Impact of a neuro-intensive care service for newborns.

BACKGROUND: Advances in treating the injured neonatal brain have given rise to neuro-intensive care services for newborns. This study assessed the impact of one such service in a cohort of newborns treated with therapeutic hypothermia. METHODS: Our newborn neuro-intensive care service was started in November 2012. From January 2008 to October 2016, a cohort of 158 newborns was treated with therapeutic hypothermia, 29 before and 129 after the inception of the service. This study compared the outcomes of newborns treated by the service with those of newborns treated before. Multivariate regression analysis associating length-of-stay and treatment pre- or post-service was adjusted for five-minute Apgar score, time-to-target temperature, seizures, and mortality. RESULTS: The neuro-intensive care service was also associated with a decrease in mortality (17% before service to 5.4% with the service, p = 0.03), though this association is likely multifactorial and reflects the application of therapeutic hypothermia to a wider variety of patients. However, the service was independently associated with decreased length-of-stay (mean 22 pre-service to 13 days with the service, p < 0.0005.)CONCLUSIONS:The service educated referring hospitals in recognizing therapeutic hypothermia candidates, which increased the number of treated newborns, and created a number of procedures to streamline the delivery of treatment. While the increasing number and variety of patients treated could spuriously reduce length-of-stay, length-of-stay was still significantly reduced after adjustment, providing evidence that neuro-intensive care services for newborns can improve hospital outcomes.

Early prediction of a significant patent ductus arteriosus in infants <32 weeks gestational age.

BACKGROUND: The optimal thresholds for identification of preterm infants at greatest risk for adverse sequelae related to patent ductus arteriosus have not been well delineated. Our aim was to determine hemodynamic parameters in the first 24 hours using continuous non-invasive vital and structural measurements to predict which infants required PDA treatment in our institution. METHODS: Retrospective secondary analysis of data from infants born 23 to 32 weeks gestational age with cardiac output and stroke volume via electrical cardiometry, cerebral tissue oximetry measurements, mean arterial blood pressure (BP), heart rate, and oxygen saturation and functional echocardiography results at 12 hours of life were recorded when available (93 percent of subjects). RESULTS: A total of 292 infants, of which 55 (26±2 weeks, 862±268 grams) were treated for PDA. Treated infants demonstrated increased left ventricular output (p < 0.001) and lower mean BP (p = 0.010). The optimal area under the receiver operating characteristic curve (AUC) for predicting PDA treatment in our all gestations cohort is a mean BP at 15 hours of life of <33 mm Hg (AUC = 0.854, p < 0.001, 95% CI 0.792, 0.916). For infants <28 weeks a mean BP at 13 hours of life of <33 mm Hg (AUC = 0.741, p < 0.050, 95% CI 0.642, 0.839). CONCLUSIONS: In our cohort increased left ventricular output and lower mean BP predicted a clinically significant PDA requiring treatment.

Hemodynamic effects of sodium bicarbonate administration.

OBJECTIVE: To describe the hemodynamic changes that occur with sodium bicarbonate (NaHCO3) administration in premature neonates. STUDY DESIGN: This retrospective study included premature neonates 23 to 31+6 weeks of gestational age who underwent continuous cardiac and cerebral monitoring as participants in prospective trials at our institution, and who received NaHCO3 infused over 30 min in the first 24 h of life. Blood pressure (BP), heart rate, cardiac output (CO), SpO2 and cerebral oximetry (StO2) were captured every 2 s. A baseline was established for all continuous data and averaged over the 10 min before NaHCO3 administration. Baseline was compared with measurements over 10 min epochs until 80 min after administration. Arterial blood gases before and within 1 h of administration were also compared. Significance was set at P<0.05. RESULTS: A total of 36 subjects received NaHCO3 (1.3±0.3 mEq kg-1) in the first 24 h (14±8.5 h) of life. NaHCO3 administration increased pH (7.23 vs 7.28, P<0.01) and decreased base deficit (-8.9 vs -6.8, P<0.01) and PaCO2 (45 vs 43 mm Hg, P<0.05). There was a transient but significant (P<0.05) decrease in systemic BP coinciding with an increase in cerebral oxygenation without an increase in oxygen extraction. CO did not change. CONCLUSION: Early postnatal NaHCO3 administration does not acutely improve CO but does cause transient fluctuations in cerebral and cardiovascular hemodynamics in extremely premature infants.

Prospective study of infantile haemangiomas: incidence, clinical characteristics and association with placental anomalies.

BACKGROUND: The aetiology and exact incidence of infantile haemangiomas (IHs) are unknown. Prior studies have noted immunohistochemical and biological characteristics shared by IHs and placental tissue. OBJECTIVES: We investigated the possible association between placental anomalies and the development of IHs, as well as the demographic characteristics and other risk factors for IHs. PATIENTS AND METHODS: Pregnant women (n = 578) were prospectively enrolled and their offspring followed for 9 months. Placental evaluations were performed and demographic data collected on all mother-infant pairs. RESULTS: We evaluated 594 infants: 34 haemangiomas [either IH or congenital (CH)] were identified in 29 infants, yielding an incidence of 4·5% for IH (27 infants) and 0·3% for CH (two infants). Placental anomalies were noted in almost 35% of haemangioma-related pregnancies, approximately twice the incidence noted in pregnancies with unaffected infants (P = 0·025). Other risk factors for IH included prematurity (P = 0·016) and low birth weight (P = 0·028). All IHs were present by 3 months of age, and cessation of growth had occurred in all by 9 months of age. Most occurred on the trunk. Of note, 20% of identified IHs were abortive or telangiectatic in nature, small focal lesions that did not proliferate beyond 3 months of age. Only one IH required intervention. CONCLUSIONS: This is the first prospective American study to document the incidence of IHs in infants followed from birth to early infancy. The association with placental anomalies was statistically significant. The overall incidence mirrors prior estimates, but the need for treatment was lower than previously reported.

Placental cord insertion visualization with prenatal ultrasonography.

Color Doppler and gray scale sonography can be used prenatally to identify the location of the cord insertion into the placenta. The purposes of this paper were to (1) relate sonographic identification of placental cord insertion with placental pathology; (2) evaluate the possibility that a marginal cord insertion may evolve into a velamentous cord insertion; and (3) determine the frequency and factors affecting sonographic visualization of cord insertion. Our results show that the sonographic assessment of cord insertion correlated with the pathologic outcome in 83% (106 of 128) of singleton pregnancies and at least one of the fetuses in 72% (8 of 11) of twin or triplet pregnancies. Although the sensitivity for identification of an abnormal cord insertion was low (42%), the specificity was high (95%). Our data suggest that marginal cord insertion evolved into velamentous cord insertion in one singleton and one twin. Our results showed that cord insertion was visualized in 54% of fetuses scanned in a routine clinical practice. Cord insertion visualization was possible at all gestational ages, although it was more difficult at later gestational ages. In conclusion, this study provides evidence that (1) ultrasonography (either gray scale or color Doppler) is useful in identifying normal, marginal, and velamentous cord insertion; (2) marginal cord insertion may evolve into velamentous cord insertion as pregnancy progresses; (3) in clinical practice the cord insertion site was visualized in just over half of the cases, and (4) prenatal identification of marginal and velamentous cord insertion potentially may be useful for planning obstetrical management.

Pre-cesarean blood bank orders: a safe and less expensive approach.

OBJECTIVES: To 1) characterize pre-cesarean blood bank testing, 2) describe the transfusion experience in a large series of cesarean patients, and 3) evaluate safety and cost implications of a "hold clot" order for patients at low risk for transfusion. METHODS: A review of 1111 consecutive cesarean patients used computerized perinatal and blood bank data bases and a detailed chart review of all cross-matched patients. Information collected included indications for cesarean and transfusion, etiology of hemorrhage, transfusion number and type, admission and lowest hemoglobin level, and information regarding the events leading to transfusion. A blinded review of the cross-matched patient's information assessed whether a cross-match was appropriate or could have been replaced safely by a "hold clot" (current clot tube in blood bank) order. RESULTS: Nineteen patients (1.7%) were transfused. The only patients requiring a transfusion were diagnosed with placenta previa, placenta accreta, anemia, preeclampsia/hemolysis, elevated liver enzymes, low platelets (HELLP syndrome), or hemorrhage. A comparison of two blood banking approaches (routine pre-cesarean type and screen testing versus a "hold clot" order for cesarean patients at low risk for transfusion) indicated that the latter would reduce costs by $45 per cesarean, or $95,000 annually. CONCLUSIONS: The incidence of transfusion was low (1.7%) and associated with specific diagnoses (previa, accreta, anemia, preeclampsia/HELLP, or hemorrhage). The data support the replacement of pre-cesarean type and screen testing with a "hold clot" order for patients at low risk for transfusion with negative prenatal antibody screen. This approach is safe and would reduce cost substantially.