Sandesh Shivananda

Outcomes of preterm infants <29 weeks gestation over 10-year period in Canada: a cause for concern?

Objective:To compare risk-adjusted changes in outcomes of preterm infants <29 weeks gestation born in 1996 to 1997 with those born in 2006 to 2007.Study Design:Observational retrospective comparison of data from 15 units that participated in the Canadian Neonatal Network during 1996 to 1997 and 2006 to 2007 was performed. Rates of mortality and common neonatal morbidities were compared after adjustment for confounders.Result:Data on 1897 infants in 1996 to 1997 and 1866 infants in 2006 to 2007 were analyzed. A higher proportion of patients in the later cohort received antenatal steroids and had lower acuity of illness on admission. Unadjusted analyses revealed reduction in mortality (unadjusted odds ratio (UAOR): 0.83, 95% confidence interval (CI): 0.63, 0.98), severe retinopathy (UAOR: 0.68, 95% CI: 0.50 to 0.92), but increase in bronchopulmonary dysplasia (UAOR: 1.61, 95% CI: 1.39 to 1.86) and patent ductus arteriosus (UAOR: 1.22, 95% CI: 1.07 to 1.39). Adjusted analyses revealed increases in the later cohort for bronchopulmonary dysplasia (adjusted odds ratio (AOR): 1.88, 95% CI: 1.60 to 2.20) and severe neurological injury (AOR: 1.49, 95% CI: 1.22 to 1.80). However, the ascertainment methods for neurological findings and ductus arteriosus differed between the two time periods.Conclusion:Improvements in prenatal care has resulted in improvement in the quality of care, as reflected by reduced severity of illness and mortality. However, after adjustment of prenatal factors, no improvement in any of the outcomes was observed and on the contrary bronchopulmonary dysplasia increased. There is need for identification and application of postnatal strategies to improve outcomes of extreme preterm infants.

Pharmacology of milrinone in neonates with persistent pulmonary hypertension of the newborn and suboptimal response to inhaled nitric oxide.

Objectives: Persistent pulmonary hypertension of the newborn is a common problem with significant morbidity and mortality. Inhaled nitric oxide is the standard care, but up to 40% of neonates are nonresponders. Milrinone is a phosphodiesterase III inhibitor which increases the bioavailability of cyclic adenosine monophosphate and has been shown to improve pulmonary hemodynamics in animal experimental models. The primary objective was to investigate the pharmacological profile of milrinone in persistent pulmonary hypertension of the newborn. Secondary objectives were to delineate short-term outcomes and safety profile. Subjects and Methods: An open label study of milrinone in neonates with persistent pulmonary hypertension of the newborn was conducted. Patients received an intravenous loading dose of milrinone (50 &mgr;g/kg) over 60 mins followed by a maintenance infusion (0.33–0.99 &mgr;g/kg/min) for 24–72 hrs. Physiologic indices of cardiorespiratory stability and details of cointerventions were recorded. Serial blood milrinone levels were collected after the bolus, following initiation of the maintenance infusion to determine steady state levels, and following discontinuation of the drug to determine clearance. Echocardiography was performed before and after (1, 12 hrs) milrinone initiation. Interventions: Milrinone. Measurements and Main Results: Eleven neonates with a diagnosis of persistent pulmonary hypertension of the newborn who met eligibility criteria were studied. The median (SD) gestational age and weight at birth were 39.2±1.3 wks and 3481±603g. The mean (± sd) half-life, total body clearance, volume of distribution, andsteady state concentration of milrinone were 4.1±1.1 hrs, 0.11±0.01L/kg/hr, 0.56±0.19L/kg, and 290.9±77.7ng/mL. The initiation of milrinone led to an improvement in PaO2 (p = 0.002) and a sustained reduction in FIO2 (p < 0.001), oxygenation index (p < 0.001), mean airway pressure (p = 0.03), and inhaled nitric oxide dose (p < 0.001). Although a transient reduction in systolic arterial pressure (p < 0.001) was seen following the bolus, there was overall improvement in base deficit (p = 0.01) and plasma lactate (p = 0.04) with a trend towards lower inotrope score. Serial echocardiography revealed lower pulmonary artery pressure, improved right and left ventricular output, and reduced bidirectional or right-left shunting (p < 0.05) after milrinone treatment. Conclusions: The pharmacokinetics of milrinone in persistent pulmonary hypertension of the newborn is consistent with published data. The administration of intravenous milrinone led to better oxygenation and improvements in pulmonary and systemic hemodynamics in patients with suboptimal response to inhaled nitric oxide. These data support the need for a randomized controlled trial in neonates.

Variation in the management of persistent pulmonary hypertension of the newborn: a survey of physicians in Canada, Australia, and New Zealand.

BACKGROUND Despite advances in management of persistent pulmonary hypertension of the newborn (PPHN), the risk of mortality and adverse neurological sequelae remains high. Characterizing variation in practices is a crucial step toward improved patient outcome. OBJECTIVE Evaluate intensive care practices in Canada and the Australia-New Zealand region (AUS-NZ). METHODS A prospective cross-sectional online survey of neonatologists was conducted. A 35-item questionnaire was developed, validated, and piloted to collect information on diagnosis, inhaled nitric oxide (iNO) practices, alternative vasodilators or cardiotropes, and echocardiography. Variation among survey respondents as well as intergroup comparison was performed. RESULTS Data were collected from 217 respondents. Echocardiography and arterial blood gas were the most common diagnostic tests to assess the severity of PPHN. iNO administration is more frequently scrutinized in Canada (36% versus 10% [AUS-NZ], p < 0.001). Canadian physicians reported higher use of intravenous milrinone (p < 0.001), vasopressin (p = 0.02), and inhaled prostacyclin (p = 0.02), but lower use of sildenafil (p = 0.01) for refractory pulmonary hypertension. A greater proportion of neonatologists in AUS-NZ were trained to perform echocardiography (p < 0.001) to optimize treatment decisions. CONCLUSION Wide variation exists in the management of PPHN. There is a need to provide more guidance regarding principles of management in PPHN, while recognizing the dynamic nature of cardiopulmonary physiology in individual patients.

Survey of noninvasive respiratory support practices in Canadian neonatal intensive care units

To evaluate practice variation with respect to noninvasive respiratory support (NRS) use across Canadian neonatal intensive care units (NICUs).

National variations in retinopathy of prematurity screening criteria in Canada: existent guidelines and actual practice patterns

OBJECTIVE To survey the current inclusion criteria used for retinopathy of prematurity (ROP) screening across tertiary level 3 neonatal intensive care units (NICUs) in Canada. PARTICIPANTS Clinical directors from 29 level 3 NICUs in Canada. METHODS Survey of all 29 level 3 NICUs in Canada in September 2010. The survey inquired about the current ROP screening criteria in use in each centre including which neonates are enrolled in the screening program and the timing of when screening begins. The survey was sent via email to the clinical directors at each site. Nonrespondents were contacted by telephone. RESULTS In total, 23 centres replied, representing a 79% response rate with the survey. Seven different ROP screening inclusion criteria were found to be in use, although one of the centres did not have a clear inclusion protocol. The variation between centres was significant, with some using a combination of birth weight and gestational age and others using birth weight or gestational age alone as their criterion. There was also variation in the timing of initial eye examinations, with 8 different criteria currently in use. Discrepancies were also found among treatment patterns at the centres. CONCLUSIONS Despite the publication of updated Canadian guidelines in 2000, there continues to be significant variation in the actual inclusion criteria being used across the country. Therefore, a need exists for comprehensive, evidence-based Canadian guidelines to optimize the screening inclusion criteria for ROP.

Compression force on the upper jaw during neonatal intubation: Mannequin study

Neonatal intubation is a technically challenging procedure, and pressure‐related injuries to surrounding structures have been reported. The primary objective of this study was to determine the pressure exerted on the upper jaw during tracheal intubation using a neonatal mannequin.

Video recording of neonatal resuscitation: A feasibility study to inform widespread adoption

AIM To determine the feasibility of introducing video recording (VR) of neonatal resuscitation (NR) in a perinatal centre. METHODS This was a prospective cohort quality improvement study on preterm infants and their caregivers. Based on evidence and experience of other centers using VR intervention, a contextually relevant implementation and evaluation strategy was designed in the planning phase. The components of intervention were pre-resuscitation team huddle, VR of NR and video debriefing (VD), all occurring on the same day. Various domains of feasibility and sustainability as well as feasibility criteria were predefined. Data for analysis was collected using quantitative and qualitative methods. RESULTS Seventy-one caregivers participated in VD of 14 NRs facilitated by six trained instructors. Ninety-one percent of caregivers perceived enhanced learning and patient safety and, 48 issues were identified related to policy, caregiver roles, and latent safety threats. Ninety percent of caregivers expressed their willingness to participate in VD activity and supported the idea of integrating it into a resuscitation team routine. Eighty-three percent and 50% of instructors expressed satisfaction with video review software and quality of audio VR. No issues about maintenance of infant or caregivers’ confidentiality and erasure of videos were reported. Criteria for feasibility were met (refusal rate of < 10%, VR performed on > 50% of occasions, and < 20% caregivers’ perceiving a negative impact on team performance). Necessary adaptations to enhance sustainability were identified. CONCLUSION VR of NR as a standard of care quality assurance activity to enhance caregivers’ learning and create opportunities that improve patient safety is feasible. Despite its complexity with inherent challenges in implementation, the intervention was acceptable, implementable, and potentially sustainable with adaptations.

Macrolides do not affect the incidence of moderate and severe bronchopulmonary dysplasia in symptomatic ureaplasma‐positive infants

The aim of this study was to compare the incidence of bronchopulmonary dysplasia (BPD) in symptomatic ureaplasma‐positive treated preterm infants and asymptomatic preterm infants not tested or treated for ureaplasma.

Neonatal outcomes of preterm twins according to mode of birth and presentation

Abstract Purpose: To compare neonatal outcomes of twins delivered <33 weeks’ gestation in tertiary centers in Canada according to the mode of birth and presentation. Materials and methods: This retrospective cohort from the Canadian Neonatal Network database studied preterm twins born from 24 + 0 to 32 + 6 weeks’ gestation between 2005 and 2012. Twins were grouped by the mode of birth: both vaginal, combined vaginal/cesarean section (CS), and both CS. Additionally, twins were grouped by the mode of presentation: both vertex, vertex/breech, breech/vertex, and both breech. The primary outcome was a composite of mortality or severe neonatal morbidity (severe neurological injury [intraventricular hemorrhage grade 3/4 or periventricular leukomalacia], bronchopulmonary dysplasia, retinopathy of prematurity, and necrotizing enterocolitis). Results: Of the 6636 twins, 1934 (29%) were delivered vaginally, 418 (6%) by combined vaginal birth/CS, and 4284 (65%) were born by CS. The composite did not differ between the groups. However, severe neurological injury was decreased (adjusted odds ratio [AOR], 0.77; 95% confidence interval [CI], 0.61–0.98) and respiratory distress syndrome (AOR, 1.34; 95%CI, 1.15–1.56) was increased when both the twins were delivered by CS. Conclusions: Preterm twin infants born via CS experienced less severe neurological injury when compared to those delivered vaginally, but had an increase in respiratory distress syndrome.

Introduction of microsystems in a level 3 neonatal intensive care unit—an interprofessional approach

BackgroundGrowth of neonatal intensive care units in number and size has raised questions towards ability to maintain continuity and quality of care. Structural organization of intensive care units is known as a key element for maintaining the quality of care of these fragile patients. The reconstruction of megaunits of intensive care to smaller care units within a single operational service might help with provision of safe and effective care.Methods/DesignThe clinical team and patient distribution lay out, admission and discharge criteria and interdisciplinary round model was reorganized to follow the microstructure philosophy. A working group met weekly to formulate the implementation planning, to review the adaptation and adjustment process and to ascertain the quality of implementation following the initiation of the microsystem model.DiscussionIn depth examination of microsystem model of care in this study, provides systematic evaluation of this model on variable aspects of health care. The individual projects of this trial can be source of solid evidence for guidance of future decisions on optimized model of care for the critically ill newborns.Trial registrationClinicalTrial.gov, NCT02912780. Retrospectively registered on 22 September 2016.