Ventilator-Associated Pneumonia in the Neonatal Intensive Care Unit.

See Bonus NeoBriefs videos and downloadable teaching slides Intubated infants in the NICU are at risk of developing ventilator-associated pneumonia (VAP), a common type of health care-associated infection. The Centers for Disease Control and Prevention developed guidelines for diagnosing VAP in patients younger than 1 year, which include worsening gas exchange, radiographic findings, and at least 3 defined clinical signs of pneumonia. VAP in infants is treated with empiric antibiotics selected based on local resistance patterns and individualized patient data. Many NICUs have implemented prevention bundles in an effort to decrease VAP by ensuring the cleanest environment for intubated neonates (hand hygiene, sterile handling of equipment), positioning of infants to prevent gastric reflux, and constantly reevaluating for extubation readiness. Although these prevention bundle elements are intuitive and generally low risk, none are based on strong research support. This article reviews the epidemiology, pathogenesis, diagnosis, treatment, and prevention of VAP in NICU patients, focusing on recent evidence, highlighting areas of emerging research, and identifying persistent knowledge gaps.

Early continuous renal replacement therapy during infant extracorporeal life support is associated with decreased lung opacification.

Lung opacification on chest radiography (CXR) is common during extracorporeal life support (ECLS), often resulting from pulmonary edema or inflammation. Concurrent use of continuous renal replacement therapy (CRRT) during ECLS is associated with improved fluid balance and cytokine filtration; through modification of these pathologic states, CRRT may modulate lung opacification observed on CXRs. We hypothesize that early CRRT use during infant ECLS decreases lung opacification on CXR. We conducted a retrospective cohort study comparing CXRs from infants receiving ECLS and early CRRT (n = 7) to matched infants who received ECLS alone (n = 7). The CXR obtained prior to ECLS, all CXRs obtained within the first 72 h of ECLS, and daily CXRs for the remainder of the ECLS course were analyzed. The outcome measure was the degree of opacification, determined by independent assessment of two, blinded pediatric radiologists using a modified Edwards et al.'s lung opacification scoring system (from Score 0: no opacification to Score 5: complete opacification). 220 CXRs were assessed (cases: 93, controls: 127). Inter-rater reliability was established (Cohen's weighted к = 0.74; p < 0.0001, good agreement). At baseline, the mean opacification score difference between cases and controls was 1 point (cases: 1.8, controls 2.8; p = 0.049). Using mixed modeling analysis for repeated measures accounting for differences at baseline, the average overall opacification score was 1.2 points lower in cases than controls (cases: 2.1, controls: 3.3; p < 0.0001). The overall distribution of scores was lower in cases than controls. Early CRRT utilization during infant ECLS was associated with decreased lung opacification on CXR.

Early Continuous Renal Replacement Therapy Improves Nutrition Delivery in Neonates During Extracorporeal Life Support.

OBJECTIVE: Optimizing nutrition in neonatal patients as soon as possible after extracorporeal life support (ECLS) initiation is imperative as malnutrition can worsen both short- and long-term outcomes. Fluid restriction, used to manage the fluid overload that commonly complicates neonatal ECLS, severely impairs nutrition delivery. Continuous renal replacement therapy (CRRT) can be used to help manage fluid overload. We hypothesize that early CRRT utilization ameliorates the need for fluid restriction and allows providers to prescribe higher parenteral nutrition (PN) volumes leading to better nutrition delivery. DESIGN: The design of the study was a retrospective chart review, and the setting was a single, level III neonatal intensive care unit. SUBJECTS: Neonatal patients (n = 42) treated with ECLS between January 1, 2008, and December 31, 2013. INTERVENTIONS: Comparisons were made between 2 groups: neonates who received ECLS without early CRRT initiation (group 1; n = 23) and with early CRRT initiation (group 2; n = 19). MAIN OUTCOME MEASURES: The main outcome measures were goal total fluid intake, prescribed PN volume, protein, glucose infusion rate, intralipid, and kilocalories. RESULTS: Infants who received early CRRT were prescribed higher mean total fluid intake goals (group 1: 99 mL/kg/day vs. group 2: 119 mL/kg/day, P < .001) and higher mean volumes of PN (group 1: 61 mL/kg/day vs. group 2: 81 mL/kg/day, P < .001) over the first 72 hours of ECLS compared with infants who did not receive early CRRT. Early CRRT receivers also were prescribed greater mean amounts of protein during the first 72 hours of ECLS (group 1: 2.7 g/kg/day vs. group 2: 3 g/kg/day, P = 0.03). There were no significant changes noted in prescribed glucose infusion rates, intralipid, or total kilocalories. CONCLUSIONS: Institution of early CRRT in neonates on ECLS allows for administration of greater volumes of PN with improved protein delivery. This study characterizes one benefit of early CRRT initiation in neonates on ECLS and suggests these patients could experience improved nutritional outcomes.

Implementing a practice change: early initiation of continuous renal replacement therapy during neonatal extracorporeal life support standardizes care and improves short-term outcomes.

PURPOSE: We hypothesized that a standardized approach to early continuous renal replacement therapy (CRRT) during neonatal extracorporeal life support (ECLS) results in greater homogeneity of CRRT initiation times with improvements in fluid balance and outcomes. METHODS: Retrospective analysis of data (2007-2015) obtained from neonates treated prior to (E1; n = 32) and after (E2; n = 31) a 2011 practice change: CRRT initiation within 48 h of ECLS. RESULTS: Birthweight, gestational age, ECLS mode, and age at ECLS initiation were similar to each epoch. Survival [E1: median 75%, E2: 71%] and length of ECLS [E1: median 221 h, E2: 180 h] were comparable. During E2, 100% of infants received CRRT (vs. E1: 37%; p < 0.001) and 97% of infants initiated CRRT within 48 h of ECLS (vs. E1: 13%; p < 0.001). Control charts demonstrate reduced practice variation. Elapsed time from ECLS to CRRT differed between Epochs [E1: median 105 h, E2: 9 h; p < 0.001] as did weight at CRRT initiation [E1: 4.13 kg (29% above baseline), E2: 3.19 kg (0%); p < 0.001]. Significant differences in weight change were noted on days 6 and 7 (E1: 14%, E2: 2%; raw data comparison yielded p < 0.05) and curves were different (p < 0.05). CONCLUSIONS: We successfully implemented a practice change, initiating CRRT within 48 h of ECLS cannulation, leading to decreased practice variation and improved short-term outcomes including decreased weight gain at CRRT initiation and faster return to baseline weight during the first 7 days of ECLS. We did not demonstrate changes in duration of ECLS, invasive ventilation, or survival.

A new method for group decision making and its application in medical trainee selection.

CONTEXT: The problems associated with generating a collaborative ranked preference list represent a common source of dilemma in academic medicine and medical education. Such issues present during the process of choosing among applicants to medical schools, during the selection of postgraduate trainees, and in the course of performance assessments and the prioritising of financial expenditures. Currently, most institutions use pseudo-quantitative methods, such as the averaging of scores awarded on an arbitrary scale. These methods are mathematically problematic and may not accurately reflect group opinion. METHODS: The present authors developed a novel algorithm for creating a collaborative preference list that generates and sorts a matrix of pairwise comparisons between applicants or choices without placing any reliance on arbitrary Likert scale-type scores. This method achieves equality in influence across individual assessors, as well as transparency and reproducibility. The authors report a case study of their experience using this new algorithm in the 2013 neonatal-perinatal fellowship match. RESULTS: When used by this group in the selection of fellowship trainees, the method proposed here allowed for greater efficiency and created a rank-order list that did not require reshuffling or significant debate. A survey of faculty staff and fellows showed much higher levels of satisfaction with the new algorithm and a unanimous desire to use the new algorithm in the future, in preference to a score-based system. CONCLUSIONS: The algorithm developed and described here may reduce arbitrariness in processes that require the collaborative creation of a preference list. This method may have wide applicability in medical education and training, and beyond. The present authors' experience of using this algorithm during the National Resident Matching Program match showed improved perceptions of fairness, ease of use and efficiency.

The Importance of Interpolation in Computerized Growth Charting.

Computer growth charting is increasingly available for clinical and research applications. The LMS method is used to define the growth curves on the charts most commonly used in practice today. The data points for any given chart are at discrete points, and computer programs may simply round to the closest LMS data point when calculating growth centiles. We sought to determine whether applying an interpolation algorithm to the LMS data for commonly used growth charts may reduce the inherent errors which occur with rounding to the nearest data point. We developed a simple, easily implemented interpolation algorithm to use with LMS data. Using published growth charts, we compared predicted growth centiles using our interpolation algorithm versus a standard rounding approach. Using a test scenario of a patient at the 50th centile in weight, compared to using our interpolation algorithm, the method of simply rounding to the nearest data point resulted in maximal z-score errors in weight of the following: 2.02 standard deviations for the World Health Organization 0-to-23 month growth chart, 1.07 standard deviations for the Fenton preterm growth chart, 0.71 standard deviations for the Olsen preterm growth chart, and 0.11 standard deviations for the CDC 2-to-18 year growth chart. Failure to include an interpolation algorithm when designing computerizing growth charts can lead to large errors in centile and z-score calculations.

Nasal foreign body removal in children.

Nasal foreign bodies in children are often managed in the pediatric emergency department. The child is usually between 2 and 4 years old, and the foreign body is most commonly a plastic toy or bead. Nasal foreign bodies are removed by a number of techniques. Positive-pressure expulsion is accomplished by orally applied pressure via a parent's mouth or an Ambu bag or by nasally applied pressure via a catheter or an oxygen source. The object can be washed out with nasally applied saline. Direct mechanical extraction is possible with a variety of tools, including forceps, hooks, or balloon-tipped catheters. Each method carries its own risks and benefits. Serious complications of nasal foreign bodies include posterior dislodgement and aspiration, trauma caused by the object itself or removal attempts, infection, and choanal stenosis. Magnets and button batteries require emergent removal as they carry the risk of septal perforation or necrosis, which may develop within a relatively short time.