[Medication errors in a neonatal unit: One of the main adverse events]. / Los errores de tratamiento en una unidad neonatal, uno de los principales acontecimientos adversos.

INTRODUCTION: Neonatal units are one of the hospital areas most exposed to the committing of treatment errors. A medication error (ME) is defined as the avoidable incident secondary to drug misuse that causes or may cause harm to the patient. The aim of this paper is to present the incidence of ME (including feeding) reported in our neonatal unit and its characteristics and possible causal factors. A list of the strategies implemented for prevention is presented. MATERIAL AND METHODS: An analysis was performed on the ME declared in a neonatal unit. RESULTS: A total of 511 MEs have been reported over a period of seven years in the neonatal unit. The incidence in the critical care unit was 32.2 per 1000 hospital days or 20 per 100 patients, of which 0.22 per 1000 days had serious repercussions. The ME reported were, 39.5% prescribing errors, 68.1% administration errors, 0.6% were adverse drug reactions. Around two-thirds (65.4%) were produced by drugs, with 17% being intercepted. The large majority (89.4%) had no impact on the patient, but 0.6% caused permanent damage or death. Nurses reported 65.4% of MEs. The most commonly implicated causal factor was distraction (59%). Simple corrective action (alerts), and intermediate (protocols, clinical sessions and courses) and complex actions (causal analysis, monograph) were performed. CONCLUSIONS: It is essential to determine the current state of ME, in order to establish preventive measures and, together with teamwork and good practices, promote a climate of safety.

[Towards a safety culture in the neonatal unit: Six years experience]. / Caminando hacia una cultura de seguridad en la unidad neonatal: experiencia de 6 años.

INTRODUCTION: A safety culture is the collective effort of an institution to direct its resources toward the goal of safety. MATERIAL AND METHODS: An analysis is performed on the six years of experience of the Committee on the Safety of Neonatal Patient. A mailbox was created for the declaration of adverse events, and measures for their correction were devised, such as case studies, continuous education, prevention of nosocomial infections, as well as information on the work done and its assessment. RESULTS: A total of 1287 reports of adverse events were received during the six years, of which 600 (50.8%) occurred in the neonatal ICU, with 15 (1.2%) contributing to death, and 1282 (99.6%) considered preventable. Simple corrective measures (notification, security alerts, etc.) were applied in 559 (43.4%), intermediate measures (protocols, monthly newsletter, etc.) in 692 (53.8%), and more complex measures (causal analysis, scripts, continuous education seminars, prospective studies, etc.) in 66 (5.1%). As regards nosocomial infections, the prevention strategies implemented (hand washing, insertion and maintenance of catheters) directly affected their improvement. Two surveys were conducted to determine the level of satisfaction with the Committee on the Safety of Neonatal Patient. A rating 7.5/10 was obtained in the local survey, while using the Spanish version of the Hospital Survey on Patient Safety Culture the rate was 7.26/10. CONCLUSIONS: A path to a culture of safety has been successfully started and carried out. Reporting the adverse events is the key to obtaining information on their nature, etiology and evolution, and to undertake possible prevention strategies.

Estrategia para mejorar la seguridad del paciente en un servicio de neonatología / Strategies to improve patient safety in a neonatology service

Fundamento. La práctica de la medicina, cada vez más compleja,aumenta el riesgo de acontecimientos adversos. La seguridad delpaciente en la atención sanitaria exige que esté libre de cualquiermal evitable.Objetivo. Analizar los errores detectados en un servicio de neonatología.Método. Se realiza un plan de estudio consistente en:1) Sesión clínica informativa sobre los errores asistenciales. 2) Creaciónde un sistema de notificación de errores anónimo. 3) Períodode reflexión para analizar los errores declarados de manera retrospectiva,con la finalidad de sensibilizar a todo el personal. 4) Creaciónde un grupo de estudio (dos médicos y dos diplomados en enfermería)para analizar de forma prospectiva los errores declaradosy establecer las estrategias necesarias para su prevención.Resultados. Durante el período de reflexión (15 días) se recogen28 errores agrupados en: errores de práctica asistencial (19), secundariosa factores humanos (7) y atribuibles al sistema (2).Durante los tres primeros meses del estudio prospectivo se notifican25 errores: de tratamiento (9), de comunicación (2), en determinacionesanalíticas (1), en la alimentación (2), de asepsia (1), deprocedimientos (7) y de identificación e información (3).Se analizan las causas que pueden producirlos, entre las cualesdestacan la falta de comunicación, la sobrecarga asistencial y lafalta de atención y rutina en el trabajo diario.Conclusiones. Debemos ser conscientes de que evitar el error está ennuestras manos. La notificación anónima del error y su análisis permiteponer en marcha medidas preventivas que repercutirán en unamejor calidad de la asistencia y seguridad de nuestros pacientes(AU)

Background. The increasingly complex practice of medicine augmentsthe risk of adverse events. The principles of patient safety inhealth care demand that the patient be spared of all avoidable harm.Objectives. To analyze the medical errors detected in a neonatologyservice.Methods. The following initiatives were implemented: 1) Trainingseminar on medical errors; 2) Implementation of a system for anonymousreporting of medical errors; 3) Review period to analyze anddiscuss the reported medical errors with the ultimate goal of raisingawareness among the personnel; 4) Establishment of a study team(two physicians and two nurses) to analyze prospectively medicalerrors and to develop the necessary preventive strategies.Results. Twenty-eight medical errors were recorded during the retrospectivereview period (15 days). The errors were grouped intothe following categories: treatment errors (19), errors secondary tohuman factors (7), and factors attributable to the system (2). Duringthe first three months of the prospective evaluation phase, 25 errorswere recorded, which corresponded to treatment (9), communication(2), laboratory errors (1), nutrition (2), antisepsis (1), procedures(7), and identification and information (3). The potential causes forthe errors were analyzed; among them were lack of communication,patient care overload, lack of attention, and daily routines.Conclusions. We must be aware that avoiding medical errors is inour hands. The anonymous reporting and its analysis allow for theimplementation of preventive measures that will lead to an improvementin patient care and patient safety(AU)

Attempt to normalize simulated exhaled nitric oxide according to ventilatory settings.

BACKGROUND: Simulated exhaled nitric oxide (eNO) depends on ventilatory settings used in different experimental conditions. OBJECTIVES: To normalize the simulated minute exhaled nitric oxide according to different ventilatory settings. WORKING HYPOTHESIS: Different ventilatory settings influence the concentrations of exhaled nitric oxide and these results can be normalized. METHODOLOGY AND STUDY DESIGN: We used a rubber lung model (50 ml) with an orifice through which a 3 mm endotracheal tube was introduced. The NO, which simulated that of endogenous production, was delivered through the base of the lung using a unidirectional rotameter and obtaining a concentration of around 25 ppb. The sample of gas was recorded through a 6 F arterial catheter introduced into the endotracheal tube to its tip. The ventilator used was a Babylog 8000. Air delivered was compressed and filtered and had an NO content of under 0.3 ppb. The NO level assessed was the plateau value given by the software of the Sievers NOA apparatus. Each experiment involved sampling during 1 min, three times. Normalization was done using a multiple cubic regression formula. RESULTS: An increase in respiratory frequency or in peak of inspiratory pressure were accompanied by a decrease in eNO (ppb). Minute volume was adjusted for the percentage of leakage given by the ventilator. Normalization was obtained analyzing 518 respirations with different ventilatory settings. The coefficient of variation fell from 15.5% to 0.27%. Validation of the normalization formula was performed in other three groups (320, 372, and 372 respirations) with different simulated NO concentrations (25, 16, and 50 ppb), resulting in reduction of the coefficient of variation from 42.7% to 9.3%, from 42.3% to 10.6% and from 45.2% to 9.6%, respectively. CONCLUSIONS: Normalization of simulated minute eNO according to ventilatory settings is possible using the equipment and experimental set-up reported. Extrapolation to patients is not possible without constraints.

Amioplasia congénita y consumo materno de cocaína / Congenital amyoplasia and maternal cocaine use

Introducción: La artrogriposis múltiple congénita (AMC) es unsíndrome caracterizado por contracturas congénitas no progresivas de dos o más articulaciones. La forma clásica de AMC llamada amioplasia es siempre esporádica. En la artrogriposis neurógena, la forma más frecuente (90%), la afectación inicial se encuentra en las neuronas del asta anterior de la médula, las raíces nerviosas o el nervio periférico. Casos clínicos: Se exponen dos casos de recién nacidos que desarrollaron una clínica similar de amioplasia. El primer niño tenía contracturas articulares, atrofia de los músculos de las extremidades inferiores e incontinencia. El segundo niño presentó paraplejía fláccida con atrofia muscular y atonía muscular abdominal. Las dos madres eran consumidoras de cocaína durante el embarazo. En ambos pacientes los exámenes neurofisiológicos demostraron una denervación a diferentes niveles de la médula espinal. Discusión: Se ha postulado como causa de amioplasia congénita una necrosis de la médula espinal fetal debida a hipotensión sistémica. En adultos se han descrito casos de episodio cerebrovascular relacionados con el consumo de cocaína. Probablemente, los mecanismos están relacionados con la estimulación adrenérgica, la vasoconstricción cerebral y cambios bruscos en la presión arterial. En ambos casos las características clínicas descritas al nacer fueron debidas a denervación de la médula espinal a diferentes niveles. Los defectos encontrados en nuestros pacientes podrían estar asociados a consumo materno de cocaína durante el embarazo, que produciría vasoconstricción del pequeño lecho vascular eisquemia-infarto por alteración vascular en la médula espinal del feto

Introduction: Arthrogryposis multiplex congenita (AMC) is a term used to describe a disorder characterized by multiple, nonprogressive joint contractures at birth. The classic form of peripheral AMC, referred to as amyoplasia, is always sporadic. In neurogenic arthrogryposis, the most frequent form (90%), the initial injury would be in the anterior horm cells of the spinal cord, the nerve roots or the peripheral nerve. Case reports: We report the cases of two newborns who presented similar clinical signs of amyoplasia. One had joint contractures, muscle atrophy and incontinence. The other has flaccid paraplegia with muscle atrophy in lower limbs and abdominal muscle atony. Both mothers consumed cocaine during pregnancy. In both patients, neurophysiological examination demonstrated denervation at different levels of spinal cord. Discussion: Necrosis of the fetal spinal cord caused by systemic hypotension has been postulated as a cause of amyoplasia. The mechanism of cocaine-related cerebrovascular accidents in adults is probably related to adrenergic stimulation, cerebral vasoconstriction adna a sudden surge in blood pressure. In our two cases, the clinical findings reported at birth were due to denervation at different levels of the spinal cord. Therefore, the defects in our patients may be associated with maternal use of cocaine during pregnancy, producing small vessel vasoconstriction and vascular disruption in the fetal spinal cord

Repercusión fetal y neonatal del shock anafiláctico materno / Impact of maternal anaphylactic shock on the fetus and the newborn

Ante un shock en una embarazada (de causa hemorrágica, séptica, anafiláctica u otra) se debe tener en cuenta que hay dos pacientes vulnerables: la madre y el feto. La mejoría de la madre puede ser conseguida con la administración de inotrópicos, los cuales pueden dañar el feto al disminuir la circulación placentaria. La lesión fetal dependerá de la causa, la intensidad y la duración del shock, así como de la maduración del feto y de los fármacos empleados en su tratamiento. El factor más importante en el tratamiento del shock de la gestante será el rápido restablecimiento de la presión arterial en la madre sin reducir la perfusión placentaria. La lesión fetal puede pasar desapercibida inicialmente, por lo que será imprescindible efectuar un seguimiento clínico y de neuroimagen tanto del feto como del posterior recién nacido

Shock (hemorrhagic, septic, anaphylactic or of some other etiology) during pregnancy involves two vulnerable patients: the mother and the fetus. The recovery of the mother can be achieved with the administration of inotropic agents, but these drugs can harm the fetus by reducing the placental circulation. The extent of the damage depends on the cause, the severity and the duration of the shock, as well as the maturity of the fetus and the drugs employed to treat the mother. The most important factor in the treatment of shock in the pregnant woman is the rapid restoration of her arterial pressure without reducing the placental perfusion. Since the fetal lesion may initially go undetected, prenatal and postnatal clinical follow-up and neuroimaging are indispensable

Efficacy of three treatment schedules in severe meconium aspiration syndrome.

AIM: To compare three different schedules in severe meconium aspiration syndrome (MAS) treatment: standard, bronchoalveolar lavage (BAL) with diluted surfactant, and diluted surfactant BAL plus a single early dexamethasone dose. METHODS: Twenty-four full-term newborns with severe MAS (needing mechanical ventilation and with oxygenation index > or = 15) were divided into three groups: group I (historical control group; n = 6) treated with standard therapy; group II (n = 7) treated in the first hours of life with one BAL using diluted surfactant (beractant 5 mg/mL) in a volume of 15 mL/kg in four aliquots; and group III (n = 11) treated with one diluted surfactant BAL and a previous single dose of intravenous dexamethasone (0.5 mg/kg). RESULTS: At 12 h, groups II and III showed a significant improvement in oxygenation index (OI) compared with group I (14.7% and 27.0% vs -19.6% respectively; p = 0.012). Group III also showed a significantly lower OI than group I at 24 h (63.6% vs -27.9%) and at 48 h (87.1% vs 49.6%). Group III, in comparison to group I, showed a lower FiO2 requirement at 12 h (0.66 vs 1), at 24 h (0.4 vs 0.87) and at 48 h (0.35 vs 0.67), and a decrease in the number of days of inhaled nitric oxide administration, mechanical ventilation, oxygen therapy and hospitalisation period. All patients from groups II and III survived and none developed pneumothorax or respiratory infections. CONCLUSION: Diluted surfactant BAL in the first hours of life combined with an intravenous single dose of dexamethasone may be an effective treatment for severe MAS.

Plasma nitrite/nitrate and endothelin-1 concentrations in neonatal sepsis.

AIM: To determine the changes in plasma nitrite/nitrate (NOx) and endothelin-1 (ET-1) concentrations during neonatal sepsis. METHODS: In a prospective study, 60 consecutive newborns meeting the criteria for sepsis and without receiving exogenous nitric oxide (25 haemoculture-positive [HC+] and 35 haemoculture-negative [HC-]) were compared with 68 healthy newborns (46 full-term and 22 preterm). NOx and ET-1 concentrations were measured in each newborn within 48 h of diagnosis of sepsis and then every third day up to three determinations. SNAP-II and SNAPPE-II severity scores were performed at the moment of highest clinical severity. RESULTS: At the beginning of the sepsis period, controls and septicaemic newborns had similar NOx and ET-1 levels, with the exception of infants with severe HC+ sepsis. Throughout the sepsis period, NOx increased in moderate HC+ sepsis and decreased in HC--sepsis, reaching a significant difference at the end of the study period (59.9 +/- 72.7 vs 33.9 15.3 micromol/L; p = 0.036). Meanwhile, ET-1 in newborns with severe HC+ sepsis remained higher than that in the moderate HC+ sepsis group and HC--group, reaching significant differences in all the periods. The highest ET-1 value was positively correlated with SNAP-II and SNAPPE-II scores. CONCLUSION: NOx concentrations increased throughout the neonatal HC+ sepsis period, reaching significant differences after 7-9 d. The highest ET-1 levels in neonatal HC+ sepsis emerged before the NOx peak, at 3-5 d, and later decreased. Only newborns with severe HC+ sepsis presented a significant increase in ET-1 concentrations from the beginning of the septicaemic process.

Varicela neonatal: a propósito de un caso con bronconeumonía y edema hemorrágico pulmonar / Neonatal varicella: report of a case of bronchopneumonia and hemorrhagic pulmonary edema

Se presenta el caso de un recién nacido, hijo de madre con varicela iniciada 20 días antes del parto, que presentó un deterioro brusco del estado general a las 2 h de vida, con cianosis, distrés respiratorio y emisión de espuma rosada por la boca. Fue diagnosticado de bronconeumonía bilateral de probable etiología varicelosa, con componente de edema hemorrágico pulmonar. Precisó ventilación mecánica y soporte inotrópico durante 48 h, respondiendo de forma favorable al tratamiento intravenoso con aciclovir. Se obtuvo positividad de proteína C reactiva (PCR)-virus de la varicela zoster (VHZ) en líquido cefalorraquídeo (LCR) y seroconversión de IgG anti-VHZ a los 10 días de vida (AU)

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[Neonatal varicella: report of a case of bronchopneumonia and hemorrhagic pulmonary edema]. / Varicela neonatal: a propósito de un caso con bronconeumonía y edema hemorrágico pulmonar.

We describe the case of a male newborn infant, whose mother developed varicella 20 days before delivery. At 2 hours of life the infant's general state suddenly deteriorated and he presented cyanosis, respiratory distress and emission of pink foam in his mouth. The infant was diagnosed with bilateral bronchopneumonia, of probable varicellosus etiology, with a component of hemorrhagic pulmonary edema. He required mechanical ventilation and inotropic support for 48 hours. Response to endovenous acyclovir was favorable. At 10 days of life varicella-zoster virus (VZV) in cerebrospinal fluid was detected by polymerase chain reaction and seroconversion of IgG anti-VZV was positive.

Hijos de madre con neoplasia / Children of mothers with neoplastic diseases

Objetivo: Estudio de los recién nacidos (RN) de madre con neoplasia maligna, diagnosticada durante o antes de la gestación. Material y métodos: Revisión de 24 historias clínicas de recién nacidos y sus madres. Resultados: Los tumores más frecuentes han sido: carcinoma de mama (29 por ciento), linfoma de Hodgkin (16 por ciento) y carcinoma de cérvix (16 por ciento). La mitad fueron diagnosticados duran-te la gestación, y en 8 de ellos se indujo el parto (7 mediante cesárea) a las 33 (3), 34 (2), 36 (1) y 37 (2) semanas para iniciar el tratamiento materno. El 41 por ciento de los RN fue pretérmino, edad gestacional media de 33 semanas. En relación con el tratamiento materno (poliquimioterapia), únicamente se observó un caso de leucopenia transitoria a las 24 h de vida. En el grupo de madres con tumor durante la gestación se apreció una mayor incidencia de prematuridad (58 por ciento fren-te al 25 por ciento, no significativo), electiva en el 60 por ciento, así como del número de cesáreas (58 por ciento frente al 8 por ciento, P= 0,014). En relación con la población asistida en el hospital, los hijos de madre con tumor necesitan una mayor práctica de cesárea (33 por ciento frente al 18,5 por ciento, no significativo) y condicionan una mayor incidencia de prematuridad (42 por ciento frente al 10,8 por ciento, P 4,001). Conclusiones: Los RN hijos de madre con neoplasia maligna presentan una incidencia mayor de patología perinatal, asociada con la prematuridad y sus complicaciones. Esta incidencia se incrementa en el grupo con tumor diagnosticado durante la gestación, en el que la urgencia de iniciar un tratamiento en la madre condiciona frecuentemente la indicación de cesárea electiva antes del término. Se aconseja un seguimiento a largo plazo (AU)

[Neurological and growth follow-up of cardiac patients operated on before 45 days of life]. / Seguimiento neurológico y somatométrico de operados cardíacos antes de los 45 días de vida.

OBJECTIVE: Our aim was to study the neurological and growth disorders in patients undergoing cardiac surgery during the neonatal period. PATIENTS AND METHODS: Ninety clinical records of newborns with congenital heart disease that were operated between 1985 and 1996 and were under the age of 45 days with a minimum follow-up period of 12 months were reviewed. RESULTS: Of the 37 patient records considered, 33 (89.1%) were neurosensorially normal, 2 had minor handicaps and 2 moderate handicaps. There were 15 (40.5%) with the weight and 9 (24.3%) with the length below the 10th percentile. Although exitus, handicaps and growth disorders were more frequent in those patients operated in the extracorporal circulation, there were no significant differences. The growth disorders were greater in complex heart diseases and in pulmonary atresia, but significant differences were only related to the weight. CONCLUSIONS: Because at least 11% of these patients showed neurological disorders, a neurological follow-up is necessary. The number of post-operated patients with growth disorders was high, but catch-up growth resulted in recovery. A greater number of neurological and growth disorder has been found in complex heart disease, where only a palliative treatment could be employed. Although the complete correction of the cardiopathy may imply an early mortality, long time prognosis for survivors is much better.

[Morbidity of the newborn infant born to a diabetic mother in relation to macrosomia]. / Morbilidad del recién nacido hijo de madre diabética en relación con la macrosomía.

OBJECTIVE: A descriptive study of an infant of a diabetic mother was carried out in order to analyze if macrosomia (weight greater than P90 for gestational age) is a good criteria in order to predict associated complications. PATIENTS AND METHODS: A total of 382 diabetic mothers were attended between January 1994 and December 1996. RESULTS: Most of the complications were similar to those reported in the literature. In infants of diabetic mothers there is a significant increase in malformations (7.1%), sepsis (10.7%), hypertrophic cardiomyopathy (12.1%), respiratory distress (12.7%), hypoglycemia (50%), polyglobulia (30.4%) and jaundice (7.1%). We did not find any differences for traumatisms (8.25%), acute fetal suffering (19.6%) or hypocalcemia (1.8%). Respiratory distress was related to gestational age. CONCLUSIONS: The high weight for gestational age is a good parameter to predict complications in the infants of diabetic mothers.

[Analysis of a case of severe congenital toxoplasmosis]. / Análisis de un caso de toxoplasmosis congénita grave.

BACKGROUND: To describe a case of severe congenital toxoplasmosis because of inadequate surveillance of a seronegative pregnant woman and to evaluate the usefulness of different microbiological diagnostic methods after birth. METHODS: We applied serology, DNA amplification by one-tube semi-nested PCR, cell culture and mice inoculation analysis. RESULTS: Anti. T. gondii serology was useful for the diagnosis of congenital toxoplasmosis. PCR analysis of neonate cerebrospinal fluid and peripheral blood were positive, and yielded negative results after a few days of specific treatment. Cellular culture and mice inoculation yielded negative results. CONCLUSIONS: Our results suggest that serology and PCR are useful methods for the diagnosis of toxoplasmosis in newborns. Prenatal toxoplasmosis screening and suitable follow up of the seronegative pregnant women are necessary to prevent cases of severe infection in our area.

Changes in TcPCO2 regarding pulmonary mechanics due to pneumotachometer dead space in ventilated newborns.

The aim of this study was to analyze the effect of added dead space on PaCO2 after application of a pneumotachometer during the measurement of pulmonary mechanics. The study was based on 24 observations of TcPCO2 changes during the measurement of pulmonary function in 9 newborns subjected to mechanical ventilation. All newborns remained stable during the 23 minutes of the test. The introduction of a low dead space pneumotachometer (1.7 mL) for 10 minutes led to an increase in TcPCO2 of 5.40 +/- 2.66 mm Hg, from 39.76 +/- 8.69 to 45.17 +/- 9.22. Pulmonary mechanics indexes that correlated with the percentage of CO2 increase were peak inspiratory flow and expiratory time/time constant. When the pneumotachometer was removed, TcPCO2 fell but remained 0.99 +/- 2.13 mm Hg above basal TcPCO2. Final TcPCO2 tended to relate negatively with the minute volume. We conclude that this transient increase in PaCO2 should be born in mind in neonates with a high basal level and can be prevented by maintaining a long expiratory time and a high minute volume.

[Alcoholic embryofetopathy. Neonatal case reports for the past twelve years]. / Embriofetopatía alcohólica. Casuística neonatal propia en los últimos doce años.

OBJECTIVE: Alcohol embryopathy represents an important pediatric and obstetric problem, not only for the high risk of adverse effects on the neurodevelopment of the fetus and child, but for the imperative need for detecting and preventing alcohol consumption during pregnancy. In this study the clinical manifestations of newborns with maternal antecedents of alcohol consumption are reviewed. PATIENTS AND METHODS: Our experience from 1985 to 1996 with all newborns diagnosed as "children of an alcoholic mother, without associated clinical findings or partial forms (fetal alcohol effect) or as "alcohol embryofetopathy (complete forms) is reviewed. In this study we have reviewed the obstetric and neonatal records of 33 newborns born to 33 alcohol abusers, collecting both maternal (serological tests, alcohol and other substances consumed during pregnancy) and neonatal (gestational age, birth weight, birth length, head circumference, pathology, physical anomalies, cardiovascular defects and acute withdrawal symptoms) data. RESULTS: Our findings are similar to those described in other reports as regards to the incidence (1.9/1,000 newborns) and clinical manifestations, with the exception only in the low proportion of microcephalia. In our experience, alcohol consumption in pregnancy is associated with a high risk of low birth weight (39%) and intrauterine growth retardation (21%), malformations (42%, 9% cardiopathies), prematurity (54%) and maternal drug addiction (24%, with HIV serology positive in 18%). Acute withdrawal symptoms were detected in 24% of these newborns.