Jonathan M. Whitfield

Medical Futility in the Neonatal Intensive Care Unit: Hope for a Resolution

Contemporary medical practice in the NICU sometimes leads to conflicts between providers and parents in which the parent demands continuation of life-sustaining treatment that the medical team deems medically inappropriate or futile. Such conflicts can be difficult to resolve and trying for all parties. Here we describe a conflict involving a 25-week-gestation, 825-g newborn with multiple intractable medical problems and resolution of the conflict through ethics consultation under provisions of the Texas Advance Directives Act. The process established under Texas law sets conceptual and temporal boundaries around the problem of medical futility and provides a legal safe harbor for physicians who seek to withdraw life-sustaining treatments in the setting of medical futility, allowing resolution of such conflicts in a timely and effective manner. As such, it may provide a model for physicians in other states to follow.

Prevention of meconium aspiration syndrome: an update and the Baylor experience.

The approach to preventing meconium aspiration syndrome (MAS) in the newborn has changed markedly over the last 30 years. In the late 1970s, all infants born through meconium-stained amniotic fluid (MSAf) had upper-airway suctioning before delivery of the shoulders and then had tracheal intubation and suctioning in the delivery room. Now suctioning of the upper airway is no longer recommended, and only “depressed” infants are intubated for tracheal suctioning. The incidence of MAS and the associated high mortality rate have both declined significantly over time. This is due to improved antepartum and intrapartum obstetrical management as well as the postdelivery resuscitation of the neonate born through MSAf. MAS is no longer considered to be solely a postnatal disorder that is preventable with routine delivery room suctioning of the trachea; rather, it is considered a complex and multifactorial disorder with antenatal as well as intrapartum factors. The incidence and severity of MAS have been positively affected by a combined obstetrical and neonatal approach to the infant born through MSAf. In this article, we detail our experience at Baylor University Medical Center with MAS and its prevention and review the current literature.

Insulin Infusions in Extremely Low Birth Weight Infants

To the Editor. We read with interest the article by Fuloria et al on insulin infusions in extremely low birth weight (ELBW) infants.1The authors concluded that priming the tubing with a higher concentration of insulin (5 U/mL) before the initiation of a standard insulin infusion therapy should accelerate the achievement of steady-state insulin delivery and correction of hyperglycemia in ELBW.1 This approach would require two insulin concentrations for the routine preparation of these infusions. In our view, this increases the likelihood of errors, especially during shifts when less experienced personnel are present in the NICU. To combat this problem and minimize the loss of insulin in the infusion system, we have, until recently, added serum albumin to the insulin infusion solutions. However, shortages and costs of albumin have led us to retrospectively compare the effectiveness of insulin infusions in ELBW infants with and without albumin. The albumin insulin solutions had 10 mL of the 5% albumin added to the solution, …

In search of excellence--the Neonatal Intensive Care Quality Improvement Collaborative.

As part of its effort to improve the quality of care in the neonatal intensive care unit at Baylor University Medical Center (BUMC), the unit has participated in the Vermont Oxford Network. This network tracks outcomes and pools data, allowing comparisons and benchmarking. A group of 34 nurseries from the Vermont Oxford Network has collaborated in an innovative quality improvement initiative. This article describes this initiative, called the Neonatal Intensive Care Quality Collaborative 2000 project, and its impact on the neonatal service at BUMC. The project promotes the practice of 4 key habits: the habit for change, the habit for understanding the processes of care, the habit for collaborative learning, and the habit for using evidence-based practices of care.

Neonatal care at Baylor University Medical Center: You've come a long way, baby!

When Texas Baptist Memorial Sanitarium—the predecessor of Baylor University Medical Center (BUMC)—was chartered in 1903, the notion of successfully treating premature infants must have seemed like an impossible dream. Although Baylor provided pediatric services from the beginning (the first pediatrician in Texas was Hugh Leslie Moore, Baylors first chief of pediatrics), neonatology would require technological advances that would not be available until the 1960s and 1970s (1) (Figures ​(Figures11 and ​and22). Figure 1 An early infant hyperbaric pressure chamber used for delivery room resuscitation in the 1960s. It did not work! Figure 2 A modern high-frequency oscillatory ventilator with the capability of delivering very small tidal breaths at up to 900 breaths per minute. Children were among the patients at the Texas Baptist Memorial Sanitarium in the early 1900s. In 1922, the addition of a 5-story Childrens Building enhanced the provision of services in pediatrics as well as in obstetrics and gynecology (1). In 1937, obstetrical services were relocated to the new Florence Nightingale Maternity Hospital. As more women began to give birth in hospitals instead of at home, this maternity hospital became increasingly busy and was soon overcrowded. At the height of the post–World War II baby boom, the number of births at Baylor peaked at 7000 per year in a facility designed to handle about 1800 per year. In 1954, fundraising began for a new women and childrens building, which opened in 1959 and was later renamed the Karl and Esther Hoblitzelle Hospital (2). The Blanche Swanzy Lange Special Care Nursery originally opened in 1975 on the first floor of Hoblitzelle Hospital next to the labor and delivery suite. The unit was named for Blanche Swanzy Lange, wife of the chairman of the board of the Communities Foundation of Texas, which provided initial funding. The foundation continues to support the nursery each year. In 1981, 2 famous births occurred at BUMC: Laura and George W. Bush became the proud parents of twin daughters (the granddaughters of then–Vice President George Bush) (Figure ​(Figure33). Multiple births are considered high risk, so the neonatal facilities and specialists available at BUMC made it the logical choice for this special delivery. Figure 3 George W. Bush holding his newborn twin daughters, born at Baylor University Medical Center in 1981. By the 1990s, the labor and delivery area and the neonatal intensive care unit (NICU) needed to be expanded to accommodate the increasing number of high-risk deliveries (Figure ​(Figure44). The Baylor Health Care System (BHCS) Foundation spearheaded the Labor of Love Campaign, and on February 29, 1996, the expanded and remodeled NICU opened on the seventh floor of Hoblitzelle Hospital as part of the James M. and Dorothy D. Collins Women and Childrens Center. The nursery grew dramatically during the 1990s, with the number of patient days more than doubling to almost 20,000 in 2003. When the entire BHCS is considered, the current number of NICU patient days per year in neonatology is >25,000. Figure 4 The new spacious, developmentaly less-stimulating NICU environment with acoustic tile to decrease noise, indirect lighting, and 150 square feet per patient instead of the 50–80 square feet per patient that existed in the first floor of Hoblitzelle. ... The Lange NICU has a multidisciplinary staff of almost 300 people, including physicians, nurses, respiratory therapists, neonatal nurse practitioners (NNPs), pediatric nurse practitioners, registered dietitians, social workers, educators, and a chaplain. Although the unit is designed for 72 patients, the division often sees more than that number. Widely recognized for its excellent care, the BUMC neonatal unit has been featured many times in both the local and national media over the past decade. Almost 10 years ago, the staff in the neonatal division developed the following mission statement: Neonatology will provide comprehensive, high-quality, and state-of-the-art care for well and sick newborn infants and their families. As caregivers in the neonatology team, we will utilize optimally all the resources of BHCS to provide an integrated and excellent service for the newborn in need of these services to all the communities we serve. This mission statement, which hangs on the wall in the NICU, has served the unit well over the years and acts as a compass to help guide us along our challenging but rewarding path.