A comparative review of maternal and neonatal outcome among pregnant women with COVID-19 in first and second wave in a tertiary care centre of South Rajasthan

Background: Corona virus disease 2019 has taken a huge toll over health infrastructure and care all across the world. This article depicts our experience of COVID-19 in pregnant women and analyses maternal and neonatal outcome of same in first and second wave of this pandemic. Aim and objectives of the study were to compare the demographic characteristics, presenting features and fetomaternal outcome in COVID positive pregnant women in first v/s second wave in a tertiary care hospital.Methods: The RTPCR COVID-19 positive pregnant women admitted during the period April-2020 to March-2021 were considered in 1st wave of COVD-19 and that from April-2021 till June-2021 as 2nd wave of COVID-19. Data like baseline characteristics, past medical, obstetric history, clinical presentation, laboratory results, imaging findings, management modalities, maternal and neonatal outcome were analysed and compared.Results: Peak of 1st wave of COVID-19 was found during the months of July-September 2020, while of 2nd in April-June 2021. Most women presented with COVID-19 RTPCR positive were asymptomatic both in 1st and 2nd wave. Though most patients were managed on room air in both waves, 6.52% and 9.38% were on oxygen, 1.09% and 10.94% were managed with mechanical ventilation and BIPAP in 1st and 2nd wave respectively. There was significant (p<0.05) increase in maternal deaths in the 2nd wave (7.03%) as compared to 1st wave (1.09%).Conclusions: A significantly large number of patients were affected in 2nd wave of COVID-19 pandemic with more morbidity and mortality. Neonatal population remained relatively unaffected in both waves.

Refeeding Syndrome in the Neonatal Intensive Care Unit

Refeeding syndrome (RS) has not been well defined in the neonatal population, although hypophosphatemia is identified as the most common manifestation. The American Society for Parenteral and Enteral Nutrition recently provided recommendations for the prevention and management of RS in children and adults; however, specific neonatal recommendations were not provided. In an effort to provide an overview of the incidence of RS or hypophosphatemia in the neonatal population and the impact of patient-specific and nutrition factors, a review of the literature was conducted. The literature search included articles published in the English language in Medline, PubMed, and EPub between 1946 and December 2020. Relevant citations within identified articles were also reviewed. Sixteen studies representing 3688 neonates were included. There was variation in the incidence of hypophosphatemia (20%–90%), hypokalemia (8.8%–66.7%), and hypomagnesemia (1%–8.3%) between studies. There was significant variability in definitions of hypophosphatemia, patient populations (e.g., gestational age, small for gestational age status, intrauterine growth restriction), and initial nutrition between studies (i.e., initial amino acid intake, calcium and phosphate ratio), proving it difficult to identify the overall incidence of neonatal RS. Clinical outcomes associated with hypophosphatemia identified in the studies included increased duration of mechanical ventilation, development of bronchopulmonary dysplasia, and increased mortality. Vigilant monitoring of serum phosphate, potassium, and magnesium is required in the first week of life. In addition, early addition of phosphate in a 1:1 molar ratio with calcium is recommended in the first week of life for patients who are at greatest risk for RS.

Laryngeal Mask Use in the Neonatal Population: A Survey of Practice Providers at a Regional Tertiary Care Center in the United States

Objective The aim of this study was to evaluate the level of training, awareness, experience, and confidence of neonatal practice providers in the use of laryngeal mask (LM), and to identify the barriers in its implementation in the neonatal population. Study Design Descriptive observational study utilizing an anonymous online questionnaire among healthcare providers at the Oklahoma Children's Hospital who routinely respond to newborn deliveries and have been trained in the Neonatal Resuscitation Program (NRP). Participants included physicians, trainees, nurse practitioners, nurses, and respiratory therapists. Results Ninety-five participants completed the survey (27.5% response rate). The sample consisted of 77 NRP providers (81%), 11 instructors (12%), and 7 instructor mentors (7%). Among 72 respondents who had undergone LM training, 51 (54%) had hands-on manikin practice, 4 (4%) watched the American Academy of Pediatrics (AAP) NRP educational video, and 17 (18%) did both. Nurses (39 out of 46) were more likely to have completed LM training than were physicians (31 out of 47). With only 11 (12%) participants having ever placed a LM in a newly born infant, the median confidence for LM placement during neonatal resuscitation was 37 on a 0 to 100 scale. Frequently reported barriers for LM use in neonates were limited experience (81%), insufficient training (59%), preference for endotracheal tube (57%), and lack of awareness (56%). Conclusion While the majority of the neonatal practice providers were trained in LM placement, only a few had ever placed one in a live newborn, with a low degree of confidence overall. Future practice improvement should incorporate ongoing interdisciplinary LM education, availability of LM in the labor and delivery units, and promotion of awareness of LM as an alternative airway. Key Points

Peripherally Inserted Central Catheters: Evaluation of Diluted Lipid Emulsion as Lubricant for Improved Guidewire Removal in a Neonatal Population.

Background: Medical management of neonates is often predicated upon safe and reliable vascular access which may be related to physiological monitoring, medical treatment, supportive therapy and diagnostic or procedural purposes. For this, peripherally inserted central catheters (PICCs) are deemed safe to provide vascular access and infusion related therapy in the neonatal intensive care setting. Purpose: PICCs are associated with a reduced incidence of complications compared to short peripheral catheters. Despite a reduced complication rate, the impact for the patient has to be considered severe. Difficult PICC guidewire removal during the insertion procedure is known to cause catheter damage, resulting in leakage or breakage of the catheter itself. The aim of this study was to assess and compare the incidence of therapy failure related to the use of preflush fluids (normal saline (NSS) versus diluted lipid solution(DLS)) used before PICC guidewire removal. Method and Setting: This was a retrospective observational study and performed on the Neonatal Intensive Care Unit (NICU) of the Women’s Wellness and Research Centre, Hamad Medical Corporation, Qatar. The single site study included 507 neonates who required intravenous therapy. Results: The results show that the use of a diluted lipid preflush resulted in significantly less therapy failures, compared with the control group. This remains significant after adjusting for day of insertion, gestational age, birth weight and catheter type.Conclusion: DLS preflush demonstrated a benefit over the use of a NSS preflush to enhance PICC guidewire removal in patients admitted to the NICU. The risk for the development of maintenance-related complications leading to premature removal of the device, decreased significantly if the preflush DLS was used. During the study period no known complications related to the used lipid solution were identified. Implications for Practice and Research: This study is the first of its kind ever published in international literature and supports the enhancement of guidewire removal by using a diluted lipid preflush. When the requirement for vascular access is most pertinent, using a diluted lipid preflush is a safe and effective method to remove the guidewire in order to facilitate long-term vascular access amongst the neonatal population.

132. Standardized Antimicrobial Administration Ratios to Guide Antimicrobial Stewardship in the Neonatal Intensive Care Unit: a Single Center Experience

Background Antimicrobial stewardship (AMS) is particularly challenging in the neonatal population. Both under- and overuse can negatively impact outcomes. There are limited reports of strategies to improve AMS in the neonatal population. Standardized Antimicrobial Administration Ratios (SAARs) are novel metrics of antimicrobial use, recently introduced for neonatal populations by the National Healthcare Safety Network (NHSN). We describe our experience using SAARs to guide AMS in the neonatal intensive care unit (NICU). Methods This was a retrospective study conducted from January 2020 to April 2021. A team consisting of AMS and NICU department staff identified and implemented AMS strategies. Based on a review of NICU SAAR data, a goal was set to reduce third generation cephalosporin use by encouraging aminoglycoside use when appropriate. The pre-implementation period was January 2020 to May 2020 and the post-implementation period was July 2020 to April 2021. Antibiotic use was measured as SAARs and compared between study periods. The primary outcome was the neonatal SAAR for third generation cephalosporins. Secondary outcomes included SAARs for aminoglycosides and all neonatal antibacterial agents. SAARs were compared using the NHSN Statistics Calculator. Results For third generation cephalosporins, there were 385 observed antimicrobial days (OAD) and 115 expected antimicrobial days (EAD) in the pre-implementation period compared to 597 OAD and 228 EAD in the post implementation period. This resulted in a SAAR of 3.34 and 2.62, respectively; a reduction of 22% (p &lt; 0.001). For aminoglycosides, there were 713 OAD and 584 EAD compared to 1617 OAD and 1155 EAD. This resulted in a SAAR of 1.22 and 1.4; an increase of 15% (p = 0.002). For all neonatal antibacterial agents, there were 2716 OAD and 1739 EAD compared to 5321 OAD and 3438 EAD. This resulted in a SAAR of 1.56 and 1.55; indicating no change in use (p = 0.70). See Table 1 for results. Table 1. Antibiotic Use Conclusion While this initiative resulted in decreased use of third generation cephalosporins, this was not associated with a decrease in antibiotic use overall. Use of SAARs in the NICU may be helpful in both identifying opportunities to improve antibiotic use and monitoring antibiotic use over time. Disclosures Steven Smoke, PharmD, Karius (Advisor or Review Panel member) Shionogi (Scientific Research Study Investigator, Advisor or Review Panel member)

To Sedate or Not to Sedate for Less Invasive Surfactant Administration: An Ethical Approach

Less invasive surfactant administration (LISA) is an effective, minimally invasive technique of administering surfactant to infants with respiratory distress syndrome. While termed less invasive, LISA still requires airway instrumentation with direct laryngoscopy, thus may be considered painful. However, the issue of whether or not to routinely sedate infants for LISA remains contentious, with significant variation in practice between centres. Proponents for giving pharmacological analgesia and/or sedation predominantly focus on patient comfort during the procedure. However, those who favour non-pharmacological measures of pain management focus on the potential for procedural success without the risk of adverse events, such as respiratory depression and potentially the need for escalation to intubation, which may occur with pharmacological agents. The neonatal population who may benefit from LISA is varied. Due to this variety in presentation type, gestational age, and unit experience, there is a need to provide an individualized, tailored approach to sedation and analgesia for these infants. Using a blanket approach to sedation will lead to infants being exposed to sedative medications on the assumption of potential distress, rather than in response to signs of actual distress. This places the infant at risk of the adverse reactions, potentially without them ever having needed the beneficial effect of the medications. This seems an unnecessary risk. This article explores the ethical arguments pertaining to analgesia and sedation during the LISA technique, concluding that a standardized approach to the usage of pharmacological sedation is undesirable. Moreover, we maintain that procedural analgesia and sedation should be based on individualized, infant-centred assessment, rather than on a rigid, standardized approach.

Use of Topical Nitroglycerine in the Neonatal Population Following Peripheral Tissue Ischaemia: Case Report and Updates about Safety Concerns

Neonatal thrombosis is a well-described morbidity occurring in the neonatal intensive care unit. Critically ill neonates are most vulnerable to developing thrombosis with serious complications. Fingers and toes ischaemia secondary to vascular occlusion following central lines insertion remains an uncommon occurrence. The therapeutic approach for peripheral tissue injury using local warming, anticoagulants, thrombolytics or topical hyaluronidase showed limited benefits and potential side effects. Here we report an unusual case of finger ischaemia treated successfully using topical nitroglycerine. This complements previous reports confirming the efficacy and safety of this drug and highlighting its potential benefit in neonates.

Recomendaciones para el cuidado y la atención de los recién nacidos prematuros en tiempos de la pandemia de COVID-19: Revisión integrada de la literatura.

Objective: To describe recommendations for the care and handling of preterm infants in the COVID-19 pandemic scenario. Methods: Integrated Literature Review (ILR) conducted in 2020 in databases in the Virtual Health Library (VHL) by extracting scientific productions from the databases: MEDLINE, SCIELO, PUBMED and LILACS, with a final sample of 14 publications. Results: Among the recommendations found in the studies analyzed, regarding childbirth, it is recommended to choose the best time, route and place, prioritizing the use of a negative pressure room. After delivery, newborns should have the umbilical cord clamped, be cleaned and dried as soon as possible, and isolated and tested early. After initial care, the use of a mask and hand hygiene is recommended before each meal or other close contact with the newborn. Ideally, suspected or contaminated RN should be kept in isolation and constantly monitored, with a quarantine period of at least 14 days. Conclusions: The knowledge of nurses and other health care professionals about prevention and control measures for newborn infection with COVID-19 is critical to the prevention, control, and reduction of the impact of the pandemic on the neonatal population. Keywords: Coronavirus infections, COVID-19, Nursing Care, Neonatal Nursing and Premature Birth Infections