Evaluation and treatment of thrombocytopenia in the neonatal intensive care unit

Phlebotomy-induced anaemia excepted, thrombocytopenia is the most common haematological abnormality in neonatal intensive care unit (NICU) patients. Roughly one-quarter of all NICU patients and half of all sick preterm neonates develop thrombocytopenia. Whereas a large number of varied precipitating conditions has been identified, early-onset thrombocytopenia (>72 h) is most commonly associated with fetomaternal conditions complicated by placental insufficiency and/or fetal hypoxia, e.g. maternal pre-eclampsia and fetal intrauterine growth restriction. The resulting neonatal thrombocytopenia is usually mild to moderate, resolves spontaneously and requires no specific therapy. Deviation from this pattern of thrombocytopenia suggests the presence of more significant precipitating conditions. The most important of these are the immune thrombocytopenias, and every NICU should develop investigation and treatment protocols to manage these cases promptly and avoid unnecessary risk of haemorrhage. In contrast, late-onset thrombocytopenia (>72 h) is almost always associated with sepsis or necrotizing enterocolitis and the associated thrombocytopenia is severe, prolonged and often requires treatment by platelet transfusion. Unfortunately, evidence-based guidelines for platelet transfusion therapy in NICU patients are currently unavailable, making it difficult to define widely accepted thresholds for transfusion and leading to a significant variation in transfusion practice between centres.
Conclusion : While improving this situation remains a pressing need, the growing evidence that impaired megakaryocytopoiesis and platelet production are major contributors to many neonatal thrombocytopenias suggests that recombinant haemopoietic growth factors, including thrombopoietin and interleukin-11, may be useful future therapies to ameliorate neonatal thrombocytopenia.     

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.     

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.     

Evaluation of device-associated infections in a neonatal intensive care unit

Device-associated infections are common in Neonatal Intensive Care Units (NICUs) in accordance with the frequent use of invasive devices, and they must be continuously and closely monitored for infection control. Six hundred newborn infants hospitalized longer than 72 hours in Ege University Children's Hospital NICU between January 2008 and December 2010 were prospectively followed for occurrence of device-associated infections (central venous catheter- and umbilical catheter-associated blood stream infections [CVC/UC BSI] and ventilator-associated pneumonia [VAP]). In a total of 10,052 patient days, the VAP rate was 13.76/1000 ventilator days with a ventilator utilization ratio of 0.29, and the CVC/UC BSI rate was 3.8/1000 catheter days with a catheter utilization ratio of 0.24. The CVC/UC BSI rate was lower than national averages, being close to rates reported from developed countries. The VAP rate was higher than the national and international rates and was associated with prolonged mechanical ventilation and very low birth weight. VAP also appeared to be an important risk factor for mortality. The most frequent agents were gram-negative pathogens for VAP and coagulase-negative staphylococci for CVC/UC BSIs, with resistance patterns similar to the previous years. In conclusion, with device utilization rates similar to those in developed countries, our CVC/UC BSI rate was comparable, but the VAP rate was higher than that of the developed countries. Necessary precautions are urgently needed to decrease VAP rates and VAP-related mortality.     

Withholding treatment, withdrawing treatment, and palliative care in the neonatal intensive care unit

Advances in pharmacology and technology have sharply reduced mortality of extremely preterm infants at the expense of an increasing number of survivors with handicaps and disabilities. The EURONIC study among neonatal intensive care units across Europe demonstrates that treatment of infants born at the limits of viability raises challenging ethical, moral, legal, and emotional dilemmas among neonatologists, nurses, and parents alike. When is it wise to withhold or withdraw intensive care and, if so, what are the needs of the nonviable or dying infant, family, and neonatal staff to provide a humane and compassionate death? This process begins with a thorough determination of diagnosis and prognosis, followed by decision making on the basis of futility of treatment or quality-of-life issues, and counseling of parents. Withholding or withdrawing of intensive care should be synonymous with palliative care. Perinatal audit and after-care of the family complete the process. The Dutch viewpoint and practice guidelines on withholding and withdrawing of neonatal intensive care are presented.     

数字视频脑电图在儿科重症监护室的应用

儿科重症监护室(NICU、PICU)的患儿常存在各种原因导致脑损伤,数字视频脑电图检查可为病因诊断、病情变化监测、评估、预后等提供帮助,现将数字视频脑电图在 NICU 和 PICU 中常见疾病中的应用进行综述。     

Endocarditis in neonatal intensive care unit

Summary The clinical spectrum of infective endocarditis (IE) in infants is examined in four infants between 3 and 9 months of age. None of the patients had signs of IE; all four had an anatomically normal heart. Echocardiograms showed echodense vegetations in the left side of heart in three cases and in the right side in one. Three of the four patients recovered after the episode of endocarditis. Three of the four patients had necrotizing enterocolitis in the neonatal period. The important predisposing factor was the presence of indwelling central catheter for intravenous nutrition. Unlike previously reported cases, coagulase-negativeStaphylococci andEnterococci were important causative organisms in this high-risk nursery population.Presented in part at the APS/SPR Meeting in Anaheim, California, May 8, 1990.     

Antibiotic stewardship in the neonatal intensive care unit

Antibiotic stewardship (ABS) refers to the coordinated interventions to appropriately prescribe and administer the most pathogen-specific, narrow-spectrum antibiotic regimens, in the correct doses, for the appropriate duration, and continually evaluate prescriber and administration compliance. The main historical driver for ABS has been antibiotic resistance, which is fuelled by antibiotic therapy. Additionally, short and long term consequences of antibiotic therapy on the developing immune system have emerged as further specific hazards of antibiotic exposure in neonates. The implementation of an ABS program, can be through ward-focused, multidisciplinary, antimicrobial teams, with promotion of evidence-based antimicrobial prescribing guidelines. Nursing and medical leadership should promote a united, pan-unit culture of it being “everybody's job” to embed an ABS program, alongside robust infection prevention practices and active promotion of breastfeeding. This review article will discuss the drivers for antibiotic stewardship and strategies for implementation of antibiotic stewardship within neonatal units.     

Implementing pay-for-performance in the neonatal intensive care unit

Pay-for-performance initiatives in medicine are proliferating rapidly. Neonatal intensive care is a likely target for these efforts because of the high cost, available databases, and relative strength of evidence for at least some measures of quality. Pay-for-performance may improve patient care but requires valid measurements of quality to ensure that financial incentives truly support superior performance. Given the existing uncertainty with respect to both the effectiveness of pay-for-performance and the state of quality measurement science, experimentation with pay-for-performance initiatives should proceed with caution and in controlled settings. In this article, we describe approaches to measuring quality and implementing pay-for-performance in the NICU setting.     

Caffeine use in the neonatal intensive care unit

Caffeine is the most frequently used medication in the neonatal intensive care unit. It is used for the prevention and treatment of apnea, although this has been associated with lower incidence of bronchopulmonary dysplasia (BPD) and patent ductus arteriosus as well as intact survival at 18–21 months of life. Although neurodevelopmental advantage was no longer statistically significant at age 5 years, caffeine was associated with sustained improvement in co-ordination and less gross motor impairment than placebo. The mechanism of action of caffeine on prevention of apnea and activation of breathing seems to be through central inhibition of adenosine receptors. However, its impact on BPD and neurodevelopmental outcomes might be induced through its effects as anti-inflammatory mediator, protection of white matter, and induction of surfactant protein B. Whereas long-term studies have documented the safety of caffeine as used in current practice, further studies are clearly needed to identify optimum dosing, and time of starting and discontinuing caffeine.     

Fungal infections in the neonatal intensive care unit

The past 2 decades have witnessed a 4- to 6-fold increase in the incidence of fungal infections in the neonatal intensive care unit. Although symptoms are similar to those of the more commonly encountered bacterial infections ascribable to maternal genital flora, fungal infections derive from different predisposing factors and require a distinctly different approach to diagnosis and treatment. This article reviews the most common presentations of fungal infection in the nursery, the risk factors for susceptible infants, and the treatment strategies that generally are accepted. Copyright © 2001 by W.B. Saunders Company     

Fungal infections in the neonatal intensive care unit

Fungal pathogens, primarily Candida, cause approximately 9 percent of all late-onset infections in the neonatal intensive care unit. Candida can be acquired both vertically and horizontally, so disease in the neonate is a mixture of nosocomially and perinatally acquired infection. Systemic candidiasis predominantly affects the most immature infants with more severe underlying disease. The spectrum of diseases caused by Candida ranges from uncomplicated fungemia to multiorgan dissemination; some unusual manifestations include invasive fungal dermatitis, spontaneous intestinal perforation, and brain abscesses. Although Candida is the predominant fungal pathogen in the nursery, other organisms are implicated sporadically. Catheter-associated sepsis caused by Malassezia is seen occasionally in neonates receiving lipid infusions. Filamentous fungi, both Aspergillus and zygomycetes, cause predominantly cutaneous or gastrointestinal tract infections, often associated with breaches in the mucocutaneous barrier. Knowledge of the epidemiology and clinical presentation of fungal infections in these infants is growing, but more research is needed. Copyright © 2001 by W.B. Saunders Company     

Pneumomediastinum in the neonatal and paediatric intensive care unit

The incidence, aetiology and pathophysiology of pneumomediastinum (PM), an uncommon and potentially serious disease in neonates and children, were evaluated. A retrospective chart review of all patients diagnosed with PM who were hospitalised in the intensive care unit of the University Children’s Hospital Zürich, Switzerland, from 2000 to 2006, was preformed. We analysed the incidence, severity and causes of PM and investigated the possible differences between neonatal and non-neonatal cases. Seven children and nine neonates were identified with PM. All patients had a good outcome. Six cases of PM in the group of children older than 4 weeks were deemed to be caused by trauma, infection and sports, whereas one case was idiopathic. All nine neonatal cases presented with symptoms of respiratory distress. We were able to attribute four cases of neonatal PM to pulmonary infection, immature lungs and ventilatory support. Five neonatal cases remained unexplained after careful review of the hospital records. In conclusion, PM in children and neonates has a good prognosis. Mostly, it is associated with extrapulmonary air at other sites. It is diagnosed by chest X-ray alone. We identified mechanical events leading to the airway rupture in most children >4 weeks of life, whereas we were unable to identify a cause in half of the neonates studied (idiopathic PM).     

Bacterial changes in neonatal intensive care unit

Organisms routinely cultured from throat swabs and infectious agents of sepsis and/or meningitis were reviewed. During the last 12 years, Klebsiella pneumoniae and Escherichia coli have been replaced by Staphylococcus aureus and Pseudomonas aeruginosa as the predominant isolates from throat swabs after admission. These change in the etiologic pattern of infectious agents of sepsis and/or meningitis, i.e., K. pneumoniae, E. coli, S. aureus, P. aeruginosa and staphylococcus epidermidis, were in agreement with the organisms isolated from the throat swabs after admission. The S. aureus isolated from throat swabs after admission showed a decrease in the bacterial activity of cloxacillin, cephazolin and cefotaxime since 1978.     

新生儿重症监护室噪音的危害与控制

新生儿重症监护室(NICU)内噪音对新生儿具有潜在性危害.该文总结了噪音对新生儿的生理和心理的影响,同时指出提高医务人员对噪音危害的认识、加强NICU管理、科学设计和建设NICU、更新设备及改进医疗过程等,可减少NICU的噪音污染.