Cost of nitric oxide therapy in neonates.

A retrospective observational cohort study was performed to review the cost of inhaled nitric oxide (iNO) therapy in a UK neonatal intensive care setting over a 4-year period. 188 neonates with a median (IQR) gestational age and birth weight of 27 (24-37) weeks and 980 (695-2812) g, respectively, were treated with iNO. The median (IQR) duration of iNO therapy was 60 (22-129) hours. The mean cost of iNO therapy was approximately £820 per baby treated equivalent to £8.50 per hour of therapy. Alternative pricing models suggested a calculated cost of iNO therapy of between approximately £950 and £1350 per baby.

Quality improvement programme to increase the rate of deferred cord clamping at preterm birth using the Lifestart trolley.

AIM: To increase the documented use of the Lifestart trolley to allow premature infants' (<32 weeks' gestation) resuscitation and stabilisation with an intact umbilical cord at delivery. DESIGN: A 13-month quality improvement programme from April 2018 to April 2019 was undertaken using Plan, Do, Study and Act (PDSA) cycles. Data were reviewed from 113 consecutive preterm (<32 weeks) deliveries to identify whether Lifestart was used and whether 2 min deferred cord clamping (DCC) occurred in eligible infants as per hospital policy. Episodes of non-compliance were analysed, causes established and interventions implemented to reduce similar future non-compliance. Data collected were presented graphically and included in alternate monthly newsletters to staff, which also included lessons learnt from the reviews of non-compliance. RESULTS: Documented use of the Lifestart rose from 10% at the start of the project to 79% in the final month. Not all babies are eligible for DCC. Within this project, 40 (35%) of preterm infants were not eligible to receive DCC. Of those that were eligible, the rate of DCC increased from 17% in the first 3 months to 92% in the last 3 months of the project (p<0.0001). IMPLICATIONS AND RELEVANCE: By undertaking regular PDSA cycles and improving education surrounding importance of DCC, we have noted a significant improvement in the use of Lifestart, which in turn facilitates DCC.The learning from this project has been used to create an instructional video to help maintain the improved compliance rates.

Variation in the definition of pulmonary hypertension and clinical indications for the use of nitric oxide in neonatal clinical trials.

AIM: Pulmonary hypertension (PH) frequently complicates neonatal hypoxaemic respiratory failure, but is inconsistently defined. We aimed to describe the variation among randomised controlled trials (RCTs) of inhaled nitric oxide (iNO), in relation to the definition of PH and/or hypoxaemic respiratory failure used to select patients for trial inclusion. METHODS: PubMed, Cochrane Library and ClinicalTrials.gov were systematically searched for RCTs of iNO in neonates. Included studies were assessed for clinical and/or echocardiography criteria used to define PH/hypoxaemic respiratory failure. RESULTS: Thirty-two trials were included in this review, of which 23 enrolled infants ≥34 weeks' gestation. Echocardiographic diagnosis was used in 21 studies, but there was considerable variation in the echocardiographic parameters used to diagnose PH. The most commonly used indices included markers of tricuspid regurgitation and extrapulmonary shunt. CONCLUSION: There is wide variation in the definition of PH used to select infants for inclusion into RCTs of iNO therapy in neonates. We recommend that an international consensus be reached on which parameters should be used and the thresholds defining severity of disease.

Quality improvement programme to improve compliance with initial respiratory support guideline at preterm birth.

AIM: CPAP (continuous airway pressure) use as respiratory support from birth increases the proportion of babies who survive without bronchopulmonary dysplasia. Although we introduced a guideline for CPAP use in 2015, our intubation rate remained high (61.7%). We aimed to reduce the intubation rate into the interquartile range for the Vermont Oxford Neonatal (VON) network. METHODS: A multi-disciplinary team was established. Data relating to resuscitation in all babies born before 32 weeks gestation or with a birth weight below 1500 g during 2017/2018 were collected prospectively. Episodes when CPAP was not used were identified, and series of Plan, Do, See, Act (PDSA) cycles performed. Performance data were displayed graphically to staff along with lessons learnt. RESULTS: The rate of intubation at birth for VLBW babies fell from 61.7% into the VON interquartile range at 49.6% during the project (P = .02). Intubation rate in babies born between 26 and 30 weeks gestation fell from 66% to 41% (the VON network mean). CONCLUSION: The NICU is a complex system. Altering clinical practice is challenging, even with good clinical evidence to support change. Quality improvement using frequent PDSA cycles enabled us to alter our practice. Preterm intubation rates are now within the desired range.

Etiology of childhood bacteremia and timely antibiotics administration in the emergency department.

BACKGROUND: Bacteremia is now an uncommon presentation to the children's emergency department (ED) but is associated with significant morbidity and mortality. Its evolving etiology may affect the ability of clinicians to initiate timely, appropriate antimicrobial therapy. METHODS: A retrospective time series analysis of bacteremia was conducted in the Alder Hey Children's Hospital ED between 2001 and 2011. Data on significant comorbidities, time to empirical therapy, and antibiotic susceptibility were recorded. RESULTS: A total of 575 clinical episodes were identified, and Streptococcus pneumoniae (n = 109), Neisseria meningitidis (n = 96), and Staphylococcus aureus (n = 89) were commonly isolated. The rate of bacteremia was 1.42 per 1000 ED attendances (95% confidence interval: 1.31-1.53). There was an annual reduction of 10.6% (6.6%-14.5%) in vaccine-preventable infections, and an annual increase of 6.7% (1.2%-12.5%) in Gram-negative infections. The pneumococcal conjugate vaccine was associated with a 49% (32%-74%) reduction in pneumococcal bacteremia. The rate of health care-associated bacteremia increased from 0.17 to 0.43 per 1000 ED attendances (P = .002). Susceptibility to empirical antibiotics was reduced (96.3%-82.6%; P < .001). Health care-associated bacteremia was associated with an increased length of stay of 3.9 days (95% confidence interval: 2.3-5.8). Median time to antibiotics was 184 minutes (interquartile range: 63-331) and 57 (interquartile range: 27-97) minutes longer in Gram-negative bacteremia than in vaccine-preventable bacteremia. CONCLUSIONS: Changes in the etiology of pediatric bacteremia have implications for prompt, appropriate empirical treatment. Increasingly, pediatric bacteremia in the ED is health care associated, which increases length of inpatient stay. Prompt, effective antimicrobial administration requires new tools to improve recognition, in addition to continued etiological surveillance.

Evidence for a second meal cognitive effect: glycaemic responses to high and low glycaemic index evening meals are associated with cognition the following morning.

Low glycaemic index (GI) foods consumed at breakfast can enhance memory in comparison to high-GI foods; however, the impact of evening meal GI manipulations on cognition the following morning remains unexplored. Fourteen healthy males consumed a high-GI evening meal or a low-GI evening meal in a counterbalanced order on two separate evenings. Memory and attention were assessed before and after a high-GI breakfast the following morning. The high-GI evening meal elicited significantly higher evening glycaemic responses than the low-GI evening meal. Verbal recall was better the morning following the high-GI evening meal compared to after the low-GI evening meal. In summary, the GI of the evening meal was associated with memory performance the next day, suggesting a second meal cognitive effect. The present findings imply that an overnight fast may not be sufficient to control for previous nutritional consumption.