RESUMEN

OBJECTIVE: To describe the association between intermittent hypoxemic events (IHEs) and severe neurodevelopmental impairment (SNDI) or death in extremely premature infants. STUDY DESIGN: Retrospective study of extremely premature infants 230/7-276/7 weeks gestational age (GA) and birthweight (BW) ≤1250 grams (g) admitted to a level IV neonatal intensive care unit (NICU) from 2013 to 2017. IHEs, defined as events with SpO2 ≤ 80 % lasting 10 s to 5 min, were algorithmically identified using data extracted from bedside monitors at 2 s intervals (0.5 Hz). The primary outcome was SNDI at 18-24 months corrected age (CA), defined as a Bayley-III motor, language or cognitive composite score ≤69, or death before discharge while the secondary outcome was SNDI alone. We used mixed-effects regression models to evaluate the relationship between mean daily IHE rate per postnatal week of life for the first 12 weeks and the outcomes, and logistic regression models to assess the association between outcomes and summary measures of hypoxic burden for the entire NICU hospitalization. RESULTS: The mortality rate was 7 % (18/249) during NICU hospitalization. Of 249 infants born during this time period, IHE and neurodevelopmental outcome data were fully available for 65 infants (mean GA 26 ± 1.4 weeks, mean birth weight (BW) 738 ± 199 g. The outcome of SNDI alone occurred in 34 % (22/65) with a majority demonstrating motor or language delay on the Bayley-III. Although mean daily IHE rate/week was not associated with SNDI or death, total IHE duration was associated with increased odds of SNDI (OR (95 % CI) 1.03 (1.01, 1.05), p = 0.008) in models adjusted for GA. CONCLUSIONS: In a cohort of extremely premature infants 23-27 weeks GA, each hour of total IHE duration (SpO2 ≤ 80 %) was associated with a 2.7 % (0.7 %, 4.8 %) increase in the odds of SNDI at 18-24 months CA.

Asunto(s)

Trastornos del Desarrollo del Lenguaje , Trastornos del Neurodesarrollo , Recién Nacido , Lactante , Humanos , Recien Nacido Extremadamente Prematuro , Estudios Retrospectivos , Hipoxia/epidemiología , Edad Gestacional , Trastornos del Neurodesarrollo/epidemiología

RESUMEN

Since the declaration of the novel SARS-CoV-2 virus pandemic, health systems/ health-care-workers globally have been overwhelmed by a vast number of COVID-19 related hospitalizations and intensive care unit (ICU) admissions. During the early stages of the pandemic, the lack of formalized evidence-based guidelines in all aspects of patient management was a significant challenge. Coupled with a lack of effective pharmacotherapies resulted in unsatisfactory outcomes in ICU patients. The anticipated increment in ICU surge capacity was staggering, with almost every ICU worldwide being advised to increase their capacity to allow adequate care provision in response to multiple waves of the pandemic. This increase in surge capacity required advanced planning and reassessments at every stage, taking advantage of experienced gained in combination with emerging evidence. In University Hospital Southampton General Intensive Care Unit (GICU), despite the initial lack of national and international guidance, we enhanced our ICU capacity and developed local guidance on all aspects of care to address the rapid demand from the increasing COVID-19 admissions. The main element of this success was a multidisciplinary team approach intertwined with equipment and infrastructural reorganization. This narrative review provides an insight into the approach adopted by our center to manage patients with COVID-19 critical illness, exploring the initial planning process, including contingency preparations to accommodate (360% capacity increment) and adaptation of our management pathways as more evidence emerged throughout the pandemic to provide the most appropriate levels of care to our patients. We hope our experience will benefit other intensive care units worldwide. This article is categorized under: Infectious Diseases > Genetics/Genomics/Epigenetics.

Asunto(s)

COVID-19 , Pandemias , Humanos , SARS-CoV-2 , Cuidados Críticos/métodos , Capacidad de Reacción

RESUMEN

BACKGROUND: Antibiotics are widely used in very low-birth-weight infants (VLBW, <1500 g), and excess exposure, particularly to broad-spectrum antibiotics, is associated with significant morbidity. An antibiotic spectrum index (ASI) quantifies antibiotic exposure by relative antimicrobial activity, adding information to exposure measured by days of therapy (DOT). We compared ASI and DOT across multiple centers to evaluate differences in antibiotic exposures. METHODS: We extracted data from patients admitted to 3 level-4 NICUs for 2 years at 2 sites and for 1 year at a third site. We calculated the ASI per antibiotic days and DOT per patient days for all admitted VLBW infants <32 weeks gestational age. Clinical variables were compared as percentages or as days per 1,000 patient days. We used Kruskal-Wallis tests to compare continuous variables across the 3 sites. RESULTS: Demographics were similar for the 734 VLBW infants included. The site with the highest DOT per patient days had the lowest ASI per antibiotic days and the site with the highest mortality and infection rates had the highest ASI per antibiotic days. Antibiotic utilization varied by center, particularly for choice of broad-spectrum coverage, although the organisms causing infection were similar. CONCLUSION: An antibiotic spectrum index identified differences in prescribing practice patterns among 3 NICUs unique from those identified by standard antibiotic use metrics. Site differences in infection rates and unit practices or guidelines for prescribing antibiotics were reflected in the ASI. This comparison uncovered opportunities to improve antibiotic stewardship and demonstrates the utility of this metric for comparing antibiotic exposures among NICU populations.

Asunto(s)

Programas de Optimización del Uso de los Antimicrobianos , Unidades de Cuidado Intensivo Neonatal , Recién Nacido , Lactante , Humanos , Antibacterianos/uso terapéutico , Recién Nacido de muy Bajo Peso , Estudios Retrospectivos

RESUMEN

OBJECTIVE: The aim of this article was to evaluate high-frequency positive pressure ventilation (HFPPV) compared with high-frequency oscillatory ventilation (HFOV) as a rescue ventilation strategy for patients with congenital diaphragmatic hernia (CDH). HFPPV is a pressure-controlled conventional ventilation method utilizing high respiratory rate and low positive end-expiratory pressure. STUDY DESIGN: Seventy-seven patients diagnosed with CDH from January 2005 to September 2019 who were treated with stepwise progression from HFPPV to HFOV versus only HFOV were included. Fisher's exact test and the Kruskal-Wallis test were used to compare outcomes. RESULTS: Patients treated with HFPPV + HFOV had higher survival to discharge (80 vs. 50%, p = 0.007) and to surgical intervention (95.6 vs. 68.8%, p = 0.003), with average age at repair 2 days earlier (p = 0.004). Need for extracorporeal membrane oxygenation (p = 0.490), inhaled nitric oxide (p = 0.585), supplemental oxygen (p = 0.341), and pulmonary hypertension medications (p = 0.381) were similar. CONCLUSION: In CDH patients who fail respiratory support with conventional ventilation, HFPPV may be used as an intermediary mode of rescue ventilation prior to HFOV without adverse effects. KEY POINTS: · HFPPV may be used as an intermediary mode of rescue ventilation prior to HFOV without adverse effect.. · HFPPV is more widely available and can mitigate the limitations faced when using HFOV.. · HFPPV allows for intra- or interhospital transfer of neonates with CDH..

RESUMEN

BACKGROUND: Continuous heart rate (HR) and oxygenation (SpO2) metrics can be useful for predicting adverse events in very low birth weight (VLBW) infants. To optimize the utility of these tools, inter-site variability must be taken into account. METHODS: For VLBW infants at three neonatal intensive care units (NICUs), we analyzed the mean, standard deviation, skewness, kurtosis, and cross-correlation of electrocardiogram HR, pulse oximeter pulse rate, and SpO2. The number and durations of bradycardia and desaturation events were also measured. Twenty-two metrics were calculated hourly, and mean daily values were compared between sites. RESULTS: We analyzed data from 1168 VLBW infants from birth through day 42 (35,238 infant-days). HR and SpO2 metrics were similar at the three NICUs, with mean HR rising by ~10 beats/min over the first 2 weeks and mean SpO2 remaining stable ~94% over time. The number of bradycardia events was higher at one site, and the duration of desaturations was longer at another site. CONCLUSIONS: Mean HR and SpO2 were generally similar among VLBW infants at three NICUs from birth through 6 weeks of age, but bradycardia and desaturation events differed in the first 2 weeks after birth. This highlights the importance of developing predictive analytics tools at multiple sites. IMPACT: HR and SpO2 analytics can be useful for predicting adverse events in VLBW infants in the NICU, but inter-site differences must be taken into account in developing predictive algorithms. Although mean HR and SpO2 patterns were similar in VLBW infants at three NICUs, inter-site differences in the number of bradycardia events and duration of desaturation events were found. Inter-site differences in bradycardia and desaturation events among VLBW infants should be considered in the development of predictive algorithms.

Asunto(s)

Algoritmos , Recién Nacido de muy Bajo Peso , Unidades de Cuidado Intensivo Neonatal , Signos Vitales , Femenino , Frecuencia Cardíaca , Humanos , Recién Nacido , Masculino , Oximetría

RESUMEN

OBJECTIVE: To compare the incidence of bronchopulmonary dysplasia (BPD) based on the 1988 Vermont Oxford Network (VON) criteria, National Institutes of Health (NIH) 2001 definition, and NIH 2018 definition. METHODS: BPD incidence by each definition was compared in premature infants born at a single center between 2016 and 2018. Comorbidities were compared between those with and without BPD according to the newest definition. RESULTS: Among 352 survivors, BPD incidence was significantly different at 9%, 28% and 34% according to VON, NIH 2001 and NIH 2018 definitions, respectively (p < 0.05). According to the newest definition, any grade of BPD was associated with more co-morbidities than those without BPD (P < 0.001). CONCLUSION: At a center that emphasizes use of early noninvasive respiratory support, the incidence of BPD was significantly higher according to the NIH 2018 definition compared to other two definitions. The relationship between BPD diagnosis and long-term clinical outcomes remains unclear.

Asunto(s)

Displasia Broncopulmonar , Enfermedades del Prematuro , Displasia Broncopulmonar/diagnóstico , Displasia Broncopulmonar/epidemiología , Humanos , Incidencia , Lactante , Recién Nacido , Recien Nacido Prematuro , Unidades de Cuidado Intensivo Neonatal

RESUMEN

Importance: Infection in neonates remains a substantial problem. Advances for this population are hindered by the absence of a consensus definition for sepsis. In adults, the Sequential Organ Failure Assessment (SOFA) operationalizes mortality risk with infection and defines sepsis. The generalizability of the neonatal SOFA (nSOFA) for neonatal late-onset infection-related mortality remains unknown. Objective: To determine the generalizability of the nSOFA for neonatal late-onset infection-related mortality across multiple sites. Design, Setting, and Participants: A multicenter retrospective cohort study was conducted at 7 academic neonatal intensive care units between January 1, 2010, and December 31, 2019. Participants included 653 preterm (<33 weeks) very low-birth-weight infants. Exposures: Late-onset (>72 hours of life) infection including bacteremia, fungemia, or surgical peritonitis. Main Outcomes and Measures: The primary outcome was late-onset infection episode mortality. The nSOFA scores from survivors and nonsurvivors with confirmed late-onset infection were compared at 9 time points (T) preceding and following event onset. Results: In the 653 infants who met inclusion criteria, median gestational age was 25.5 weeks (interquartile range, 24-27 weeks) and median birth weight was 780 g (interquartile range, 638-960 g). A total of 366 infants (56%) were male. Late-onset infection episode mortality occurred in 97 infants (15%). Area under the receiver operating characteristic curves for mortality in the total cohort ranged across study centers from 0.71 to 0.95 (T0 hours), 0.77 to 0.96 (T6 hours), and 0.78 to 0.96 (T12 hours), with utility noted at all centers and in aggregate. Using the maximum nSOFA score at T0 or T6, the area under the receiver operating characteristic curve for mortality was 0.88 (95% CI, 0.84-0.91). Analyses stratified by sex or Gram-stain identification of pathogen class or restricted to infants born at less than 25 weeks' completed gestation did not reduce the association of the nSOFA score with infection-related mortality. Conclusions and Relevance: The nSOFA score was associated with late-onset infection mortality in preterm infants at the time of evaluation both in aggregate and in each center. These findings suggest that the nSOFA may serve as the foundation for a consensus definition of sepsis in this population.

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Bacteriemia/mortalidad , Fungemia/mortalidad , Infecciones por Bacterias Gramnegativas/mortalidad , Infecciones por Bacterias Grampositivas/mortalidad , Sepsis Neonatal/mortalidad , Puntuaciones en la Disfunción de Órganos , Peritonitis/mortalidad , Bacteriemia/microbiología , Bacteriemia/fisiopatología , Infecciones Relacionadas con Catéteres/microbiología , Infecciones Relacionadas con Catéteres/mortalidad , Infecciones Relacionadas con Catéteres/fisiopatología , Femenino , Fungemia/microbiología , Fungemia/fisiopatología , Edad Gestacional , Infecciones por Bacterias Gramnegativas/microbiología , Infecciones por Bacterias Gramnegativas/fisiopatología , Infecciones por Bacterias Grampositivas/microbiología , Infecciones por Bacterias Grampositivas/fisiopatología , Mortalidad Hospitalaria , Humanos , Recien Nacido con Peso al Nacer Extremadamente Bajo , Recien Nacido Extremadamente Prematuro , Recién Nacido , Recien Nacido Prematuro , Recién Nacido de muy Bajo Peso , Unidades de Cuidado Intensivo Neonatal , Perforación Intestinal , Masculino , Sepsis Neonatal/fisiopatología , Peritonitis/microbiología , Peritonitis/fisiopatología , Pronóstico , Medición de Riesgo

RESUMEN

A mobile septage treatment unit was built in India using readily available filters and membranes (mesh fabric, sand, granular activated carbon (GAC), microfilter, ultrafilter) and installed on the bed of a small truck. The target application was emptying of septic or sewage holding tanks and concentration of suspended solids while generating a liquid that could be discharged. The system was evaluated for operational and treatment performance while processing septage in the field at 108 sites in Tamil Nadu, India. After one phase of evaluation (Phase I), the system was improved and three replicate systems with slight modifications were fabricated for a second round of evaluation (Phase II) alongside the original, but modified unit. In Phase I, 105 m3 of septage was processed at an average flow of 623 L h-1 and with high removal efficiencies: 83% chemical oxygen demand (COD), 75% total suspended solids (TSS), and 98.4% total coliform (TC). In Phase II, the original and three new systems combined treated 168 m3 of septage. One of the new systems doubled in capacity and processed septage at an average flow of 2700 L h-1 while the other three averaged 1290 L h-1. The removal efficiencies in Phase II were 80% COD, 81% TSS, and 99% TC averaged between the four systems. Pass through of soluble contaminants (e.g. soluble COD, NH3-N) remain the primary challenge for treatment performance. Success may be limited with some septage due to seasonality, location, or septage age, and further validation and optimization may be necessary. However, the septage in this study was treated to local standards, and the system offers a method of onsite treatment while reducing the need of costly and often inefficient septage emptying services. Further, the system can be produced at a cost competitive to traditional septage hauling trucks.

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Aguas del Alcantarillado , Eliminación de Residuos Líquidos , Análisis de la Demanda Biológica de Oxígeno , India

RESUMEN

There is a great need for simple methods for digestate management for potential household sanitation systems based on anaerobic digestion of minimally diluted fecal waste in countries that lack safe sanitation. Herein, a full-scale three-stage filter for nitrogen and phosphorus removal from anaerobic digester effluent was implemented in Madagascar. It included a trickling filter with crushed charcoal (for aerobic nitrification), a submerged anaerobic filter with bamboo chips (for denitrification), and a submerged filter with scrap iron (for phosphorus removal). All filter materials were sourced locally. Three parallel replicate systems were operated in two sequential 8-week phases for a total of 16 continuous weeks. Though the influent feed was not as expected, with much of nitrogen in the feed coming in as organic N and not as NH3-N, the filters still removed 38-49% of total incoming nitrogen. The filters achieved high rates of nitrogen transformation along with removing solids (73-82% turbidity removal), chemical oxygen demand (67-75% removal), and phosphorus (31-50% removal). Overall, the reaction rates from this full-scale study were in line with previous lab-scale investigations with scaled-down systems, supporting their application in real-world scenarios. Based on this study, simple effluent filters can support nutrient removal for small-scale and onsite fecal sludge treatment systems.

Asunto(s)

Eliminación de Residuos Líquidos/métodos , Análisis de la Demanda Biológica de Oxígeno , Reactores Biológicos , Carbón Orgánico , Desnitrificación , Heces/química , Humanos , Nitrificación , Nitrógeno/análisis , Nutrientes , Fósforo , Aguas del Alcantarillado

RESUMEN

OBJECTIVES: The objective of this study was to define the association between the burden of severe hypoxemia (SpO2 ≤70%) in the first week of life and development of severe ICH (grade III/IV) in preterm infants. STUDY DESIGN: Infants born at <32 weeks or weighing <1500 g underwent prospective SpO2 recording from birth through 7 days. Severe hypoxemia burden was calculated as the percentage of the error-corrected recording where SpO2 ≤70%. Binary logistic regression was used to model the relationship between hypoxemia burden and severe ICH. RESULTS: A total of 163.3 million valid SpO2 data points were collected from 645 infants with mean EGA = 27.7 ± 2.6 weeks, BW = 1005 ± 291 g; 38/645 (6%) developed severe ICH. There was a greater mean hypoxemia burden for infants with severe ICH (3%) compared to those without (0.1%) and remained significant when controlling for multiple confounding factors. CONCLUSION: The severe hypoxemia burden in the first week of life is strongly associated with severe ICH.

Asunto(s)

Hipoxia , Enfermedades del Prematuro , Hemorragias Intracraneales , Correlación de Datos , Femenino , Edad Gestacional , Humanos , Hipoxia/sangre , Hipoxia/diagnóstico , Hipoxia/epidemiología , Recién Nacido , Recien Nacido Prematuro , Enfermedades del Prematuro/sangre , Enfermedades del Prematuro/diagnóstico , Enfermedades del Prematuro/epidemiología , Recién Nacido de muy Bajo Peso , Hemorragias Intracraneales/sangre , Hemorragias Intracraneales/diagnóstico , Hemorragias Intracraneales/epidemiología , Hemorragias Intracraneales/etiología , Masculino , Oximetría/métodos , Oxígeno/análisis , Índice de Severidad de la Enfermedad , Estados Unidos/epidemiología

RESUMEN

Over 1/3 of the global population lacks access to improved sanitation, leading to disease, death, and impaired economic development. Our group is working to develop rapidly deployable, cost-effective, and sustainable solutions to this global problem that do not require significant investments in infrastructure. Previously, we demonstrated the feasibility of a toilet system that recycles blackwater for onsite reuse as flush water, in which the blackwater is electrochemically treated to remove pathogens due to fecal contamination. However, this process requires considerable energy (48-93 kJ/L) to achieve complete disinfection of the process liquid, and the disinfected liquid retains color and chemical oxygen demand (COD) in excess of local discharge standards, negatively impacting user acceptability. Granular activated carbon (GAC) efficiently reduces COD in concentrated wastewaters. We hypothesized that reduction of COD with GAC prior to electrochemical treatment would both improve disinfection energy efficiency and user acceptability of the treated liquid. Here we describe the development and testing of a hybrid system that combines these technologies and demonstrate its ability to achieve full disinfection with improved energy efficiency and liquid quality more suitable for onsite reuse and/or discharge.

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Técnicas Electroquímicas/métodos , Eliminación de Residuos Líquidos/instrumentación , Eliminación de Residuos Líquidos/métodos , Aparatos Sanitarios , Análisis de la Demanda Biológica de Oxígeno , Carbón Orgánico/química , Desinfección/métodos , Técnicas Electroquímicas/instrumentación , Diseño de Equipo , Reciclaje , Aguas Residuales/química , Aguas Residuales/microbiología , Purificación del Agua/instrumentación , Purificación del Agua/métodos

RESUMEN

The treatment of high-strength anaerobic digester effluent in laboratory-scale trickling filters for nitrification and then anaerobic filters for denitrification is reported. Five media types were investigated in the trickling filters: biochar, granular activated carbon (GAC), zeolite, Pall rings, and gravel. Three media were tested in five denitrifying filters: sand (S), bamboo wood chips (B), eucalyptus wood chips (E), bamboo with sand (B+S), and eucalyptus with sand (E+S). The different wood chips served as a supplemental electron donor for denitrification. From six months of operation, biochar, GAC, zeolite, Pall rings, and gravel media had turbidity (NTU) removal efficiencies of 90, 91, 77, 74, and 74%, respectively, and ammonia removal efficiencies of 83, 87, 85, 30, and 80%, respectively, which was primarily by nitrification to nitrate. For the anaerobic filters, S, B, B+S, E, and E+S had nitrate removal efficiencies of 30, 66, 53, 35, and 35%, and turbidity removal efficiencies of 88, 89, 84, 89, and 88%, respectively. Biochar and bamboo were selected as the best combination of media for trickling filter and anaerobic filter sequential treatment. Based on an average initial influent of 600 mg NH3-N L-1, 50 mg NO3-N L-1, and 980 NTU, the biochar filter's effluent would be 97 mg NH3-N L-1, 475 mg NO3-N L-1, and 120 NTU. The bamboo filter's final effluent would be 82 mg NH3-N L-1, 157 mg NO3-N L-1, and 13 NTU, which corresponds to 63% removal of total N and 99% removal of turbidity. These filter media thus present a simple option for sustainable post-treatment for nitrogen management and effluent polishing in low-resources settings.

Asunto(s)

Desnitrificación , Filtración/métodos , Nitrificación , Nitrógeno/análisis , Eliminación de Residuos Líquidos/métodos , Purificación del Agua/métodos , Reactores Biológicos , Carbón Orgánico

RESUMEN

The Anaerobic Digestion Pasteurization Latrine (ADPL) is a self-contained and energy neutral on-site sanitation system using anaerobic digestion of fecal sludge to generate biogas and then uses the biogas to pasteurize the digester effluent at 65-75°C to produce a safe effluent that can be reused locally as a fertilizer. Two ADPL systems were installed on residential plots with 17 and 35 residents in a peri-urban area outside of Eldoret, Kenya. Each system comprised three toilets built above a floating dome digester and one heat pasteurization system to sanitize the digested effluent. ADPLs are simple systems, with no moving parts and relying on gravity-induced flows. Adoption at the two sites was successful, and residents reported that the systems had little to no odor or flies. ADPLs were monitored for biogas production and temperatures in the pasteurization system. ADPLs serving 17 and 35 residents produced on average 16 and 11 Lbiogas/person/day (maximum of 20 and 15 Lbiogas/p/d), respectively. The temperature in the sterilization system was greater than 65°C on 58% and 87% of sampling days during the most stable period of operation. Treated effluent was analyzed periodically for chemical oxygen demand (COD), biochemical oxygen demand (BOD), total ammonia nitrogen (TAN), pH, and fecal coliform (FC). On average, the effluent at the two locations contained 4,540 and 6,450 mg COD/L (an 85% or 89% reduction of the estimated input), 2,050 and 3,970 mg BOD/L, and 2,420 and 4,760 mg NH3-N, respectively, and greater than 5 log reductions of FC (nondetectable) in the sterilization tank. Results from this field study show that anaerobic digestion of minimally diluted fecal sludge can provide enough energy to pasteurize digester effluent and that the ADPL may be a suitable option for on-site fecal sludge treatment.