to 1 in 780 live births (1). As specialist management is usually provided by a tertiary centre, most paediatricians will be involved only in the detection and diagnosis of these conditions. This is reflected in undergraduate and postgraduate paediatric training in IEMs, which is focused mainly on diagnosis and less on management. When patients with disorders of intermediary metabolism (such as aminoacidopathies, fatty acid oxidation disorders, organic acidurias and urea cycle defects) are unwell, catabolism occurs owing to an increased metabolic rate and, often, vomiting or a reduced oral intake. This catabolic state results in the breakdown of endogenous proteins and fat, which can result in the accumulation of toxic metabolites. To avoid this, patients are instructed to switch to an unwell dietary plan that will provide extra calories, less substrate and reduce catabolism (2,3). If this fails, patients are instructed to attend hospital promptly for further management. Delay in commencing emergency management in this situation may result in irreversible end organ damage and a worse prognosis (4–7). It has been our experience that patients presenting to emergency departments with decompensating IEMs often forget their emergency letters, and this has also been noted elsewhere (7). This occasionally leads to delayed recognition of significant illness, and a subsequent delay in appropriate emergency management. Having seen this occur on a number of occasions, we decided to evaluate the knowledge base of paediatric junior doctors in the acute management of decompensated IEMs. A questionnaire (Data S1 in supporting information) was designed and circulated to paediatric junior doctors in two tertiary level paediatric hospitals and two secondary level paediatric units, all of which are paediatric training centres. Candidates were asked about their level of experience in paediatrics and specifically in IEMs. They were not allowed to access computers or books while completing the questionnaire. Three sample scenarios involving IEMs seen commonly at our clinic that are associated with decompensation were chosen for the purpose of the questionnaire. Glutaric aciduria type 1 (GA1) has a relatively high incidence in Ireland. Maple syrup urine disease (MSUD) is included in the national newborn screening programme, and this patient group present frequently to emergency departments. Medium chain acyl Co-A dehydrogenase deficiency (MCADD) was included owing to its relatively high incidence. A five-point Likert scale assessed the confidence of the junior doctors in their ability to manage the initial acute presentation of these three sample IEMs. Ratings of extremely confident and reasonably confident were grouped into a confident category, and ratings of unconfident or very unconfident were grouped as unconfident for the purpose of displaying results. Those who reported being neither confident nor unconfident were categorised as neutral. A multiple choice format questionnaire assessed the junior doctors’ knowledge regarding the emergency management steps in three separate scenarios of an unwell child with MSUD, MCADD and GA1. Answer options for each situation included five correct answers and five answers which were either indifferent or potentially harmful. All 34 paediatric juniors approached completed the questionnaire. Fourteen (41.2%) senior house officers and 20 (58.8%) registrars were included. The mean duration of paediatric experience was 3 years (range 2 months–6 years). Twenty-two (64.7%) had no training or rotation, in a department specialising in IEMs. Acta Pædiatrica ISSN 0803–5253