Newborns should be receiving premedication before elective intubation

BACKGROUND: Intubation is a common neonatal procedure. Premedication is accepted as a standard of care, but its use is not universal and wide variations exist in practice. OBJECTIVE: To evaluate current practices for premedication use prior to elective neonatal intubation in South Africa (SA). METHOD: We invited 481 clinicians to participate in a cross-sectional web-based survey. RESULTS: We received responses from 28.3% of the clinicians surveyed; 54.1% were from the private sector and 45.9% from the state sector. Most respondents worked in medium-sized neonatal units with six to ten beds. Most paediatricians (76.0%) worked in the private sector, and 78.6% of neonatologists in the state sector. Premedication was practised by 71.9% of the respondents, but only 38.5% of neonatal units had a written policy. Sedatives were used for premedication by 63.2% of the respondents. Midazolam (41.5%), morphine (34.0%) and ketamine (20.8%) were most commonly used. Muscle relaxants and atropine were not routinely administered. Suxamethonium was the muscle relaxant of choice. Varied combinations of agents or single agents were used. Midazolam used alone was the preferred option. CONCLUSION: This first survey of premedication for neonatal intubation in SA revealed variations in practice, with a minority of clinicians following a written policy. The findings can be used to benchmark practice and inform the design of local collaborative trials aimed at determining optimal premedication prior to neonatal intubation. The survey demonstrates clinicians' reluctance to participate in surveys, suggesting a need for a national collaborative network to obtain representative data

Impact of an educational intervention and clinical performance dashboard on neonatal bloodstream infections

Background. Blood cultures are the most direct method of detecting bacteraemia. Reducing contamination rates improves the specificity and positive predictive value of the blood culture. Clinical performance dashboards have been shown to be powerful tools in improving patient care and outcomes.Objectives. To determine whether prospective surveillance of bloodstream infections (BSIs), introduction of an educational intervention and the use of a clinical performance dashboard could reduce BSIs and blood culture contamination rates in a neonatal nursery. Methods. We compared two time periods, before and after an intervention. Blood culture data were extracted from the local microbiology laboratory database. The educational intervention included the establishment of hand-washing protocols, blood culture techniques and video tools. A clinical performance dashboard was developed to demonstrate the monthly positive blood culture and contamination rates, and this was highlighted and referred to weekly at the unit staff meeting. Results. Before the intervention, 1 460 blood cultures were taken; 206 (14.1%) were positive, of which 104 (7.1% of the total) were contaminants. In the period following the intervention, 1 282 blood cultures were taken; 131 (10.2%) were positive, of which 42 (3.3% of the total) were contaminants. The number of positive blood cultures and contamination rates after the intervention were both statistically significantly reduced (p=0.002 and p<0.001, respectively). Conclusion. This study demonstrates that adopting a relatively simple educational tool, making use of a clinical performance dashboard indicator and benchmarking practice can significantly reduce the level of neonatal sepsis while also reducing contaminated blood cultures.

Newborns should be receiving premedication before elective intubation

Background. Intubation is a common neonatal procedure. Premedication is accepted as a standard of care, but its use is not universal and wide variations exist in practice.Objective. To evaluate current practices for premedication use prior to elective neonatal intubation in South Africa (SA).Method. We invited 481 clinicians to participate in a cross-sectional web-based survey.Results. We received responses from 28.3% of the clinicians surveyed; 54.1% were from the private sector and 45.9% from the state sector. Most respondents worked in medium-sized neonatal units with six to ten beds. Most paediatricians (76.0%) worked in the private sector, and 78.6% of neonatologists in the state sector. Premedication was practised by 71.9% of the respondents, but only 38.5% of neonatal units had a written policy. Sedatives were used for premedication by 63.2% of the respondents. Midazolam (41.5%), morphine (34.0%) and ketamine (20.8%) were most commonly used. Muscle relaxants and atropine were not routinely administered. Suxamethonium was the muscle relaxant of choice. Varied combinations of agents or single agents were used. Midazolam used alone was the preferred option.Conclusion. This first survey of premedication for neonatal intubation in SA revealed variations in practice, with a minority of clinicians following a written policy. The findings can be used to benchmark practice and inform the design of local collaborative trials aimed at determining optimal premedication prior to neonatal intubation. The survey demonstrates clinicians’ reluctance to participate in surveys, suggesting a need for a national collaborative network to obtain representative data

Rapid versus slow rate advancement of feeds for enterally fed extremely low birth weight infants < 1000g: randomised controlled trial

Background The timeous achievement of full enteral nutrition in a preterm infant is a critical prerequisite for optimal growth, neurodevelopment and long-term wellbeing. However, the optimal enteral feeding regimen for preterm infants has not been established, and wide variations occur in practice. The debate on the most appropriate feeding strategy is nuanced by studies suggesting that early introduction of enteral feeds and the rapid advancement of enteral feeds may increase the risk of feeding intolerance and may be involved in the pathogenesis of necrotising enterocolitis (NEC). Objective 1. To review randomised controlled trials (RCT); examining the effect that the rate of advancement of enteral feeds has on the incidence of; NEC, mortality, growth, health care utilisation and other morbidities in very low birth weight (VLBW) and extremely low birth weight (ELBW) infants. 2. To establish the safety and efficacy of commencing enteral breast milk feeds at 24 ml/kg/day on the day of birth and advancing enteral breast milk feeds at 36 ml/kg/day, in infants weighing ≤ 1000 g