Video Recordings to Analyze Preventable Management Errors in Pediatric Resuscitation Bay.

OBJECTIVE: In treating patients of different ages and diseases in the pediatric resuscitation bay, management errors are common. This study aimed to analyze the adherence to advanced trauma life support and pediatric advanced life support guidelines and identify management errors in the pediatric resuscitation bay by using video recordings. METHODS: Video recording of all patients admitted to the pediatric resuscitation bay at University Children's Hospital Zurich during a 13-month period was performed. Treatment adherence to advanced trauma life support guidelines and pediatric advanced life support guidelines and errors per patient were identified. RESULTS: During the study period, 128 patients were recorded (65.6% with surgical, 34.4% with medical diseases). The most common causes for admission were traumatic brain injury (21.1%), multiple trauma (20.3%), and seizures (14.8%). There was a statistically significant correlation between accurate handover from emergency medical service to hospital physicians and adherence to airway, breathing, circulation, and disability sequence (correlation coefficient [CC], 0.205; P = 0.021), existence of a defined team leader and adherence to airway, breathing, circulation, and disability sequence (CC, 0.856; P < 0.001), and accurate hand over and existence of a defined team leader (CC, 0.186; P = 0.037). Unexpected errors were revealed. Cervical spine examination/stabilization was omitted in 40% of admitted surgical patients, even in 20% of patients with an injury of spine/limbs. CONCLUSIONS: Video recording is a useful tool to evaluate patient management in the pediatric resuscitation bay. Analyzing errors of missing the adherence to the guidelines helps to pay attention and focus on specific items to improve patient care.

Five-year experience of clinical ethics consultations in a pediatric teaching hospital.

Our retrospective study presents and evaluates clinical ethics consultations (CECs) in pediatrics as a structure for implementing hospital-wide ethics. We performed a descriptive and statistical analysis of clinical ethics decision making and its implementation in pediatric CECs at Zurich University Children's Hospital. Ninety-five CECs were held over 5 years for 80 patients. The care team reached a consensus treatment recommendation after one session in 75 consultations (89 %) and on 82 of 84 ethical issues (98 %) after two or more sessions (11 repeats). Fifty-seven CECs recommended limited treatment and 23 maximal treatment. Team recommendations were agreed outright by parents and/or patient in 59 of 73 consultations (81 %). Initial dissensus yielded to explanatory discussion or repeat CEC in seven consultations (10 %). In a further seven families (10 %), no solution was found within the CEC framework: five (7 %) required involvement of the child protection service, and in two families, the parents took their child elsewhere. Eventual team-parent/patient consensus was reached in 66 of 73 families (90 %) with documented parental/patient decisions (missing data, n = 11). Patient preference was assessable in ten CECs. Patient autonomy was part of the ethical dilemma in only three CECs. The Zurich clinical ethics structure produced a 98 % intra-team consensus rate in 95 CECs and reduced initial team-parent dissensus from 21 to 10 %. Success depends closely on a standardized CEC protocol and an underlying institutional clinical ethics framework embodying a comprehensive set of transparently articulated values and opinions, with regular evaluation of decisions and their consequences for care teams and families.

Impact of chorioamnionitis and preeclampsia on neurodevelopmental outcome in preterm infants below 32 weeks gestational age.

AIM: Intrauterine conditions may interfere with foetal brain development. We compared the neurodevelopmental outcome between infants <32 weeks gestational age after maternal preeclampsia or chorioamnionitis and controls. METHODS: Case-control study on infants with maternal preeclampsia, chorioamnionitis and controls (each n = 33) matched for gestational age. Neurodevelopment at 2 years was assessed with the Bayley Scales of Infant Development II. RESULTS: A total of 99 infants were included with a median gestational age of 29 weeks (range 25-32). Median mental developmental index (MDI) was 96 in the control, 90 in the chorioamnionitis and 86 in the preeclampsia group. Preeclampsia infants had a lower MDI compared with the control group (univariate p = 0.021, multivariate p = 0.183) and with the chorioamnionitis group (univariate p = 0.242; multivariate p = 0.027). Median psychomotor index was 80.5 in the control, 80 in the preeclampsia and 85 in the chorioamnionitis group and was not different between these three groups (p > 0.05). Chorioamnionitis or preeclampsia exposure was not associated with major neurodevelopmental impairments (cerebral palsy, MDI<70, PDI<70). CONCLUSION: The results of this preliminary study suggest that preeclampsia and chorioamnionitis play a relatively minor role among risk factors for adverse neurodevelopment outcome. Postnatal factors such as ventilation and bronchopulmonary dysplasia may have a greater impact on neurodevelopmental outcome.

Near-infrared spectroscopy measurements of cerebral oxygenation in newborns during immediate postnatal adaptation.

OBJECTIVE: In view of growing concerns regarding the optimal supplementation of oxygen at birth, we measured cerebral oxygenation during the first minutes of life. STUDY DESIGN: Using near-infrared spectroscopy, changes in cerebral oxygenated hemoglobin (O(2)Hb), dexoxygenated hemoglobin (HHb), and tissue oxygenation index (TOI) were measured during the first 15 minutes of life in 20 healthy newborn infants delivered at term by elective cesarean section. RESULTS: O(2)Hb and TOI increased rapidly within the first minutes of life (median slope for O(2)Hb, 3.4 micromol/L/min; range, 1.4 to 20.6 micromol/L/min; median slope for TOI, 4.2 %/min; range, -0.4 to 27.3%/min), and cerebral HHb decreased (median slope, -4.8 micromol/L/min; range, -0.2 to -20.6 micromol/L/min). O(2)Hb, TOI, and HHb all reached a plateau within 8 minutes. CONCLUSIONS: A significant increase in cerebral O(2)Hb and TOI and a significant decrease in HHb occur during immediate adaptation in healthy term newborns, reaching a steady plateau at around 8 minutes after birth.

Early enteral feeding in conservatively managed stage II necrotizing enterocolitis is associated with a reduced risk of catheter-related sepsis.

AIMS: To compare the effect of fasting period duration on complication rates in neonates managed conservatively for necrotizing enterocolitis (NEC) Bell stage II. METHODS: We conducted a multicenter study to analyze retrospectively multiple data collected by standardized questionnaire on all admissions for NEC between January 2000 and December 2006. NEC was staged using modified Bell criteria. We divided the conservatively managed neonates with NEC Bell stage II into two groups (those fasted for <5 days and those fasted for >5 days) and compared the complication rates. RESULTS: Of the 47 conservatively managed neonates Bell stage II, 30 (64%) fasted for <5 days (range 1-4 days) and 17 (36%) for >5 days (range 6-16 days). There were no significant differences for any of the patient characteristics analyzed. One (3%) and four (24%) neonates, respectively, developed post-NEC bowel stricture. One (3%) and two neonates (12%) suffered NEC relapse. None and five (29%) neonates developed catheter-related sepsis. CONCLUSION: Shorter fasting after NEC appears to lower morbidity after the acute phase of the disease. In particular, shorter-fasted neonates have significantly less catheter-related sepsis. We found no benefit in longer fasting.

Longtime performance and reliability of two different PtcCO2 and SpO2 sensors in neonates.

OBJECTIVES: Blood gas monitoring is necessary in treatment of critically ill neonates. Whereas SaO2 can be estimated by pulse oximetry, PaCO2 is still most often assessed from blood samples. AIM: To compare long time performance of an ear sensor for combined assessment of transcutaneous carbon dioxide (PtcCO2) and oxygen saturation (SpO2) (TOSCA Monitor; Radiometer, Switzerland) with a conventional PtcCO2 monitor (MicroGas 7650-500 rapid, Radiometer, Switzerland) in critically ill neonates. METHODS: Prospective, observational study. Twenty critically ill neonates were monitored for PtcCO2 and SpO2 using the Tosca and the MicroGas monitor for 24 h. TOSCA ear sensor was changed to the other ear lobe after 12 h and the MicroGas sensor four hourly on the trunk. Values obtained were compared with SaO2 and PaCO2 from arterial blood gas analysis using Bland-Altman analysis. Data are presented as median (range). RESULTS: Eighty-two paired measurements were obtained. Median age of the 20 patients was 4.5 days (1-26 days) and weight was 3.05 kg (0.98-3.95 kg). Bias and precision between PaCO2 and PtcCO2 were 0.14 and 1.45 kPa for the Tosca monitor and -0.08 and 1.2 kPa for the MicroGas monitor, respectively. The two biases were significantly different (P = 0.0036). SpO2 assessment by TOSCA was comparable to SaO2 values (bias 0.26% and precision 4.14%). CONCLUSION: The TOSCA monitor allows safe estimation of PtcCO2 and SaO2 in neonates. Measurements of PtcCO2 were less reliable with TOSCA compared with conventional monitoring but still allow assessing a trend of ventilation status in newborn patients.

Feeding problems in preterm infants of preeclamptic mothers.

AIM: Maternal disease can cause prematurity and neonatal complications, notably feeding problems. To determine the relationship between maternal disease and the nature and severity of neonatal feeding problems, we compared feeding profiles, time to demand feeding and length of hospital stay between preterm infants of preeclamptic mothers, mothers with amniotic infection and mothers with other disease causing prematurity. METHODS: The retrospective study used labour ward data collected from 2002 to 2005 in a tertiary university centre to analyse three groups of singletons born at <32 completed gestational weeks to mothers with preeclampsia (n = 61), amniotic infection (n = 55) and non-preeclamptic non-amniotic infection controls (n = 55). The groups were similar in gestational age, birthweight and sex ratio; all infants received enteral feeding according to departmental guidelines. Feeding profiles and enteral/oral nutrition were compared. RESULTS: Feeding problems occurred in 46% of the preeclamptic group, 11% of the amniotic infection group and 13% of controls. Full oral demand feeding was established at 36 0/7 weeks postmenstrual age, 35 3/7 weeks (P = 0.03) and 35 2/7 weeks (P < 0.0001), respectively. Feeding problems were the main cause of delay (7-10 days) in hospital discharge in the preeclamptic group (P = 0.0002). CONCLUSIONS: Feeding problems are greater, and hospital stay longer, in preterm infants of preeclamptic mothers than in other preterm infants.

17-Hydroxyprogesterone in premature infants as a marker of intrauterine stress.

AIMS: Amniotic infection (AI) and preeclampsia (PE), which are commonly the reason for prematurity, inflict stress of different duration on immature fetuses. Whether chronic stress, as reflected by intrauterine growth retardation, influences the level of 17-OH progesterone (17-OHP), was not previously examined. METHODS: We analyzed 17-OHP and TSH levels during neonatal screenings in the first hours of life of 90 premature infants born between 25 and 33 weeks of gestation in infants with AI (n=37) or with PE (n=53). Control of acute stress parameters was derived from umbilical arterial cord blood pH and base excess (BE). RESULTS: Mean 17-OHP levels of infants born to mothers with PE were 85.7 nmol/L compared to 54.6 nmol/L (P<0.001) in AI infants. 17-OHP was even higher when intrauterine growth restriction was present (99.8 nmol/L). Antenatal steroids and mode of delivery did not significantly affect 17-OHP levels. CONCLUSIONS: Stress of relatively long duration, as in cases of PE, leads to a significant increase of 17-OHP level in preterm infants. The postnatal 17-OHP level may be considered as a measure for severity of intrauterine stress and might be used as an individualized indicator for earlier intensive care.

Acceleration of lung maturation in a human fetus following maternal isotretinoin intake.

The viability of the human fetus increases significantly beyond 25 weeks' gestation as the lung development progresses towards the 'saccular' stage. We report on a fetus of 22 weeks' gestation whose lung maturation was accelerated by 4 weeks, most likely due to the unintentional exposure to the retinoid isotretinoin (13-cis-retinoic acid) during pregnancy. Although retinoids are known to be stored within the lungs and to play a key role in lung differentiation and growth, their storage within the lung is limited during this critical developmental period. Even though glucocorticosteroids are used clinically to enhance lung maturation in the face of impending preterm birth, there are no data yet which demonstrate that glucocorticosteroids, when given alone, are effective in promoting lung maturation prior to 24 weeks' gestation. Strong evidence however, indicates that glucocorticosteroids promote the utilization of lung retinoids immediately before birth. Our observation of increased lung maturation, in conjunction with the above information suggests that retinoids alone or in combination with glucocorticosteroids might promote lung maturation more effectively than glucocorticosteroids alone when birth seems inevitable at a very early gestational age.

Frequency and potential cause of bronchus-associated lymphoid tissue in fetal lungs.

Bronchus-associated lymphoid tissue consists of lymphoid follicles with or without a germinal center within the bronchial wall. Bronchus-associated lymphoid tissue is part of the integrated mucosal immune system and present in about 50% of healthy infants. We examined a series of 141 fetal and neonatal lungs and detected bronchus-associated lymphoid tissue in 100% of cases with amniotic infection while postpartum perinatal pneumonia did not elicit bronchus-associated lymphoid tissue formation. Only rarely and in low density, bronchus-associated lymphoid tissue was present in non-infected fetuses. The in utero formation of bronchus-associated lymphoid tissue seems to be a reactive phenomenon and - as has been shown in another study - does not portend an adverse prognosis.

The pulmonary paradox in premature infants: in-utero infected lungs do better than those with accelerated maturation.

AIMS: To document, and explain, the pulmonary paradox whereby despite relative lung immaturity, preterm infants exposed to amniotic infection (AI) have better postnatal pulmonary function than those exposed to preeclampsia (PE). METHODS: Lung maturation was characterized in 65 preterm perinatal deaths [AI (n=40) and PE (n=25)] and postnatal respiratory function in 100 preterm survivors [AI (n=50) and PE (n=50)]. RESULTS: At autopsy, lung architecture was in advance of gestational age in 5% of AI infants versus 40% of PE infants (P<0.001). In survivors, the groups were similar in age and Apgar scores. At birth, 40% of the AI group required continuous positive airway pressure or mechanical ventilation versus 24% of the PE group (NS). However, 24 hours later, only 1 AI infant had deteriorated compared to 40% of PE infants (P<0.05). CONCLUSIONS: Accelerated morphologic lung maturation in preterm PE infants does not translate into improved postnatal respiratory function. Most likely, this is due to a relative lack of surfactant, ascribable to low stimulant cytokine and high TNF-alpha levels. An intrauterine history supplemented by an antenatal cytokine profile could identify an increased exogeneous surfactant need in preterm infants exposed to PE.

An infant with pulmonary hypertension due to a congenital porto-caval shunt.

A 20-month-old male child died during an episode of acute bronchitis. The autopsy revealed massive hypertrophy and acute dilatation of the right heart which was caused by pulmonary hypertension exhibiting plexogenic arteriopathy and necrotizing arteriitis of small lung vessels. Further examination revealed complete old fibrotic occlusion of the extrahepatic portal vein and a large porto-systemic shunt. Esophageal varices indicating portal hypertension were not present. Histology showed enlarged hepatic arteries within the portal tracts while branches of the portal vein were lacking. The placenta had been examined at the time of birth and multiple chorangiomas reported. Furthermore, multiple old and florid occlusions of fetal vessels had been detected together with focal lymphoplasmocytic inflammation, which may indicate that intrauterine infection and vascular compromise were the cause of the complete closure of the portal vein around birth. The association of pulmonary hypertension with liver disease is well known, and portal hypertension has been considered a key factor in the pathogenesis of pulmonary hypertension. However, this case illustrates that portal hypertension is not a requisite for the development of pulmonary hypertension. It rather suggests that plexogenic arteriopathy of the lungs can be caused by porto-caval shunting independent of liver damage and portal hypertension. Toxic metabolites of nutrients or residual activity of pancreatic enzymes reaching the pulmonary vascular bed may be involved in the pathogenesis.