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INTRODUCTION: The incidence of thrombocytopenia in neonates receiving extracorporeal membrane oxygenation (ECMO) with and without concurrent continuous renal replacement therapy (CRRT) and associated complications have not been well described. The primary aims of the current study were to (1) characterize thrombocytopenia in neonates receiving ECMO (including those treated concurrently with CRRT) and (2) evaluate risk factors (including CRRT utilization) associated with severe thrombocytopenia. In a planned exploratory secondary aim, we explored the association of severe thrombocytopenia with outcomes in neonates receiving ECMO. METHODS: We conducted a retrospective single-center chart review of neonates who received ECMO 07/01/14-03/01/20 and evaluated associations between CRRT, severe thrombocytopenia (platelet count <50,000/mm3), and outcomes (ECMO duration, length of stay, and survival). RESULTS: Fifty-two neonates received ECMO; 35 (67%) received concurrent CRRT. Severe thrombocytopenia occurred in 27 (52%) neonates overall and in 21 (60%) neonates who received concurrent CRRT. Underlying diagnosis, ECMO mode, care unit, and moderate/severe hemolysis differed between those who did and did not receive CRRT. CRRT receivers experienced shorter hospital stays than CRRT non-receivers, but ECMO duration, length of intensive care unit (ICU) stay, and survival did not differ between groups. CRRT receipt was associated with severe thrombocytopenia. Exploratory classification and regression tree (CART) analysis suggests CRRT use, birthweight, and ICU location are all predictors of interest for severe thrombocytopenia. CONCLUSIONS: In our cohort, CRRT use during ECMO was associated with severe thrombocytopenia, and patients who received ECMO with CRRT experienced shorter hospital stays than those who did not receive CRRT. Exploratory CART analysis suggests CRRT use, birthweight, and ICU location are all predictors for severe thrombocytopenia and warrant further investigations in larger studies.
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Terapia de Substituição Renal Contínua , Oxigenação por Membrana Extracorpórea , Trombocitopenia , Humanos , Oxigenação por Membrana Extracorpórea/efeitos adversos , Recém-Nascido , Estudos Retrospectivos , Trombocitopenia/terapia , Trombocitopenia/etiologia , Masculino , Feminino , Terapia de Substituição Renal Contínua/métodos , Tempo de Internação , Resultado do Tratamento , Fatores de RiscoRESUMO
BACKGROUND: Hemophagocytic lymphohistiocytosis (HLH) is a rare disease that can be triggered by cytomegalovirus, a relatively common infectious exposure to neonates. The clinical presentation is common to many acute illnesses seen in extreme premature infants; however, there are key clinical and laboratory findings that can lead to the diagnosis. PURPOSE: We present a case of an extreme premature infant of 25 weeks' gestation who developed cytomegalovirus-induced HLH. Using the current published protocols that are used in pediatric cancer can be adapted for use in a premature infant, which led to remission of HLH and eventual discharge from the neonatal intensive care unit. IMPLICATIONS FOR PRACTICE: There are published treatment protocols used in pediatric oncology that when initiated early can lead to favorable outcomes and remission in even the most fragile neonates. IMPLICATIONS FOR RESEARCH: Additional studies are needed on the pharmacokinetics, dosing, and side effects on medications used for treatment of HLH in preterm infants. Additional research is needed to improve the clinician's ability to reach the diagnosis as well as define treatment strategies that provide optimal outcomes.
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Antineoplásicos Fitogênicos/uso terapêutico , Antivirais/uso terapêutico , Infecções por Citomegalovirus/tratamento farmacológico , Glucocorticoides/uso terapêutico , Imunossupressores/uso terapêutico , Linfo-Histiocitose Hemofagocítica/tratamento farmacológico , Medula Óssea/patologia , Ciclosporina/uso terapêutico , Infecções por Citomegalovirus/complicações , Infecções por Citomegalovirus/diagnóstico , Dexametasona/uso terapêutico , Etoposídeo/uso terapêutico , Ganciclovir/análogos & derivados , Ganciclovir/uso terapêutico , Humanos , Lactente , Lactente Extremamente Prematuro , Recém-Nascido , Células Matadoras Naturais , Linfo-Histiocitose Hemofagocítica/diagnóstico , Linfo-Histiocitose Hemofagocítica/etiologia , Masculino , Receptores de Interleucina-2/sangue , Resultado do Tratamento , ValganciclovirRESUMO
Congenital heart disease (CHD) is the most commonly reported birth defect in newborns. Neonates with CHD are more likely to be born prematurely, and a higher proportion of preterm neonates have CHD than their term counterparts. The implications of preterm birth on the cardiac and noncardiac organ systems are vast and require special management considerations. The feasibility of surgical interventions in preterm neonates is frequently limited by patient size and delicacy of immature cardiac tissues. Thus, special care must be taken when considering the appropriate timing and type of cardiac intervention. Despite improvements in neonatal cardiac surgical outcomes, preterm and early term gestational ages and low birthweight remain important risk factors for in-hospital mortality. Understanding the risks of early delivery of neonates with prenatally diagnosed CHD may help guide perioperative management in neonates who are born preterm. In this review, we will describe the risks and benefits of early delivery, postnatal cardiac and noncardiac evaluation and management, surgical considerations, overall outcomes, and future directions regarding optimization of perinatal evaluation and management of fetuses and preterm and early term neonates with CHD.
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Cardiopatias Congênitas , Doenças do Prematuro , Nascimento Prematuro , Feminino , Idade Gestacional , Cardiopatias Congênitas/diagnóstico , Cardiopatias Congênitas/terapia , Humanos , Recém-Nascido de Baixo Peso , Recém-Nascido , Doenças do Prematuro/diagnóstico , Doenças do Prematuro/terapia , GravidezRESUMO
There have been significant changes in the graduate medical (resident) education in the United States over the last two decades. These changes have been the result of a wide range of societal, governmental, and regulatory alterations which have either directly or indirectly impacted today's physicians-in-training experiences and autonomy, raising concerns about their readiness for independent practice at the completion of training. This article reviews the evolution of these changes and the promise that simulation training holds as one of the keys to ensuring continuing excellence in the training of today's and tomorrow's physicians.
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Educação de Pós-Graduação em Medicina/métodos , Internato e Residência/métodos , Neonatologia/educação , Ensino/métodos , Educação de Pós-Graduação em Medicina/tendências , Setor de Assistência à Saúde/tendências , Humanos , Internato e Residência/tendências , Ensino/tendênciasRESUMO
BACKGROUND: The safety and efficacy of early, low-dose, prolonged therapy with inhaled nitric oxide in premature newborns with respiratory failure are uncertain. METHODS: We performed a multicenter, randomized trial involving 793 newborns who were 34 weeks of gestational age or less and had respiratory failure requiring mechanical ventilation. Newborns were randomly assigned to receive either inhaled nitric oxide (5 ppm) or placebo gas for 21 days or until extubation, with stratification according to birth weight (500 to 749 g, 750 to 999 g, or 1000 to 1250 g). The primary efficacy outcome was a composite of death or bronchopulmonary dysplasia at 36 weeks of postmenstrual age. Secondary safety outcomes included severe intracranial hemorrhage, periventricular leukomalacia, and ventriculomegaly. RESULTS: Overall, there was no significant difference in the incidence of death or bronchopulmonary dysplasia between patients receiving inhaled nitric oxide and those receiving placebo (71.6 percent vs. 75.3 percent, P=0.24). However, for infants with a birth weight between 1000 and 1250 g, as compared with placebo, inhaled nitric oxide therapy reduced the incidence of bronchopulmonary dysplasia (29.8 percent vs. 59.6 percent); for the cohort overall, such treatment reduced the combined end point of intracranial hemorrhage, periventricular leukomalacia, or ventriculomegaly (17.5 percent vs. 23.9 percent, P=0.03) and of periventricular leukomalacia alone (5.2 percent vs. 9.0 percent, P=0.048). Inhaled nitric oxide therapy did not increase the incidence of pulmonary hemorrhage or other adverse events. CONCLUSIONS: Among premature newborns with respiratory failure, low-dose inhaled nitric oxide did not reduce the overall incidence of bronchopulmonary dysplasia, except among infants with a birth weight of at least 1000 g, but it did reduce the overall risk of brain injury. (ClinicalTrials.gov number, NCT00006401 [ClinicalTrials.gov].).
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Displasia Broncopulmonar/prevenção & controle , Pneumopatias/terapia , Óxido Nítrico/administração & dosagem , Síndrome do Desconforto Respiratório do Recém-Nascido/terapia , Administração por Inalação , Peso ao Nascer , Displasia Broncopulmonar/epidemiologia , Feminino , Humanos , Recém-Nascido , Recém-Nascido Prematuro , Recém-Nascido de muito Baixo Peso , Hemorragias Intracranianas/prevenção & controle , Leucomalácia Periventricular/prevenção & controle , Masculino , Óxido Nítrico/efeitos adversos , Respiração Artificial/efeitos adversos , Síndrome do Desconforto Respiratório do Recém-Nascido/mortalidade , Análise de SobrevidaRESUMO
The purpose of this study was to evaluate the clinical utility of an investigational flat-panel digital radiography system for low-dose portable neonatal imaging. Thirty image-pairs from neonatal intensive care unit patients were acquired with a commercial Computed Radiography system (Agfa, ADC 70), and with the investigational system (Varian, Paxscan 2520) at one-quarter of the exposure. The images were evaluated for conspicuity and localization of the endings of ancillary catheters and tubes in two observer performance experiments with three pediatric radiologists and three neonatologists serving as observers. The results indicated no statistically significant difference in diagnostic quality between the images from the investigational system and from CR. Given the investigational system's superior resolution and noise characteristics, observer results suggest that the high detective quantum efficiency of flat-panel digital radiography systems can be utilized to decrease the radiation dose/exposure to neonatal patients, although post-processing of the images remains to be optimized. The rapid availability of flat-panel images in portable imaging was found to be an added advantage for timely clinical decision-making.
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Proteção Radiológica/instrumentação , Intensificação de Imagem Radiográfica/instrumentação , Ecrans Intensificadores para Raios X , Cateterismo/métodos , Análise de Falha de Equipamento , Humanos , Recém-Nascido , Miniaturização , Doses de Radiação , Proteção Radiológica/métodos , Intensificação de Imagem Radiográfica/métodosRESUMO
OBJECTIVE: To compare the percentage of nebulized albuterol delivered with conventional (intermittent mandatory ventilation) vs. synchronous (assist-control and assist-control with flow synchronization) ventilation in a neonatal lung model. DESIGN: Prospective in vitro laboratory study. SETTING: Research laboratory. SUBJECT: Neonatal lung model. INTERVENTIONS: The model simulated an intubated neonate with a spontaneous respiratory rate of 40, 60, or 80 breaths per minute and compliance and resistance values of bronchopulmonary dysplasia. A VIP Bird ventilator was used for all ventilator modes. Albuterol 2.5 mg was administered with a T Up-Draft II Neb-U-Mist nebulizer attached to a 12.75-cm (10-mL) reservoir of circuit tubing. Albuterol was collected onto a filter (particle retention
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We evaluated the analytical performance of the i-STAT Portable Clinical Analyzer (PCA), a point-of-care testing system consisting of a hand-held analyzer and single-use cartridges that measure different panels of electrolytes, metabolites, blood gases, and hematocrit in 65-100 microl of blood. Our objective was to determine whether PCA measurements at the bedside of patients in the neonatal and pediatric intensive care units of the MUSC Children's Hospital would be as reliable as those performed by the clinical laboratory's primary methods (Radiometer ABL 725 blood gas analyzer; Vitros 750 chemistry analyzer; and Coulter STKS hematology analyzer). Four cartridge types: (a) EC8+ (sodium; potassium; chloride; urea; glucose; pH; blood gases [PO2; pCO2]), (b) EC6+ (sodium; potassium; ionized calcium; glucose; hematocrit; pH), (c) G3+ (pH; PO2; pCO2), and (d) creatinine, were assessed for reproducibility, linearity, and method comparisons using aqueous samples, blood samples supplemented with several analytes, and -225 blood samples from patients. Reproducibility (CV) was good (< 2%) for electrolytes, glucose, urea, and pH, satisfactory (< 6.5%) for blood gases and creatinine, but poor (21%) for hematocrit. Linearity concentrations spanning the clinically relevant ranges were verified for all analytes. Method comparison studies with samples separated into 2 subgroups by patient age (> or < 3 mo) showed that agreement between the PCA and the primary methods was clinically acceptable. After the PCA was implemented for clinical testing, the observation of discrepant results of creatinine concentrations in neonatal blood samples that would have affected clinical management led to a second creatinine comparison study (59 additional samples) and to our eventual discontinuation of the PCA creatinine assay. This problem notwithstanding, the successful implementation of the PCA is attributed to careful analytical evaluations and ongoing communication with the clinical staff.
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Análise Química do Sangue/instrumentação , Gasometria/instrumentação , Hospitais Pediátricos , Hospitais Universitários , Unidades de Terapia Intensiva Pediátrica , Sistemas Automatizados de Assistência Junto ao Leito , Desenho de Equipamento , Hematócrito , Humanos , Lactente , Recém-Nascido , Reprodutibilidade dos TestesRESUMO
BACKGROUND: Although inhaled nitric oxide has been shown to reduce the use of extracorporeal membrane oxygenation, there is limited data on its effect on long-term outcomes. OBJECTIVE: The purpose of our study is to report on the 1 year outcome of neonates treated with inhaled nitric oxide compared to a group of neonates who did not receive nitric oxide. METHODS: We have previously reported on the in-hospital outcomes of 248 neonates who were >34 weeks' gestational age and were randomized to receive low-dose inhaled nitric oxide or placebo. Extracorporeal membrane oxygenation was used in 78 (64%) neonates in the control group and in 48 (38%) neonates in the inhaled nitric oxide group (p=0.001). We now report on the outcome of neonates followed to 1 year of age. RESULTS: Of the 248 neonates twenty-four (10%) died before 1 year of age. There was no difference in mortality between the two groups (11% in the control group and 9% in the inhaled nitric oxide group). Of the 224 surviving infants, we were able to contact the parents or guardians of 201 (90%) children. There were no intergroup differences in the numbers of patients reported as requiring medications for pulmonary disease (14% in the control group and 14% in the inhaled nitric oxide group) or the need for supplemental oxygen (1% in the control group and 0% in the inhaled nitric oxide group). The number of neonates reported to have an abnormal neurological examination or developmental delay was also similar in both groups (14% in the control group and 19% in the inhaled nitric oxide group). CONCLUSIONS: The use of low-dose inhaled nitric oxide reduces the use of extracorporeal membrane oxygenation without increasing the incidence of adverse outcomes to 1 year of age.
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Hipertensão Pulmonar/tratamento farmacológico , Óxido Nítrico/administração & dosagem , Óxido Nítrico/uso terapêutico , Vasodilatadores/administração & dosagem , Vasodilatadores/uso terapêutico , Administração por Inalação , Peso ao Nascer , Relação Dose-Resposta a Droga , Feminino , Seguimentos , Humanos , Hipertensão Pulmonar/mortalidade , Lactente , Recém-Nascido , Masculino , Taxa de Sobrevida , Fatores de Tempo , Resultado do TratamentoRESUMO
The Accreditation Council for Graduate Medical Education has partnered with member boards of the American Board of Medical Specialties to initiate the next steps in advancing competency-based assessment in residency programs. This initiative, known as the Milestone Project, is a paradigm shift from traditional assessment efforts and requires all pediatrics residency programs to report individual resident progression along a series of 4 to 5 developmental levels of performance, or milestones, for individual competencies every 6 months beginning in June 2014. The effort required to successfully make this shift is tremendous given the number of training programs, training institutions, and trainees. However, it holds great promise for achieving training outcomes that align with patient needs; developing a valid, reliable, and meaningful way to track residents' development; and providing trainees with a roadmap for learning. Recognizing the resources needed to implement this new system, the authors, all residency program leaders, provide their consensus view of the components necessary for implementing and sustaining this effort, including resource estimates for completing this work. The authors have identified 4 domains: (1) Program Review and Development of Stakeholders and Participants, (2) Assessment Methods and Validation, (3) Data and Assessment System Development, and (4) Summative Assessment and Feedback. This work can serve as a starting point and framework for collaboration with program, department, and institutional leaders to identify and garner necessary resources and plan for local and national efforts that will ensure successful transition to milestones-based assessment.
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Consenso , Educação de Pós-Graduação em Medicina , Internato e Residência , Pediatria/educação , Logro , Competência Clínica , Educação Baseada em Competências , Currículo , Humanos , Conselhos de Especialidade Profissional , Estados UnidosRESUMO
BACKGROUND: Our objective was to improve breastfeeding initiation rates at an urban medical center. METHODS: A breastfeeding educational program for health care providers was developed and implemented in 1995. The outcome variable of interest was the change in breastfeeding initiation rate during 2 periods, 1993-1994 and 1996 to 1999, stratified by weight (> 2,000, 1,500 to 2,000, and < 1,500 g). RESULTS: The breastfeeding initiation rate in 1996 to 1999 for all mothers of newborns admitted to the hospital was 47.1% (4,107/8,724), compared with the 1993-1994 rate of 18.9% (816/4,315). During the second period, the breastfeeding rate among mothers of infants < 1,500 g was 60.8% (468/770), compared with 19.2% (56/293) during the earlier study period. Stratified by weight, the greatest improvement in rates of breastfeeding initiation and at discharge was seen with mothers of preterm infants. CONCLUSION: A breastfeeding educational program that interfaced with medical staff and mothers at an urban medical university was associated with increased rates of breastfeeding initiation.
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Centros Médicos Acadêmicos/estatística & dados numéricos , Aleitamento Materno/estatística & dados numéricos , Educação em Saúde/estatística & dados numéricos , Hospitais Urbanos/estatística & dados numéricos , Avaliação de Programas e Projetos de Saúde/estatística & dados numéricos , Atitude do Pessoal de Saúde , Alimentação com Mamadeira/estatística & dados numéricos , Ciências da Nutrição Infantil , Feminino , Humanos , Fenômenos Fisiológicos da Nutrição do Lactente , Recém-Nascido , Gravidez , Fatores SocioeconômicosRESUMO
BACKGROUND: Our objective was to determine whether perinatal referral patterns and clinical outcomes for very low birthweight infants changed in relation to changing Medicaid financial policies in coastal South Carolina. METHODS: Referral patterns and outcome indicators for very low birthweight infants were compared during two periods in a cohort design. RESULTS: A total of 520 infants were identified over two funding periods. A decrease in the proportion of nonwhite very low birthweight infants was identified. There was an increase in very low birthweight infants with Medicaid funding born outside our level III center. CONCLUSIONS: Changes in financial public policy have been successful in the movement of low risk pregnancies into the private sector. However, an increased proportion of deliveries of very low birthweight infants occurred outside the level III center.