Improving the neonatal team handoff process in a level IV NICU: reducing interruptions and handoff duration.

BACKGROUND: Neonatal intensive care unit (NICU) patients are at increased risk for handoff communication failures due to complexity and prolonged length of stay. We report a quality initiative aimed at reducing avoidable interruptions during neonatal handoffs while monitoring handoff duration and provider satisfaction. METHODS: Observational time series between August 2015 and March 2018 in an academic level IV NICU. NICU I-PASS and process changes were implemented using plan-do-study-act cycle, and statistical process control charts were used in the analysis. Unmatched preintervention and postintervention satisfaction surveys were compared using Mann-Whitney U tests. RESULTS: There was special cause variation in the mean number of avoidable interruptions per handoff from 4 to 0.3 (92% reduction). The mean duration of handoff was reduced ~1 min/patient. Provider satisfaction with the quality of handoffs also improved from a mean of 3.36 to 3.75 on a 1-5 Likert scale (p=0.049). CONCLUSIONS: Standardisation of NICU handoff with NICU I-PASS and process changes led to the sustained reduction in avoidable interruptions with the added benefit of reduced handoff length and improved provider satisfaction.

Tyrosine phosphorylation of apoptotic proteins during hyperoxia in mitochondria of the cerebral cortex of newborn piglets.

The present study tests the hypothesis that hyperoxia results in increased tyrosine phosphorylation of apoptotic proteins Bcl-2, Bcl-xl, Bax & Bad in the mitochondrial fraction of the cerebral cortex of newborn piglets. Twelve newborn piglets were divided into normoxic [Nx, n = 6], exposed to a FiO(2) of 0.21 for 1 h and hyperoxic [Hyx, n = 6], exposed to FiO(2) of 1.0 for 1 h. PaO(2) in Hyx group was maintained at 400 mmHg while the Nx group was kept at 80 to 100 mmHg. The density (O.D.x mm(2)) of phosphorylated Bcl2 protein on westernblot was 19.3 +/- 3.6 in Nx and 41.5 +/- 18.3 in Hyx, (P < 0.05). The density of phosphorylated Bcl-xl protein density was 26.9 +/- 7.0 in Nx and 47.9 +/- 2.5 in Hyx, (P < 0.05). Phosphorylated Bax density was 43.5 +/- 5.0 in Nx and 43.3 +/- 5.2 in Hyx. Phosphorylated Bad density was 23.6 +/- 3.9 in Nx, 24.4 +/- 4.7 in Hyx. The data show that during hyperoxia there is a significant increase in tyrosine phosphorylation of Bcl2 and Bcl-xl, while the phosphorylation of proapototic proteins Bax & Bad was not altered. We conclude that hyperoxia leads to post translational modification of anti apoptotic proteins Bcl2 and Bcl-xl in cerebral cortical mitochondria. We propose that phosphorylation of Bcl2 will result in loss of its antiapoptotic potential by preventing its dimerization with Bax leading to activation of the caspase pathway and subsequent neuronal death in the cerebral cortex of the newborn piglets.

Mechanism of Ca(2+)/calmodulin-dependent protein kinase IV activation and of cyclic AMP response element binding protein phosphorylation during hypoxia in the cerebral cortex of newborn piglets.

Previously we showed that hypoxia results in increased neuronal nuclear Ca(2+) influx, Ca(2+)/calmodulin-dependent protein kinase IV activity (CaM KIV) and phosphorylation of c-AMP response element binding (CREB) protein. The aim of the present study was to understand the importance of neuronal nuclear Ca(2+) in the role of CaM KIV activation and CREB protein phosphorylation associated with hypoxia. To accomplish this the present study tests the hypothesis that clonidine administration will block increased nuclear Ca(2+) influx by inhibiting high affinity Ca(2+)/ATPase and prevent increased CaM KIV activity and CREB phosphorylation in the neuronal nuclei of the cerebral cortex of hypoxic newborn piglets. To accomplish this piglets were divided in three groups: normoxic, hypoxic, and hypoxic-treated with clonidine. The piglets that were in the Hx+Cl group received clonidine 5 min prior to hypoxia. Cerebral tissue hypoxia was confirmed biochemically by tissue levels of ATP and phosphocreatine (PCr). The data show that clonidine prevents hypoxia-induced increase in CaM KIV activity and CREB protein phosphorylation. We conclude that the mechanism of hypoxia-induced activation of CaM KIV and CREB phosphorylation is nuclear Ca(2+) influx mediated. We speculate that nuclear Ca(2+) influx is a key step that triggers CREB mediated transcription of apoptotic proteins and hypoxic mediated neuronal death.

Effect of nitric oxide synthase inhibition during post-hypoxic reoxygenation on Bax and Bcl-2 protein expression and DNA fragmentation in neuronal nuclei of newborn piglets.

Previous studies have shown that cerebral tissue hypoxia results in increased generation of oxygen-free radicals including nitric oxide (NO), expression of the proapoptotic protein Bax and fragmentation of nuclear DNA. The present study tests the hypothesis that post-hypoxic reoxygenation for 6 h following hypoxia (FiO2=0.06 for 1 h) results in continued hypoxia-induced, NO-mediated expression of the Bax protein and nuclear DNA fragmentation in the cerebral cortex of newborn piglets. Piglets were divided into normoxic (Nx), hypoxic (Hx, FiO2=0.06 for 1 h), hypoxic with 6 h reoxygenation (Hx+reox) and hypoxic with 6 h reoxygenation injected with 7-nitroindazole sodium salt (7-NINA), a selective nNOS inhibitor, immediately after hypoxia (Hx+7-NINA). Cerebral tissue hypoxia was documented by levels of ATP and phosphocreatine (PCr). Bax and Bcl-2 were analyzed by Western blot and DNA fragmentation was determined by agarose gel electrophoresis. ATP and PCr values in Hx, Hx+reox and Hx+7-NINA were significantly different from Nx (P<0.05 vs. Nx). Bax protein (ODxmm2) was 128.9+/-38.7 in Nx; 223.6+/-45.8 in Hx (P<0.05 vs. Nx); 340.5+/-73.2 in Hx+reox (P<0.05 vs. Nx, Hx and Hx+7-NINA); and 202.2+/-34.8 in Hx+7-NINA (P=NS vs. Hx). Bcl-2 protein (ODxmm2) was 14.9+/-2.7 in Nx, 12.4+/-2.1 in Hx, (P<0.05 vs. Nx), 15.7+/-3.8 in Hx+reox, (P<0.05 vs. Hx) and 13.1+/-2.2 in Hx+7-NINA (P=NS among groups). Nuclear DNA fragmentation (ODxmm2) was 147+/-15 in Nx; 797+/-84 in Hx (P<0.05 vs. Nx); 1134+/-127 in Hx+reox (P<0.05 vs. Nx, Hx and Hx+7-NINA); and 778+/-146 in Hx+7-NINA (P=NS vs. Hx, P<0.05 vs. Hx+reox). The results show that post-hypoxic reoxygenation results in increased expression of Bax protein without affecting Bcl-2 protein and increased fragmentation of nuclear DNA, which are prevented by 7-NINA. We conclude that during post-hypoxic reoxygenation the increase in Bax protein expression and fragmentation of nuclear DNA are mediated by NO derived from nNOS. We propose that in addition to NO-mediated nuclear DNA damage, the hypoxia-induced increased ratio of Bax/Bcl-2 protein will lead to caspase-activated cascade of hypoxic neuronal death during post-hypoxic reoxygenation.

Methimazole associated neutropenia in a preterm neonate treated for hyperthyroidism.

Maternal Graves' disease is relatively uncommon with an estimated incidence of 0.4%-1% of all pregnancies, but only 1-5% of newborns delivered to mothers with Graves' disease develop overt clinical signs and symptoms of hyperthyroidism. Here, we describe a case of a 1380-gram female neonate who was born at 30-week gestation to a mother with Graves' disease. Our patient presented with hyperthyroidism followed by transient hypothyroidism requiring treatment with levothyroxine. While hyperthyroid, she was treated with methimazole, iodine, and a beta-blocker. 20 days after the initiation of methimazole, she developed neutropenia. The neutrophil counts started to improve immediately after the initiation of the weaning of methimazole. To the best of our knowledge, this is the first case reported in the literature of methimazole induced neutropenia in a preterm infant being treated for neonatal Graves' disease.

Nitric oxide-mediated expression of Bax protein and DNA fragmentation during hypoxia in neuronal nuclei from newborn piglets.

The present study tests the hypothesis that nitric oxide mediates the hypoxia-induced increase in expression of Bax and in DNA fragmentation in the cerebral cortex of newborn piglets, and that administration of N-nitro-L-arginine (NNLA), a nitric oxide synthase inhibitor, will prevent a change in hypoxia-induced expression of apoptotic genes and DNA damage. Piglets were assigned to normoxic, hypoxic, or NNLA-pretreated hypoxic groups. Cerebral tissue hypoxia was documented biochemically by measuring ATP and phosphocreatine (PCr) levels. Cerebral cortical neuronal nuclei were isolated and nuclear proteins were separated electrophoretically and probed with specific antibodies against Bcl-2 or Bax proteins. Neuronal nuclear DNA from normoxic, hypoxic, and NNLA-pretreated hypoxic animals was isolated, separated by electrophoresis on 1% agarose gel and stained with ethidium bromide. Cerebral hypoxia resulted in an increase in nuclear membrane Bax protein levels from 121.33+/-47.7 optical density (OD)xmm(2) in normoxic to 273.67+/-67.3 ODxmm(2) in hypoxic group (P<0.05 vs. normoxic), but levels in NNLA-pretreated hypoxic group were 155.78+/-48.3 ODxmm(2) (P<0.05 vs. hypoxic, P=NS vs. normoxic). Similarly, cerebral hypoxia resulted in the density of DNA fragments increasing from 1530.3+/-309.8 OD/mm(2) in the normoxic group to 5383.3+/-775 OD/mm(2) in the hypoxic group (P<0.05), while levels in NNLA-pretreated hypoxic group were 3574.0+/-952 OD/mm(2) (P<0.05 compared to hypoxic and normoxic groups). The data show that NNLA-pretreatment prevents the hypoxia-induced increase in Bax expression and DNA fragmentation demonstrating that the hypoxia-induced Bax gene expression and the DNA fragmentation are NO-mediated.

The effect of hypocapnia (PaCO2 27 mmHg) on CaM kinase IV activity, Bax/Bcl-2 protein expression and DNA fragmentation in the cerebral cortex of newborn piglets.

The present study tests the hypothesis that a PaCO(2) of 27 mmHg for 1 hr results in increased neuronal nuclear Ca(++)/calmodulin-dependent protein kinase IV (CaM kinase IV) activity, pro-apoptotic protein expression and DNA fragmentation in the cerebral cortex of newborn piglets. Hypocapnic (HC) and normocapnic newborn piglets were studied. Tissue levels of ATP and phosphocreatine (PCr) were lower in the HC group. CaM kinase IV activity and Bax protein density were higher in the HC group. Bcl-2 protein density was the same in both groups, resulting in an increased ratio of Bax/Bcl-2 in the HC group. Density of nuclear DNA fragments was greater in the HC group and varied inversely with ATP and PCr levels. We conclude that hypocapnia (PaCO(2) 27 mmHg) results in increased expression of pro-apoptotic proteins and fragmentation of nuclear DNA in newborn piglets.

Nitric oxide-mediated Ca2+/calmodulin-dependent protein kinase IV activity during hypoxia in neuronal nuclei from newborn piglets.

The present study tested the hypothesis that hypoxia results in increased Ca(2+)/calmodulin-dependent protein kinase IV (CaM kinase IV) activity and that inhibition of nitric oxide (NO) synthase by N-nitro-L-arginine (NNLA) prevents the hypoxia- induced increase in neuronal nuclear CaM kinase IV activity in newborn piglets. CaM kinase IV activity was determined in normoxic (Nx), hypoxic (Hx), and NNLA-pretreated Hx piglets. Cerebral hypoxia was confirmed biochemically. There was a significant difference between CaM kinase IV activity (pmoles/mg protein/min) in Nx (285.22+/-86.12), Hx (494.77+/-99.79, P<0.05 vs. Nx), and NNLA-pretreated Hx (249.55+/-53.85)(P=NS vs. Nx, P<0.05 vs. Hx) animals. The results demonstrate that the cerebral tissue hypoxia results in an increase in neuronal nuclear CaM kinase IV activity, and the hypoxia-induced increase in CaM kinase IV activity is NO-mediated.

Nuclear Ca(++)-influx, Ca (++)/calmodulin-dependent protein kinase IV activity and CREB protein phosphorylation during post-hypoxic reoxygenation in neuronal nuclei of newborn piglets: the role of nitric oxide.

The present study tests the hypothesis that post-hypoxic reoxygenation results in an nitric oxide (NO)-mediated increase in nuclear Ca(++)-influx, increased calmodulin kinase (CaM kinase) IV activity, and increased Ser(133) phosphorylation of cyclic AMP response element binding (CREB) protein in neuronal nuclei of the cerebral cortex of newborn piglets. Piglets were divided into normoxic (Nx), hypoxic (Hx, FiO(2) = 0.07 for 1 h), hypoxic with 6 h reoxygenation (Hx + reox), and Hx + reox injected with 7-nitroindazole sodium salt (7-NINA), a nNOS inhibitor, immediately after hypoxia (Hx + 7-NINA). Cerebral tissue hypoxia was documented by ATP and phosphocreatine (PCr) levels. Nuclear Ca(++)-influx was determined using (45)Ca(++) and CaM kinase IV activity determined by (33)P-incorporation into syntide-2. Ser(133) phosphorylation of CREB protein was determined by Western blot analysis using a specific anti-phosphorylated Ser(133)-CREB protein antibody. ATP and PCr values in Hx, Hx + reox, and Hx + 7-NINA were significantly different from Nx (P < 0.05 versus Nx). Ca(++)-influx (pmoles/mg protein/min) was 3.79 +/- 0.91 in Nx; 11.81 +/- 2.54 in Hx (P < 0.05 versus Nx), 16.55 +/- 3.55 in Hx + reox (P < 0.05 versus Nx), and 12.40 +/- 2.93 in Hx + 7-NINA (P = NS versus Hx). CaM kinase IV activity (pmoles/mg protein/min) was 1,220 +/- 76 in Nx, 2,403 +/- 254 in Hx (P < 0.05 versus Nx), 1,971 +/- 147 in Hx + reox (P < 0.05 versus Hx), and 1,939 +/- 125 Hx + 7-NINA (P < 0.05 versus Hx). Ser(133) phosphorylated CREB protein expression (OD x mm(2)) was 87 +/- 2 in Nx, 203 +/- 24 in Hx (P < 0.05 versus Nx), 186 +/- 23 in Hx + reox (P < 0.05 Nx, P = NS versus Hx), and 128 +/- 10 in Hx + 7-NINA (P < 0.05 versus Hx and Hx + reox). The results show that post-Hx administration of 7-NINA prevents the increased nuclear Ca(++)-influx and CREB protein phosphorylation at Ser(133) during reox. We conclude that post-Hx increase in nuclear Ca(++)-influx leading to increased phosphorylation of CREB protein is mediated by NO derived from nNOS. However, hypoxia-induced increase in CaM Kinase IV activity decreased during the post-Hx reox. We propose that hypoxia-induced increase in CaM Kinase IV activity leads to increased phosphorylation of CREB protein and transcription of proapoptotic genes during post-Hx reox resulting in Hx neuronal death.

Increased neuronal nuclear calcium influx in neonatal seizures.

We hypothesized that neonatal seizures lead to increased Ca(2+) influx (nCa(2+)I) in neuronal nuclei of newborn rats and that such increase is nitric-oxide mediated. Neuronal nuclear (45)Ca(2+) influx (nCa(2+)I) was measured in neuronal nuclei of 25 10-day-old male rat-pups newborn brains. They were divided into five groups (n = 5/group). (I) control; (II) hypoxia without seizures; (III) hypoxia with seizures; (IV) kainate, 2 mg/kg intraperitoneal (i.p.)-induced seizures and (V) 7-nitroindazole (7-NINA), 1 mg/kg i.p. pretreated, kainate-induced seizures. nCa(2+)I was significantly (P < 0.05) increased following hypoxia or seizures (hypoxic- or kainate-induced). Post-hypoxic seizures further enhanced nCa(2+)I increase induced by hypoxia (P < 0.05). 7-NINA abated the nCa(2+)I increase induced by kainate. We conclude that (1) kainate or hypoxia-induced seizures in newborn rats modify the neuronal nuclear membrane function, resulting in increased nCa(2+)I, (2) seizures exacerbate the hypoxia-induced increased nCa(2+)I incurred after hypoxia and (3) intranuclear calcium surges during kainate-induced neonatal seizures are nitric oxide-mediated.

Hypercapnia-induced modifications of neuronal function in the cerebral cortex of newborn piglets.

There is significant controversy over the effects of hypercapnia on the human newborn brain. Previous studies have shown that 1 h of an arterial CO2 pressure (Paco2) of 80 mm Hg alters brain cell membrane Na+K+-ATPase enzyme activity in the cerebral cortex of newborn piglets. The present study tests the hypothesis that hypercapnia (either a Paco2 of 65 or 80 mm Hg) results in decreased energy metabolism and alters neuronal nuclear enzyme activity and protein expression, specifically Ca++/calmodulin-dependent kinase (CaMK) IV activity, phosphorylation of cAMP response element binding protein (CREB), and expression of apoptotic proteins in cortical neuronal nuclei of newborn piglets. Studies were performed in 20 anesthetized normoxic piglets ventilated at either a Paco2 of 65 mm Hg, 80 mm Hg, or 40 mm Hg for 6 h. Energy metabolism was documented by ATP and phosphocreatine (PCr) levels. Results show ATP and PCr levels were significantly lower in the hypercapnic groups than the normocapnic. CaMK IV activity, phosphorylated CREB density, and Bax protein expression were all significantly higher in the hypercapnic groups than the normocapnic group. Bcl-2 protein was similar in all three groups, making the ratio of Bax/Bcl-2 significantly higher in the hypercapnic groups than in the normocapnic group. We conclude that hypercapnia alters neuronal energy metabolism, increases phosphorylation of transcription factors, and increases the expression of apoptotic proteins in the cerebral cortex of newborn piglets and therefore may be deleterious to the newborn brain.

Nitration of Bax and Bcl-2 proteins during hypoxia in cerebral cortex of newborn piglets and the effect of nitric oxide synthase inhibition.

Previous studies have shown that cerebral tissue hypoxia results in increased expression of Bax protein, thereby altering the ratio of Bax to Bcl-2 or formation of Bax/Bcl-2 heterodimer. Hypoxia also induces the generation of nitric oxide free radicals in the cerebral cortex of newborn animals. The present study tests the hypothesis that tissue hypoxia will result in nitration of Bax and Bcl-2 proteins in the neuronal nuclei of newborn piglets. Studies were performed in 22 piglets, 3-5 days old, divided into normoxic (n = 7), hypoxic (n = 9) and hypoxic + NNLA (n = 6) groups. Hypoxia was induced by decreasing the FiO(2) (5-7%) for 60 min and cerebral hypoxia documented by determining tissue ATP and phosphocreatine (PCr) levels. The density of protein bands was expressed as absorbance (OD x mm(2)). PCr levels were 3.03 +/- 0.85 micromol/g brain in the normoxic group and 0.88 +/- 0.32 micromol/g brain in the hypoxic group (p < 0.001 vs. normoxia) and 0.55 +/- 0.13 (p < 0.001 vs. normoxia) in the NNLA-treated hypoxic group. There was increased nitration of Bax protein in hypoxic neuronal nuclei as compared to normoxic and NNLA-treated-hypoxic group nuclei: 211.61 +/- 25.93 versus 124.8 +/- 14.88 and 133.86 +/- 7.42 OD x mm(2), respectively (p < 0.001 vs. normoxia). Nitration of Bcl-2 was not altered significantly in either group. We conclude that there is increased nitric oxide-mediated nitration of Bax in cortical neuronal nuclei during hypoxia and that this increase correlates inversely with the decrease in tissue energy levels. We speculate that, during hypoxia, nitration of Bax and Bcl-2 proteins may regulate heterodimer formation and activation of programmed cell death mechanisms.

NMDA receptor modification during graded hypoxia in the cerebral cortex of newborn piglets.

Previous studies have shown that the cerebral N-methyl-D-aspartate (NMDA) receptor is altered during hypoxia in newborn piglets. The present study tests whether modification of the glutamate and ion channel sites of the NMDA receptor correlates with the progressive decrease in cerebral energy metabolism induced by hypoxia. Degrees of cerebral hypoxia were attained by exposure of ventilated piglets to decreased oxygen at different concentrations and confirmed by tissue phosphocreatine levels. During graded hypoxia, the number of glutamate sites decreased, the affinity of the ion channel site increased, the inhibition by Zn(2+) increased, the activation by glutamate increased, and the activation by glycine decreased. Therefore, modification of the NMDA receptor correlates with the energy state of the tissue. Alterations in receptor phosphorylation may gradually modify the NMDA receptor and may be initiated by subtle decreases in tissue oxygenation in the newborn brain.

Expression of phosphorylation of N-methyl-D-aspartate receptor subunits during graded hypoxia in the cerebral cortex of newborn piglets.

The present study tests the hypothesis that during graded hypoxia, N-methyl-D-aspartate (NMDA) receptor expression and phosphorylation are altered in the cerebral cortex of newborn piglets. Studies were performed in anesthetized, ventilated piglets, 6 normoxic and 9 exposed to different lengths of decreased fractions of inspired oxygen to achieve varying biochemical levels of phosphocreatine (PCr). P(2) membrane proteins were immunoprecipitated with antiphosphoserine, antiphosphotyrosine, or antiphosphothreonine antibodies and separated by sodium dodecyl sulfate polyacrylamide gel electrophoresis. Proteins were transblotted and probed with NMDA receptor subunit 1 (NR1), NR2A or NR2B antibodies. As tissue PCr levels decreased from 3.5 to 0.5 micromol/g brain during hypoxia, NR1, NR2A and NR2B protein increased by 84, 56 and 38%, respectively. Phosphorylated serine, tyrosine and threonine residues also increased during hypoxia on the three subunits. However, the increase in subunit protein exceeded the increase in phosphorylated residues for all three subunits. Therefore, the ratio of phosphorylated/dephosphorylated serine, tyrosine and threonine residues decreased with worsening hypoxia. We speculate that an alteration in the ratio of phosphorylated/dephosphorylated residues of the NMDA receptor may regulate receptor activation during hypoxia.

The effect of moderate hypocapnic ventilation on nuclear Ca2+-ATPase activity, nuclear Ca2+ flux, and Ca2+/calmodulin kinase IV activity in the cerebral cortex of newborn piglets.

Previous studies have shown that hypocapnia results in fragmentation of nuclear DNA in the cerebral cortex of newborn piglets. We tested the hypothesis that hypocapnia results in decreased ATP and phosphocreatine (PCr) levels and increased nuclear high-affinity Ca++-ATPase activity, intranuclear Ca++ flux, and CaM kinase IV activity in neuronal nuclei of piglets. Three groups of piglets were ventilated as either hypocapnic (a PaCO2 of 20 mm Hg), normocapnic (a PaCO2 of 40 mm Hg), or corrected hypocapnic (ventilated as hypocapnic but with CO2 added to maintain normocapnia) for 1 h. Tissue ATP levels were lower in the hypocapnic than in the normocapnic group. PCr levels were lower and 45Ca++-influx, Ca++-ATPase activity and CaM kinase IV activity were higher in hypocapnic than in normocapnic or corrected hypocapnic piglets. We conclude that hypocapnia alters nuclear membrane Ca++ flux mechanisms and may alter neuronal phosphorylation mechanisms in the cerebral cortex of piglets.