Daksha Patel

Effect of a Statewide Neonatal Resuscitation Training Program on Apgar Scores Among High-Risk Neonates in Illinois

Objective. The national Neonatal Resuscitation Program (NRP), started in 1987, provided training to hospital delivery room personnel to standardize knowledge and skills to reduce neonatal morbidity and mortality and increase successful resuscitation during the first few critical minutes after birth. The Apgar score continues to be used as the best established index of immediate postnatal health. The purpose of this study was to evaluate the impact of the NRP instruction in Illinois hospitals by examining Apgar scores among high-risk infants who are likely to benefit from the NRP. Methods. A retrospective 3-time period cohort design was used (before the introduction of the NRP, 1985–1988; transition when NRP training occurred, 1989–1990; and after NRP training was completed at least once for some delivery room personnel in each Illinois hospital, 1991–1995). Illinois computerized birth certificate files on a selected group of 636 429 high-risk neonates provided information on Apgar scores and maternal characteristics. The American Academy of Pediatrics provided instructor lists to determine when NRP training started and when it was fully implemented in Illinois. Illinois Department of Public Health provided data to categorize hospitals into levels based on type and intensity of neonatal services (Level I, II, II+, III). High-risk neonates were defined as meeting 1 of the following criteria: maternal age <20 years old or >35 years old, birth weight <2500 g or >4000 g, presence of a maternal medical risk factor, and no prenatal care or prenatal care started after the first trimester. Several exclusion criteria were applied including the following: birth records with missing data, multiple birth or congenital anomaly, and hospital information that indicate no birth deliveries in 1 of the 11 study years or delivery outside of a hospital. One-minute and 5-minute Apgar scores were divided into categories for analysis (0–3, 4–6, 7–10). No change or a decrease in a low (0–6) 1-minute Apgar when compared with the 5-minute Apgar was a primary measure to evaluate effect of NRP resuscitation. Variables examined included the following: race/ethnicity, maternal age, level of education, presence of maternal medical risk factor, trimester started prenatal care, complications of labor and delivery, and a low birth weight. Analysis consisted of χ2 tests, relative risk calculations, and logistic regression to reveal independent associations with no change in low 1-minute Apgar score or continued low (0–6) 5-minute Apgar. Results. A total of 636 429 high-risk birth records was selected for detailed analyses out of 2 077 533 births in Illinois between 1985 and 1995 for 193 hospitals. The number of active NRP instructors in Illinois changed dramatically during the study period; for example, 1 to 6 between 1987 and 1988 to 1096 to 1242 between 1991 and 1995. The percentage of neonates reported to have low (<7) 1-minute Apgar score decreased in 1991 to 1995 overall and for each of 4 hospital levels. Overall and by hospital level, there was a statistically significant lower proportion of high-risk newborns who showed a decrease or no change in their 5-minute Apgar scores after the NRP instruction. After adjusting for several maternal characteristics, logistic regression analysis revealed that high-risk newborns with a low 1-minute Apgar were more likely to increase their 5-minute Apgar after the NRP instruction in 1991 to 1995. Additional analyses indicated that very low birth weight and low birth weight newborns benefited the most from NRP instruction. Conclusion. Although previous research has shown that the NRP instruction improves knowledge and skill among health care personnel in the delivery room, both short-term and long-term, there has been little evidence to demonstrate NRP impact on infant morbidity. Several strategies were used in this study to control for bias and to adjust for secular trends in decreased infant morbidity during the study period. This study demonstrated sufficient support for the hypothesis that a significant improvement occurred among neonates in their Apgar score after the NRP instruction in Illinois. Empirical support is provided for the clinical effectiveness of NRP instruction.

Glucose given after hypoxic ischemia does not affect brain injury in piglets.

Background and Purpose Giving glucose before hypoxic ischemia worsens brain injury in piglets. Does giving glucose after hypoxic ischemia affect severity of injury? Methods Forty‐three 0‐ to 3‐day‐old pigs were used. All piglets received 2 U/kg insulin before injury to prevent stress‐induced hyperglycemia. Hypoxic ischemic brain damage was induced by clamping both carotid arteries and reducing arterial blood pressure to two thirds of normal by hemorrhage at time 0. At 15 minutes the fraction of inspired oxygen (Fio2) was reduced to 6%. At 30 minutes Fio2 was increased to 100%, the carotids were released, and the withdrawn blood was reinfused. The piglets were then randomized to receive either 2 mL/kg of 50% dextrose followed by 2 mL/kg per hour for 2 hours or an equal volume of saline. Results Neurological examination scores (20 is normal, 5 is brain dead, by blinded observer) at 1 day postinjury were similar in the two groups: glucose, median 15.5 (25th percentile, 12.2; 75th percentile, 18); controls, 15.6 (9.3, 18). Piglets were killed at 3 days with brain preservation at death. Pathological examination scores (sum of scores from cortex, hippocampus, and basal ganglia: 30 is normal, 3 is total necrosis) by blinded observer were similar in the two groups: glucose, 26 (18, 28); controls, 25 (16.5, 28); NS. Conclusions Although elevated glucose levels during hypoxic ischemic injury worsen brain injury in the piglet, elevated glucose levels after injury do not affect the severity of the injury. (Stroke. 1994;25:1443‐1448.)

Glucose affects the severity of hypoxic-ischemic brain injury in newborn pigs.

Background and Purpose The administration of glucose has been shown to worsen brain injury in adult animals but has no effect on the severity of injury in newborn rats. We wished to see whether the results in newborn rats could be extended to another newborn animal. Methods In 44 0- to 3-day-old piglets, hypoxic-ischemic central nervous system damage was induced by ligation of both carotid arteries and reduction of their blood pressure to two-thirds normal for one-half hour. In the last 15 minutes of this half hour, oxygen concentration was reduced to 6%. The piglets were randomized to receive either 2 mL/kg 50% dextrose in water followed by 2 mL/kg per hour for 2.5 hours beginning before ischemia or enough insulin to reduce their resting blood sugar to approximately 2 mmol/L. Results Neurological exam scores in the glucose-treated piglets at 1 day after injury were significantly worse than those in the insulin-treated group. Pathological examination scores were poorer in the glucose-treated group (13.6±1.9 [mean ± SEM]) than in the insulin-treated group (24.7 ± 1.4, P <.01). Conclusions Increasing serum glucose during hypoxic-ischemic injury to the newborn piglets brain worsens brain injury.

Desmethyl tirilazad improves neurologic function after hypoxic ischemic brain injury in piglets.

Objective: Desmethyl tirilazad is a lipid‐soluble free radical quencher. Deferoxamine reduces free radicals by chelating iron and reducing hydroxyl formation. Free radical inhibitors have shown promise in several hypoxic ischemic brain injury models, and we wished to see if this work could be extended to our newborn piglet model. Design: Randomized controlled trial. Subjects: Piglets (0 to 3 days old). Intervention: Carotid snares and arterial and venous catheters were placed under 1.5% isoflurane anesthesia. In Experiment 1, piglets were randomly assigned to receive either 3 mg/kg desmethyl tirilazad or vehicle at −15 and 90 mins. In Experiment 2, piglets were randomly assigned to receive either 20 mg/kg desmethyl tirilazad at −15 mins followed by 8 mg/kg/hr for 90 mins or 100 mg/kg deferoxamine at −15 mins or vehicle. At time 0, both carotid arteries were clamped and blood was withdrawn to reduce the blood pressure to two‐thirds normal. At 15 mins, inspired oxygen was reduced to 6%. At 30 mins, the carotid snares were released, the withdrawn blood was reinfused, and the oxygen was switched to 100%. On the third day after the hypoxic ischemic injury, the animals were killed by perfusing their brains with 10% formalin. We tested the timing of lipid peroxidation and inhibition of lipid peroxidation by these agents by freezing the brains of a subset of pigs in liquid nitrogen. Measurements: Neurologic examination and brain pathology were scored by blinded observers. Thiobarbituric acid‐reactive substance and oxidized and reduced glutathione were measured on frozen brains. Main Results: Desmethyl tirilazad (20 mg/kg) and 100 mg/kg deferoxamine inhibit lipid peroxidation. Desmethyl tirilazad (20 mg/kg) improves neurologic exam, but 3 mg/kg Desmethyl tirilazad or 100 mg/kg deferoxamine does not. Neither desmethyl tirilazad nor deferoxamine improves pathologic results. Conclusions: High‐dose desmethyl tirilazad improves neurologic function after hypoxic ischemic brain injury in the newborn piglet.

U- 74389G DOES NOT AFFECT THE SEVERITY OF HYPOXIC ISCHEMIC BRAIN INJURY IN THE PIGLET. 2243

U- 74389G DOES NOT AFFECT THE SEVERITY OF HYPOXIC ISCHEMIC BRAIN INJURY IN THE PIGLET. 2243

Critical pathway implementation reduced neonatal intensive care unit length of stay. 1405

Critical pathways are multifunctional, multidisciplinary guidelines for the care of the patients developed by collaborative efforts of nursing, medical and social work staff Gestational age specific critical pathways were developed in 1993-1994 and implemented in 1995. Neonates who were transferred out, expired or required NICU observation for one day were excluded from the study. Once per month 60 minutes long sessions were devoted to develop, implement and examine the effectiveness of the implementation by pediatric residents, attending physicians, subspecialty consultants and faculty. Duration of length of stay (LOS) was compared for NICU patients by birth weight category and unpaired one tailed students t test was performed to calculate statistical significance. A p value of <0.05 was considered significant. N equals number of neonates. Conclusion: Although implementation of critical pathway did not reveal statistical significance, it showed a trend towards reduced mean length of stay for neonates in all birth weight categories except in 1001-1500 weight category. The reduced length of stay resulted in monetary benefits. Table