Acute kidney injury in sick neonates: a comparative study of diagnostic criteria, assessment of risk factors and outcomes.

INTRODUCTION: Neonatal acute kidney injury (nAKI) poses unique challenges with diagnostic criteria specific to neonates evolving over time. Urine output (UOP) criterion has a special place in the diagnosis of nAKI although significant clarity on the ideal diagnostic threshold for UOP is not established. Risk factors peculiar to the tropical region for acute kidney injury (AKI) in neonates needs attention. It would be interesting to assess for kidney function in neonates who survived AKI during the dynamic phase of infancy. OBJECTIVES: To compare criteria of modified kidney disease improving global outcome (mKDIGO) and neonatal risk, injury, failure, loss, and end-stage criteria (nRIFLE) in diagnosing AKI in sick neonates; to study the risk factors for AKI and clinical outcomes at the end of neonatal ICU stay and during infancy. METHODS: This prospective study was conducted at a tertiary neonatal ICU that screened and staged sick neonates by applying mKDIGO and nRIFLE criteria. Risk factors were assessed and glomerular filtration rate was calculated by cystatin C in survivors of nAKI for 12 months post conception age. RESULTS: nAKI was observed in 30% (49/163) of sick neonates. The mKDIGO (94%) detected a higher number of neonates with AKI compared to nRIFLE (49%). Based on only UOP, nRIFLE diagnosed a higher proportion of neonates with mild AKI compared to mKDIGO (29% versus 16%), respectively. Besides known risk factors, hypernatremic dehydration (18%) was an important risk factor for AKI. With 20% mortality, the risk of developing AKI was comparable using either mKDIGO or nRIFLE diagnostic criteria. At the end of infancy, mean cystatin C eGFR of neonates was 101.3 ± 29.2 ml/1.73 m2/min. CONCLUSION: In sick neonates, mKDIGO criteria performed better than nRIFLE in detecting AKI. However, the risk of mortality was comparable using either diagnostic criterion. Hypernatremic dehydration was an important risk factor for AKI and renal function of neonates following complete recovery of AKI was normal at the end of infancy.

Therapeutic hypothermia for moderate and severe hypoxic ischaemic encephalopathy in newborns using low-cost devices - ice packs and phase changing material.

Background: Different methods have been used for therapeutic hypothermia for neonates with moderate-to-severe hypoxic ischaemic encephalopathy (HIE). As standard cooling devices are expensive, there is a need to establish the safety and efficacy of low-cost devices such as ice packs (IP) and phase changing material (PCM). Aim: To assess the efficacy and safety of therapeutic hypothermia (TH) and the clinico-laboratory profile of neonates who underwent cooling with IP or PCM. Methods: The study was retrospective. TH for moderate-to-severe HIE was initiated with IP between 2012 and 2014 and with PCM (MiraCradleTM) from September 2014. A standard protocol for inclusion and management during TH was used for all newborns. All data were collected by means of a local cooling registry. Results: Sixty-two cooled newborns (IP 29, PCM 33) were included in the study. Mean gestational age was 38.6 (1.7) weeks and mean birthweight 2920.6 g (450.7); 66.1% were inborn and 91.9% had moderate encephalopathy. Mean (SD) core temperature during cooling was 33.47°C (0.33) for PCM and 33.44°C (0.34) for IP. Adverse events observed during TH were thrombocytopenia (54.8%), coagulopathy (30.6%), shock (30.6%), skin changes (12.9%) and persistent pulmonary hypertension (8.1%). Forty-nine infants were discharged, two died and 11 were discharged against medical advice. TH was prematurely stopped in seven newborns with serious adverse events such as disseminated intravascular coagulation (DIC), gangrene and arrhythmia (IP 5, PCM 2). Conclusion: Low-cost devices are safe and effective alternatives for maintaining TH in low-resource settings with adequate monitoring. Abbreviations: DAMA, discharged against medical advice; DIC, disseminated intravascular coagulation; HELIX, Hypothermia for Encephalopathy in Low- and Middle-Income Countries Trial; HIE, hypoxic ischaemic encephalopathy; IP, ice packs; LMIC, low- and middle-income countries; NICHD, National Institute of Child Health and Human Development; PCM, phase changing; TH, therapeutic hypothermia (TH); TOBY, total body hypothermia for neonatal encephalopathy.

Onsite mentoring of special newborn care unit to improve the quality of newborn care.

BACKGROUND: It has been possible to set up special newborn care units (SNCUs) and to improve the survival of newborns in India. However, several challenges remain affecting their effective functioning. Different approaches have been attempted and several policies have also been implemented to address this issue. OBJECTIVES: To evaluate the feasibility of implementing best practices in neonatal care by onsite mentoring in an SNCU over 4 months. METHODS: The mentoring team was from a tertiary care hospital in Karnataka. The SNCU was functioning at the district hospital, catering to approximately 3500 live births per year. Onsite mentoring was carried out from August 2016 to November 2016. This was a prospective implementation research. Framework focused on infection control, preterm care, care at birth, advocacy for infrastructure and resources, and facility-based refresher training. RESULTS: A total of 16 visits were done by the mentoring team and 2 weeks of in-house residency. There were improvements in hand hygiene compliance from 0% to 87.5%, in cleaner IV site (from 50% to 100%), decreased unnecessary oxygen administration (from 75% to 33.3%), decreased antibiotic usage (from 70.5% to 35.5%), decrease in the number of babies receiving >5 days of antibiotics (from 41.6% to 0%), and increased kangaroo mother care initiation rate from 0% to 41.6%. The facility got level IIA accreditation by the end of the intervention period. CONCLUSIONS: Onsite mentorship program of SNCU is feasible and planning should be contextual. With the problems being uniform across most facilities, the model could be replicated across the country.

Decreasing Central Line-associated Bloodstream Infections Through Quality Improvement Initiative.

OBJECTIVE: To study the impact of a quality improvement (QI) initiative using care bundle approach on Central-line associated bloodstream infections (CLABSI) rates. METHODS: A QI team for infection control in NICU was formed in a tertiary-care neonatal intensive care unit (NICU) from June 2015 to August 2016. Baseline data were collected over first 3 months followed by the intervention period of 1 year. Measures with respect to strengthening hand hygiene and central line bundle care were implemented during the intervention period. Audits assessing the compliance to hand hygiene and CLABSI bundle protocols were used as process indicators. Multiple PDSA cycles were used to strengthen the practices of proposed interventions, documentation of data and audits of the processes during the study period. RESULTS: The QI initiative achieved a 89% reduction in CLABSI from the baseline rate of 31.7 to 3.5 per 1000 line-days. The blood stream Infections reduced from 7.3 to 2.3 per 1000 patient-days. The overall mortality showed a reduction from 2.9% to 1.7% during the intervention period. There was a significant improvement in compliance with hand hygiene protocol and compliance with CLABSI protocols. CONCLUSION: This study demonstrated that simple measures involving hand hygiene and strengthening of the care bundle approach through quality improvement could significantly reduce the blood stream Infections and CLABSI rates.

Phase Changing Material for Therapeutic Hypothermia in Neonates with Hypoxic Ischemic Encephalopathy - A Multi-centric Study.

OBJECTIVE: To assess the feasibility and safety of cooling asphyxiated neonates using phase changing material based device across different neonatal intensive care units in India. DESIGN: Multi-centric uncontrolled clinical trial. SETTING: 11 level 3 neonatal units in India from November 2014 to December 2015. PARTICIPANTS: 103 newborn infants with perinatal asphyxia, satisfying pre-defined criteria for therapeutic hypothermia. INTERVENTION: Therapeutic hypothermia was provided using phase changing material based device to a target temperature of 33.5±0.5oC, with a standard protocol. Core body temperature was monitored continuously using a rectal probe during the cooling and rewarming phase and for 12 hours after the rewarming was complete. OUTCOME MEASURES: Feasibility measure - Time taken to reach target temperature, fluctuation of the core body temperature during the cooling phase and proportion of temperature recordings outside the target range. Safety measure - adverse events during cooling. RESULTS: The median (IQR) of time taken to reach target temperature was 90 (45, 120) minutes. The mean (SD) deviation of temperature during cooling phase was 33.5 (0.39) ºC. Temperature readings were outside the target range in 10.8% (5.1% of the readings were <33oC and 5.7% were >34oC). Mean (SD) of rate of rewarming was 0.28 (0.13)oC per hour. The common adverse events were shock/ hypotension (18%), coagulopathy (21.4%), sepsis/probable sepsis (20.4%) and thrombocytopenia (10.7%). Cooling was discontinued before 72 hours in 18 (17.5%) babies due to reasons such as hemodynamic instability/refractory shock, persistent pulmonary hypertension or bleeding. 7 (6.8%) babies died during hospitalization. CONCLUSIONS: Using phase changing material based cooling device and a standard protocol, it was feasible and safe to provide therapeutic hypothermia to asphyxiated neonates across different neonatal units in India. Maintenance of target temperature was comparable to standard servo-controlled equipment.