Withholding or withdrawing life-sustaining treatment in extremely low gestational age neonates

2020 ◽  
pp. fetalneonatal-2020-318855
Author(s):  
April R Dworetz ◽  
Girija Natarajan ◽  
John Langer ◽  
Kathy Kinlaw ◽  
Jennifer R James ◽  
...  
Keyword(s):  
Brain Injury ◽  
Gestational Age ◽  
Assisted Ventilation ◽  
Research Network ◽  
Severe Brain Injury ◽  
Clinical Factors ◽  
Life Sustaining Treatment ◽  
Hispanic White ◽  
Primary Modality ◽  
Extremely Low Gestational Age

ObjectiveTo identify sociodemographic and clinical factors associated with withholding or withdrawing life-sustaining treatment (WWLST) for extremely low gestational age neonates.DesignObservational study of prospectively collected registry data from 19 National Institute of Child Health and Human Development Neonatal Research Network centres on neonates born at 22–28 weeks gestation who died >12 hours through 120 days of age during 2011–2016. Sociodemographic and clinical factors were compared between infants who died following WWLST and without WWLST.ResultsOf 1168 deaths, 67.1% occurred following WWLST. Withdrawal of assisted ventilation (97.4%) was the primary modality. WWLST rates were inversely proportional to gestational age. Life-sustaining treatment was withheld or withdrawn more often for non-Hispanic white infants than for non-Hispanic black infants (72.7% vs 60.4%; 95% CI 1.00 to 1.92) or Hispanic infants (72.7% vs 67.2%; 95% CI 1.32 to 3.72). WWLST rates varied across centres (38.6–92.6%; p<0.001). The centre with the highest rate had adjusted odds 4.89 times greater than the average (95% CI 1.18 to 20.18). The adjusted odds of WWLST were higher for infants with necrotiing enterocolitis (OR 1.77, 95% CI 1.21 to 2.59) and severe brain injury (OR 1.98, 95% CI 1.44 to 2.74).ConclusionsAmong infants who died, WWLST rates varied widely across centres and were associated with gestational age, race, ethnicity, necrotiing enterocolitis, and severe brain injury. Further exploration is needed into how race, centre, and approaches to care of infants with necrotiing enterocolitis and severe brain injury influence WWLST.

Do transport factors increase the risk of severe brain injury in outborn infants <33 weeks gestational age?

2019 ◽  
Vol 40 (3) ◽  
pp. 385-393 ◽  
Author(s):  
Stephanie Redpath ◽  
◽  
Prakesh S. Shah ◽  
Gregory P. Moore ◽  
Junmin Yang ◽  
...  
Keyword(s):  
Brain Injury ◽  
Gestational Age ◽  
Severe Brain Injury ◽  
Transport Factors

Admission Systolic Blood Pressure and Outcomes in Preterm Infants of ≤ 26 Weeks' Gestation

2017 ◽  
Vol 34 (13) ◽  
pp. 1271-1278 ◽  
Author(s):  
Yanyu Lyu ◽  
Xiang Ye ◽  
Tetsuya Isayama ◽  
Ruben Alvaro ◽  
Chuks Nwaesei ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Brain Injury ◽  
Preterm Infants ◽  
Gestational Age ◽  
Early Mortality ◽  
Composite Outcome ◽  
Severe Brain Injury ◽  
Extremely Preterm ◽  
Extremely Preterm Infants ◽  
The Relationship

Objective To examine the relationship between admission systolic blood pressure (SBP) and adverse neonatal outcomes. Specifically, we aimed to identify the optimal SBP that is associated with the lowest rates of adverse outcomes in extremely preterm infants of ≤ 26 weeks' gestation. Methods In this retrospective study, inborn neonates born at ≤ 26 weeks' gestational age and admitted to tertiary neonatal units participating in the Canadian Neonatal Network between 2003 and 2009 were included. The primary outcome was early mortality (≤ 7 days). Secondary outcomes included severe brain injury, late mortality, and a composite outcome defined as early mortality or severe brain injury. Nonlinear multivariable logistic regression models examined the relationship between admission SBP and outcomes. Results Admission SBP demonstrated a U-shaped relationship with early mortality, severe brain injury, and composite outcome after adjustment for confounders (p < 0.01). The lowest risks of early mortality, severe brain injury, and composite outcome occurred at admission SBPs of 51, 55, and 54 mm Hg, respectively. Conclusion In extremely preterm infants of ≤ 26 weeks' gestational age, the relationship between admission SBP, and early mortality and severe brain injury was “U-shaped.” The optimal admission SBP associated with lowest rates of adverse outcome was between 51 and 55 mm Hg.

scholarly journals The Association between Evidence-Based Healthcare Practices and Outcomes among Preterm Births in China

Neonatology ◽  
2021 ◽  
pp. 1-7
Author(s):  
Di Jin ◽  
Xinyue Gu ◽  
Siyuan Jiang ◽  
Yanchen Wang ◽  
Tongling Yang ◽  
...  
Keyword(s):  
Brain Injury ◽  
Preterm Infants ◽  
Gestational Age ◽  
Early Death ◽  
Evidence Based ◽  
Severe Brain Injury ◽  
Evidence Based Practices ◽  
Very Preterm Infants ◽  
Very Preterm ◽  
Evidence Based Healthcare

<b><i>Introduction:</i></b> Very preterm infants are at high risk of early death or severe brain injury, with potential for impaired long-term neurodevelopmental function and physical health. There are evidence-based healthcare practices that can reduce the incidence. <b><i>Materials and Methods:</i></b> Infants born at 24–31<sup>6</sup> weeks gestational age and admitted within 24 h to NICUs participating in the Chinese Neonatal Network in 2019 were included. We examined the association between 4 evidence-based practices: inborn (born in a tertiary hospital in the Chinese Neonatal Network), ACS (any antenatal corticosteroid), MgSO<sub>4</sub> (prenatal magnesium sulfate), and NT (normothermic temperature [36.0–37.5°C] at admission) and early death and/or severe brain injury in the study population. <b><i>Results:</i></b> Of 6,035 eligible infants, the incidence of early death and/or severe brain injury was 10.6%. Exposure to ACS only was associated with significant lower incidence of death and/or severe brain injury than none (aOR, 0.71; 95% CI: 0.57–0.88), but not MgSO<sub>4</sub> only (aOR, 0.97; 95% CI: 0.81–1.17), NT only (aOR, 0.91; 95% CI: 0.76–1.08), or inborn only (aOR, 0.91; 95% CI: 0.72–1.15). The association between number of practices and incidence of early death and/or severe brain injury is as follows: none = 23% (31/138), any 1 = 14% (84/592), any 2 = 12% (185/1,538), any 3 = 9% (202/2,285), and all 4 = 9% (140/1,482). <b><i>Discussion/Conclusion:</i></b> More comprehensive use of evidence-based practices was associated with improved survival without severe brain injury among very preterm infants born at &#x3c;32 weeks gestational age.

scholarly journals Early Blood Gas Predictors of Bronchopulmonary Dysplasia in Extremely Low Gestational Age Newborns

2014 ◽  
Vol 2014 ◽  
pp. 1-8 ◽  
Author(s):  
Sudhir Sriram ◽  
Joy Condie ◽  
Michael D. Schreiber ◽  
Daniel G. Batton ◽  
Bhavesh Shah ◽  
...  
Keyword(s):  
Bronchopulmonary Dysplasia ◽  
Gestational Age ◽  
Assisted Ventilation ◽  
Blood Gas ◽  
Increased Risk ◽  
Multivariable Models ◽  
Gas Measurements ◽  
Reduced Risk ◽  
Extremely Low Gestational Age

Aim. To determine among infants born before the 28th week of gestation to what extent blood gas abnormalities during the first three postnatal days provide information about the risk of bronchopulmonary dysplasia (BPD).Methods. We studied the association of extreme quartiles of blood gas measurements (hypoxemia, hyperoxemia, hypocapnea, and hypercapnea) in the first three postnatal days, with bronchopulmonary dysplasia, among 906 newborns, using multivariable models adjusting for potential confounders. We approximated NIH criteria by classifying severity of BPD on the basis of the receipt of any O2on postnatal day 28 and at 36 weeks PMA and assisted ventilation.Results. In models that did not adjust for ventilation, hypoxemia was associated with increased risk of severe BPD and very severe BPD, while infants who had hypercapnea were at increased risk of very severe BPD only. In contrast, infants who had hypocapnea were at reduced risk of severe BPD. Including ventilation for 14 or more days eliminated the associations with hypoxemia and with hypercapnea and made the decreased risk of very severe BPD statistically significant.Conclusions. Among ELGANs, recurrent/persistent blood gas abnormalities in the first three postnatal days convey information about the risk of severe and very severe BPD.

Confronting the grey zone after severe brain injury

2019 ◽  
Vol 3 (6) ◽  
pp. 707-711 ◽  
Author(s):  
Andrew Peterson ◽  
Adrian M. Owen
Keyword(s):  
Brain Injury ◽  
Ethical Issues ◽  
Vegetative State ◽  
Clinical Care ◽  
Grey Zone ◽  
Severe Brain Injury ◽  
New Methods ◽  
Legal Decision Making ◽  
Technological Developments ◽  
The Brain

In recent years, rapid technological developments in the field of neuroimaging have provided several new methods for revealing thoughts, actions and intentions based solely on the pattern of activity that is observed in the brain. In specialized centres, these methods are now being employed routinely to assess residual cognition, detect consciousness and even communicate with some behaviorally non-responsive patients who clinically appear to be comatose or in a vegetative state. In this article, we consider some of the ethical issues raised by these developments and the profound implications they have for clinical care, diagnosis, prognosis and medical-legal decision-making after severe brain injury.

Impact of routine S100B protein assay on CT scan use in children with mild traumatic brain injury

2020 ◽  
Vol 0 (0) ◽  
Author(s):  
Fleur Lorton ◽  
Jeanne Simon-Pimmel ◽  
Damien Masson ◽  
Elise Launay ◽  
Christèle Gras-Le Guen ◽  
...  
Keyword(s):  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Mild Traumatic Brain Injury ◽  
University Hospital ◽  
S100b Protein ◽  
Research Network ◽  
Ct Scans ◽  
Intermediate Risk ◽  
Protein Assay ◽  
The Impact

AbstractObjectivesTo evaluate the impact of implementing a modified Pediatric Emergency Care Applied Research Network (PECARN) rule including the S100B protein assay for managing mild traumatic brain injury (mTBI) in children.MethodsA before-and-after study was conducted in a paediatric emergency department of a French University Hospital from 2013 to 2015. We retrospectively included all consecutive children aged 4 months to 15 years who presented mTBI and were at intermediate risk for clinically important traumatic brain injury (ciTBI). We compared the proportions of CT scans performed and of in-hospital observations before (2013–2014) and after (2014–2015) implementation of a modified PECARN rule including the S100B protein assay.ResultsWe included 1,062 children with mTBI (median age 4.5 years, sex ratio [F/M] 0.73) who were at intermediate risk for ciTBI: 494 (46.5%) during 2013–2014 and 568 (53.5%) during 2014–2015. During 2014–2015, S100B protein was measured in 451 (79.4%) children within 6 h after mTBI. The proportion of CT scans and in-hospital observations significantly decreased between the two periods, from 14.4 to 9.5% (p=0.02) and 73.9–40.5% (p<0.01), respectively. The number of CT scans performed to identify a single ciTBI was reduced by two-thirds, from 18 to 6 CT scans, between 2013–2014 and 2014–2015. All children with ciTBI were identified by the rules.ConclusionsThe implementation of a modified PECARN rule including the S100B protein assay significantly decreased the proportion of CT scans and in-hospital observations for children with mTBI who were at intermediate risk for ciTBI.

scholarly journals Simplified evaluation of CONsciousness disorders (SECONDs) in individuals with severe brain injury: A validation study

2021 ◽  
Vol 64 (5) ◽  
pp. 101432
Author(s):  
Charlène Aubinet ◽  
Helena Cassol ◽  
Olivier Bodart ◽  
Leandro R.D. Sanz ◽  
Sarah Wannez ◽  
...  
Keyword(s):  
Brain Injury ◽  
Validation Study ◽  
Severe Brain Injury ◽  
Consciousness Disorders

scholarly journals Inter-physician variability in strategies linked to treatment limitations after severe traumatic brain injury; proactivity or wait-and-see

2021 ◽  
Vol 22 (1) ◽  
Author(s):  
Annette Robertsen ◽  
Eirik Helseth ◽  
Reidun Førde
Keyword(s):  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Severe Traumatic Brain Injury ◽  
Ethical Issues ◽  
Ethical Reasoning ◽  
Depth Information ◽  
Worst Case ◽  
Life Sustaining Treatment ◽  
Wait And See ◽  
Prognostic Uncertainty

Abstract Background Prognostic uncertainty is a challenge for physicians in the neuro intensive care field. Questions about whether continued life-sustaining treatment is in a patient’s best interests arise in different phases after a severe traumatic brain injury. In-depth information about how physicians deal with ethical issues in different contexts is lacking. The purpose of this study was to seek insight into clinicians’ strategies concerning unresolved prognostic uncertainty and their ethical reasoning on the issue of limitation of life-sustaining treatment in patients with minimal or no signs of neurological improvement after severe traumatic brain injury in the later trauma hospital phase. Methods Interviews with 18 physicians working in a neurointensive care unit in a large Norwegian trauma hospital, followed by a qualitative thematic analysis focused on physicians’ strategies related to treatment-limiting decision-making. Results A divide between proactive and wait-and-see strategies emerged. Notwithstanding the hospital’s strong team culture, inter-physician variability with regard to ethical reasoning and preferred strategies was exposed. All the physicians emphasized the importance of team—family interactions. Nevertheless, their strategies differed: (1) The proactive physicians were open to consider limitations of life-sustaining treatment when the prognosis was grim. They initiated ethical discussions, took leadership in clarification and deliberation processes regarding goals and options, saw themselves as guides for the families and believed in the necessity to prepare families for both best-case and worst-case scenarios. (2) The “wait-and-see” physicians preferred open-ended treatment (no limitations). Neurologically injured patients need time to uncover their true recovery potential, they argued. They often avoided talking to the family about dying or other worst-case scenarios during this phase. Conclusions Depending on the individual physician in charge, ethical issues may rest unresolved or not addressed in the later trauma hospital phase. Nevertheless, team collaboration serves to mitigate inter-physician variability. There are problems and pitfalls to be aware of related to both proactive and wait-and-see approaches. The timing of best-interest discussions and treatment-limiting decisions remain challenging after severe traumatic brain injury. Routines for timely and open discussions with families about the range of ethically reasonable options need to be strengthened.

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