A Randomized Controlled Trial of Glycerin Suppositories During Phototherapy in Premature Neonates.

OBJECTIVE: To determine if glycerin suppositories were effective in reducing total duration of phototherapy in premature neonates. We hypothesized that glycerin suppositories would have no effect on phototherapy duration or total serum bilirubin levels. DESIGN: Prospective randomized controlled double-blinded trial. SETTING: Level IV NICU. PARTICIPANTS: Neonates born between 30 weeks, 0 days and 34 weeks, 6 days gestational age who developed physiologic hyperbilirubinemia needing phototherapy. METHODS: Neonates were randomized to the no-suppository group or to the suppository group. Neonates were randomized to receive glycerin suppositories every 8 hours while under phototherapy or to a sham group. The primary outcome was total hours of phototherapy. Secondary outcomes included peak total serum bilirubin levels, time from start to discontinuation of phototherapy, rate of decline in bilirubin levels, repeat episodes of phototherapy, and number of stools while the neonates received phototherapy. RESULTS: A total of 39 neonates were assigned to the no-suppository group and 40 to the suppository group. Withholding suppositories was not inferior to providing suppositories. The total hours of phototherapy were not longer (i.e., noninferior) among neonates not provided suppositories (61 ± 53 hours) than among those given suppositories (72 ± 49 hours). There were no differences in peak bilirubin levels, rate of bilirubin decline, or repeat episodes of phototherapy. CONCLUSION: Routine use of glycerin suppositories among preterm neonates who receive phototherapy does not affect bilirubin levels or phototherapy duration.

Simulation to Standardize Patient Care and Maintain Procedural Competency.

Simulation-based training is a means to teach procedural skills and to help advanced practice providers maintain procedural competency and credentialing. There is growing recognition of the importance of requiring providers to demonstrate competency of invasive procedures in a simulated environment prior to performing these high-risk procedures on patients. This article describes the development and implementation of the simulation procedural program at the University of Rochester Medical Center. In addition to contributing to the education of our providers, such a program can lead to improved patient quality, safety, and outcomes through the standardization of patient care. The innovative use of simulation can lead to effective heath care education and improvement in patient safety.

An evidence-based catheter bundle alters central venous catheter strategy in newborn infants.

OBJECTIVE: To assess whether introduction of an evidence-based percutaneously inserted central catheter (PICC) care bundle reduced the risk of central line-associated bloodstream infection (CLABSI), thus altering the comparative risk of CLABSI in infants. STUDY DESIGN: This retrospective cohort study included all infants for whom an umbilical venous catheter (UVC) was placed as part of routine care between Jan 1, 2006, and Dec 31, 2009, a period during which standardized PICC insertion and care bundles were introduced. Duration of UVC use was divided in ≤ 7 days and >7 days. RESULTS: Infants in the ≤ 7 days UVC group had 1.0 CLABSI/1000 catheter days, and infants in the >7 days UVC group had 4.0 CLABSI/1000 catheter days (P < .001). Controlling for birth weight, gestational age, and antibiotic use, the >7 days UVC group had a greater risk of CLABSI (OR, 5.48) than the ≤ 7 days UVC group. CLABSI rate increased more rapidly in UVC than PICC with increasing duration of catheter rose. CONCLUSIONS: Replacement of a UVC with a PICC when central venous access is needed after 7 days of age may reduce CLABSI.

Exploring the association between pain intensity and facial display in term newborns.

BACKGROUND: Facial expression is widely used to judge pain in neonates. However, little is known about the relationship between intensity of the painful stimulus and the nature of the expression in term neonates. OBJECTIVES: To describe differences in the movement of key facial areas between two groups of term neonates experiencing painful stimuli of different intensities. METHODS: Video recordings from two previous studies were used to select study subjects. Four term neonates undergoing circumcision without analgesia were compared with four similar male term neonates undergoing a routine heel stick. Facial movements were measured with a computer using a previously developed 'point-pair' system that focuses on movement in areas implicated in neonatal pain expression. Measurements were expressed in pixels, standardized to percentage of individual infant face width. RESULTS: Point pairs measuring eyebrow and eye movement were similar, as was the sum of change across the face (41.15 in the circumcision group versus 40.33 in the heel stick group). Point pair 4 (horizontal change of the mouth) was higher for the heel stick group at 9.09 versus 3.93 for the circumcision group, while point pair 5 (vertical change of the mouth) was higher for the circumcision group (23.32) than for the heel stick group (15.53). CONCLUSION: Little difference was noted in eye and eyebrow movement between pain intensities. The mouth opened wider (vertically) in neonates experiencing the higher pain stimulus. Qualitative differences in neonatal facial expression to pain intensity may exist, and the mouth may be an area in which to detect them. Further study of the generalizability of these findings is needed.

Risk factors for umbilical venous catheter-associated thrombosis in very low birth weight infants.

BACKGROUND: Thrombosis in neonates is a rare but serious occurrence, usually associated with central catheterization. The objective of this study was to investigate the risk factors associated with catheter related thrombosis in very low birth weight (VLBW) infants. PROCEDURE: The present retrospective study was performed using data from a randomized trial of duration of umbilical venous catheters (UVC) placement among infants <1,250 g birth weight. Twenty-two cases of UVC-associated thrombosis were identified in this sample. The remaining study sample (n = 188) served as the comparison group. Data on thrombosis, platelets, gestational age, birth weight, hematocrit, serum sodium, maternal preeclampsia, blood group, infant of diabetic mother (IDM) and demographic factors were collected using database and record review. RESULTS: Among the total subjects (n = 210), 112 (53%) were males and 126 (60%) were Caucasians, with mean gestational age of 27.7 +/- 2.1 weeks (standard deviation) and mean birth weight of 923 +/- 195 g. Bivariate analysis revealed significant association of thrombosis with hematocrit >55% in the first week (odds ratio [OR] 5.4; 95% confidence interval [CI] 2.0-14.6; P = 0.0003), being small for gestational age (SGA) (OR, 2.9; 95% CI, 1.2-7.4; P = 0.02) and maternal preeclampsia (OR, 3.97; 95% CI, 1.6-9.84; P = 0.0017). In multivariate logistic regression analysis, only hematocrit >55% was independently associated with thrombus (OR, 3.7; 95% CI 1.1-11.8; P = 0.03). CONCLUSIONS: This study demonstrates a significant, independent association between elevated hematocrit and development of UVC-associated thrombosis. Careful monitoring for catheter-associated thrombosis may be indicated in VLBW infants who have hematocrit >55% in the first week of life.

A randomized trial comparing long-term and short-term use of umbilical venous catheters in premature infants with birth weights of less than 1251 grams.

BACKGROUND: Umbilical vein and percutaneous central venous catheters are often used in preterm infants, but they can lead to complications, including infection. OBJECTIVE: We hypothesized that long-term umbilical vein catheter use would result in fewer infections than short-term umbilical vein catheter use followed by percutaneous central venous catheter placement. DESIGN/METHODS: Infants < or = 1250 g with umbilical vein catheters placed at admission were randomly assigned to a long-term (umbilical vein catheter up to 28 days) or short-term (umbilical vein catheter for 7-10 days followed by percutaneous central venous catheter) group. Catheter infection was defined as symptoms and > or = 1 positive blood culture for definite pathogens or >1 positive culture for other organisms, with a catheter in place. Clinically significant echocardiogram findings were defined as thrombi threatening vascular occlusion, crossing/blocking heart valves, or otherwise felt to be significant by the cardiologist. The primary outcome was time from birth to catheter infection, analyzed by the log-rank test. RESULTS: There were 106 subjects in the short-term group and 104 in the long-term group with birth weights of 915 +/- 198 and 931 +/- 193 g and gestational ages of 27.8 +/- 2.0 and 27.7 +/- 2.2 weeks, respectively. The distribution of time to catheter infection did not differ between the groups. The overall incidence of catheter infection was 13% in the short-term group and 20% in the long-term group. Median age at catheter infection was 11.5 days in the short-term group and 14 days in the long-term group. There were 7.4 infections per 1000 catheter-days in the short-term group and 11.5 per 1000 in the long-term group. Seven infections in the short-term group were in umbilical vein catheters, and 18 infections in the long-term group were in umbilical vein catheter. Echocardiograms detected 4 infants in the short-term group and 7 infants in the long-term group with significant thrombosis. All significant thrombi were at the site of the umbilical vein catheter tip. No thrombus caused hemodynamic compromise, no child had clinical symptoms of thrombosis, and none required therapy. Of the 45 small-for-gestational-age infants in the study, 9 developed thrombi (short-term group, 4; long-term group, 5). The incidence of thrombi was higher in the small-for-gestational-age group (20%) versus other study subjects (9%). There were no differences in time to full feedings or to regain birth weight or in the incidence of necrotizing enterocolitis or death. CONCLUSIONS: Infection and complication rates were similar between infants managed with an umbilical vein catheter in place for up to 28 days compared with infants managed with an umbilical vein catheter replaced by a percutaneous central venous catheter after 7 to 10 days. Umbilical vein catheter durations beyond the current Centers for Disease Control and Prevention-recommended limit of 14 days may be reasonable.

Risk of persistent renal insufficiency in premature infants following the prenatal use of indomethacin for suppression of preterm labor.

OBJECTIVE: To determine the risk of persistent renal insufficiency (RI) in premature infants following the use of antenatal indomethacin for suppression of preterm labor. STUDY DESIGN: This population-based, retrospective review consisted of infants admitted during a 5-year period (1994-1999) to a tertiary referral neonatal intensive care nursery. Data were reviewed on 37 infants whose mothers received indomethacin for tocolysis, and on 37 matched controls. Renal insufficiency was defined as infant creatinine (Cr) > or = 1.5 mg/dl (133 micromol/l) for > or = 1 day. RESULTS: Infants whose mothers had received indomethacin for tocolysis were more likely than matched controls to have RI (9 of 37 vs 2 of 37, p = 0.04). Among infants of indomethacin-treated mothers with elevated Cr, serum Cr remained > or = 1.5 mg/dl (133 micromol/l) for a median of 6 days and > 1.0 mg/dl (88 micromol/l) for a median of 19 days. The peak Cr and length of elevation were closely correlated (r(2) = 0.63, p < 0.0001). CONCLUSION: Antenatal indomethacin can result in significant, prolonged RI in the infant. It may pose important risks to renal function and homeostasis in premature infants.