Effect of increased opiate exposure on three years neurodevelopmental outcome in extremely preterm infants.

BACKGROUND: International guidelines recommend the use of item based scales for the assessment of pain and sedation. In our previous study, the implementation of the Neonatal Pain Agitation and Sedation Scale (N-PASS), and the associated systematic assessment and treatment of pain and sedation reduced pain and over-sedation in our intervention group, but lead to a significant increase of individual opiate exposure. This increased opiate exposure was not associated with impaired motor and mental development at one year of age. As one-year follow-up is not necessarily representative for future outcomes, we retested our sample at three years of age. METHODS: Fifty-three patients after (intervention group) and 61 before implementation (control group) of the N-PASS and the Vienna Protocol for the Management of Neonatal Pain and Sedation (VPNPS), were compared for motor, mental and behavioural development at three-years follow-up using the Bayley Scales of Infant Development. RESULTS: Cumulative opiate exposure was not associated with mental (p = .31) and motor (p = .20) problems when controlling for other important medical conditions, but was associated to lower behavioural scores (p = .007). No statistically significant differences were found with regard to mental (p = .65), psychomotor (p = .12) and behavioural (p = .61) development before and after the implementation of the N-PASS and the VPNPS. CONCLUSION: Implementing a neonatal pain and sedation protocol increased opiate exposure without affecting neurodevelopmental outcome at three-years of age.

Is it possible to make a reliable prognosis within the first hour of life for very low birth weight infants delivered after preterm premature rupture of membranes?

BACKGROUND: One third of all preterm births are due to preterm premature rupture of membranes (pPROM). An accurate prognostic evaluation after admission to the neonatal intensive care unit is necessary. OBJECTIVE: The aim of this study was to identify prognostic factors within the first hour of life for mortality, short-term pulmonary morbidity, chronic lung disease (CLD) and severe cerebral morbidity in very low birth weight (VLBW) infants after pPROM. METHODS: This retrospective study included 300 infants with pPROM who fit the study criteria and were derived from a cohort of 1,435 VLBW infants. A total of 17 obstetric and neonatal factors were evaluated by univariate and multivariate analysis. RESULTS: Gestational age at birth and 5-min Apgar score correlated significantly with all 4 outcomes. The results of the first blood gas analysis correlated with 3 outcomes and the first mean arterial pressure with 2 outcomes. Anhydramnios and a lower number of courses of antenatal steroids correlated with higher mortality, and preterm labor correlated with CLD. The multivariate analysis revealed gestational age, 5-min Apgar score, the results of the first blood gas analysis, the first mean arterial pressure and anhydramnios to be significant predictors. The positive predictive value ranged from 20 to 81%, and the negative predictive value ranged from 79 to 92%. CONCLUSION: Gestational age at birth and parameters reflecting postnatal adaptation were the most precise factors for assessment of the prognosis of VLBW infants after pPROM within the first hour of life. Apart from anhydramnios, obstetric factors did not predict neonatal outcome. At 1 h of age, our models of perinatal risk factors were more effective in predicting a favorable outcome than an adverse outcome.

Support for fast comprehension of ICU data: visualization using metaphor graphics.

OBJECTIVES: The time-oriented analysis of electronic patient records on (neonatal) intensive care units is a tedious and time-consuming task. Graphic data visualization should make it easier for physicians to assess the overall situation of a patient and to recognize essential changes over time. METHODS: Metaphor graphics are used to sketch the most relevant parameters for characterizing a patient's situation. By repetition of the graphic object in 24 frames the situation of the ICU patient is presented in one display, usually summarizing the last 24 h. RESULTS: VIE-VISU is a data visualization system which uses multiples to present the change in the patient's status over time in graphic form. Each multiple is a highly structured metaphor graphic object. Each object visualizes important ICU parameters from circulation, ventilation, and fluid balance. CONCLUSION: The design using multiples promotes a focus on stability and change. A stable patient is recognizable at first sight, continuous improvement or worsening condition are easy to analyze, drastic changes in the patient's situation get the viewers attention immediately.

Three years experience with a patient data management system at a neonatal intensive care unit.

We report about our experience with the patient data management system (PDMS) Hewlett Packard CareVue 9000 at two neonatal ICUs. We describe our PDMS configuration (hard- and software), local adjustments and enhancements such as knowledge based systems for calculating the parenteral nutrition of newborn infants (VIE-PNN), for advising medication (VIE-Nmed), and for managing mechanical ventilation (VIE-VENT), and the results of a structured interview with our staff members about the acceptance of the system. Despite some criticism nearly all collaborators liked the system, especially because of its time saving automated documentation of vital data and mechanical ventilation parameters. More than 2/3 preferred the computer assisted documentation to charting by hand, only 1/41 would have liked to return to paper documentation. All staff members possessed excellent (15/39) or good (24/39) knowledge of the system. Main points of critique were the system's therapy planning facilities (medication administration records), the restrictive facilities for documenting patient care and the yet unsolved problems of data evaluation and export. PDM systems have to be constantly adapted to the user's needs and to the changing clinical environment. Living with the system asks for an intensive dialog with the system and its functionalities, for creativity and well defined ideas about the future system development.