Philipp Deindl

Background: Night‐shift work may influence attention and emotion processing, potentially affecting clinical assessment. We investigated whether neonatal pain evaluation and associated visual‐attentional and pupillary responses differed between rested and post‐night‐shift assessments in experienced NICU professionals. Methods: In this prospective within‐subject study, 20 NICU professionals evaluated 42 standardized video clips of term neonates exposed to nonnoxious, short noxious, or prolonged noxious stimuli. Participants were assessed after at least 1 day off work and within 2 h after completing one or more consecutive night shifts. Pain ratings, eye‐tracking metrics, and pupil diameter were compared between conditions. Results: Overall pain ratings did not differ significantly between rested and post‐night‐shift assessments (3.56 ± 0.69 vs. 3.61 ± 0.72; p = 0.643; Cohen′s d = 0.11). Pupillary responses also showed no statistically significant differences. Exploratory eye‐tracking analyses suggested reduced visual exploration after night‐shift exposure, including fewer visits across several areas of interest and shorter fixation duration on the infant′s body. These secondary analyses were unadjusted for multiple comparisons and should therefore be considered hypothesis‐generating. Conclusions: No statistically significant differences in neonatal pain ratings or pupillary responses were detected following routine night‐shift work, whereas exploratory eye‐tracking measures suggested differences in visual‐attentional patterns. Given the small, selected sample and exploratory design, these findings do not establish equivalent or preserved performance between conditions. Larger prospective studies incorporating objective sleep measures and clinically relevant outcomes are warranted.

Inappropriate ventilator settings, non-adherence to a lung-protective ventilation strategy, and inadequate patient monitoring during mechanical ventilation can potentially expose critically ill children to additional risks. We set out to improve team theoretical knowledge and practical skills regarding pediatric mechanical ventilation and to increase compliance with treatment goals. An educational initiative was conducted from August 2019 to July 2021 in a neonatal and pediatric intensive care unit of the University Children’s Hospital, Hamburg-Eppendorf, Germany. We tested baseline theoretical knowledge using a multiple choice theory test (TT) and practical skills using a practical skill test (PST), consisting of four sequential Objective Structured Clinical Examinations of physicians and nurses. We then implemented an educational bundle that included video self-training, checklists, pocket cards, and reevaluated team performance. Ventilators and monitor settings were randomly checked in all ventilated patients. We used a process control chart and a mixed-effects model to analyze the primary outcome. A total of 47 nurses and 20 physicians underwent assessment both before and after the implementation of the initiative using TT. Additionally, 34 nurses and 20 physicians were evaluated using the PST component of the initiative. The findings revealed a significant improvement in staff performance for both TT and PST (TT: 80% [confidence interval (CI): 77.2–82.9] vs. 86% [CI: 83.1–88.0]; PST: 73% [CI: 69.7–75.5] vs. 95% [CI: 93.8–97.1]). Additionally, there was a notable increase in self-confidence among participants, and compliance with mechanical ventilation treatment goals also saw a substantial rise, increasing from 87.8% to 94.5%. Implementing a pediatric mechanical ventilation education bundle improved theoretical knowledge and practical skills among interprofessional pediatric intensive care staff and increased treatment goal compliance in ventilated children.

Background Bilateral diaphragmatic agenesis (DA) is a rare congenital defect leading to a bilateral herniation of abdominal organs into the thorax cavity [1]. Diaphragmatic defects are often associated with congenital anomalies and genetic syndromes. However, the occurrence of DA in association with Cornelia de Lange (CDL) Syndrome is very rare [2]. Aim To discuss the current diagnosis and treatment options of DA associated with CDL Syndrome. Methods This report describes the case of a male, late preterm neonate with prenatally diagnosed DA and CDL Syndrome. Results The infant presented with severe respiratory distress after birth, bilateral pulmonary hypoplasia, and herniation of abdominal organs into the chest cavity. The postnatal management was performed according to the recommendations of the Congenital Diaphragmatic Hernia EURO Consortium, including immediate intubation and invasive mechanical ventilation [3]. Chest auscultation revealed a decreased air entry, only reaching the upper lungs. Physical examination confirmed congenital malformations associated with CDL Syndrome, including microcephaly, facial dysmorphia with micro- and retrognathia, long philtrum, long eyelashes, and cleft palate. In addition, the x-ray showed bilateral diaphragm agenesis with herniation of the liver, spleen, and stomach into the thorax resulting in pronounced bilateral pulmonary hypoplasia. Despite inhaled nitric oxide, the application of intensive high-frequency oscillatory ventilation oxygenation gradually deteriorated. Due to the unfavorable prognosis, an interdisciplinary consensus was reached to forego extracorporeal membrane oxygenation (ECMO). The boy died at four hours of age. The parents declined an autopsy, photographic documentation, and postmortem computer tomography. Conclusion DA remains a life-threatening disease despite early prenatal MRI diagnosis, comprehensive treatment of respiratory insufficiency, including intubation, lung-protective ventilation, extensive supportive therapy, and ECMO use [4]. Article published online: 06 June 2023 © 2023. Thieme. All rights reserved. Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany

Aim: To investigate the impact of the level of pain experienced by infants born preterm on neurodevelopmental outcomes during their stay in a neonatal intensive care unit.Method: In this retrospective data analysis we included all surviving infants born preterm with a gestational age between 23 and 32 weeks from 2011 to 2015, who were assessed using the Neonatal Pain, Agitation, and Sedation Scale and examined at 1 year of age using the Bayley Scales of Infant Development. We excluded all infants who had suffered severe neurological morbidities and undergone surgical interventions.Results: A total of 196 infants born preterm were included in the analyses: 105 in the ‘no pain group’ and 91 in the ‘pain group’. Significant differences between the groups were detected for both mental and motor development (p = 0.003, 95% confidence interval [CI] 2.23–10.92; p = 0.025, 95% CI 0.64–9.78). The results remained significant after controlling for other important medical conditions (p = 0.001, 95% CI −19.65 to −5.40; p = 0.010, 95% CI −16.18 to −2.29).Interpretation: Neonatal pain exposure was associated with altered neurodevelopmental outcomes of infants born very preterm at a corrected age of 12 months. This observation highlights the importance of adequate pain management to reduce the risk of poor neurodevelopmental outcomes in these vulnerable patients.

Introduction: Inappropriate ventilator settings, non-adherence to a lung-protective ventilation strategy, and inadequate patient monitoring during mechanical ventilation can potentially expose critically ill children to additional risks. We set out to improve team theoretical knowledge and practical skills regarding pediatric mechanical ventilation and to increase compliance with treatment goals. Methods: An educational initiative was conducted from August 2019 to July 2021 in a neonatal and pediatric intensive care unit of the University Children's Hospital, Hamburg-Eppendorf, Germany. We tested baseline theoretical knowledge using a multiple choice theory test (TT) and practical skills using a practical skill test (PST), consisting of four sequential Objective Structured Clinical Examinations of physicians and nurses. We then implemented an educational bundle that included video self-training, checklists, pocket cards, and reevaluated team performance. Ventilators and monitor settings were randomly checked in all ventilated patients. We used a process control chart and a mixed-effects model to analyze the primary outcome. Results: Staff members took part in 183 theory tests (TT) and 169 practical skill tests (PST). The initiative was associated with a substantial increase in staff TT and PST performance (CI) (TT: 80 [77.2–82.9]% vs. 86 [83.1–88.0]%, PST: 73 [69.7–75.5]% vs. 95 [93.8–97.1]%), self-confidence, and compliance with mechanical ventilation treatment goals (87.8% vs. 94.5%). Discussion: Implementing a pediatric mechanical ventilation education bundle improved theoretical knowledge and practical skills among multi-professional pediatric intensive care staff and increased treatment goal compliance in ventilated children.

Objective: Malposition of peripherally inserted central catheters (PICCs) is common. Recommendations for PICC insertion depths are scarce and comprise complex equations. This study aimed to develop diagrams and tables for the recommendation of PICC insertion depths in neonates based on anthropometric parameters. Study Design: In this retrospective single-center study, the individual optimal PICC insertion depths were correlated with body weight, length, and head circumference. Using linear regression analysis, line charts and tables for the recommendation of PICC insertion depth were generated and compared with previously published recommendations. Result: PICC insertion depths of 204 infants (gestational age at PICC installation: 24.0–44.9 weeks) with 131 (64%) PICC in the upper extremities and 73 (36%) in the lower extremities were analyzed. Linear logistic regression models revealed R² values between 0.387 and 0.884. Conclusion: The charts and table developed in this study enable a fast and accurate determination of recommended PICC insertion depths in neonates.

Introduction: Crying newborns signal a need or discomfort as part of the innate communication system. Exposure to pain is related to infants’ unfavorable neurodevelopmental outcomes. There is a tremendous need for more objective methods to assess neonatal pain. An audio analysis of acoustic utterances could provide specific information on the patient’s pain level. Methods: We analyzed 67 videos of 33 term-born newborns recorded during a planned capillary blood sample, including the stimuli, non-noxious thermal stimulus, short noxious stimulus, and prolonged unpleasant stimulus, between December 2020 and March 2021. Two expert raters evaluated the infants’ pain responses using the Neonatal Facial Coding System (NFCS). The mean values of 123 timbre features of the recorded audio data were analyzed by using specific toolboxes and libraries from the following programming environments: MIRtoolbox (MATLAB), MiningSuite (MATLAB), Essentia (Python), AudioCommons timbral models (Python), and Librosa (Python). Results: The NFCS values were significantly higher during the short noxious stimulus (p < 0.001) and prolonged unpleasant stimulus (p < 0.001) than during the non-noxious thermal stimulus, whereas NFCS values during the short noxious stimulus and prolonged unpleasant stimulus were similar (p = 0.79). Brightness, roughness, percussive energy, and attack times were identified as the features having the highest impact on the NFCS. Conclusion: This hypothesis-generating study identified several salient acoustic features highly associated with pain responses in term newborns. Our analysis is an encouraging starting point for the targeted analysis of pain-specific acoustic features of neonatal cries and vocalizations from the perspective of real-time acoustic processing.

Less invasive surfactant administration (LISA) has been introduced at our tertiary Level IV perinatal center since 2016 with an unsatisfactory success rate, which we attributed to an inconsistent, non-standardized approach and ambiguous patient inclusion criteria. This study aimed to improve the LISA success rate to at least 75% within 12 months by implementing a highly standardized LISA approach combined with team training. The Plan Do Study Act method of quality improvement was used for this initiative. Baseline assessment included a review of patient medical records 12 months before the intervention regarding patient characteristics, method success rate, respiratory, and adverse outcomes. A multi-professional team developed a standardized LISA approach and a training program including an educational film, checklists, pocket cards, and team briefings. Twenty-one preterm infants received LISA before and 24 after the intervention. The mean LISA success rate improved from 62% before the intervention to 92% (p = 0.029) after the intervention. Implementing a highly standardized LISA approach and multi-professional team training significantly improved the methods’ success rate.

Background: Medical simulation training requires realistic simulators with high fidelity. This prospective multi-center study investigated anatomic precision, physiologic characteristics, and fidelity of four commercially available very low birth weight infant simulators. Methods: We measured airway angles and distances in the simulators Premature AirwayPaul (SIMCharacters), Premature Anne (Laerdal Medical), Premie HAL S2209 (Gaumard), and Preterm Baby (Lifecast Body Simulation) using computer tomography and compared these to human cadavers of premature stillbirths. The simulators’ physiologic characteristics were tested, and highly experienced experts rated their physical and functional fidelity. Results: The airway angles corresponded to those of the reference cadavers in three simulators. The nasal inlet to glottis distance and the mouth aperture to glottis distance were only accurate in one simulator. All simulators had airway resistances up to 20 times higher and compliances up to 19 times lower than published reference values. Fifty-six highly experienced experts gave three simulators (Premature AirwayPaul: 5.1 ± 1.0, Premature Anne 4.9 ± 1.1, Preterm Baby 5.0 ± 1.0) good overall ratings and one simulator (Premie HAL S2209: 2.8 ± 1.0) an unfavorable rating. Conclusion: The simulator physiology deviated significantly from preterm infants’ reference values concerning resistance and compliance, potentially promoting a wrong ventilation technique. Impact: Very low birth weight infant simulators showed physiological properties far deviating from corresponding patient reference values. Only ventilation with very high peak pressure achieved tidal volumes in the simulators, as aimed at in very low birth weight infants, potentially promoting a wrong ventilation technique. Compared to very low birth weight infant cadavers, most tested simulators accurately reproduced the anatomic angular relationships, but their airway dimensions were relatively too large for the represented body. The more professional experience the experts had, the lower they rated the very low birth weight infant simulators.

An adequate blood volume is important for neonatal adaptation. The study objective was to quantify the cumulative iatrogenic blood loss in very low birth weight (VLBW) infants by blood sampling and the necessity of packed red cell transfusions from birth to discharge from the hospital. In total, 132 consecutive VLBW infants were treated in 2019 and 2020 with a median birth weight of 1180 g (range 370–1495 g) and a median length of stay of 54 days (range 0–154 days) were included. During the initial four weeks of life, the median absolute amount of blood sampling was 16.5 mL (IQR 12.3–21.1 mL), sampling volume was different with 14.0 mL (IQR 12.1–16.2 mL) for non-transfused infants and 21.6 mL (IQR 17.5–29.4 mL) for transfused infants. During the entire length of stay, 31.8% of the patients had at least one transfusion. In a generalized logistic regression model, the cumulative amount of blood sampling (p < 0.01) and lower hematocrit at birth (p = 0.02) were independent predictors for the necessity of blood transfusion. Therefore, optimized patient blood management in VLBW neonates should include sparse blood sampling to avoid iatrogenic blood loss.