Jens Schwindt

Epidural Catheter Placement in Neonates: Sonoanatomy and Feasibility of Ultrasonographic Guidance in Term and Preterm Neonates

Background: We report the first prospective sonoanatomic study in neonates with the aim to perform ultrasonographic-guided epidural catheter placement in this age group. Method: One hundred forty-five neonates with a body weight ≤4 kg (0.53-4 kg) were included in this prospective study. The study was divided into 3 consecutive parts. In the first part, the neuraxial sonoanatomy of 60 neonates was evaluated. In the second part, 50 neonates scheduled for major abdominal surgery were enrolled. In this part, the depth of the ligamentum flavum measured with ultrasound was matched up to the depth evaluated clinically with the loss-of-resistance technique. In the third part, ultrasonographic epidural catheter placement was performed in 35 neonates weighing between 620 g and 4 kg. Results: The ligamentum flavum, the dura mater, and the termination of the spinal cord could be identified in all patients. The first part showed a good correlation between body weight and depth of the ligamentum flavum. The median termination of the spinal cord corresponded to vertebral level L2. The second part confirmed a good correlation between depth of the ligamentum flavum evaluated clinically and the depth predicted with ultrasound. Finally, real-time ultrasound-guided epidural placement was possible in all 35 neonates. Conclusion: Ultrasound examination of the spinal cord anatomy provides valuable information for epidural catheter placement in neonates. Ultrasonography enables a real-time identification of the tip of the needle within the epidural space and a visualization of the spread of local anesthetic in these patients.

A Randomized, Controlled Trial of the Effects of Adding Vitamin B12 and Folate to Erythropoietin for the Treatment of Anemia of Prematurity

BACKGROUND. Premature infants, especially those with birth weights of <1500 g, often suffer from anemia of prematurity and associated problems. Erythropoietin therapy is a safe effective way to prevent and to treat anemia of prematurity. We hypothesized that combined administration of vitamin B12 and folate with erythropoietin and iron would enhance erythropoietin-induced erythropoiesis. METHODS. In a randomized, controlled trial, 64 premature infants (birth weight: 801–1300 g) receiving erythropoietin and iron supplementation were assigned randomly to receive either vitamin B12 (3 μg/kg per day) and folate (100 μg/kg per day) (treatment group) or a lower dose of folate (60 μg/kg per day) (control group). RESULTS. During the 4-week observation period, vitamin B12 and folate enhanced erythropoietin-induced erythropoiesis significantly, as indicated by a 10% increase in red blood cell counts, compared with folate alone. Hemoglobin and hematocrit levels remained stable in the treatment group, whereas they decreased in the control group. Vitamin B12 levels in the treatment group increased over baseline and control values, whereas red blood cell folate levels were comparable between the groups. Subsequent analysis showed slight nonsignificant differences in baseline red blood cell count, hemoglobin level, hematocrit level, and mean corpuscular volume values, which must be addressed as a limitation. CONCLUSIONS. With the limitation of a slight imbalance in baseline data between the study groups, combined therapy with vitamin B12, folate, erythropoietin, and orally and intravenously administered iron seemed more effective in stimulating erythropoiesis among premature infants, compared with erythropoietin, iron, and low-dose folate alone. Additional trials are necessary to confirm these data.

Effects of a Combined Therapy of Erythropoietin, Iron, Folate, and Vitamin B12 on the Transfusion Requirements of Extremely Low Birth Weight Infants

OBJECTIVES. Erythropoietin is frequently administered to premature infants to stimulate erythropoiesis. The primary goal of erythropoietin therapy is to reduce transfusions, but the efficacy of erythropoietin has not been convincingly demonstrated in this regard. The aim of this trial was to investigate whether combined administration of vitamin B12, folic acid, iron, and erythropoietin could decrease transfusion requirements in extremely low birth weight infants. PATIENTS AND METHODS. In a randomized, controlled trial, extremely low birth weight infants with a birth weight ≤800g and a gestational age ≤32 weeks were randomly assigned to a group receiving combination treatment or a control arm. RESULTS. The treatment increased levels of folate in red blood cells, vitamin B12, ferritin, transferrin receptor levels in plasma, and reticulocyte counts. The proportion of infants requiring no transfusions was lower in the treatment group (38%) as compared with controls (5%). The treatment group and the need for mechanical ventilation were independent predictors of the number of transfusions in multiple regression analysis. Cox regression analysis indicated that combined therapy resulted in a 79% risk reduction for any transfusion. CONCLUSION. Combined treatment with erythropoietin, intravenous iron, folate, and vitamin B12 during the first weeks reduces the need for transfusion in extremely low birth weight infants.

Changes in thrombopoiesis and platelet reactivity in extremely low birth weight infants undergoing erythropoietin therapy for treatment of anaemia of prematurity.

Erythropoietin (Epo) is frequently administered to premature infants to stimulate erythropoiesis. There is evidence from studies in animals and healthy adults that Epo also interacts with thrombopoiesis and platelet function. This study investigates the effect of Epo therapy on platelet reactivity, peripheral platelet counts and thiazole orange-positive (TO+) platelets in extremely low birth weight (ELBW) infants. In a randomised-controlled trial, ELBW infants with a birth weight < or =800 g and a gestational age < or =32 weeks were either randomised to a group receiving Epo during the first weeks of life or to a control group. Our results show that thrombin receptor-activating peptide (TRAP-6) -induced expression of P-selectin increased significantly during the first two weeks of Epo treatment. With the exception of week five, the number of TO+ platelets was significantly higher during the first eight weeks in Epo-treated infants compared to controls. The increase of TO+ platelets was not paralleled by an increase in total platelet count. We can conclude that Epo therapy has a short-lasting effect on platelet reactivity toTRAP-6 in ELBW infants during the first two weeks of life. Furthermore, Epo therapy is associated with an increase in the number of TO+ platelets compared to controls.

Significant Reduction of Catheter-associated Blood Stream Infections in Preterm Neonates After Implementation of a Care Bundle Focusing on Simulation Training of Central Line Insertion.

Background: Central line–associated blood stream infections (CLABSIs) are common problems in neonatal intensive care units (NICUs). Implementation of catheter care bundles has been shown to reduce CLABSI rates. We developed a care bundle aiming at establishing a uniform central line insertion technique and improving teaching practices focusing on simulation-based techniques. The purpose of this study was to assess the impact of this care bundle on CLABSI rates in very low birth weight infants (VLBWI). Methods: In September 2010, a CLABSI prevention bundle was introduced in our NICU, consisting of simulation-based standardization and education of a peripherally inserted central catheter insertion technique. Data of all VLBWI admitted to our NICU during 2010–2012 were analyzed. Diagnosis of CLABSI required a positive blood culture in the presence of a central venous catheter and clinical signs of infection. Results: Five hundred twenty-six VLBWI admitted during the study period were included into the analysis. CLABSI rates decreased significantly from 13.9 in 2010 to 9.5 in 2011 and 4.7 in 2012 (P < 0.0001). This significant reduction was true for the overall population and for subgroups separated by birth weight. Distribution of blood culture pathogens revealed a constant absolute and relative decline of infections with coagulase-negative staphylococci from 2010 (n = 43/50, 86%) to 2012 (n = 12/18, 67%), as opposed by a slight increase of Staphylococcus aureus infections (n = 1/50, 2% in 2010 versus n = 2/18, 11% in 2012). Conclusion: Our data provide evidence of a potential effect of simulation-based training of central line placement in decreasing CLABSI rates in VLBWI and encourage its implementation into care bundles.

An instructional video enhanced bag-mask ventilation quality during simulated newborn resuscitation

Approximately 20% of newborns infants need respiratory support at birth. This study evaluated whether video‐based education could improve quality of positive pressure ventilation (PPV) performed by inexperienced staff during neonatal resuscitation.

Erweiterte Maßnahmen der kardiopulmonalen Reanimation bei Kindern und Jugendlichen. Kommentierte Zusammenfassung der aktuellen Empfehlungen des European Resuscitation Council

ZusammenfassungDie erweiterten Reanimationsmaßnahmen beinhalten die Gabe von Medikamenten, Herzrhythmusanalyse und Defibrillation. Reanimationssituationen sind in der Pädiatrie insgesamt selten und stellen für alle Beteiligten eine hohe kognitive Herausforderung und eine große emotionale Belastung dar. Daher sind ständige Schulungsmaßnahmen zum Erlernen und zur Auffrischung der Basic-Life-Support(BLS)- und Advanced-Life-Support(ALS)-Maßnahmen erforderlich. Hierfür werden spezielle Kinderreanimationskurse des European Resuscitation Council (European Paediatric Life Support, EPLS; http://www.erc.edu) angeboten. Sogenannte nichttechnische Fertigkeiten, wie Kommunikation, Teamführung und Aufgabenverteilung im Team, gewinnen zunehmend an Bedeutung und sollten in Trainingskonzepte integriert werden. Hier finden teamorientierte Ausbildungskonzepte an hochmodernen Patientensimulatoren wachsende Verbreitung. Allerdings gibt es in den Leitlinien kein eindeutiges Statement über die verpflichtende Durchführung von Trainings und die Häufigkeit von Wiederholungen. Es gibt zunehmende Hinweise darauf, dass erlerntes Wissen und auch Fähigkeiten schon nach wenigen Monaten wieder verloren gehen. Daher wird postuliert, dass jährliche Trainings möglicherweise nicht ausreichend sind. Die Autoren hoffen, dass die vorliegende Zusammenfassung zu einer hohen Akzeptanz und zur weiteren Verbreitung der aktuellen internationalen Leitlinien für die lebensrettenden Maßnahmen bei Kindern beiträgt.AbstractThe extended resuscitation measures include the administration of medications, heart rhythm analysis and defibrillation. Resuscitation situations in pediatrics are rare events and represent a high cognitive challenge and a significant emotional burden for all concerned; therefore, continuous training measures for learning and refreshing pediatric basic life support (BLS) and advanced life support (ALS) techniques is essential. For this purpose the European Resuscitation Council provides special child resuscitation courses (European pediatric life support, EPLS, http://www.erc.edu). So-called non-technical skills, such as communication, team leadership and task distribution within the team are becoming increasingly more important and should be integrated into training concepts. Team-oriented training concepts using state of the art patient simulators are becoming more widespread; however, in the guidelines there is no clear statement about an obligatory participation in training or the frequency of refresher courses. There is an increasing amount of evidence that acquired knowledge and also skills become lost even after only a few months; therefore, it is postulated that annual training refreshers are possibly not sufficient. The authors hope that the summary provided here will contribute to a greater acceptance and wider distribution of the current guidelines for life-saving measures in children.

Erweiterte Maßnahmen der kardiopulmonalen Reanimation bei Kindern und Jugendlichen@@@Extended measures for cardiopulmonary resuscitation in children and adolescents: Kommentierte Zusammenfassung der aktuellen Empfehlungen des European Resuscitation Council@@@Summary of the current recommendations of the European Resuscitation Council with comments

ZusammenfassungDie erweiterten Reanimationsmaßnahmen beinhalten die Gabe von Medikamenten, Herzrhythmusanalyse und Defibrillation. Reanimationssituationen sind in der Pädiatrie insgesamt selten und stellen für alle Beteiligten eine hohe kognitive Herausforderung und eine große emotionale Belastung dar. Daher sind ständige Schulungsmaßnahmen zum Erlernen und zur Auffrischung der Basic-Life-Support(BLS)- und Advanced-Life-Support(ALS)-Maßnahmen erforderlich. Hierfür werden spezielle Kinderreanimationskurse des European Resuscitation Council (European Paediatric Life Support, EPLS; http://www.erc.edu) angeboten. Sogenannte nichttechnische Fertigkeiten, wie Kommunikation, Teamführung und Aufgabenverteilung im Team, gewinnen zunehmend an Bedeutung und sollten in Trainingskonzepte integriert werden. Hier finden teamorientierte Ausbildungskonzepte an hochmodernen Patientensimulatoren wachsende Verbreitung. Allerdings gibt es in den Leitlinien kein eindeutiges Statement über die verpflichtende Durchführung von Trainings und die Häufigkeit von Wiederholungen. Es gibt zunehmende Hinweise darauf, dass erlerntes Wissen und auch Fähigkeiten schon nach wenigen Monaten wieder verloren gehen. Daher wird postuliert, dass jährliche Trainings möglicherweise nicht ausreichend sind. Die Autoren hoffen, dass die vorliegende Zusammenfassung zu einer hohen Akzeptanz und zur weiteren Verbreitung der aktuellen internationalen Leitlinien für die lebensrettenden Maßnahmen bei Kindern beiträgt.AbstractThe extended resuscitation measures include the administration of medications, heart rhythm analysis and defibrillation. Resuscitation situations in pediatrics are rare events and represent a high cognitive challenge and a significant emotional burden for all concerned; therefore, continuous training measures for learning and refreshing pediatric basic life support (BLS) and advanced life support (ALS) techniques is essential. For this purpose the European Resuscitation Council provides special child resuscitation courses (European pediatric life support, EPLS, http://www.erc.edu). So-called non-technical skills, such as communication, team leadership and task distribution within the team are becoming increasingly more important and should be integrated into training concepts. Team-oriented training concepts using state of the art patient simulators are becoming more widespread; however, in the guidelines there is no clear statement about an obligatory participation in training or the frequency of refresher courses. There is an increasing amount of evidence that acquired knowledge and also skills become lost even after only a few months; therefore, it is postulated that annual training refreshers are possibly not sufficient. The authors hope that the summary provided here will contribute to a greater acceptance and wider distribution of the current guidelines for life-saving measures in children.

Erweiterte Maßnahmen der kardiopulmonalen Reanimation bei Kindern und Jugendlichen

ZusammenfassungDie erweiterten Reanimationsmaßnahmen beinhalten die Gabe von Medikamenten, Herzrhythmusanalyse und Defibrillation. Reanimationssituationen sind in der Pädiatrie insgesamt selten und stellen für alle Beteiligten eine hohe kognitive Herausforderung und eine große emotionale Belastung dar. Daher sind ständige Schulungsmaßnahmen zum Erlernen und zur Auffrischung der Basic-Life-Support(BLS)- und Advanced-Life-Support(ALS)-Maßnahmen erforderlich. Hierfür werden spezielle Kinderreanimationskurse des European Resuscitation Council (European Paediatric Life Support, EPLS; http://www.erc.edu) angeboten. Sogenannte nichttechnische Fertigkeiten, wie Kommunikation, Teamführung und Aufgabenverteilung im Team, gewinnen zunehmend an Bedeutung und sollten in Trainingskonzepte integriert werden. Hier finden teamorientierte Ausbildungskonzepte an hochmodernen Patientensimulatoren wachsende Verbreitung. Allerdings gibt es in den Leitlinien kein eindeutiges Statement über die verpflichtende Durchführung von Trainings und die Häufigkeit von Wiederholungen. Es gibt zunehmende Hinweise darauf, dass erlerntes Wissen und auch Fähigkeiten schon nach wenigen Monaten wieder verloren gehen. Daher wird postuliert, dass jährliche Trainings möglicherweise nicht ausreichend sind. Die Autoren hoffen, dass die vorliegende Zusammenfassung zu einer hohen Akzeptanz und zur weiteren Verbreitung der aktuellen internationalen Leitlinien für die lebensrettenden Maßnahmen bei Kindern beiträgt.AbstractThe extended resuscitation measures include the administration of medications, heart rhythm analysis and defibrillation. Resuscitation situations in pediatrics are rare events and represent a high cognitive challenge and a significant emotional burden for all concerned; therefore, continuous training measures for learning and refreshing pediatric basic life support (BLS) and advanced life support (ALS) techniques is essential. For this purpose the European Resuscitation Council provides special child resuscitation courses (European pediatric life support, EPLS, http://www.erc.edu). So-called non-technical skills, such as communication, team leadership and task distribution within the team are becoming increasingly more important and should be integrated into training concepts. Team-oriented training concepts using state of the art patient simulators are becoming more widespread; however, in the guidelines there is no clear statement about an obligatory participation in training or the frequency of refresher courses. There is an increasing amount of evidence that acquired knowledge and also skills become lost even after only a few months; therefore, it is postulated that annual training refreshers are possibly not sufficient. The authors hope that the summary provided here will contribute to a greater acceptance and wider distribution of the current guidelines for life-saving measures in children.

Offene Fragen im Bereich der Versorgung und Reanimation von Neugeborenen

1 Pädiatrische Simulation und Patientensicherheit, SIMCharacters Training GmbH, Pressbaum (bei Wien), Österreich 2 PaediatricWorking Group, Austrian Resuscitation Council, Wien, Österreich 3 Klinik für Kinderund Jugendmedizin, Universitätsklinikum Tübingen, Tübingen, Deutschland 4 Kinderklinik und Kinderpoliklinik, Dr. von Haunersches Kinderspital, Ludwig-Maximilians-Universität, München, Deutschland 5 PAEDSIM, Teamtraining für Kindernotfälle e. V, Tübingen, Deutschland