Dennis C. Stevens

An Analysis of Tolazoline Therapy in the Critically-Ill Neonate

There were 47 seriously-ill neonates with medical causes of respiratory distress and 10 infants with severe respiratory distress secondary to a congenital diaphragmatic hernia treated with tolazoline according to a strict protocol designed to manage persistent fetal circulation (PFC). Of the 47 infants, 28 (60%) had a positive response defined as an increase in the pO2 greater than or equal to 24 mm Hg within 4 hr of beginning the drug. Of 7 infants, 4 with congenital diaphragmatic hernia had a positive response. The mean increase in the pO2 for the 47 infants was statistically significant (p less than .05). Of the 47 infants with medical disorders, 27 survived (survival 57%), whereas only 2 of the 10 infants with congenital diaphragmatic hernia and severe persistent fetal circulation survived (survival 28%). Erythema (60%), hematest positive gastric aspirates (55%), thrombocytopenia (45%), hyponatremia (40%) and increased gastric aspirates (36%) were the most common adverse effects occurring during tolazoline infusion. Hypotension occurred in nine cases, but was transient. Of the 27 survivors, 20 with medical causes of persistent fetal circulation were evaluated at age 1 yr. Eighty percent of these infants studied were considered normal as defined by an MDI and PI of the Bayley Scales of greater than or equal to 70. These data suggest that tolazoline is a useful adjunct in the management of neonates with PFC. In addition, tolazoline was more effective in mechanically ventilated neonates treated with respiratory paralytic agents. Although tolazoline resulted in a significant improvement in the paO2 in 4 infants with congenital diaphragmatic hernia, it did not appear to improve mortality in these infants.

The impact of architectural design upon the environmental sound and light exposure of neonates who require intensive care: an evaluation of the Boekelheide Neonatal Intensive Care Nursery

Objectives:To evaluate the differences in environmental sound, illumination and physiological parameters in the Boekelheide Neonatal Intensive Care Unit (BNICU), which was designed to comply with current recommendations and standards, as compared with a conventional neonatal intensive care unit (CNICU).Study Design:Prospectively designed observational study.Result:Median sound levels in the unoccupied BNICU (37.6 dBA) were lower than the CNICU (42.1 dBA, P<0.001). Median levels of minimum (6.4 vs 48.4 lux, P<0.05) and maximum illumination (357 vs 402 lux, P<0.05) were lower in the BNICU. A group of six neonates delivered at 32 weeks gestation showed significantly less periodic breathing (14 vs 21%) and awake time (17.6 vs 29.3%) in the BNICU as compared to the CNICU.Conclusion:Light and sound were both significantly reduced in the BNICU. Care in the BNICU was associated with improved physiological parameters.

Observations on the sonographic measurement of cervical length and the risk of premature birth

OBJECTIVE There is increasing evidence that sonographic measurement of cervical length may be a useful predictor of the risk of spontaneous premature birth. The purpose of this study is to determine whether the measurement of cervical length in a high-risk population at 24 weeks gestation, or the relative change over 24-28 weeks gestation, is more accurate in predicting the risk of spontaneous preterm birth before 35 weeks gestation. METHODS Over a 4-year period from 1993-1996, 443 patients with a singleton pregnancy who were at increased risk of preterm birth were studied by serial endovaginal sonography performed at 24 and 28 weeks gestation. RESULTS There was a positive association between a short cervix and increased risk of preterm birth (F = 13.3, P < .0001). The variable with the highest predictive value for preterm birth was the cervical length at 24 weeks gestation. Changes over time did not substantially improve the predictive accuracy for spontaneous preterm birth. CONCLUSIONS We conclude that a short cervix as determined by endovaginal sonography has a significant association with preterm birth in a high-risk obstetric population. Measurements taken at 24 weeks gestation are most accurate in assessing this risk, and serial observations of the cervix over time have less accuracy for predicting preterm birth.

Respiratory paralysis to improve oxygenation and mortality in large newborn infants with respiratory distress

The nonsynchronous respiratory efforts of neonates with surgically correctable disorders may inhibit effective mechanical ventilation. The records of 25 infants treated with metocurine for muscular paralysis to improve mechanical ventilation were reviewed. All patients were greater than 35 (37.6 +/- 2.1) weeks gestation and 2.27 (2.98 +/- .47) kg. All required ventilatory support with an FiO2 of 100%. The mortality rate of this group of infants was 20% as compared with 73% (p < .001) in a similar group of 26 infants managed without paralysis. In 10 of the 25 infants treated with metocurine, pre- and 1 hr postparalysis paO2 values were available. The mean paO2 prior to paralysis was 62 (45--111) mm Hg and the mean post-paralysis paO2 was 144 (75--227) mm Hg, representing at 132% increase in paO2 (p < .001). The mean dosage for metocurine was 3.5 (1.45--6.79) mg/kg/day; however, those requiring paralysis for greater than 7 days showed a dramatically increasing requirement. These preliminary data suggest that respiratory paralysis reduces right-to-left shunting, improves paO2 and decreases mortality in large infants with severe respiratory distress requiring ventilatory support.

Implementation of a Multidisciplinary Team That Includes a Registered Dietitian in a Neonatal Intensive Care Unit Improved Nutrition Outcomes

This study determined whether nutrition outcomes of neonates who were receiving neonatal intensive care were improved with the implementation of a fully functioning multidisciplinary team that included a registered dietitian. A medical record review was conducted of neonates with birth weights of 1500 g or less who were cared for in Sanford Childrens Hospital neonatal intensive care unit from January 1 to December 31, 2001 (prior to functioning multidisciplinary team establishment) and January 1 to December 31, 2004 (subsequent to establishment of a multidisciplinary team). Data from charts in the 2 time periods were examined for differences in nutrition outcomes. Outcome variables included length of stay, birth weight, discharge weight, weight gained for specified time periods, weight at full feeds, weight gain per day, length, head circumference, and number of days to start enteral feeding. Analysis of covariance, controlling for the effect of birth weight, was used to determine differences and was considered significant at P < .05. The mean length of stay (65 days, 95% confidence interval [CI]: 48-68 vs 72 days, 95% CI: 53-73) was not different for the 2 periods. The mean weight at the beginning of enteral feeding was significantly less in the period prior to the establishment of the multidisciplinary team (1099 g, 95% CI: 955-1165 vs 1164 g, 95% CI: 1067-1211, respectively). Weight at discharge, total weight gained, total daily weight gained, daily weight gain from birth to the initiation of enteral feeds, daily weight gain from birth to full feeds, and head circumference growth were significantly greater for neonates in the postgroup than in the pre-multidisciplinary team group. Implementation of a multidisciplinary team that included a registered dietitian improved the nutrition outcomes of low birth weight infants in a neonatal intensive care unit.

Respiratory distress following elective repeat cesarean section

The clinical course and chest radiographs of 47 infants with respiratory distress after elective cesarean section were reviewed. The mean difference between the gestational age determined prenatally and that postnatally was 2.6 +/- 1.6 weeks. However, 14 of the infants were delivered at term. All 47 infants required more than 40% oxygen, and 18 infants required a respirator. Fifteen infants developed a pneumothorax; one, a pneumopericardium; one, bronchopulmonary dysplasia; and one infant died. Chest radiographs and the clinical course were consistent with hyaline membrane disease in 17 patients; respiratory distress syndrome type II in 24; and in three the radiographic findings were normal. These data suggest that some of the respiratory morbidity subsequent to elective repeat cesarean section is not secondary to iatrogenic delivery of a premature infant, and that much of it is not due to hyaline membrane disease. These data emphasize that respiratory distress in an infant delivered by elective cesarean section does not necessarily suggest poor prenatal care in regard to the timing of delivery.

A Comprehensive Comparison of Open-Bay and Single-Family-Room Neonatal Intensive Care Units at Sanford Children's Hospital.

Objective: This paper summarizes the results of a comprehensive comparison of open-bay (OPBY) and single-family-room (SFR) neonatal intensive care unit (NICU) designs. Background: The NICU expanded from 7000 ft2 in two large rooms to 27,000 ft2 with 45 individual family spaces. Results: Sound measurements indicated a significant reduction in the unoccupied SFR to less than half of the levels in the OPBY NICU. However, respiratory support equipment generated levels well above those of the ambient environment. Illumination was significantly reduced in the SFR. Ambient illumination in nursing work areas was less than recommended. In other comparisons with the OPBY NICU the SFR NICU was shown to have: a shorter interval until full enteric feedings were established; improved parent satisfaction; improved staff perceptions of the environment and care; a decrease in nurses State-Trait Anxiety scores; an increased need for total numbers of staff and nursing staff per shift; increased walking per shift by nurses and nurse practitioners; and improved sleep time in a very small sample of patients. Analysis of the cost of construction showed comparable cost per ft2; however, the cost per bed in the SFR NICU was much greater because of the increased area of this facility. Highly notable findings of this investigation included the same incidence of adverse outcomes of care and a reduction in the adjusted direct cost of care in the SFR NICU. Conclusion: These data overwhelmingly support the SFR NICU in preference to the traditional OPBY facility. They substantiate that the SFR NICU should be the new standard for NICU care.

Supraventricular tachycardia with edema, ascites, and hydrops in fetal sheep

Continuous supraventricular tachycardia was induced in 13 fetal sheep for 72 to 216 hours. The PaO2 decreased from 18.1 +/- 1.2 (SEM) to 15.4 +/- 0.9 mm Hg and the PaCO2 increased from 41.5 +/- 1.2 (SEM) to 46.0 +/- 1.0 (SEM) mm Hg with pacing. The hematocrit, total protein, albumin, serum [Na+] and [K+], and osmolality remained unchanged throughout the study. All study fetuses showed signs of ascites (mean = 88 +/- 67.5 [SD] ml), and one was grossly hydropic. Six fetuses, all of which had greater than or equal to 50 ml of ascites, died as the results of pacing. Gross pathologic findings in 13 fetuses included: cardiomegaly in seven, cyanotic myocardium in two, hepatomegaly in seven, pulmonary congestion in two, generalized edema in three, and massive edema (hydrops) in one. None of these conditions was found in the 14 control animals. There was no correlation of the severity of effects upon the fetus and the induced heart rate, the duration of tachycardia, or the site of implantation of the pacemaker. The conclusion was that organomegaly, generalized edema, and hydrops fetalis were the direct result of supraventricular tachycardia in utero; the exact mechanism of production and the reasons for the variable manifestations of tachycardia remain unclear.

A Comparison of Parent Satisfaction in an Open-Bay and Single-Family Room Neonatal Intensive Care Unit

Objective: The purpose of this research was to test the hypothesis that parental satisfaction with neonatal intensive care is greater in a single-family room facility as compared with a conventional open-bay neonatal intensive care unit (NICU). Methods: This investigation was a prospective cohort study comparing satisfaction survey results for parents who responded to a commercially available parent NICU satisfaction survey following the provision of NICU care in open-bay and single-family room facilities. A subset of 16 items indicative of family-centered care was also computed and compared for these two NICU facilities. Results: Parents whose babies received care in the single-family room facility expressed significantly improved survey responses in regard to the NICU environment, overall assessment of care, and total survey score than did parents of neonates in the open-bay facility. With the exception of the section on nursing in which scores in both facilities were high, nonsignificant improvement in median scores for the sections on delivery, physicians, discharge planning, and personal issues were noted. The total median item score for family-centered care was significantly greater in the single-family room than the open-bay facility. Conclusions: Parental satisfaction with care in the single-family room NICU was improved in comparison with the traditional open-bay NICU. The single-family room environment appears more conducive to the provision of family-centered care. Improved parental satisfaction with care and the potential for enhanced family-centered care need to be considered in decisions made regarding the configuration of NICU facilities in the future.

A comparison of the direct cost of care in an open-bay and single-family room NICU

Objective:This research examined the proposition that the direct costs of care were no different in an open-bay (OPBY) as compared with a single-family room (SFR) neonatal intensive care (NICU) environment.Study Design:This was a sequential cohort study.Result:General linear models were implemented using clinical and cost data for all neonates admitted to the two cohorts studied. Costs were adjusted to year 2007 U.S. dollars. Models were constructed for the unadjusted regression and subsequently by adding demographic variables, treatment variables, length of respiratory support and length of stay. With the exception of the last, none were found to achieve significance. The full model had R2=0.799 with P=0.0095 and predicted direct costs of care less in the SFR NICU.Conclusion:For the time, location and administrative practices in place, this study demonstrates that care can be provided in the SFR NICU at no additional cost as compared with OPBY NICU.