R A van Lingen

Incidents and errors in neonatal intensive care: A review of the literature

Objectives: To examine the characteristics of incident reporting systems in neonatal intensive care units (NICUs) in relation to type, aetiology, outcome and preventability of incidents. Methods: Systematic review. Search strategy: Medline, Embase, Cochrane Library. Included: relevant systematic reviews, randomised controlled trials, observational studies and qualitative research. Excluded: non-systematic reviews, expert opinions, case reports and letters. Participants: hospital units supplying neonatal intensive care. Intervention: none. Outcome: characteristics of incident reporting systems; type, aetiology, outcome and preventability of incidents. Results: No relevant systematic reviews or randomised controlled trials were found. Eight prospective and two retrospective studies were included. Overall, medication incidents were most frequently reported. Available data in the NICU showed that the total error rate was much higher in studies using voluntary reporting than in a study using mandatory reporting. Multi-institutional reporting identified rare but important errors. A substantial number of incidents were potentially harmful. When a system approach was used, many contributing factors were identified. Information about the impact of system changes on patient safety was scarce. Conclusions: Multi-institutional, voluntary, non-punitive, system based incident reporting is likely to generate valuable information on type, aetiology, outcome and preventability of incidents in the NICU. However, the beneficial effects of incident reporting systems and consecutive system changes on patient safety are difficult to assess from the available evidence and therefore remain to be investigated.

Epidemiology of neonatal group B streptococcal disease in the Netherlands before and after introduction of guidelines for prevention

Objectives: (1) To describe the epidemiology of neonatal group B streptococcal (GBS) disease over five years (1997–2001) in the Netherlands, stratified for proven and probable sepsis and for very early (<12 h), late early (12 h – <7 days) and late (7–90 days) onset sepsis. (2) To evaluate the effect of the introduction in January 1999 of guidelines for prevention of early onset GBS disease based on risk factors. Methods: Data on cases were collected in collaboration with the Dutch Paediatric Surveillance Unit and corrected for under-reporting by the capture-recapture technique. Results: Total incidence of proven very early onset, late early onset and late onset GBS sepsis was 0.32, 0.11 and 0.14 per 1000 live births, respectively, and of probable very early onset, late early onset and late onset GBS sepsis was 1.10, 0.18 and 0.02 per 1000 live births, respectively. Maternal risk factors were absent in 46% of the proven early onset cases. Considerably more infants with proven GBS sepsis were boys. 64% of the infants with proven very early onset GBS sepsis were first borns compared with 47% in the general population. After the introduction of guidelines the incidence of proven early onset sepsis decreased considerably from 0.54 per 1000 live births in 1997–8 to 0.36 per 1000 live births in 1999–2001. However, there was no decrease in the incidence of meningitis and the case fatality rate in the first week of life. The incidence of late onset sepsis also remained unchanged. Conclusion: After the introduction prevention guidelines based on risk factors there has been a limited decrease in the incidence of proven early onset GBS sepsis in the Netherlands. This study therefore recommends changing the Dutch GBS prevention guidelines.

Randomised controlled trial evaluating effects of morphine on plasma adrenaline/noradrenaline concentrations in newborns

Objectives: To determine the effects of continuous morphine infusion in ventilated newborns on plasma concentrations of adrenaline (epinephrine) and noradrenaline (norepinephrine) and their relation to clinical outcome. Design: Blinded, randomised, placebo controlled trial. Setting: Level III neonatal intensive care units in two centres. Patients: A total of 126 ventilated neonates (inclusion criteria: postnatal age <3 days, duration of ventilation <8 hours, indwelling arterial catheter for clinical purposes; exclusion criteria: severe asphyxia, severe intraventricular haemorrhage, major congenital anomalies, neuromuscular blockers). Interventions: Plasma adrenaline and noradrenaline concentrations were determined in patients during blinded morphine (n  =  60) and placebo (n  =  66) infusion (100 μg/kg plus 10 μg/kg/h). Results: Plasma concentrations at baseline (nmol/l with interquartile range in parentheses) were comparable in infants treated with morphine (adrenaline, 0.22 (0.31); noradrenaline, 2.52 (2.99)) or placebo (adrenaline, 0.29 (0.46); noradrenaline, 2.44 (3.14)). During infusion, median adrenaline concentrations were 0.12 (0.28) and 0.18 (0.35) and median noradrenaline concentrations were 2.8 (3.7) and 3.8 (4.0) for the morphine and placebo treated infants respectively. Multivariate analyses showed that noradrenaline (p  =  0.029), but not adrenaline (p  =  0.18), concentrations were significantly lower in the morphine group than the placebo group. Furthermore, noradrenaline concentrations were related to the length of stay in the neonatal intensive care unit. Conclusions: Continuous morphine infusion significantly decreased plasma noradrenaline concentrations in ventilated newborns compared with placebo treatment. The results of this study support the idea that routine morphine administration decreases stress responses in ventilated neonates.

Loss of triglycerides and carotenoids in human milk after processing

Objective: Human milk (HM) is considered to be the best nutrition for preterm infants. However, storage, heating or tube feeding can cause a decline in essential nutrients, which can lead to the loss of antioxidant vitamins, resulting in an increased risk for oxygen radical diseases. Recently we found that carotenoids, present in human milk, can play a role in the antioxidant protection of preterm infants. In this study we evaluated the effect of processing HM and infant formula on the triglycerides and carotenoid concentrations. Design: The triglyceride, α- and β-carotene, lutein and lycopene concentrations of 30 samples of mature HM of mothers who delivered a term infant and 10 samples of infant formula were measured after refrigeration, freezing, microwave heating and tube feeding with and without exposure to normal light and phototherapy, imitating the clinical feeding routine in the NICU. Results: After tube feeding triglyceride, lutein and β-carotene concentrations decreased with 33%, 35% and 26% respectively. The decrease in triglycerides in HM accounts for 16% of the total caloric intake of neonates. Triglyceride and carotenoid concentrations in HM remained stable after refrigeration, freezing or low temperature microwave heating, except for lutein which decreased after refrigeration and freezing. In infant formula no differences were found. Conclusions: Mature human milk can be stored safely in a freezer and heated in a microwave oven without loss of fat or carotenoids. The clinically important loss of fat during tube feeding is probably the most important contributing factor to the decrease in lutein and β-carotene in tube feeding, with only a small role for peroxidation during light-exposure.

Body temperature measurement in VLBW infants by continuous skin measurement is a good or even better alternative than continuous rectal measurement

Background: An inadequate body temperature in preterm infants influences morbidity and mortality. Continuous rectal measurement is a reliable method to measure body temperature but might have adverse effects and is even contra‐indicated in case of low platelets or necrotising enterocolitis. A save and non‐invasive method to measure body temperature is the transcutaneous ‘zero heat flow’ method.

Maternal haemolysis, elevated liver enzymes and low platelets syndrome: Specific problems in the newborn

To evaluate the effects of maternal haemolysis, elevated liver enzymes and low platelets (HELLP) syndrome on the fetus and neonate we retrospectively investigated the outcome of 87 pregnancies. All women showed thrombocytopenia, elevated liver enzymes and haemolysis. None of them died. Nine infants were stillborn (9.9%). Of the 82 liveborn infants, 66 were delivered by caesarian section. Median gestational age of the liveborn infants was 32.6 weeks, mean birth weight was 1576g±699 g (mean±SD). Of these infants, 44% were small for gestational age. Perinatal asphyxia rate was 21.6%. Nine infants died in the 1 st week after birth. Complications during admission included neonatal respiratory disease (43.2%), hyperbilirubinaemia (44.7%), persistent ductus arteriosus (16.2%), thrombocytopenia (34%) and hypoglycaemia (16.2%). Artificial ventilation was necessary in 37 infants. Mean duration of admission was 51 days. HELLP syndrome is associated with poor perinatal outcome; the incidence of caesarian section is high and there is an increased risk for preterm birth and growth retardation. No specific neonatal pathology due to maternal HELLP syndrome was found.

Morphine in ventilated neonates: Its effects on arterial blood pressure

Objective: To study the effects of continuous morphine infusion on arterial blood pressure in ventilated neonates. Design: Blinded randomised placebo controlled trial. Setting: Level III neonatal intensive care unit in two centres. Patients: A total of 144 ventilated neonates. Inclusion criteria were postnatal age <3 days, ventilation <8 hours, and indwelling arterial line. Exclusion criteria were severe asphyxia, severe intraventricular haemorrhage, major congenital anomalies, neuromuscular blockers. Intervention: Arterial blood pressure was measured before the start and during the first 48 hours of masked infusion of drug (morphine/placebo; 100 μg/kg + 10 μg/kg/h). Outcome measures: Arterial blood pressure and blood pressure variability. Results: There were no significant differences in overall mean arterial blood pressure between the morphine group (median (interquartile range) 36 mm Hg (6) and the placebo group (38 mm Hg (6)) (p  =  0.11). Although significantly more morphine treated patients (70%) showed hypotension than the placebo group (47%) (p  =  0.004), the use of volume expanders and vasopressor drugs was not significantly different (morphine group, 44%; placebo group, 48%; p  =  0.87), indicating the limited clinical significance of this side effect. Blood pressure variability was not influenced by routine morphine analgesia (p  =  0.81) or additional morphine (p  =  0.80). Patients with and without intraventricular haemorrhage showed no differences in blood pressure (Mann-Whitney U test 1953; p  =  0.14) or incidence of hypotension (χ2 test 1.16; df 1; p  =  0.28). Conclusions: Overall arterial blood pressure, use of inotropes, and blood pressure variability were not influenced by morphine infusion. Therefore the clinical impact of hypotension as a side effect of low dose morphine treatment in neonates is negligible.

Surfactant replacement therapy in neonates with respiratory failure due to bacterial sepsis

We describe four newborns (gestational ages 29‐37 weeks; birthweights 1380‐3040 grams) who were mechanically ventilated for respiratory insufficiency because of bacterial sepsis. A beneficial effect of bovine surfactant (Alvofact, dosages 50 or lOOmg/kg) was found, as shown by decreases in mean airway pressures and oxygen demands. No side effects were seen after instillation.

Minimal enteral feeding, fetal blood flow pulsatility, and postnatal intestinal permeability in preterm infants with intrauterine growth retardation

Objective: To study the effect of minimal enteral feeding (MEF) on intestinal permeability and feeding tolerance in preterm infants with intrauterine growth retardation (gestational age < 37 weeks, birth weight for gestational age p < 10). Furthermore, to determine whether fetal blood flow pulsatility or intestinal permeability predict feeding tolerance in these infants. Design: Randomised controlled trial. Methods: Within 48 hours of birth, infants were randomised to MEF or no enteral feeding (NEF) for five days in addition to parenteral feeding. Intestinal permeability was measured by the sugar absorption test before (SAT1) and after (SAT2) the study. The sugar absorption test measured the urinary lactulose/mannitol (LM) ratio after oral ingestion of a solution (375 mosm) containing mannitol and lactulose. Charts of all infants were assessed for measures of feeding tolerance. Fetal blood flow pulsatility index (U/C ratio) was measured within the seven days before birth. Results: Of the 56 infants enrolled, 42 completed the study: 20 received MEF and 22 NEF. The decrease in LM ratio (LM ratio 1 − LM ratio 2) was not significantly different between the two groups (0.25 v 0.11; p  =  0.14). Feeding tolerance, growth, and incidence of necrotising enterocolitis were not significantly different between the two groups. Neither the U/C nor the LM ratio 1 predicted feeding tolerance. Conclusions: The results suggest that MEF of preterm infants with intrauterine growth retardation has no effect on the decrease in intestinal permeability after birth. Neither fetal blood flow pulsatility nor intestinal permeability predicts feeding tolerance.

Streptococcal pharyngitis and epiglottitis in a newborn infant

We describe a newborn infant withStreptococcus sanguis septicaemia and concomitant upper airway obstruction due to epiglottitis and pharyngitis. This rare infection of the supraglottic region was treated with endotracheal intubation and antibiotics. Full recovery occurred within 4 days.