Annie J. Rohan

“Proactive” Management of Percutaneously Inserted Central Catheters Results in Decreased Incidence of Infection in the ELBW Population

OBJECTIVE: Extremely low birth weight (ELBW) infants often acquire catheter-related infections (CRIs) when a percutaneously inserted central catheter (PICC) is used for parenteral nutrition or drug administration. Our objective was to compare the incidence of CRIs after we established a “PICC Maintenance Team” for the proactive management — compared to expectant management — of these lines.STUDY DESIGN: We did a prospective collection and analysis of catheter-related sepsis data over a 15-month period from February 1, 1998 through May 1, 1999. Eligible patients included all neonates weighing <1000 g at birth.RESULTS: There was a significantly decreased incidence of CRIs, to a rate of 7.1%, or 5.1/1000 catheter days (p<0.05).CONCLUSION: “Proactive” management of PICC, significantly reduced the incidence of CRIs. The reduction in infection rate is estimated to save 180 hospitalized patient days/100 very low birth weight neonates, with a concomitant savings in morbidity and medical expense.

Oral feeding readiness assessment in premature infants.

AbstractOral feeding readiness is a complex concept. More evidence is needed on how to approach beginning oral feedings in premature hospitalized infants. This article provides a review of literature related to oral feeding readiness in the premature infant and strategies for promoting safe and efficient progression to full oral intake. Oral feeding readiness assessment tools, clinical pathways, and feeding advancement protocols have been developed to assist with oral feeding initiation and progression. Recognition and support of oral feeding readiness may decrease length of hospital stay and have a positive impact on reducing healthcare costs. Supporting effective cue-based oral feeding through use of rigorous assessment or evidence-based care guidelines can also optimize the hospital experience for infants and caregivers, which, in turn, can promote attachment and parent satisfaction.

The utility of pain scores obtained during ‘regular reassessment process’ in premature infants in the NICU

Objective:To examine the association of pain assessment scores achieved through regular reassessment practice, as required by the Joint Commission (JC), with painful events and the use of analgesics in premature, ventilated infants.Study Design:A cross-sectional study was performed in two tertiary level neonatal intensive care units. Pain was assessed at regular intervals at each center using validated multidimensional instruments in accordance with the JC standards.Result:Sample comprised 196 ventilated premature infant patient-days. Overall, 2% of scores suggested the presence of pain, and 0.1% of pain scores were associated with analgesia. Ventilated infants who were exposed to multiple pain-associated procedures in a day never demonstrated pain score elevations despite infrequent preemptive or continuous analgesic administration.Conclusion:Pain assessment scores achieved using regular reassessment processes were poorly correlated with exposure to pain-associated procedures or conditions. Low pain scores achieved through regular reassessment may not correlate to low pain exposure. Resources that are expended on regular reassessment processes may need to be reconsidered in light of the low yield for clinical alterations in care in this setting.

Hypoxia in the term newborn: part one-cardiopulmonary physiology and assessment.

In this first of a three-part series on hypoxia in the term newborn, the emphasis is on cardiopulmonary adaptation of the newborn. This article includes definitions and features of neonatal hypoxia and reviews structural abnormalities of the heart and great vessels, along with pulmonary hypertension. During the transitional phase from intrauterine to extrauterine life, newborn infants require close monitoring in order to recognize and address abnormalities in adaptation. The evaluation of the hypoxic infant is one of the most common problems for the pediatric clinician; although there are several common causes for newborn cyanosis, myriad disorders spanning all organ systems exist as possibilities etiologies. Knowledge of the breadth of feasible diagnoses and a systematic approach to the assessment of these term newborns are essential for accurate diagnosis, treatment, and referral.

Hypoxia in the term newborn: part three--sepsis and hypotension, neurologic, metabolic and hematologic disorders.

Causes of hypoxia and cyanosis in the term newborn can be found within all physiologic systems and take the form of hundreds of specific diagnoses. In the first and second parts of this series, a wide range of cardiac and pulmonary causes for newborn hypoxia and cyanosis have been examined. Because they are familiar, cardiac and pulmonary diagnoses often represent our reactionary opinions—the options that we first entertain even before a proper systematic approach to the infant has been taken. In this final of a three part series, neurologic, hematologic and metabolic disorders are explored as a cause for abnormal oxygenation, as well as sepsis and hypotension. It is within these final categories that we find many of the obscure possibilities for neonatal hypoxia—the diagnoses that often require rigorous testing, or more sophisticated laboratory interpretation. Without consideration of these elusive entities, however, appropriate treatment and referral will be unnecessarily delayed.

Pain-associated stressor exposure and neuroendocrine values for premature infants in neonatal intensive care.

Recurrent stress during neonatal intensive care taxes the adaptive capacity of the premature infant and may be a risk factor for suboptimal developmental outcomes. This research used a descriptive, cross-sectional design and a life course perspective to examine the relationship between resting adrenocorticoid values at 37 postmenstrual weeks of age and cumulative pain-associated stressor exposure in prematurely born infants. Subjects were 59 infants born at under 35 completed weeks of gestation, who were at least 2 weeks of age, and who had been cared for in the NICU since birth. No significant relationships were identified between cortisol values and any of the study variables (number of skin breaking procedures, hours of assisted ventilation, gestational age at birth, exposure to antenatal steroids, history of severe academia, birthweight, days of age to attain birthweight, weight at testing, days of age at testing, recent pain-associated procedures, and 17-OHP value). A significant negative correlation (Spearman rank, one-tailed) between the number of skin-breaking procedures and 17-OHP values was identified (r = -.232, p = .039). Recurrent pain-associated stressor exposure may be a more important factor in explaining the variance of 17-OHP values at 37 postmenstrual weeks of age than birthweight, gestational age, or chronological age.

Concussion evaluation and management in pediatrics.

Concussions are among the most complex injuries to assess and manage in sports medicine and primary care. Sports concussion in youth has received much attention in recent years because research shows that improperly managed concussion can lead to long-term cognitive deficits and mental health problems. There are several notable risk factors affecting the incidence and severity of concussion in school-age children and adolescents, including a history of a previous concussion. A more conservative approach for return to activities following concussion has been proposed for children and adolescents. Programs of individualized, stepwise increases in physical activity have largely replaced use of algorithms for assigning a grade and activity expectations to concussions. Although validity and reliability testing is ongoing to support use of concussion assessment instruments in pediatric patients, it is practical and appropriate that clinicians incorporate symptom checklists, sideline and balance assessment tools, and neurocognitive assessment instruments into their practice in accordance with evidence-based guidelines.

Identifying and assessing the substance-exposed infant.

AbstractAs the rate of opioid prescription grows, so does fetal exposure to opioids during pregnancy. With increasing fetal exposure to both prescription and nonprescription drugs, there has been a concurrent increase in identification of Neonatal Withdrawal Syndrome (NWS) and adaptation difficulties after birth. In addition, extended use of opioids, barbiturates, and benzodiazepines in neonatal intensive care has resulted in iatrogenic withdrawal syndromes. There is a lack of evidence to support the use of any one specific evaluation strategy to identify NWS. Clinicians caring for infants must use a multimethod approach to diagnosis, including interview and toxicology screening. Signs of NWS are widely variable, and reflect dysfunction in autonomic regulation, state control, and sensory and motor functioning. Several assessment tools have been developed for assessing severity of withdrawal in term neonates. These tools assist in determining need and duration of pharmacologic therapy and help in titration of these therapies. Considerable variability exists in the pharmacologic and nonpharmacologic approaches to affected babies across settings. An evidence-based protocol for identification, evaluation, and management of NWS should be in place in every nursery. This article provides an overview of identification and assessment considerations for providers who care for babies at risk for or who are experiencing alterations in state, behavior, and responses after prenatal or iatrogenic exposure to agents associated with the spectrum of withdrawal.

Prenatal Toxicology Screening for Substance Abuse in Research: Codes and Consequences

Prenatal substance abuse has long been identified as a risk factor for the developing fetus, and implicated in pediatric cognitive, neuropsychological and physiologic problems. Conservative estimates suggest that prenatal substance abuse affects hundreds of thousands of pregnancies annually and is associated with developmental delays, learning disabilities, social disturbances and lifelong health issues for the child. Prenatally substance-exposed children experience higher levels of child abuse and neglect, are more likely to need foster parenting, and have higher rates of subsequent substance abuse than non-exposed children (1, 2). The scientific necessity to screen for substance abuse in research participants raises ethical issues when illicit drug use is uncovered. The impact of legislative policies restricting maternal rights in the setting of substance abuse needs to be considered by researchers as potentially intruding into confidential relationships between research participants and investigators. Moreover, the legal implications for substance-abusing pregnant research subjects may not surprisingly act as a deterrent to their participation in research studies altogether. By its nature, research with pregnant women involves the protection of two research participants. Even observational studies in pregnancy require extra scrutiny by the IRB, with adherence to special requirements mandated for vulnerable populations. Complicated by ongoing contentious debate over maternal and fetal rights, the resolution of research dilemmas in pregnancy is often not ideal. It is important for those involved in perinatal research to be familiar not only with current controversies about the consequences of perinatal substance abuse for both mother and child, but also with policies guiding ethical obligation of the provider under these circumstances, and pertinent legislation directing provider action in certain cases.

Hypoxia in the term newborn: part two-primary pulmonary disease, obstruction, and extrinsic compression.

Pediatric care providers are repeatedly called upon to evaluate a cyanotic newborn in the labor and delivery suite, or in the well-baby nursery. A myriad of disorders spanning all-organ systems exist as possibilities for each of these problems, although several causes for newborn cyanosis are particularly common. In this second of a three-part series, primary pulmonary disease, airway obstruction, and extrinsic compression of the lungs as causes for newborn hypoxia are explored. It is in this group of disorders that we find the answers for the greatest number of these cyanotic dilemmas. Knowledge of the breadth of diagnoses, and respect for the variety of clinical possibilities, is the first step in providing a patient with accurate diagnosis, treatment, and referral.