Implementation of morbidity and mortality conference in a community hospital NICU and narrative review.

Background: The process of morbidity and mortality review (MMR) is recognized as an essential component of quality improvement, patient safety, attitudes towards patient safety, and continuing education. Despite the common use of MMR for all disciplines of medical care, recommendations have not been published regarding the implementation of MMR in a community hospital setting in the United States. Objectives: Review the literature on MMR conferences. Describe the implementation of an MMR conference in a community hospital neonatal intensive care unit (NICU). Conclusions: The establishment of a case overview method of MMR is feasible for a community hospital NICU. It increases staff and physician group awareness and education over common and complex mortality and morbidity etiologies, improves staff participation with unit management, links case presentation with open discussion and action items, and identifies opportunities for systemic changes to improve patient care.

Blood Pressure Profiles in Infants With Hypoxic Ischemic Encephalopathy (HIE), Response to Dopamine, and Association With Brain Injury.

Objective: To describe mean arterial blood pressure (MABP), responsiveness to dopamine, and relationship to brain injury in infants with moderate/severe hypoxic-ischemic encephalopathy (HIE) undergoing therapeutic hypothermia (TH). We hypothesized that, when utilized, dopamine would rapidly and effectively increase MABP in treated patients. Methods: Continuous arterial blood pressure measurements were prospectively recorded from infants with moderate/severe HIE undergoing TH in a multi-institutional cohort from 2010 to 2018. Treatment with dopamine was at the discretion of the medical team for hypotension/hypoperfusion. MABP values of treated infants were compared to those obtained at an equivalent time period in control infants receiving TH but not dopamine (24 h after birth). MRI was obtained per unit protocols and included T1/T2/DWI sequences. Injury was classified as no injury/mild injury or moderate/severe injury using a standardized scoring system. Seizures were confirmed with conventional EEG. Results: Eighteen infants were treated with dopamine and were similar to untreated controls (n = 36) with the exception of lower cord gas pH (6.92 ± 0.2 vs. 7.07 ± 0.2, p < 0.05). Dopamine was initiated at a mean of 24 h after birth. MABP was significantly lower in the dopamine group at the start of therapy (39.9 ± 2.0 vs. 49.1 ± 1.3, p < 0.01) and 1 h later (44.3 ± 2.0 vs. 49.8 ± 1.1, p < 0.05). However, after 9 h of treatment, dopamine increased the MABP by an average of 9 mmHg and MABP values were similar to untreated controls for the remainder of the observation period. There were no significant differences in rates of seizures, brain injury, or death. Conclusion: Neonates with moderate/severe HIE treated with dopamine during TH had MABP significantly lower than controls. The majority of infants responded to dopamine monotherapy following adequate volume resuscitation. An association between requirement for dopamine and severity of brain injury was not detected.

Placental Pathology, Cerebral Blood Flow, and Intraventricular Hemorrhage in Preterm Infants: Is There a Link?

BACKGROUND: There is growing evidence to support an association between placental inflammation and neurological sequelae of preterm infants. The goal of this study is to evaluate the relationship between placental pathology, post-natal Doppler cerebral resistive indices (RI's), and intraventricular hemorrhage (IVH) in premature infants. METHODS: In a retrospective cohort study, preterm infants born between 23 0/7 and 32 6/7 weeks' gestation at Parkland Hospital were examined with placental pathology and serial ultrasound Doppler to evaluate for the primary outcome of IVH and death. RESULTS: A total of 255 infants were included, and 166 (65%) had at least one significant placental pathology, most commonly chorioamnionitis. Infants with placental pathologies were significantly more likely to have mothers with clinical chorioamnionitis and to have lower gestational ages. There was no observed association between placental pathology and IVH or death. Secondary analysis demonstrated that resistive indices obtained from the first and second head ultrasounds were not different in infants with IVH. CONCLUSION: In this study, we observed a high rate of placental pathologies but no alterations in cerebral indices on ultrasound, or differences in rates of IVH or death. Additional studies are necessary to delineate the relationship between placental pathology, white matter brain injury, and outcomes.