The use of mechanical ventilation protocols in Canadian neonatal intensive care units

OBJECTIVES:To identify the proportion of Canadian neonatal intensive care units with existing mechanical ventilation protocols and to determine the characteristics and respiratory care practices of units that have adopted such protocols.METHODS:A structured survey including 36 questions about mechanical ventilation protocols and respiratory care practices was mailed to the medical directors of all tertiary care neonatal units in Canada and circulated between December 2012 and March 2013.RESULTS:Twenty-four of 32 units responded to the survey (75%). Of the respondents, 91% were medical directors and 71% worked in university hospitals. Nine units (38%) had at least one type of mechanical ventilation protocol, most commonly for the acute and weaning phases. Units with pre-existing protocols were more commonly university-affiliated and had higher ratios of ventilated patients to physicians or respiratory therapists, although this did not reach statistical significance. The presence of a mechanical ventilation protocol was highly correlated with the coexistence of a protocol for noninvasive ventilation (P<0.001, OR 4.5 [95% CI 1.3 to 15.3]). There were overall wide variations in ventilation practices across units. However, units with mechanical ventilation protocols were significantly more likely to extubate neonates from the assist control mode (P=0.039, OR 8.25 [95% CI 1.2 to 59]).CONCLUSION:Despite the lack of compelling evidence to support their use in neonates, a considerable number of Canadian neonatal intensive care units have adopted mechanical ventilation protocols. More research is needed to better understand their role in reducing unnecessary variations in practice and improving short- and long-term outcomes.     

NICU新生儿院内感染情况及危险因素分析

目的：通过分析该院新生儿重症监护室(NICU)2012年1月至2013年10月新生儿院内感染的发生情况,探讨院内感染发生的危险因素。方法回顾性分析NICU住院时间超过48 h新生儿的临床资料,分析院内感染发生、发展及相关的危险因素。结果该研究中1357例患儿发生院内感染202例次,院内感染发生率为14．89%(202/1375),日感染率为10．44‰(202/19355)。不同出生体重与胎龄患儿院内感染发生率比较有统计学意义,其中出生体重<1000 g患儿院感发生率为75．00%,胎龄<30周患儿院内感染发生率为52．63%。最常见的院内感染类型是肺炎[43．07%(87/202)]与败血症[26．73%(54/202)]。院内感染患儿比非院内感染患儿住院时间长(中位住院时间：20 d与10 d)(P<0．01),住院费用高(中位住院费用：21045．32元与8108．23元)(P<0．01)。单因素分析结果显示,院内感染患儿与非院内感染患儿在胎龄、出生体重、5 min Apgar评分、窒息抢救史、感染前抗生素使用、机械通气、中心静脉置管、胸腔闭式引流管、感染前胸腹部手术方面比较差异有显著统计学意义,Logistic 回归分析显示,机械通气、中心静脉置管及感染前使用抗生素为院内感染的独立危险因素。结论 NICU新生儿院内感染发生率比较高,机械通气、中心静脉置管及感染前使用抗生素为NICU院内感染独立危险因素。     

中国新生儿重症监护病房中实施家长参与早产儿住院期间综合管理与常规护理的平行对照研究

目的探讨在中国NICU实施家长参与早产儿住院期间综合管理（FICare）的可行性。方法以平行对照设计试验方案,对在中南大学湘雅三医院NICU中符合FICare组纳入标准的早产儿行FICare模式干预（建立FICare组医护团队,NICU改造,掌握六步洗手法、脐带护理、口腔护理、留置胃管管饲、婴儿洗澡、袋鼠式搂抱、称体重、皮肤护理、母乳喂养等）,选择同期NICU中符合对照组纳入标准的早产儿以常规护理模式干预。主要观察住院时间,次要观察体重增长速度、开始胃肠内喂养时间和达到全胃肠内喂养的时间、母乳喂养率、院内感染率、总氧疗时间、出院30 d内再次入院率和纠正胎龄37周时NBNA评分;附加观察FICare组家长出现在NICU后FICare医护团队工作期间心理压力、医疗费用、研究期间的医疗纠纷投诉率、病房额外开支、实施FICare后与前1年同期NICU的不良事件数量等。结果FICare组和对照组分别纳入30和60例,两组基线具可比性。FICare组和对照组NICU住院时间分别为（25.9±7.1）d和（29.2±6.0）d,差异有统计学意义（P=0.035）。两组开始胃肠内喂养日龄、院内感染率差异无统计学意义;FICare组与对照组比较,达全胃肠内喂养时间较快、母乳喂养率较高、体重增长速度较快、总的氧疗时间较短、出院30 d内再次入院率较低、纠正胎龄37周时NBNA评分较高,差异均有统计学意义。当FICare组家长出现在NICU,6/6名护士均在工作期间感觉心理压力增加）,护士自愿报名参加FICare课题组却增加了7人,没有医疗纠纷投诉, 总医疗费用减少,实施FICare后与前1年同期相比NICU的不良事件数量下降（每月2.2 vs 4次）。结论在中国NICU实施FICare具可行性,继续开展FICare的后续研究是安全的,但医护人员工作压力和NICU的额外支出有所增加。     

目标性监测在新生儿重症监护病房医院感染中的应用价值

目的探讨目标性监测对控制新生儿重症监护病房(NICU)感染发生率的作用。方法回顾分析2013年1月至2015年6月入住NICU患儿经目标性监测持续改进后的医院感染率的变化。结果研究期间符合入选条件患儿1 011例中发生医院感染59例,医院感染率为5.8%,日感染率为3.5%;以每半年分期,日感染率从2013年上半年的8.0%下降至2015年上半年的2.2%;呼吸机相关性肺炎例/1 000呼吸机使用日从2013年上半年的12.8‰下降至2015年上半年的0‰;中心静脉导管相关性血流感染例/1000中心静脉置管日从2013年上半年的4.5‰下降至2015年上半年的0‰,差异均有统计学意义(P0.05)。结论通过连续性目标性监测可及时掌握NICU医院感染动态变化和危险因素,便于采取持续有效的干预措施,降低NICU医院感染率。     

Risk factors associated with gut and nasopharyngeal colonization by common Gram-negative species and yeasts in neonatal intensive care units patients

Aim

To characterize dynamics of mucosal colonization of neonates by common aerobic Gram negative species and Candida spp. and to identify independent perinatal, neonatal, and environmental factors influencing the colonization process.

Study design

The nasopharyngeal (n = 1145) and rectal (n = 1242) swabs were collected on admission and thereafter twice a week in neonates with risk factors of early onset sepsis (n = 276) admitted within the first 72 h of life. The association between colonization by different microbes and a total of 22 predefined risk factors was assessed using univariate and multiple logistic regression analyses.

Results

Throughout the study about half of the patients had rectal (55.8%) or nasopharyngeal colonization (42.8%) with common Gram-negative microorganisms. Colonization dynamics and risk factors were in general similar for a given bacterial species in both mucosal sites; nonfermentative microbes more often found in nasopharyngeal swabs and Enterobacteriaceae in rectal swabs. All organisms except Escherichia coli were influenced by the duration of intensive care unit stay but other risk factors were species specific, perhaps reflecting their mode of acquisition. While colonization by E. coli and Candida albicans was associated with perinatal factors like term birth, vaginal delivery, and breast milk feeding; colonization by Klebsiella pneumoniae, Enteribacter cloacae, Acinetobacter spp. and non-albicans Candida spp. were mostly determined by hospital environment (treatment unit and period, artificial interventions and their duration) and gestation age ≤ 28 weeks.

Conclusions

The knowledge of risk factor profiles may permit the development of strategies to prevent heavy colonization and subsequent invasive disease in high risk infants.     

Social determinants of health and the neonate in the neonatal intensive care

It is increasingly recognised that social determinants of health such as socioeconomic inequalities, parental education level, addiction behaviors, mental health difficulties and breast-feeding rates all influence immediate and long-term outcomes in neonatal intensive care unit (NICU) graduates. Awareness, recognition and appropriate management of these risks may help alleviate some of these effects. This review looks at various social determinants and their effects on patients and families in the NICU.     

新生儿重症监护病房医院内感染高危因素及防治策略

随着新生儿重症监护病房(neonatal intensive care unit,NICU)诊治技术的不断发展,医院内感染逐渐增多.做好NICU院内感染的监控工作,对提高新生儿的存活率及NICU的管理水平至关重要.该文分析探讨医院内感染的原因,并讨论医院内感染的防治对策.     

Risk factors for nosocomial sepsis in newborn intensive and intermediate care units

Abstract A multicentre prospective study was performed to estimate the incidence of hospital infections and to identify the most relevant risk factors for sepsis in a large and unselected population of high-risk newborns. The study involved 49 neonatal intensive care units and 17 neonatal intermediate care units in Italy. Newborns were followed up from admittance to the units until discharge. Data on demographics and clinical characteristics, exposure to the principal invasive procedures, and onset of infectious complications were prospectively collected. Only infections developing after 48 h from admittance to the unit were recorded. A multiple logistic regression was performed to identify which factors were independently associated with sepsis. Among the 8263 newborns included in the analysis, the incidence of infected newborns was 14.4 per 100 newborns and 0.9/100 days of stay. The incidence of infections was 19.1/100 newborns and 1.2/100 days of stay. Sepsis represented 15.4% of all infections (incidence 2.9/100 newborns and 0.2/100 days of stay). The following factors were independently associated with sepsis: umbilical catheterization, both through the vein and the artery for more than 5 days; mechanical ventilation for more than 5 days; necrotizing enterocolitis; birth weight equal to or less than 2500 g; nasogastric tube; total parenteral nutrition; and transfer from other hospitals. Umbilical catheters accounted for the highest proportion of sepsis (62%), followed by arterial catheters (31%), nasopharyngeal cannulae (26%), tracheal cannulae (20%), and nasal cannulae (20%). The population attributable risk for the other procedures was less than 10%.Conclusion This study demonstrates that in a large and unselected newborn population, several host factors and invasive procedures are independently associated with an increased risk of sepsis. After adjustment for clinical severity, intravascular catheterization and assisted ventilation were found to be responsible for a considerable proportion of observed sepsis. They shoudl therefore be considered as priorities for interventions, aimed both at reducing unnecessary use and promoting more strict compliance with aseptic practices.     

纤维支气管镜在NICU中的应用进展

纤维支气管镜诊疗技术已成为NICU中的一项重要的辅助诊疗手段,其应用提高了新生儿呼吸系统疾病的临床诊治水平.随着设备的改进、医务人员操作水平的不断提高,目前已应用于体重低至600 g的早产儿.本文着重介绍了近年来纤维支气管镜在危重症新生儿应用的新进展、主要诊断和治疗适应证,同时探讨了其在新生儿应用中的安全性.     

Bacterial nosocomial infections in neonatal intensive care unit,Zagazig University Hospital,Egypt

Effective strategies to prevent nosocomial infections (NI) among neonates in neonatal intensive care unit (NICU) require a comprehensive study of epidemiology, risk factors and outcomes.ObjectivesThe purpose of this study was to determine the occurrence of NI, associated risk factors, distribution of pathogens and their susceptibility to antibiotics and calculating the death rates among the studied neonates in the NICU of the Zagazig University Hospital.MethodsA prospective cohort study was conducted over a period of one year, 418 non infected neonates at admission were included, where; Blood, Pus, CSF and Urine specimen were collected and processed.ResultsOut of 418 neonates; 161 (38.5%) developed NI. Most of the infections were caused by Klebsiella (34.2%) and Staphylococcus aureus (26.1%). The main neonatal NI was bloodstream infection (58.0%), followed by pneumonia NI (46.0%). Low birth weight (LBW) and prematurity were reported to be important risk factors for NI. Neonates with NI had a significantly prolonged hospital stay. The death rate for NI was 26.7%.ConclusionHigh incidence rate of NI in neonates admitted to NICU was documented, particularly premature and low birth weight neonates. Early identification of NI and its risk factors remain the keys to successful management of this condition.     

Invasive antenatal procedures and requirement for neonatal intensive care unit admission

Neonatal respiratory difficulties are increased following second trimester amniocentesis. In preterm, prolonged rupture of the membranes, respiratory outcome is particularly poor when rupture occurs in the first trimester. It therefore seems likely that first trimester/early amniocentesis (EA) would be associated with severe respiratory problems necessitating a high neonatal intensive care unit (NICU) admission rate. To test that hypothesis, the requirement for admission to the NICU of 278 infants whose mothers had undergone EA, 262 whose mothers had undergone chorion villus sampling (CVS group) and 264 controls whose mothers had undergone no invasive procedures were reviewed as were their diagnoses if they needed admission. There was no significant difference in the mode of delivery, gestational age or gender distribution of the three groups and the median maternal age of the EA and CVS groups was similar. Nineteen EA, eight CVS and five control infants required admission to the NICU (EA versus controls, P < 0.01; EA versus CVS plus controls, P < 0.005). Nine EA, one CVS and four control infants had suffered respiratory problems (EA versus CVS P < 0.05). Logistic regression analysis demonstrated that immaturity and EA were significantly associated with a requirement for NICU admission. We conclude infants whose mothers have undergone EA may be at increased risk for NICU admission, this is partly due to respiratory problems but the association is uncommon. Received: 1 August 1996 / Accepted: 12 December 1996     

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.