Recent discussions
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Виктория Антонова
Thank you for going through this investigative process. As an RN of 37 years and a NRP instructor for 25 years I agree. I am employed in a large University Medical Center and not using tracheal visualization/suctioning of non-vigorous infants (MAS babies) has not changed outcomes. If a MAS infant was placed on ECHMO there were also other factors contributing to this procedure. -
Виктория Антонова
Thank you to all the colleagues who have already commented and to those who intend to do so. The the ILCOR Neonatal task force will look at all comments made. We intend to derive themes from comments and subsequently review and revise as appropriate based on the themes raised and the evidence quoted. However, the whole purpose of the ILCOR/GRADE process has always been to assess the available evidence. We are not able to make changes based upon anecdote, although recommendations and guidelines do not preclude experts making treatment decisions appropriate to individual cases as long as they can be justified. Again thank you all for this great feedback and engagement. Jonathan Wyllie Vice Chair Neonatal Task Force -
Виктория Антонова
Agree with the author's treatment recommendations -
Виктория Антонова
I agree with not performing "routine suctioning" . But, in depressed babies with pea-soup like meconium covered baby, one may be consider to intubate and suction once at least. If HR is low, then, continue with PPV via the ET tube. One will need a large RCT to prove or disprove the benefit vs. potential risk of intubation and suctioning. I do not buy the argument that lack of experienced people to intubate is a reason for not intubating. As NRP instructors, We should teach and help maintain competency with intubation. Intubation and establishing an airway is one of the most critical procedures any care provider attending a high risk delivery should be able to perform. One may use video assisted intubation to hep with successful intubation. This will still need oropharyngeal suctioning to visualize vocal cords. -
Виктория Антонова
In modern medicine the lowest common denominator is that deliveries are not always occurring at delivery centers with highly experienced individuals capable of rapid and accurate intubation. Training for intubations has decreased and many more infants are managed without invasive ventilation. For those that work at training hospitals, many have noticed the confidence, skill level, exposure and experience for trainees has decreased and diluted. Pediatric residents who will become pediatricians and neonatologist do less NICU service time and have less opportunities for procedures with the increase in trainees. NNPs students are nurses that have less time with NICU and delivery room exposure prior to training with some programs accepting individuals with as little as 1 year of bedside nursing. PA programs are increasing and many having very little to no neonatal experience prior to starting a PA Neonatal residency. All of this has lead to a decrease in the necessary skills to rapidly assess and perform the critical procedure of intubation because of the increasing pool of trainees and the combined diluted experience they have prior to starting. They then have a relatively short period of time to acquire that skill to the proficiency that some people have been doing for 10-20 years. There was a time when an individual could perform 5 intubations in a day, now they may struggle to perform 5 intubations a month. We need to look at this globally and remove ourselves from the scope of our primary institutions or from our experience level and ability to intubate. We must consider the 6 Bed Special Care Nursery covered by a moonlighting pediatrician with no respiratory therapist or NNP to assist overnight just as much as 60 bed Level III delivery unit with 2 neonatologist on at night with a handful of experience NNPs. Globally the skill level has been diluted by shifts in how we train and practice medicine and its difficult to address; its a good thing when an infant doesn't need the unnecessary procedure of intubation but a bad thing when a provider can't successfully perform the act rapidly on a single attempt. There is no NRP requirement for a provider to be "highly skilled" so we can't make the assumption that all providers are "highly skilled". The best we are left for is providing a generalized recommendation based off the imperfect data that exist. The only way the get the true answer to what is best is a RCT with enough power to answer all of our outcome questions AND looking at the providers' skill level, duration to intubation, number of attempts, etc; unfortunately that is unlikely to happen due to multiple factors. -
Виктория Антонова
I fully agree with the CoSTAR and a prima facie position of primum non nocere, until there is evidence that an invasive intervention is actually beneficial. One minor point; "cognitive" is preferred to "mental" development. -
Виктория Антонова
After 33 yearas of neonatal doctor the recommendation for "no tracheal suctioning" was not a good. for me at least one suction pass was best and then intubation if necessary . But as Susan posted above NO suctioning IS vertiam a bad idea for non-vigorous infants with thick meconium. I suggest That The recommendation should be for one tracheal suction pass, and then intubation if needed. Os clean that Will be Several passes delaying intubation and possibly not clear the airway that much better,. AGAIN no suctioning is not a good practice. -
Виктория Антонова
I agree as an RN and NPR instructor in a smaller hospital where intubation is not always immediately available. -
Виктория Антонова
I am disappointed that this protocol will remain unchanged. Although I do not have a study to back up my thoughts, I have been a NICU Nurse for 36 years, and a NRP Instructor for 30 of those years. I have seen many babies saved the prolonged and difficult healing process from MAS because they received direct visualization and suctioning, after being born through particulate meconium and are non-vigorous with HR <100 (or absent). When particulate meconium, which is in the airway, is blown into the chest with PP ventilation, healing is much more difficult. We have an experienced incubator at every MSAF delivery. We never intunate/suction vigorous infants. I continue to advocate for direct visulization/ suction of the sickest MSAF infants. -
Виктория Антонова
Thank you for submitting an early recommendation for this important issue! I agree with the new /revised statement. As a pediatrician working at the bedside and present for deliveries, I agree there is a real potential for delay in vital PPV with multiple ETT intubation and suctioning attempts. I’ve worked under both systems and believe infants get more prompt airway / breathing assistance with the more direct path of offering PPV immediately.