[Medication errors in a neonatal unit: One of the main adverse events]. / Los errores de tratamiento en una unidad neonatal, uno de los principales acontecimientos adversos.

INTRODUCTION: Neonatal units are one of the hospital areas most exposed to the committing of treatment errors. A medication error (ME) is defined as the avoidable incident secondary to drug misuse that causes or may cause harm to the patient. The aim of this paper is to present the incidence of ME (including feeding) reported in our neonatal unit and its characteristics and possible causal factors. A list of the strategies implemented for prevention is presented. MATERIAL AND METHODS: An analysis was performed on the ME declared in a neonatal unit. RESULTS: A total of 511 MEs have been reported over a period of seven years in the neonatal unit. The incidence in the critical care unit was 32.2 per 1000 hospital days or 20 per 100 patients, of which 0.22 per 1000 days had serious repercussions. The ME reported were, 39.5% prescribing errors, 68.1% administration errors, 0.6% were adverse drug reactions. Around two-thirds (65.4%) were produced by drugs, with 17% being intercepted. The large majority (89.4%) had no impact on the patient, but 0.6% caused permanent damage or death. Nurses reported 65.4% of MEs. The most commonly implicated causal factor was distraction (59%). Simple corrective action (alerts), and intermediate (protocols, clinical sessions and courses) and complex actions (causal analysis, monograph) were performed. CONCLUSIONS: It is essential to determine the current state of ME, in order to establish preventive measures and, together with teamwork and good practices, promote a climate of safety.

[Towards a safety culture in the neonatal unit: Six years experience]. / Caminando hacia una cultura de seguridad en la unidad neonatal: experiencia de 6 años.

INTRODUCTION: A safety culture is the collective effort of an institution to direct its resources toward the goal of safety. MATERIAL AND METHODS: An analysis is performed on the six years of experience of the Committee on the Safety of Neonatal Patient. A mailbox was created for the declaration of adverse events, and measures for their correction were devised, such as case studies, continuous education, prevention of nosocomial infections, as well as information on the work done and its assessment. RESULTS: A total of 1287 reports of adverse events were received during the six years, of which 600 (50.8%) occurred in the neonatal ICU, with 15 (1.2%) contributing to death, and 1282 (99.6%) considered preventable. Simple corrective measures (notification, security alerts, etc.) were applied in 559 (43.4%), intermediate measures (protocols, monthly newsletter, etc.) in 692 (53.8%), and more complex measures (causal analysis, scripts, continuous education seminars, prospective studies, etc.) in 66 (5.1%). As regards nosocomial infections, the prevention strategies implemented (hand washing, insertion and maintenance of catheters) directly affected their improvement. Two surveys were conducted to determine the level of satisfaction with the Committee on the Safety of Neonatal Patient. A rating 7.5/10 was obtained in the local survey, while using the Spanish version of the Hospital Survey on Patient Safety Culture the rate was 7.26/10. CONCLUSIONS: A path to a culture of safety has been successfully started and carried out. Reporting the adverse events is the key to obtaining information on their nature, etiology and evolution, and to undertake possible prevention strategies.

[Influence of in-home nursing care on the weight of the early discharged preterm newborn]. / Evolución del peso del prematuro con alta precoz y atención domiciliaria de enfermería.

INTRODUCTION: In-Home nursing care of the preterm newborn helps to bring the family situation to normal, promotes breastfeeding and development of the newborn, and enables the reorganization of health care resources. The purpose of this paper is to demonstrate that in-home nursing care of the preterm newborn leads to an increase in weight and a similar morbidity. PATIENTS AND METHODOLOGY: A total of 65 cases and 65 controls (matched by weight, age and sex) were studied, all of them preterm newborns born in hospital and weighing less than 2100 g at discharge. In-home nursing care was carried out by a pediatrician neonatologist, as well as two nurses specialized in neonatology who made several visits to the home. Weight gain was calculated as g/day and g/Kg/day, comparing the first week of the study with the week prior to the beginning of the study. RESULTS: The groups were comparable. Weight gain in the group with home nursing care was 38 g per day, significantly higher than the weight gain in the control group (31 g/day). The independent predictive variables of the increase in g/Kg/day during the study were in-home nursing care, male gender, breastfeeding less, and not having suffered from a peri-intraventricular hemorrhage. Neonatal morbidity was similar in both groups. CONCLUSIONS: In-home care was associated with a greater weight gain of the newborn at home than during their stay in the hospital, and can be considered safe because neonatal morbidity was not increased.

[Neonatal convulsions and subarachnoid hemorrhage after in utero exposure to paroxetine]. / Convulsiones y hemorragia subaracnoidea tras exposición a paroxetina in utero.

INTRODUCTION: Selective serotonin reuptake inhibitors (SSRIs) are often used as antidepressants in pregnant women. SSRIs do not appear to increase the teratogenic risk when used in their recommended doses. However, not enough information is available at this time about the risk of toxicity and complications in newborns, after mother treatment with SSRI during the third trimester of pregnancy. We are limited to the existing reports that describe newborns with symptoms due to hyperserotoninemia or withdrawal. CASE REPORT: One newborn whose mother had been treated with paroxetine 20 mg/day during pregnancy, presented convulsions and subarachnoid haemorrhage in the first six hours of life. The newborn did not present symptoms of hypoxic ischaemic encephalopathy, withdrawal syndrome, infection, metabolic alterations, cerebral malformations or coagulopaties. DISCUSSION: The most probable etiology is that the paroxetine could decrease the seizure threshold, taking place the first seizure during delivery. The difficult fetal extraction would have provoked the subarachnoid haemorrhage in a patient with an impaired haemostatic function due to a depletion of platelet serotonin and may also contribute the increased vascular fragility due to paroxetine and reported in adults or in animals. CONCLUSION: Neonatal convulsions and subarachnoid haemorrhage may occur after paroxetine treatment in the third trimester of pregnancy. An accurate follow up of these newborns in the firsts days of life is strongly recommended.

[Blood ammonia and transaminases in full term infants suffering from perinatal asphyxia]. / Amoniaco y transaminasas en sangre en el recién nacido a término afectado de asfixia perinatal.

AIMS: To find hepatic markers of perinatal asphyxia. PATIENTS AND METHODS: Variations in blood ammonia during the first week of life and in transaminase in serum during the first 48 hours were analysed in four groups of newly born infants (NBI): Group I or control, in which 65 NBI were included, with suspected unconfirmed infection and no other pathologies; Group II, made up of 15 NBI with loss of foetal well being (LFW) with no posterior neurological clinical features; Group III, consisting of 27 NBI with LFW criteria and mild hypoxic ischemic encephalopathy (HIE); and Group IV, with 25 NBI with LFW criteria and mild HIE according to Amiel s criteria. RESULTS: The average blood ammonia values in full term infants remain steady during the first week of life (87.66 21.69 mg/dL), as occurs in infants with LFW but without HIE (89.08 24.69 mg/dL) and in those with mild HIE (89.08 20.75 mg/dL). In moderate HIE, the blood ammonia level rises until the third day (108.55 7.04 mg/dL) and then drops back to the initial values (p= 0.0045). When grouped by days, these values show significant differences (p= 0.04), with higher values in Group IV. The NBI with HIE presented higher levels of transaminases, especially of AST (GOT) (p= 0.000001), and this increase is proportional to its gravity. No relation was found between values of blood ammonia and transaminases. CONCLUSIONS: Both blood ammonia and transaminases can be considered to be perinatal asphyxia markers.

Recomendaciones para el transporte perinatal / Recommendations for perinatal transport

El transporte perinatal debe formar parte de los programas de regionalización y planificarse de acuerdo con el mapa sanitario de cada comunidad dentro de un sistema de atención perinatal. Se describen los diferentes tipos de transporte, los medios utilizables con sus ventajas e inconvenientes, el material necesario, la dinámica que se debe seguir ante la necesidad de un traslado perinatal insistiendo en la relevancia del transporte intraútero y del transporte de retorno. La organización del traslado merece una consideración especial, destacando las distintas funciones de los centros coordinador, emisor, receptor y del equipo asistencial del transporte, así como algunos aspectos ético-legales (AU)

[Recommendations for the care of healthy newborn infants]. / Recomendaciones de mínimos para la asistencia al recién nacido sano.

This article makes certain recommendations on the care of the healthy newborn. Firstly, we discuss the situations that should be reported to the pediatrician/neonatologist and the reasons why the presence of these specialists is required in the delivery room (urgent or elective cesarean section, preterm labor). Secondly, we discuss the most important guidelines to follow in the delivery room and after birth. Concerning care in the delivery room, we stress the importance of care of the newborn (especially of the umbilical cord), bonding between the mother and child, identification of the newborn, assessment of neonatal adaptation to extrauterine life, prevention of ophthalmia neonatorum and hypoprothrombinemia, placing the baby correctly in the crib and hepatitis B prophylaxis. Concerning the postnatal period, we recommend feeding (promotion of breast feeding), rooming-in with the mother if the newborn is hospitalized in the nursery screening for hypoacousia and metabolic diseases, and discharge with special surveillance in cases of early discharge.

Asfixia perinatal y parálisis cerebral / Asfixia perinatal y parálisis cerebral

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[Invasive catheters in neonates]. / Catéteres invasivos en el recién nacido.

OBJECTIVE: The care of very sick babies requires the use of invasive catheters in the neonatal intensive care unit. Our objective was to review the invasive catheters placed (umbilical and epicutaneous) between 1994 and 1998 and describe the guidelines used to take care of the intravenous lines. PATIENTS AND METHODS: Two periods were compared (January 1994 until June 1997 and July 1997 until September 1998) and characteristics of the patient and catheter were analyzed. During the first period, sepsis related to the catheter was diagnosed according to clinical and analytical criteria and required a positive blood culture. The same criteria were required in the second period, but coincidence of the organisms in the peripheral and catheter blood culture was also needed. RESULTS: A total of 1,285 central catheters were studied in 958 newborn admissions. Umbilical catheter were used in 6% of the cases and epicutaneous in 23%, most of which were in the upper extremities. The most frequent reason to remove the catheter was the end of the indication. The incidence of catheter related sepsis in the first period was 1% and during the second period 6%. Strict diagnostic criteria used in the second period were more predictive for sepsis. If premature babies were considered alone, the incidence increased to 14%. The most frequent organism isolated was Staphylococcus epidermidis. CONCLUSIONS: To decrease the incidence of sepsis related to catheters, a strict protocol for placement and maintenance must be followed.

[Risk and outcome factors in necrotizing enterocolitis]. / Factores de riesgo y pronósticos en la enterocolitis necrotizante.

OBJECTIVE: The objective of this study was to identify risk and outcome factors in necrotizing enterocolitis (NEC). PATIENTS AND METHODS: We have studied 72 cases of NEC collected from 1987 until 1994 in the three hospitals of the integrated Unit. A case-control study matched for gestational age and center was performed for 26 risk factors. Conditional logistic regression was used in significant bivariate variables. The 18 outcome factors had the same statical treatment, but without the paired design. RESULTS: Serous infections previous to NEC, apnea and feeding increments greater than 20 cc/kg/day have been identified as risk factors for preterm babies (p < 0.05). Severe acidosis and pneumoperitoneum have been found significant outcome variables, but with very low discriminatory capacity. CONCLUSIONS: It has been found difficult to identify risk factors for NEC besides the gestational age. Outcome factors have very low sensitivity. Preventive treatment should be directed to decrease the effect of the inflammatory mediators in the gastrointestinal tract.

[Perinatal factors predicting hypoxic-ischemic encephalopathy in asphyxic newborn infants]. / Factores perinatales predictivos de encefalopatía hipoxicoisquémica en el recién nacido asfíctico.

Between 1 May 1984 and 30 April 1985, 1,354 term or posterm neonates being white and having asphyxia in controlled delivery were studied to predict development of neurological signs and its seriousness. In each case correlations were estimated between the existence of neurological signs and its grade and 100 gestational, obstetric and neonatal factors of potential predictor. The discriminatory analysis indicated that the more significants predictors were: Apgar at five minutes, prolonged labor, twins, resuscitation, DIP I, cephalhematoma, caput succedaneum, umbilical artery pH, urgent cesarean section, hemorrhagic amniotic fluid, gestational edema, variable DIP, high forceps. A discriminatory value less than or equal to 2 predicts no neurological sign in 93.8%, while a value greater than or equal to 3 predicts moderate or serious signs is 98.4%.

[Percutaneous microcatheters: experience in a neonatal pathology center]. / Microcatéteres percutáneos: experiencia en un centro de patología neonatal.

We have performed 113 percutaneous catheterization in 87 newborn babies, locating them centrally in 60 cases (53%). In 69 (61%) cases the duration of catheter was as long as desired. Average duration was 14.65 days. No important complications were detected. We think that this in a useful technique that allows a long term circulatory access, even central venous lines. Aseptic procedure is mandatory as well as X-ray control of the distal tip of the catheter.

[Plasmacoagulase-negative Staphylococcus sepsis: experience in a neonatal intensive care unit]. / Sepsis a estafilococo plasmocoagulasa negativo: experiencia en una unidad de cuidados intensivos neonatales.

Among 1,049 admissions in the newborn department, during 18 months, authors found 148 positive blood cultures to staphylococci epidermidis (EPN). Recovery of EPN from blood should not be dismissed as a contaminant. 11 newborn were considered to have septicemia by EPN, that means 1.04% of all admissions and 5.6% of babies admitted in intensive care. They find that catheters (100%), assisted ventilation (45.4%) and previous surgery (36.3%) are significant predisposing risk factors. Clinical and laboratory pattern was not different of other sepsis except its late onset. Two patient died. Vancomycin is considered the drug of choice.

[Systemic Candida infections]. / Infecciones sistémicas por candidas.

Seven cases of neonatal systemic candidiasis are summarized. This means an incidence of 8.3% respect total amount of newborns admitted and 3.7% of babies admitted in the intensive care unit. Clinical presentation was not specific. Five blood cultures were positive and in two cases meningitis was recognized. Two cases died. Six cases were treated with amphotericin B and 5-fluorocytosine and in one case renal toxicity appear.