Langerhans Cell Histiocytosis Presenting as Enterocolitis and Shock in Neonate.

INTRODUCTION: Enterocolitis is a relatively common disease in neonatal period that can be a result of many underlying pathologies. One of them, which is an unusual disorder especially in neonatal age and with gastrointestinal involvement, is Langerhans cell histiocytosis (LCH). This case shows a severe neonatal LCH with digestive involvement which required intensive care and had an abnormal presentation, being hard to diagnose attributable to the diversity of symptoms. CASE REPORT: Eleven-day-old newborn presented for excessive weight loss followed by deterioration to shock, abdominal distension, digestive bleeding, and purpuric exanthema. Exploratory laparotomy identified aggressive enterocolitis. After stabilization, a significant hepatosplenomegaly persists as well as bicytopenia, pyrexia, and cutaneous lesions evolving tangible purple. LCH was diagnosed through histology of cutaneous biopsy. CONCLUSIONS: Gastrointestinal involvement in neonatal LCH is infrequent and its symptoms can be really unspecific. It is important to know that the first clinical manifestation is usually dermatologic with very diverse morphologies. Having a high suspect rate will lead us to an early diagnosis with its correspondent impact upon the outcome.

Smart pumps and random safety audits in a Neonatal Intensive Care Unit: a new challenge for patient safety.

BACKGROUND: Random safety audits (RSA) are a safety tool enabling prevention of adverse events, but they have not been widely used in hospitals. The aim of this study was to use RSAs to assess and compare the frequency of appropriate use of infusion pump safety systems in a Neonatal Intensive Care Unit (NICU) before and after quality improvement interventions and to analyse the intravenous medication programming data. METHODS: Prospective, observational study comparing the frequency of appropriate use of Alaris® CC smart pumps through RSAs over two periods, from 1 January to 31 December 2012 and from 1 November 2014 to 31 January 2015. Appropriate use was defined as all evaluated variables being correctly programmed into the same device. Between the two periods they were established interventions to improve the use of pumps. The information recorded at the pumps with the new security system, also extracted for one year. RESULTS: Fifty-two measurements were collected during the first period and 160 measurements during the second period. The frequency of appropriate use was 73.13 % (117/160) in the second period versus 0 % (0/52) in the first period (p < 0.0001). Information was recorded on 44,924 infusions; in 46.03 % (20,680/44,924) of cases the drug name was recorded. In 2.5 % (532/20,680) of cases there was an attempt to exceed the absolute limit. CONCLUSIONS: Random Safety Audits were a very useful tool for detecting inappropriate use of pumps in the NICU. The improvement strategies were effective for improving appropriate use and programming of the intravenous medication infusion pumps in our NICU.

[Early hypophosphataemia in at risk newborns. Frequency and magnitude]. / Hipofosforemia precoz en recién nacidos de riesgo. Frecuencia y magnitud.

OBJECTIVE: To determine the frequency and magnitude of neonatal hypophosphataemia (<4mg/dL) in a neonatal Intensive Care Unit and to describe risk groups. PATIENTS AND METHODS: Retrospective study of hospitalised newborns over a 44 month period (phase 1). Retrospective study of <1,500g/<32 weeks of gestation newborns over a 6 month period (phase 2). Prospective study of <1,500g or 1,550-2,000g, and intrauterine growth restriction (IUGR) newborns. Measurements were made on the 1st, 3rd, 7th, and 14th days of life (phase 3). RESULTS: Phase 1: 34 (2.4%) of 1,394 patients had a diagnosis of hypophosphataemia, 76% of them ≤32 weeks of gestation and <1500 grams, and 24% >32 weeks with weight

[Real-time safety audits in a neonatal unit]. / Auditorías de seguridad en tiempo real en una unidad neonatal.

BACKGROUND: Random audits are a safety tool to help in the prevention of adverse events, but they have not been widely used in hospitals. The aim of the study was to determine, through random safety audits, whether the information and material required for resuscitation were available for each patient in a neonatal intensive care unit and determine if factors related to the patient, time or location affect the implementation of the recommendations. MATERIAL AND METHODS: Prospective observational study conducted in a level III-C neonatal intensive care unit during the year 2012. The evaluation of written information on the endotracheal tube, mask and ambu bag prepared of each patient and laryngoscopes of the emergency trolley were included within a broader audit of technological resources and study procedures. The technological resources and procedures were randomly selected twice a week for audit. Appropriate overall use was defined when all evaluated variables were correctly programmed in the same procedure. RESULTS: A total of 296 audits were performed. The kappa coefficient of inter-observer agreement was 0.93. The rate of appropriate overall use of written information and material required for resuscitation was 62.50% (185/296). Mask and ambu bag prepared for each patient was the variable with better compliance (97.3%, P=.001). Significant differences were found with improved usage during weekends versus working-day (73.97 vs. 58.74%, P=.01), and the rest of the year versus 3rd quarter (66.06 vs. 52%, P=.02). CONCLUSIONS: Only in 62.5% of cases was the information and the material necessary to attend to a critical situation urgently easily available. Opportunities for improvement were identified through the audits.

Hipofosforemia precoz en recién nacidos de riesgo. Frecuencia y magnitud / Early hypophosphataemia in at risk newborns. Frequency and magnitude

OBJETIVO: Conocer la frecuencia y la magnitud de la hipofosforemia neonatal (< 4 mg/dl) en una UCIN y definir los grupos de riesgo. PACIENTES Y MÉTODOS: Estudio retrospectivo en neonatos hospitalizados, en periodo de 44 meses (fase 1). Estudio retrospectivo en < 1.500 g/< 32 semanas de gestación en período posterior de 6 meses (fase 2). Estudio prospectivo en < 1.500 g o CIR con peso 1.500-2.000 g. Determinaciones en días 1, 3, 7 y 14 de vida (fase 3). RESULTADOS: Fase 1: 34 de 1.394 pacientes (2,4%) fueron diagnosticados de hipofosforemia, 76% de ellos ≤ 32 semanas de gestación y < 1.500 g, y 24% > 32 semanas con peso < P10. Fase 2: 12 de 73 pacientes (16,4%) fueron diagnosticados de hipofosforemia, 5 (6,8%) con hipofosofremia< 2mg/dl. De ellos 8 fueron CIR y 4 < 1.000 g. Cinco pacientes asociaron hipopotasemia y 3 hipercalcemia. Fase 3: 9 de 20 pacientes (45%) presentaron hipofosforemia, todos < 1.000 g o con peso al nacer < 1.200 g y percentil < 10. El 33% de las muestras de los días 1, 3 y 7 mostraron hipofosforemia, < 2 mg/dl en 4 muestras. Asociaron hipopotasemia leve 5 casos (55%) e hipercalcemia leve 2 (22%). La hipofosforemia se asoció a menor nutrición enteral y más aporte parenteral de aminoácidos en los primeros días. CONCLUSIONES: La hipofosforemia es frecuente y puede ser crítica en la primera semana en prematuros < 1.000 g y en los nacidos con desnutrición fetal y peso < 1.200 g que reciben aminoácidos en la nutrición parenteral precoz

OBJECTIVE: To determine the frequency and magnitude of neonatal hypophosphataemia (< 4 mg/dL) in a neonatal Intensive Care Unit and to describe risk groups. PATIENTS AND METHODS: Retrospective study of hospitalised newborns over a 44 month period (phase 1). Retrospective study of < 1,500g /< 32 weeks of gestation newborns over a 6 month period (phase 2). Prospective study of < 1,500 g or 1,550-2,000 g, and intrauterine growth restriction (IUGR) newborns. Measurements were made on the 1st, 3rd, 7th, and 14th days of life (phase 3). RESULTS: Phase 1: 34 (2.4%) of 1,394 patients had a diagnosis of hypophosphataemia, 76% of them ≤ 32 weeks of gestation and < 1500 grams, and 24% > 32 weeks with weight < P10. Phase 2: 12 (16.4%) of 73 patients had a diagnosis of hypophosphataemia, with < 2 mg/dL in 5 (6.8%). Eight (75%) of those with hypophosphataemia had IUGR, and 4 (25%) weighed < 1,000 g. Five cases had associated hypokalaemia, and three hypercalcaemia. Phase 3: 9 (45%) of 20 patients had hypophosphataemia, all of them < 1,000 g or < 1,200 g and weight percentile < 10. Thirty-three percent of samples on days 1, 3, and 7 showed hypophosphataemia, four of them < 2mg/dL. There was mild hypokalaemia in 5 (55%), and mild hypercalcaemia in 2 (22%) cases. Hypophosphataemia was associated with lower enteral nutrition and higher parenteral amino acid intake in the early days of life. CONCLUSIONS: Hypophosphataemia is common, and can be severe, in the first week of life in premature infants < 1,000 grams, and newborns < 1,200 g with foetal malnutrition and receiving amino acids in early parenteral nutrition

Auditorías de seguridad en tiempo real en una unidad neonatal / Real-time safety audits in a neonatal unit

Introducción: Las auditorías en tiempo real son una herramienta de seguridad que apenas se ha aplicado anteriormente en el ámbito hospitalario. El objetivo del estudio fue determinar mediante auditorías si la información y el material necesario para la reanimación estaban disponibles para cada paciente de cuidados intensivos y si factores relacionados con el paciente, el momento o su ubicación en la unidad influyen en el cumplimiento de las recomendaciones. Material y métodos: Estudio observacional prospectivo realizado durante el año 2012 en una unidad neonatal nivel III-C. Dentro de un estudio más amplio de auditorías de recursos tecnológicos y procedimientos se incluyó la evaluación de la información escrita sobre el tubo endotraqueal, mascarilla y ambú de cada paciente y los laringoscopios del carro de parada. Dos veces por semana al azar se seleccionaba qué procedimiento o recurso se iba a evaluar. Se definió la variable uso global adecuado cuando todos los ítems evaluados eran correctos en el mismo procedimiento. Resultados: Se realizaron 17 auditorías que incluyeron 296 valoraciones. El coeficiente kappa interobservador fue 0,93. La frecuencia de uso global adecuado de la información y el material de reanimación fue de 62,50% (185/296). La mascarilla y ambú preparado en cada paciente fue la variable mejor cumplimentada (97,3%; p = 0,001). El uso global adecuado fue mejor en días festivos que en laborables (73,97 vs. 58,74%; p = 0,01) y el resto del año frente al verano (66,06 vs. 52%; p = 0,02). Conclusiones: Solo en el 62,5% de los casos toda la información y el material necesario para atender una situación crítica de forma urgente estaba fácilmente disponible. Gracias a las auditorías se identificaron oportunidades de mejora (AU)

Background: Random audits are a safety tool to help in the prevention of adverse events, but they have not been widely used in hospitals. The aim of the study was to determine, through random safety audits, whether the information and material required for resuscitation were available for each patient in a neonatal intensive care unit and determine if factors related to the patient, time or location affect the implementation of the recommendations. Material and methods: Prospective observational study conducted in a level III-C neonatal intensive care unit during the year 2012. The evaluation of written information on the endotracheal tube, mask and ambu bag prepared of each patient and laryngoscopes of the emergency trolley were included within a broader audit of technological resources and study procedures. The technological resources and procedures were randomly selected twice a week for audit. Appropriate overall use was defined when all evaluated variables were correctly programmed in the same procedure. Results: A total of 296 audits were performed. The kappa coefficient of inter-observer agreement was 0.93. The rate of appropriate overall use of written information and material required for resuscitation was 62.50% (185/296). Mask and ambu bag prepared for each patient was the variable with better compliance (97.3%, P=.001). Significant differences were found with improved usage during weekends versus working-day (73.97 vs. 58.74%, P=.01), and the rest of the year versus 3rd quarter (66.06 vs. 52%, P=.02). Conclusions: Only in 62.5% of cases was the information and the material necessary to attend to a critical situation urgently easily available. Opportunities for improvement were identified through the audits (AU)