The Landscape of Resource Utilization After Resuscitation of 22-, 23-, and 24-Weeks' Gestation Infants.

OBJECTIVE: To compare estimated healthcare resources needed to care for 22 through 24 weeks' gestation infants. STUDY DESIGN: This multicenter, retrospective cohort study included 1505 live in-born and out-born infants 22 through 24 weeks' gestational age at delivery from 6 pediatric tertiary care hospitals from 2011 through 2020. Median neonatal intensive care unit (NICU) length of stay (LOS) for each gestational age was used as a proxy for hospital resource utilization, and the number of comorbidities and medical technology use for each infant were used as estimates of future medical care needs. Data were analyzed using Kruskal-Wallis with Nemenyi's posthoc test and Fisher's exact test. RESULTS: Of the identified newborns, 22-week infants had shorter median LOS than their 23- and 24-week counterparts due to low survival rates. There was no significant difference in LOS for surviving 22-week infants compared with surviving 23-week infants. Surviving 22-week infants had similar proportions of comorbidities and medical technology use as 23-week infants. CONCLUSIONS: Compared with 23- and 24-week infants, 22-week infants did not use a disproportionate amount of hospital resources. Twenty-two-week infants should not be excluded from resuscitation based on concern for increased hospital care and medical technology requirements. As overall resuscitation efforts and survival rates increase for 22-week infants, future research will be needed to assess the evolution of these results.

Acute Delivery Room Resuscitation of Neonates Exposed to Selective Serotonin Reuptake Inhibitors.

OBJECTIVE: To determine whether full-term neonates with in utero exposure to selective serotonin reuptake inhibitors (SSRI) require respiratory support in the delivery room, as indicated by the standardized Neonatal Resuscitation Program algorithm, significantly more often than nonexposed neonates. STUDY DESIGN: In this retrospective cohort study, we extracted data from medical records of full-term neonates with and without in utero SSRI exposure, defined as documentation of third trimester maternal SSRI treatment. A hospital-based sample was identified at Northwestern Medical Hospital in Chicago, Illinois. Full-term singleton newborns identified in a 6-month period (n = 4933) were selected for study. Neonates with a major congenital anomaly were excluded. The primary outcome was initiation of respiratory support in the delivery room, as indicated by the Neonatal Resuscitation Program algorithm. RESULTS: Of the 4933 full-term singleton neonates, 3.3% were exposed to SSRI in utero. Respiratory support was initiated significantly more often in SSRI exposed (12.9%) than unexposed (4.2%) neonates (covariate-adjusted OR, 4.04; 95% CI, 2.40-6.49). In utero SSRI exposure also was associated with a higher rate of neonatal intensive care unit admission (covariate-adjusted OR, 2.19; 95% CI, 1.30-3.50) and 1-minute Apgar score of ≤5 (covariate-adjusted OR, 3.51; 95% CI, 2.07-5.67). CONCLUSIONS: In this cohort, in utero SSRI exposure was associated with a significantly greater odds of resuscitation in the delivery room as well as neonatal intensive care unit admission. Although the mechanism underlying these associations have not been determined and causality cannot be assumed, these findings support a recommendation that third trimester SSRI exposure be considered a risk factor for needing resuscitation.

Mortality and Advanced Support Requirement for Patients With Cancer With COVID-19: A Mathematical Dynamic Model for Latin America.

PURPOSE: In the midst of a global pandemic, evidence suggests that similar to other severe respiratory viral infections, patients with cancer are at higher risk of becoming infected by COVID-19 and have a poorer prognosis. METHODS: We have modeled the mortality and the intensive care unit (ICU) requirement for the care of patients with cancer infected with COVID-19 in Latin America. A dynamic multistate Markov model was constructed. Transition probabilities were estimated on the basis of published reports for cumulative probability of complications. Basic reproductive number (R0) values were modeled with R using the EpiEstim package. Estimations of days of ICU requirement and absolute mortality were calculated by imputing number of cumulative cases in the Markov model. RESULTS: Estimated median time of ICU requirement was 12.7 days, median time to mortality was 16.3 days after infection, and median time to severe event was 8.1 days. Peak ICU occupancy for patients with cancer was calculated at 16 days after infection. Deterministic sensitivity analysis revealed an interval for mortality between 18.5% and 30.4%. With the actual incidence tendency, Latin America would be expected to lose approximately 111,725 patients with cancer to SARS-CoV-2 (range, 87,116-143,154 patients) by the 60th day since the start of the outbreak. Losses calculated vary between < 1% to 17.6% of all patients with cancer in the region. CONCLUSION: Cancer-related cases and deaths attributable to SARS-CoV-2 will put a great strain on health care systems in Latin America. Early implementation of interventions on the basis of data given by disease modeling could mitigate both infections and deaths among patients with cancer.

Effects of a Resuscitation Strategy Targeting Peripheral Perfusion Status versus Serum Lactate Levels among Patients with Septic Shock. A Bayesian Reanalysis of the ANDROMEDA-SHOCK Trial.

Rationale: A recent randomized controlled trial showed that a peripheral perfusion-guided resuscitation strategy was associated with lower mortality and less organ dysfunction when compared with lactate-guided resuscitation strategy in patients with septic shock, but the difference in the primary outcome, 28-day mortality, did not reach the proposed statistical significance threshold (P = 0.06). We tested different analytic methods to aid in the interpretation of these results.Objectives: To reassess the results of the ANDROMEDA-SHOCK trial using both Bayesian and frequentist frameworks.Methods: All patients recruited in ANDROMEDA-SHOCK were included. Both a post hoc Bayesian analysis and a mixed logistic regression analysis were performed. The Bayesian analysis included four different priors (optimistic, neutral, null, and pessimistic) for mortality endpoints. The probability of having a Sequential Organ Failure Assessment in the lowest quartile at 72 hours was assessed using Bayesian networks.Measurements and Main Results: In the Bayesian analysis, the posterior probability that a peripheral perfusion-targeted resuscitation strategy is superior to lactate-targeted resuscitation at 28 days was above 90% for all priors; the probability of benefit at 90 days was above 90% for all but the pessimistic prior. Using an optimistic prior, posterior median odds ratios were 0.61 (95% credible interval, 0.41-0.90) and 0.68 (95% credible interval, 0.47-1.01) for 28-day and 90-day mortality, respectively. The comparable frequentist odds ratios for 28-day and 90-day mortality were 0.61 (95% confidence interval [CI], 0.38-0.92) and 0.70 (95% CI, 0.45-1.08), respectively. The odds that that patients in the peripheral perfusion-targeted resuscitation arm had Sequential Organ Failure Assessment scores in the lower quartile at 72 hours was 1.55 (95% CI, 1.02-2.37).Conclusions: Peripheral perfusion-targeted resuscitation may result in lower mortality and faster resolution of organ dysfunction when compared with a lactate-targeted resuscitation strategy.

Resuscitation Strategies in Early Septic Shock: A Survey of Puerto Rico Intensive Care Physicians.

OBJECTIVE: Severe sepsis and Septic Shock may progress in the first hours after presentation and has been associated with an increased mortality. Prompt recognition and treatment of early septic shock (ESS) may improve survival. The purpose of our study was to describe the monitoring and management strategies of ESS, within Intensive Care Units (ICU) in Puerto Rico (PR). METHODS: In order to achieve our objective, a self-administered survey, previously validated by the Canadian Critical Care Trials Group, was administered to 25 physicians during a Critical Care Medicine (CCM) Meeting. Questions about usual monitoring and resuscitation end-points were administered. RESULTS: Most of the participants were affiliated to community hospitals (84%) and 92% were pulmonary or CCM specialists, with more than 15 years of working experience (80%). Monitoring devices and parameters mostly used by at least 85% of the respondents were: Oxygen Saturation, Foley catheters, Telemetry, Heart Rate, Blood Pressure, and Urinary Output. Intra-arterial lines and Central Venous Pressure were less used. Most use normal saline (96%), as the initial fluid of resuscitation. Only 24% would use inotropes to improve perfusion. CONCLUSION: Significant variability exists in the management of ESS among physicians in the ICU in PR. Compared to other studies, fewer physicians in PR use invasive monitoring techniques. These results highlight the need for quality education and training in CCM as well as continuing education in the field.

Antecedents and Outcomes of Abnormal Cranial Imaging in Moderately Preterm Infants.

OBJECTIVES: To describe the frequency and findings of cranial imaging in moderately preterm infants (born at 290/7-336/7 weeks of gestation) across centers, and to examine the association between abnormal imaging and clinical characteristics. STUDY DESIGN: We used data from the Neonatal Research Network Moderately Preterm Registry, including the most severe early (≤28 days) and late (>28 days) cranial imaging. Stepwise logistic regression and CART analysis were performed after adjustment for gestational age, antenatal steroid use, and center. RESULTS: Among 7021 infants, 4184 (60%) underwent cranial imaging. These infants had lower gestational ages and birth weights and higher rates of small for gestational age, outborn birth, cesarean delivery, neonatal resuscitation, and treatment with surfactant, compared with those without imaging (P < .0001). Imaging abnormalities noted in 15% of the infants included any intracranial hemorrhage (13.2%), grades 3-4 intracranial hemorrhage (1.7%), cystic periventricular leukomalacia (2.6%), and ventriculomegaly (6.6%). Histologic chorioamnionitis (OR, 1.47; 95% CI, 1.19-1.83), gestational age (0.95; 95% CI, 0.94-0.97), antenatal steroids (OR, 0.55; 95% CI, 0.41-0.74), and cesarean delivery (OR, 0.66; 95% CI, 0.53-0.81) were associated with abnormal imaging. The center with the highest rate of cranial imaging, compared with the lowest, had a higher risk of abnormal imaging (OR, 2.08; 95% CI, 1.10-3.92). On the classification and regression-tree model, cesarean delivery, center, antenatal steroids, and chorioamnionitis, in that order, predicted abnormal imaging. CONCLUSION: Among the 60% of moderately preterm infants with cranial imaging, 15% had intracranial hemorrhage, cystic periventricular leukomalacia or late ventriculomegaly. Further correlation of imaging and long-term neurodevelopmental outcomes in moderately preterm infants is needed.

Provider Perspectives Regarding Resuscitation Decisions for Neonates and Other Vulnerable Patients.

OBJECTIVES: To use structured surveys to assess the perspectives of pediatric residents and neonatal nurses on resuscitation decisions for vulnerable patients, including neonates. STUDY DESIGN: Pediatric providers were surveyed using scenarios for 6 critically ill patients of different ages with outcomes explicitly described. Providers were asked (1) whether resuscitation was in each patient's best interest; (2) whether they would accept families' wishes for comfort care (no resuscitation); and (3) to rank patients in order of priority for resuscitation. In a structured interview, each participant explained how they evaluated patient interests and when applicable, why their answers differed for neonates. Interviews were audiotaped; transcripts were analyzed using thematic analysis and mixed methods. RESULTS: Eighty pediatric residents and neonatal nurses participated (response rate 74%). When making life and death decisions, participants considered (1) patient characteristics (96%), (2) personal experience/biases (85%), (3) family's wishes and desires (81%), (4) disease characteristics (74%), and (5) societal perspectives (36%). These factors were not in favor of sick neonates: of the participants, 85% reported having negative biases toward neonates and 60% did not read, misinterpreted, and/or distrusted neonatal outcome statistics. Additional factors used to justify comfort care for neonates included limited personhood and lack of relationships/attachment (73%); prioritization of family's best interest, and social acceptability of death (36%). When these preconceptions were discussed, 70% of respondents reported they would change their answers in favor of neonates. CONCLUSIONS: Resuscitation decisions for neonates are based on many factors, such as considerations of personhood and family's interests (that are not traditional indicators of benefit), which may explain why decision making is different for the neonatal population.

Latent class analysis shows that paediatricians' opinions about the advanced resuscitation of extremely preterm infants were diverse and influenced by personal beliefs.

AIM: The aim of this study was to survey paediatricians, who taught neonatal resuscitation in Brazil, about when they would apply advanced resuscitation in the delivery room for newborn infants born at 23-26 weeks of gestational age. METHODS: This cross-sectional study focused on an electronic questionnaire that was sent to paediatricians who acted as instructors for the Brazilian Neonatal Resuscitation Program from December 2011 to September 2013. The primary outcome was the gestational age at which the respondent would apply advanced resuscitation in the delivery room. Latent class analysis identified the profiles of the instructors, and logistic regression identified the variables associated with belonging to one of the derived classes. RESULTS: The 560 (82%) instructors who agreed to participate fell into three latent classes: pro-resuscitation, intermediate and pro-limitation, with high, intermediate and low probabilities of performing advanced resuscitation in neonates born at 23-26 weeks. In the multivariate model, group membership was associated with the paediatrician's age, years of practice and personal importance of religion and the patient's birthweight, future quality of life and probability of death. CONCLUSION: The opinions of paediatricians performing advanced resuscitation on extremely preterm infants in the delivery room were diverse and influenced by personal beliefs.

Caracterización de pacientes ingresados a la sala de reanimación de urgencias: estudio descriptivo en un hospital regional chileno, período 2013-2016 / Profile of patients in the emergency reanimation unit: obserbational study in a chilean hospital, 2013 to 2016

Introducción: Las patologías que podrían motivar el ingreso a una Sala de Reanimación (SR) son múltiples, y asimismo, presentarse en cualquier momento, independientemente del sexo y la edad. A pesar de esta versatilidad, no existen investigaciones que describan la realidad chilena y la literatura extranjera es escasa. En consecuencia, nuestro estudio buscó caracterizar clínico-demográficamente a los pacientes ingresados a SR del Hospital San Juan de Dios de Los Andes, Chile. Materiales y métodos: Estudio de corte transversal. Se trabajó con base de datos anonimizada. El tamaño muestral calculado fue de al menos 1014 sujetos (intervalo de confianza de 95%, precisión de 3%). Se incluyeron los ingresos entre enero de 2013 y junio de 2016, obteniendo una muestra de 1018 pacientes. Variables estudiadas: sexo, edad, diagnóstico general, diagnóstico específico, mes y horario. Se trabajó con Microsoft Excel® utilizando estadística descriptiva. Aprobado por comité éticocientífico. Resultados: 58,1% (n=593) hombres; 42,5% (n=434) mayores de 64 años. Diagnósticos generales más frecuentes: cardiovascular (50,3%) (n=512), neurológico (16,3%) (n=166) y traumático (11,7%) (n=119). Diagnósticos específicos más frecuentes: taquiarritmia (15,9%) (n=162) e infarto miocárdico (12,6%) (n=128). La mayor cantidad de ingresos se registró en enero, febrero y junio (promedio 28 ingresos), y entre las 20 y 00 hrs (22,8%) (n=232). Discusión: Existe un amplio predominio de las enfermedades cardiovasculares. La distribución por mes, sexo y edad parece estar supeditada al comportamiento de dicho grupo; no así la distribución por horarios, ya que las enfermedades cardiovasculares suelen presentarse matinalmente. En general, nuestros resultados coinciden con la literatura extranjera disponible.

Introduction: Admission to Resuscitation Room could be engendered by many different pathologies, which could appear at any time without regard to sex and age. Nevertheless, in spite of this versatility, there are no investigations that describe the Chilean reality, and the foreign literature is limited. Thus, our study sought to characterize clinically and demographically the patients admitted to RR of the Hospital San Juan de Dios de Los Andes, Chile. Materials and methods: A cross-sectional study was carried out based on an anonymised database. The calculated sample size was at least 1014 subjects (95% confidence interval, 3% accuracy). Convenience sampling was used, including admissions between January of 2013 and June of 2016, obtaining a sample of 1018 patients. Variables studied: sex, age, general diagnosis, specific diagnosis, month and schedule. We worked with Microsoft Excel® using descriptive statistics. Approved by ethical-scientific committee. Results: 58.1% (n=593) of the sample were men; with a 42.5% (n=434) of the whole sample being older than 64 years of age. Most frequent general diagnoses: cardiovascular (50.3%) (n=512), neurological (16.3%) (n=166) and traumatic (11.7%) (n=119). Most frequent specific diagnoses: tachyarrhythmia (15.9%) (n=162) and myocardial infarction (12.6%) (n= 128). The highest amount of admission was registered in January, February and June (average 28), and between 8 P.M. and midnight (22.8%) (n=232). Discussion: There is an apparent predominance of cardiovascular diseases. The distribution by month, sex and age seems to be contingent on the behavior of this group. This is not the case for the distribution by schedules, since cardiovascular diseases usually appear during the morning. In general, our results coincide with the available foreign literature.

Necesidad de reanimación en prematuros menores de 32 semanas expuestos a sulfato de magnesio para neuroprotección fetal / Need for resuscitation in preterm neonates less than 32 weeks treated with antenatal magnesium sulphate for neuroprotection

Introducción: El empleo de sulfato de magnesio para neuroprotección fetal es un tratamiento cada vez más frecuente. Objetivo: Estudiar la asociación entre sulfato de magnesio administrado a la gestante y la necesidad de reanimación neonatal. Pacientes y método: Estudio prospectivo de un grupo de prematuros menores de 32 semanas expuestos al sulfato de magnesio como neuroprotector y otro grupo retrospectivo inmediatamente anterior al inicio de este tratamiento. En ambos grupos se descartaron los casos que no habían recibido maduración pulmonar con corticoides. Se analizaron y compararon el porcentaje de reanimación y diferentes comorbilidades. Resultados: Se incluyó a 107 prematuros, 56 expuestos al sulfato de magnesio. El porcentaje de reanimación avanzada fue similar en ambos grupos. No se encontraron diferencias en mortalidad, ventilación mecánica invasiva, tiempo de la primera deposición y otras comorbilidades. Conclusiones: El sulfato de magnesio para neuroprotección no aumenta de forma significativa la necesidad de reanimación de los prematuros menores de 32 semanas.

Introduction: Magnesium sulphate administration is recommended for foetal neuroprotection in pregnant women at imminent risk of early preterm birth. Objective: To evaluate the relationship between intrapartum magnesium sulphate for foetal neuroprotection and delivery room resuscitation of preterm infants less 32 weeks. Patients and method: A prospective observational study was conducted on preterm infants less 32 weeks exposed to magnesium sulphate for neuroprotection, and a comparison made with another historic group immediately before starting this treatment. Cases in both groups that had not reached lung maturity with corticosteroids were rejected. The rates of resuscitation, morbidity and mortality for each of the groups were analysed and compared. Results: There was a total of 107 preterm, with 56 exposed to magnesium sulphate. Rate of advanced resuscitation were similar between the two groups. There were no other differences in mortality, invasive mechanical ventilation, time to first stool, and other comorbidities. Conclusions: Intrapartum magnesium sulphate for foetal neuroprotection was not associated with an increased need for intensive delivery room resuscitation and other morbidities in these cohorts of less than 32 weeks preterm infants.

Factors associated with the need for ventilation at birth of neonates weighing ≥2,500 g.

OBJECTIVES: Approximately 20-40% of annual global neonatal deaths occur among infants with birthweights ≥2,500 g, and most of these deaths are associated with intrapartum asphyxia in low- and middle-income countries. This study aims to evaluate the peripartum variables associated with the need for resuscitation at birth of neonates weighing ≥2,500 g. METHOD: This case-control retrospective study was performed on data from all public reference maternity units in the state of Ceará, Northeast Brazil, between March 2009 and March 2010. The subjects were singleton neonates without malformations weighing ≥2,500 g, who required positive-pressure ventilation in the delivery room. The controls had a 1-minute Apgar score of ≥8 and did not undergo resuscitation. Variables associated with positive-pressure ventilation in the delivery room were evaluated via conditional multivariate logistic regression. RESULTS: Of the 2,233 live births with birth weights ≥2,500 g, 1-minute Apgar scores ≤7, and no malformations, 402 patients met the inclusion criteria, and they were paired with 402 controls. Risk variables for positive-pressure ventilation at birth were a gestational age <37 weeks (OR: 3.54; 95% CI: 1.14-10.92) and meconium-stained amniotic fluid (8.53; 4.17-17.47). Cervical examination at maternal admission (0.57; 0.38-0.84) and a written follow-up of the labor (0.68; 0.46-0.98) were identified as protective variables. CONCLUSIONS: Significant flaws in obstetric care are associated with the need for positive-pressure ventilation at birth for neonates weighing ≥2,500 g.

Labor stimulation with oxytocin: effects on obstetrical and neonatal outcomes.

OBJECTIVE: to evaluate the effects of labor stimulation with oxytocin on maternal and neonatal outcomes. METHOD: descriptive and analytical study with 338 women who gave birth at a tertiary hospital. Obstetric and neonatal variables were measured and compared in women submitted and non-submitted to stimulation with oxytocin. Statistics were performed using Chi-square test, Fisher exact test, Student t-test; and crude Odds Ratio with 95% confidence interval were calculated. A p < 0.05 was considered statistically significant. RESULTS: stimulation with oxytocin increases the rates of cesarean sections, epidural anesthesia and intrapartum maternal fever in primiparous and multiparous women. It has also been associated with low pH values of umbilical cord blood and with a shorter duration of the first stage of labor in primiparous women. However, it did not affect the rates of 3rd and 4th degree perineal lacerations, episiotomies, advanced neonatal resuscitation, 5-minute Apgar scores and meconium. CONCLUSION: stimulation with oxytocin should not be used systematically, but only in specific cases. These findings provide further evidence to health professionals and midwives on the use of oxytocin during labor. Under normal conditions, women should be informed of the possible effects of labor stimulation with oxytocin.

Factors associated with the need for ventilation at birth of neonates weighing >/=; 2, 500 g

OBJECTIVES: Approximately 20-40% of annual global neonatal deaths occur among infants with birthweights ≥2,500 g, and most of these deaths are associated with intrapartum asphyxia in low- and middle-income countries. This study aims to evaluate the peripartum variables associated with the need for resuscitation at birth of neonates weighing ≥2,500 g. METHOD: This case-control retrospective study was performed on data from all public reference maternity units in the state of Ceará, Northeast Brazil, between March 2009 and March 2010. The subjects were singleton neonates without malformations weighing ≥2,500 g, who required positive-pressure ventilation in the delivery room. The controls had a 1-minute Apgar score of ≥8 and did not undergo resuscitation. Variables associated with positive-pressure ventilation in the delivery room were evaluated via conditional multivariate logistic regression. RESULTS: Of the 2,233 live births with birth weights ≥2,500 g, 1-minute Apgar scores ≤7, and no malformations, 402 patients met the inclusion criteria, and they were paired with 402 controls. Risk variables for positive-pressure ventilation at birth were a gestational age <37 weeks (OR: 3.54; 95% CI: 1.14-10.92) and meconium-stained amniotic fluid (8.53; 4.17-17.47). Cervical examination at maternal admission (0.57; 0.38-0.84) and a written follow-up of the labor (0.68; 0.46-0.98) were identified as protective variables. CONCLUSIONS: Significant flaws in obstetric care are associated with the need for positive-pressure ventilation at birth for neonates weighing ≥2,500 g.

[Need for resuscitation in preterm neonates less than 32 weeks treated with antenatal magnesium sulphate for neuroprotection]. / Necesidad de reanimación en prematuros menores de 32 semanas expuestos a sulfato de magnesio para neuroprotección fetal.

INTRODUCTION: Magnesium sulphate administration is recommended for foetal neuroprotection in pregnant women at imminent risk of early preterm birth. OBJECTIVE: To evaluate the relationship between intrapartum magnesium sulphate for foetal neuroprotection and delivery room resuscitation of preterm infants less 32 weeks. PATIENTS AND METHOD: A prospective observational study was conducted on preterm infants less 32 weeks exposed to magnesium sulphate for neuroprotection, and a comparison made with another historic group immediately before starting this treatment. Cases in both groups that had not reached lung maturity with corticosteroids were rejected. The rates of resuscitation, morbidity and mortality for each of the groups were analysed and compared. RESULTS: There was a total of 107 preterm, with 56 exposed to magnesium sulphate. Rate of advanced resuscitation were similar between the two groups. There were no other differences in mortality, invasive mechanical ventilation, time to first stool, and other comorbidities. CONCLUSIONS: Intrapartum magnesium sulphate for foetal neuroprotection was not associated with an increased need for intensive delivery room resuscitation and other morbidities in these cohorts of less than 32 weeks preterm infants.

Labor stimulation with oxytocin: effects on obstetrical and neonatal outcomes / Estimulação do parto com oxitocina: efeitos nos resultados obstétricos e neonatais / Estimulación del parto con oxitocina: efectos en los resultados obstétricos y neonatales

Abstract Objective: to evaluate the effects of labor stimulation with oxytocin on maternal and neonatal outcomes. Method: descriptive and analytical study with 338 women who gave birth at a tertiary hospital. Obstetric and neonatal variables were measured and compared in women submitted and non-submitted to stimulation with oxytocin. Statistics were performed using Chi-square test, Fisher exact test, Student t-test; and crude Odds Ratio with 95% confidence interval were calculated. A p < 0.05 was considered statistically significant. Results: stimulation with oxytocin increases the rates of cesarean sections, epidural anesthesia and intrapartum maternal fever in primiparous and multiparous women. It has also been associated with low pH values of umbilical cord blood and with a shorter duration of the first stage of labor in primiparous women. However, it did not affect the rates of 3rd and 4th degree perineal lacerations, episiotomies, advanced neonatal resuscitation, 5-minute Apgar scores and meconium. Conclusion: stimulation with oxytocin should not be used systematically, but only in specific cases. These findings provide further evidence to health professionals and midwives on the use of oxytocin during labor. Under normal conditions, women should be informed of the possible effects of labor stimulation with oxytocin.

Resumo Objetivo: avaliar os efeitos da estimulação do parto com oxitocina nos resultados maternos e neonatais. Método: estudo descritivo e analítico, com 338 mulheres que deram à luz em um hospital de nível terciário. Variáveis obstétricas e neonatais foram medidas e comparadas em mulheres com e sem estimulação com oxitocina. Estatísticas foram feitas utilizando-se o teste Qui-quadrado, teste exato de Fisher e o teste t-Student; e as Odds Ratio brutas com intervalo de confiança de 95% foram calculadas. Um valor de p < 0,05 foi considerado estatisticamente significativo. Resultados: a estimulação com oxitocina aumentou as taxas de cesarianas, anestesia peridural, febre materna intraparto em primíparas e multíparas. Ela também foi associada com baixos valores de pH do cordão umbilical e com uma menor duração da primeira fase do parto em primíparas. No entanto, ela não afetou as taxas de laceração perineal de terceiro e quarto graus, a episiotomia, a reanimação neonatal avançada, o teste de Apgar de 5 minutos e o mecônio. Conclusão: a estimulação com oxitocina não deveria ser utilizada de maneira sistemática, mas apenas em casos muito específicos. Estes resultados fornecem evidências adicionais aos profissionais de saúde e às parteiras sobre o uso de oxitocina durante o parto. Em condições normais, as mulheres deveriam ser informadas sobre os possíveis efeitos da estimulação com oxitocina.

Resumen Objetivo: valorar los efectos de la estimulación del parto con oxitocina en los resultados maternos y neonatales. Método: estudio descriptivo y analítico con 338 mujeres que parieron en un hospital de tercer nivel. Variables obstétricas y neonatales fueron medidas y comparadas en mujeres con y sin estimulación con oxitocina. Estadísticos Chi-cuadrado, test exacto de Fisher, test t-Student, Odd Ratio cruda y un intervalo de confianza del 95% fueron calculados. Un valor p < 0,05 se consideró estadísticamente significativo. Resultados: la estimulación con oxitocina incrementó el ratio de cesáreas, analgesia epidural, fiebre materna intraparto en primíparas y multíparas; también se relacionó con bajos valores de pH de cordón umbilical, y menor duración de la primera fase del parto en primíparas. Sin embargo no afectó la tasa de desgarros de 3-4 grado, episiotomías, reanimación neonatal avanzada, test de Apgar a los 5 minutos o meconio. Conclusión: la estimulación con oxitocina no debería emplearse de forma sistemática, sino solo en casos muy indicados. Estos hallazgos proporcionan mayor evidencia a los profesionales y matronas a cerca del uso de oxitocina durante el parto. En condiciones normales, las mujeres deberían estar informadas de los posibles efectos de la estimulación con oxitocina.

Surviving Sepsis Campaign: association between performance metrics and outcomes in a 7.5-year study.

PURPOSE: To determine the association between compliance with the Surviving Sepsis Campaign (SSC) performance bundles and mortality. DESIGN: Compliance with the SSC performance bundles, which are based on the 2004 SSC guidelines, was measured in 29,470 subjects entered into the SSC database from January 1, 2005, through June 30, 2012. Compliance was defined as evidence that all bundle elements were achieved. SETTING: Two hundred eighteen community, academic, and tertiary care hospitals in the United States, South America, and Europe. PATIENTS: Patients from the emergency department, medical and surgical wards, and ICU who met diagnosis criteria for severe sepsis and septic shock. METHODS: A multifaceted, collaborative change intervention aimed at facilitating adoption of the SSC resuscitation and management bundles was introduced. Compliance with the SSC bundles and associated mortality rate was the primary outcome variable. RESULTS: Overall lower mortality was observed in high (29.0%) versus low (38.6%) resuscitation bundle compliance sites (p < 0.001) and between high (33.4%) and low (32.3%) management bundle compliance sites (p = 0.039). Hospital mortality rates dropped 0.7% per site for every three months (quarter) of participation (p < 0.001). Hospital and intensive care unit length of stay decreased 4% (95% CI: 1% - 7%; p = 0.012) for every 10% increase in site compliance with the resuscitation bundle. CONCLUSIONS: This analysis demonstrates that increased compliance with sepsis performance bundles was associated with a 25% relative risk reduction in mortality rate. Every 10% increase in compliance and additional quarter of participation in the SSC initiative was associated with a significant decrease in the odds ratio for hospital mortality. These results demonstrate that performance metrics can drive change in clinical behavior, improve quality of care, and may decrease mortality in patients with severe sepsis and septic shock.

Surviving Sepsis Campaign: association between performance metrics and outcomes in a 7.5-year study.

PURPOSE: To determine the association between compliance with the Surviving Sepsis Campaign (SSC) performance bundles and mortality. DESIGN: Compliance with the SSC performance bundles, which are based on the 2004 SSC guidelines, was measured in 29,470 subjects entered into the SSC database from January 1, 2005 through June 30, 2012. Compliance was defined as evidence that all bundle elements were achieved. SETTING: Two hundred eighteen community, academic, and tertiary care hospitals in the United States, South America, and Europe. PATIENTS: Patients from the emergency department, medical and surgical wards, and ICU who met diagnosis criteria for severe sepsis and septic shock. METHODS: A multifaceted, collaborative change intervention aimed at facilitating adoption of the SSC resuscitation and management bundles was introduced. Compliance with the SSC bundles and associated mortality rate was the primary outcome variable. RESULTS: Overall lower mortality was observed in high (29.0%) versus low (38.6%) resuscitation bundle compliance sites (p < 0.001) and between high (33.4%) and low (32.3%) management bundle compliance sites (p = 0.039). Hospital mortality rates dropped 0.7% per site for every 3 months (quarter) of participation (p < 0.001). Hospital and intensive care unit length of stay decreased 4% (95% CI 1-7%; p = 0.012) for every 10% increase in site compliance with the resuscitation bundle. CONCLUSIONS: This analysis demonstrates that increased compliance with sepsis performance bundles was associated with a 25% relative risk reduction in mortality rate. Every 10% increase in compliance and additional quarter of participation in the SSC initiative was associated with a significant decrease in the odds ratio for hospital mortality. These results demonstrate that performance metrics can drive change in clinical behavior, improve quality of care, and may decrease mortality in patients with severe sepsis and septic shock.

Serial neutrophil values facilitate predicting the absence of neonatal early-onset sepsis.

OBJECTIVE: To validate established neonatal neutrophil reference ranges (RRs) and determine the utility of serial measurements of neutrophil values in the first 24 hours to predict the absence of neonatal early-onset sepsis (EOS). STUDY DESIGN: Retrospective study of 2073 admissions to the neonatal intensive care unit (2009-2011). Neonates were classified as blood culture-positive, proven EOS (n = 9), blood culture-negative but clinically suspect EOS (n = 292), and not infected (n = 1292). Neutrophil values from 745 not-infected neonates without perinatal complications were selected to validate RR distributions. Positive and negative predictive values were calculated; area under receiver operating characteristic curves (AUCs) were constructed to predict the presence or absence of EOS. Neutrophil value scores were established to determine whether serial neutrophil values predict the absence of EOS. RESULTS: Seventy-seven percent of admissions to the neonatal intensive care unit were evaluated for EOS: 9 (0.56%) had proven EOS with positive blood culture ≤ 37 hours; 18% had clinically suspect EOS. Neutropenia occurred in preterm neonates, and nonspecific neutrophilia was common in uninfected neonates. The distribution of neutrophil values differed significantly between study groups. The specificity for absolute total immature neutrophils and immature to total neutrophil proportions was 91% and 94%, respectively, with negative predictive value of 99% for proven and 78% for proven plus suspect EOS. Absolute total immature neutrophils and immature to total neutrophil proportions had the best predictability for EOS >6 hours postnatal with an AUC ∼ 0.8. Neutrophil value scores predicted the absence of EOS with AUC of 0.9 and 0.81 for proven and proven plus suspect EOS, respectively. CONCLUSION: Age-dependent neutrophil RRs remain valid. Serial neutrophil values at 0, 12, and 24 hours plus blood culture and clinical evaluation can be used to discontinue antimicrobial therapy at 36-48 hours.

Resuscitation at birth in neonates with meningomyelocele.

AIMS: Compare the need for neonatal resuscitation procedures between newborn infants with and without meningomyelocele (MMC). RESULTS: This retrospective case-control study included 94 neonates with MMC, defined as open spinal dysraphism with exposure of nervous tissue, and 94 controls without malformations, paired with MMC infants by gender, mode of delivery, gestational age and time of birth. Infants were born at a university hospital in São Paulo, Brazil, from 2001 to 2010. After adjusting for perinatal variables (prenatal care, maternal hypertension, birth during the day shift, cephalic presentation, meconium in the amniotic fluid, gestational age <37 weeks and small-for-gestational-age infants), MMC increased the chance of positive pressure ventilation at birth [odds ratio (OR) 4.55 95% confidence interval (CI) 1.82-11.41], intubation at birth (OR 3.94 95% CI 1.14-13.59) and 1-min Apgar score 95% CI 0.99-7.57). CONCLUSION: MMC is an independent factor associated with the need for positive pressure ventilation and intubation at birth.

Caracterización de recién nacidos reanimados durante el año 2011 en el Hospital Clínico Regional de Concepción / Characterization of neonatal resuscitation during 2011 at Regional Clinical Hospital of Concepcion

INTRODUCCIÓN: La asfixia es responsable del 19 por ciento de las muertes neonatales que ocurren en el mundo. La reanimación neonatal disminuye la mortalidad en estos Recién Nacidos (RN). 10 por ciento de los RN requieren maniobras de reanimación, de éstos, 1 por ciento requiere reanimación avanzada. OBJETIVOS: Caracterizar los RN reanimados durante el año 2011 en un hospital público. Materiales y métodos: Estudio descriptivo retrospectivo, con historias clínicas correspondientes a la totalidad de RN durante el 2011 en el Hospital Clínico Regional de Concepción. Se seleccionaron RN que requirieron maniobras de reanimación desde ventilación a presión positiva. Se analizaron datos demográficos, Apgar, maniobras realizadas y antecedentes maternos. RESULTADOS: Del total de RN vivos (4095) fueron reanimados 130 (3,17 por ciento), de estos últimos un 57,69 por ciento de término. El 11,5 por ciento fue de muy bajo peso y el 11,5 por ciento de extremo bajo peso al nacer. Hubo parto vaginal en 49,6 por ciento y cesárea urgencia 40,8 por ciento. En relación al Apgar al (1’) resultó <7 en 93,18 por ciento de los RN. Se utilizó Ventilación a Presión Positiva (VPP) en 66,15 por ciento; reanimándose sólo con aire un 12,9 por ciento de RN de término y todos los RN Pretérmino fueron reanimados con oxígeno, regulado por oximetría de pulso. Se realizó intubación endotraqueal en 26,92 por ciento; 6,92 por ciento requirió masaje cardiaco y medicamentos. El 96,15 por ciento sobrevivió y 48,15 por ciento fueron hospitalizados en UCI. DISCUSIÓN: El porcentaje de RN reanimados fue bajo en comparación a lo señalado en la literatura, pese a ser un centro de referencia. La mayoría de los reanimados fue de término. La maniobra más utilizada fue la VPP.

INTRODUCTION: Asphyxia is responsible for 19 percent of neonatal deaths that occur worldwide. Neonatal resuscitation contributes to lower morbidity and mortality in newborns. 10 percent of newborns require some assistance to begin breathing at birth; of this group less than 1 percent require extensive resuscitative measures. OBJECTIVE: To characterize newborns resuscitated during2011 in a public hospital. Material and method: Descriptive retrospective study, including all infants born during 2011 in Regional Clinical Hospital of Concepción. Neonates that required resuscitation measures were selected from positive ventilation pressure. Demographic data, Apgar score, resuscitation measures and maternal history were analyzed. RESULTS: Out of the 4095 living newborns, 130 of them (3.17 percent) were resuscitated. Of this group, 57.69 percent were of term gestation, 11.5 percent of them were very low weight and 11.5 percent extremely low weight. Vaginal delivery ocurred in 49.6 percent and urgency cesarean section in 40.8 percent. Apgar score at (1’) resulted <7 in 93.18 percent of neonates. Positive-pressure ventilation was used in 66.15 percent; using air in 12.9 percent of term infants. All preterm infants were resuscitated with oxygen, regulated by pulse oximetry. Endotracheal intubation was used in 6.92 percent; whereas 6.92 percent required cardiac massage and drugs. 96.15 percent survived and 48.15 percent were admitted to ICU. DISCUSSION: The percentage of resuscitated neonates was low in comparison to the pointed out in literature, despite being a reference center. The majority of resuscitated infants had term gestation. The most used resuscitation measure was positive pressure ventilation.