Placental Transfusion, Timing of Plastic Wrap or Bag Placement, and Preterm Neonates.

OBJECTIVE: Compare delivery room practices and outcomes of infants born at less than 32 weeks' gestation or less than 1,500 g who have plastic wrap/bag placement simultaneously during placental transfusion to those receiving plastic wrap/bag placement sequentially following placental transfusion. STUDY DESIGN: Retrospective analysis of data from a multisite quality improvement initiative to refine stabilization procedures pertaining to placental transfusion and thermoregulation using a plastic wrap/bag. Delivery room practices and outcome data in 590 total cases receiving placental transfusion were controlled for propensity score matching and hospital of birth. RESULTS: The simultaneous and sequential groups were similar in demographic and most outcome metrics. The simultaneous group had longer duration of delayed cord clamping compared with the sequential group (42.3 ± 14.8 vs. 34.1 ± 10.3 seconds, p < 0.001), and fewer number of times cord milking was performed (0.41 ± 1.26 vs. 0.86 ± 1.92 seconds, p < 0.001). The time to initiate respiratory support was also significantly shorter in the simultaneous group (97.2 ± 100.6 vs. 125.2 ± 177.6 seconds, p = 0.02). The combined outcome of death or necrotizing enterocolitis in the simultaneous group was more frequent than in the sequential group (15.3 vs. 9.3%, p = 0.038); all other outcomes measured were similar. CONCLUSION: Timing of plastic wrap/bag placement during placental transfusion did affect duration of delayed cord clamping, number of times cord milking was performed, and time to initiate respiratory support in the delivery room but did not alter birth hospital outcomes or respiratory care practices other than the combined outcome of death or necrotizing enterocolitis. KEY POINTS: · Plastic bag placement during placental transfusion is effective in stabilization of preterms.. · Plastic bag placement after placental transfusion is effective in stabilization of preterms.. · Plastic bag placement during placental transfusion and risk of death or necrotizing enterocolitis needs additional study..

Cost-effectiveness of three strategies of managing tunnelled, cuffed haemodialysis catheters in clinically mild or asymptomatic bacteraemias.

BACKGROUND: Immediate tunnelled, cuffed catheter (TCC) removal is the current standard of care when bacteraemia is associated with severe clinical symptoms. When minimal or no symptoms are present, the optimal strategy of TCC management is controversial. The following three strategies have been proposed: TCC 'salvage' (antibiotic administration without TCC removal), TCC exchange over a guidewire with antibiotics or immediate TCC removal with delayed reinsertion and antibiotics. METHODS: We developed a decision-analytic model to assess the cost-effectiveness of each strategy for episodes of TCC-associated bacteraemia presenting with minimal symptoms, in a hypothetical cohort of haemodialysis patients followed for a 3 month period. Data regarding the probability of treatment failure due to recurrent infection for each strategy, secondary infectious complications and patient mortality were obtained from existing clinical trials and from the 1998 United States Renal Data System database. Costs were substituted with the current 2000 New York hospital charges. RESULTS: Tunnelled, cuffed catheter exchange over a guidewire was associated with a reduction in net charges of $5241 and $750 when compared with TCC salvage and immediate TCC removal, respectively. The expected 3 month patient survival for TCC guidewire exchange and immediate TCC removal were similar (93%), whereas survival for TCC salvage was worse (89%). Tunnelled, cuffed catheter guidewire exchange remained the most cost-effective strategy when the probability of treatment failure with recurrent bacteraemia in 3 months was <25% for this strategy. CONCLUSIONS: Tunnelled, cuffed catheter guidewire exchange is the most cost-effective strategy of catheter management when mild or no symptoms are present.