Reducing Unplanned Extubations in a Level IV Neonatal Intensive Care Unit: The Elusive Benchmark.

Unplanned extubation (UE) is a common adverse event in the neonatal intensive care unit (NICU). At our level IV NICU, we initiated a quality improvement project in 2012 to reduce UE rates from 7.47 to below 100 intubated days. We describe the strategies used. METHODS: Multiple plan-do-study-act cycles were performed to address key drivers. Important interventions focused on staff education, consistent use of a new endotracheal (ET) tube securing device, 2 providers during bedside activities, documentation of ET tube position, and targeted sedation. Process measures included immediate root cause analyses for UE events and the use of the endotracheal tube securing device. The primary outcome was the UE rate per 100 intubated days. RESULTS: Over a nearly 6-year study period, quarterly UE rates decreased from 7.19 to 0.66 per 100 intubated days. The proportion of neonates requiring reintubation remained stable (64%-76%). Rates of root cause analysis completion and use of the ET securing device were more than 90% in the last 3 years of the study. The majority (61%) of UE events occurred in infants with birth weights greater than 2 kg, and 46% of infants had a prior UE. UE was associated with desaturation (50%), bradycardia (22%), and the need for resuscitation (7%). CONCLUSIONS: This quality improvement effort in a level IV NICU achieved a reduction in UE rates to below 1 per 100 intubated days after more than 5 years. Consistency in practices and widespread communication with the staff was critical to the effort.

A Non-Lethal Osteogenesis Imperfecta Type II Mutation.

BACKGROUND: We discuss the ethical decision points in a case report that describes a novel COL1A1 mutation associated to Osteogenesis Imperfecta type II, but with a non-lethal outcome. CASE: A 33-year-old female underwent a 21-week ultrasound that revealed short bowed femurs and humeri with old fractures and bowed tibias and fibulas. Amniotic fluid testing revealed a novel COL1A1 mutation (c.1840G>A; p.Gly614Arg). OI Type II diagnosis was made. A previously reported mutation of the same gene but different locus (c.1840G>C; p.Gly614Arg) led to a lethal form of OI type II. The newborn was delivered via a cesarean delivery and intravenous bisphosphonates (Zaledronic acid) was administered every 3 months. Currently the infant is 22 months old, is growing, with mild bilateral conductive hearing loss. CONCLUSION: The unexpected clinical outcome should serve as a reminder that phenotypic variability can occur with genetic mutations. Our case shows that the diagnosis of the type of OI should be based not only on clinical findings and genetic investigations but also on the clinical course over time.

Newborn With Enlarged Erythematous Mass on Back: Case Report and Review of Medical Literature.

Newborn skin nodules are usually benign and self-resolving skin condition. Differential diagnosis of such lesions include cysts, hemangioma, abscess, cellulitis, sclerema neonatorum, subcutaneous fat necrosis, neurofibromatosis, benign tumors, or malignant tumors such as rhabdomyosarcoma, infantile fibrosarcoma, or neuroblastoma. We report a case of congenital subcutaneous fat necrosis in a 7-day-old baby presenting with multiple erythematous mass on back.