Neonatal hypotension: two years'experience in a neonatal intensive care nursery

ABSTRACT. Routine measurement of blood pressure in high risk neonates admitted to the intensive care nursery during a 2 year period resulted in detection of 18 infants with persistent hypotension requiring definitive treatment. The perinatal events in these babies were compared to those in a control group of infants. No single well defined factor responsible for neonatal hypotension could be found in the antenatal period or during labour. However 14 of the 18 babies were asphyxiated at the time of admission compared to 6 of 18 controls (p<0.02). Seventeen of 18 babies were preterm. Treatment consisted of maintenance of ventilation, oxygenation and acid-base status, volume expansion when indicated and inotropic agents. Nine of the 18 hypotensive babies died compared to 1 of 18 controls. Failure to respond within a few hours of commencement of treatment indicated poor prognosis.     

Neonatal mortality and cerebral palsy: the impact of neonatal intensive care

Neonatal deaths and cases of cerebral palsy amongst West Australian infants born between 1968–75 were analysed by birthweight and in relation to other factors. Both mortality and cerebral palsy incidence fell over time. Male rates fell selectively more than those for females. A shift in the birthweight distribution of total live births to heavier babies accounted for 22% of the fall in neonatal mortality, and 56% of the fall in cerebral palsy incidence over this time. Although selective changes in the maternal age and parity of mothers delivering occurred, they were responsible for only a small per cent of the falls in either neonatal mortality or cerebral palsy. Other parameters of improved maternal health contributing to the falls could not be ascertained. Maternal age and parity are still strongly associated with mortality. Cerebral palsy incidence was not associated with age, but was markedly higher at the high parities. The most important findings related to neonatal mortality and cerebral palsy rates by birthweight. Neonatal mortality improved in all weight groups, only slightly more in the low, compared with the high birthweight babies. Cerebral palsy incidence however, improved most markedly in the heavier babies and thus those of low birthweight contributed relatively more to the cerebral palsy population recently than before neonatal intensive care was introduced. Thus the impact of neonatal intensive care on the low birthweight population in Western Australia has been mainly in terms of neonatal mortality. Other factors besides intensive care have obviously contributed to the observed falls in both mortality and cerebral palsy.     

Neonatal hypotension: two years' experience in a neonatal intensive care nursery

Routine measurement of blood pressure in high risk neonates admitted to the intensive care nursery during a 2 year period resulted in detection of 18 infants with persistent hypotension requiring definitive treatment. The perinatal events in these babies were compared to those in a control group of infants. No single well defined factor responsible for neonatal hypotension could be found in the antenatal period or during labour. However 14 of the 18 babies were asphyxiated at the time of admission compared to 6 of 18 controls (p less than 0.02). Seventeen of 18 babies were preterm. Treatment consisted of maintenance of ventilation, oxygenation and acid-base status, volume expansion when indicated and inotropic agents. Nine of the 18 hypotensive babies died compared to 1 of 18 controls. Failure to respond within a few hours of commencement of treatment indicated poor prognosis.     

Impact of neonatal intensive care.

Mortality in infants less than 33 weeks'' gestation and in those of very low birthweight in Brighton has fallen since 1978. This reduction is not due simply to a decline in the incidence of major congenital abnormalities; evidence indicates that it can be attributed to the introduction of respiratory support.     

Covering the costs of care in neonatal intensive care units.

The continued rise of health care costs, despite private and governmental control efforts, has sustained cost containment as a central issue for health care researchers and policy makers. In keeping with these concerns, the Florida Health Care Cost Containment Board conducted a study of neonatal intensive care units (NICUs) in Florida to ascertain the costs, charges, and net revenues associated with NICU services in individual hospitals, to document cost shifting and cross-subsidization as a means of financing NICU care for indigent populations, and to assess the fiscal impact of NICUs in state-sponsored vs non-state-sponsored Regional Perinatal Intensive Care Center hospitals providing NICU care. Hospitals in the state-sponsored program reported a loss of approximately $16.5 million in contrast to the non-state-sponsored hospitals, which reported a gain of $1 million. Payment being generated by private-pay patients amounted to almost 60% of total revenues but constituted less than one third of the costs in state-sponsored hospitals, indicating a high level of cost shifting. Government support of state-sponsored NICUs, while substantial, has been insufficient; increasing constraints on this funding source would likely worsen the deficit and increase the necessity of cost shifting.     

Neonatal outcomes of very preterm infants from a neonatal intensive care center

Background

Information about clinical outcomes of very preterm (VPT) infants in tertiary neonatal intensive care unit (NICU) setting is scant in China. This study aimed to investigate the mortality and morbidity of VPT infants admitted to BaYi Children’s Hospital, which serves as a NICU referral center for the city of Beijing, China.

Methods

Retrospectively collected perinatal/neonatal data on all admissions of infants born at <32 weeks of gestational age and subsequently admitted to the VPTNICU from clinical records between October 2010 and September 2011.

Results

Totally 729 infants were identified. 90% of VPT infants were outborn. The overall survival of the infants to discharge was 92%, which increased with increasing gestational age (range from 69% at <28 weeks to 99% at 31 weeks). The incidence of bronchopulmonary dysplasia was 4%, retinopathy of prematurity requiring treatment 2%, intraventricular hemorrhage III-IV 6%, and periventricular leukomalacia 2%. 10% of the VPT infants had a major morbidity at discharge.

Conclusions

The outcomes of the VTP infants at this referral NICU were comparable to those in tertiary centers in developed countries. The most common complications were lower than those in other cohorts. Accordingly, high-volume NICU may minimize the adverse effects of VPT infants’ transport.     

Preventing the scars of neonatal intensive care.

Two cases are reported of serious extravasation injuries due to parenteral nutrition in infants born at 24 and 28 weeks' gestation. Major scarring and the need for plastic surgery were prevented by using a technique of subcutaneous hyaluronidase and saline flushing.     

Otitis media in the neonatal intensive care unit.

Thirty-eight of 125 premature infants who were hospitalized in a neonatal intensive care unit (NICU) had abnormal tympanic membrane mobility compatible with otitis media. Twenty-five of these 38 had received antibiotics within one week of otoscopic examination and were considered to have either serous otitis or partially treated bacterial otitis media; tympanocentesis was not performed in them. Tympanocentesis was performed in the remaining 13 infants who had not received antibiotics. Bacterial otitis media was confirmed in ten of the 13. Either staphylococcal (six cases) or Gram-negative enteric organisms (four cases) were isolated in cultures obtained by tympanocentesis in these cases. The four cases of Gram-negative infections occurred in infants within six weeks of birth. Nasotracheal intubation for more than seven days was significantly correlated with impaired tympanic membrane mobility compatible with otitis media. Otitis media occurs frequently among premature infants who are hospitalized in an NICU, and it should be looked for in any infant in whom sepsis is clinically suspected.     

Palliative care in the neonatal intensive care unit

With increasing facilities for antenatal diagnosis, lowering gestation for intiation of intensive care, palliative care in the perinatal period is increasingly recognized as a specialist area. There have been standards and pathways developed in the UK that provides guidance to health professionals. Providing holistic perinatal palliative care depends on close multiprofessional working between the neonatal team and the palliative care professionals who are being integrated into the core neonatal services. Even though most neonates will continue to receive end of life care within the NICU, there are increasing number of families who choose to have end of life care either at home or a hospice. There is a need to develop services across the regions to provide equitable access to excellent clinical care as well as ongoing support to families following loss of a neonate. This short article explores the issues raised in the provision of palliative care in the perinatal period and offers practical guidance for paediatricians in this emerging area.     

Wound care in the neonatal intensive care unit

The skin is a vital organ with key protective functions. Infants in the NICU are at risk for skin injury because of developmental immaturity and intensive care treatments. When skin injury occurs, the neonatal nurse is challenged to provide wound care to optimize functional and cosmetic healing. Optimal wound care requires basic knowledge of the mechanisms of injury, physiology of wound healing, host factors affecting wound healing, and wound assessment. This knowledge provides the basis for determining appropriate wound treatment, including dressing selection. Attention to pain issues associated with wound care is difficult because of the infant's developmental stage, but is essential because of the potentially negative life-long impact of pain. The premature infant's propensity for skin stripping limits the selection of appropriate dressing, as does the paucity of research examining wound care products in this population.     

Transcutaneous bilirubinometry in neonatal intensive care units.

AIMS: To study the influence of several clinical and paraclinical factors on the association between jaundice meter readings and plasma bilirubin concentration; and to comment on the usefulness of the jaundice meter as a screening device for hyperbilirubinaemia in neonatal intensive care units. METHODS: Three hundred and seventy seven newborn babies admitted to the neonatal intensive care unit for various causes were included in the study. When the plasma bilirubin concentration needed to be determined for clinical reasons, the extent of the yellow skin colour was measured transcutaneously, using a jaundice meter. The haemoglobin concentration was also determined. This had no independent influence on the jaundice meter readings. The yellow skin colour was significantly and positively correlated with the bilirubin concentration and the presence of respiratory distress syndrome (RDS), and negatively with gestational age and postnatal ages. CONCLUSIONS: These findings were interpreted as being due to variations in the ability of albumin to bind bilirubin, and in the basal yellow skin colour. It was impossible to derive simple criteria for detection of hyperbilirubinemia by jaundice meter readings in this study group.     

Neonatal bacterial sepsis in a neonatal intensive care unit: A 5 year analysis

Objective : To study the pattern of neonatal sepsis in a neonatal intensive care unit (NICU) during a 5 year period and assess the relationship between maternal risk factors and early onset sepsis (EOS).
Methodology : The study reported here was a retrospective analysis of 209 episodes of septicaemia and 5 episodes of bacterial meningitis in 198 newborn infants, 22 of whom died. Eighty-one infants had EOS (≤72h) and 117 infants had late onset sepsis (LOS >72 h). All infants had clinical evidence of sepsis, a computerized haematological score for sepsis of 4 or greater, and either treatment with antibiotics for 7 days or more or had earlier death due to sepsis. The organisms causing neonatal sepsis were analyzed according to the day of onset, gestational age, birthweight and year of infection.
Results : Sepsis occurred in 5.6 per 1000 live births and 3.8% of NICU admissions. There were 81 episodes of EOS and 128 of LOS. Coagulase negative staphylococci (CONS) 38.8%, group B Streptococcus (GBS) 20.1% and Gram-negative bacilli (GNB) 20.1% were the common causes of sepsis; and GBS (50.6%) and CONS (60.9%) were the most common organisms in EOS and LOS, respectively. The mean gestational age and birthweight were heigher in babies with EOS than compared with LOS. The higher likelihood of probable rather than definite infection in infants with EOS was related to more mothers in the EOS group receiving intrapartum antibiotics. GNB infection was more common in their babies.
Conclusions : GBS and CONS were the most common causes of EOS and LOS, respectively. The use of maternal intrapartum antibiotics interferes with neonatal blood culture results. Because blood cultures are not always positive in neonatal septicaemia, a combination of clinical, haematological and other microbiological evidence should be used when diagnosing neonatal septicaemia.