Neonatal intubation: what are we doing?

: How and when the forces are applied during neonatal intubation are currently unknown. This study investigated the pattern of the applied forces by using sensorized laryngoscopes during the intubation process in a neonatal manikin. Nine users of direct laryngoscope and nine users of straight-blade video laryngoscope were included in a neonatal manikin study. During each procedure, relevant forces were measured using a force epiglottis sensor that was placed on the distal surface of the blade. The pattern of the applied forces could be divided into three sections. With the direct laryngoscope, the first section showed either a quick rise of the force or a discontinuous rise with several peaks; after reaching the maximum force, there was a sort of plateau followed by a quick drop of the applied forces. With the video laryngoscope, the first section showed a quick rise of the force; after reaching the maximum force, there was an irregular and heterogeneous plateau, followed by heterogeneous decreases of the applied forces. Moreover, less forces were recorded when using the video laryngoscope.    Conclusions: This neonatal manikin study identified three sections in the diagram of the forces applied during intubation, which likely mirrored the three main phases of intubation. Overall, the pattern of each section showed some differences in relation to the laryngoscope (direct or video) that was used during the procedure. These findings may provide useful insights for improving the understanding of the procedure. What is Known: • Neonatal intubation is a life-saving procedure that requires a skilled operator and may cause direct trauma to the tissues and precipitate adverse reactions. • Intubation with a videolaryngoscope requires less force than with a direct laryngoscope, but how and when the forces are applied during the whole neonatal intubation procedure are currently unknown. What is New: • Forces applied to the epiglottis during intubation can be divided into three sections: (i) an initial increase, (ii) a sort of plateau, and (iii) a decrease. • The pattern of each section shows some differences in relation to the laryngoscope (direct or videolaryngoscope) that is used during the procedure

Applied forces with direct versus indirect laryngoscopy in neonatal intubation: a randomized crossover mannequin study

Purpose: In adult mannequins, videolaryngoscopy improves glottic visualization with lower force applied to upper airway tissues and reduced task workload compared with direct laryngoscopy. This trial compared oropharyngeal applied forces and subjective workload during direct vs indirect (video) laryngoscopy in a neonatal mannequin. Methods: We conducted a randomized crossover trial of intubation with direct laryngoscopy, straight blade videolaryngoscopy, and hyperangulated videolaryngoscopy in a neonatal mannequin. Thirty neonatal/pediatric/anesthesiology consultants and residents participated. The primary outcome measure was the maximum peak force applied during intubation. Secondary outcome measures included the average peak force applied during intubation, time needed to intubate, and subjective workload. Results: Direct laryngoscopy median forces on the epiglottis were 8.2 N maximum peak and 6.8 N average peak. Straight blade videolaryngoscopy median forces were 4.7 N maximum peak and 3.6 N average peak. Hyperangulated videolaryngoscopy median forces were 2.8 N maximum peak and 2.1 N average peak. The differences were significant between direct laryngoscopy and straight blade videolaryngoscopy, and between direct laryngoscopy and hyperangulated videolaryngoscopy. Significant differences were also found in the top 10th percentile forces on the epiglottis and palate, but not in the median forces on the palate. Time to intubation and subjective workload were comparable with videolaryngoscopy vs direct laryngoscopy. Conclusions: The lower force applied during videolaryngoscopy in a neonatal mannequin model suggests a possible benefit in reducing potential patient harm during intubation, but the clinical implications require assessment in future studies. Registration: ClinicalTrials.gov (NCT05197868); registered 20 January 2022

Impact of personal protective equipment on neonatal resuscitation procedures: a randomised, cross-over, simulation study

none6Healthcare providers should use personal protective equipment (PPE) when performing aerosol-generating medical procedures during highly infectious respiratory pandemics. We aimed to compare the timing of neonatal resuscitation procedures in a manikin model with or without PPE for prevention of SARS-COVID-19 transmission.noneCavallin, Francesco; Lupi, Fiorenzo; Bua, Benedetta; Bellutti, Marion; Staffler, Alex; Trevisanuto, DanieleCavallin, Francesco; Lupi, Fiorenzo; Bua, Benedetta; Bellutti, Marion; Staffler, Alex; Trevisanuto, Daniel

Device positioning with LISA vs. INSURE: a crossover randomized controlled manikin trial

Objective We aimed to compare time of device positioning, success of procedure and operator's opinion with LISA vs. INSURE in a manikin simulating an extremely low birthweight infant. Methods A randomized controlled crossover (AB/BA) trial of surfactant administration with LISA vs. INSURE in a preterm manikin. Forty-two tertiary hospital consultants and pediatric residents with previous experience with LISA and INSURE participated. The primary outcome measure was the time of device positioning. The secondary outcome measures were: success of the first attempt, number of attempts, correct depth, and participant's opinion on difficulty in using the device. Results Median time of device positioning was shorter with LISA vs. INSURE (median difference -8 s, 95% confidence interval -16 to -1 s; p = .04). Success at first attempt was 35/40 with LISA (83%) and 31/40 with INSURE (74%) (p = .42). Median number of attempts was 1 (IQR 1-1) with LISA and 1 (IQR 1-2) with INSURE (p = .08). Correct depth was achieved in 30/40 with LISA (71%) and 37/40 with INSURE (88%) (p = .12). Participants found LISA easier to insert in the trachea (p = .002) but INSURE easier to place at the correct depth (p = .008). Handling the device (p = .43), visualizing the glottis (p = .17) and overall difficulty in using the device (p = .13) were not statistically different. Conclusions In a preterm manikin model, positioning a thin catheter (LISA) was quicker and easier than a tracheal tube (INSURE), but the magnitude of the difference was unlikely to be clinically relevant and the tracheal tube was easier to place at the correct depth. Registration clinicaltrial.gov NCT04944108

Rigid versus soft catheter for less invasive surfactant administration: A crossover randomized controlled manikin trial

BackgroundWe compared surfactant administration with a rigid versus soft catheter in a manikin simulating an extremely preterm infant. MethodsRandomized controlled crossover (AB/BA) trial. Fifty tertiary hospital consultants and pediatric residents. The primary outcome was the time of device positioning. The secondary outcomes were the success of the first attempt, the number of attempts, and the participant's opinion. ResultsMedian time of device positioning was 19 s (interquartile range [IQR]: 15-25) with rigid catheter and 40 s (IQR: 28-66) with soft catheter (p < 0.0001). Success at first attempt was 92% with rigid catheter and 74% with soft catheter (p = 0.01). Median number of attempts was 1 (IQR: 1-1) with rigid catheter and 1 (IQR: 1-2) with soft catheter (p = 0.009). Participants found the rigid catheter easier to use (p < 0.0001). ConclusionsIn a preterm manikin model, using a rigid catheter for less invasive surfactant administration was quicker and easier to use than a soft catheter

Marked versus unmarked tip catheter for less invasive surfactant administration: A crossover randomised controlled manikin trial

AimLess invasive surfactant administration is becoming increasingly popular, but health-care providers may experience some difficulties in achieving the correct positioning of the catheter in the trachea. We compared catheters with marked versus unmarked tips in terms of correct depth positioning in the trachea, total time, number of attempts and participant's opinion on using the device in a manikin model. MethodsA randomised controlled crossover trial of surfactant administration with less invasive surfactant administration catheters with marked versus unmarked tip in a preterm infant manikin. Fifty tertiary hospital consultants and paediatric residents with previous experience in surfactant administration participated. The primary outcome measure was the positioning of the device at the correct depth in the trachea. The secondary outcome measures were the total time and the number of attempts for positioning the device in the trachea, and participant's opinion on using the device. ResultsCorrect depth in the trachea was achieved by 38 (76%) and 28 (56%) participants using the catheters with marked and unmarked tip, respectively (P = 0.04). Median time of device positioning (P = 0.08) and number of attempts (P = 0.13) were not statistically different between the two catheters. Participants found the catheter with the marked tip easier to use (P = 0.007), especially concerning the insertion in the trachea (P = 0.04) and the positioning at the correct depth (P = 0.004). ConclusionsIn a preterm manikin model, the marked tip catheter offered a higher chance of achieving the correct depth of the device in the trachea and was favoured by the participants

"Delirium Day": A nationwide point prevalence study of delirium in older hospitalized patients using an easy standardized diagnostic tool

Background: To date, delirium prevalence in adult acute hospital populations has been estimated generally from pooled findings of single-center studies and/or among specific patient populations. Furthermore, the number of participants in these studies has not exceeded a few hundred. To overcome these limitations, we have determined, in a multicenter study, the prevalence of delirium over a single day among a large population of patients admitted to acute and rehabilitation hospital wards in Italy. Methods: This is a point prevalence study (called "Delirium Day") including 1867 older patients (aged 65 years or more) across 108 acute and 12 rehabilitation wards in Italian hospitals. Delirium was assessed on the same day in all patients using the 4AT, a validated and briefly administered tool which does not require training. We also collected data regarding motoric subtypes of delirium, functional and nutritional status, dementia, comorbidity, medications, feeding tubes, peripheral venous and urinary catheters, and physical restraints. Results: The mean sample age was 82.0 ± 7.5 years (58 % female). Overall, 429 patients (22.9 %) had delirium. Hypoactive was the commonest subtype (132/344 patients, 38.5 %), followed by mixed, hyperactive, and nonmotoric delirium. The prevalence was highest in Neurology (28.5 %) and Geriatrics (24.7 %), lowest in Rehabilitation (14.0 %), and intermediate in Orthopedic (20.6 %) and Internal Medicine wards (21.4 %). In a multivariable logistic regression, age (odds ratio [OR] 1.03, 95 % confidence interval [CI] 1.01-1.05), Activities of Daily Living dependence (OR 1.19, 95 % CI 1.12-1.27), dementia (OR 3.25, 95 % CI 2.41-4.38), malnutrition (OR 2.01, 95 % CI 1.29-3.14), and use of antipsychotics (OR 2.03, 95 % CI 1.45-2.82), feeding tubes (OR 2.51, 95 % CI 1.11-5.66), peripheral venous catheters (OR 1.41, 95 % CI 1.06-1.87), urinary catheters (OR 1.73, 95 % CI 1.30-2.29), and physical restraints (OR 1.84, 95 % CI 1.40-2.40) were associated with delirium. Admission to Neurology wards was also associated with delirium (OR 2.00, 95 % CI 1.29-3.14), while admission to other settings was not. Conclusions: Delirium occurred in more than one out of five patients in acute and rehabilitation hospital wards. Prevalence was highest in Neurology and lowest in Rehabilitation divisions. The "Delirium Day" project might become a useful method to assess delirium across hospital settings and a benchmarking platform for future surveys

Understanding Factors Associated With Psychomotor Subtypes of Delirium in Older Inpatients With Dementia

Objectives: Few studies have analyzed factors associated with delirium subtypes. In this study, we investigate factors associated with subtypes of delirium only in patients with dementia to provide insights on the possible prevention and treatments. Design: This is a cross-sectional study nested in the \u201cDelirium Day\u201d study, a nationwide Italian point-prevalence study. Setting and Participants: Older patients admitted to 205 acute and 92 rehabilitation hospital wards. Measures: Delirium was evaluated with the 4-AT and the motor subtypes with the Delirium Motor Subtype Scale. Dementia was defined by the presence of a documented diagnosis in the medical records and/or prescription of acetylcholinesterase inhibitors or memantine prior to admission. Results: Of the 1057 patients with dementia, 35% had delirium, with 25.6% hyperactive, 33.1% hypoactive, 34.5% mixed, and 6.7% nonmotor subtype. There were higher odds of having venous catheters in the hypoactive (OR 1.82, 95% CI 1.18-2.81) and mixed type of delirium (OR 2.23, CI 1.43-3.46), whereas higher odds of urinary catheters in the hypoactive (OR 2.91, CI 1.92-4.39), hyperactive (OR 1.99, CI 1.23-3.21), and mixed types of delirium (OR 2.05, CI 1.36-3.07). We found higher odds of antipsychotics both in the hyperactive (OR 2.87, CI 1.81-4.54) and mixed subtype (OR 1.84, CI 1.24-2.75), whereas higher odds of antibiotics was present only in the mixed subtype (OR 1.91, CI 1.26-2.87). Conclusions and Implications: In patients with dementia, the mixed delirium subtype is the most prevalent followed by the hypoactive, hyperactive, and nonmotor subtype. Motor subtypes of delirium may be triggered by clinical factors, including the use of venous and urinary catheters, and the use of antipsychotics. Future studies are necessary to provide further insights on the possible pathophysiology of delirium in patients with dementia and to address the optimization of the management of potential risk factors

Drug Prescription and Delirium in Older Inpatients: Results From the Nationwide Multicenter Italian Delirium Day 2015-2016

Objective: This study aimed to evaluate the association between polypharmacy and delirium, the association of specific drug categories with delirium, and the differences in drug-delirium association between medical and surgical units and according to dementia diagnosis. Methods: Data were collected during 2 waves of Delirium Day, a multicenter delirium prevalence study including patients (aged 65 years or older) admitted to acute and long-term care wards in Italy (2015-2016); in this study, only patients enrolled in acute hospital wards were selected (n = 4,133). Delirium was assessed according to score on the 4 "A's" Test. Prescriptions were classified by main drug categories; polypharmacy was defined as a prescription of drugs from 5 or more classes. Results: Of 4,133 participants, 969 (23.4%) had delirium. The general prevalence of polypharmacy was higher in patients with delirium (67.6% vs 63.0%, P =.009) but varied according to clinical settings. After adjustment for confounders, polypharmacy was associated with delirium only in patients admitted to surgical units (OR = 2.9; 95% CI, 1.4-6.1). Insulin, antibiotics, antiepileptics, antipsychotics, and atypical antidepressants were associated with delirium, whereas statins and angiotensin receptor blockers exhibited an inverse association. A stronger association was seen between typical and atypical antipsychotics and delirium in subjects free from dementia compared to individuals with dementia (typical: OR = 4.31; 95% CI, 2.94-6.31 without dementia vs OR = 1.64; 95% CI, 1.19-2.26 with dementia; atypical: OR = 5.32; 95% CI, 3.44-8.22 without dementia vs OR = 1.74; 95% CI, 1.26-2.40 with dementia). The absence of antipsychotics among the prescribed drugs was inversely associated with delirium in the whole sample and in both of the hospital settings, but only in patients without dementia. Conclusions: Polypharmacy is significantly associated with delirium only in surgical units, raising the issue of the relevance of medication review in different clinical settings. Specific drug classes are associated with delirium depending on the clinical setting and dementia diagnosis, suggesting the need to further explore this relationship