Ethical Issues around Death and Withdrawal of Life Support in Neonatal Intensive Care

Amongst all the traumatic experiences in a human life, death of child is considered the most painful, and has profound and lasting impact on the life of parents. The experience is even more complex when the death occurs within a neonatal intensive care unit, particularly in situations where there have been conflicts associated with decisions regarding the redirection of life-sustaining treatments. In the absence of national guidelines and legal backing, clinicians are faced with a dilemma of whether to prolong lifesustaining therapy even in the most brain-injured infants or allow a discharge against medical advice. Societal customs, vagaries, and lack of bereavement support further complicate the experience for parents belonging to lower socio-economic classes. The present review explores the ethical dilemmas around neonatal death faced by professionals in India, and suggests some ways forward.

Acid Suppression in Neonates: Friend or Foe?

Medications that reduce gastric acid secretion are commonly prescribed for treating gastroesophageal reflux disease. However,several studies have shown that these medications are not very effective, and are associated with adverse effects. This articlediscusses the physiology of gastric acid secretion, clinical indications and pharmacology of acid suppressing medications, andpossible adverse effects of these medications

Incubadora neonatal con ventilación mecánica embebida / Mechanical Ventilation embedded in Neonatal Incubator

RESUMEN Se presenta un equipo de soporte de vida neonatal (ESVIN) que emplea la terapia térmica y terapia ventilatoria (neumática) en un solo equipo para proveer ventilación pulmonar con aire caliente, humedecido y enriquecido con oxígeno, en un ambiente caliente, humidificado y estéril. El equipo es capaz de simultáneamente dar ventilación pulmonar e incubar, siendo una de sus características principales la minimización de la condensación del agua en el corrugado y ofrece la característica adicional de evitar la movilización y/o desconexión del neonato para realizar ciertos procedimientos tales como: cirugías e intubaciones, entre otras. Los principales resultados son el tiempo de acceso al neonato menor a 2 s y minimización de la condensación de agua. Asimismo, los resultados del control térmico son de tiempo de estabilización en el habitáculo de 75 minutos para la temperatura de 36 °C y tiempo de estabilización de la temperatura de la piel del neonato de 58 minutos.

ABSTRACT A neonatal life support equipment (ESVIN) employing simultaneously thermal therapy and ventilatory (pneumatic) therapy is presented in a single kit to provide pulmonary ventilation with warm, moistened and oxygen enriched air in a warm, humidified and sterile environment. The invention behind ESVIN provided simultaneously pulmonary ventilation and incubation having optimized the minimization of water condensation in the corrugated pipe and offered the additional feature of avoiding the mobilization and / or disconnection of the neonate to perform certain procedures such as: surgeries and intubations, among others. ESVIN has an access to newborns of less than 2 s and non-visible water condensation. The main results in thermal control were a stabilization time in the newborn compartment of 75 minutes for the temperature of 36 °C and a stabilization of the temperature of the skin of the neonate of 58 minutes.

National Survey of Kangaroo Care Practice, Barriers, Knowledge, and Belief / 임상간호연구

PURPOSE: A National survey was conducted to assess neonatal intensive care nurses' practice, barriers, knowledge, and belief regarding Kangaroo Care (KC). METHODS: A descriptive survey was conducted. Kangaroo care questionares were sent to nurses in all hospitals in Korea whose were identified as providing neonatal intensive care services(N=263). Descriptive statistics were used to summarized the data. RESULTS: Among 67 neonatal care units, 61.1% adapted KC in their practice. About 60% of nurses in the KC providing hospital actually practiced KC. Major barrier of practicing KC were infant safety concerns, as well as work load of nurses. Respondants who had practiced KC were more knowledgable and were more positive in their belief regarding KC. CONCLUSION: The findings suggest that in order to overcome barriers of practicing KC, educational programs are recommended designed for nurses. In addition, development of KC practice guideline is necessary to facilicate successful and safe KC.

Dimensionamento de pessoal de unidades neonatais em um hospital universitário / Sizing of staff of neonatal units in a university hospital

O objetivo foi avaliar o dimensionamento de pessoal de enfermagem de unidades neonatais de um hospital universitário em relação a sua formação e experiência profissional da equipe de enfermagem e a adequação à legislação profissional vigente. Estudo descritivo, quantitativo, realizado na Unidade de Tratamento Intensivo e de Cuidados Intermediários Neonatal. Utilizou-se dois instrumentos para coleta de dados com equipe de enfermagem e sobre a relação profissionais e ocupação de leitos. Os funcionários apresentaram média de experiência em unidades neonatais de 14 anos; a maioria tinha mais de uma formação profissional (59,3%). O número de enfermeiros estava abaixo do preconizado pela legislação profissional vigente (12,5%) e o de auxiliares de enfermagem acima (56,2%); em 51,9%havia funcionários de outros setores realizando horas extras. Concluiu-se que apesar de qualificada, oque pode determinar uma assistência diferenciada, a equipe não atende as normas para dimensionamento profissional preconizado para a assistência nessas unidades especializadas.

The aim was to evaluate the size of the nursing neonatal units of a university hospital regarding the educationand professional experience of the nursing staff and the adequacy of existing legislation professional staff.Descriptive, quantitative study, conducted at the Intensive Care Unit and Neonatal Intermediate Care. We usedtwo instruments to collect data with the nursing staff and the professional relationship and bed occupancy. Employees had an average experience in neonatal units of 14 years; most had more than one vocational training (59.3%). The number of nurses was below the recommended by current professional legislation (12.5%) and nursing assistants above (56.2%); 51.9% were employees in other sectors doing overtime. It was concluded that although qualified, which can determine a differentiated service, the team does not meet the recommended sizing standards for professional assistance in these specialized units.

El estrés en padres de bebés prematuros internados en la Unidad de Cuidados Intensivos Neonatales: traducción y adaptación de la escala Parental Stressor Scale: Neonatal Intensive Care Unit (PSS: NICU - M.S. Miles y D. Holditch Davis, 1987; M.S. Miles y S.G. Funk, 1998) / The stress of parents with a newborn child in the neonatology intensive care unit: translation and adaptation of the Parental Stressor Scale: Neonatal Intensive Care Unit (PSS: NICU - Miles, M.S. & Holditch Davis, D. 1987; Miles, M.S. & Funk, S.G., 1998)

El estrés que genera en los padres tener un hijo internado en la Unidad de Cuidados Intensivos Neonatológicos (UCIN) ha sido investigado en profundidad. Algunos autores han encontrado que el nivel de estrés y los síntomas depresivos, constituyen los factores con mayor poder explicativo y predictivo respecto de cómo la familia afrontará la internación (Speer, Leef, Epps & Locke, 2002). Es así, que desde hace varios años ha surgido el interés en evaluar el nivel de estrés percibido por los padres que afrontan un suceso como este, para lo cual se ha utilizado, a nivel mundial, la Escala Parental Stressor Scale: Neonatal Intensive Care Unit (Escala de Estrés Parental: Unidad de Cuidados Intensivos Neonatales (EEP: UCIN) (Miles & Holditch Davis, 1987; Miles & Funk, 1998). La misma ha demostrado poseer muy buenas propiedades psicométricas de validez y coniabilidad en diversos países. Es el objetivo de este trabajo presentar los primeros pasos del proceso de adaptación de la prueba Escala de Estrés Parental: Unidad de Cuidados Intensivos Neonatológicos (EEP: UCIN) a nuestro medio. Se analizarán especialmente el funcionamiento de los reactivos, a partir del análisis de discriminación de ítems, y de las correlaciones ítem-total, y se mostrará la versión final de la prueba obtenida, la cual se validará en futuros estudios.

The stress of parents who have a child hospitalizated in the Neonatal Intensive Care Unit (NICU) has been investigated thoroughly. Some authors have found that the level of stress and the depressive symptoms are two of the major predicting factors regarding how the family will be coping with the hospitalization (Speer, Leef, Epps and Locke, 2002). As interest in assessing the level of stress perceived by parents coping with this event has grown, Parental Stress Scale: Intensive Care Unit (PSS: NICU) (Miles & Holditch Davis,1987; Miles & Funk, 1998) has turned to be the best instrument worldwide used. It has demonstrated adequate psychometric properties, specially regarding validity and reliability in several countries. In this study, it is focus on the irst steps in the process of adaptation and the analysis of item functioning. Also, the analysis of item discrimination and the item-total correlation, are presented, as they contributed in obtaining the inal version of the adapted version of this instrument which will be validated in future studies.

Establishment of Paediatric and Neonatal Intensive Care Units at Patan Hospital, Kathmandu: Critical Determinants and Future Challenges.

Introduction: Although preventive medicine and primary care are priorities in developing countries, they must be supported by appropriate care of sick and extremely sick children in the medical facilities. Lack of resources and absence of skilled physicians and nurses may lead to poor outcomes in critically ill patients. Intensive care of newborns and children is thought to be very expensive with a low cost-benefit ratio. This presentation discusses the critical factors that facilitated the establishment of PICU and NICU in an urban public hospital in Nepal, where a good standard of Level 2 care was already provided. Aims and objectives: A cooperative model of creation and transfer of technology from the West to a resource-poor country was envisaged. PICU and NICU with six beds each were established. Design and setting: The Nick Simons Foundation, USA provided financial support for design, building and furnishing of a new Mother and Child Wing at Patan Hospital. A generous grant of $300,000 again by the Nick Simons Foundation helped equip the units. Donated equipments also included procedures, medication and storage carts. Methodology: A total of 22 volunteers, 21 from USA and one from Netherlands, were recruited to complete the three months of training. An extensive curriculum was prepared. The trainer team had monthly teleconferences and regular communications with the Chief of Paediatric Services and Nursing Director of Patan Hospital via e-mails and telephone. Responsibilities of volunteers and the host hospital were identified. Results: After 3 years of preparation, the project started in June 2009. All day lectures on topics in critical care, mock case scenarios, practical equipment training and simulated procedures led to the graduation of 60 nurses. Twenty five physicians were trained for three months. The expert team worked with the locals in preparing the units, arranging furniture and equipment, stocking carts, making inventory and preparing protocols. A protocol handbook was developed on topics such as mechanical ventilation, sedation, admission/discharge criteria, procedures and management of different disease states. Various charts such as nurse observation charts, notes by residents, procedure hand offs at change of shifts were designed and printed. Infection control practices and methods of sterilizing non disposable articles were identified and protocols written. At the end of three months the units were functioning with trained local manpower and reasonable modern equipment. Conclusion: Developing nations may not have enough resources to establish much needed critical care facilities. Developed countries can help by funding basic infrastructure and providing expertise in order to transfer knowledge and technology. Involvement in planning from the beginning and training at the host site is a preferred model of transfer of technology.

Evaluación psicológica de la familia con un bebé en la Unidad de Cuidados Intensivos Neonatológicos (UCIN): construcción de un inventario para evaluar el Potencial Resiliente Familiar (IPRF) / Psychological assessment of a family with a newborn child in the Neonatology Intensive Care Unit: design of an inventory to assess the Resilient Potential Of The Family (RPFI)

Importantes aportes de instrumental evaluativo comienzan a realizarse desde la Psicología Positiva que se destaca por su interés en nuevas variables de estudio como la Resiliencia Familiar. Al mismo tiempo, diversas investigaciones corroboran la importancia que tiene el funcionamiento familiar como apoyo y sostén para los padres que atraviesan la internación de un bebé en la Unidad de Cuidados Intensivos Neonatológicos (UCIN). En este trabajo se presentan los primeros avances en el proceso de construcción y validación de un Inventario para evaluar el Potencial Resiliente de la Familia que atraviesa esta problemática. Los postulados de F. Walsh (1996, 2004) brindan fundamento teórico a esta prueba que analiza los Sistemas de Creencias Familiares, los Patrones Organizacionales Familiares y la Comunicación Familiar que permiten analizar. Los resultados obtenidos en un trabajo de campo preliminar permitieron arribar a una versión definitiva tras un análisis de discriminación de los ítems que permitió su depuración. En esta etapa se encuentra en curso el estudio de las propiedades psicométricas de esta versión final en una muestra amplia y representativa.

Important contributions of assessment instruments coming from Positive Psychology are being published. Interest is shown in new constructs like Family Resilience. At the same time, different researches confirm the importance of the family functioning as support and holding for parents with a preterm newborn child in a Neonatology Intensive Care Unit (NICU)This study presents preliminary analysis of the design and validation process of an Inventory for Family Potential Resilience. F. Walsh (1996, 2004) theoretical approach is taken as conceptual framework for three dimensions Family Believes Systems, Family Organizational Patterns and Family Comunication which allows a deep analysis of Family Potential Resilience. Results obtained from a preliminary pilot study allowed us to analyze item discrimination and to obtain the final version of instrument. At this stage, psychometric properties of final inventory are examined in a bigger sample of representative participants.

Nosocomial infections in neonatal intensive care units: Profile, risk factor assessment and antibiogram.

Objective. To determine the profile and risk factors of neonatal nosocomial infections and determine the antibiotic susceptibilities of these isolates. Methods. Cohort study was conducted at Kasturba Medical College, Mangalore, from July 2005 to September 2006. Neonates admitted for more than forty-eight hours in the NICU, who developed infections/ sepsis as evidenced by the clinical findings were included in the study. Chi-square test, Proportion tests were used, P value of <0.05 was considered significant. Results. Extended spectrum beta lactamase (ESBL) producing Klebsiella species and Methicillin resistant Staphylococcus aureus (MRSA) were the predominant nosocomial pathogens. Significant risk factors included prematurity, low birth weight and increased duration of hospital stay. Conclusion. A revised infection control program with emphasis on handwashing techniques and antibiotic cycling helped to control these hospital infections.

Non-rotavirus infection causing apnea in a neonate.

Apnea in a premature infant is not always due to immaturity and caffeine is not always the answer. We report a case of apnea in a preterm infant who presented at two weeks of life with increase in frequency of apnea that did not respond to caffeine. Family history was significant for diarrhea in a sibling. Stool PCR was positive for Norovirus Genogroup II. Enteric isolation was instituted and the apnea resolved spontaneously with conservative management. Re-emergence of apnea or persistent apnea necessitates further investigation to elucidate the etiology.

Incidence and Clinical Manifestations of Rotaviral Infections in a Neonatal Intensive Care Unit

PURPOSE:This study was conducted to investigate the incidence and clinical manifestations of rotaviral infections in the neonatal intensive care unit (NICU). We also investigated whether neonates referred from other hospitals cause outbreaks of rotaviral infections in the NICU. METHODS:Neonates diagnosed with rotaviral infections in the NICU at Korea University Ansan Hospital between January 2002 and December 2006 were evaluated retrospectively. RESULTS:Of 1,501 neonates admitted to the NICU, the number of rotaviral infections was 94 (6.3%) and the prevalence was 4.9 cases per 1,000-hospital days. Of 223 neonates referred from other hospitals to our NICU, 24 (10.8%) were confirmed to have rotaviral infections at the time of referral. Common symptoms of rotaviral infections were jaundice diarrhea or loose stools, vomiting, fever, apnea, irritability, seizures, and moaning sounds. Necrotizing enterocolitis of stage II or more was diagnosed in 3 premature neonates, accounting for 3.2% of total infected neonates and 6.8% of premature infected patients. There were no statistically significant differences in the prevalence of symptoms between term and preterm neonates, except for jaundice that is more frequent in premature infants. In time series analysis, the admission of neonates who were born at other hospitals and diagnosed with rotaviral infections were associated 1 month later by increased cases of neonates with rotaviral infections who were born at our hospital, whereas new cases of rotaviral infections among inborn neonates were decreased 2 and 4 months later (P<0.05). CONCLUSION:Rotaviral infections in NICU were not rare and showed vague symptoms. Three cases (3.2%) were diagnosed with stage II or more necrotizing enterocolitis. The referred neonates with rotaviral infections may induce outbreaks in the NICU, therefore awareness and strict surveillance for rotaviral infections should be performed at the time of referral.

O cotidiano no alojamento materno, das mães de crianças internadas em uma Unidade de Terapia Intensiva Neonatal / The daily routine of rooming-in mothers whose children are in a Neonatal Intensive Care Unit

OBJETIVOS: conhecer o cotidiano no alojamento de mães, cujas crianças estão internadas em uma Unidade de Terapia Intensiva Neonatal. MÉTODOS: pesquisa qualitativa realizada no Hospital Sofia Feldman, em Belo Horizonte, Minas Gerais, Brasil. Os dados foram obtidos por meio de observação participante e grupo focal, e os instrumentos utilizados para registro dos dados foram os diários de campo, gravadores e fitas. Para análise dos dados utilizou-se a análise de conteúdo. RESULTADOS: ao decidir permanecer no alojamento materno a mãe se sente dividida entre atender as necessidades do filho hospitalizado, as demandas da família e as suas próprias necessidades. A vivência no ambiente hospitalar exige que a mãe se adapte a uma nova dinâmica, determinada pelas rotinas e normas institucionais. A permanência no alojamento materno, ao mesmo tempo em que surge como uma possibilidade das mães estabelecerem relações de amizade e solidariedade, é um espaço de relações conflituosas entre elas. CONCLUSÕES: na adaptação da mãe ao novo cotidiano, revelou-se importante a convivência entre as mães, a família e os profissionais de saúde. O estudo aponta para a importância do profissional de saúde aproximar-se da realidade vivenciada pelas mães, para facilitar sua adaptação.

OBJECTIVES: to investigate the daily routine of mothers rooming-in at the Neonatal Intensive Care Unit. METHODS: qualitative research carried out at the Sofia Feldman Hospital in Belo Horizonte, in the State of Minas Gerais, Brazil. The data was obtained by way of participant observation and a focus group and the instruments used to record the data were field diaries, recorders and tapes. Content analysis was used to analyze the data. RESULTS: when deciding to room in, the mothers feel divided between meeting the needs of the hospitalized child, the demands of the family and their own needs. Living in a hospital environment requires that mothers become detached from her daily routine and adapt to a new pattern which is determined by the institutional routines and norms. Rooming presents mothers with the opportunity to establish relationships of friendship and solidarity, but it is also a time of conflicting relations for them. CONCLUSIONS: the relationships between the mothers, and with their families and health workers were shown to be important for adaptation to the rooming-in process. The study showed the importance for health workers to get more involved in the real-life situation of the mothers in order to facilitate their adaptation to the new daily routine.

Clinical Evaluation of i-STAT in the Neonatal Intensive Care Unit / 대한진단검사의학회지

BACKGROUND: i-STAT (i-STAT Corporation, Princeton NJ, USA), a hand-held point-of-care testing (POCT) analyzer with rapidity and minimal sample requirement, has the potential to bring about a significant impact on the management of neonates. However, there should be an overall deliberation of the routine use of i-STAT in the neonatal intensive care unit (NICU) as to whether it is technically reliable and cost-effective. The aim of this study was to assess the clinical aspects of the implementation of i-STAT in the NICU. METHODS: We surveyed physicians and nurses to measure the present status of POCT. We ana-lyzed 84 tests performed in the central laboratory, 88 tests by blood gas analyzer in NICU, and 95 tests by i-STAT for NICU patients. We investigated the indications, turnaround time (TAT), cycle time, and impact on patient care in each case during both pre- and post-i-STAT periods. Costs and user acceptability were also examined. RESULTS: Survey responders wanted rapid results but did not accept the responsibility for the quality of POCT. Turnaround time of i-STAT was shorter than that of the central laboratory, but did not make an impact on cycle time. The cost of i-STAT is 2.2 times higher than central laboratory cost, but the users were satisfied with i-STAT mainly because of its small sample volume and speed. Central laboratory testing volume decreased by 14.3% after the introduction of i-STAT. CONCLUSIONS: i-STAT may be acceptable in the NICU setting. However, the behavioral patterns of physicians need to be changed and a selective use of i-STAT is warranted to maximize its cost-effectiveness. Future studies on the clinical outcome are required to substantiate the potential role of i-STAT.

Clinical characteristics of inborn and outborn infants admitted to the NICU

Regionalization of high-risk perinatal care has been advocated because intensive care for small and ill newborn infants lowers mortality and morbidity. This report is based on analysis of admissions to the Neonatal Intensive Care unit (NICU) at the Wonju christian Hospital during the 4-year period from January, 1988 to December, 1991. There were 786 inborn infants and 1155 outborn infants admitted to the NICU. The results of our study follow; 1) Mean gestational ages were 36.8 weeks in inborn infants and 39.0 weeks in outborn infants. Mean birth weight was 2.5kg in inborn and 3.0kg in outborn infants. 2) The high-risk maternal factors, such as cesarian section delivery, eclampsia, preeclampsia, multiple pregnancy and placental anomaly were significantly more frequent in inborn infants than in outborn infants. 3) Perinatal sphyxia, HMD and transient tachypnea of newborn (TTN) were more common in inborn than in outborn infants, but pneumonia, meconium aspiration syndrome, and seizure were more common in outborn infants. 4) The positivity of bacterial cultures in blood and urine was higher in outborn infants than in inborn infants. The most frequently isolated microorganism was staphylococcus species in both inborn and outborn infants. 5) Hospital days, duration of TPN, duration of mechanical ventilation, frequency of seizure, and frequency of transfusion were longer or more frequent in inborn than in outborn infants. 6) Mortality rate was higher in inborn infants than in outborn infants. 7) In outborn infants, mortality rate was higher in infants whose transporting time was longer than 2 hours than for infants within 2 hour distances. However, this difference was not statistically significant. 8) These findings suggest that many lower birth weight and severly ill infants were not transported to the NICU of Wonju Christian Hospital perhaps due to poor transport systems, distance or socio-economic status. In conclusion, the improvement of transporting systems and socio-economic conditions will be required within this region.