STYLETS FOR ENDOTRACHEAL INTUBATION: DO THEY HELP?

A stylet, or an introducer, to assist in the endotracheal intubation of the neonate has long been considered "optional" by the Neonatal Resuscitation Program.¹ Stylets are avoided by some clinicians, because of fear of traumatizing the tissues during intubation, or because stylets can be difficult to remove from small endotracheal tubes, potentially dislodging a successfully placed tube. However, other clinicians still use stylets in the belief that they increase the success of intubation. Little evidence exists to support either view.

In an unblinded randomized controlled trial,² investigators studied intubations attempted by pediatric residents or fellows on 232 neonates (302 intubations) in a tertiary perinatal center. Infants were randomized to be intubated with either an endotracheal tube alone or an endotracheal tube and stylet. Successful intubation at the first attempt assessed by colorimetric detection of expired carbon dioxide was the primary outcome.

Intubation was successful in 57% of the stylet group and 53% of the no-stylet group (P = .47). No differences in duration of attempt or occurrence of upper airway trauma were noted between the groups, nor were differences observed across subgroups of neonates, including birth weight, gestational age, and location of intubation (delivery room or neonatal intensive care unit). A nonsignificant trend was seen toward a higher likelihood of success when a stylet was used by operators who had never successfully intubated a neonate. The investigators suggest that this finding should be confirmed in a larger trial. Overall, they concluded that the use of an endotracheal stylet did not improve success rates of neonatal intubation by pediatric trainees.

References

1. American Academy of Pediatrics. Neonatal Resuscitation Textbook. 6th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2011.

2. Kamlin CO, O'Connell LA, Morley CJ, et al. A randomized trial of stylets for intubating newborn infants. Pediatrics. 2013;131:e198-e205.

ALCOHOL-IMPREGNATED DISINFECTION CAPS

Catheter hub contamination is believed to be one of the key causes of central line-associated bloodstream infections (CLABSIs). Manually scrubbing catheter hubs (access ports) with alcohol is an intervention frequently used to minimize contamination of central catheters and avoid the introduction of pathogens.

Alcohol-impregnated disinfection caps are twist-on protective caps that contain a small sponge saturated with 70% isopropyl alcohol. The caps are designed to cover the needleless access ports on central venous catheters, including peripherally inserted central catheters (PICCs). These small caps are relatively inexpensive compared with many of the practices adopted by hospitals to reduce the rate of CLABSI.

A recent 3-phase study¹ compared the use of disinfecting caps with a traditional manual scrubbing protocol and found a sharp reduction in the rate of CLABSIs when adult PICCs were managed with the disinfecting caps. Caps were associated with reductions in contamination of catheters, as evidenced by lower median numbers of colony-forming units per milliliter. Caps were also associated with a reduction in CLABSI rates from 1.43 to 0.69 per 1000 line-days (P = .04).

An economic analysis showed that for a cost of $2.07 per catheterized patient per day, 21 catheter infections and 4 deaths could be prevented. Further study in neonates is warranted to determine whether alcohol-impregnated caps have similar benefits in PICCs that are maintained for much longer periods of time, as is typical in the neonatal intensive care unit.

Reference

1. Wright MO, Tropp J, Schora DM, et al. Continuous passive disinfection of catheter hubs prevents contamination and bloodstream infection. Am J Infect Control. 2013;41:33-38.

UPDATED RETINOPATHY SCREENING GUIDELINES

Until we figure out how to eradicate retinopathy of prematurity (ROP), the most important aspect in the prevention of poor visual outcomes is screening and identifying infants with early changes in the developing retina. A new statement¹ outlines the principles on which an effective program to detect ROP in infants at risk might be based, to assist in the identification of infants who could benefit from treatment and make appropriate recommendations on the timing of future screening and treatment interventions. This statement replaces the previous 2006 statement on ROP.²

The new recommendations are too lengthy to reproduce here, but in brief, they describe the following:

* how to identify infants who should undergo retinal screening examinations;

* how the retinal examination should be conducted and by whom;

* the timing of acute-phase ROP screening, with evidence-based screening schedules based on gestational age at birth;

* schedule of follow-up examinations based on the findings of the screening retinal examination;

* the conclusion of acute retinal screening examinations based on the retinal ophthalmoscopic findings and patient age;

* the use of digital photographic retinal images for remote interpretation;

* revised ROP treatment recommendations based on retinal findings and accomplished within 72 hours of determination of treatable disease to minimize the risk for retinal detachment;

* the use of intravitreal bevacizumab;

* communicating findings of examinations, progression, and treatment plans to parents; and

* development of unit-specific criteria for screening and follow-up of at-risk infants, and arranging for continuity of care for transferred or discharged infants.

References

1. American Academy of Pediatrics Section on Ophthalmology, American Academy of Ophthalmology; American Association for Pediatric Ophthalmology and Strabismus, and American Association of Certified Orthoptists. Screening examination of premature infants for retinopathy of prematurity. Pediatrics. 2013;131:189-195.

2. Section on Ophthalmology American Academy of Pediatrics; American Academy of Ophthalmology; American Association for Pediatric Ophthalmology and Strabismus. Screening examination of premature infants for retinopathy of prematurity. Pediatrics. 2006;117:572-576.

MEDWATCH: WHAT YOU NEED TO KNOW

MedWatch is a program administered by the U.S. Food and Drug Administration (FDA) to allow healthcare professionals to report serious problems that they believe may be associated with medical products, including drugs and medical devices. Reports made through the MedWatch program provide a rapid signal to FDA that a problem might exist, and help the FDA identify and respond to safety concerns with certain products.

The FDA asks healthcare professionals, including nurses, to report any serious adverse event that might be associated with a drug, biologic agent, medical device, dietary supplement, or cosmetic product. The FDA is particularly interested in serious adverse events that are not listed in the product labeling. "Serious" means fatalities, hospitalizations, and medically significant events.

Healthcare professionals are also urged to report therapeutic failures, such as cases in which the drug or device failed to work as it should. Healthcare professionals should also report use errors associated with drugs or devices. Use errors might be the result of poor communication or ambiguities in product names, directions for use, or packaging.

Finally, the FDA would like to know about product quality issues, such as suspected counterfeit products, defective components, potential contamination, device malfunctions, and poor packaging.

Any of these issues should be reported to MedWatch even if you are not sure that the product was the cause. Reporting is easy-just go to https://www.accessdata.fda.gov/scripts/medwatch/medwatch-online.htm. For more information, go to http://www.fda.gov/medwatch.

WHEN TO CLAMP THE CORD?

The timing of the umbilical cord clamping after birth has been debated for decades. It used to be common to delay clamping the cord for as long as 5 minutes after delivery, but this interval has steadily shortened, so that cords are typically clamped within 15 to 20 seconds of birth.¹ In the meantime, much research has attempted to determine whether early or later cord clamping has any benefits or alternatively, adverse effects, on either preterm or full-term newborns.²

Recently, the American College of Obstetricians and Gynecologists Committee on Obstetric Practice issued a statement, "Timing of Umbilical Cord Clamping After Birth." In this statement, the committee summarizes the evidence related to early versus delayed cord clamping in term and preterm neonates, concluding that in term infants, the evidence is insufficient to support or to refute the benefits from delayed umbilical cord clamping.

However, the evidence to date supports a different stance for preterm infants. In preterm infants, delaying umbilical cord clamping to 30 to 60 seconds after birth while the infant is held at a level below the placenta is associated with neonatal benefits, including improved transitional circulation, better establishment of red blood cell volume, and reduced need for blood transfusion. The single most important clinical benefit for preterm infants is the possibility for a nearly 50% reduction in intraventricular hemorrhage. The committee also emphasizes that the timing of umbilical cord clamping should not be altered for the purpose of collecting umbilical cord blood for banking.

References

1. Committee on Obstetric Practice. Committee Opinion No. 543: Timing of umbilical cord clamping after birth. Obstet Gynecol. 2012;120:1522-1526.

2. Rabe H, Diaz-Rossello JL, Duley L, Dowswell T. Effect of timing of umbilical cord clamping and other strategies to influence placental transfusion at preterm birth on maternal and infant outcomes. Cochrane Database Syst Rev. 2012;8:CD003248.