Pediatric Bag Research Articles

Assessment of Ventilation Using Adult and Pediatric Manual Resuscitators in a Simulated Adult Patient.

The bag-valve-mask (BVM) or manual resuscitator bag is used as a first-line technique to ventilate patients with respiratory failure. Volume-restricted manual resuscitator bags (eg, pediatric bags) have been suggested to minimize overventilation and associated complications. There are studies that both support and caution against the use of a pediatric resuscitator bag to ventilate an adult patient. In this study, we evaluated the ability of pre-hospital clinicians to adequately ventilate an adult manikin with both an adult- and pediatric-size manual resuscitator bag without the assistance of an advanced airway or airway adjunct device. This study was conducted at an international conference in 2022. Conference attendees with pre-hospital health care experience were recruited to ventilate an adult manikin using a BVM for 1 min with both an adult and pediatric resuscitator bag, without the use of adjunct airway devices, while 6 ventilatory variables were collected or calculated: tidal volume (VT), breathing frequency, adequate breaths (VT > 150 mL), proportion of adequate breaths, peak inspiratory pressure (PIP), and estimated alveolar ventilation (EAV). A total of 208 participants completed the study. Ventilation with the adult-sized BVM delivered an average VT of 290.4 mL compared to 197.1 mL (P < .001) when using the pediatric BVM. PIP with the adult BVM was higher than with the pediatric BVM (10.6 cm H2O vs 8.6 cm H2O, P < .001). The median EAV with the adult bag (1,138.1 [interquartile range [IQR] 194.0-2,869.9] mL/min) was markedly greater than with the pediatric BVM (67.7 [IQR 0-467.3] mL/min, P < .001). Both pediatric- and adult-sized BVM provided lower ventilation volumes than those recommended by professional guidelines for an adult. Ventilation with the pediatric BVM was significantly worse than with the adult bag when ventilating a simulated adult subject.

"Do it cheaper": A cost-effective Endobag for small specimens.

A simple technique that permits to reduce the cost during gynecologic laparoscopic surgery. Small specimens may be retrieved with the use of a modified urine pediatric bag.

Effectiveness of a Real-Time Ventilation Feedback Device for Guiding Adequate Minute Ventilation: A Manikin Simulation Study.

Background and objectives: It is often challenging even for skilled rescuers to provide adequate positive pressure ventilation consistently. This study aimed to investigate the effectiveness of a newly developed real-time ventilation feedback device (RTVFD) that estimates tidal volume (TV) and ventilation interval (VI) in real time. Materials and methods: We conducted a randomised, crossover, manikin simulation study. A total of 26 medical providers were randomly assigned to the RTVFD-assisted ventilation (RAV) first group (n = 13) and the non-assisted ventilation (NV) first group (n = 13). Participants provided ventilation using adult and paediatric bag valves (BVs) for 2 min each. After a washout period, the simulation was repeated by exchanging the participants’ groups. Results: The primary outcome was optimal TV in the RAV and NV groups using adult and paediatric BVs. A secondary outcome was optimal VI in the RAV and NV groups using adult and paediatric BVs. The proportions of optimal TV values were higher for the RAVs when using both adult and paediatric BVs (adult BV: 47.29% vs. 18.46%, p < 0.001; paediatric BV: 89.51% vs. 72.66%, p < 0.001) than for the NVs. The proportions of optimal VI were significantly higher in RAVs when using both adult and paediatric BVs than that in NVs (adult BV: 95.64% vs. 50.20%, p < 0.001; paediatric BV: 95.83% vs. 57.14%, p < 0.001). Additionally, we found that with paediatric BVs, the simulation had a higher OR for both optimal TV (13.26; 95% CI, 9.96–17.65; p < 0.001) and VI (1.32; 1.08–1.62, p = 0.007), regardless of RTVFD use. Conclusion: Real-time feedback using RTVFD significantly improves the TV and VI in both adult and paediatric BVs in a manikin simulation study.

It's In The Bag: Tidal Volumes in Adult and Pediatric Bag Valve Masks.

IntroductionA bag valve mask (BVM) is a life saving device used by all levels of health care professionals during resuscitative care. We focus most of our time optimizing the patient’s position, firmly securing the mask, and frequency of ventilations. However, despite our best efforts to control these factors, we may still be precipitating harm to the patient. Multiple studies have shown the tidal volumes typically delivered by the adult BVM are often higher than recommended for lung-protective ventilation protocols. In this study we measure and compare the ventilation parameters delivered by the adult and pediatric BVM ventilators.MethodsA RespiTrainer Advance® adult mannequin was used to simulate a patient. Healthcare providers were directed to manually ventilate an intubated mannequin for two minutes using adult and pediatric sized BVMs. Tidal volume, minute ventilation, peak pressure, and respiration rate was recorded.ResultsThe adult BVM provided a mean tidal volume of 807.7mL versus the pediatric BVM providing 630.7mL, both of which exceeded the upper threshold of 560mL of tidal volume necessary for lung protective ventilation of an adult male with an ideal body weight of 70kg. The adult BVM exceeded this threshold by 44.2% versus the pediatric BVM’s 12.6% with 93% of participants exceeding the maximum threshold with the adult BVM and 82.3% exceeding it with the pediatric BVM.ConclusionThe pediatric BVM in our study provided far more consistent and appropriate ventilation parameters for adult patients compared to an adult BVM, but still exceeded the upper limits of lung protective ventilation parameters. The results of this study highlight the potential dangers in using an adult BVM due to increased risk of pulmonary barotrauma. These higher tidal volumes can contribute to lung injury. This study confirms that smaller BVMs may provide safer ventilatory parameters. Future studies should focus on patient-centered outcomes with BVM.

Defining Competency in Neonatal and Pediatric Bag Mask Ventilation

Defining Competency in Neonatal and Pediatric Bag Mask Ventilation

Defining Competency in Neonatal and Pediatric Bag Mask Ventilation

Bag-mask ventilation (BMV) is a lifesaving skill required of neonatal and pediatric practitioners, including all those who hold NRP and PALS certification. As neonatal and pediatric practice evolves and further specializes, trainee exposure and opportunity to perform BMV has changed. There exists no standardized definition or measurement of competency in this procedure. Currently, performance in BMV is most often described by global assessment by an expert provider from which competency to perform BMV is inferred. As assessment …

Metabolomics evaluation of early-storage red blood cell rejuvenation at 4°C and 37°C.

Refrigerated red blood cell (RBC) storage results in the progressive accumulation of biochemical and morphological alterations collectively referred to as the storage lesion. Storage-induced metabolic alterations can be in part reversed by rejuvenation practices. However, rejuvenation requires an incubation step of RBCs for 1 hour at 37°C, limiting the practicality of providing "on-demand," rejuvenated RBCs. We tested the hypothesis that the addition of rejuvenation solution early in storage as an adjunct additive solution would prevent-in a time window consistent with the average age of units transfused to sickle cell recipients at Duke (15 days)-many of the adverse biochemical changes that can be reversed via standard rejuvenation, while obviating the incubation step. Metabolomics analyses were performed on cells and supernatants from AS-1 RBC units (n = 4), stored for 15 days. Units were split into pediatric bag aliquots and stored at 4°C. These were untreated controls, washed with or without rejuvenation, performed under either standard (37°C) or cold (4°C) conditions. All three treatments removed most metabolic storage by-products from RBC supernatants. However, only standard and cold rejuvenation provided significant metabolic benefits as judged by the reactivation of glycolysis and regeneration of adenosine triphosphate and 2,3-diphosphoglycerate. Improvements in energy metabolism also translated into increased capacity to restore the total glutathione pool and regenerate oxidized vitamin C in its reduced (ascorbate) form. Cold and standard rejuvenation of 15-day-old RBCs primes energy and redox metabolism of stored RBCs, while providing a logistic advantage for routine blood bank processing workflows.

In vitro quality of apheresis platelets divided into paediatric-sized units and stored in PVC bags plasticised with TOTM, BTHC or DINCH.

Two of the predictive factors of the quality of small volumes of platelets suitable for paediatric use are bag size and material. This study evaluated the storage properties of paediatric platelet aliquots in TOTM-, BTHC- or DINCH-PVC bags. (i) Three apheresis platelet concentrates (PC) were pooled and split into three units. One was retained as an adult unit (control; polyolefin bag). The second and third units were split into four MacoPharma TOTM-PVC and BTHC-PVC paediatric bags, respectively. (ii) Two apheresis PC were pooled and split into two units. One PC was retained as an adult unit, and the other was split into four Fresenius DINCH-PVC paediatric bags. Testing was performed on storage for pH, blood gases, hypotonic shock response, soluble CD62P, LDH, glucose and lactate, ATP, CD62P, CD63, platelet-derived microparticles and annexin V. The volumes, platelet yields and pH of all paediatric units met local specifications. The TOTM-PVC bag showed no worse quality than the adult bag up to day 7 for all parameters studied, and it maintained pH higher than BTHC-PVC and DINCH-PVC over storage. The BTHC-PVC bag was shown to be the most gas permeable; however, it had the highest glucose consumption rates and the highest platelet activation. All bags showed an acceptable in vitro quality. Overall, the TOTM-PVC paediatric bag showed better platelet quality compared to the other storage bags, whereas storage in the BTHC-PVC bag resulted in poorer platelet quality.

Can EMS Providers Provide Appropriate Tidal Volumes in a Simulated Adult-sized Patient with a Pediatric-sized Bag-Valve-Mask?

Introduction: In the prehospital setting, Emergency Medical Services (EMS) professionals rely on providing positive pressure ventilation with a bag-valve-mask (BVM). Multiple emergency medicine and critical care studies have shown that lung-protective ventilation protocols reduce morbidity and mortality. Our primary objective was to determine if a group of EMS professionals could provide ventilations with a smaller BVM that would be sufficient to ventilate patients. Secondary objectives included 1) if the pediatric bag provided volumes similar to lung-protective ventilation in the hospital setting and 2) compare volumes provided to the patient depending on the type of airway (mask, King tube, and intubation). Methods: Using a patient simulator of a head and thorax that was able to record respiratory rate, tidal volume, peak pressure, and minute volume via a laptop computer, participants were asked to ventilate the simulator during six 1-minute ventilation tests. The first scenario was BVM ventilation with an oropharyngeal airway in place ventilating with both an adult- and pediatric-sized BVM, the second scenario had a supraglottic airway and both bags, and the third scenario had an endotracheal tube and both bags. Participants were enrolled in convenience manner while they were on-duty and the research staff was able to travel to their stations. Prior to enrolling, participants were not given any additional training on ventilation skills. Results: We enrolled 50 providers from a large, busy, urban fire-based EMS agency with 14.96 (SD = 9.92) mean years of experience. Only 1.5% of all breaths delivered with the pediatric BVM during the ventilation scenarios were below the recommended tidal volume. A greater percentage of breaths delivered in the recommended range occurred when the pediatric BVM was used (17.5% vs 5.1%, p < 0.001). Median volumes for each scenario were 570.5mL, 664.0mL, 663.0mL for the pediatric BMV and 796.0mL, 994.5mL, 981.5mL for the adult BVM. In all three categories of airway devices, the pediatric BVM provided lower median tidal volumes (p < 0.001). Conclusion: The study suggests that ventilating an adult patient is possible with a smaller, pediatric-sized BVM. The tidal volumes recorded with the pediatric BVM were more consistent with lung-protective ventilation volumes.

An investigation of red blood cell concentrate quality during storage in paediatric-sized polyvinylchloride bags plasticized with alternatives to di-2-ethylhexyl phthalate (DEHP).

Di-2-ethylhexyl phthalate (DEHP) is a blood bag plasticizer. It is also a toxin, raising concerns for vulnerable populations, for example, neonates and infants. Here, the in vitro quality of red cell concentrates (RCC) stored in paediatric bags formulated with alternative plasticizers to DEHP was compared. RCC were pooled and split into polyvinylchloride (PVC)/DEHP, PVC/1,2-cyclohexanedicarboxylic acid diisononyl ester (DINCH) or PVC/butyryl trihexyl citrate (BTHC) bags. Quality was assessed on storage days 5, 21, 35 and 43. Metabolism differed among the bags: pCO2 levels were lowest and pO2 were highest in BTHC bags. Glucose consumption and lactate production suggested higher metabolic rates in BTHC bags. ATP levels were best maintained in DINCH bags (day 43 mean level: 2·86 ± 0·29 μmol/g Hb). RCC in BTHC bags had the greatest potassium release (54·6 ± 3·0 mm on day 43). From day 21, haemolysis was higher in BTHC bags (P < 0·01) and by day 43 had exceeded 0·8% (0·85 ± 0·10%). RCC in BTHC bags showed more microparticle formation than RCC in DEHP or DINCH bags. The results suggest that the BTHC formulation used was detrimental to RBC quality. DINCH bags could be a viable alternative to DEHP: they outperformed DEHP bags energetically, with better maintenance of ATP levels.

Blood Bag Plasticizers Influence Red Blood Cell Vesiculation Rate without Altering the Lipid Composition of the Vesicles

Background: Polyvinyl chloride (PVC) plasticized with di(2-ethylhexyl) phthalate (DEHP) is commonly used for blood collection and storage. DEHP has protective effects on RBC membranes, but is also a toxin. Methods: A paired study was conducted to investigate the influence of DEHP and two alternative plasticizers, 1,2-cyclohexane-dicarboxylic acid diisononyl ester (DINCH) and n-butyryl-tri-n-hexyl citrate (BTHC), on the preservation of RBCs stored for 42 days in PVC pediatric bags. The RBC membrane was evaluated for supernatant hemoglobin (Hb), release of extracellular microvesicles (EVs), osmotic fragility, deformability, and lipid composition. Results: In BTHC-plasticized bags, the supernatant Hb increase during storage was 2 times greater than in DINCH- and DEHP-plasticized bags. By day 21, EV concentrations had doubled from day-5 levels in DINCH- and DEHP-, and trebled in BTHC-plasticized bags. RBC mean cell volumes were greater in BTHC- than in DINCH- or DEHP-plasticized bags (p < 0.001). Osmotic fragility differed significantly among plasticizers (p < 0.01). After day 21, RBC deformability decreased in all, but to a greater extent in the bags with BTHC. Phospholipid composition of RBCs and EVs was not different among plasticizers. Conclusion: Membrane stabilization capacity differed among the plasticizers. RBC in BTHC bags stored more poorly, while DEHP and DINCH bags offered better protection against vesiculation, osmotic stress, and Hb loss.

Effect of Manual Hyperinflation on Arterial Oxygenation in Paediatric Patients with Upper Lobe Collapse after Cardiac Surgery

Lung hyperinflation is a technique used by physiotherapists to mobilize and remove excess bronchial secretions, reinflate areas of pulmonary collapse and improve oxygenation. To assess the efficacy of manual hyperinflation in improving arterial oxygenation (PaO2) of paediatric patients with upper lobe lung collapse after cardiac surgery. 18 paediatric patients who had undergone heart surgery and having upper lobe collapse in the post-op ventilation period underwent Manual Hyperinflation (MH). Parameters in cluded arterial oxygen tension (PaO2) value in ABG analysis, clinical findings such as collapsed upper lung lobe in chest radiograph and air entry in auscultation were collected before and 30 min post MH session and documented. The patients were treated with manual hyperinflation delivered using a pediatric AMBU bag with pressure of about 40 cm H 2O. Four sets of eight bag compressions with inflation rate of 10 breaths per minute were delivered during each manual hyperinflation. The result showed that there was a significant improvement in arterial oxygenation (PaO 2) by administering manual hyperinflation therapy for the upper lobe col lapse in post-op ventilated paediatric patients. In this study, it is evident that manual hyperinflation is an effective technique in management of Lung collapse (upper lobe) in post-op pediatric patients. This clearly demonstrates that further research in this area is warranted.

A new utilization area for hyperbaric oxygen? Improving quality of stored blood.

Since blood bags have the ability for diffusion of gases, we investigated whether hyperbaric oxygen (HBO) exposure affects several vital parameters of stored blood. Bloods obtained from the same persons were used as both control and HBO groups and stored in pediatric bags with citrate-phosphate-dextrose solution. HBO administration was performed at 2.5 atm for 90 min, started 1 day after blood collection and repeated every 2 days for a total of 10 times. The study was terminated on the 21st day. Complete blood count, glucose, pH, and osmotic fragility values were measured every week. Glucose and pH levels decreased in stored blood. In the HBO-exposed group, these decreases were less than in the control. In addition, mean corpuscular and platelet volumes tended to increase during storing process, but with HBO, these indexes remained lower, near physiologic levels. Another interesting finding of the study was the relative stable osmotic fragility ratio in the HBO group compared to the control blood. HBO exposure has positive effects on pH, stability of erythrocytes, and energy source (glucose) of the medium. Thus, we concluded that HBO may be a useful application for life and quality of stored blood.

Red Blood Cell Storage In Pediatric Transfer Bags Is Correlated With Increased Levels Of Hemolysis and Altered Osmotic Fragility

Red blood cells (RBCs) intended for pediatric transfusion are currently obtained from banked RBC units, from which selected volumes of RBC aliquots are transferred from to smaller pediatric bags. Certain conditions, such as repeated transfusions, limited inventory, and hospitals' distance from blood banks, may require storage at 1-6 °C of pediatric bags for up to six weeks. In this study, we compared the recovery of RBCs stored in pediatric bags from a selected manufacturer (Pedi-Pak, Genesis BPS) to that of their parent unit. We demonstrated that temporary storage in pediatric bags can modify RBC quality, particularly in regard to end of storage hemolysis, and stress-induced oxidative hemolysis.Packed leukoreduced RBCs from 10 healthy donors were stored under routine blood banking procedures (4 °C) for six weeks. At day 1, 20 mL of packed RBCs from each parent unit were transferred to a pediatric bag by sterile docking. RBC hemolytic propensity in each bag type was evaluated at selected time points (3, 7, 14, 21, 28, 35 and 42 days). Storage hemolysis was measured by supernatant cell-free hemoglobin using Drabkin's assay. Osmotic stress was induced by incubating RBCs in hypotonic buffer containing glycerol. Oxidative hemolysis was induced by incubating RBCs with 2,2′-azobis (2-methylpropionamidine) dihydrochloride (AAPH). Mechanical stress was achieved by shaking RBC suspensions in the presence of one metal bead (3/32”) for 180 minutes on a plate shaker. Complete blood counts were obtained by a commercial blood counter (Hemavet). Statistical analysis was performed by repeated measures two-way ANOVA using a commercial software (GraphPad Prism 6).Percent storage hemolysis was higher at all tested time points in the pediatric bags compared to their parent units. Significant differences were recorded on day 21 (0.24±0.09 % in Pedi-Pak versus 0.18±0.11 % in parent units, n=10, p=0.0484) and over. At the end of storage, hemolysis levels in pediatric bags were twice than that of their parent units (0.52±0.25 % in Pedi-Pak versus 0.25±0.14 % in parent units, n=10, p<0.0001). Similarly, RBCs stored in pediatric bags were more susceptible to AAPH-induced oxidative hemolysis (37.7±7.7 % in Pedi-Pak versus 31.7±7.4 % in parent units, Day 42, n=10, p<0.0001). Conversely, RBCs stored in pediatric bags demonstrated enhanced resistance to osmotic fragility at testing days 7-42 (21.2±6.9 % in Pedi-Pak versus 25.5±8.8 % in parent units, Day 42, n=10, p=0.0069). No significant differences between the two bag types were found in regard to mechanical fragility or RBC indices obtained by complete blood counts.This study suggests that RBCs stored in pediatric bags from a selected manufacturer have altered in vitro recovery. It is not clear whether these changes affect transfusion outcomes, however, higher levels of free hemoglobin and increased susceptibility to oxidative stress may increase the risks of transfusion-related injuries, as free hemoglobin is redox active and capable of inducing hypertension via nitric oxide scavenging. The differences in hemolysis and osmotic fragility between the two RBC groups may stem from the type of plasticizers used in each bag (butyryl trihexyl citrate (BTHC) in Pedi-Pak versus bis(2-ethylhexyl) phthalate (DEHP) in parent units). Other factors may be related to differences in surface area to volume ratio of the different sized bags. Understanding the effects of the storage bag on RBC recovery can improve the quality and safety of RBC products used for pediatric transfusion. Disclosures:No relevant conflicts of interest to declare.

Neonatal and Pediatric Manual Hyperinflation: Influence of Oxygen Flow on Ventilation Parameters

Although self-inflating bags are widely used for manual hyperinflation, they do not allow ventilation parameters, such as pressure or volume, to be set. We studied the ventilation performance of neonatal and pediatric self-inflating bags. We asked 22 physiotherapists to manually hyperinflate 2 lung models (neonatal and pediatric), using self-inflating bags from 3 manufactures (Hudson, Laerdal, and JG Moriya), with flows of 0, 5, 10, and 15 L/min. A pneumotachograph recorded tidal volume (V(T)), peak inspiratory pressure (PIP), peak inspiratory flow (PIF), peak expiratory flow (PEF), and inspiratory time. The V(T), PIP, and inspiratory time delivered by the Hudson, Laerdal, and JG Moriya bags, in both neonatal and pediatric self-inflating bags, were significantly different (P < .001). The PEF and PIF delivered were different only when using the neonatal self-inflating bags (P < .001). The V(T), PIP, and PIF delivered with a flow of 0 L/min were lower than with 15 L/min (P < .05) with all the tested bags, in both the neonatal and pediatric sizes. The performance of the tested neonatal and pediatric bags varied by manufacturer and oxygen flow. There was an increase in VT, PIP, and PIF related to the increase of oxygen flow from 0 L/min to 15 L/min. The neonatal bags showed higher ventilation parameters variation than the pediatric bags.

Overall equipment effectiveness: a production work tool applied to a parenteral nutrition robot in a University Hospital

Background‘All in one’ parenteral nutrition bags are prepared in our University Hospital by a robot. Overall Equipment Effectiveness (OEE) is an indicator usually used in pharmaceutical industry to monitor and...

Root Causes of Errors in a Simulated Prehospital Pediatric Emergency

Systematic evaluation of prehospital provider performance during actual resuscitations is difficult. Although prior studies reported pediatric drug-dosing mistakes and other types of management errors, the underlying causes of those errors were not investigated. The objective of this study was to identify causes of errors during a simulated, prehospital pediatric emergency. Two-person emergency medical services (EMS) crews from five geographically diverse agencies participated in a validated simulation of an infant with altered mental status, seizures, and respiratory arrest using their own equipment and drugs. A scoring protocol was used to identify errors. A debriefing conducted by a trained facilitator immediately after the simulated event elicited root causes of active and latent errors, which were analyzed by thematic qualitative assessment methods. Forty-five crews completed the study. Clinically important themes that emerged from the data included oxygen delivery, equipment organization and use, glucose measurement, drug administration, and inappropriate cardiopulmonary resuscitation. Delay in delivery of supplemental oxygen resulted from two different automaticity errors and a 54% failure rate in using an oropharyngeal airway (OPA). Most crews struggled to locate essential pediatric equipment. Three found broken or inoperable bag/valve/masks (BVMs), resulting in delayed ventilation. Some mistrusted their intraosseous (IO) injection gun device; others used it incorrectly. Only 51% of crews measured blood glucose; some discovered that glucometers were not stored in their sealed pediatric bags. The error rate for diazepam dosing was 47%; for midazolam, it was 60%. Underlying causes of dosing errors were found in four domains (cognitive, procedural, affective, and teamwork), and they included incorrect estimates of weight, incorrect use of the Broselow pediatric emergency tape, faulty recollection of doses, difficulty with calculations under stress, mg/kg to mg to mL conversion errors, inaccurate measurement of volumes, use of the wrong end of prefilled syringes, and failure to crosscheck doses with partners. Simulation, followed immediately by facilitated debriefing, uncovered underlying causes of active cognitive, procedural, affective, and teamwork errors, latent errors, and error-producing conditions in EMS pediatric care.

Novel target volume marked adult bag to deliver accurate tidal volume for paediatric and adolescent resuscitation

Aim To overcome limitations of inaccurate tidal volume (TV) delivery by conventional selfinflating paediatric and adult bags during paediatric and adolescent resuscitation, we designed a novel target volume marked bag (TVMB) with four compression points marked on an adult bag surface. The aim of this study was to evaluate the TVMB in delivering preset TV. Methods Fifty-three subjects (28 doctors, 17 nurses, 8 paramedics) participated in this simulation trial. TVMB, paediatric bag and adult bag were connected to a gas flow analyser for measuring TV and peak inspiratory pressure (PIP). In a random cross-over setting, participants delivered 10 ventilations using the adult bag, paediatric bag or TVMB in each of four target volume ranges (100–200 ml, 200–300 ml, 300–400 ml, 400–500 ml). We compared TV and PIP for the adult bag, paediatric bag and TVMB in each subject. Results Compared with the paediatric bag, TVMB showed higher rates of accurate TV delivery in the 200–300 ml target volume range (87–90% versus 32–35%; p < 0.05). Compared with the adult bag, TVMB showed higher rates of accurate TV delivery in all target volume ranges (75–90% versus 45–50%; p < 0.05). The frequency of too high or low TV delivery was higher with the adult bag than TVMB (20–30% versus 0–5%; p < 0.05). There was no significant difference in PIP between the paediatric bag and TVMB (within 5 cm H 2O; p < 0.05). Conclusions TVMB could deliver accurate TV in various target volume ranges for paediatric and adolescent resuscitation.

A new method to evaluate nicotine exposure in infants

Exposure of infants to parental smoking has been associated with several adverse health effects [6]. It was the aim of this study to find an easily applicable method to collect urine samples from infants and to correlate cotinine concentrations with parental smoking habits. This study was approved by the local Ethics Committee. Filter paper strips (Schleicher and Schuell, Germany) were placed in the nappies of infants. After wetting, the paper strips were air-dried, cut into small pieces, and extracted with 0.01 M phosphate buffer solution for 24 h. From this eluate, cotinine was analysed by ELISA and correlated to creatinine concentration (expressed as ng cotinine/mg creatinine, CCR). The parents’ smoking habits were evaluated by a structured questionnaire. CCR was determined in 93 infants (38 females) with a median age of 63 days (range 25–221 days). Exclusion criteria were questionnaires with incomplete information and urine creatinine levels 30 ng/mg, a cut-off level based on a previous study [2]. We found a significant correlation ( P <0.01) between maternal smoking habits and cotinine concentrations of infants (Table 1). This new method was used to avoid the inconvenience and higher failure rate of paediatric collection bags, especially in female infants [4]. A good correlation between urine collected on filter paper and native urine samples had been shown previously [5]. The method is inexpensive and therefore well suited for large series. By use of this technique, we confirmed the findings of previous reports describing a good correlation between the CCR of infants and maternal smoking habits, but not paternal smoking habits [1]. This is the first study to demonstrate this simple-touse, inexpensive way of verifying nicotine exposure in infants. The results of using filter paper strips are comparable to those using standard methods. Moreover, the method is easier to handle than any other used previously.

Developing a Strategy to Improve Ventilation in an Unprotected Airway with a Modified Mouth-to-Bag Resuscitator in Apneic Patients

The strategies to ensure safety during ventilation of an unprotected airway are limiting airway pressure and/or inspiratory flow. In this prospective, randomized study we assessed the effect of face mask ventilation with small tidal volumes in the modified mouth-to-bag resuscitator (maximal volume, 500 mL) versus a pediatric self-inflatable bag versus automatic pressure-controlled ventilation in 40 adult apneic patients during induction of anesthesia. The mouth-to-bag resuscitator requires the rescuer to blow up a balloon inside the self-inflating bag that subsequently displaces air which then flows into the patient's airway. Respiratory variables were measured with a pulmonary monitor (CP-100). Mouth-to-bag resuscitator and pressure-controlled ventilation resulted in significantly lower (mean +/- sd) peak airway pressure (8 +/- 2 and 8 +/- 1 cm H(2)O), peak inspiratory flow rate (0.7 +/- 0.1 and 0.7 +/- 0.1 L/s), and larger inspiratory time fraction (33% +/- 5% and 47% +/- 2%) in comparison to pediatric self-inflating bag ventilation (12 +/- 3 cm H(2)O; 1 +/- 0.2 L/s; 27% +/- 4%; all P < 0.001). The tidal volumes were similar between groups. No stomach inflation occurred in either group. We conclude that using a modified mouth-to-bag resuscitator or automatic pressure-controlled ventilation with similar small tidal volumes during face mask ventilation resulted in an approximately 25% reduction in peak airway pressure when compared with a standard pediatric self-inflating bag.