Neonatal autopsy-is it relevant in today's era?

Autopsy of infants can provide vital information about the cause of death and contributes to the detection of diagnostic errors, especially in a low- or middle-income country. To observe the clinicopathological agreement in neonatal deaths in neonatal intensive care units (NICU) and comment on the additional information retrieved by autopsy. A retrospective observational study was conducted in the NICU from January 2020 to December 2022. Neonatal deaths were analyzed, and clinical details and autopsy findings were collected. Both clinical and pathological diagnoses were classified according to the Goldman classification. Twenty-two newborn infants were enrolled. The mean gestational age was 33.5 (±4.38) weeks, and the median birth weight was 1510 (1005-2100) g. There was complete concordance between clinical and pathological diagnosis in 11 (50%) cases. Major diagnostic errors occurred in 41% of cases. Respiratory system disorders (lung infections, airway anomalies) accounted for six (54%) cases of missed diagnosis. Our study showed that the diagnosis was revised after autopsy in about one-third of cases, and newer findings were identified in one-fifth of cases.

Comparison of Blood Pressure Measurements by Currently Available Multiparameter Monitors and Mercury Column Sphygmomanometer in Patients Admitted in Pediatric Intensive Care Unit.

Background: The multiparameter monitor (MPM) is replacing mercury column sphygmomanometers (MCS) in acute care settings. However, data on the former's accuracy in critically ill children are scarce and mostly extrapolated from adults. We compared non-invasive blood pressure (NIBP) measurements by MPMs with MCS in pediatric intensive care unit (PICU). Patients: Adequately sedated and hemodynamically stabilized children (age, 1-144 months) were prospectively enrolled. Materials and methods: Three NIBP measurements were obtained from MCS (Diamond®, India) and MPM (Intellivue MX800® or Ultraview SL®) in rapid succession in the upper limb resting in supine position. Respective three measurements were averaged to obtain a paired set of NIBP readings, one each from MCS and MPM. Such readings were obtained thrice a day. NIBP readings were then compared, and agreement was assessed. Results: From 39 children [median age (IQR), 30 (10-72) months], 1,690 sets of NIBP readings were obtained. A-third of readings were from infants and children >96 months, while 383 (22.6%) readings were from patients on inotropes. Multiparameter monitors gave significantly higher NIBP readings compared to MCS [median systolic blood pressure (SBP), 6.5 (6.4-6.7 mm Hg); diastolic blood pressure (DBP), 4.5 (4.3-4.6 mm Hg); mean arterial pressure (MAP), 5.3 (5.1-5.4 mm Hg); p < 0.05]. It was consistent across age, gender, and critical care characteristics. Multiparameter monitors overestimated SBP in 80% of readings beyond the maximal clinically acceptable difference (MCAD). Conclusions: Non-invasive blood pressure readings from MCS and MPMs are not interchangeable; SBP was 6-7 mm Hg higher with the latter. Overestimation beyond MCAD was overwhelming. Caution is required while classifying systolic hypotension with MPMs. Confirmation with auscultatory methods is advisable. More studies are required to evaluate currently available MPMs in different pediatric age groups. How to cite this article: Khan AA, Gupta PK, Baranwal AK, Jayashree M, Sahoo T. Comparison of Blood Pressure Measurements by Currently Available Multiparameter Monitors and Mercury Column Sphygmomanometer in Patients Admitted in Pediatric Intensive Care Unit. Indian J Crit Care Med 2023;27(3):212-221.

Meconium Peritonitis Presenting with Nonimmune Hydrops and Mirror Syndrome.

Meconium peritonitis (MP) presenting as hydrops is a rare entity. A 34-week hydropic infant was born to mother diagnosed with a case of nonimmune hydrops. Postnatally, the neonate was diagnosed as a case of MP based on clinical examination and investigations. The neonate underwent exploratory laparotomy which revealed diffuse MP with ileal perforation. She underwent resection of ileal perforation with ileocolic anastomosis. The index case highlights the importance of thorough clinical examination and abdominal X-ray in the diagnosis of MP.

Extracorporeal Cardiopulmonary Resuscitation in Indian Scenario: A Web-based Survey.

BACKGROUND: Practice and knowledge of extracorporeal cardiopulmonary resuscitation (ECPR) in an Indian setting is not known. The etiology could be multifactorial, such as lack of awareness, lack of facilities, and lack of finances. Unless we identify and rectify the underlying problems, utilization of this aspect of extracorporeal membrane oxygenation (ECMO) support would be difficult. MATERIALS AND METHODS: This cross-sectional observational study was done over 6 months in three phases: (A) Formation of questionnaire/tool kit by Delphi method for 1 month (July 2019), (B) circulation of questionnaire to participants in the form of Google Forms and data collection for 2 months (August and October 2019), and (C) analysis, compilation of data, and writing the final report over 1 month (November 2019). RESULTS: Sixty-four participants responded. The majority of the respondents were intensivists (50%). Only six respondents (9.5%) had done ECPR at their center with median ECPRs per year of 2 (1-10). All ECPRs were being done in private sector hospitals. The most common indication for initiation was conventional cardiopulmonary resuscitation (CPR) for more than 10 minutes without return of spontaneous circulation (ROSC)(n = 4, 66%). In all cases, the intensivists took decision for the initiation of ECPR. The rest 57 did not have the experience of ECPR at their center due to lack of equipment and experience (50%) and financial issues (50%). CONCLUSION AND CLINICAL SIGNIFICANCE: There is a huge need to increase the awareness of the ECPR program and teams to be trained in India. We also suggest that the tertiary care medical institutions in public sector as well as the private sector that is offering critical care courses should train fellows on ECPR to employ it at times when needed to improve the outcomes of critically ill patients. HOW TO CITE THIS ARTICLE: Gulla K M, Sahoo T, Pooboni S K, et al. Extracorporeal Cardiopulmonary Resuscitation in Indian Scenario: A Web-based Survey. Indian J Crit Care Med 2021;25(6):675-679.

Delayed cord clamping in Rh-alloimmunised infants: a randomised controlled trial.

Despite advancement in medical care, Rh alloimmunisation remains a major cause of neonatal hyperbilirubinaemia, neuro-morbidity, and late-onset anaemia. Delayed cord clamping (DCC), a standard care now-a-days, is yet not performed in Rh-alloimmunised infants due to paucity of evidence. Hence, we randomised these infants of 28- to 41-week gestation to delayed cord clamping (N = 36) or early cord clamping (N = 34) groups. The primary outcome variable was venous packed cell volume (PCV) at 2 h of birth. The secondary outcomes were incidence of double volume exchange transfusion (DVET) and partial exchange transfusion (PET), duration of phototherapy (PT), functional echocardiography (parameters measured: superior vena cava flow, M-mode fractional shortening, left ventricular output, myocardial perfusion index, and inferior vena cava collapsibility) during hospital stay, and blood transfusion (BT) until 14 weeks of life. Neonates were managed as per unit protocol. The baseline characteristics of enrolled infants were comparable between the groups. The median (IQR) gestation and mean (SD) birth weight of enrolled infants were 35 (33-37) weeks and 2440 (542) g, respectively. The DCC group had a higher mean PCV at 2 h of life (48.4 ± 9.2 vs. 43.5 ± 8.7, mean difference 4.9% (95% CI 0.6-9.1), p = 0.03). However, incidence of DVET and PET, duration of PT, echocardiography parameters, and BT until 14 weeks of postnatal age were similar between the groups.Conclusion: DCC in Rh-alloimmunised infants improved PCV at 2 h of age without significant adverse effects.Trial registration: Clinical Trial Registry of India (CTRI), Ref/2016/11/012572 http://ctri.nic.in/Clinicaltrials, date of trial registration 19.12.2016, date of first patient enrolment 1 January 2017.What is Known:•Delayed cord clamping improves haematocrit, results in better haemodynamic stability, and decreases the need of transfusion in early infancy.•However, due to lack of evidence, potential risk of hyperbilirubinaemia, and exacerbation of anaemia (following delayed cord clamping), early cord clamping is the usual norm in Rh-alloimmunised infantsinfants.What is New:•Delayed cord clamping in Rh-alloimmunised infants improves haematocrit at 2 h of life without any increase in incidence of serious adverse effects.

Fluid and Parenteral Nutrition Practices in Extreme Preterm Neonates Among Neonatology Practitioners in India: A Web-based Survey.

An online survey pertinent to fluid and parenteral nutrition practices in extreme preterm neonates was undertaken with responses from 123 neonatology practitioners across India. The initial fluid rate of 80 mL/kg/day was preferred by 67% neonatologists for 750-1000 g neonates. Half of them increased the fluid rates when weight loss per day was >2%. Practices vary widely across settings and guideline tailor made to clinical conditions is needed.

Transient Abnormal Myelopoiesis: An Abnormal Course and the Efficacy of Delayed Treatment.

Transient abnormal myelopoiesis (TAM) is observed in a few neonates with Down syndrome. While a large proportion undergo complete remission without any treatment, some of them can develop myeloid leukemia of Down syndrome (ML-DS) in the future. Without proper treatment, mortality can be high. Here we have described an interesting and difficult-to-treat case of a neonatal with Down syndrome who presented with anemia, thrombocytopenia, and 75% blasts. We came across multiple challenges in treatment due to severe pneumonia.

Comparison of Ultrasound-Guided Umbilical Venous Catheter Insertion with Blind Method: A Randomized Controlled Trial.

Introduction: Ultrasonography (USG) can be used in neonates to manipulate and place the umbilical catheter in the correct position. Although chest radiograph (CXR) is the gold standard, a noninvasive method like USG without radiation exposure may be an alternative bedside armamentarium to the clinician. The purpose of the study was to evaluate whether USG-guided umbilical venous catheter (UVC) insertion is superior to the conventional method for the successful insertion of UVC. Method: The neonates born between 25 and 42 weeks of gestation requiring parenteral fluids and admission to neonatal intensive care unit (NICU) between September 2020 and November 2022 were randomized in two weight-based strata: ≤1,200 and >1,200 g. USG-guided UVC insertion was done in the intervention group and blind UVC insertion was done in the control group. Results: Out of 112 enrolled neonates, 58 were in the USG-guided group and 54 in the blind group. There was no significant difference in the failure rate between the intervention and control groups (20% versus 29% [RR: 0.69, 95% CI: 0.36-1.33]). The sensitivity and specificity of USG in locating tip position were 97 and 46.8%, respectively. The mean procedure time in USG and blind groups was 8.9 and 8.3 min, respectively (p value 0.56). Conclusion: USG does not reduce the failure rates during the insertion of umbilical catheters. However, being a safe, noninvasive procedure, it can be considered a rescue modality to CXR in NICUs equipped with portable USG for guiding UVC insertion.

Quality improvement initiative to reduce Medical Adhesive Related Skin injury (MARSI) in very preterm babies admitted to neonatal intensive care unit.

INTRODUCTION: Sick preterm neonates are most vulnerable to developing skin injuries. Despite sound knowledge and application of evidence-based practices for preventing medical adhesive-related skin injury (MARSI), the incidence of MARSI was 30 events per 1000 adhesive application days in our unit. AIMS AND OBJECTIVES: We aimed to reduce the median MARSI rate from the existing 30 per 1000 MARSI days to <5 per 1000 MARSI over 5 months from June 2023 to October 2023. MATERIAL & METHODS: With the point-of-care quality improvement (QI) approach, a prospective study was planned to reduce the incidence of MARSI among sick very preterm newborns (<32 weeks gestational age) and eventually improve overall skin condition during hospital stay. Sequential Plan-Do-Study-Act cycles were implemented based on the identified risk factors recognised during recurring team discussions. RESULTS: We demonstrated a reduction in the MARSI rate from 30 events per 1000 adhesive applications (during baseline assessment) to zero events per 1000 adhesive applications at the end of the study period. It was temporally related to the assessment of skin risk stratification at admission using a validated tool, regular assessment of neonatal skin condition score based on the skin risk stratification, and reinforcement of MARSI prevention bundle by application of barrier spray. Awareness regarding 'skin injury prevention' bundles was continually generated among healthcare professionals. The MARSI rate remained <5 events per adhesive application in the sustenance phase over 6 months. CONCLUSION: Implementing evidence-based skin care practices resulted in a significant reduction in iatrogenic cutaneous injury events in very preterm neonates.

Elizabethkingia meningoseptica Outbreak in NICU: An Observational Study on a Debilitating Neuroinfection in Neonates.

BACKGROUND: Elizabethkingia meningoseptica is an emerging nosocomial pathogen implicated in neonatal sepsis with high mortality and morbidities. However, there is very limited data regarding the characteristics as well as outcomes following this infection, particularly in developing countries. METHODS: We conducted a retrospective observational study of all infants with culture-positive Elizabethkingia sepsis as part of an outbreak, to study their clinical and epidemiological characteristics, as well as their antimicrobial susceptibility patterns, using a structured proforma from the neonatal intensive care unit database. Analysis was done using descriptive statistics and predictors of mortality and hydrocephalus were also identified. RESULTS: Of the 21 neonates enrolled, 9 (42.9%) were male, with a mean gestational age and birth weight of 31.7 ± 3.4 weeks and 1320 ± 364 g, respectively. The median (interquartile range) age of onset of illness was 7 (5-12) days. The overall mortality rate was 23.8%, and among survivors, 50% had neurologic complications requiring intervention. Vancomycin and ciprofloxacin were the most used antibiotics for treatment in our series, with a median duration of 26 (17-38) days. On univariate analysis, shock at presentation was significantly associated with increased mortality (P = 0.04) while, seizures (P = 0.04) and elevated cerebrospinal fluid protein levels (P = 0 .01) at onset of illness predicted progressive hydrocephalus in surviving neonates. CONCLUSION: E. meningoseptica sepsis is associated with high morbidity and mortality. Early diagnosis and prompt initiation of appropriate antibiotics are critical for improving survival and neurodevelopmental outcomes. Though isolation of the organism by environmental surveillance is always not possible, with proper infection control measures, the infection can be controlled.

Short-term neurodevelopment and growth outcomes of very and moderate preterm Indian infants.

OBJECTIVE: To study the growth and neurodevelopmental outcome of very and moderate preterm infants (VMPT) compared to term appropriate-for-age (term AGA) infants at 18-months corrected age. METHODS: This prospective cohort study enrolled consecutively born 212 VMPT infants and 250 term AGA controls delivered during study period. OUTCOME MEASURES: Major neurodevelopmental impairment (NDI) defined as any one of cerebral palsy, motor (MoDQ) or mental developmental quotient (MoDQ) <70 on Developmental Assessment Scale for Indian infants, visual or hearing impairment, or epilepsy, and growth outcomes. RESULTS: Among 195 VMPT and 240 term AGA infants who completed follow-up, the frequency of major NDI was 12.8% and 2.5% respectively (RR 5.1; 95% CI [2.13-12.19]). Major NDI was higher among infants <28 weeks gestation (39%) and birthweight <1000 grams (27%). A quarter of VMPT infants exhibited wasting and 18% stunting than 7% each among controls. CONCLUSION: VMPT infants had a higher frequency of major NDI and growth failure at 18-months.

Neonatal Total Parenteral Nutrition: Clinical Implications From Recent NICE Guidelines.

Postnatal growth failure and its impact on the long term outcomes in preterm neonates is a long-standing problem. Optimal and aggressive nutrition strategies are required to ameliorate these concerns. Total parenteral nutrition (TPN) is widely practiced in management of preterm neonates. Recently published National Institute for Health and Care Excellence (NICE) guidelines provide recommendations for best practices for parenteral nutrition in neonates. However, healthcare associated sepsis, expertise as well as infrastructure of TPN, monitoring facilities and cost remain major constraints for widespread use of TPN in resource limited settings. Current update is aimed to summarize NICE and European society for Clinical Nutrition and Metabolism (ESPEN) guidelines to inform best practice for TPN for neonatologists in India.

Technology-dependent children.

In recent past, revolution in medical technology resulted in improved survival rates and outcomes of critically ill children. Unfortunately, its impact relating to morbidity is not well documented. Although survival rates of these critically ill children who are medically fragile and technology-dependent have improved, we as health professionals are still in the learning curve to improve the quality of life of these children at home. Factors such as support from society, infrastructure, and funding play an important role in technology-dependent child care at home. In this review, commonly prescribed home-based medical technologies such as home ventilation, enteral nutrition, renal replacement therapy, and peripherally inserted central catheter, which are useful for quick revision, are described.

International Guidelines 2020 for the Management of Septic Shock in Children.

The recent version of pediatric septic shock guidelines, 2020 have addressed practical issues pertaining to pediatric septic shock management, which can be applicable to resource-limited setting as well. Supportive aspects in management of septic shock such as ventilation, antibiotic stewardship, and nutrition are addressed compared to previous guidelines that concentrated more on first-hour management. The current guideline needs to be adapted to local clinical practice cautiously in the light of experience, clinical acumen and judgement.

Rh Alloimmunisation: Current Updates in Antenatal and Postnatal Management.

In spite of advances in medical science, Rh alloimmunisation remains one of the leading causes of preventable neuro-morbidities and significant neonatal hyperbilirubinemia in lower-middle income countries. Despite availability of effective antenatal preventive strategy (Anti-D), its uptake in antenatal period is low due to ignorance. Further, once diagnosed, there is lack of adequate antenatal follow up in health care facility. Some of these cases even remain undiagnosed in antenatal period only to present as a case of severe hyperbilirubinemia and kernicterus in late neonatal period. Thus, there is an urgent need for creating awareness and educating health care professionals for early detection and timely management in both antenatal and postnatal period. Following two doses of anti-D prophylaxis (one in antenatal period and one in immediate postnatal period) the incidence of Rh alloimmunisation can reduce to <1%. It is recommended to follow all Rh alloimmunised pregnancies antenatally with serial indirect Coombs test titre (till critical titre is reached) followed by serial Doppler velocimetry of middle cerebral artery in a perinatal centre where facility for intrauterine transfusion as well as advanced neonatal care is available. Postnatal management of these infants comprises of confirmation of diagnosis, aggressive phototherapy and in selective cases, double volume exchange transfusion. With appropriate antenatal and postnatal management, the prognosis of Rh alloimmunised pregnancy remains favourable and long term outcome of Rh alloimmunised infants remain comparable with their normal counterparts.

Inherited Bleeding Disorders in North Indian Children: 14 years' Experience from a Tertiary Care Center.

Inherited bleeding disorders are not uncommon in pediatric practice: most of them being chronic, require lifelong replacement therapy. To frame a management policy, it is essential to assess the load and pattern of bleeding disorders in the local population. However, there is paucity of data reporting the clinical spectrum of coagulation and platelet function disorders in Indian children. Hence to find out the exact burden and clinico-investigational profile of these patients we conducted this study. In this retrospective case review, detailed clinical information was extracted from case records in 426 children with a suspected diagnosis of hereditary bleeding disorder registered in the Pediatric Hematology clinic of a tertiary referral centre over a period of 14 years (1998-2011) and pooled for analysis. In our cohort prevalence of hemophilia A, hemophilia B, platelet function disorders, von Willebrand disease and other rare factor deficiencies were 72%, 11%, 7%, 4% and 4% respectively. Common clinical spectrum included skin bleeds, arthropathy, mucosal bleeds. 10% had deeper tissue bleeding and 16% received replacement therapy at the first visit. Nearly 3/4th of cases were lost for follow up after the initial visit. Hemophilia A was the commonest inherited bleeding disorder in our population. Skin bleeds and arthropathy were common clinical presentations. Factor replacement therapy was restricted to a minority. There is an urgent need for establishing centres of excellence with administrative commitment for factor replacement therapy for comprehensive management of such children in resource-limited countries.