Embracing bioethics in neonatal intensive care, part I: evolving toward neonatal evidence-based ethics

Ethical treatment dilemmas are not new to the NICU. With technologic advances over the past 20 years, NICU care has developed rapidly, and survival rates have improved for some of the tiniest and most critically ill infants. In guiding clinical practice, however, standards in evidenced-based medicine have often superseded standards in evidence-based ethics. Part I of this article presents a historical review of neonatal care and an overview of cases that have set precedents in neonatal ethical debate. It also includes recommendations for enhancing the skills of neonatal nurses as patient advocates in NICU ethical issues, an area that is, at times, controversial and baffling to clinicians.     

Candidemia in neonatal intensive care units: Barcelona, Spain

BACKGROUND: Candida spp. are increasingly important hospital-acquired pathogens in neonatal intensive care units (NICU) and cause considerable mortality in preterm infants. Most studies have been limited to a single institution. The aim of this study was to determine the epidemiology of candidemia in all Barcelona NICUs. METHODS: We conducted prospective population-based surveillance for candidemia in Barcelona, Spain, during 2002-2003. This report focuses on the results from 5 participating hospitals with NICUs. RESULTS: We detected 24 cases, resulting in an annual incidence of 32.6 cases per 100,000 live births and 1.1 cases per 100 NICU discharges. Median gestational age was 27.5 weeks (range, 24-40.5), and there were 21 cases among very low birth weight infants. Among the 20 (83%) cases evaluated for the presence of end organ infection, endophthalmitis occurred in 2 cases, and endocarditis, meningitis and peritonitis occurred in 1 case each. Candida parapsilosis was the most frequent species isolated (67%). All isolates were fluconazole-susceptible. Crude mortality was 21%. CONCLUSIONS: The preponderance of C. parapsilosis candidemias observed in Barcelona NICUs is similar to reports from the literature. Morbidity and mortality associated with neonatal candidemia remain high.     

Death in neonatal intensive care

The aim of this study was to review the frequency of decisions to withdraw treatment from neonates who had died in a large neonatal intensive care unit the reasons for these decisions, and the procedures followed. A 12 month retrospective review of medical and nursing records was undertaken. There were 67 deaths; treatment was withdrawn from 52 infants who were dead or dying, from 9 infants on the basis of a severe congenital abnormality, and from 6 infants with severe acquired brain damage. The decision-making process and the management of treatment withdrawal are reviewed. It is concluded that withdrawal of treatment resulting in death occurs frequently in the neonatal intensive care service of National Women's Hospital, Auckland, New Zealand, but is usually a recognition of the inevitable. Truly elective withdrawal of treatment is uncommon in the immature infant, but does occur in the context of multiple abnormalities or severe birth asphyxia, where it follows a formal procedure.     

Breast-feeding in neonatal intensive care

Objective : To determine the incidence of breast-feeding in very preterm babies while in neonatal intensive care.
Methodology : A retrospective records analysis of all 151 babies with gestational age less than 35 weeks admitted to the neonatal intensive care unit (NICU) of a major teaching hospital in 1993.
Results : On discharge 64% of babies were having some breast milk (45% having breast milk alone, 19% both breast milk and formula), and 38% some breast-feeding (17% being solely breast-fed, the other 21% combining breast-feeding with either bottle-feeding or an intragastric tube [IGT]). Breast milk was the first milk for 41% of babies, with 83% having breast milk at some stage.
Increasing gestational age was associated with a decreased likelihood of first milk being breast milk (73% of those less than 29 weeks compared to 21% of those aged 33–34 weeks, P <0.001), but with increased rates of breast-feeding (23 compared to 59%, P = 0.01) and breast milk consumption (42 compared to 73%, P = 0.04).
Conclusions : Breast-feeding rates in NICU are well below those found on discharge for full term babies. Both maternal and staff-related factors contribute to this. More and better education of mothers, doctors and nurses as well as changes to some unit practices could increase these rates.     

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.     

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.     

Bacterial endocarditis in neonatal intensive care

OBJECTIVES: To ascertain the incidence of bacterial endocarditis in a level III neonatal nursery. To document the clinical features, assess survival, and evaluate the role of central venous catheters in neonates with bacterial endocarditis. METHODOLOGY: Index cases were identified by retrospective review of the echocardiographic records of infants admitted to the neonatal nursery from 1983 to 1995. Data obtained by review of the clinical records of these infants, and case-matched controls. RESULTS: From January 1983 to December 1995, 12,249 infants were admitted to the Special Care Nursery. Eight infants with endocarditis were identified, an incidence of 0.07%. Presenting symptoms and signs were often vague and nonspecific. Gestation less than 32 weeks, birthweight less than 1500 g, thrombocytopenia and neutropenia or neutrophilia were common features. Infants with endocarditis had a significantly higher Clinical Risk Index for Babies score than those without endocarditis. The tricuspid valve was involved in seven infants, six of whom had a percutaneous central venous catheter in situ before diagnosis. Mitral valve involvement occurred in two infants, neither of whom had central lines inserted. However, compared to infants without endocarditis, the placement of a central venous line was not of statistical significance. Seven of the eight infants survived following prolonged antibiotic therapy. CONCLUSIONS: Bacterial endocarditis is a rare but serious condition which is usually not fatal. In the premature newborn infant, presenting signs and symptoms are often nonspecific. Endocarditis should therefore be considered in the unwell very low birthweight infant.     

Computed radiography in neonatal intensive care

The Authors report their experience in the employment of a computerized digital radiographic system in Neonatal Intensive Care. The analog screen-film system is replaced by photosensitive imaging plates, scanned after X-ray exposure by a laser that releases the digital image, which can then be manipulated on computer work-stations. In a period of twelve months about 200 chest-abdomen X-ray examinations in Neonatal Intensive Care have been performed using this method with good technical and diagnostic results. The use of digital radiography in the neonatal area is of high interest: this system produces good guality images, these is a reduction in radiation dose and retakes, the system allows selective enhancement of different structures and their magnification.     

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.     

Cost of neonatal intensive care

ABSTRACT. An analysis was made of the costs of provision for the intensive care of inborn babies in an inner city hospital equipped to deal with high risk obstetrics. Costs showed the expected inverse proportion to birthweight. The larger number of more mature babies nevertheless contributed almost 2/3 of the total cost. The adjusted cost/survivor ("adjusted'to reflect the fact that only the survivors benefit) was $39,845 for babies less than 801 g; $26,100 for those between 801 g and 1,000 g; $14,137 between 1,001 g and 1,500 g and $4,782 over 1,500 g. The largest single expense was in nursing salaries which constituted 60–80% of the total outlay.
No data are available for precise comparison. The figures are presented as a basis on which to begin forming judgements of the cost effectiveness of newborn intensive care.     

Cost of neonatal intensive care

Neonates are among those patients generating the highest hospital costs in recent years. There are no published data on the costs of neonatal intensive care in our country. The aim of our study was to analyse the cost of neonatal intensive care in a tertiary care unit. The average hospital charges per day were higher among non-survivors, (Rs. 1857) compared to survivors (Rs. 727). Care of more than 1250 gms infant is cost beneficial in our set up.     

Handling during neonatal intensive care

The handling received by very low birthweight newborns undergoing intensive care in the first few days of life and the effects of this were studied. Infants were handled an average of 4.3 hours (18%) of the total 24 hour observation time and received a mean 234 handling procedures. Parental handling contributed 35% of the total time but was usually benign except in that it could interfere with the infant's rest. Many procedures were associated with undesirable consequences. Endotracheal suctioning was invariably associated with hypoxaemia and was often carried out more frequently, or took longer, than was optimal. Transcutaneous oxygen monitoring, although considered routine for all intensive care infants, was only carried out for 50% of the observation time and often did not accompany periods of likely intensive handling. Increasing technology in neonatal intensive care often results in increased handling of sick infants. Each new innovation, as well as routine procedures, should be viewed in the light of the continuum of neonatal intensive care events, and handling kept to a minimum.     

Cost of neonatal intensive care

An analysis was made of the costs of provision for the intensive care of inborn babies in an inner city hospital equipped to deal with high risk obstetrics. Costs showed the expected inverse proportion to birthweight. The larger number of more mature babies nevertheless contributed almost 2/3 of the total cost. The adjusted cost/survivor ("adjusted" to reflect the fact that only the survivors benefit) was $39,845 for babies less than 801 g; $26,100 for those between 801 g and 1,000 g; $14,137 between 1,001 g and 1,500 g and $4,782 over 1,500 g. The largest single expense was in nursing salaries which constituted 60-80% of the total outlay. No data are available for precise comparison. The figures are presented as a basis on which to begin forming judgements of the cost effectiveness of newborn intensive care.     

Cholestasis in neonatal intensive care unit: incidence, aetiology and management

Aim:  Prevalence, aetiology, management and outcome of cholestasis were evaluated in infants admitted to neonatal intensive care unit (NICU).
Methods:  Medical records of all infants admitted to two Italian level III NICUs from January 2005 to August 2007 were retrospectively reviewed. The role of ursodeoxycholic acid (UDCA) therapy was also investigated.
Results:  Twenty-seven of 1289 enrolled infants developed cholestasis. In 25 infants, cholestasis had a multifactorial basis, while in two, no aetiology was found. UDCA did not significantly affect clinical and biochemical course of cholestasis. During a period of 12 months, eight cholestatic infants died, one underwent liver transplantation and 18 fully recovered.
Conclusion:  Infants admitted in NICU have a rate of cholestasis higher than that reported in the general population of live births; in most cases, cholestasis is associated to multiple risk factors and shows a favourable outcome. UDCA does not seem to affect clinical course of cholestasis in this setting.     

Perinatal transport: problems in neonatal intensive care capacity

OBJECTIVE: To assess the quantity and nature of transfers within the Yorkshire perinatal service, with the aim of identifying suitable outcome measures for the assessment of future service improvements. DESIGN/SETTING: Collection of data on perinatal transfers from all neonatal and maternity units located in the Yorkshire region of the United Kingdom from May to November 2000. PATIENTS: Expectant mothers (in utero transfers) and neonates (ex utero transfers). INTERVENTIONS: None MAIN OUTCOME MEASURES: Quantification of in utero and ex utero transfers; the reasons for and resources required to support transfers; the nature of each transfer (acute, specialist, non-acute, into or out of region). RESULTS: In the period studied, there were 800 transfers (337 in utero; 463 ex utero); 306 transfers were "acute" (80% of transfers in utero), 214 because of specialist need, and 280 "non-acute". Some 37% of capacity transfers occurred from the two level 3 units in the region. Of 254 transfers out of the 14 neonatal units for intensive care, 44 (17.3%) were transferred to hospitals outside the normal neonatal commissioning boundaries. CONCLUSIONS: The study highlights a continuing apparent lack of capacity within the neonatal service in the Yorkshire region, resulting in considerable numbers of neonatal and maternal transfers.