M.T. Esqué Ruiz

Recomendaciones de mínimos para la asistencia al recién nacido sano

Las recomendaciones incluidas en este documento van dirigidas a la asistencia del recien nacido sano. Tras senalar las situaciones que deben comunicarse al pediatra-neonatologo y los motivos por los que este sera requerido a sala de partos (en caso de cesarea urgente o electiva por patologia grave o parto prematuro), se comentan las principales normas de actuacion en la sala de partos y en el puerperio. En sala de partos se insiste en: cuidados del recien nacido, en especial del cordon umbilical; promocion del vinculo madre-hijo; identificacion del recien nacido;evaluacion de la adaptacion a la vida extrauterina; profilaxis de la oftalmia neonatal y de la enfermedad hemorragica del recien nacido; colocacion en la cama; profilaxis de la hepatitis B. Las normas de actuacion puerperales se refieren a alimentacion, favoreciendo la lactancia materna; hospitalizacion junto a la madre; cribado de la hipoacusia y endocrinometabolico; alta de la maternidad, con especial vigilancia del alta precoz.

Recomendaciones para el transporte perinatal

El transporte perinatal debe formar parte de los programas de regionalizacion y planificarse de acuerdo con el mapa sanitario de cada comunidad dentro de un sistema de atencion perinatal. Se describen los diferentes tipos de transporte, los medios utilizables con sus ventajas e inconvenientes, el material necesario, la dinamica que se debe seguir ante la necesidad de un traslado perinatal insistiendo en la relevancia del transporte intrautero y del transporte de retorno. La organizacion del traslado merece una consideracion especial, destacando las distintas funciones de los centros coordinador, emisor, receptor y del equipo asistencial del transporte, asi como algunos aspectos etico-legales.

Los errores de tratamiento en una unidad neonatal, uno de los principales acontecimientos adversos

INTRODUCTION Neonatal units are one of the hospital areas most exposed to the committing of treatment errors. A medication error (ME) is defined as the avoidable incident secondary to drug misuse that causes or may cause harm to the patient. The aim of this paper is to present the incidence of ME (including feeding) reported in our neonatal unit and its characteristics and possible causal factors. A list of the strategies implemented for prevention is presented. MATERIAL AND METHODS An analysis was performed on the ME declared in a neonatal unit. RESULTS A total of 511 MEs have been reported over a period of seven years in the neonatal unit. The incidence in the critical care unit was 32.2 per 1000 hospital days or 20 per 100 patients, of which 0.22 per 1000 days had serious repercussions. The ME reported were, 39.5% prescribing errors, 68.1% administration errors, 0.6% were adverse drug reactions. Around two-thirds (65.4%) were produced by drugs, with 17% being intercepted. The large majority (89.4%) had no impact on the patient, but 0.6% caused permanent damage or death. Nurses reported 65.4% of MEs. The most commonly implicated causal factor was distraction (59%). Simple corrective action (alerts), and intermediate (protocols, clinical sessions and courses) and complex actions (causal analysis, monograph) were performed. CONCLUSIONS It is essential to determine the current state of ME, in order to establish preventive measures and, together with teamwork and good practices, promote a climate of safety.

Asfixia perinatal y parálisis cerebral

La parálisis cerebral es un término descriptivo que señala la existencia de un trastorno motor crónico no progresivo que tiene su origen en etapas tempranas de la vida1. Little, al describir este trastorno, estableció que su causa principal era el daño cerebral adquirido durante el nacimiento2. Posteriormente, este daño fue atribuido a “asfixia perinatal”, una enfermedad compleja debida al compromiso del metabolismo celular aeróbico por hipoxia y/o hipoperfusión tisular. Cien años después de la publicación de Little, el desarrollo y la introducción de los modernos sistemas de monitorización fetal crearon la esperanza de que sería posible reducir la incidencia de parálisis cerebral, al posibilitar una detección precoz de la asfixia y permitir establecer intervenciones obstétricas de rescate más precoces3-5. Durante los últimos 30 años, estas creencias en obstetras, pediatras, legisladores y en la sociedad en su conjunto han conducido a una sobrestimación de la asfixia perinatal como causa de discapacidad permanente en los niños, a expectativas desmesuradas acerca de la capacidad de monitorización fetal durante el parto para prevenir la parálisis cerebral, a un porcentaje creciente de partos por cesárea y quizás a un exceso de intervenciones obstétricas con sus costes y riesgos inherentes. Este fenómeno es ilustrado por el espectacular aumento de partos por cesárea que han pasado de aproximadamente un 4% en los años setenta a cifras superiores al 20% en muchas partes del mundo6,7. Finalmente, como corolario de todo lo anterior, ha tenido lugar un aumento progresivo del coste de los seguros de responsabilidad profesional1,3-5. Durante la última década, han entrado en crisis varias convicciones alrededor de la asfixia perinatal y su relación con la parálisis cerebral, al ponerse de manifiesto que la mayoría de los casos de parálisis cerebral no tienen su origen en la asfixia intraparto, que la generalización de la monitorización fetal no ha conllevado una reducción franca en la incidencia de parálisis cerebral, que ésta puede desarrollarse a pesar de un control y manejo obstétrico adecuados, y que la asfixia perinatal es una condición compleja y mal definida que precisa una redefinición en el terreno de la práctica clínica. Existe, por tanto, la necesidad de divulgar entre los profesionales sanitarios, legisladores y la población los nuevos conocimientos actuales. Éstos indican que sólo un 10%, aproximadamente, de todos los casos de parálisis cerebral se pueden atribuir a asfixia intraparto y que no existe evidencia de que las prácticas obstétricas actuales puedan reducir la presente incidencia de parálisis cerebral1,3-5. Por otra parte, es esencial un mayor rigor tanto en la utilización de la etiqueta diagnóstica de “asfixia perinatal”, como a la hora de atribuir a la misma la discapacidad permanente en un niño. Los términos “sufrimiento fetal y asfixia perinatal” son confusos, mal definidos y se utilizan habitualmente de forma intercambiable. En general, pediatras, obstetras y legisladores creen conocer bien el significado del término asfixia perinatal (“agresión del feto o del recién nacido por déficit de oxígeno y/o de una perfusión tisular adecuada”) y, sin embargo, no disponemos de una definición precisa ni certera de asfixia perinatal. Tradicionalmente, en el terreno de la práctica clínica, la existencia de un episodio asfíctico perinatal ha sido inferido de la presencia en forma aislada o en combinación, de una serie de indicadores clínicos indirectos, como son: líquido amniótico teñido de meconio, alteraciones en el registro cardiotocográfico fetal, acidosis fetal, bajas puntuaciones de Apgar y fracaso para iniciar movimientos respiratorios tras el nacimiento. Sin embargo, estos marcadores tradicionales de asfixia no se correlacionan bien entre sí y, sobre todo, tienen un papel muy limitado para predecir morbilidad neurológica precoz o tardía1,4. Por ello, estos antecedentes perinatales presentan serias limitaciones operativas para establecer el diagnóstico de asfixia, y per se sólo permiten definir una situación de riesgo. Aunque la presencia

Caminando hacia una cultura de seguridad en la unidad neonatal: experiencia de 6 años

INTRODUCTION A safety culture is the collective effort of an institution to direct its resources toward the goal of safety. MATERIAL AND METHODS An analysis is performed on the six years of experience of the Committee on the Safety of Neonatal Patient. A mailbox was created for the declaration of adverse events, and measures for their correction were devised, such as case studies, continuous education, prevention of nosocomial infections, as well as information on the work done and its assessment. RESULTS A total of 1287 reports of adverse events were received during the six years, of which 600 (50.8%) occurred in the neonatal ICU, with 15 (1.2%) contributing to death, and 1282 (99.6%) considered preventable. Simple corrective measures (notification, security alerts, etc.) were applied in 559 (43.4%), intermediate measures (protocols, monthly newsletter, etc.) in 692 (53.8%), and more complex measures (causal analysis, scripts, continuous education seminars, prospective studies, etc.) in 66 (5.1%). As regards nosocomial infections, the prevention strategies implemented (hand washing, insertion and maintenance of catheters) directly affected their improvement. Two surveys were conducted to determine the level of satisfaction with the Committee on the Safety of Neonatal Patient. A rating 7.5/10 was obtained in the local survey, while using the Spanish version of the Hospital Survey on Patient Safety Culture the rate was 7.26/10. CONCLUSIONS A path to a culture of safety has been successfully started and carried out. Reporting the adverse events is the key to obtaining information on their nature, etiology and evolution, and to undertake possible prevention strategies.

Evolución del peso del prematuro con alta precoz y atención domiciliaria de enfermería

INTRODUCTION In-Home nursing care of the preterm newborn helps to bring the family situation to normal, promotes breastfeeding and development of the newborn, and enables the reorganization of health care resources. The purpose of this paper is to demonstrate that in-home nursing care of the preterm newborn leads to an increase in weight and a similar morbidity. PATIENTS AND METHODOLOGY A total of 65 cases and 65 controls (matched by weight, age and sex) were studied, all of them preterm newborns born in hospital and weighing less than 2100 g at discharge. In-home nursing care was carried out by a pediatrician neonatologist, as well as two nurses specialized in neonatology who made several visits to the home. Weight gain was calculated as g/day and g/Kg/day, comparing the first week of the study with the week prior to the beginning of the study. RESULTS The groups were comparable. Weight gain in the group with home nursing care was 38 g per day, significantly higher than the weight gain in the control group (31 g/day). The independent predictive variables of the increase in g/Kg/day during the study were in-home nursing care, male gender, breastfeeding less, and not having suffered from a peri-intraventricular hemorrhage. Neonatal morbidity was similar in both groups. CONCLUSIONS In-home care was associated with a greater weight gain of the newborn at home than during their stay in the hospital, and can be considered safe because neonatal morbidity was not increased.INTRODUCTION In-Home nursing care of the preterm newborn helps to bring the family situation to normal, promotes breastfeeding and development of the newborn, and enables the reorganization of health care resources. The purpose of this paper is to demonstrate that in-home nursing care of the preterm newborn leads to an increase in weight and a similar morbidity. PATIENTS AND METHODOLOGY A total of 65 cases and 65 controls (matched by weight, age and sex) were studied, all of them preterm newborns born in hospital and weighing less than 2100 g at discharge. In-home nursing care was carried out by a pediatrician neonatologist, as well as two nurses specialized in neonatology who made several visits to the home. Weight gain was calculated as g/day and g/Kg/day, comparing the first week of the study with the week prior to the beginning of the study. RESULTS The groups were comparable. Weight gain in the group with home nursing care was 38 g per day, significantly higher than the weight gain in the control group (31 g/day). The independent predictive variables of the increase in g/Kg/day during the study were in-home nursing care, male gender, breastfeeding less, and not having suffered from a peri-intraventricular hemorrhage. Neonatal morbidity was similar in both groups. CONCLUSIONS In-home care was associated with a greater weight gain of the newborn at home than during their stay in the hospital, and can be considered safe because neonatal morbidity was not increased.