Improving Consistency and Accuracy of Neonatal Amplitude-Integrated Electroencephalography.

OBJECTIVE: This study aimed to improve the utilization of amplitude-integrated electroencephalography (aEEG) in a neonatal unit by improving aEEG documentation, aEEG knowledge, and pattern recognition ability of neonatal staff. METHODS: A quality improvement (QI) program comprising the two Plan-Do-Study-Act (PDSA) cycles was conducted in a level-3 neonatal intensive care unit. The first cycle was focused on improving aEEG documentation with the primary outcome indicator being compliance with aEEG documentation. The second cycle was focused on aEEG interpretation in a health care professional education program with the outcome indicators being accuracy of seizure identification on aEEG and change in conventional EEGs (cEEG) performed. Other outcome indicators included accuracy in identification of background pattern, sleep-wake cycles and artifacts. Process indicators included improvement in aEEG-related knowledge. RESULTS: First PDSA cycle includes lectures on aEEG interpretation, a bedside key, and documentation form. Second PDSA cycle includes online aEEG education pack and detailed aEEG guideline. There was a significant improvement in aEEG documentation after the implementation of both PDSA cycles. Seven of the 46 patients (15.2%) had isolated electrographic seizures which would not have been identified in the pre-aEEG monitoring era. There was an increase in the number of patients with cEEGs done but a steady decrease in number of cEEGs per patient. CONCLUSION: With the successful application of standardized QI methods, improvements in outcome indicators, such as correct aEEG pattern recognition and improved coverage of at risk infants with cEEGs, were observed. Our QI measures were associated with improvement in aEEG pattern recognition. KEY POINTS: · Consistent and accurate use of aEEG is challenging.. · Standardized forms and guidelines improve aEEG interpretation consistency and documentation.. · Interactive self-paced online education packs can improve aEEG knowledge and pattern recognition..

End-of-life decision-making for newborns: a 12-year experience in Hong Kong.

SETTING: Neonatal end-of-life decisions could be influenced by cultural and ethnic backgrounds. These practices have been well described in the West but have not been systematically studied in an Asian population. OBJECTIVES: To determine: (1) different modes of neonatal death and changes over the past 12 years and (2) factors influencing end-of-life decision-making in Hong Kong. DESIGN: A retrospective study was conducted to review all death cases from 2002 to 2013 in the busiest neonatal unit in Hong Kong. Modes of death, demographical data, diagnoses, counselling and circumstances around the time of death, were collected and compared between groups. RESULTS: Of the 166 deaths, 46% occurred despite active resuscitation (group 1); 35% resulted from treatment withdrawal (group 2) and 19% occurred from withholding treatment (group 3). A rising trend towards treatment withdrawal was observed, from 20% to 47% over the 12-year period. Similar number of parents chose extubation (n=44, 27%) compared with other modalities of treatment limitation (n=45, 27%). Significantly more parents chose to withdraw rather than to withhold treatment if clinical conditions were 'stable' (p=0.03), whereas more parents chose withholding therapy if treatment was considered futile (p=0.03). CONCLUSION: In Hong Kong, a larger proportion of neonatal deaths occurred despite active resuscitation compared with Western data. Treatment withdrawal is, however, becoming increasingly more common. Unlike Western practice, similar percentages of parents chose other modalities of treatment limitation compared with direct extubation. Cultural variance could be a reason for the different end-of-life practice adopted in Hong Kong.

A double-blind randomised controlled trial of fish oil-based versus soy-based lipid preparations in the treatment of infants with parenteral nutrition-associated cholestasis.

BACKGROUND: Infants receiving prolonged parenteral nutrition (PN) are at risk of PN-associated cholestasis (PNAC). This can progress to hepatic failure and death if PN cannot be discontinued. Fish oil-based parenteral lipid preparation (FOLP) has been shown to be beneficial in case studies. OBJECTIVES: (1) To evaluate whether FOLP could halt or reverse the progression of PNAC compared with soy-based parenteral lipid preparation (SLP) and (2) to assess the effects of FOLP on liver function and physical growth. DESIGN: double-blind randomised controlled trial. SETTING: level III neonatal intensive care unit. PARTICIPANTS: infants with PNAC (plasma-conjugated bilirubin concentration ≥ 34 µmol/l or 2 mg/dl) expected to be PN-dependent for >2 weeks. INTERVENTION: to receive either FOLP or SLP at 1.5 g/kg/day. PRIMARY OUTCOME MEASURE: reversal of PNAC within 4 months after commencement of lipid treatment; secondary outcomes: rate of change of weekly liver function tests, infant growth parameters, blood lipid profile and episodes of late-onset sepsis. RESULTS: A total of 9 infants were randomised to the FOLP group and 7 to the SLP group. There was no significant difference in reversal of PNAC at 4 months between groups. Rates of increase of plasma-conjugated bilirubin and alanine aminotransferase in the SLP group were significantly greater than the FOLP group (13.5 vs. 0.6 µmol/l per week and 9.1 vs. 1.1 IU/l per week, respectively, p = 0.03). Increased enteral nutrition was associated with significant improvement of PNAC in infants receiving FOLP compared with SLP (-8.5 vs. -1.6 µmol/l per 10% increase in enteral nutrition, respectively). The study was terminated prematurely. CONCLUSIONS: progression of PNAC in PN-dependent infants can be halted by replacing SLP with FOLP and reversed by increasing the proportion of enteral nutrition in infants receiving FOLP. Replacement of SLP with FOLP in PN-dependent infants who develop PNAC may be considered.

Gut-associated biomarkers L-FABP, I-FABP, and TFF3 and LIT score for diagnosis of surgical necrotizing enterocolitis in preterm infants.

OBJECTIVES: To evaluate the use of gut barrier proteins, liver-fatty acid binding protein (L-FABP), intestinal-fatty acid binding protein (I-FABP), and trefoil factor 3 (TFF3), as biomarkers for differentiating necrotizing enterocolitis (NEC) from septicemic/control infants and to identify the most severely affected surgical NEC from nonsurgical NEC infants. BACKGROUND: Clinical features and routine radiologic investigations have low diagnostic utilities in identifying surgical NEC patients. METHODS: The diagnostic utilities of individual biomarkers and the combination of biomarkers, the LIT score, were assessed among the NEC (n = 20), septicemia (n = 40), and control groups (n = 40) in a case-control study for the identification of proven NEC and surgical NEC infants. RESULTS: Plasma concentrations of all gut barrier biomarkers and the LIT score were significantly higher in the NEC than in the septicemia or control group (P < 0.01). Using median values of biomarkers and the LIT score in the NEC group as cutoff values for identifying NEC from septicemic/control cases, all had specificities of 95% or more and sensitivities of 50%. Significantly higher levels of biomarkers and the LIT score were found in infants with surgical NEC than in nonsurgical NEC cases (P ≤ 0.02). The median LIT score of 4.5 identified surgical NEC cases with sensitivity and specificity of 83% and 100%%, respectively. A high LIT score of 6 identified nonsurvivors of NEC with sensitivity and specificity of 78% and 91%, respectively. CONCLUSIONS: The LIT score can effectively differentiate surgical NEC from nonsurgical NEC infants and nonsurvivors of NEC from survivors at the onset of clinical presentation. Frontline neonatologists and surgeons may, therefore, target NEC infants who are most in need of close monitoring and those who may benefit from early surgical intervention.

Rapid identification and differentiation of Gram-negative and Gram-positive bacterial bloodstream infections by quantitative polymerase chain reaction in preterm infants.

OBJECTIVE: To evaluate the usefulness of the Gram-specific probe-based quantitative polymerase chain reaction test for rapid detection and differentiation of Gram-negative and Gram-positive bacterial bloodstream infection in preterm infants. DESIGN: Cross-sectional study. SETTING: University-affiliated Level III neonatal intensive care unit. PATIENTS: Preterm infants with clinical features suggestive of late-onset infection. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: In addition to the full sepsis screen, 0.5 mL of EDTA blood was collected aseptically for Gram-specific quantitative polymerase chain reaction evaluation. The results were analyzed with respect to outcomes of bacterial culture in blood and other body fluids, including peritoneal and cerebrospinal fluids. The diagnostic utilities of the quantitative polymerase chain reaction were determined. A total of 218 suspected infection episodes were investigated, of which 42 episodes were culture positive and 176 were culture negative. For Gram-negative infection, the quantitative polymerase chain reaction test correctly identified 19 of 22 episodes, and the sensitivity and specificity were 86.4% and 99.0%, respectively. For Gram-positive infection, the test correctly identified 14/19 episodes, and the sensitivity and specificity were 73.7% and 98.5%. The remaining one episode was Candida albicans septicemia. None of the episodes with positive quantitative polymerase chain reaction test were classified into the wrong Gram stain category. More importantly, despite negative blood culture in five infants suffering from intra-abdominal sepsis (peritonitis [n = 4] and hepatosplenic abscess [n = 1]), the quantitative polymerase chain reaction test could detect the Gram-specific category of causative organisms in blood. CONCLUSIONS: The Gram-specific quantitative polymerase chain reaction test is reliable and highly specific for rapid identification and differentiation of Gram-negative and Gram-positive bloodstream and intra-abdominal infections. The result could be made available within 5 hrs after the specimen reaches the laboratory. A positive test is able to "rule in" bacterial bloodstream infection before blood culture results become available, and serves as a guide to predict the virulence of the causative organism according to its Gram-specific category so that critical patients can be targeted for intensive treatment.

Rescue treatment of infants with intestinal failure and parenteral nutrition-associated cholestasis (PNAC) using a parenteral fish-oil-based lipid.

Four preterm infants with intestinal failure and severe parenteral nutrition-associated cholestasis (PNAC) received fish-oil-based parenteral lipid as rescue treatment in substitution for the standard soybean-based lipid preparation. The progression of liver disease was halted in 3 infants and they recovered with complete resolution of PNAC. The condition in two of these infants would almost certainly have progressed to end-stage hepatic failure if they had continued to receive long-term parenteral nutrition and <30% of total nutrition enterally. The remaining infant with residual inflamed bowel, protracted feeding intolerance and repeated episodes of sepsis did not respond. Our findings suggest that fish-oil-based parenteral lipid emulsion may contribute to effective treatment of PNAC in selected patients, which should be further evaluated in randomized controlled trials.

Infants born to mothers with severe acute respiratory syndrome.

Severe acute respiratory syndrome (SARS) is a newly discovered infectious disease caused by a novel coronavirus. During the community outbreak in Hong Kong, 5 liveborn infants were born to pregnant women with SARS. A systematic search for perinatal transmission of the SARS-associated coronavirus, including serial reverse transcriptase-polymerase chain reaction assays, viral cultures, and paired serologic titers, failed to detect the virus in any of the infants. In addition, none of the infants developed clinical, radiologic, hematologic, or biochemical evidence suggestive of SARS. One preterm infant developed jejunal perforation and another developed necrotizing enterocolitis with ileal perforation shortly after birth. This case series is the first report to describe the clinical course of the first cohort of liveborn infants born to pregnant women with SARS.