Megan M. Gray

Medical improvisation training to enhance the antenatal counseling skills of neonatologists and neonatal fellows: a pilot study

Abstract Introduction: Neonatologists must be skilled at providing antenatal counseling to expectant parents of premature infants at the limits of viability. We conducted a medical improvisation workshop with the objective of enhancing antenatal counseling skills. Methods: Pre- and postworkshop questionnaires were collected to examine the impact of the training. A follow-up survey was distributed 3 months after the workshop to examine the impact of the training on antenatal counseling skills. Results: Nine neonatologists and three neonatal fellows participated in the workshop. Participants reported the skills learned in the workshop could enhance the quality of antenatal counseling. On follow-up survey, 90% of subjects reported improvements in the quality of their antenatal counseling. Discussion: Participation in a medical improvisation workshop resulted in enhancements of self-perceived antenatal counseling skills. Medical improvisation training may provide a feasible and effective method of communication training for neonatologists. Further research into this innovative method are needed.

Neonatal resuscitation: advances in training and practice

Each year in the US, some four hundred thousand newborns need help breathing when they are born. Due to the frequent need for resuscitation at birth, it is vital to have evidence-based care guidelines and to provide effective neonatal resuscitation training. Every five years, the International Liaison Committee on Resuscitation (ILCOR) reviews the science of neonatal resuscitation. In the US, the American Heart Association (AHA) develops treatment guidelines based on the ILCOR science review, and the Neonatal Resuscitation Program (NRP) translates the AHA guidelines into an educational curriculum. In this report, we review recent advances in neonatal resuscitation training and practice. We begin with a review of the new 7th edition NRP training curriculum. Then, we examine key changes to the 2015 AHA neonatal resuscitation guidelines. The four components of the NRP curriculum reviewed here include eSim®, Performance Skills Stations, Integrated Skills Station, and Simulation and Debriefing. The key changes to the AHA neonatal resuscitation guidelines reviewed include initial steps of newborn care, positive-pressure ventilation, endotracheal intubation and use of laryngeal mask, chest compressions, medications, resuscitation of preterm newborns, and ethics and end-of-life care. We hope this report provides a succinct review of recent advances in neonatal resuscitation.

Characterization of a severe case of PIK3CA-related overgrowth at autopsy by droplet digital polymerase chain reaction and report of PIK3CA sequencing in 22 patients: Characterization of a severe case of PIK3CA-related overgrowth at autopsy by droplet digital PCR and report of PIK3CA sequencing in 22 patients

PIK3CA‐related overgrowth spectrum (PROS) refers to a group of disorders of segmental overgrowth of a wide variety of tissues as well as venous and lymphatic malformations. Clinical and molecular diagnosis can be challenging due to phenotypic heterogeneity and difficulties detecting low‐level mosaicism using standard methods. Here, we report a patient with a severe presentation of PIK3CA‐related overgrowth with analysis of 27 posthumously collected tissues by droplet digital polymerase chain reaction (PCR) at autopsy. This patient had a complicated medical course, with coagulopathy, ischemic brain injury, and sepsis resulting in multi‐organ failure and death at age 2 months despite sirolimus therapy. Five of the 27 tissues analyzed possessed a mosaic PIK3CA mutation (p.E545K), with mutation levels ranging from 3 to 20% across affected tissues. We found no correlation between tissue‐specific disease severity and mutation levels, likely reflecting sampling limitations. We also tested a series of 22 individuals with somatic overgrowth and/or vascular‐lymphatic malformations using a targeted next generation sequencing panel and found PIK3CA mutations in nine individuals, identifying three novel PIK3CA variants. This report expands the clinical and molecular spectrum of PROS, emphasizes that different molecular methods can be complimentary in the diagnosis of these disorders, and highlights the risk of coagulopathy in a subset of patients with PIK3CA‐related overgrowth.

Accuracy of the nasal-tragus length measurement for correct endotracheal tube placement in a cohort of neonatal resuscitation simulators

Objective:Nasal-tragus length (NTL) estimates of endotracheal tube (ETT) depth are replacing weight-based estimates for endotracheal tube depth in neonates requiring endotracheal intubation. Existing neonatal simulators were designed before interest in using the NTL, and may lack fidelity in this measurement. The objective of this study is to evaluate the accuracy of the adjusted NTL formula and the Neonatal Resuscitation Program (NRP) gestational age/weight-based ETT depth chart in predicting proper endotracheal tube insertion depth in a cohort of neonatal simulators.Study design:The NTL and appropriate intubation depth to the mid-trachea were measured for 11 commonly used neonatal intubation simulators.Results:The NTL+1 cm formula incorrectly estimates the mid-tracheal depth in 82% of simulators, and the weight-based chart incorrectly estimates depth in 75% of test simulators. Only one simulator experienced a mainstem intubation with ETT insertion to the depth predicted by the NTL+1 cm formula.Conclusions:The majority of neonatal resuscitation simulations lacked physical fidelity with regard to mid-tracheal ETT insertion depth. The NRP gestational age/weight-based chart outperformed the NTL+1 cm formula but still resulted in endotracheal tube misplacement in the majority of neonatal simulators. The majority of simulators had adequate functional fidelity using either method for ETT depth estimation.

Every three-hour versus every six-hour oral feeding in preterm infants: a randomised clinical trial

This trial compares two oral feeding schedules, every three‐hour and every six‐hour oral feeding attempts, to determine which schedule allows for more rapid attainment of full oral feeding in preterm infants.

Procedural training and assessment of competency utilizing simulation

This review examines the current environment of neonatal procedural learning, describes an updated model of skills training, defines the role of simulation in assessing competency, and discusses potential future directions for simulation-based competency assessment. In order to maximize impact, simulation-based procedural training programs should follow a standardized and evidence-based approach to designing and evaluating educational activities. Simulation can be used to facilitate the evaluation of competency, but must incorporate validated assessment tools to ensure quality and consistency. True competency evaluation cannot be accomplished with simulation alone: competency assessment must also include evaluations of procedural skill during actual clinical care. Future work in this area is needed to measure and track clinically meaningful patient outcomes resulting from simulation-based training, examine the use of simulation to assist physicians undergoing re-entry to practice, and to examine the use of procedural skills simulation as part of a maintenance of competency and life-long learning.

Use and perceived safety of stylets for neonatal endotracheal intubation: a national survey

ObjectiveTo examine the use and perceived safety of stylets for neonatal intubation in a cohort of providers in the United States.Study designA cross-sectional survey was sent to members of the American Academy of Pediatrics Section on Neonatal-Perinatal Medicine.ResultA total of 640 responses were received. 57% reported using a stylet ‘every time’ or ‘almost every time’ they intubated. The preferred stylet bend was a smooth bend of <30 degrees. 71% of respondents believed that stylets were safe. Reported complications from stylet use included tube dislodgement during stylet removal (32%), airway injury with bleeding (9%), and tracheal perforation (2%).ConclusionStylet use was common. There was fair consistency on preference for stylet bend and position. Stylet use was believed to be safe, but complications were observed by many respondents. Additional studies are needed to examine the risks and benefits of stylet use during neonatal intubation.

Premedication with paralysis improves intubation success and decreases adverse events in very low birth weight infants: a prospective cohort study

ObjectiveTo characterize the impact of premedication with and without a paralytic agent on the safety of tracheal intubation (TI) in infants ≤1500 g.Study designA prospective observational cohort study between February 2015 and June 2017. The primary outcomes were associations between the use of different premedication regimens with number of TI attempts, TI adverse events (TIAEs), and changes in heart rate.ResultsData were collected on 237 TIs. Median postmenstrual age at intubation was 28 completed weeks and weight was 953 g. Premedication with a paralytic was associated with fewer intubation attempts compared to premedication without a paralytic (p = 0.037). Premedication with a paralytic was associated with fewer TIAEs (p < 0.001) and less bradycardia compared to the other two regimens (p = 0.003) compared to premedication without a paralytic.ConclusionsPremedication with a paralytic was associated with fewer intubation attempts, fewer TIAEs, and less bradycardia. Premedication with a paralytic may improve intubation safety in VLBWs.

Effect of Video-based Telemedicine on Transport Management of Simulated Newborns

OBJECTIVE Video-based telemedicine is a reliable tool to assess the severity of respiratory distress in children, increasing the appropriateness of triage and disposition for acutely ill children. Telemedicine simulations may identify patterns in regional transport management and influence attitudes toward telemedicine. METHODS The objective was to determine the effect of videos on simulated neonatal transport care compared with telephone management. Participants received information about a newborn requiring respiratory support by an audio recording and made management decisions based on only that information. Four videos of varying respiratory distress on respiratory support were then shown. After each video, participants again rated patient stability and recommended management. RESULTS Sixteen neonatologists completed the cases. Compared with the telephone call, there were significant differences in ratings of patient stability and confidence in their assessment after watching the videos. When given the same information, participants were less likely to recommend intubation after viewing an infant in mild respiratory distress than after the telephone call (P < .05). Most participants felt that viewing the videos was helpful in formulating their assessment and plan. CONCLUSION Video-based telemedicine simulations influenced the perceived stability of neonates during transport. Viewing the patient increased provider confidence in their assessment and recommendations.