Perception of neonatology staff regarding the availability of equipment and supplies for the care of patients in need of nCPAP.

BACKGROUND: Respiratory distress syndrome (RDS) is Mexico's second leading cause of neonatal mortality. The 75% reduction in mortality due to RDS has been attributed to the use of nasal continuous positive airway pressure (nCPAP). A survey was conducted to determine the perception of the medical staff regarding the availability of nCPAP equipment and supplies in Mexican hospitals with neonatal intensive care units (NICUs). METHODS: We sent a survey via e-mail to several neonatologists in each state of the country, requesting only one response per hospital. We performed statistical analysis with SPSS software. RESULTS: We received 195 surveys from private (HPri) and public (HPub) hospitals with NICUs nationwide: 100% of HPri and 39% of HPub. More than 75% of the nursing and medical staff had received formal training in nCPAP in 11% of HPri and 5% of HPub. The perceived availability of CPAP equipment was 83.7% vs. 52.1%; nasal cannula supply, 75.5% vs. 36.3%; air/oxygen blender availability, 51.0% vs. 32.9%, in HPri and HPub, respectively. The observed differences were statistically significant. Significant differences were also found among healthcare institutions. CONCLUSIONS: The availability of CPAP equipment and consumables between HPub and HPri is unbalanced and is lower in public institutions. Bubble CPAP is not included essential equipment in the national catalog of instruments and equipment for public hospitals, and its request is complicated. The training of CPAP staff and the availability of bubble CPAP and supplies in public hospitals should be improved.

INTRODUCCIÓN: El síndrome de dificultad respiratoria (SDR) es la segunda causa de mortalidad neonatal en México. La reducción del 75% de la mortalidad por SDR se le ha atribuido al uso de la presión positiva nasal continua de las vías respiratorias (nCPAP). Se realizó una encuesta con el objetivo de conocer la percepción del personal médico acerca de la disponibilidad del equipo e insumos para nCPAP en hospitales de México que cuenten con unidades de cuidados intensivos neonatales (UCIN). MÉTODOS: La encuesta se envió por correo electrónico a varios neonatólogos de cada estado del país y se solicitó una sola respuesta por cada hospital. El análisis estadístico se realizó con el software SPSS. RESULTADOS: Se recibieron 195 encuestas respondidas tanto de hospitales privados (HPri) como públicos (HPub) que cuentan con UCIN a escala nacional: el 100% de HPri y el 39% de HPub. Más del 75% del personal de enfermería y médico recibió una capacitación formal en nCPAP en el 11% de HPri y el 5% de HPub. La percepción de disponibilidad de equipos de presión positiva continua de las vías respiratorias (CPAP) fue del 83.7% vs. el 52.1%; el abasto de cánulas nasales, del 75.5% vs. el 36.3%; la disponibilidad del mezclador aire/oxígeno, del 51.0 % vs. el 32.9%, en HPri y HPub, respectivamente. Las diferencias fueron estadísticamente significativas. También se encontraron diferencias significativas entre las instituciones de salud. CONCLUSIONES: La disponibilidad de equipo y material de consumo para CPAP entre HPub y HPri es desequilibrada, y es menor en las instituciones públicas. El CPAP burbuja no se encuentra incluido en el cuadro básico de equipo médico y se dificulta su solicitud. Debe mejorarse la capacitación del personal en CPAP y la disponibilidad de CPAP burbuja e insumos en los hospitales públicos.

Perception of neonatology staff regarding the availability of equipment and supplies for the care of patients in need of nCPAP / Percepción del personal de neonatología sobre la disponibilidad de equipo e insumos para la atención de pacientes con necesidad de nCPAP

Abstract Background: Respiratory distress syndrome (RDS) is Mexico's second leading cause of neonatal mortality. The 75% reduction in mortality due to RDS has been attributed to the use of nasal continuous positive airway pressure (nCPAP). A survey was conducted to determine the perception of the medical staff regarding the availability of nCPAP equipment and supplies in Mexican hospitals with neonatal intensive care units (NICUs). Methods: We sent a survey via e-mail to several neonatologists in each state of the country, requesting only one response per hospital. We performed statistical analysis with SPSS software. Results: We received 195 surveys from private (HPri) and public (HPub) hospitals with NICUs nationwide: 100% of HPri and 39% of HPub. More than 75% of the nursing and medical staff had received formal training in nCPAP in 11% of HPri and 5% of HPub. The perceived availability of CPAP equipment was 83.7% vs. 52.1%; nasal cannula supply, 75.5% vs. 36.3%; air/oxygen blender availability, 51.0% vs. 32.9%, in HPri and HPub, respectively. The observed differences were statistically significant. Significant differences were also found among healthcare institutions. Conclusions: The availability of CPAP equipment and consumables between HPub and HPri is unbalanced and is lower in public institutions. Bubble CPAP is not included essential equipment in the national catalog of instruments and equipment for public hospitals, and its request is complicated. The training of CPAP staff and the availability of bubble CPAP and supplies in public hospitals should be improved.

Resumen Introducción: El síndrome de dificultad respiratoria (SDR) es la segunda causa de mortalidad neonatal en México. La reducción del 75% de la mortalidad por SDR se le ha atribuido al uso de la presión positiva nasal continua de las vías respiratorias (nCPAP). Se realizó una encuesta con el objetivo de conocer la percepción del personal médico acerca de la disponibilidad del equipo e insumos para nCPAP en hospitales de México que cuenten con unidades de cuidados intensivos neonatales (UCIN). Métodos: La encuesta se envió por correo electrónico a varios neonatólogos de cada estado del país y se solicitó una sola respuesta por cada hospital. El análisis estadístico se realizó con el software SPSS. Resultados: Se recibieron 195 encuestas respondidas tanto de hospitales privados (HPri) como públicos (HPub) que cuentan con UCIN a escala nacional: el 100% de HPri y el 39% de HPub. Más del 75% del personal de enfermería y médico recibió una capacitación formal en nCPAP en el 11% de HPri y el 5% de HPub. La percepción de disponibilidad de equipos de presión positiva continua de las vías respiratorias (CPAP) fue del 83.7% vs. el 52.1%; el abasto de cánulas nasales, del 75.5% vs. el 36.3%; la disponibilidad del mezclador aire/oxígeno, del 51.0 % vs. el 32.9%, en HPri y HPub, respectivamente. Las diferencias fueron estadísticamente significativas. También se encontraron diferencias significativas entre las instituciones de salud. Conclusiones: La disponibilidad de equipo y material de consumo para CPAP entre HPub y HPri es desequilibrada, y es menor en las instituciones públicas. El CPAP burbuja no se encuentra incluido en el cuadro básico de equipo médico y se dificulta su solicitud. Debe mejorarse la capacitación del personal en CPAP y la disponibilidad de CPAP burbuja e insumos en los hospitales públicos.

Papel actual de la presión positiva continua en la vía aérea en el síndrome de dificultad respiratoria y nuevas evidencias / Current role of -and new evidence for- continuous positive airway pressure in respiratory distress syndrome

La ventilación mecánica y el uso temprano o profiláctico de surfactantes han sido el estándar de manejo de neonatos con síndrome de dificultad respiratoria. La evidencia a favor de esta práctica está sustentada en metaanálisis de ensayos clínicos bien controlados. A finales de los 80, estudios observacionales mostraron que los centros que utilizaban la presión positiva continua en la vía aérea (CPAP) nasal como método primario de asistencia ventilatoria, tenían menor tasa de displasia broncopulmonary asistían menos a la ventilación a sus neonatos. La falta de evidencias más sólidas ha sido una de las causas por las que este modo de atención haya permanecido restringido a pocos centros perinatales. Se revisaron los ensayos clínicos de la última década que comparan el uso profiláctico o temprano de CPAP nasal vs la ventilación mecánica en neonatos de muy bajo peso, con el uso profiláctico o selectivo de surfactante, y la extubación pronta o programada. Las investigaciones recientes permiten afirmar que el CPAP nasal temprano es una alternativa a la intubación y surfactante, en prematuros extremos en sala de partos. Disminuye la necesidad de la ventilación mecánica, del uso de surfactante y esferoides para la displasia broncopulmonar. Un umbral bajo para surfactante en neonatos asistidos tempranamente con CPAP disminuye la necesidad de ventilación mecánica.

Mechanical ventilation and early or prophylactic surfactant has been the standard of care for many years in neonates with respiratory distress syndrome (RDS). The evidence for this practice is supported in metaanalysis of well-controlled clinical trials. Observational studies showed by the end of the 1980s that perinatal centers that used continuous positive airway pressure (CPAP) as the primary method of ventilatory support had a lower rate of bronchopulmonary dysplasia and used less ventilation for their neonates. Lack of more solid evidence has been one of the reasons for which this method of care of RDS has remained restricted to few perinatal centers worldwide. Randomized multicenter clinical trials carried out during the last decade in very low birth weight neonates, which compare prophylactic or early nasal CPAP vs. mechanical ventilation with prophylactic or selective surfactant with early or programmed extubation, were reviewed. Recent clinical trials enable us to assert that early nasal CPAP is an alternative to intubation, and surfactant in the delivery room diminishes the need for mechanical ventilation, use of surfactant and steroids for bronchopulmonary dysplasia. A low threshold for surfactant in neonates supported early with CPAP diminishes the need for mechanical ventilation.

[Confounding effect of prematurity in the neonatal death associated with obstetric maternal morbidity]. / Efecto confusor de la prematuridad en la muerte neonatal asociada con morbilidad obstétrica materna.

BACKGROUND: Prematurity is considered the main factor of neonatal mortality in developed countries (60 to 80% of cases). OBJECTIVE: To determine if obstetric morbidity and/or prematurity are associated with neonatal death. PATIENTS AND METHODS: A cohort of 25,365 live newborns since January 1st 2000 to December 31st 2004 was studied. Neonatal mortality was compared according to the number of prenatal visits, single or multifetal pregnancy, the presence or not of preeclampsia/eclampsia, cesarean section or vaginal delivery, and duration of rupture of membranes, stratifying by weeks of gestational age or by preterm and term gestation, as it was convenient. Chi-square test and Odds Ratio (OR) with 95% Confidence Intervals were calculated (CI). RESULTS: There was not significant statistical difference in neonatal mortality at less number of prenatal visits, between single and twin pregnancies, in the presence of preeclampsia/eclampsia and pregnancies without complications, when they were stratified by group of gestational age. When it was controlled gestational age, malformations and maternal-fetal and obstetrical morbidity, there was not difference in mortality of neonates born vaginally or by cesarean section. It was observed an increased risk or neonatal mortality in preterm neonates with 48 hours or more of rupture of membranes (OR 3.05 CI 95% 1.64-5.66) CONCLUSIONS: Performing and stratified analysis, prematurity was the factor associated with neonatal mortality, and not the number of prenatal visits, multifetal pregnancy, preeclampsia/eclampsia, or cesarean section. The duration of rupture of membranes is an independent factor of prematurity for neonatal mortality.

[Impact of maternal antecedents on neonatal mortality in a regional perinatal hospital]. / Repercusión de los antecedentes maternos en la mortalidad neonatal de un hospital perinatal.

OBJECTIVE: Determine the prevalence of maternal risk factors and evaluate their impact on neonatal mortality in a regional perinatal center. MATERIALS AND METHODS: A cohort of 25,365 live newborns was studied between January 1st 2000 and December 31st 2004. Maternal antecedents were registered in a data base: sociodemographic; medical history; obstetric antecedents of previous pregnancies; as well as evolution of current pregnancy and birth. Newborn birth weight, gestational age and condition at discharge were registered too. Neonates who died were considered cases and controls those discharged alive. Mortality was compared to the presence or absence of risk factors in maternal medical history. Prevalence, odds ratio (OR) with 95% confidence interval, and attributable fraction in the exposed and the population were calculated with the SPSS 8.0 and Epi Info 6.4 programs. RESULTS: The most notable maternal factors associated with newborn mortality were maternal age > or = 30 years OR 1.5 (1.37-2.0), less than 7 prenatal exams OR 2.17 (1.52-3.09) (53.5% attributable fraction in the exposed and 23.3% in population), eclampsia OR 4.66 (2.82-7.64), type-II diabetes OR 5.41 (2.11-12.99), urinary tract infection OR 1.98 (1.40-2.78), positive serology to human immunodeficiency virus OR 41.75 (5.77-230.9), membrane rupture > or = 48 hours OR 22.99 (13.10-40.2), polyhydramnios OR 31.53 (19.12-51.6) and abruptio placentae OR 42.18 (21.06-83.1). CONCLUSIONS: Transpartum risk factors had a larger impact on mortality than pregnancy or pregestational factors.

[Maternal history impact in neonatal mortality]. / Influencia de los antecedentes maternos en la mortalidad neonatal.

BACKGROUND: Perinatal clinical picture allows identifying psychosocial features in pregnant women, them medical, obstetrical, and pregnancy history, present delivery, and neonatal mortality risk factors. OBJECTIVE: To know prevalence of maternal risk factors and evaluates them impact on neonatal mortality. MATERIALS AND METHODS: A cohort of 25,365 live newborns was studied between January 1st 2000 and December 31st 2004. Maternal sociodemographic and obstetrical history was registered in a database; as well as weight, gestational age, and neonate discharge condition. Dead neonates were considered cases and controls those discharged alive. Mortality was compared with maternal history. Prevalence, odds ratio (OR) with 95% confidence interval, and exposed and population attributable fraction were calculated with the SPSS 8.0 and Epi Info 6.4 applications. RESULTS: Maternal factors associated with newborn mortality were: maternal age > or = 30 years OR 1.5 (1.37-2.0), less than seven prenatal consultations OR 2.17 (1.52-3.09), 53.5% of attributable fraction in exposed and 23.3% in population, eclampsia OR 4.66 (2.82-7.64), type 2 diabetes OR 5.41 (2.11-12.99), urinary tract infection OR 1.98 (1.40-2.78), positive serology to HIV OR 41.75 (5.77-230.9), membrane rupture > or = 48 hours OR 22.99 (13.10-40.2), polyhydramnios OR 31.53 (19.12-51.6) and premature separation of the placenta OR 42.18 (21.06-83.1). CONCLUSIONS: Risk factors history during delivery has a larger impact on mortality than pregnancy or pregestational factors.

[Neonatal mortality in a regional perinatal hospital in Merida, Yucatan, 1995-2004. II. Analysis of causes and risk factors]. / Mortalidad neonatal en un hospital perinatal regional de Mérida, Yucatán, de 1995 al 2004. II. Anlisis de causas y factores de riesgo.

OBJECTIVE: To analyze the causes of neonatal mortality, its distribution, the moment of appearance and risk factors. PATIENTS AND METHOD: We studied a cohort of 46,297 live newborns born at the mentioned hospital, weighing 500 g or more. In a database we registered: birth weight, gestational age, days of hospital stay, discharged condition, one and five Apgar minute score, morbidity, death causes, moment of death, reducible death/reducible difficult death rate presented in less than 24 hours, 1 to 6 days, and 7 to 27 postnatal days. We compared morbidity, mortality, and risk factors in a three-year period to facilitate the analysis. RESULTS: Mortality increased with the lesser one minute Apgar score: 0.2, 9.7 and 42.9% when score was 7-10, 4-6, or 0-3, respectively, and 0.6, 41.9 and 62.9% at five minute Apgar score. Malformations were the first cause of death, which increased from 28.6 to 40.3%. Respiratory distress syndrome mortality decreased 34% and that of meconium aspiration syndrome 53%. Reducible death/hardly reducible death rate occurred from 1 to 6 days decreased 67%, from 5.2 to 1.7 (reference value 1). CONCLUSIONS: Preventable causes of death decreased significantly, particularly those related to perinatal causes, although they are still high compared with developed countries.

[Neonatal mortality in a regional perinatal hospital in Merida, Yucatan, 1995-2004 I. Analysis of the gross, specific rates]. / Mortalidad neonatal en un hospital perinatal regional de Mérida, Yucatán, de 1995 al 2004 I. Análisis de las tasas crudas y específicas.

OBJECTIVE: To evaluate the neonatal mortality and the specific neonatal mortality rates by groups of birthweight and gestacional age, at the Ignacio García Téllez National Medical Center which is a reference tertiary perinatal center of the Social Security Mexican Institute for the Yucatan Peninsula, along the period of 1995-2004. MATERIAL AND METHODS: A cohort of 46,297 live newborns was studied with birtweight of 500 grams or more, that were discharged between January 1st 1995 and December 31st 2004. Birthweight, gestational age, length of hospitalization, condition at discharge were captured in a data base. Triennial analysis of mortality was done. RESULTS: The proportion of neonates with birthweight <2,500 g increased and 19% neonates <1,000 g 50%, the increment was 21% for preterm neonates, 46% for immature, and 40% for those extremely immature. The early neonatal mortality rate diminished from 7.0 to 6.9, the late mortality from 3.0 to 2.2, the neonatal from 10.0 to 9.2/1,000 live newborn, the survival increased 232% in neonates with birthweight between 500-749 g, 25% between 750-999 g, 5.8% between 1,000-1,249 g, 8.2% between 1,250-1,499 g. The neonatal mortality decreased 31.8% from the expected, because the adjusted neonatal mortality rate was 13.5 compared with the observed 9.2/1,000 live newborn. CONCLUSIONS: There was a significant increase of the survival with lesser birthweight and gestational age, although it was not reflected in the brut neonatal mortality rate because there was an increase of the risk population.

[Graphic representation of the neonatal mortality risk at a regional perinatal center in Mérida, Yucatán, México]. / Representación gráfica del riesgo de mortalidad neonatal en un centro perinatal regional en Mérida, Yucatán, México.

OBJECTIVE: To determine the neonatal mortality risk according to gestational age and birth weight. MATERIAL AND METHODS: The cohort consisted of 19,668 newborns of Centro Médico Nacional (National Medical Center) Ignacio García Téllez, a tertiary level healthcare institution of the Instituto Mexicano del Seguro Social (Mexican Institute of Social Security, IMSS) of the Yucatan Peninsula. All newborns discharged from the hospital between January 1st, 1995 and October 31st, 1999 were included in the study. Birth weight, gestational age, and conditions upon discharge were recorded. Absolute risk (AR) of mortality was calculated for each week-of-gestation- and birth group. RESULTS: Observed AR in newborns 34 to 44 weeks of gestational age and weighing at least 2,250 g was 0.4, while that for those 26 to 32 weeks of gestational age and weighing between 1000 g was 15%. CONCLUSIONS: AR of neonatal mortality increased inversely proportional to gestational age and birth weight. These data can be used as reference values for our hospital and for comparison with other hospitals. The English version of this paper is available at: http://www.insp.mx/salud/index.html.

Representacián gráfica del riesgo de mortalidad neonatal en un centro perinatal regional en Mérida, Yucatán, México / Graphic representation of the neonatal mortality risk at a regional perinatal center in Mérida, Yucatán, México

OBJECTIVE: To determine the neonatal mortality risk according to gestational age and birth weight. MATERIAL AND METHODS: The cohort consisted of 19,668 newborns of Centro MÚdico Nacional (National Medical Center) Ignacio GarcÝa TÚllez, a tertiary level healthcare institution of the Instituto Mexicano del Seguro Social (Mexican Institute of Social Security, IMSS) of the Yucatan Peninsula. All newborns discharged from the hospital between January 1st, 1995 and October 31st, 1999 were included in the study. Birth weight, gestational age, and conditions upon discharge were recorded. Absolute risk (AR) of mortality was calculated for each week-of-gestation- and birth group. RESULTS: Observed AR in newborns 34 to 44 weeks of gestational age and weighing at least 2,250 g was 0.4, while that for those 26 to 32 weeks of gestational age and weighing between 1000 g was 15. CONCLUSIONS: AR of neonatal mortality increased inversely proportional to gestational age and birth weight. These data can be used as reference values for our hospital and for comparison with other hospitals.

Encefalopatía hipóxico isquémica con lesiones ganglio-talámicas selectivas: presentación de un caso / The hypoxic-ischemic encephalopathy in neonate: a case report

El propósito de este informe es hacer notar la naturaleza selectiva de las lesiones encontradas en un neonato con encefalopatía hipóxico isquémica. Se hace mención de la utilidad del ultrasonido transfontanelar para identificarlas y, cómo se correlacionan los hallazgos con lo referido en la literatura médica. Caso clínico. Se presenta un recién nacido a término, que cursó con encefalopatía poshipóxica causada por la ruptura uterina. El paciente cursó con grave afectación neurológica y datos incompletos de muerte cerebral. Las imágenes del ultrasonido y la tomografía computarizada mostraron zonas hemorrágicas cuya extensión comprendió casi completamente los tálamos y los ganglios basales. Discusión. Los hallazgos ultrasonográficos y tomográficos encontrados en este caso suelen estar relacionados con una elevada letalidad y secuelas graves. Por lo tanto, son indicadores de valor pronóstico. Las lesiones encontradas son semejantes a las provocadas experimentalmente en primates mediante asfixia total.

Mortalidad perinatal en un hospital regional de tercer nivel / Perinatal mortality in a perinatal third leve regional center

Con el objetivo de determinar la tasa de mortalidad perinatal y las causas de muerte en el Departamento de Neonatología del Hospital de Gineco-Pediatría del Centro Médico Nacional "El Fénix"., IMSS, en Mérida, durante 1993, se estudiaron a todos los pacientes que nacieron y fallecieron en la Unidad. La mortalidad perinatal se dividió en intrauteria, neonatal temprana y tardía. Se analizaron estos tres componentes de acuerdo a la edad gestacional, peso al nacimiento y trofismo. Se presentaron 4526 nacimientos, incluidos 41 mortinatos, con una tasa global de 27.1 muertos por 1000 nacimientos. Se encontró que la mortalidad neonatal fue más frecuente en pacientes menores a los 1.500 g y en los menores de 30 semanas de gestación. De acuerdo a la edad gestacional no hubo diferencias significativas entre la mortalidad temprana y tardía, en relación al peso la mortalidad neonatal temprana es más frecuente en pacientes menores de 1,500 g e hipotróficos. Las principales causas de muerte fueron los problemas respiratorios, y la asfixia perinatal. Es necesario mejorar el control prenatal, establecer la atención perinatal por niveles y regionalizarla para poder impactar en las tasa se mortalidad