Factors Associated With Failure of Non-invasive Ventilation in Preterm Neonates Requiring Initial Respiratory Support.

BACKGROUND: Non-invasive ventilation (NIV) modalities minimize the requirement for invasive mechanical ventilation (IMV) in preterm neonates, therefore improving neonatal outcomes, as IMV is linked to increased complications. However, NIV has demonstrated an elevated likelihood of failure, for which various studies have been done, but very little research is available addressing the factors that are responsible for NIV failure in resource-limited areas of developing nations. Understanding the underlying factors and their association with NIV failure in very and moderately preterm neonates at a tertiary care hospital would be important in devising targeted strategies to increase NIV success and newborn outcomes. OBJECTIVE: To compare the following factors in neonates of 28-34 weeks gestational age with or without failure of NIV: fraction of inspired oxygen (FiO2) at the time of initiating NIV, time at surfactant administration, respiratory distress syndrome presence, antenatal steroid use, time taken for post-surfactant administration stabilization, gestational age, development of bronchopulmonary dysplasia, and average weight gained or lost. STUDY DESIGN AND PARTICIPANTS: This was a longitudinal observational study. One hundred two preterm neonates with a gestational age of 28-34 weeks in the neonatal intensive care unit (NICU) requiring NIV support within 24 hours of admission. METHODS: Eligible newborns were re-evaluated at 72 hours after commencing NIV. Outcome was evaluated as success (no NIV or NIV with positive end-expiratory pressure (PEEP)<8 cm H2O and FiO2<0.7) or failure (NIV with PEEP≥8 cm H2O or FiO2≥0.7, intubation, or death). It was compared with regard to many parameters. RESULTS:  About 40 (39%) study participants reported NIV failure within 72 hours of initiating NIV. In the NIV failure group, male babies constituted 75% (P = 0.027), the median gestational age (IQR) was 29 (29-31) weeks (P = 0.015), the median birth weight (IQR) was 1088 (960-1293.5) grams (P = 0.003), and the median weight gain or loss (IQR) was a loss of 21 (-70.5 to 11.75) grams (P<0.001). Vaginal birth comprised 67.5% of the NIV failure group, showing greater failure rates than births out of lower segment cesarean section (LSCS) (P = 0.003) Conclusion: NIV failure showed a significant association with lesser gestational age, male sex, lower birth weight, vaginal method of delivery, and lesser weight gain during hospital stay.

Use of point of care quality improvement methodology to improve newborn care, immediately after birth, at a tertiary care teaching hospital, in a resource constraint setting.

After birth, separation of mothers and newborn is a common practice in many hospitals in our country. After delivery, we take the normal newborn to the radiant warmer in the resuscitation area for routine care. This was the existing process of care at our hospital. The frontline delivery team undertook quality improvement initiative to understand and document factors creating challenges in delivering evidence-based practice of providing immediate skin-to-skin care (SSC), delayed cord clamp (DCC) and early breast feeding within 1 hour of birth. Some of the barriers identified were early newborn mother separation and late transfer of mother from delivery room to the observation area. Additionally, there was a challenge of high delivery load with variation in understanding and provision of SSC and drying on mother's abdomen. These made sustenance of improved care practices difficult. Using the Plan-Do-Study-Act (PDSA) approach some successful change ideas tested were pre-delivery counselling, avoiding separation of mother and newborn at birth by providing SSC and continuing it in the post-delivery observation area and getting family member's help in first breast feed. The delivery team adapted these successful change ideas by multiple iterations, group discussions and feedback. This resulted in improved and sustained compliance of pre-delivery counselling, SSC, DCC and initiating breast feed within 1 hour, from minimal compliance to a median compliance of 51%, 56%, 59% and 61%, respectively, over 36 months period. We undertook this quality improvement initiative at Delhi (India) at a tertiary care teaching hospital. The implementation of WHO recommended evidence-based practices benefitted more than 10 000 mother-newborn dyads annually over 2 years, using Point of Care Quality Improvement method. Implementation of evidence-based practice is possible in challenging situations using PDSA approach. The resultant contextualised processes are convenient and have better success at sustainability.

Profile of adverse events following immunization with measles rubella vaccine at a tertiary care hospital in East Delhi, India.

BACKGROUND: As a part of a measles and rubella (MR) campaign, the MR vaccine replaced the two-dose measles vaccine at 9-12 months and 16-24 months of age under the Universal Immunization Program (UIP). Although adverse events following immunization (AEFIs) following the measles and MMR vaccine at 9 months of age have been studied, AEFIs following the MR vaccine at 9 months of age have not been studied. As the MR vaccine a is very recent introduction in the UIP for routine immunization at 9 months of age, we intend to investigate the AEFI profile of MR vaccination at 9 months of age by active surveillance. AIM: We aimed to study the profile of the AEFIs with MR vaccine at 9-12 months of age in children vaccinated at the immunization clinic at the Pediatrics Department of a tertiary care hospital in East Delhi, India. METHODS: Our study was a prospective observational study (telephonic survey). Children who attended Pediatrics OPD for the first dose of the MR vaccine at 9-12 months of age were enrolled in the study. Demographic details of the children who received the first dose of MR vaccine at 9-12 months of age at the immunization clinic of the hospital were recorded in a case record form. A telephone survey was conducted on day 7 and day 30 post-vaccination for AEFIs. RESULT: A total of 278 children were enrolled in the study, but 7 were unavailable for the further telephone survey. A total of 42 (15.5%) AEFIs were reported, of which 39 (94%) were in the initial 7 days and 3 (6%) were in the following 21 days following immunization. Of the AEFIs reported, the most common symptom was fever (38%), followed by upper respiratory tract infection (30.9%), local swelling at injection site (26.1%), and skin rash (4%). CONCLUSION: MR vaccine introduced in National Immunization Schedule is found to be safe for use in children except for a few minor reactions.

Neonatal ventriculitis: a case series and review of literature.

Ventriculitis after meningitis is a serious complication in the neonatal age group. The role of intraventricular antibiotics in treatment is controversial. We present five such cases which were refractory to conventional intravenous antibiotic therapy, had persistent features of ventriculitis and in whom raised intracranial pressure (ICP) necessitated insertion of an external ventricular drain (EVD). Three of the five infants required intraventricular antibiotics but also developed EVD-related complications. Early diagnosis of ventriculitis and treatment is necessary to avoid a fatal outcome. Intravenous antibiotics are the treatment of choice, but intraventricular therapy may be considered in refractory cases. As the incidence of EVD-associated ventriculitis is high, proper care of EVDs and their early removal is mandatory.

Cardiac rhabdomyoma--a case report.

Cardiac tumors are rare in neonates, most are benign hamartomas (rhabdomyomas) of the muscle cells. Due of large size, they may cause homodynamic instability and even death in neonatal period. They are rarely diagnosed prenatally and are found in multiple forms. In ∼50% of the cases, rhabdomyoma is associated with tuberous sclerosis.