David J. Annibale

Hyaline membrane disease: The role of ethnicity and maternal risk characteristics

OBJECTIVE Our objective was to explore the association between maternal ethnicity and maternal antepartum complications of pregnancy, maternal sociodemographic factors, and newborn characteristics with the incidence of hyaline membrane disease. STUDY DESIGN By using a retrospective cohort analysis the incidence of hyaline membrane disease was determined for 2295 preterm infants. The study population consisted of all live, inborn infants delivered vaginally from 1982 to 1987. Statistical differences were assessed by use of chi 2 and Students t tests. A logistic regression procedure determined the relationship of ethnicity and hyaline membrane disease after the study was controlled for all other significant population differences. RESULTS The differences between black and white populations in marital status, were statistically significant years of education, prolonged rupture of membranes, anemia, and chronic hypertension were statistically significant. Infants of black mothers were diagnosed with hyaline membrane disease less often than infants of white mothers (overall and at each gestational age interval). After the study was controlled for population differences, infants of black mothers were still found to experience hyaline membrane disease less often. CONCLUSION These data suggest that hyaline membrane disease occurs less frequently, is less severe, and is accompanied by fewer related complications in black preterm infants.

Randomized, controlled trial of nasopharyngeal continuous positive airway pressure in the extubation of very low birth weight infants

We conducted a prospective, randomized controlled trial to determine whether extubation of very low birth weight infants was facilitated by the use of nasopharyngeal continuous positive airway pressure (CPAP). Eligible infants included patients weighing 600 to 1500 gm at birth who required tracheal intubation within 48 hours of birth and who met specific predetermined criteria for extubation by day 14 of life. We also sought to determine whether varying the duration of nasopharyngeal CPAP influenced the likelihood of successful extubation. Infants underwent random assignment to receive nasopharyngeal CPAP until resolution of lung disease (n = 40), 6 hours of nasopharyngeal CPAP (n = 42), or oxygen supplementation delivered by hood (n = 42). Extubation failure was predefined as a requirement for > or = 80% oxygen, pH < or = 7.20, severe apnea, or predefined clinical deterioration, and extubation success was predefined as the ability to remain free of a requirement for mechanical ventilation for 7 days and a 66% reduction in the need for supplemental oxygen. Each group was similar with regard to race, sex, and birth weight. Extubation was successful in 62%, 61%, and 60% of infants. After stratification by birth weight, there were no significant differences in the rates of successful extubation among the treatment groups. We conclude that nasopharyngeal CPAP does not improve the likelihood of successful extubation of very low birth weight infants who are ready for extubation within the first 2 weeks of life.

Predicting Extubation Outcome in Preterm Newborns: A Comparison of Neural Networks with Clinical Expertise and Statistical Modeling

Even though ventilator technology and monitoring of premature infants has improved immensely over the past decades, there are still no standards for weaning and determining optimal extubation time for those infants. Approximately 30% of intubated preterm infants will fail attempted extubation, requiring reintubation and resuming of mechanical ventilation. A machine-learning approach using artificial neural networks (ANNs) to aid in extubation decision making is hereby proposed. Using expert opinion, 51 variables were identified as being relevant for the decision of whether to extubate an infant who is on mechanical ventilation. The data on 183 premature infants, born between 1999 and 2002, were collected by review of medical charts. The ANN extubation model was compared with alternative statistical modeling using multivariate logistic regression and also with the clinicians own predictive insight using sensitivity analysis and receiver operating characteristic curves. The optimal ANN model used 13 parameters and achieved an area under the receiver operating characteristic curve of 0.87 (out-of-sample validation), comparing favorably with multivariate logistic regression. It also compared well with the clinicians expertise, which raises the possibility of being useful as an automated alert tool. Because an ANN learns directly from previous data obtained in the institution where it is to be used, this makes it particularly amenable for application to evidence-based medicine. Given the variety of practices and equipment being used in different hospitals, this may be particularly relevant in the context of caring for preterm newborns who are on mechanical ventilation.

Use of Recombinant Factor VIIa in Infants with Severe Coagulopathy

The risk of hemorrhage in infants with severe coagulopathies unresponsive to fresh frozen plasma (FFP) infusions may preclude therapeutic invasive interventional procedures. We describe the successful use of recombinant factor VIIa (rFVIIa) in two such infants, the first with cirrhosis requiring paracentesis and the second with necrotizing enterocolitis requiring laparotomy. This report reviews the current concepts on the mechanism of action of the drug rFVIIa and considers its expanded use in infants unresponsive to FFP replacement.

Early Discharge With Home Antibiotic Therapy in the Treatment of Neonatal Infection

OBJECTIVE:To determine the feasibility and cost of home antibiotic therapy for a select group of neonates.METHODS:A cohort of neonates at a university hospital who met criteria for home antibiotic therapy at discharge were prospectively followed (November 1995 to October 1997) for type and duration of antibiotic therapy as well as for hospital readmission.RESULTS:During the study period, 95 infants diagnosed with sepsis, presumed sepsis, pneumonia, or uncomplicated meningitis (having received >10 days of in-hospital therapy) met prior, established, criteria for home antibiotic therapy. The mean ± SD birth weight of the cohort was 3160 ± 526 gm, with a mean gestational age of 38.4 ± 2.1 weeks. A total of 59 infants (62%) received antimicrobial therapy for a clinical presentation consistent with sepsis or presumed sepsis, and 24 infants (25%) were treated for pneumonia. Ampicillin and gentamicin were prescribed for 56% of the cohort, and ceftriaxone was prescribed for 21% of the cohort. Four of those infants were switched from intravascular ampicillin/gentamicin therapy to intramuscular ceftriaxone after discharge due to loss of intravascular access. With a bilirubin level of >8, four additional infants were changed from ceftriaxone back to ampicillin and gentamicin to complete coverage. The mean age at discharge was 5.2 days, with a mean hospitalization cost of

Antibiotic timing in neonates with suspected hospital-acquired infections.

6121 for that period. There were no rehospitalizations or emergency department visits secondary to a worsening clinical course.CONCLUSION: In this cohort of neonates who met early discharge and defined home antibiotic therapy criteria, there were no serious complications or treatment failures reported; in addition, there were fewer costs compared with continued inpatient treatment.

NICU Bedside Caregivers Sustain Process Improvement and Decrease Incidence of Bronchopulmonary Dysplasia in Infants 30 Weeks Gestation

There exists general agreement within neonatology that antibiotics should be administered promptly to neonates with possible bacterial sepsis and meningitis. We initiated a series of quality improvement cycles designed to reduce delays in the initiation of antibiotic therapy to less than 2 hours when hospital-acquired infection (HAI) was suspected. All infants in this study were in neonatal intensive care (level II or III) who were started on antibiotics for a suspected HAI (defined as an infection that occurred 72 hours after admission to the NICU) were audited. Through a series of quality improvement cycles, we analyzed sources of delays in the initiation of antibiotic therapy from the time the order was written through administration. In subsequent cycles, we intervened to reduce delays through education, standardize the evaluation process, and develop an online ordering system that streamlined the workflow patterns in the nurseries and pharmacy. Using a prospective cohort design, we compared antibiotic delivery times after each process improvement cycle. Antibiotic delivery time was reduced from a median of 137.5 minutes to 75 minutes and variation of practice was reduced in terms of standard deviation and range (P < .001). The use of computerized physician order entry significantly improved the writing of STAT orders (P < .0001). A systematic analysis of workflow patterns and efficiencies, coupled with improvement cycles targeting delays and development of a computerized physician order entry system, allowed us to improve antibiotic delivery time in neonates with suspected HAI in an intensive care nursery system.

A new method for group decision making and its application in medical trainee selection.

BACKGROUND: The objective of this study was to investigate whether a respiratory care bundle, implemented through participation in the Vermont Oxford Network-sponsored Neonatal Intensive Care Quality Improvement Collaborative (NIC/Q 2005) and primarily dependent on bedside caregivers, resulted in sustained decrease in the incidence of bronchopulmonary dysplasia (BPD) in infants < 30 wk gestation. METHODS: A retrospective cohort study was conducted. Infants inborn between 23 wk and 29 wk + 6 d of gestation were included. Patients with congenital heart disease, significant congenital or lung anomalies, or death before intubation were excluded. Four time periods (T1–T4) were identified: T1: September 1, 2002 to August 31, 2004; T2: September 1, 2004 to August 31, 2006; T3: September 1, 2006 to August 31, 2008; T4: September 1, 2008 to August 31, 2010. RESULTS: A total of 1,050 infants were included in the study. BPD decreased significantly in T3 post-implementation of the respiratory bundle compared with T1 (29.9% vs 51.2%, respectively; adjusted odds ratio [aOR] = 0.06 [95% CI 0.03–0.13], P = < .001). The decrease was not sustained into T4. There was a significant increase in the rate of BPD-free survival to discharge in T3 compared with T1 (53.1% vs 47%; aOR = 1.68 [95% CI 1.11–2.56], P = .01) that was also not sustained. The rate of infants requiring O2 at 28 d of life decreased significantly in T3 versus T1 (40.3% vs 69.9%, respectively; aOR = 0.12 [95% CI 0.07–0.20], P = < .001). Increases in the rate of surfactant administration by 1 h of life and rate of caffeine use were observed in T4 versus T1, respectively. There was a significant decrease in median ventilator days and a significant increase in the median number of noninvasive CPAP days throughout the study period. CONCLUSIONS: In this study, implementation of a respiratory bundle managed primarily by nurses and respiratory therapists was successful in increasing the use of less invasive respiratory support in a consistent manner among very low birthweight infants at a single institution. However, this study and others have failed to show sustained improvement in the incidence of BPD despite sustained process change.

Prospective, controlled study of an intervention to reduce errors in neonatal antibiotic orders

The problems associated with generating a collaborative ranked preference list represent a common source of dilemma in academic medicine and medical education. Such issues present during the process of choosing among applicants to medical schools, during the selection of postgraduate trainees, and in the course of performance assessments and the prioritising of financial expenditures. Currently, most institutions use pseudo‐quantitative methods, such as the averaging of scores awarded on an arbitrary scale. These methods are mathematically problematic and may not accurately reflect group opinion.

The Weight-Specific Benefits of Assist-Control, Flow-Synchronized (AC/FS) Ventilation Compared to Intermittant Mandatory Ventilation (IMV) in VLBW Neonates † 1083

Objective:To evaluate the effectiveness of an interactive computerized order set with decision support (ICOS-DS) in preventing medication errors in neonatal late-onset sepsis (LOS).Study Design:Prospective, controlled comparison of error rates in antibiotic orders for neonates admitted to the Medical University of South Carolina neonatal intensive care unit with suspected LOS (after postnatal day of life 3) prior to (n=153) and after (n=146) implementation of the ICOS-DS. Antibiotic orders were independently evaluated by two pharmacists for prescribing errors, potential errors and omissions. Prescribing errors included>10% overdoses or underdoses, inappropriate route, schedule or antibiotic, drug–drug or drug–disease interactions, and incorrect patient demographics. Potential errors included misspelled drugs, leading decimals, trailing zeroes, impractical doses and error-prone abbreviations. Multiple errors and omissions in an order were counted individually.Results:Overall error rate per order decreased from 1.7 to 0.8 (P<0.001) and potential error rate from 1.0 to 0.06 (P<0.001). The reduction in omission error rate per order from 0.2 to 0.1 was not significant (P=0.17). The prescribing error rate per order increased from 0.4 to 0.7 (P=0.03) because of the use of incorrect patient weights (P<0.001). Renal dysfunction was significantly associated with an increased risk of prescribing errors (odds ratio=3.7, P=0.01) which was not significantly different for handwritten versus ICOS-DS orders (P=0.15).Conclusions:The ICOS-DS significantly improved the quality of neonatal LOS antibiotic orders although the use of incorrect patient weights was increased. In both groups, orders for patients with renal dysfunction were at risk for prescribing errors. Further evaluation of interventions to promote medication safety for this population is needed.