RESUMEN
OBJECTIVE: Determine prevalence and associations with pulmonary hypertension (PH) in preterm infants. STUDY DESIGN: Prospective institutional echocardiographic PH screening at 36 to 38 weeks' corrected gestational age (GA) for infants born <32 weeks' GA who had bronchopulmonary dysplasia (BPD; group BPD), and infants without BPD who had a birth weight (BW) <750 g, or clinical suspicion for PH (group NoBPD). RESULTS: Two hundred and four infants were screened (GA 25.9±2 weeks, BW 831±286 g). The PH prevalence in group BPD was higher than in group NoBPD (44/159 (28%) vs 5/45 (11%); P=0.028). In group BPD, BW and GA were lower in infants with PH compared with NoPH. Following correction for BW and GA, necrotizing enterocolitis (NEC), severe intraventricular hemorrhage (IVH), atrial septal defect (ASD), and mortality were independently associated with PH in infants with BPD. In group NoBPD, NEC was the only identified factor associated with PH. Altogether, screening only those infants with NEC and infants with BPD who also had a BW <840 g would have yielded a 84% sensitivity for detecting PH, and reduced the number of screening echocardiograms by 43%. CONCLUSIONS: PH in prematurity is associated with NEC in infants with and without BPD. In infants with BPD, smaller GA and BW, severe IVH, ASD and mortality are also associated with PH. Infants without identified PH-associated factors may not require routine echocardiographic PH screening.
Asunto(s)
Displasia Broncopulmonar/complicaciones , Enterocolitis Necrotizante/complicaciones , Hipertensión Pulmonar/diagnóstico por imagen , Recien Nacido Extremadamente Prematuro , Tamizaje Neonatal , Peso al Nacer , Connecticut/epidemiología , Ecocardiografía , Femenino , Edad Gestacional , Humanos , Lactante , Mortalidad Infantil , Recién Nacido de Bajo Peso , Recién Nacido , Modelos Logísticos , Masculino , Estudios ProspectivosRESUMEN
The REDUCE MRSA Trial (Randomized Evaluation of Decolonization vs Universal Clearance to Eliminate Methicillin-Resistant Staphylococcus aureus), a large multicenter, randomized controlled trial in adult intensive care units (ICUs), found universal decolonization to be more effective than surveillance and isolation procedures with or without targeted decolonization for reducing rates of MRSA-positive clinical cultures. The Agency for Healthcare Research and Quality and the Centers for Disease Control and Prevention subsequently published protocols for implementing universal decolonization in ICUs based on the trial's methods. Caution should be exercised before widely adopting these procedures in neonatal intensive care units (NICUs), particularly strategies that involve bathing with chlorhexidine and mupirocin application due to the potential for adverse events in their unique patient population, especially preterm infants. Large multicenter trials in the NICUs are needed to evaluate the efficacy, short- and long-term safety, and cost effectiveness of these strategies prior to their widespread implementation.
Asunto(s)
Unidades de Cuidado Intensivo Neonatal , Unidades de Cuidados Intensivos , Staphylococcus aureus Resistente a Meticilina/efectos de los fármacos , Staphylococcus aureus Resistente a Meticilina/crecimiento & desarrollo , Infecciones Estafilocócicas/microbiología , Infecciones Estafilocócicas/prevención & control , Adulto , Clorhexidina/efectos adversos , Humanos , Recién Nacido , Enfermedades del Prematuro , Mupirocina/efectos adversosRESUMEN
OBJECTIVE: To reduce exposure to hyperoxia and its associated morbidities in preterm neonates. STUDY DESIGN: A multidisciplinary group was established to evaluate oxygen exposure in our neonatal intensive care unit. Infants were assigned target saturation ranges and signal extraction technology implemented to temporally quantify achievement of these ranges. The outcomes bronchopulmonary dysplasia/death, retinopathy of prematurity (ROP)/death, severe ROP and ROP requiring surgery were compared in a pre- versus post-intervention evaluation using multivariate analyses. RESULT: A total of 304 very low birth weight pre-initiative infants were compared with 396 post-initiative infants. Multivariate analyses revealed decreased odds of severe ROP (adjusted odds ratio (OR): 0.41; 95% confidence interval (CI): 0.24-0.72) and ROP requiring surgery (adjusted OR 0.31; 95% CI: 0.17-0.59) post-initiative. No differences in death were observed. CONCLUSION: Significant reductions in severe ROP and ROP requiring surgery were observed after staff education and implementation of new technology to quantify success in achieving targeted saturations and reinforce principles and practices.
Asunto(s)
Hiperoxia/terapia , Oxígeno/sangre , Displasia Broncopulmonar/prevención & control , Femenino , Humanos , Hiperoxia/sangre , Hiperoxia/complicaciones , Recién Nacido , Recien Nacido Prematuro , Recién Nacido de muy Bajo Peso , Unidades de Cuidado Intensivo Neonatal , Masculino , Oximetría , Retinopatía de la Prematuridad/prevención & controlRESUMEN
The epidemiology, etiology and outcome of neonatal sepsis are changing over time. While monitoring longitudinal trends in neonatal sepsis in our institution, we encountered a case of late-onset neonatal sepsis due to Leclercia adecarboxylata. A Gram-negative rod previously not encountered in the clinical setting, L. adecarboxylata has recently emerged as a human pathogen, primarily in immunosuppressed patients. This report describes the clinical and laboratory features of this case of late-onset L. adecarboxylata sepsis, and reviews significant features of infection associated with this emerging pathogen.
Asunto(s)
Infecciones por Enterobacteriaceae/diagnóstico , Enterobacteriaceae , Insuficiencia Multiorgánica/etiología , Síndrome de Dificultad Respiratoria del Recién Nacido/terapia , Choque Séptico/diagnóstico , Rotura Gástrica/complicaciones , Infecciones por Enterobacteriaceae/terapia , Resultado Fatal , Femenino , Humanos , Recién Nacido , Recien Nacido Prematuro , Insuficiencia Multiorgánica/diagnóstico , Insuficiencia Multiorgánica/terapia , Síndrome de Dificultad Respiratoria del Recién Nacido/complicaciones , Choque Séptico/terapia , Rotura Gástrica/diagnóstico , Rotura Gástrica/terapiaRESUMEN
OBJECTIVE: The objective of this study is to compare complication rates between peripherally inserted central catheters (PICCs) and peripherally inserted non-central catheters (PINCCs) in the neonatal intensive care unit (NICU). STUDY DESIGN: A retrospective, observational study was conducted. The PICCs were catheters whose tip terminated in the vena cavae, and PINCCs were defined as those whose tip fell short of this location. Complication rates were assessed using generalized estimating equations modeling. RESULT: A total of 91 PINCCs and 889 PICCs were placed in 750 neonates. In all, 44.0% of PINCCs had a major complication compared with 25.2% of PICCs (P=0.0001). The unadjusted (unadj.) complication rate among PINCCs was 51.7 per 1000 line days and 15.9 for PICCs (unadj. rate ratio: 3.25; 95% confidence interval (CI): 2.32, 4.55). After adjusting for multiple confounders, the risk remained significantly higher for PINCCs (adjusted odds ratio: 2.41; 95% CI: 1.33, 4.37). CONCLUSION: The rate of associated complications with the use of PINCCs in the NICU population is more than twice that of the PICCs.
Asunto(s)
Cateterismo Venoso Central/efectos adversos , Cateterismo Periférico/efectos adversos , Unidades de Cuidado Intensivo Neonatal , Centros Médicos Académicos , Cateterismo Venoso Central/métodos , Cateterismo Venoso Central/estadística & datos numéricos , Cateterismo Periférico/métodos , Cateterismo Periférico/estadística & datos numéricos , Estudios de Cohortes , Intervalos de Confianza , Connecticut , Cuidados Críticos/métodos , Falla de Equipo , Seguridad de Equipos , Femenino , Hospitales Pediátricos , Humanos , Incidencia , Recién Nacido , Masculino , Oportunidad Relativa , Control de Calidad , Estudios Retrospectivos , Medición de RiesgoRESUMEN
OBJECTIVE: Owing to resident work-hour reductions and more permanent personnel in the newborn intensive care unit (NICU), we sought to determine if pediatric housestaff are missing learning opportunities in procedural training due to non-participation. STUDY DESIGN: A prospective, observational study was conducted at an academic NICU using self-reported data from neonatal personnel after attempting 188 procedures on 109 neonates, and analyzed using Fisher's exact and χ (2)-tests. RESULT: Housestaff first attempted 32% of procedures (P<0.001) and were less likely to make attempts early in the academic year (P<0.001). There was no significant difference in attempts based on urgency of situation (P=0.742). Of procedures performed by non-housestaff personnel, 93% were completed while housestaff were present elsewhere in the unit. CONCLUSION: Pediatric housestaff performed the minority of procedures in the NICU, even in non-urgent situations, and were often uninvolved in other procedures, representing missed learning opportunities.
Asunto(s)
Unidades de Cuidado Intensivo Neonatal , Internado y Residencia , Pediatría/educación , Femenino , Humanos , Masculino , Estudios ProspectivosRESUMEN
Selective resuscitation refers to the practice of providing resuscitative efforts to one or some (but not all) infants born in the setting of multiple gestation. When one fetus is known to have a severe anomaly or severe growth restriction, parents are sometimes offered this option. In the setting of extreme prematurity, in the absence of an anomaly or severe growth restriction, parents are generally expected to make one unified decision for all the infants involved. The introduction of the Outcome Estimator, a tool that provides the ability to make individual outcome predictions for each fetus in a multiple gestation at borderline gestational age, based on contributing variables such as weight and gender, has led to the ethical dilemma of whether parents in this setting should also be offered the option of selective resuscitation. No convincing ethical argument for denying the parents the right to decide for each individual infant is apparent.
Asunto(s)
Sistemas de Apoyo a Decisiones Clínicas/ética , Enfermedades del Prematuro/terapia , Padres , Órdenes de Resucitación/ética , Gemelos , Privación de Tratamiento/ética , Femenino , Humanos , Recién Nacido , Recien Nacido Prematuro , Masculino , Embarazo , Segundo Trimestre del EmbarazoRESUMEN
OBJECTIVE: To explore how neonates with respiratory failure are selected for extracorporeal membrane oxygenation (ECMO) once severity of illness criteria are met, and to determine how conflicts between ECMO providers and parents over the initiation of ECMO are addressed. STUDY DESIGN: A cross-sectional study was conducted using a data collection survey, which was sent to the directors of neonatal respiratory ECMO centers. RESULT: The lowest birth weight and gestational age at which respondents would consider placing a neonate on ECMO were frequently below recommended thresholds. There was wide variability in respondents' willingness to place neonates on ECMO in the presence of conditions such as intraventricular hemorrhage and hypoxic ischemic encephalopathy. The number of respondents who would never seek to override parental refusal of ECMO was equal to the number who would always do so. CONCLUSION: Significant variability exists in the selection criteria for neonatal ECMO and in how conflicts with parents over the provision of ECMO are resolved.
Asunto(s)
Oxigenación por Membrana Extracorpórea/normas , Selección de Paciente , Insuficiencia Respiratoria/terapia , Peso al Nacer , Recolección de Datos , Oxigenación por Membrana Extracorpórea/estadística & datos numéricos , Edad Gestacional , Adhesión a Directriz , Humanos , Recién Nacido , Índice de Severidad de la EnfermedadRESUMEN
The survival of infants with homozygous alpha-thalassemia, once considered a lethal diagnosis, is now possible through in utero and postnatal diagnostic and therapeutic interventions. We report the survival of a newborn with homozygous alpha-thalassemia complicated by pulmonary hypoplasia and persistent pulmonary hypertension, an association not previously reported.