Infants with congenital anomalies admitted to neonatal intensive care units

The objective of this study was to describe the congenital anomalies in 17 Canadian neonatal intensive care units (NICUs) and their impact on mortality, morbidity, and resource utilization. This study was performed using a database analysis of 19,507 consecutive admissions. Results show that 13.7% of admissions had one or more anomalies. There was wide variation in incidence between NICUs (4.4 to 36.6%). Congenital anomalies were associated with increased severity of illness, and higher mortality, morbidity, and resource use. Inclusion of congenital anomalies improves mortality prediction in regression analyses models. Congenital anomalies have a significant impact on NICU outcomes and resource use.     

Prediction of length of hospital stay in neonatal units for very low birth weight infants.

OBJECTIVE: To develop models for estimating the length of hospital stay (LOS) of very low birth weight infants (VLBW), based on perinatal risk factors present during the first week of life and during the entire hospitalization period. STUDY DESIGN: The files of 155 VLBW were analyzed, and the influence of individual risk factors were initially evaluated by univariate analysis, using multiple-regression. Two mathematical models were built to estimate the LOS. RESULTS: The first model, using risk factors present during the first 3 days of life, is as follows: LOS = -0.074A + 22.06B + 22.85C - 16.78D - 2.07E + 10.51F + 203.12 (R2 = 0.63). (The letters are added to show what each number represents: A: birth weight; B: occurrence of respiratory distress syndrome; C: endotracheal intubation during resuscitation; D: 1-minute Apgar score; E: gestational age; F: presence of complications during delivery.) The second model, using factors present during the entire hospitalization period, is: LOS = 0.61G + 29.19H + 24.68I + 14.21J + 23.56K + 9.54L + 7.41M + 20.43 (R2 = 0.82). (G: age receiving nutritional support of > or = 120 kcal/kg per day; H: occurrence of systemic candidiasis; I: birth weight < 1000 gm; J: presence of delivery complication; K: occurrence of bronchopulmonary dysplasia; L: birth weight > or = 1000 gm and < or = 1249 gm; M: occurrence of anemia). CONCLUSION: Both models are applicable for estimating the hospitalization period, and the addition of variables present during the entire hospitalization period improved the accuracy of the model.     

Comparison of neonatal mortality rates between transports to tertiary and intermediate neonatal intensive care units

The differential of neonatal mortality rates between infant transports to tertiary and to intermediate neonatal intensive care units (NICUs) was examined based on 8,391 one-time infant transports from community hospitals to tertiary or intermediate NICUs in Southern California in the three-year period 1981-1983. Among the demographic, birth and delivery, and diagnostic characteristics studied, nine were identified to be related significantly to the higher neonatal mortality rate among transports to tertiary NICUs: birthweight, gestational age, necessity of intubation, multiple clinical conditions, presence of cardiac, neurologic, and genitourinary problems, anomalies, and syndromes. Adjusting for differences in the number of cases with necessity of intubation and the presence of the five clinical problems reduced the neonatal mortality ratio of tertiary to intermediate NICUs from 1:56 to 1:01, while adjustment for birthweight and gestational age differences reduced the ratio from 1.56 to 1.54. This analysis indicates that the difference of neonatal mortality between the two levels of NICUs can be explained to a larger extent by the higher proportion of infants requiring intubation with serious clinical problems. Birthweight and gestational age played only a minor role in this respect.     

Back transport of neonates: effect on hospital length of stay.

INTRODUCTION:In a regionalized perinatal system, recovering neonates may be back transported from a regional Neonatal Intensive Care Unit (NICU) to community hospitals closer to their residence to convalesce prior to hospital discharge.OBJECTIVE:This study evaluates the practice of neonatal back transport for growth and the duration of total hospitalization.METHODS:We conducted a retrospective study comparing length of stay (LOS) for infants back transported from a regional NICU to a level II nursery for convalescent care (BT), with LOS for infants eligible for back transport discharged home from the Regional Center (RC).RESULTS:A total of 221 infants were studied. BT infants (n=104) had lower birth weights (median; 1955 vs 2700 g, p=0.001), more frequently needed mechanical ventilation (84 vs 65%, p=0.002) and parenteral nutrition (71 vs 55%, p=0.013), less frequently were evaluated by subspecialists (20 vs 59% p=0.0001), and had longer total LOS (median; 20 vs 11 days, p<0.0001) compared to infants discharged home from the RC (n=117). However, in the subgroup with birth weights 相似文献   

Evaluation of a lactation support service in a children's hospital neonatal intensive care unit.

Breastfeeding hospitalized infants can be difficult. The authors assessed the effectiveness of an International Board Certified Lactation Consultants (IBCLC) service to increase the proportion of infants given their own mother's milk (OMM) in a children's hospital neonatal intensive care unit (NICU). The charts of 350 randomly selected patients admitted the year before and after implementation of the service in July 1997 were abstracted. Factors significantly associated with infants being given OMM included infant sex, ethnicity, length of NICU stay, and 5-minute Apgar score. After comparison of the periods before and after program implementation, the proportion of NICU infants ever given their OMM was found to have increased from 31% to 47% (P = .002). This increase differed significantly in relation to infants' clinical status and/or management (5-minute Apgar score, length of NICU stay, and age at NICU admission) but not in relation to maternal factors. Mothers with infants in the NICU should have access to lactation counseling.     

Cost-effectiveness analysis of Malaysian neonatal intensive care units.

OBJECTIVE: To perform a cost-effective analysis on the care of infants between 1000 and 1500 g birthweight (the study group), where outcomes are measured as survival to 1 year of age. METHODOLOGY: This was a multicenter observational study to determine the outcome, cost and cost-effectiveness of neonatal intensive care provided by Ministry of Health (MOH) Pediatric services. A total of 333 patients enrolled were eligible for analysis according to the inclusion and exclusion criteria of this study. RESULTS: Overall survival probability of the study group infants at 1 year of age was 78%. Survival at 1-year of age was 77% for infants with birth weight 1000 to 1249 g, 79% for 1250 to 1499 g. Survival at 1 year of age for the sample group was 53% for 22 to 27 weeks gestation, 80% for 28 to 36 weeks. The average cost-effectiveness ratio (CER) of neonatal intensive care for the study group infants was US$3979 [corrected] per survivor at 1 year of age (95% confidence interval US$3411, 5160). CONCLUSION: There was variability in the outcome and cost-effectiveness between the neonatal units, which need to be further assessed. However, neonatal intensive care services provided for the study group infants were cost-effective compared to that in developed countries.     

The changing epidemiology of preterm twins and triplets admitted to neonatal intensive care units in Canada, 2003 to 2008

We describe trends in the rates of admission of preterm twin and triplet infants to neonatal intensive care units (NICUs) across Canada and compare their neonatal outcomes over a 6-year period. Temporal trends of admission rates for 5193 twins and triplets < 33 weeks' gestational age to participating NICUs in the Canadian Neonatal Network between 2003 and 2008 were assessed. Trends in infant outcomes were evaluated using logistic regression. The proportion of twins increased from 26.1 to 28.0 per 100 admissions between 2003 and 2008 (7% increase, p = 0.02). In contrast, the proportion of triplets decreased from 5.0 to 3.3 per 100 admissions (34% reduction, p = 0.04). These trends were significant in mothers ≥ 35 years of age. Neonatal outcomes improved for preterm twins (mortality, p < 0.01; survival without any major morbidity, p < 0.01; severe neurological injury, p = 0.02; and severe retinopathy of prematurity, p = 0.03). Similar improvements were observed for triplets, but the sample size was insufficient to reach statistical significance. The rate of NICU admissions for preterm twins at < 33 weeks' gestation has increased in recent years, whereas for triplets it has gradually declined. Neonatal outcomes of preterm twins improved over the study period.     

Admission volume is associated with mortality of neonatal respiratory failure in emerging neonatal intensive care units

Objective: The aim of this survey was to explore the relationship between admission volume and mortality of neonates with hypoxemic respiratory failure (NRF) in emerging neonatal intensive care units (NICUs).

Methods: NRF from 55 NICUs were retrospectively included with death risk as the major outcome. Perinatal comorbidities, underlying disease severity, respiratory support, facility utilization, and economic burden in the early postnatal period were compared among five NICU admission volume categories defined by NRF incidence, with score for neonatal acute physiology perinatal extension II (SNAPPE-II) also assessed as initial severity.

Results: Compared to NICUs with NRF?p?r?=?.282, p?p?Conclusions: Neonates in NICUs with smaller NRF admission volume and decreased magnitude of ventilator use had a higher risk of death as assessed by SNAPPE-II, which should be targeted in the quality improvement of newly established, resource-limited NICUs.     

Cytomegalovirus infection in infants admitted to a neonatal intensive care unit

Abstract

Objectives: To determine the incidence of congenital cytomegalovirus (CMV) infection and the frequency of postnatal infection in a neonatal intensive care unit (NICU).

Methods: Urine samples of 135 infants who were admitted to the NICU during a 6 month period were evaluated to detect CMV using a nested PCR assay. A breast milk sample was obtained to determine viral excretion. Clinical characteristics of infected and non-infected infants were compared.

Results: Congenital CMV infection was confirmed in two (1.48%) infants. Post-natal infection was documented in four of 36 (11.1%) infants that were evaluated. CMV excretion was detected in 43 of 116 mothers. Gestational age of infants born to mothers who excreted CMV was shorter than that of infants of mothers with negative results (33.1 versus 34.2 weeks; p?=?0.07).

Conclusions: CMV excretion in breast milk is frequent and is associated to congenital and postnatal infection. Further studies are necessary to assess the impact of CMV infection during pregnancy and neonatal outcomes.     

Measuring developmentally appropriate practice in neonatal intensive care units.

OBJECTIVE: Neonatal intensive care units (NICUs) impose stressors on development. Comparative studies have focused mostly on the units' medical qualities and less on their developmental 'ecology'. The aim of the study was to develop a tool for measuring the various domains of a developmentally appropriate practice in the NICU environment, and to assess its implementation in Israel. STUDY DESIGN: A questionnaire, designed for NICU senior staff members, was completed by 76 respondents representing 24 NICUs in Israel. The tool that measures developmentally appropriate practice as applied in the NICU environment includes the following three domains: (a) parental and family involvement, (b) environmental control and (c) individualized care and assessment. These measures jointly produce the developmentally appropriate neonatal intensive-care practice (DANIP) index. RESULT: High variability was found in the application of procedures and programs considered developmentally appropriate. Units with a relatively large multidisciplinary team scored high. Overall, the NICUs in Israel did not consistently follow an integrated form of the developmental care as provided by the Neonatal Individualized Developmental Care and Assessment Program. It was found that individualized care and assessment was significantly and positively linked to control of the environment (r=0.53, P<0.01) and to parental and family involvement (r=0.76, P<0.01); the latter two scales were not associated. Of the three DANIP domains, parental involvement was salient. Although the staff highly appreciated the importance of environmental control and individualized care, application was limited. CONCLUSION: The DANIP index provides a good starting point for comparative studies.     

Outcome of hematopoietic stem cell recipients who were mechanically ventilated and admitted to intensive care units.

BACKGROUND/PURPOSE: To evaluate the ICU mortality rate of mechanically ventilated hematopoietic stem cell transplantation (HSCT) recipients and to identify the factors that were associated with ICU mortality. The impact of surgical lung biopsy (SLB) in patients with unexplained pulmonary infiltrates was also evaluated. METHODS: Forty-one mechanically ventilated HSCT recipients admitted to the ICU during the study period were enrolled. The medical records were reviewed and data at ICU admission were analyzed. Data were compared between ICU survivors and nonsurvivors. The pathologic findings of SLB and the resulting impact on treatment were analyzed. RESULTS: Eight patients (19.5%) survived the ICU stay, and seven (17%) lived to hospital discharge. The most common etiologies of ICU mortality included bacterial pneumonia, cytomegalovirus pneumonia, diffuse alveolar hemorrhage, sepsis, and aspergillosis. The factors associated with higher mortality were older age when performing HSCT, older age at ICU admission, higher acute physiology and chronic health evaluation (APACHE) II score, shock, higher respiratory rate, and higher heart rate at the time of ICU admission. Ten patients underwent SLB which resulted in treatment changes in five of them. Three patients had complications of SLB and one patient died of complications. CONCLUSION: The ICU mortality rate of mechanically ventilated HSCT recipients was high. Factors associated with ICU mortality were older age, high APACHE II score, presence of shock, and higher respiratory or heart rate at the time of ICU admission. SLB might provide specific diagnosis in HSCT recipients with unexplained pulmonary infiltrates and aid modification of treatment.     

Neurologic and non-neurologic predictors of mortality in ischemic stroke patients admitted to the intensive care unit.

BACKGROUND/PURPOSE: Patients with severe strokes may have different associated medical comorbidities from those with mild strokes. This study evaluated the neurologic and non-neurologic medical predictors of mortality in patients with severe cerebral infarction in the acute stage. METHODS: Patients admitted to a neurologic intensive care unit (ICU) due to cerebral infarction were included. Neurologic and non-neurologic predictors for in-unit mortality were determined by logistic regression analyses. Two models using (A) neurologic factors and (B) combined neurologic and non-neurologic factors as mortality predictors were developed. The performance of the models in predicting overall, neurologic and non-neurologic mortalities was compared by areas under the receiver-operating characteristic curves (AUC) of the derived regressive equations. RESULTS: Of 231 patients with cerebral infarction admitted to the ICU, 34 (14.7%) died during ICU stay. Conscious state and acute physiologic abnormalities were significant predictors of mortality. The length of ICU stay in patients with non-neurologic mortality was longer than in those with neurologic mortality (p = 0.044). The AUC of Model B was larger than that of Model A in predicting overall (0.768 +/- 0.045 vs. 0.863 +/- 0.033, p = 0.005) and non-neurologic mortalities (0.570 +/- 0.073 vs. 0.707 +/- 0.074, p = 0.009), while there was no difference in predicting death from neurologic causes (0.858 +/- 0.044 vs. 0.880 +/- 0.032, p = 0.217). CONCLUSION: Impaired consciousness and acute physiologic abnormalities are independent predictors of mortality for severe ischemic stroke during the acute stage. Neurologic factors predict early mortality from intrinsic cerebral dysfunction, while non-neurologic factors, especially the associated physiologic abnormalities, predict late mortality from medical complications.     

Ethnic differences in risk factors for neonatal mortality and morbidity in the neonatal intensive care unit.

OBJECTIVE: Although our knowledge about how to care for high-risk neonates who require intensive care is continually improving, disparities in health outcomes among various ethnic groups living in developed countries are becoming more evident. The purpose of this study was to identify the risk factors for neonatal intensive care unit (NICU) mortality among Canadian-born minority infants and, furthermore, to determine whether ethnicity was in itself an independent predictor of mortality or major morbidity in the NICU. STUDY DESIGN: Data were prospectively gathered on 6528 infants admitted to nine regionally located NICUs across Canada. Multiple logistic regressions were used to develop risk-adjusted models for NICU mortality and major morbidity. RESULT: Despite adjusting for differences in small for gestational age (SGA), outborn status and gestational age less than or equal to 28 weeks, South Asian infants still had significantly greater odds of mortality in the NICU. Neonatal sepsis was the strongest predictor of mortality among African infants, even greater than birth at 28 weeks or less. At significantly greater odds of survival with major morbidity were Aboriginal males and East Asian females. CONCLUSION: There are ethnic disparities in the risks of neonatal mortality and morbidity in the NICU. Understanding these differences is important to be able to determine specific areas to target in improving healthcare delivery and reducing disparities in health outcomes among Canada's diverse population.     

Studying determinants of length of hospital stay.

Clinicians are accustomed to focusing on individual patients. However, when studying how long their patients stay in the hospital, the focus must widen. Length of stay summarizes the performance of the entire, exceedingly complex, NICU system. Ordinary statistical methods for modeling patient outcomes assume that what happens to one patient is unrelated to what happens to another. However, patients in the same NICU are exposed to similar hospital practices, so patient outcomes may be correlated. Length of stay data must be analyzed by methods that account for possibly correlated outcomes. In addition, to improve patient care and outcomes, predictive models must include determinants clinicians can influence. Such variables describe care process exposures, available beds, demand for beds, and staffing levels.     

Is breast milk collected at home suitable for raw consumption by neonates in Brazilian public neonatal intensive care units?

This study was designed to verify if breast milk collected at home is appropriate for raw consumption by neonates in a Brazilian public neonatal intensive care unit (NICU). From May 1998 to February 2000, microbiological characteristics of breast milk samples collected at home were analyzed. The milk samples were considered appropriate for raw consumption if mesophilic bacteria count was < 2500 CFU/mL and potential pathogens were not detected. Of 90 milk samples collected from 32 mothers of hospitalized neonates, 36 (40%) were rejected because of potentially pathogenic bacteria (72.2%), mesophilic bacteria count > or = 2500 CFU/mL (13.9%), and both conditions (13.9%). The most frequent nonpathogenic and potentially pathogenic bacteria isolated were Staphylococcus coagulase negative and Klebsiella pneumoniae, respectively. Using univariate analysis, demographic, socioeconomic, educational, and house characteristics were not found to be associated with milk contamination. Breast milk collected at home may not be appropriate for raw consumption in Brazilian NICUs. Pasteurization could improve its microbiological quality. Further studies are needed.