The association of placental pathology and neurodevelopmental outcomes in patients with neonatal encephalopathy.

BACKGROUND: Studies conflict on how acute versus chronic placental pathology impacts outcomes after neonatal encephalopathy from presumed hypoxic-ischemic encephalopathy (HIE). We examine how outcomes after presumed HIE vary by placental pathology categories. METHODS: We performed retrospective chart review for neonates with presumed HIE, regardless of severity, focusing on 50 triads for whom placental specimens were available for re-review. Placentas were categorized as having only acute, any chronic, or no lesions. Primary outcomes included in-hospital morbidity/mortality and long-term neurodevelopmental symptoms. Secondary outcomes assessed neonatal MRI and EEG. RESULTS: Demographics did not differ between groups. Forty-seven neonates were treated with therapeutic hypothermia. Placental acuity category was not associated with primary or secondary outcomes, but clinical and/or histopathological chorioamnionitis was associated with abnormal EEG background and post-neonatal epilepsy (16.7%, n = 3 with chorioamnionitis versus 0%, n = 0 without chorioamnionitis, p = 0.04). CONCLUSIONS: When grouped by acute, chronic, or absent placental lesions, we observed no association with in-hospital, neurodevelopmental, MRI, or EEG outcomes. When reanalyzed by the presence of chorioamnionitis, we found that chorioamnionitis appeared to be associated with a higher risk of EEG alterations and post-neonatal epilepsy. Despite our limited sample size, our results emphasize the critical role of placental examination for neuroprognostication in presumed HIE. IMPACT: Neonatal encephalopathy presumed to result from impaired fetal cerebral oxygenation or blood flow is called hypoxic ischemic encephalopathy (HIE). Prior studies link placental pathology to various outcomes after HIE but disagree on the impact of acute versus chronic pathology. Our study determines that neurodevelopmental outcomes, in-hospital outcomes, injury on MRI, and EEG findings in patients with HIE are not differentially associated with acute versus chronic placental pathology. Chorioamnionitis is associated with an increased risk of abnormal EEG patterns and post-neonatal epilepsy. Histopathologic chorioamnionitis without clinical symptoms is common in HIE, emphasizing the crucial role of placental pathology for neuroprognostication.

Augmented Reality-Assisted Video Laryngoscopy and Simulated Neonatal Intubations: A Pilot Study.

BACKGROUND: For novice providers, achieving competency in neonatal intubation is becoming increasingly difficult, possibly because of fewer intubation opportunities. In the present study, we compared intubation outcomes on manikins using direct laryngoscopy (DL), indirect video laryngoscopy (IVL) using a modified disposable blade, and augmented reality-assisted video laryngoscopy (ARVL), a novel technique using smart glasses to project a magnified video of the airway into the intubator's visual field. METHODS: Neonatal intensive care nurses (n = 45) with minimal simulated intubation experience were randomly assigned (n = 15) to the following 3 groups: DL, IVL, and ARVL. All participants completed 5 intubation attempts on a manikin using their assigned modalities and received verbal coaching by a supervisor, who viewed the video while assisting the IVL and ARVL groups. The outcome and time of each attempt were recorded. RESULTS: The DL group successfully intubated on 32% of attempts compared to 72% in the IVL group and 71% in the ARVL group (P < .001). The DL group intubated the esophagus on 27% of attempts, whereas there were no esophageal intubations in either the IVL or ARVL groups (P < .001). The median (interquartile range) time to intubate in the DL group was 35.6 (22.9-58.0) seconds, compared to 21.6 (13.9-31.9) seconds in the IVL group and 20.7 (13.2-36.5) seconds in the ARVL group (P < .001). CONCLUSIONS: Simulated intubation success of neonatal intensive care nurses was significantly improved by using either IVL or ARVL compared to DL. Future prospective studies are needed to explore the potential benefits of this technology when used in real patients.

Patterns of phlebotomy blood loss and transfusions in extremely low birth weight infants.

OBJECTIVE: Characterize frequency and volume of blood draws and transfusions in extremely low birth weight infants in the first 10 weeks of life. STUDY DESIGN: We included infants with a birth weight <1000 g born 23 0/7-29 6/7 weeks gestational age (GA) and with a length of stay ≥10 weeks, admitted between 2014 and 2016 to a single neonatal intensive care unit. RESULTS: Of 54 infants, median (25th, 75th percentile) GA and birth weight were 25 weeks (24, 26) and 665 g (587, 822), respectively. Median number of blood draws per infant decreased from 57 (49, 65) in week 1 to 12 (8, 22) in week 10. Median volume of blood extracted was 83 mL (70, 97), and median number of blood transfusions was 8 (5, 10). CONCLUSIONS: This cohort experienced a high number and volume of blood draws. Draw frequency and transfusions decreased over the first 10 weeks of life.

Negative Temperature Differential in Preterm Infants Less Than 29 Weeks Gestational Age: Associations With Infection and Maternal Smoking.

BACKGROUND: Hypothermia is related to increased morbidity and mortality in very preterm infants; continuous temperature monitoring is necessary. Thermoregulation is limited in preterm infants. OBJECTIVES: The purpose of the research was to assess and describe negative temperature differential (NTD) and assess the associations of NTD with infant demographic characteristics, medical history, and clinical events. METHODS: An exploratory, case study design was used. Abdominal and foot temperature was measured every minute over the first 2 weeks of life in 22 preterm infants at less than 29 weeks gestational age. RESULTS: All infants experienced NTD. Daily NTD in all infants across all study days ranged from 0 to 70.7%; 2-week mean NTD over all infants ranged from 7.3% to 38.5%. Four infants treated for late onset of infection had a higher NTD than 18 infants without infection (M = 27.8%, SD = 9.52 vs. M = 16.4%, SD = 5.34, p < .05). Although not statistically significant, higher mean percentage of NTD was noted in infants having early onset infection (24.1% vs. 16.4%), African American race (20.0% vs. 15.3%), and/or being born to a mother who smoked during pregnancy (26.6% vs. 16.7%). DISCUSSION: A larger study is needed to examine associations between NTD and race, maternal smoking history, and infection. NTD might be used as a biomarker to guide acute clinical care and identify infants at risk for acute and chronic morbidity.

Perfusion Index in Very Low Birth Weight Premature Infants During Their First 2 Weeks of Life.

BACKGROUND: Our program of research focuses on thermal and circulatory stability in extremely premature infants. In prior studies, we found that infants have long periods of time in which foot temperature (FT) is higher than central temperature. We thus wanted to determine whether blood flow in the foot is increased when FT is elevated. Perfusion index (PI) can be used as a clinical indicator of peripheral perfusion, but reports on use of PI in premature infants are lacking. We employed exploratory methodology to examine foot perfusion and temperature in very low birth weight infants. AIMS: For premature infants after birth: (1) describe foot PI values for the first 2 weeks of life and (2) describe the relationship of longitudinal FT and PI. STUDY DESIGN: Case study design with longitudinal FT and PI in 17 infants born at <29 weeks' gestation with birth weight < 1,200 g for 2 weeks after birth. RESULTS: Infants averaged 851 g at birth and were 24-29 weeks' gestational age. The mean PI across all infants for 14 days was 1.04, SD = 0.79. Using a repeated measures multilevel model approach confirmed that FT and PI were positively related in these infants. CONCLUSIONS: These findings demonstrate that perfusion is increased in the periphery in extremely premature infants when FT is increased. PI measures can be used as a trend for peripheral perfusion, and these values increase over the first 2 weeks of life in infants weighing more than 750 g.

Effect of methicillin-resistant Staphylococcus aureus colonization in the neonatal intensive care unit on total hospital cost.

The rate of methicillin-resistant Staphylococcus aureus (MRSA) infection is increasing in neonatal intensive care units. We determined the economic impact of isolating and cohorting MRSA-colonized neonates on total hospital cost at a 49-bed, level III-IV neonatal intensive care unit.

Methicillin-resistant Staphylococcus aureus outbreak in an intensive care nursery: potential for interinstitutional spread.

BACKGROUND: After surveillance surveys documented the absence of methicillin-resistant Staphylococcus aureus (MRSA) in our intensive care nursery, an outbreak of MRSA infection occurred there during a 7-month period in 2005. METHODS: Control measures included reinforcement of hand hygiene and contact precautions procedures. Active surveillance cultures were obtained on all neonates, including interinstitutional transfers. A cohort unit was dedicated exclusively for neonates with MRSA. Pulsed-field gel electrophoresis was performed on isolates to determine relatedness. We surveyed transferring hospitals to evaluate MRSA activity and surveillance practices in their nurseries. RESULTS: Twenty-five neonates were colonized with MRSA; 9 of these had clinical infections. Isolates from 18 of 21 neonates from this outbreak and 4 neonates from a previous cluster were identical, including 1 isolate obtained upon transfer from another institution. Admission and discharge logs from a 9-month period showed that 127 of 460 admissions (27.6%) were admitted from 34 hospitals, and 247 of 460 (53.7%) were discharged to 32 hospitals. Among 30 transferring hospitals responding to our survey, MRSA activity occurred in 2 of 28 (7%) level 1 nurseries, 4 of 11 (36%) level 2 nurseries and 6 of 10 (60%) level 3 nurseries. Nine of the 30 hospitals (30%) performed some active surveillance. CONCLUSIONS: Interinstitutional transfer can play a role in the initiation and propagation of MRSA outbreaks in neonatal nurseries. The burden of MRSA in area nurseries and the rate of transfers affect the potential for interhospital spread of MRSA and may justify changes in policy regarding surveillance for MRSA and communication between hospitals.