Embedding best transfusion practice and blood management in neonatal intensive care.

BACKGROUND: Transfusion is a common procedure for neonates receiving intensive care management. Recognising a paucity of patient blood management (PBM) programmes in neonates, we aimed to embed blood management and best transfusion principles in the neonatal intensive care unit (NICU) by aligning local policies, providing targeted education and partnering with parents. METHODS: Practice-based evidence for clinical practice improvement (PBE-CPI) methodology was used. Previous hospital accreditation audits were reviewed and a neonate-specific transfusion audit was developed. Audit was performed at baseline and repeated following the intervention period. NICU clinicians received targeted education in obtaining informed consent, prescription and safe administration of blood components during a 'Blood Month' awareness period. A neonate-specific parent handout about transfusion was developed in partnership with parents. A pilot video demonstrating a shared consent discussion was also developed to assist in the consent process. Parents' knowledge, concerns and feedback regarding transfusion practice was sought at baseline (survey) and on project completion (experience trackers). RESULTS: Neonate-specific baseline transfusion audit showed inconsistent consent, monitoring and documentation processes in neonatal transfusions. Post-targeted education audit showed improvement in these parameters. The targeted PBM and transfusion-related education delivered during 'Blood Month' was well-received by staff. Parents' feedback about the NICU transfusion consenting process was consistently positive. NICU medical and nursing clinicians (n=25) surveyed agreed that the parent handout was well set out, easy to understand and recommended that it be used to complement practice. CONCLUSION: PBE-CPI tools aligned with Australian PBM guidelines for clinicians and parents were well-accepted by clinical stakeholders and were associated with practice improvement in PBM awareness and transfusion consent processes. This PBE-CPI project developed NICU-specific consent information, not previously available, by partnering with parents to ensure quality of care in transfusion practice. Adoption of this also helps to meet accreditation for Australian Blood Management Standards. These strategies and tools translate readily into other NICUs to embed and support best PBM and transfusion practice.

Post-transitional adaptation of the left heart in uncomplicated, very preterm infants.

BACKGROUND: The postnatal period in preterm infants involves multiple physiological changes occurring immediately after birth and continuing for days or weeks. To recognise and treat compromise, it is important to measure cardiovascular function. The aim of this study was to describe longitudinal left ventricular function using conventional and novel echocardiography techniques in preterm infants who did not experience significant antenatal or postnatal complications and treatments. METHODS: We prospectively obtained cardiac ultrasound images at days 3, 7, 14, 21, and 28 in 25 uncomplicated, preterm infants <30 weeks of gestation. Speckle tracking analysis of the four chambers and short-axis images provided parameters of left ventricular volume, deformation, and basal myocardial velocities. The patent ductus arteriosus, cardiac dimensions, and atrial volume were also measured. RESULTS: Stroke volume increased by 24% during the study period (1.05-1.30 ml/kg, p<0.05). Cardiac length, diameter, and systolic basal myocardial velocity increased with unchanged wall stress and deformation parameters. Diastolic function parameters resembled that of the fetus with predominance of atrial contraction compared with early diastolic velocities. Blood pressure and estimates of left ventricular filing pressure increased, suggesting that left ventricular compliance did not change in this period. CONCLUSION: Stroke volume increased in the first 28 days after preterm birth. The preterm heart adapted by increasing its size, while maintaining systolic and atrial function, independent of early diastolic maturation. Longitudinal deformation of the left ventricle remained unchanged, suggesting relatively preserved function with maturation.

Cardiac Function After the Immediate Transitional Period in Very Preterm Infants Using Speckle Tracking Analysis.

BACKGROUND: The postnatal period in preterm infants involves multiple physiologic changes starting directly after birth and continuing for days or weeks. To recognize and treat compromise, it is important to measure cardiovascular function. We used a novel technique (speckle tracking echocardiography, STE) to measure cardiac function in this period. METHODS: We obtained cardiac ultrasound images at day 3, 7, 14, 21 and 28 in preterm infants <30-week gestation. Conventional measures included cardiac size, left ventricular stroke volume, atrial volume and the patent ductus arteriosus (PDA). Four chamber images were analyzed with STE, which provided parameters of left ventricular volume, longitudinal deformation and myocardial velocities. RESULTS: Images of 54 infants (gestational age 23-29 weeks) were analyzed. STE-derived stroke volume correlated well with conventional echocardiography-derived stroke volume, but agreement was suboptimal. Most STE parameters showed good reliability. All volume parameters and systolic and atrial velocities increased over time. Cardiac deformation and early diastolic velocity did not change. A PDA was associated with 33 % increased stroke volume at day 3 up to 98 % at day 28 with a spherically enlarged heart and increased filling pressure. CONCLUSION: Speckle tracking echocardiography analysis is a feasible and reliable technique that can simultaneously obtain systolic and diastolic volumes, longitudinal deformation and myocardial velocities from one ultrasound window. Preterm hearts maintain cardiac function well during the first weeks of life, even with increased preload as a consequence of a PDA.

Regional (spinal, epidural, caudal) versus general anaesthesia in preterm infants undergoing inguinal herniorrhaphy in early infancy.

BACKGROUND: With improvements in neonatal intensive care, more preterm infants are surviving the neonatal period and presenting for surgery in early infancy. Inguinal hernia is the most common condition requiring early surgery, appearing in 38% of infants whose birth weight is between 751 grams and 1000 grams. Approximately 20% to 30% of otherwise healthy preterm infants having general anaesthesia for inguinal hernia surgery at a postmature age have at least one apnoeic episode within the postoperative period. Research studies have failed to adequately distinguish the effects of apnoeic episodes from other complications of extreme preterm gestation on the risk of brain injury, or to investigate the potential impact of postoperative apnoea upon longer term neurodevelopment. In addition to episodes of apnoea, there are concerns that anaesthetic and sedative agents may have a direct toxic effect on the developing brain of preterm infants even after reaching postmature age. It is proposed that regional anaesthesia may reduce the risk of postoperative apnoea, avoid the risk of anaesthetic-related neurotoxicity and improve neurodevelopmental outcomes in preterm infants requiring surgery for inguinal hernia at a postmature age. OBJECTIVES: To determine if regional anaesthesia reduces postoperative apnoea, bradycardia, the use of assisted ventilation, and neurological impairment, in comparison to general anaesthesia, in preterm infants undergoing inguinal herniorrhaphy at a postmature age. SEARCH METHODS: The following databases and resources were searched: the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, 2015, Issue 2), MEDLINE (December 2002 to 25 February 2015), EMBASE (December 2002 to 25 February 2015), controlled-trials.com and clinicaltrials.gov, reference lists of published trials and abstracts published in Pediatric Research and Pediatric Anesthesia. SELECTION CRITERIA: Randomised and quasi-randomised controlled trials of regional (spinal, epidural, caudal) versus general anaesthesia, or combined regional and general anaesthesia, in former preterm infants undergoing inguinal herniorrhaphy in early infancy. DATA COLLECTION AND ANALYSIS: At least two of three review authors (LJ, JF, AL) independently extracted data and performed analyses. Authors were contacted to obtain missing data. The methodological quality of each study was assessed according to the criteria of the Cochrane Neonatal Review Group. Data were analysed using Review Manager 5. Meta-analyses were performed with calculation of risk ratios (RR) and risk difference (RD), along with their 95% confidence intervals (CI) where appropriate. MAIN RESULTS: Seven small trials comparing spinal with general anaesthesia in the repair of inguinal hernia were identified. Two trial reports are listed as 'Studies awaiting classification' due to insufficient information on which to base an eligibility assessment. There was no statistically significant difference in the risk of postoperative apnoea/bradycardia (typical RR 0.72, 95% CI 0.48 to 1.06; 4 studies, 138 infants), postoperative oxygen desaturation (typical RR 0.82, 95% CI 0.61 to 1.11; 2 studies, 48 infants), the use of postoperative analgesics (RR 0.42, 95% CI 0.15 to 1.18; 1 study, 44 infants), or postoperative respiratory support (typical RR 0.09, 95% CI 0.01 to1.64; 3 studies, 98 infants) between infants receiving spinal or general anaesthesia. When infants who had received preoperative sedatives were excluded, the meta-analysis supported a reduction in the risk of postoperative apnoea in the spinal anaesthesia group (typical RR 0.53, 95% CI 0.34 to 0.82; 4 studies, 129 infants). Infants with no history of apnoea in the preoperative period and receiving spinal anaesthesia (including a subset of infants who had received sedatives) had a reduced risk of postoperative apnoea and this reached statistical significance (typical RR 0.34, 95% CI 0.14 to 0.81; 4 studies, 134 infants). Infants receiving spinal rather than general anaesthesia had a statistically significant increased risk of anaesthetic agent failure (typical RR 7.83, 95% CI 1.51 to 40.58; 3 studies, 92 infants). Infants randomised to receive spinal anaesthesia had an increased risk of anaesthetic placement failure of borderline statistical significance (typical RR 7.38, 95% CI 0.98 to 55.52; typical RD 0.15, 95% CI 0.03 to 0.27; 3 studies, 90 infants). AUTHORS' CONCLUSIONS: There is moderate-quality evidence to suggest that the administration of spinal in preference to general anaesthesia without pre- or intraoperative sedative administration may reduce the risk of postoperative apnoea by up to 47% in preterm infants undergoing inguinal herniorrhaphy at a postmature age. For every four infants treated with spinal anaesthesia, one infant may be prevented from having an episode of postoperative apnoea (NNTB=4). In those infants without preoperative apnoea, there is low-quality evidence that spinal rather than general anaesthesia may reduce the risk of preoperative apnoea by up to 66%. There was no difference in the effect of spinal compared with general anaesthesia on the overall incidence of postoperative apnoea, bradycardia, oxygen desaturation, need for postoperative analgesics or respiratory support. Limitations on these results included varying use of sedative agents, or different anaesthetic agents, or combinations of these factors, in addition to trial quality aspects such as allocation concealment and inadequate blinding of intervention and outcome assessment. The meta-analyses may have inadequate power to detect a difference between groups for some outcomes, with estimates of effect based on a total population of fewer than 140 infants.The effect of newer, rapidly acting, quickly metabolised general anaesthetic agents on safety with regard to the risk of postoperative apnoea and neurotoxic exposure has not so far been established in randomised trials. There is potential for harm from postoperative apnoea and direct brain toxicity from general anaesthetic agents superimposed upon pre-existing altered brain development in infants born at very to extreme preterm gestation. This highlights the clear need for the examination of neurodevelopmental outcomes in the context of large randomised controlled trials of general, compared with spinal, anaesthesia, in former preterm infants undergoing surgery for inguinal hernia.There is a particular need to examine the impact of the choice of spinal over general anaesthesia on respiratory and neurological outcomes in high-risk infant subgroups with severe respiratory disease and previous brain injury.

Early microvascular changes in the preterm neonate: a comparative study of the human and guinea pig.

Dysfunction of the transition from fetal to neonatal circulatory systems may be a major contributor to poor outcome following preterm birth. Evidence exists in the human for both a period of low flow between 5 and 11 h and a later period of increased flow, suggesting a hypoperfusion-reperfusion cycle over the first 24 h following birth. Little is known about the regulation of peripheral blood flow during this time. The aim of this study was to conduct a comparative study between the human and guinea pig to characterize peripheral microvascular behavior during circulatory transition. Very preterm (≤28 weeks GA), preterm (29-36 weeks GA), and term (≥37 weeks GA) human neonates underwent laser Doppler analysis of skin microvascular blood flow at 6 and 24 h from birth. Guinea pig neonates were delivered prematurely (62 day GA) or at term (68-71 day GA) and laser Doppler analysis of skin microvascular blood flow was assessed every 2 h from birth. In human preterm neonates, there is a period of high microvascular flow at 24 h after birth. No period of low flow was observed at 6 h. In preterm animals, microvascular flow increased after birth, reaching a peak at 10 h postnatal age. Blood flow then steadily decreased, returning to delivery levels by 24 h. Preterm birth was associated with higher baseline microvascular flow throughout the study period in both human and guinea pig neonates. The findings do not support a hypoperfusion-reperfusion cycle in the microcirculation during circulatory transition. The guinea pig model of preterm birth will allow further investigation of the mechanisms underlying microvascular function and dysfunction during the initial extrauterine period.

Transitional hemodynamics in preterm infants with a respiratory management strategy directed at avoidance of mechanical ventilation.

BACKGROUND: Early respiratory management of very low birth weight infants has changed over recent years to a practice of early use of CPAP with early selective surfactant administration, and decreased use of mechanical ventilation. One strategy is to use the combination of surfactant and prompt extubation to nasal continuous positive airway pressure (INtubate, SURfactant, Extubate, or INSURE). The aim of this study is to describe blood flow and ductal flow in a prospective cohort during the transitional period when this respiratory management strategy is used. METHODS: Inborn infants <29week gestation underwent INSURE within 30min of birth using 200mg/kg Curosurf. Blood pressure and blood flow parameters (RVO, LVO, SVC flow, ductus arteriosus) were measured at 6, 24 and 72h of age and information on morbidity was collected. RESULTS: Sixty-eight infants with a median (range) weight of 940 (450-1380) g were studied. 13 (19%) patients needed mechanical ventilation within 72h of life (INSURE failure). Blood flows and blood pressure were within reported ranges. Eleven (16%) patients had a blood pressure

Speckle tracking echocardiography in very preterm infants: feasibility and reference values.

BACKGROUND: Speckle tracking echocardiography (STE) applies computer software analysis on images generated by conventional ultrasound to define and follow a cluster of speckles from frame to frame and calculates parameters of motion (velocity, displacement) and deformation (strain, strain rate). We explored STE of the left ventricle in stable very preterm infants. METHODS: Apical 4 chamber clips (4CH) and short axis clips (SAX) at the level of the papillary muscle were analyzed using TomTec software with manual tracing of cardiac borders. The software automatically segmented the ventricle into 6 equidistant segments and provided segmental and global analysis of deformation parameters. Tracking accuracy was scored visually. RESULTS: Seventy-four clips from 51 infants with a median gestational age of 28weeks were analyzed. Feasibility of 4CH was 95.5% for longitudinal and 96.2% for radial parameters. The reliability of longitudinal and circumferential deformation parameters was good, but radial parameters were less reliable. 4CH mean (SD) global peak systolic longitudinal and radial strain (%) and strain rate (s(-1)) were -18.7(2.6), -1.73(0.28), 23.6(9.1) and 1.94(0.65), and SAX circumferential and radial strain and strain rate were -19.5(3.7), -1.97(0.46), 32.1(14.4) and 2.37(0.80). CONCLUSION: STE is feasible in preterm infants. Optimal image acquisition is paramount. Longitudinal parameters in 4CH and circumferential in SAX were most robust.

Intestinal strictures post-necrotising enterocolitis: clinical profile and risk factors.

BACKGROUND: Intestinal stricture is an important complication of necrotising enterocolitis (NEC). We aimed to describe clinical profile and identify the risk factors for post-NEC intestinal strictures. METHOD: A retrospective study of infants with NEC over 10 year period. RESULTS: Of the 61 infants with NEC, 18 (29.5%) developed intestinal strictures. Leucocytosis and longer length of bowel resection during acute stage of NEC was associated with a later diagnosis of intestinal stricture. Infants with NEC who did not develop stricture had non-specific intestinal dilatation on abdominal x-ray during acute NEC. Intestinal strictures were diagnosed at a median interval of 34 days after NEC. Majority of strictures (67%) occurred in the colon. A significant proportion (77%) of infants with intestinal stricture had associated co-morbidities. No mortality occurred in infants with intestinal strictures. CONCLUSION: The incidence of post-NEC intestinal stricture is high but development of stricture is difficult to predict. Leucocytosis during NEC and length of bowel resected at surgery may be associated with development of post-NEC intestinal stricture. A substantial number of infants with post-NEC intestinal stricture fail to thrive, have co-morbidities and need prolonged hospitalisation.

Bilious vomiting in the newborn: 6 years data from a Level III Centre.

BACKGROUND: Bilious vomiting in the newborn is an urgent condition that frequently requires neonatal and paediatric surgical involvement. Investigations involve abdominal X-ray and contrast imaging in most cases. We aimed to describe the prevalence of surgical intervention in this cohort and assess the reliability of contrast imaging in accurate prediction of underlying condition. METHODS: A retrospective audit of data from December 2001 to October 2007 was undertaken. Data on newborns admitted to a level III unit with bilious vomiting was extracted. Infants with bilious aspirates but no vomiting were excluded. RESULTS: Sixty-one infants were admitted to the unit during the period with bilious vomiting. Most of them were out born (83.6%). Mean (and standard deviation) gestation was 38.3 weeks (+/-3.2); weight was 3173.5 grams (+/-717.6); day of admission was 3.68 days (1-28); and length of stay in the unit was 9.96 days (1-48). There were 52 (85.2%) abnormal X-rays and 21 (34.4%) abnormal contrast studies. Sixteen (26.6%) babies had laparotomies of which 6 were malrotations with volvulus, 2 small bowel obstructions, 2 meconium ileus, 2 Hirschsprung's disease, 2 other findings, while 2 were normal. Positive predictive value (number of accurate predictions of surgical findings) for barium contrast studies was 85.7% in this series. CONCLUSION: Bile stained vomiting is a surgical emergency and prompt investigation is the key in the management. Contrast studies still form the backbone of such investigations.

Surfactant and patent ductus arteriosus.

OBJECTIVE: To investigate the relationship between surfactant replacement therapy and the development of a haemodynamically significant ductus arteriosus. METHODS: All premature infants at 28-32 wk gestation with a clinical diagnosis of respiratory distress syndrome were retrospectively reviewed and subdivided into two groups; intubated, mechanically ventilated and received surfactant (Group 1); and received nasal continuous positive airway pressure alone (Group 2). The relationship between groups and characteristics of the hemodynamically significant ductus arteriosus was analyzed. RESULTS: Seventy babies were identified of whom 35 (50%) received surfactant. Babies in group I and II were comparable for gestational age, birthweight, antenatal steroids, gender and fluid intake in first week of life. Babies treated with surfactant therapy were found to be more likely to have a haemodynamically significant ductus arteriosus (p<0.01), larger transductal diameter (p=0.01) and increased rate of therapeutic interventions to close the ductus (p<0.01). Ventilation parameters (mean airway pressure and fractional inspired oxygen) were higher in group I. CONCLUSION: Neonates with respiratory distress syndrome (RDS) who were treated with surfactant replacement are at increased risk of a hemodynamically significant ductus arteriosus that requires therapeutic intervention. Whether the relationship reflects their underlying lung disease or is a direct effect of surfactant requires prospective evaluation.