63 Characterizing Organizational Risk Factors and Clinical Impacts of Unplanned Extubations among Infants in the Neonatal Intensive Care Unit

2021 ◽  
Vol 26 (Supplement_1) ◽  
pp. e44-e45
Author(s):  
Gabriella Le Blanc ◽  
Elias Jabbour ◽  
Sharina Patel ◽  
Marco Zeid ◽  
Wissam Shalish ◽  
...  
Keyword(s):  
Mechanical Ventilation ◽  
Intensive Care ◽  
Neonatal Intensive Care ◽  
Tertiary Care ◽  
Organizational Factors ◽  
Subject Area ◽  
Administrative Databases ◽  
Perinatal Medicine ◽  
Unplanned Extubations ◽  
Increased Risk

Abstract Primary Subject area Neonatal-Perinatal Medicine Background Organizational factors in neonatal intensive care units (NICUs) can increase the risk of adverse events, such as unplanned extubations (UPEs). UPE is the premature and unanticipated removal of an endotracheal tube. UPE and subsequent reintubation may increase the risk for lung injury and bronchopulmonary dysplasia (BPD) among preterm infants. Objectives First, we aimed to assess the association between daily nursing overtime and UPEs in the NICU. Second, we aimed to evaluate the association between UPE, re-intubation after UPE, and BPD in the sub-group of infants born < 29 weeks’ gestational age (GA). Design/Methods We conducted a retrospective cohort study including infants admitted to a tertiary care NICU between 2016-2019. Daily nursing hours were obtained from local administrative databases. Patient data was collected from the local Canadian Neonatal Network database. Association between ratio of daily nursing overtime hours/total nursing hours (OTR) was compared between days with and without UPEs, using logistic regression analyses. Associations between UPE and BPD among infants born <29 weeks requiring mechanical ventilation was evaluated in a 1:1 propensity-score matched (PSM) cohort. Infants were matched based on GA ± 2 weeks, mechanical ventilation days at time of UPE ± 5 days and SNAPII>20. Results There were 108/1370 (7.8%) days with ≥ 1 UPE, for a total of 116 UPE events from 87 patients (23-42 weeks GA). Higher median OTR was observed on days with UPE compared to days without (3.3% vs. 2.5%, p=0.01). OTR was associated with higher adjusted odds of UPE (aOR 1.09, 95% CI 1.01-1.18), while other organizational variables were not (Table 1). Among ventilated infants <29 weeks’ GA (n=XX), UPE rate was 31% (59), BPD rate was 42% (81) and re-intubation rate after UPE was 59% (35). In the PSM cohort of infants <29 weeks, re-intubation after UPE, was associated with increased length of mechanical ventilation (aOR 16.45; CI 6.18, 26.72) as well as increased odds of BPD, when compared to infants not requiring re-intubation (aOR 4.97, 95% CI 1.54-18.27) (Table 2). Conclusion Higher nursing overtime was associated with increased UPEs in the NICU. Re-intubation was frequently required after a UPE. Among the infants born < 29 weeks’ GA, UPE requiring reintubation was associated with increased total length of mechanical ventilation and increased risk of BPD. Our findings highlight the role of workforce management in improving outcomes in the NICU, through reducing the incidence of UPEs.

Hypoxemic and hyperoxemic likelihood in pulse oximetry ranges: NICU observational study

2018 ◽  
Vol 104 (3) ◽  
pp. F274-F279 ◽  
Author(s):  
Thomas E Bachman ◽  
Christopher J L Newth ◽  
Narayan P Iyer ◽  
Patrick A Ross ◽  
Robinder G Khemani
Keyword(s):  
Intensive Care Unit ◽  
Mechanical Ventilation ◽  
Intensive Care ◽  
Observational Study ◽  
Preterm Infants ◽  
Neonatal Intensive Care ◽  
Tertiary Care ◽  
Term Infants ◽  
Postmenstrual Age ◽  
Preterm Group

ObjectiveDescribe the likelihood of hypoxemia and hyperoxemia across ranges of oxygen saturation (SpO2), during mechanical ventilation with supplemental oxygenation.DesignRetrospective observational study.SettingUniversity affiliated tertiary care neonatal intensive care unit.PatientsTwo groups of neonates based on postmenstrual age (PMA): <32 weeks (n=104) and >36 weeks (n=709).Main measuresHypoxemia was defined as a PaO2 <40 mm Hg, hyperoxemia as a PaO2 of >99 mm Hg and normoxemia as a PaO2 of 50–80 mm Hg. Twenty-five per cent was defined as marked likelihood of hypoxemia or hyperoxemia.ResultsFrom these infants, 18 034 SpO2–PaO2 pairs were evaluated of which 10% were preterm. The PMA (median and IQR) of the two groups were: 28 weeks (27–30) and 40 weeks (38–41). With SpO2 levels between 90% and 95%, the likelihoods of hypoxemia and hyperoxemia were low and balanced. With increasing levels of SpO2, the likelihood of hyperoxemia increased. It became marked in the preterm group when SpO2 was 99%–100% (95% CI 29% to 41%) and in the term group with SpO2 levels of 96%–98% (95% CI 29% to 32%). The likelihood of hypoxemia increased as SpO2 decreased. It became marked in both with SpO2 levels of 80%–85% (95% CI 20% to 31%, 24% to 28%, respectively).ConclusionsThe likelihood of a PaO2 <40 mm Hg is marked with SpO2 below 86%. The likelihood of a PaO2 >99 mm Hg is marked in term infants with SpO2 above 95% and above 98% in preterm infants. SpO2 levels between 90% and 95% are appropriate targets for term and preterm infants.

scholarly journals Perfusion Abnormalities Shown On Subtraction CT Angiography In Apparently Normal Lungs And Their Impact On Patient Outcome. A Prospective Cohort Study: What Could We Be Missing?

2021 ◽  
Author(s):  
Mario G. Santamarina ◽  
Felipe Martinez Lomakin ◽  
Ignacio Beddings ◽  
Dominique Boisier Riscal ◽  
Jose Chang Villacís ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Mechanical Ventilation ◽  
Risk Factor ◽  
Intensive Care ◽  
Clinical Outcomes ◽  
Ct Angiography ◽  
Independent Risk Factor ◽  
Invasive Mechanical Ventilation ◽  
Tertiary Care ◽  
Increased Risk

Abstract Background: COVID-19 pneumonia seems to affect the regulation of pulmonary perfusion. In this study, through iodine distribution maps obtained with subtraction CT angiography, we quantified and analyzed perfusion abnormalities in patients with COVID-19 pneumonia and correlated them with clinical outcomes.Methods: 205 patients were included in this cohort, from two different tertiary-care hospitals in Chile. All patients had RT-PCR confirmed SARS-CoV-2 infection. CT scans were performed within 24 h of admission, in supine position. Airspace compromise was assessed with CT severity score, and the extension of hypoperfusion in apparently healthy lung parenchyma with perfusion score. CT severity and perfusion scores were then correlated with clinical outcomes. Multivariable analyses using Cox Proportional Hazards regression were used to control for clinical confounders.Results: Fourteen patients were excluded due to uninterpretable images. This left 191 patients, 112 males and 79 females. The mean age was 60.8±16.0 years. The median SOFA score on admission was 2 and average PaFi ratio was 250±118. Patients with severe perfusion abnormalities showed significantly higher SOFA scores and lower Pa/Fi ratios when compared to individuals with mild or moderate anomalies. Severe perfusion abnormalities were associated with an increased risk of intensive care unit (ICU) admission and the requirement of invasive mechanical ventilation (IMV).Conclusion: Patients with severe perfusion anomalies have a higher risk of admission to the ICU and IMV. Perfusion alterations could be considered as an independent risk factor in patients with COVID-19 pneumonia.Summary Statement: Lung perfusion abnormalities in patients with COVID-19 pneumonia were associated with admission to Intensive Care Unit and requirement of invasive mechanical ventilation. Perfusion abnormalities could be considered as an independent risk factor in patients with COVID-19 pneumonia.

scholarly journals Profile of congenital malformations in a tertiary care level neonatal intensive care unit

2017 ◽  
Vol 4 (5) ◽  
pp. 1634
Author(s):  
Hima Bindu Tirumani ◽  
Shafia Khatija
Keyword(s):  
Intensive Care Unit ◽  
Intensive Care ◽  
Neonatal Intensive Care Unit ◽  
Congenital Malformations ◽  
Neonatal Intensive Care ◽  
Tertiary Care ◽  
Increased Risk ◽  
Deccan College ◽  
Major Congenital Malformations ◽  
One Year

Background: Congenital malformations are important causes of infant and childhood deaths, chronic illness and disability.Methods: This prospective observational study was conducted over a period of one year in Princess Esra Hospital, a tertiary level neonatal intensive care unit, Deccan College of Medical Sciences, Hyderabad, Telangana, India. All new-borns admitted to the neonatal intensive care unit over a period of 1 year from June 2014 to June 2015 were included in the study.Results: The incidence of congenital malformations (CMF) in the present study is 3%. Among the major congenital malformations, the central nervous system (CNS) and gastrointestinal (GI) malformations were more frequent than others contributing to 28.9% each. The male neonates were more frequently involved than females. Association of low birth and prematurity with increased risk of congenital malformations is also documented.Conclusions: Early prenatal diagnosis and management of common anomalies is strongly recommended.

YENİDOĞAN YOĞUN BAKIM ÜNİTELERİNDE İŞ KAZALARI RİSKLERİ VE NEDENLERİNE YÖNELİK BİR ARAŞTIRMA

2015 ◽  
Vol 3 (2) ◽  
Author(s):  
Haluk Tanrıverdi ◽  
Orhan Akova ◽  
Nurcan Türkoğlu Latifoğlu
Keyword(s):  
Intensive Care ◽  
Intensive Care Units ◽  
Physical Environment ◽  
Neonatal Intensive Care ◽  
Organizational Factors ◽  
Occupational Accidents ◽  
Neonatal Intensive Care Units ◽  
Work Related ◽  
Physical Conditions ◽  
The Relationship

This study aims to demonstrate the relationship between the qualifications of neonatal intensive care units of hospitals (physical conditions, standard applications, employee qualifications and use of personal protective equipment) and work related causes and risks, employee related causes and risks when occupational accidents occur. Accordingly, a survey was prepared and was made among 105 nurses working in 3 public and 3 private hospital's neonatal intensive care units, in the January of 2010. The survey consists of questions about the qualifications of neonatal intensive care units, work related causes and risks, and employee related causes and risks. From the regression analysis conducted, it has been found that confirmed hypotheses in several studies in the literature were not significant in this study. The sub-dimensions in which relationships has been found show that the improvement of the physical environment in workplace, the improvement of the employee qualifications and standard applications can reduce the rate of occupational accidents. According to the results of this study management should take care of the organizational factors besides to improvement of the physical environment in workplace, the improvement of the employee qualifications and standard applications.

Antimicrobial Prophylaxis Use in the Neonatal Intensive Care Unit: An Antimicrobial Stewardship Target That Deserves Attention!

2021 ◽  
Author(s):  
Isabelle Viel-Thériault ◽  
Amisha Agarwal ◽  
Erika Bariciak ◽  
Nicole Le Saux ◽  
Nisha Thampi
Keyword(s):  
Intensive Care ◽  
Antimicrobial Stewardship ◽  
Neonatal Intensive Care ◽  
Tertiary Care ◽  
Audit And Feedback ◽  
Clinical Indication ◽  
Surgical Prophylaxis ◽  
Early Onset Sepsis ◽  
Days Of Therapy ◽  
Antibiotic Courses

Objective Previous analyses of neonatal intensive care units (NICU) antimicrobial stewardship programs have identified key contributors to overall antibiotic use, including prolonged empiric therapy >48 hours for early-onset sepsis (EOS). However, most were performed in mixed NICU settings with onsite birthing units, resulting in a high proportion of inborn patient admissions. The study aimed to describe and analyze the most common reasons for antimicrobial use in an outborn tertiary care NICU. Study Design This was a 10-month review of all antimicrobial doses prescribed in a 20-bed level III NICU. The primary outcome was the total days of therapy (DOT) and length of therapy (LOT) for each clinical indication. Secondary outcomes included total DOT for each antimicrobial and appropriateness of antimicrobial courses. Results Of 235 antibiotic courses and 1,899 DOT (519 DOT/1,000 patient days) prescribed in 173 infants during the study period, the most common indications were suspected EOS, followed by prophylaxis. Among the 85 DOT/1,000 patient days (PD; 38 courses) prescribed for prophylaxis, 52.5 DOT/1,000 PD (25 courses; 62%) were for surgical prophylaxis. Of 17 postoperative antibiotic courses, 15 (88.2%) were deemed to be inappropriate mostly due to a duration greater than 24 hours postoperatively (n = 13; median LOT = 3 days). Conclusion Surgical prophylaxis is a common reason for antimicrobial misuse in outborn NICU. NICU-based prospective audit and feedback between neonatologists and antimicrobial stewardship teams alone may not be impactful in this setting. Partnerships with neonatologists and surgeons will be key to achieving the target of less than 24 hours of postoperative antimicrobials. Key Points

scholarly journals Surgical tracheostomy in a cohort of COVID-19 patients

HNO ◽  
2021 ◽  
Author(s):  
Patrick J. Schuler ◽  
Jens Greve ◽  
Thomas K. Hoffmann ◽  
Janina Hahn ◽  
Felix Boehm ◽  
...  
Keyword(s):  
Mechanical Ventilation ◽  
Respiratory Failure ◽  
Prolonged Mechanical Ventilation ◽  
Tertiary Care ◽  
Lung Compliance ◽  
Hypoxemic Respiratory Failure ◽  
Surgical Tracheostomy ◽  
Increased Risk ◽  
Open Surgical Tracheostomy ◽  
Sedative Drugs

Abstract Background One of the main symptoms of severe infection with the new coronavirus‑2 (SARS-CoV-2) is hypoxemic respiratory failure because of viral pneumonia with the need for mechanical ventilation. Prolonged mechanical ventilation may require a tracheostomy, but the increased risk for contamination is a matter of considerable debate. Objective Evaluation of safety and effects of surgical tracheostomy on ventilation parameters and outcome in patients with COVID-19. Study design Retrospective observational study between March 27 and May 18, 2020, in a single-center coronavirus disease-designated ICU at a tertiary care German hospital. Patients Patients with COVID-19 were treated with open surgical tracheostomy due to severe hypoxemic respiratory failure requiring mechanical ventilation. Measurements Clinical and ventilation data were obtained from medical records in a retrospective manner. Results A total of 18 patients with confirmed SARS-CoV‑2 infection and surgical tracheostomy were analyzed. The age range was 42–87 years. All patients received open tracheostomy between 2–16 days after admission. Ventilation after tracheostomy was less invasive (reduction in PEAK and positive end-expiratory pressure [PEEP]) and lung compliance increased over time after tracheostomy. Also, sedative drugs could be reduced, and patients had a reduced need of norepinephrine to maintain hemodynamic stability. Six of 18 patients died. All surgical staff were equipped with N99-masks and facial shields or with powered air-purifying respirators (PAPR). Conclusion Our data suggest that open surgical tracheostomy can be performed without severe complications in patients with COVID-19. Tracheostomy may reduce invasiveness of mechanical ventilation and the need for sedative drugs and norepinehprine. Recommendations for personal protective equipment (PPE) for surgical staff should be followed when PPE is available to avoid contamination of the personnel.

Implementing Potentially Better Practices to Improve Neonatal Outcomes After Reducing Postnatal Dexamethasone Use in Infants Born Between 501 and 1250 Grams

PEDIATRICS ◽  
2003 ◽  
Vol 111 (Supplement_E1) ◽  
pp. e534-e541
Author(s):  
Joseph W. Kaempf ◽  
Betty Campbell ◽  
Ronald S. Sklar ◽  
Cindy Arduza ◽  
Robert Gallegos ◽  
...  
Keyword(s):  
Mechanical Ventilation ◽  
Intensive Care ◽  
Mortality Rate ◽  
Length Of Stay ◽  
Clinical Outcomes ◽  
Airway Pressure ◽  
Neonatal Intensive Care ◽  
Positive Airway Pressure ◽  
Late Onset ◽  
Late Onset Sepsis

Objective. The purpose of this article is to describe how a neonatal intensive care unit (NICU) was able to reduce substantially the use of postnatal dexamethasone in infants born between 501 and 1250 g while at the same time implementing a group of potentially petter practices (PBPs) in an attempt to decrease the incidence and severity of chronic lung disease (CLD). Methods. This study was both a retrospective chart review and an ongoing multicenter evidence-based investigation associated with the Vermont Oxford Network Neonatal Intensive Care Quality Improvement Collaborative (NIC/Q 2000). The NICU specifically made the reduction of CLD and dexamethasone use a priority and thus formulated a list of PBPs that could improve clinical outcomes across 3 time periods: era 1, standard NICU care that antedated the quality improvement project; era 2, gradual implementation of the PBPs; and era 3, full implementation of the PBPs. All infants who had a birth weight between 501 and 1250 g and were admitted to the NICU during the 3 study eras were included (era 1, n = 134; era 2, n = 73; era 3, n = 83). As part of the NIC/Q 2000 process, the NICU implemented 3 primary PBPs to improve clinical outcomes related to pulmonary disease: 1) gentle, low tidal volume resuscitation and ventilation, permissive hypercarbia, increased use of nasal continuous positive airway pressure; 2) decreased use of postnatal dexamethasone; and 3) vitamin A administration. The total dexamethasone use, the incidence of CLD, and the mortality rate were the primary outcomes of interest. Secondary outcomes included the severity of CLD, total ventilator and nasal continuous positive airway pressure days, grades 3 and 4 intracranial hemorrhage, periventricular leukomalacia, stages 3 and 4 retinopathy of prematurity, necrotizing enterocolitis, pneumothorax, length of stay, late-onset sepsis, and pneumonia. Results. The percentage of infants who received dexamethasone during their NICU admission decreased from 49% in era 1 to 22% in era 3. Of those who received dexamethasone, the median number of days of exposure dropped from 23.0 in era 1 to 6.5 in era 3. The median total NICU exposure to dexamethasone in infants who received at least 1 dose declined from 3.5 mg/kg in era 1 to 0.9 mg/kg in era 3. The overall amount of dexamethasone administered per total patient population decreased 85% from era 1 to era 3. CLD was seen in 22% of infants in era 1 and 28% in era 3, a nonsignificant increase. The severity of CLD did not significantly change across the 3 eras, neither did the mortality rate. We observed a significant reduction in the use of mechanical ventilation as well as a decline in the incidence of late-onset sepsis and pneumonia, with no other significant change in morbidities or length of stay. Conclusions. Postnatal dexamethasone use in premature infants born between 501 and 1250 g can be sharply curtailed without a significant worsening in a broad range of clinical outcomes. Although a modest, nonsignificant trend was observed toward a greater number of infants needing supplemental oxygen at 36 weeks’ postmenstrual age, the severity of CLD did not increase, the mortality rate did not rise, length of stay did not increase, and other benefits such as decreased use of mechanical ventilation and fewer episodes of nosocomial infection were documented.

13 Impact of Catheter Choice on Procedural Success of Minimally Invasive Surfactant Therapy

2021 ◽  
Vol 26 (Supplement_1) ◽  
pp. e8-e9
Author(s):  
Soume Bhattacharya ◽  
Brooke Read ◽  
Michael Miller ◽  
Orlando daSilva
Keyword(s):  
Adverse Effects ◽  
Minimally Invasive ◽  
Neonatal Intensive Care ◽  
Tertiary Care ◽  
Surfactant Therapy ◽  
P Value ◽  
Perinatal Medicine ◽  
Procedural Success ◽  
Multi Access ◽  
The Impact

Abstract Primary Subject area Neonatal-Perinatal Medicine Background Surfactant delivery via a thin endotracheal catheter during spontaneous breathing, a technique called minimally invasive surfactant therapy (MIST), is an alternative to intubation and surfactant administration. Procedural details among different centres vary, with marked differences in the choice of catheter to instill surfactant. Studies report use of feeding catheters, multi-access catheters, vascular catheters and, recently, custom-designed catheters for this purpose. The impact of choice of catheter on procedural success and adverse effects has not been reported. Objectives The objective of the present study was to compare the procedural success and adverse effects of MIST, using a semi-rigid vascular catheter (16G Angiocath-Hobart Method) versus a flexible multi-access catheter (MAC). Design/Methods This was a retrospective review of prospectively collected data at a tertiary care neonatal intensive care unit in southwestern Ontario. All neonates who received surfactant via MIST between May 1, 2016 and September 30, 2020 were included in the study. Relevant baseline characteristics, data on procedural details (premedication, type of catheter) were collected. The procedural success, number of attempts, and adverse effects between neonates who received MIST via MAC and 16G Angiocath were compared using a Chi Square test or Fisher’s test, as appropriate. A P value of less than 0.05 was considered significant. Results A total of 139 neonates received surfactant via MIST method during the study period. 93 neonates received the surfactant via MAC, while 46 received it via Angiocath. The baseline demographic characteristics in the two groups were similar (Table 1). A higher proportion of neonates in the Angiocath group received atropine (100% vs. 76%, P =.002] and fentanyl (98% vs. 36%; p&lt;0.001) than the MAC group. The procedural success was 91% in the Angiocath group and 89% in the MAC group (p &gt;.99). Multiple attempts were needed in 24% of neonates in the Angiocath group, and 37% in the MAC group (p=0.158). More episodes of desaturations were noted in the Angiocath group (89%) than the MAC group (69%) (P=0.012). Other rates of common adverse effects were similar between the two groups (Table 2). Conclusion The overall procedural success of MIST was similar in both catheter groups. The proportion of neonates requiring multiple attempts was lower with Angiocath use, though this difference was not statistically significant. Desaturation episodes were seen more frequently in the Angiocath group, possibly related to higher use of procedural sedation in this group.

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