Cost consciousness among physicians in the neonatal intensive care unit.

OBJECTIVE: The objectives of this study were (1) to describe the prevalence and correlates of cost consciousness among physician providers in neonatology and (2) to describe knowledge of cost of common medications, laboratory/imaging evaluations, hospitalization costs and reimbursements. STUDY DESIGN: A 54-item survey was administered to members of the Section on Neonatal-Perinatal Medicine of the American Academy of Pediatrics. RESULTS: Of the 602 participants, 37% reported cost consciousness in decision making. Adjusting for years in practice, gender, training level, type of practice setting and region of practice, formalized education about costs was associated with increased cost consciousness in practice (adjusted odds ratio (AOR): 3.4; 95% confidence interval (CI): 1.2 to 9.8). Working in a private practice setting was also associated with increased cost consciousness when ordering laboratory (AOR: 3.0; (95% CI: 1.2 to 7.6)) or imaging tests (AOR: 2.0; 95% CI: 1.0 to 4.8). CONCLUSIONS: We found variation in knowledge of cost. Formal education about costs and working in a private practice setting were associated with increased cost consciousness.

The use of mobile robotic telemedicine technology in the neonatal intensive care unit.

OBJECTIVE: To describe the use of a wireless, mobile, robotic telecommunications system in the Neonatal Intensive Care Unit (NICU). STUDY DESIGN: In this prospective study utilizing 304 patient encounters on 46 preterm and term neonates in a level IIIa NICU, a bedside neonatologist ('on-site neonatologist'; ONSN) and a neonatologist at a distant location ('off-site neonatologist'; OFFSN) evaluated selected demographic information, laboratory data and clinical and radiological findings of the subjects. The OFFSN used a commercial wireless, mobile, robotic telecommunications system controlled from a remote site. The two physicians were blinded to each other's findings and agreement rates of the evaluations between the ONSN and the OFFSN were compared using kappa statistics. Agreement rates between two ONSNs using the same protocol with 39 patient encounters served as the reference standard. The dependability and timeliness of data transmission were also assessed. RESULT: Excellent or intermediate-to-good agreements were noted for all but a few physical examination assessments between both the ONSN and OFFSN and the two ONSNs. Poor agreements were found for certain physical examination parameters (breath-, heart- and bowel-sounds and capillary refill time) with or without the use of telemedicine. The median duration of the encounters by the ONSN and OFFSN and the two ONSNs was similar. Five encounters were excluded from the analysis because of technical difficulties. No complications associated with the use of the mobile robot were noted. CONCLUSION: Our findings indicate that the use of mobile robotic telemedicine technology is feasible for neonates in the NICU.

A meta-analysis of dopamine use in hypotensive preterm infants: blood pressure and cerebral hemodynamics.

OBJECTIVE: Dopamine administration results in variable effects on blood pressure in hypotensive preterm infants. The clinical benefits of dopamine administration in increasing cerebral blood flow (CBF) and reducing adverse neurological outcomes in hypotensive preterm neonates are unclear. The objective of this study was to examine the efficacy of dopamine for treatment of hypotension and investigate the changes in cerebral hemodynamics and central nervous system injury in hypotensive preterm infants following dopamine administration. STUDY DESIGN: Standard meta-analytic techniques, including random and fixed effects models, were used to calculate combined effect size correlations and significance levels. RESULT: Random effects meta-analysis found that dopamine increases mean arterial blood pressure (12 studies; N=163; r=0.88, 95% confidence interval (CI)=0.76 to 0.94) and systolic blood pressure (8 studies; N=142; r=0.81, 95% CI=0.42 to 0.94). For the increase in blood pressure, dopamine administration was associated with a significantly greater overall efficacy than dobutamine (seven studies; N=251; r=0.26; 95% CI=0.20 to 0.32), colloid (two studies; N=67; r=0.60; 95% CI=0.41 to 0.74) and hydrocortisone (one study; N=28; r=0.40; 95% CI=0.034 to 0.67). CBF increased following dopamine administration (five studies; N=75; r=0.36; 95% CI=-0.059 to 0.67) and the increase in CBF was greater in hypotensive than normotensive preterm infants (eight studies; N=153; r=0.16; 95% CI=-0.0080 to 0.32). There were no statistically significant differences in adverse neurological outcome between dopamine and dobutamine (three studies; N=118; r=-0.13; 95% CI=-0.31 to 0.059), epinephrine (two studies; N=46; r=0.06; 95% CI=-0.23 to 0.34), colloid (two studies; N=80; r=0.0070; 95% CI=-0.218 to 0.23) or hydrocortisone administration (one study; N=40; r=-0.10; 95% CI=-0.40 to 0.22). CONCLUSION: Dopamine administration increases mean and systolic blood pressure in hypotensive preterm infants, and is more effective than dobutamine, colloid or hydrocortisone alone. Dopamine administration is associated with increased CBF, with greater increases in CBF in hypotensive than in normotensive preterm infants. Dopamine is not associated with a greater incidence of adverse effects than other therapies used to treat hypotension.

Hydrocortisone for hypotension and vasopressor dependence in preterm neonates: a meta-analysis.

BACKGROUND: A full consensus has not been reached about the hemodynamic efficacy of hydrocortisone administration in hypotensive and vasopressor-dependent preterm neonates. OBJECTIVE: To examine the efficacy of hydrocortisone for treatment of hypotension and reduction of vasopressor requirements in preterm infants. METHOD: Standard meta-analytic techniques, including random and fixed effects models, were used to calculate combined effect size correlations and significance levels. RESULT: Random effects meta-analysis showed that hydrocortisone increases blood pressure (seven studies; N=144; r=0.71, 95%CI=0.18 to 0.92) and reduces vasopressor requirement (five studies; N=93; r=0.74, 95%CI=0.0084 to 0.96). The number of new or unretrieved studies averaging null results required to increase the overall p to 0.05 is k=78 for blood pressure increase and k=47 for vasopressor requirement reduction. CONCLUSION: The effects of hydrocortisone on increasing blood pressure and decreasing vasopressor requirements in preterm infants are robust with a large tolerance for future null results. Actual clinical benefits of increasing blood pressure and decreasing vasopressor requirements, however, remain unknown. Long-term sequelae of hydrocortisone administration have yet to be fully elucidated.

Effects of low oxygen saturation limits on the ductus arteriosus in extremely low birth weight infants.

OBJECTIVE: Postnatal increase in oxygen promotes constriction of the patent ductus arteriosus (PDA). According to the findings of prospective observational studies, the clinical practice of targeting lower fractional oxygen saturation between 70 and 90% has been associated with a reduced incidence of severe retinopathy of prematurity (ROP) without affecting survival or neurodevelopmental disability at 1 year of age. Our objective was to investigate the impact of the use of a lower oxygen saturation target range on the incidence of early hemodynamically significant PDA (hsPDA) and the need for ductal ligation in extremely low birth weight (ELBW, <1000 g) infants. STUDY DESIGN: In this retrospective study, we analyzed data from 263 ELBW infants managed 4 years before (episode I: target oxygen saturation 89 to 94%) and after (episode II: target oxygen saturation 83 to 89%) implementation of the use of lower oxygen saturation limits in two neonatal intensive care units. Infants with a birth weight of 1000 to 1500 g were managed with the same oxygen saturation target range (89 to 94%) during both episodes, and they served as controls. Parametric and nonparametric tests were used as appropriate and multivariate logistic regression models were used to correct for confounders. RESULTS: There was an increase in the incidence of hsPDA (63.2 vs 74.8%, P=0.043), without an increase in the need for surgical ligation (24.2 vs 29.9%, P=0.3) after implementation of the lower oxygen saturation target range policy. After adjusting for confounders, there was an increase in the odds of having an hsPDA (odds ratio (OR) 1.77, 95% confidence interval (CI) (1.03 to 3.06), P=0.04) but the odds for ductal ligation did not change in episode II (OR 1.25, 95% CI (0.70 to 2.25), P=0.4). The incidence of ROP > or = stage III (50.7 vs 15.7%; P<0.0001) and the need for laser ablation (33.8% vs 8.7%; P<0.0001) were significantly reduced. There was no change in the incidence of hsPDA or ductal ligation in the control group. CONCLUSION: Targeting lower oxygen saturation limits to minimize periods of hyperoxemia in ELBW infants reduced the incidence of severe ROP and the need for laser ablation. The incidence of early hsPDA was increased; however, final closure rate and the incidence of surgical ligation of the ductus arteriosus were not affected.

Increased carotid artery intima-media thickness following venoarterial extracorporeal membrane oxygenation in the neonatal period.

OBJECTIVE: To compare left carotid intima-media thickness (CIMT) and biochemical markers for atherogenesis in neonatal venoarterial extracorporeal membrane oxygenation (ECMO) survivors with normal controls during childhood. METHODS: Venoarterial ECMO survivors and healthy patients between 12 and 18 years of age were enrolled in a matched control prospective study. ECMO survivors were matched to controls based on chronological age and percentage of body mass index (BMI). Measured CIMT of the posterior left carotid artery and CIMT values corrected for carotid artery size were used for data analysis. RESULTS: Thirty-one neonatal venoarterial ECMO survivors were matched to 31 healthy controls. No significant differences were found between ECMO survivors and controls for age, weight, percentage of BMI, total fat composition, lipid profiles, ultrasensitive C-reactive protein or homocysteine levels. Significant differences between ECMO and controls patients were found in systolic, diastolic and mean left CIMT. CONCLUSION: Compared with controls, the thickness of the left carotid intima media is significantly increased at the age of 12 to 18 years in neonatal venoarterial ECMO survivors. The clinical significance of this increased CIMT is unknown. ECMO centers may want to incorporate assessment of CIMT in their follow-up protocols.

Concurrent use of indomethacin and dexamethasone increases the risk of spontaneous intestinal perforation in very low birth weight neonates.

BACKGROUND: Dexamethasone or indomethacin predisposes very low birth weight (VLBW) neonates to spontaneous intestinal perforation (SIP). However, no study has specifically investigated the role of the concurrent use of indomethacin and dexamethasone in SIP. OBJECTIVE: To test whether the concurrent use of indomethacin and dexamethasone increases the risk of SIP. METHODS: In this single center, retrospective, 2:1 matched, case-control study, the odds of SIP were assessed using univariate and multivariate logistic regression analysis in < or =14-day old VLBW infants. RESULTS: Sixteen VLBW infants with SIP were matched to 32 controls by birth weight. After adjusting for clinically relevant variables, patients who received > or =3 doses of indomethacin for ductal closure or intraventricular hemorrhage prophylaxis and > or =3 doses of low-dose dexamethasone (0.3 mg/kg cumulative dose over 3 days) for refractory hypotension during the first postnatal week, were 9.6 times more likely to develop SIP [95% CI 1.22, 75.71]. CONCLUSIONS: The combined use of indomethacin and dexamethasone increases the risk of SIP in VLBW neonates.

Use of high-frequency jet ventilation in neonates with hypoxemia refractory to high-frequency oscillatory ventilation.

OBJECTIVE: To describe the response to high-frequency jet ventilation in infants with hypoxemic respiratory failure unresponsive to high-frequency oscillatory ventilation. METHODS: This was a retrospective analysis of chart records on demographics, ventilator settings, blood gas analysis and calculated oxygenation index prior to and during the first 7 days of high-frequency jet ventilation in ten consecutive infants. RESULTS: Before the initiation of high-frequency jet ventilation, the ventilatory mean airway pressure (MAP; cmH2O), fraction of inspired oxygen (FiO2) and oxygenation index on high-frequency oscillatory ventilation were 14.3 +/- 1.3, 0.97 +/- 0.02 and 29 +/- 5, respectively. Three hours after the initiation of high-frequency jet ventilation, the oxygenation index improved to 18 +/- 4 (p < 0.001) and the improvement was sustained during the study period. By 6 h of high-frequency jet ventilation, the FiO2 decreased to 0.62 +/- 0.09 (p < 0.01) and, by 1-3 h of ventilation, the MAP decreased to 10.9 +/- 1.3 (p < 0.01). The improvement in FiO2 persisted for 7 days while, although the MAP remained lower throughout the study, the improvement in MAP failed to reach statistical significance after 72 h. No significant changes in pH, pCO2, or pO2 before or during high-frequency jet ventilation were noted. CONCLUSION: High-frequency jet ventilation improves hypoxemic respiratory failure unresponsive to high-frequency oscillatory ventilation in infants. These findings suggest that not all high-frequency ventilatory devices yield the same clinical results.

Relationship between fetal monitoring and resuscitative needs: fetal distress versus routine cesarean deliveries.

BACKGROUND: There is debate as to whether pediatricians should be present at all cesarean deliveries. Little published data exist regarding the differences in resuscitative needs of infants delivered by cesarean section for "fetal distress" versus those without this diagnosis. OBJECTIVE: To describe the differences in resuscitative and immediate postnatal intervention needs for neonates with fetal distress delivered by cesarean section and those without fetal distress delivered in the same manner. Also, to devise an evaluation tool to assess and compare levels of neonatal resuscitation between infants and groups of infants. METHODS: The delivery records of 1411 term infants delivered by cesarean section after uncomplicated pregnancies at Los Angeles County/University of Southern California Medical Center from March 3, 1995 through March 8, 1997 were examined retrospectively. Apgar scores and resuscitative needs were assigned to a newly devised, weighted scoring system. Resuscitation subscores and total resuscitation scores were compared using non-parametric methods. RESULTS: The fetal distress group (n = 80) had a significantly greater resuscitative needs mean score (p < 0.001) and subscores (p < 0.001 to p = 0.004) than did the non-fetal distress group (n = 419). Of the non-fetal distress group, 48.7% still received some active form of intervention. CONCLUSION: In our study group, infants with fetal distress had significantly greater intervention needs than infants without fetal distress.

A randomized trial of nasopharyngeal-synchronized intermittent mandatory ventilation versus nasopharyngeal continuous positive airway pressure in very low birth weight infants after extubation.

OBJECTIVE: To prospectively compare the incidence of respiratory failure in premature infants randomized to receive either nasopharyngeal continuous positive airway pressure (NPCPAP) or nasopharyngeal-synchronized intermittent mandatory ventilation (NP-SIMV) in the immediate postextubation period. STUDY DESIGN: This is a prospective study of very low birth weight (VLBW) infants randomized at the time of extubation to receive either NPCPAP or NP-SIMV in a university-based level III neonatal intensive care unit. Statistical analysis were performed with the Mann-Whitney U test for continuous and ordinal variables, and with the chi-squared test or Fisher's exact test for categorical variables. RESULTS: A total of 41 VLBW infants were studied; 19 were in the NPCPAP group, and 22 were in the NP-SIMV group. Respiratory failure after extubation in the NP-SIMV group was significantly lower that in the NPCPAP group (5% vs 37%, respectively (p = 0.016). No statistically significant differences between groups with regard to demographics, severity of initial illness and associated complications, time to extubation, ventilatory management before extubation, weight, age, or nutritional status at the time of extubation were noted.

Renal tolerance with the use of intralipid-amphotericin B in low-birth-weight neonates.

Amphotericin B is still the first-line therapy for neonatal fungal infections. With several comparative trials of intralipid-based amphotericin B (IL-AmB) demonstrating its clinical effectiveness and reduced renal toxicity in adults, we examined the renal tolerance and infection outcome in low-birth-weight infants in our 48-bed NICU treated with IL-AmB. Over 2 years, 52 patients (58 courses) received > or = 10 days of IL-AmB. Nineteen charts (23 episodes) were randomly accessed and reviewed. Mean birthweight = 747 grams, gestational age = 25.6 weeks, total IL-AmB dosage = 19.8 +/- 3.3 mg/kg (n = 23); 20 of these episodes were fungal culture positive (9 fungemias). Only one patient (who died during therapy) had a rise in creatinine of > 0.3 mg/dL. Overall, serum creatinine decreased significantly after Day 10 of IL-AmB therapy, from 0.93 +/- 0.42 mg/dL at baseline, to 0.54 +/- 0.24 after 19 days of therapy (p < 0.0001). Serial urine output, serum potassium and potassium supplementation data showed no significant differences from baseline. No interruption of therapy nor infusion reactions occurred. Only one death occurred attributable to fungal infection. Intralipid-amphotericin B may provide an effective alternative in the antifungal therapy of low birthweight neonates, without nephrotoxicity. Further prospective, comparative trials are warranted.