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OBJECTIVE: To describe the prevalence of and between-center variations in care practices and clinical outcomes of moderate and late preterm infants (MLPIs) admitted to tertiary Canadian neonatal intensive care units (NICUs). STUDY DESIGN: This was a retrospective cohort study including infants born at 320/7 through 366/7 weeks of gestation and admitted to 25 NICUs participating in the Canadian Neonatal Network between 2015 and 2020. Patient characteristics, process measures represented by care practices, and outcome measures represented by clinical in-hospital and discharge outcomes were reported by gestational age weeks. NICUs were compared using indirect standardization after adjustment for patient characteristics. RESULTS: Among 25â669 infants (17% of MLPIs born in Canada during the study period) included, 45% received deferred cord clamping, 7% had admission hypothermia, 47% received noninvasive respiratory support, 11% received mechanical ventilation, 8% received surfactant, 40% received antibiotics in the first 3 days, 4% did not receive feeding in the first 2 days, and 77% had vascular access. Mortality, early-onset sepsis, late-onset sepsis, or necrotizing enterocolitis occurred in <1% of the study cohort. Median (IQR) length of stay was 14 (9-21) days among infants discharged home from the admission hospital and 5 (3-9) days among infants transferred to community hospitals. Among infants discharged home, 33% were discharged on exclusive breastmilk and 75% on any breastmilk. There were significant variations between NICUs in all process and outcome measures. CONCLUSIONS: Care practices and outcomes of MLPIs varied significantly between Canadian NICUs. Standardization of process and outcome quality measures for this population will enable benchmarking and research, facilitating systemwide improvements.
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Recien Nacido Prematuro , Unidades de Cuidado Intensivo Neonatal , Humanos , Canadá , Recién Nacido , Estudios Retrospectivos , Femenino , Masculino , Centros de Atención Terciaria , Edad Gestacional , Evaluación de Procesos y Resultados en Atención de Salud , Enfermedades del Prematuro/terapia , Enfermedades del Prematuro/epidemiologíaRESUMEN
OBJECTIVE: To quantify site-specific costs and their association with survival without major morbidity (SWMM) in Canada for neonates <28 weeks of gestation admitted to large tertiary neonatal intensive care units. METHODS: We conducted a retrospective analysis of infants born at <28 weeks of gestation and admitted to Canadian Neonatal Network sites from 2010 through 2021. Sites that cared for at least 50 eligible infants by gestational age in weeks over the study period were included. Using a validated costing algorithm that assessed physician, nursing, respiratory therapy, diagnostic imaging, transfusions, procedural, medication, and certain indirect costs, we calculated site and resource-specific costs in 2017 Canadian dollars (CAD) and evaluated their relationship with SWMM. RESULTS: Seven sites with 8180 (range 841-1605) eligible neonates with a mean (SD) gestation of 25.4 [1.3] weeks were included. Survival to discharge or transfer was 85.3% with a mean (SD) length of stay of 75 (46) days. The mean (SD) total and daily costs per neonate varied between $94â992 ($60â283) and $174â438 ($130â501) CAD and $1833 ($916) to $2307 ($1281) CAD, respectively. Between sites, there was no relationship between costs and SWMM. CONCLUSIONS: There was marked variation in costs and SWMM between sites in Canada with universal health care. The lack of concordance between both outcomes and costs among sites may provide possibilities for outcomes improvement and cost containment.
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Recien Nacido Extremadamente Prematuro , Unidades de Cuidado Intensivo Neonatal , Recién Nacido , Lactante , Humanos , Estudios Retrospectivos , Canadá , Edad GestacionalRESUMEN
BACKGROUND: There have been concerns about the development of children conceived through assisted reproductive technology. Despite multiple studies investigating the outcomes of assisted conception, data focusing specifically on the neurodevelopmental outcomes of infants conceived through assisted reproductive technology and born preterm are limited. OBJECTIVE: This study aimed to evaluate and compare the neurodevelopmental outcomes of preterm infants born at <29 weeks' gestation at 18 to 24 months' corrected age who were conceived through assisted reproductive technology and those who were conceived naturally. STUDY DESIGN: This retrospective cohort study included inborn, nonanomalous infants, born at <29 weeks' gestation between January 1, 2010, and December 31, 2016, who had a neurodevelopmental assessment at 18 to 24 months' corrected age at any of the 10 Canadian Neonatal Follow-Up Network clinics. The primary outcome was neurodevelopmental impairment at 18 to 24 months, defined as the presence of any of the following: cerebral palsy; Bayley-III cognitive, motor, or language composite score of <85; sensorineural or mixed hearing loss; and unilateral or bilateral visual impairment. Secondary outcomes included mortality, composite of mortality or neurodevelopmental impairment, significant neurodevelopmental impairment, and each component of the primary outcome. We compared outcomes between infants conceived through assisted reproductive technology and those conceived naturally, using bivariate and multivariable analyses after adjustment. RESULTS: Of the 4863 eligible neonates, 651 (13.4%) were conceived using assisted reproductive technology. Maternal age; education level; and rates of diabetes mellitus, receipt of antenatal corticosteroids, and cesarean delivery were higher in the assisted reproduction group than the natural conception group. Neonatal morbidity and death rates were similar except for intraventricular hemorrhage, which was lower in the assisted reproduction group (33% [181 of 546] vs 39% [1284 of 3318]; P=.01). Of the 4176 surviving infants, 3386 (81%) had a follow-up outcome at 18 to 24 months' corrected age. Multivariable logistic regression adjusting for gestational age, antenatal steroids, sex, small for gestational age, multiple gestations, mode of delivery, maternal age, maternal education, pregnancy-induced hypertension, maternal diabetes mellitus, and smoking showed that infants conceived through assisted reproduction was associated with lower odds of neurodevelopmental impairment (adjusted odds ratio, 0.67; 95% confidence interval, 0.52-0.86) and the composite of death or neurodevelopmental impairment (adjusted odds ratio, 0.67; 95% confidence interval, 0.54-0.84). Conception through assisted reproductive technology was associated with decreased odds of a Bayley-III composite cognitive score of <85 (adjusted odds ratio, 0.68; 95% confidence interval, 0.48-0.99) and composite language score of <85 (adjusted odds ratio, 0.67; 95% confidence interval, 0.50-0.88). CONCLUSION: Compared with natural conception, assisted conception was associated with lower odds of adverse neurodevelopmental outcomes, especially cognitive and language outcomes, at 18 to 24 months' corrected age among preterm infants born at <29 weeks' gestation. Long-term follow-up studies are required to assess the risks of learning disabilities and development of complex visual-spatial and processing skills in these children as they reach school age.
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Recien Nacido Prematuro , Trastornos del Neurodesarrollo/epidemiología , Técnicas Reproductivas Asistidas , Adulto , Canadá/epidemiología , Hemorragia Cerebral Intraventricular/epidemiología , Parálisis Cerebral/epidemiología , Cesárea , Estudios de Cohortes , Diabetes Mellitus/epidemiología , Escolaridad , Femenino , Glucocorticoides/uso terapéutico , Humanos , Recién Nacido , Enfermedades del Prematuro/epidemiología , Edad Materna , Paridad , Embarazo , Complicaciones del Embarazo/epidemiología , Estudios RetrospectivosRESUMEN
BACKGROUND: Cardiovascular and renal adaptation in neonates with Respiratory Distress Syndrome (RDS) and Transient Tachypnea of the Newborn (TTN) may be different. METHODS: Neonates ≥32 weeks were diagnosed with RDS or TTN based on clinical, radiologic and lung sonographic criteria. Weight loss, feeding, urine output, and sodium levels were recorded for the first 3 days, and serial ultrasounds assessed central and organ Doppler blood flow. A linear mixed model was used to compare the two groups. RESULTS: Twenty-one neonates were included, 11 with TTN and 10 with RDS. Those with RDS showed less weight loss (- 2.8 +/- 2.7% versus - 5.6 +/- 3.4%), and less enteral feeds (79.2 vs 116 ml/kg/day) than those with TTN, despite similar fluid prescription. We found no difference in urine output, or serum sodium levels. Doppler parameters for any renal or central parameters were similar. However, Anterior Cerebral Artery maximum velocity was lower (p = 0.03), Superior Mesenteric Artery Resistance Index was higher in RDS, compared to TTN (p = 0.02). CONCLUSION: In cohort of moderately preterm to term neonates, those with RDS retained more fluid and were fed less on day 3 than those with TTN. While there were no renal or central blood flow differences, there were some cerebral and mesenteric perfusion differences which may account for different pathophysiology and management.
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Síndrome de Dificultad Respiratoria del Recién Nacido , Taquipnea Transitoria del Recién Nacido , Humanos , Recién Nacido , Pulmón/diagnóstico por imagen , Proyectos Piloto , UltrasonografíaRESUMEN
AIM: To evaluate the impact of outreach education targeting neuroprotection on outcomes of outborn infants with moderate-to-severe hypoxic ischemic encephalopathy (HIE). METHODS: A retrospective cohort study of infants admitted with moderate-to-severe HIE was conducted following the implementation of outreach education in January 2016. Key interventions were early identification and referral of infants with encephalopathy utilizing telemedicine and a centralized communication system, hands-on simulation, and interactive case discussion and dissemination of clinical management guidelines and educational resources. The association between the intervention and a composite outcome of death and/or severe brain injury on brain magnetic resonance imaging (MRI) was tested controlling for the confounding factors. RESULTS: Of 165 neonates, 37 (22.4%) died and/or had a severe brain injury. This outcome decreased from 35% (27/77) to 11% (10/88) following the implementation of outreach education (P<0.001). Eligible infants not undergoing therapeutic hypothermia within 6 hours from birth decreased from 19.5% (15/77) to 4.5% (4/88). The use of inotropes decreased from 49.3% (38/77) to 19.6% (13/88). Any core temperature below 33°C was recorded for 20/53 (38%) before and 16/78 (21%) after, while those within the target range of 33°C to 34°C at admission to a tertiary care facility increased from (15/53) 28% to (51/88) 58%. Outreach education was independently associated with decreased composite outcome of death and/or severe brain injury on MRI (adjusted odds ratio 0.2; 95% confidence interval 0.07 to 0.52). CONCLUSION: Outreach education targeting neuroprotection for infants with moderate-to-severe HIE was associated with a reduction in death and/or severe brain injury.
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OBJECTIVE: The aim of this study was to evaluate the association between neonatal seizure and neurodevelopmental impairment (NDI) at 18 to 24 months in extremely preterm neonates. The association between anticonvulsants use and NDI was also assessed. STUDY DESIGN: In this retrospective cohort study of infants born at <29 weeks' gestation from the Canadian Neonatal Network and Canadian Neonatal Follow-Up Network databases, we compared mortality and neurodevelopmental outcomes in infants who had neonatal seizures with those without seizures after adjusting for confounders. RESULTS: Of the 2,762 eligible neonates, 133 (4.8%) had seizures. Infants who had seizures were of lower gestation (25.2 vs. 26.2 weeks) and birth weight (819 vs. 920 g) and had higher rates of adverse outcomes. Neonatal seizure was associated with higher odds of composite outcome of death or significant NDI (74 vs. 27%; adjusted odds ratio [OR]: 3.4; 95% confidence interval [CI]: 2.2-5.4). Death or significant NDI was higher in infants with seizures treated with anticonvulsants than those without treatment (89 vs. 70%); however, when adjusted for confounders, it was not significantly different (adjusted OR: 3.5; 95% CI: 0.83-14.6). CONCLUSION: Neonatal seizures were independently associated with higher odds of death or significant NDI at 18 to 24 months of age. Relationship of anticonvulsant and neurodevelopmental outcomes needs further studies.
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Anticonvulsivantes/uso terapéutico , Discapacidades del Desarrollo/etiología , Recien Nacido Extremadamente Prematuro , Enfermedades del Prematuro , Convulsiones/complicaciones , Peso al Nacer , Canadá , Estudios de Cohortes , Discapacidades del Desarrollo/epidemiología , Femenino , Edad Gestacional , Humanos , Lactante , Recién Nacido , Recien Nacido Prematuro , Enfermedades del Prematuro/mortalidad , Masculino , Estudios Retrospectivos , Factores de Riesgo , Convulsiones/tratamiento farmacológicoRESUMEN
BACKGROUND: Respiratory distress syndrome (RDS) is considered one of the major contributors to severe pulmonary dysfunction and consequent death in preterm infants. Despite widespread improvements in care, including increased utilization of antenatal steroids, use of surfactant replacement therapy, and advances in conventional mechanical ventilation (CMV), chronic lung disease (CLD) occurs in 42% of surviving preterm infants born at less than 28 weeks gestational age (GA). High frequency ventilation (HFV) aims to optimize lung expansion while minimizing tidal volume (Vt) to decrease lung injury. Two methods of HFV - high frequency oscillatory ventilation (HFOV) and high frequency jet ventilation (HFJV) - are widely used, but neither has demonstrated clear superiority in elective or rescue mode. OBJECTIVES: To compare the benefits and side effects of HFJV versus HFOV for mortality and morbidity in preterm infants born at less than 37 weeks GA with pulmonary dysfunction in both elective and rescue modes. SEARCH METHODS: We used the standard search strategy of the Cochrane Neonatal Review Group to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2015, Issue 11), MEDLINE via PubMed (1966 to November 30, 2015), EMBASE (1980 to November 30, 2015), and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (1982 to November 30, 2015). We also searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomized controlled trials and quasi-randomized trials. We imposed no date, language, or publication restrictions. SELECTION CRITERIA: We planned to include randomized, cluster-randomized, and quasi-randomized controlled trials if study authors stated explicitly that groups compared in the trial were established by a random or systematic method of allocation. We planned to exclude cross-over studies, as they would not allow assessment of the outcomes of interest. DATA COLLECTION AND ANALYSIS: We used the standard methods of the Neonatal Cochrane Review Group, including independent trial assessment and data extraction. We intended to analyze the data by using risk ratios (RRs) and risk differences (RDs) and 1/RD. We planned to calculate the number needed to treat for an additional beneficial outcome (NNTB) or the number needed to treat for an additional harmful outcome (NNTH). MAIN RESULTS: We found no studies that met our inclusion criteria. AUTHORS' CONCLUSIONS: We found no evidence to support the superiority of HFJV or HFOV as elective or rescue therapy. Until such evidence is available, comparison of potential side effects or presumed benefits of either mode is not feasible.
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Ventilación con Chorro de Alta Frecuencia , Ventilación de Alta Frecuencia , Síndrome de Dificultad Respiratoria del Recién Nacido/terapia , Humanos , Recién Nacido , Recien Nacido PrematuroRESUMEN
BACKGROUND AND OBJECTIVES: Nasal intermittent positive pressure ventilation (NIPPV) has been shown to be superior to nasal continuous positive airway pressure (CPAP) postextubation in preterm neonates. However, studies have not permitted high CPAP pressures or rescue with other modes. We hypothesized that if CPAP pressures >8 cmH2O and rescue with other modes were permitted, CPAP would be noninferior to NIPPV. METHODS: We conducted a pragmatic, comparative-effectiveness, noninferiority study utilizing network-based real-world data from 22 Canadian NICUs. Centers self-selected CPAP or NIPPV as their standard postextubation mode for preterm neonates <29 weeks' gestation. The primary outcome was failure of the initial mode ≤72 hours. Secondary outcomes included failure ≤7 days, and reintubation ≤72 hours and ≤7 days. Groups were compared using a noninferiority adjusted risk-difference (aRD) margin of 0.05, and margin of no difference. RESULTS: A total of 843 infants extubated to CPAP and 974 extubated to NIPPV were included. CPAP was not noninferior (and inferior) to NIPPV for failure of the initial mode ≤72 hours (33.0% vs 26.3%; aRD 0.07 [0.03 to 0.12], Pnoninferiority(NI) = .86), and ≤7 days (40.7% vs 35.8%; aRD 0.09 [0.05 to 0.13], PNI = 0.97). However, CPAP was noninferior (and equivalent) to NIPPV for reintubation ≤72 hours (13.2% vs 16.1%; aRD 0.01 [-0.05 to 0.02], PNI < .01), and noninferior (and superior) for reintubation ≤7 days (16.4% vs 22.8%; aRD -0.04 [-0.07 to -0.001], PNI < .01). CONCLUSIONS: CPAP was not noninferior to NIPPV for failure ≤72 hours postextubation; however, it was noninferior to NIPPV for reintubation ≤72 hours and ≤7 days. This suggests CPAP may be a reasonable initial postextubation mode if alternate rescue strategies are available.
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Ventilación con Presión Positiva Intermitente , Síndrome de Dificultad Respiratoria del Recién Nacido , Recién Nacido , Humanos , Presión de las Vías Aéreas Positiva Contínua , Recien Nacido Prematuro , Canadá , Edad Gestacional , Síndrome de Dificultad Respiratoria del Recién Nacido/terapiaRESUMEN
BACKGROUND AND OBJECTIVES: Neonatal endotracheal tube (ETT) size recommendations are based on limited evidence. We sought to determine data-driven weight-based ETT sizes for infants undergoing tracheal intubation and to compare these with Neonatal Resuscitation Program (NRP) recommendations. METHODS: Retrospective multicenter cohort study from an international airway registry. We evaluated ETT size changes (downsizing to a smaller ETT during the procedure or upsizing to a larger ETT within 7 days) and risk of procedural adverse outcomes associated with first-attempt ETT size selection when stratifying the cohort into 200 g subgroups. RESULTS: Of 7293 intubations assessed, the initial ETT was downsized in 5.0% of encounters and upsized within 7 days in 1.5%. ETT downsizing was most common when NRP-recommended sizes were attempted in the following weight subgroups: 1000 to 1199 g with a 3.0 mm (12.6%) and 2000 to 2199 g with a 3.5 mm (17.1%). For infants in these 2 weight subgroups, selection of ETTs 0.5 mm smaller than NRP recommendations was independently associated with lower odds of adverse outcomes compared with NRP-recommended sizes. Among infants weighing 1000 to 1199 g: any tracheal intubation associated event, 20.8% with 2.5 mm versus 21.9% with 3.0 mm (adjusted OR [aOR] 0.62, 95% confidence interval [CI] 0.41-0.94); severe oxygen desaturation, 35.2% with 2.5 mm vs 52.9% with 3.0 mm (aOR 0.53, 95% CI 0.38-0.75). Among infants weighing 2000 to 2199 g: severe oxygen desaturation, 41% with 3.0 mm versus 56% with 3.5mm (aOR 0.55, 95% CI 0.34-0.89). CONCLUSIONS: For infants weighing 1000 to 1199 g and 2000 to 2199 g, the recommended ETT size was frequently downsized during the procedure, whereas 0.5 mm smaller ETT sizes were associated with fewer adverse events and were rarely upsized.
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Intubación Intratraqueal , Resucitación , Humanos , Recién Nacido , Estudios de Cohortes , Intubación Intratraqueal/métodos , OxígenoRESUMEN
Excessive antimicrobial use is associated with adverse neonatal outcomes. In our cohort of 27,163 infants born at <33 weeks gestational age, the first week after birth accounted for the highest rates of antimicrobial use, and variability across sites persisted after adjustment for patient characteristics correlated with illness severity.
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Antiinfecciosos , Recién Nacido , Lactante , Humanos , Edad Gestacional , Antiinfecciosos/uso terapéuticoRESUMEN
Congenital infections with SARS-CoV-2 are uncommon. We describe two confirmed congenital SARS-CoV-2 infections using descriptive, epidemiologic and standard laboratory methods and in one case, viral culture. Clinical data were obtained from health records. Nasopharyngeal (NP) specimens, cord blood and placentas when available were tested by reverse transcriptase real-time PCR (RT-PCR). Electron microscopy and histopathological examination with immunostaining for SARS-CoV-2 was conducted on the placentas. For Case 1, placenta, umbilical cord, and cord blood were cultured for SARS-CoV-2 on Vero cells. This neonate was born at 30 weeks, 2 days gestation by vaginal delivery. RT-PCR tests were positive for SARS-CoV-2 from NP swabs and cord blood; NP swab from the mother and placental tissue were positive for SARS-CoV-2. Placental tissue yielded viral plaques with typical morphology for SARS-CoV-2 at 2.8 × 102 pfu/mL confirmed by anti-spike protein immunostaining. Placental examination revealed chronic histiocytic intervillositis with trophoblast necrosis and perivillous fibrin deposition in a subchorionic distribution. Case 2 was born at 36 weeks, 4 days gestation. RT-PCR tests from the mother and infant were all positive for SARS-CoV-2, but placental pathology was normal. Case 1 may be the first described congenital case with SARS-CoV-2 cultivated directly from placental tissue.
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COVID-19 , Complicaciones Infecciosas del Embarazo , Embarazo , Chlorocebus aethiops , Recién Nacido , Animales , Femenino , Humanos , COVID-19/diagnóstico , SARS-CoV-2 , Placenta , Células Vero , Trofoblastos , Complicaciones Infecciosas del Embarazo/diagnóstico , Transmisión Vertical de Enfermedad InfecciosaRESUMEN
BACKGROUND: Evidence-based Practice for Improving Quality (EPIQ) is a collaborative quality improvement method adopted by the Canadian Neonatal Network that led to decreased mortality and morbidity in very preterm neonates. The Alberta Collaborative Quality Improvement Strategies to Improve Outcomes of Moderate and Late Preterm Infants (ABC-QI) Trial aims to evaluate the impact of EPIQ collaborative quality improvement strategies in moderate and late preterm neonates in Alberta, Canada. METHODS: In a 4-year, multicentre, stepped-wedge cluster randomized trial involving 12 neonatal intensive care units (NICUs), we will collect baseline data with the current practices in the first year (all NICUs in the control arm). Four NICUs will transition to the intervention arm at the end of each year, with 1 year of follow-up after the last group transitions to the intervention arm. Neonates born at 32 + 0 to 36 + 6 weeks' gestation with primary admission to NICUs or postpartum units will be included. The intervention includes implementation of respiratory and nutritional care bundles using EPIQ strategies, including quality improvement team building, quality improvement education, bundle implementation, quality improvement mentoring and collaborative networking. The primary outcome is length of hospital stay; secondary outcomes include health care costs and short-term clinical outcomes. Neonatal intensive care unit staff will complete a survey in the first year to assess quality improvement culture in each unit, and a sample will be interviewed 1 year after implementation in each unit to evaluate the implementation process. INTERPRETATION: The ABC-QI Trial will assess whether collaborative quality improvement strategies affect length of stay in moderate and late preterm neonates. It will provide detailed population-based data to support future research, benchmarking and quality improvement. TRIAL REGISTRATION: ClinicalTrials.gov, no. NCT05231200.
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Recien Nacido Prematuro , Nacimiento Prematuro , Lactante , Femenino , Recién Nacido , Humanos , Mejoramiento de la Calidad , Alberta/epidemiología , Unidades de Cuidado Intensivo Neonatal , Edad Gestacional , Ensayos Clínicos Controlados Aleatorios como Asunto , Estudios Multicéntricos como AsuntoRESUMEN
BACKGROUND: Early-onset sepsis results in increased morbidity and mortality in preterm infants. Antimicrobial Stewardship Programs (ASPs) address the need to balance adverse effects of antibiotic exposure with the need for empiric treatment for infants at the highest risk for early-onset sepsis. METHODS: All preterm infants <34 weeks gestational age born during a 6-month period before (January 2017-June 2017) and a 6-month period after (January 2019-June 2019) implementation of ASP in May 2018 were reviewed. The presence of perinatal sepsis risk factors, eligibility for, versus treatment with initial empiric antibiotics was compared. RESULTS: Our cohort comprised 479 infants with a mean of 30 weeks gestation and birth weight of 1400 g. Demographics were comparable, with more Cesarean section deliveries in the post-ASP cohort. Any sepsis risk factor was present in 73.6% versus 68.4% in the pre- versus post-ASP cohorts (P = 0.23). Fewer infants were treated with antibiotics in the later cohort (60.4%) compared with the earlier cohort (69.7%; P = 0.04). Despite the presence of risk factors (preterm labor in 93% and rupture of membranes in 60%), 42% of infants did not receive initial antibiotics. Twenty percent with no perinatal sepsis risk factors were deemed low-risk and not treated. CONCLUSIONS: Implementation of a neonatal ASP decreased antibiotic initiation at birth. Antibiotic use decreased (appropriately) in the subgroup with no perinatal sepsis risk factors. Of concern, some infants were not treated despite risk factors, such as preterm labor/rupture of membrane. Neonatal ASP teams need to be aware of potentially unintended consequences of their initiatives.
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Programas de Optimización del Uso de los Antimicrobianos , Trabajo de Parto Prematuro , Sepsis , Antibacterianos/efectos adversos , Cesárea , Femenino , Edad Gestacional , Humanos , Lactante , Recién Nacido , Recien Nacido Prematuro , Embarazo , Estudios Retrospectivos , Sepsis/tratamiento farmacológicoRESUMEN
OBJECTIVE: To study the impact of an evidence-based neuroprotection care (NPC) bundle on long-term neurodevelopmental impairment (NDI) in infants born extremely premature. STUDY DESIGN: An NPC bundle targeting predefined risk factors for acute brain injury in extremely preterm infants was implemented. We compared the incidence of composite outcome of death or severe neurodevelopmental impairment (sNDI) at 21 months adjusted age pre and post bundle implementation. RESULTS: Adjusting for confounding factors, NPC bundle implementation associated with a significant reduction in death or sNDI (aOR, 0.34; 95% CI 0.17-0.68; P = 0.002), mortality (aOR, 0.31; 95% CI (0.12-0.79); P = 0.015), sNDI (aOR, 0.37; 95% CI: 0.12-0.94; P = 0.039), any motor, language, or cognitive composite score <70 (aOR, 0.48; 95% CI: 0.26-0.90; P = 0.021). CONCLUSION: Implementation of NPC bundle targeting predefined risk factors is associated with a reduction in mortality or sNDI in extremely preterm infants.
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Trastornos del Neurodesarrollo , Paquetes de Atención al Paciente , Nacimiento Prematuro , Femenino , Humanos , Incidencia , Lactante , Recien Nacido Extremadamente Prematuro , Recién Nacido , Trastornos del Neurodesarrollo/epidemiología , Trastornos del Neurodesarrollo/etiología , Trastornos del Neurodesarrollo/prevención & control , NeuroprotecciónRESUMEN
We studied the effect of a low- to moderate-volume, level III-B neonatal intensive care unit (NICU) on very low-birth-weight (VLBW) outcomes. We performed a retrospective analysis of the King Abdulaziz Hospital (KAH) NICU electronic database. Short-term outcomes of all inborn VLBW infants (501 to 1500 g) in the well-equipped, well-staffed KAH NICU (2003 to 2008) were benchmarked with data (1997 to 2002) from the National Institute of Children Health and Human Development and Neonatal Research Network (NICHD-NRN). Survival without major neonatal morbidity was defined as survival without bronchopulmonary dysplasia (BPD), grade III to IV intraventricular hemorrhage (IVH), and Bell's stage II to III necrotizing enterocolitis (NEC). The survival rates of VLBW infants at the KAH NICU ( N = 250) and the NICHD-NRN ( N = 18,153) were similar (84 versus 85%). A significantly higher rate of survival without major neonatal morbidity (80 versus 70%, P = 0.002) and lower rate of BPD (14 versus 22%, P = 0.005) were observed in KAH. The rates of grade III to IV IVH, Bell's stage II to III NEC, and late-onset sepsis were comparable in both cohorts. Our low- to moderate-volume, well-equipped, well-staffed, level III-B NICU achieved outcomes similar to the NICHD-NRN. Further study is warranted to ascertain how a lower-volume NICU achieved similar outcomes, as this could then be applied to quality improvement efforts.
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Displasia Broncopulmonar/epidemiología , Hemorragia Cerebral/epidemiología , Enterocolitis Necrotizante/epidemiología , Recién Nacido de muy Bajo Peso , Unidades de Cuidado Intensivo Neonatal/estadística & datos numéricos , Femenino , Humanos , Mortalidad Infantil , Recién Nacido , Masculino , Morbilidad , Estudios Retrospectivos , Arabia Saudita/epidemiología , Factores Sexuales , Análisis de Supervivencia , Tasa de Supervivencia , Resultado del TratamientoRESUMEN
We describe a case of a term female infant born in a rural community hospital and who developed a left-sided spontaneous tension pneumothorax shortly after birth. We used telemedicine to guide the family physician and healthcare team at the referring hospital to perform a life-saving thoracentesis using an intravenous cannula. The cannula was kept in place to drain the persistent pneumothorax during transportation to the pediatric intensive care unit at the tertiary hospital.
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AIM: Safe limits of arterial partial pressure of carbon dioxide (PaCO2) and acidosis in premature infants are not well defined. Both respiratory and systemic illness along with center-specific ventilation strategies contribute to PaCO2 fluctuations and acid-base imbalances during the critical time period of first 72 h of life. This study evaluated the association between early blood gas parameters and intraventricular hemorrhage (IVH) in preterm infants. METHODS: This retrospective observational study included neonates with a gestational age (GA) of ≤29 wks, who had at least 7 blood gas analysis done within the first 72 h of life. By adjusting for known variables that predispose to IVH, multivariable logistic regression analysis was used to study the association of PaCO2 and acid-base measures with the risk of IVH. RESULTS: Between 2013-2016, among 272 neonates who met inclusion criteria and were assessed for IVH on cranial ultrasound within first week of life, 101 neonates [mean GA of 25 ± 1.5 wks] had IVH and 171 neonates [mean GA of 25 ± 1.6 wks] had normal scans. After adjustment for confounding variables, higher values of maximum lactate (OR = 1.18, 95% CI = 1.1-1.3, p < .0001) and maximum base deficit (OR = 1.19, 95% CI = 1.1-1.2, p < .0001) within 72 h of life increased the likelihood of any grade of IVH. However, time-weighted average PaCO2, maximum and minimum PaCO2 had no statistically significant effect on the risk of IVH. The relationship remained unchanged even when moderate-severe IVH was considered as the primary outcome. CONCLUSION: Severe metabolic acidosis rather than hypo/hypercapnia during the first 72 h of life was associated with higher odds of IVH in infants born at ≤29 wks of gestation. Future studies determining levels of PaCO2 that is safe for premature brain would need to control for the metabolic component of acidosis.
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Acidosis , Enfermedades del Prematuro , Hemorragia Cerebral/epidemiología , Hemorragia Cerebral/etiología , Edad Gestacional , Humanos , Hipercapnia , Lactante , Recién Nacido , Recien Nacido Prematuro , Enfermedades del Prematuro/epidemiologíaRESUMEN
OBJECTIVES: To characterize neonatal-perinatal medicine fellows' progression toward neonatal intubation procedural competence during fellowship training. METHODS: Multi-center cohort study of neonatal intubation encounters performed by neonatal-perinatal medicine fellows between 2014 through 2018 at North American academic centers in the National Emergency Airway Registry for Neonates. Cumulative sum analysis was used to characterize progression of individual fellows' intubation competence, defined by an 80% overall success rate within 2 intubation attempts. We employed multivariable analysis to assess the independent impact of advancing quarter of fellowship training on intubation success. RESULTS: There were 2297 intubation encounters performed by 92 fellows in 8 hospitals. Of these, 1766 (77%) were successful within 2 attempts. Of the 40 fellows assessed from the start of training, 18 (45%) achieved procedural competence, and 12 (30%) exceeded the deficiency threshold. Among fellows who achieved competence, the number of intubations to meet this threshold was variable, with an absolute range of 8 to 46 procedures. After adjusting for patient and practice characteristics, advancing quarter of training was independently associated with an increased odds of successful intubation (adjusted odds ratio: 1.10; 95% confidence interval 1.07-1.14). CONCLUSIONS: The number of neonatal intubations required to achieve procedural competence is variable, and overall intubation competence rates are modest. Although repetition leads to skill acquisition for many trainees, some learners may require adjunctive educational strategies. An individualized approach to assess trainees' progression toward intubation competence is warranted.