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Slidell MB, McAteer J, Miniati D, Sømme S, Wakeman D, Rialon K, Lucas D, Beres A, Chang H, Englum B, Kawaguchi A, Gonzalez K, Speck E, Villalona G, Kulaylat A, Rentea R, Yousef Y, Darderian S, Acker S, St Peter S, Kelley-Quon L, Baird R, Baerg J. Management of Gastroschisis: Timing of Delivery, Antibiotic Usage, and Closure Considerations (A Systematic Review From the American Pediatric Surgical Association Outcomes & Evidence Based Practice Committee). J Pediatr Surg 2024; 59:1408-1417. [PMID: 38796391 DOI: 10.1016/j.jpedsurg.2024.03.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 03/08/2024] [Accepted: 03/17/2024] [Indexed: 05/28/2024]
Abstract
BACKGROUND No consensus exists for the initial management of infants with gastroschisis. METHODS The American Pediatric Surgical Association (APSA) Outcomes and Evidenced-based Practice Committee (OEBPC) developed three a priori questions about gastroschisis for a qualitative systematic review. We reviewed English-language publications between January 1, 1970, and December 31, 2019. This project describes the findings of a systematic review of the three questions regarding: 1) optimal delivery timing, 2) antibiotic use, and 3) closure considerations. RESULTS 1339 articles were screened for eligibility; 92 manuscripts were selected and reviewed. The included studies had a Level of Evidence that ranged from 2 to 4 and recommendation Grades B-D. Twenty-eight addressed optimal timing of delivery, 5 pertained to antibiotic use, and 59 discussed closure considerations (Figure 1). Delivery after 37 weeks post-conceptual age is considered optimal. Prophylactic antibiotics covering skin flora are adequate to reduce infection risk until definitive closure. Studies support primary fascial repair, without staged silo reduction, when abdominal domain and hemodynamics permit. A sutureless repair is safe, effective, and does not delay feeding or extend length of stay. Sedation and intubation are not routinely required for a sutureless closure. CONCLUSIONS Despite the large number of studies addressing the above-mentioned facets of gastroschisis management, the data quality is poor. A wide variation in gastroschisis management was documented, indicating a need for high quality RCTs to provide an evidence-based approach when caring for these infants. TYPE OF STUDY Qualitative systematic review of Level 1-4 studies.
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Affiliation(s)
- Mark B Slidell
- Division of Pediatric Surgery, Johns Hopkins Children's Center, 1800 Orleans St, Baltimore, MD 21287, USA.
| | - Jarod McAteer
- Providence Hospital, 101 West 8th Avenue, Spokane, WA 99204, USA
| | - Doug Miniati
- Division of Pediatric Surgery, Kaiser Permanente Northern California, 1600 Eureka Road, Roseville, CA 95661, USA
| | - Stig Sømme
- Division of Pediatric Surgery, University of Colorado School of Medicine, 13123 East 16th Avenue, Aurora, CO 80045, USA
| | - Derek Wakeman
- University of Rochester Medical Center, School of Medicine and Dentistry, 601 Elmwood Ave, Box Surg, Rochester, NY 14642, USA
| | - Kristy Rialon
- Division of Pediatric Surgery, Texas Children's Hospital, 6701 Fannin Street, Houston, TX 77030, USA
| | - Don Lucas
- Division of Pediatric Surgery, Department of General Surgery, Naval Medical Center San Diego, 34800 Bob Wilson Drive, San Diego, CA 92134, USA
| | - Alana Beres
- Division of Pediatric Surgery, St. Christopher's Hospital for Children, 160 E Erie Ave, Philadelphia, PA 19134, USA
| | - Henry Chang
- Johns Hopkins All Children's Hospital, 501 6th Avenue South, St. Petersburg, FL 33701, USA
| | - Brian Englum
- University of Maryland Medical Center, 22 S Greene St, Baltimore, MD 21201, USA
| | - Akemi Kawaguchi
- Department of Pediatric Surgery at McGovern Medical School at The University of Texas Health Science Center at Houston, 6431 Fannin Street, Houston, TX 77030, USA
| | | | - Elizabeth Speck
- Section of Pediatric Surgery, C.S. Mott Children's Hospital, 1540 E Hospital Dr, Ann Arbor, MI 48109, USA
| | - Gustavo Villalona
- Division of Pediatric Surgery, Nemours Children's Health, 807 Children's Way, Jacksonville, FL 32207, USA
| | - Afif Kulaylat
- Division of Pediatric Surgery, Penn State Hershey Children's Hospital, 200 Campus Dr Ste 400, Hershey, PA 17033, USA
| | - Rebecca Rentea
- Pediatric Surgery Division, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108, USA
| | - Yasmine Yousef
- Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, 1001 Decarie Boulevard, Montreal, Quebec, Canada H4A 3J1
| | - Sarkis Darderian
- Pediatric Surgery Division, Children's Hospital Colorado, University of Colorado School of Medicine, 13123 East 16th Avenue, Aurora, CO 80045, USA
| | - Shannon Acker
- Pediatric Surgery Division, Children's Hospital Colorado, University of Colorado School of Medicine, 13123 East 16th Avenue, Aurora, CO 80045, USA
| | - Shawn St Peter
- Pediatric Surgery Division, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108, USA
| | - Lorraine Kelley-Quon
- Pediatric Surgery Division, Children's Hospital, 4650 W Sunset Blvd, Los Angeles, CA 90027, USA
| | - Robert Baird
- Division of Pediatric General Surgery, Department of Surgery, Faculty of Medicine, University of British Columbia, 2775 Laurel Street, 11th Floor, Vancouver, British Columbia V5Z 1M9, Canada
| | - Joanne Baerg
- Division of Pediatric Surgery, Presbyterian Health System, 201 Cedar St SE Ste 4660, Albuquerque, NM 87106, USA
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Simon A, Meier CM, Baltaci Y, Müller R, Heidtmann SA, Zemlin M, Renk H. [Update Perioperative Antibiotic Prophylaxis in Neonatology]. Z Geburtshilfe Neonatol 2023; 227:421-428. [PMID: 37579789 DOI: 10.1055/a-2125-1233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/16/2023]
Abstract
This narrative review discusses basic principles of the perioperative antibiotic prophylaxis (PAP) in premature and at term newborns and refers to some particularities concerning the indication and dosing issues. Although this is a vulnerable patient population, the spectrum of activity should not be unnecessarily broad and the regular PAP must not be prolonged beyond 24 hours.
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Affiliation(s)
- Arne Simon
- Pädiatrische Onkologie und Hämatologie, Universitätsklinikum Homburg, Homburg, Germany
| | - Clemens Magnus Meier
- Klinik für Allgemeine Chirurgie, Viszeral-, Gefäß- und Kinderchirurgie, Universitätsklinikum Homburg, Homburg, Germany
| | - Yeliz Baltaci
- Pädiatrische Onkologie und Hämatologie, Universitätsklinikum Homburg, Homburg, Germany
| | - Rachel Müller
- Pädiatrische Onkologie und Hämatologie, Universitätsklinikum Homburg, Homburg, Germany
| | | | - Michael Zemlin
- Klinik für Allgemeine Pädiatrie und Neonatologie, Universität des Saarlandes, Saarbrücken, Germany
| | - Hanna Renk
- Institut für Medizinische Mikrobiologie und Hygiene, Universitäts-Kinderklinik Tübingen, Tübingen, Germany
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Riddle S, Agarwal N, Haberman B, Karpen H, Miquel-Verges F, Nayak SP, Sullivan K, Williams S, Zaniletti I, Jacobson E. Gastroschisis and low incidence of early-onset infection: a case for antimicrobial stewardship. J Perinatol 2022; 42:1453-1457. [PMID: 35987968 DOI: 10.1038/s41372-022-01494-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Revised: 06/27/2022] [Accepted: 08/04/2022] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Early onset infection (EOI) in gastroschisis is rare. Excess antibiotic exposure in neonates increases necrotizing enterocolitis and mortality. We evaluated antibiotic exposure and EOI in gastroschisis. STUDY DESIGN Retrospective cohort analysis between 2010-2016 in the Children's Hospital Neonatal Database. Included: Infants ≥32 weeks with gastroschisis admitted <48 h. Excluded: major anomalies or surgical intervention prior to admission. PRIMARY OUTCOME EOI diagnosis (<72 h). RESULTS In 2021 patients with gastroschisis, median gestational age was 36 weeks (IQR 35, 37). 93.9% patients received empiric antibiotics after delivery, with median 7 days duration (IQR 3, 9). Only 13 patients (0.64%) had early positive blood culture. The rate of late onset blood stream infection (7.08%) was higher, and higher in complex (18%) than simple gastroschisis (4.8%, p < 0.001). CONCLUSION Despite low incidence of EOI and risks of excess antibiotic exposure, neonates with gastroschisis are exposed to long courses of empiric antibiotics. These data should stimulate interinstitution work to improve antibiotic prescribing.
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Affiliation(s)
- Stefanie Riddle
- Cincinnati Children's Hospital Medical Center and the Department of Pediatrics, University of Cincinnati College of Medicine, 3333 Burnet Ave Cincinnati OH 45229, Cincinnati, OH, USA.
| | - Nidhi Agarwal
- Arkansas Children's Hospital and Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Beth Haberman
- Cincinnati Children's Hospital Medical Center and the Department of Pediatrics, University of Cincinnati College of Medicine, 3333 Burnet Ave Cincinnati OH 45229, Cincinnati, OH, USA
| | - Heidi Karpen
- Children's Healthcare of Atlanta and Emory University School of Medicine, Atlanta, GA, USA
| | - Franscesca Miquel-Verges
- Arkansas Children's Hospital and Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Sujir Pritha Nayak
- Children's Medical Center Dallas and University of Texas Southwestern, Dallas, TX, USA
| | - Kevin Sullivan
- Nemours Children's Hospital - Delaware, Wilmington, DE and Department of Pediatrics of Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | | | | | - Elizabeth Jacobson
- Seattle Children's Hospital and University of Washington School of Medicine, 4800 Sand Point Way NE, Seattle, WA, USA
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Viel-Thériault I, Agarwal A, Bariciak E, Le Saux N, Thampi N. Antimicrobial Prophylaxis Use in the Neonatal Intensive Care Unit: An Antimicrobial Stewardship Target That Deserves Attention! Am J Perinatol 2022; 39:1288-1291. [PMID: 33454950 DOI: 10.1055/s-0040-1722600] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Previous analyses of neonatal intensive care units (NICU) antimicrobial stewardship programs have identified key contributors to overall antibiotic use, including prolonged empiric therapy >48 hours for early-onset sepsis (EOS). However, most were performed in mixed NICU settings with onsite birthing units, resulting in a high proportion of inborn patient admissions. The study aimed to describe and analyze the most common reasons for antimicrobial use in an outborn tertiary care NICU. STUDY DESIGN This was a 10-month review of all antimicrobial doses prescribed in a 20-bed level III NICU. The primary outcome was the total days of therapy (DOT) and length of therapy (LOT) for each clinical indication. Secondary outcomes included total DOT for each antimicrobial and appropriateness of antimicrobial courses. RESULTS Of 235 antibiotic courses and 1,899 DOT (519 DOT/1,000 patient days) prescribed in 173 infants during the study period, the most common indications were suspected EOS, followed by prophylaxis. Among the 85 DOT/1,000 patient days (PD; 38 courses) prescribed for prophylaxis, 52.5 DOT/1,000 PD (25 courses; 62%) were for surgical prophylaxis. Of 17 postoperative antibiotic courses, 15 (88.2%) were deemed to be inappropriate mostly due to a duration greater than 24 hours postoperatively (n = 13; median LOT = 3 days). CONCLUSION Surgical prophylaxis is a common reason for antimicrobial misuse in outborn NICU. NICU-based prospective audit and feedback between neonatologists and antimicrobial stewardship teams alone may not be impactful in this setting. Partnerships with neonatologists and surgeons will be key to achieving the target of less than 24 hours of postoperative antimicrobials. KEY POINTS · Surgical prophylaxis is a common reason for antimicrobial misuse in the NICU.. · Antimicrobial prophylaxis duration of less than 24 hours postoperatively should be encouraged.. · NICU-based prospective audit and feedback may not be impactful unless surgeons are involved..
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Affiliation(s)
- Isabelle Viel-Thériault
- Division of Infectious Diseases, Department of Pediatrics, Centre Hospitalier de l'Université Laval, Québec, Québec, Canada
| | - Amisha Agarwal
- Research Institute, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Erika Bariciak
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Nicole Le Saux
- Division of Infectious Diseases, Department of Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Nisha Thampi
- Division of Infectious Diseases, Department of Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
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5
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Carr S, Gogal C, Afshar K, Ting J, Skarsgard E. Optimizing skin antisepsis for neonatal surgery: A quality improvement initiative. J Pediatr Surg 2022; 57:1235-1241. [PMID: 35397873 DOI: 10.1016/j.jpedsurg.2022.02.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 02/23/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE Surgical site infections (SSIs) are a significant determinant of morbidity in the Neonatal Intensive Care Unit (NICU). Chlorhexidine gluconate/isopropyl alcohol (CHG-IPA) skin prep has demonstrated superiority over Povidone-Iodine (PI) in preventing SSIs in adults, however FDA labeling discourages CHG use in infants <2 months. This project aimed to i) create evidence for safe CHG skin antisepsis in neonates; and ii) evaluate the safety and effectiveness of CHG skin prep for neonatal surgery. METHODS A literature review was conducted to assess the safety and effectiveness of neonatal CHG skin antisepsis. Following stakeholder engagement, a CHG surgical skin prep protocol and validated neonatal skin integrity tool to assess prep-associated skin injury were implemented in 50 consecutive, eligible neonates ≥1500 g and ≥34 weeks post conceptual age undergoing abdominal or thoracic surgery. SSI rates were compared to a matched, historical PI skin prep cohort. RESULTS 2%CHG-70%IPA or 0.5%CHG-70%IPA were used based on gestational age cutoffs. None of the CHG patients experienced adverse skin prep outcomes while 8% developed SSIs, compared to 14% in the historical PI cohort. CONCLUSION This project engaged NICU stakeholders in quality improvement work and informed the implementation of a safe and effective CHG skin prep protocol for neonatal surgery. LOE: IV.
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Affiliation(s)
- Sophie Carr
- Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Carmina Gogal
- Clinical Care Analyst, Surgical Services and National Surgical Quality Improvement Program, BC Children's Hospital, Vancouver, Canada
| | - Kourosh Afshar
- Department of Surgery, British Columbia Children's Hospital/Department of Urologic Sciences, University of British Columbia, Vancouver, Canada
| | - Joseph Ting
- Division of Neonatology, Department of Pediatrics, University of Alberta, Edmonton, Canada
| | - Erik Skarsgard
- Department of Surgery, British Columbia Children's Hospital and the University of British Columbia, Vancouver, Canada.
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Abdelgawad MA, Parambi DGT, Ghoneim MM, Alotaibi NH, Alzarea AI, Alanazi AS, Hassan A, Tony SM, Abdelrahim ME. A meta-analysis showing the effect of surgical site wound infections and associated risk factors in neonatal surgeries. Int Wound J 2022; 19:2092-2100. [PMID: 35445789 DOI: 10.1111/iwj.13814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 03/31/2022] [Accepted: 04/06/2022] [Indexed: 11/27/2022] Open
Abstract
A meta-analysis was performed to assess the effect of surgical site wound infections and risk factors in neonates undergoing surgery. A systematic literature search up to January 2022 incorporated 17 trials involving 645 neonates who underwent surgery at the beginning of the trial; 198 of them had surgical site wound infections, and 447 were control for neonates. The statistical tools like the dichotomous or continuous method used within a random or fixed-influence model to establish the odds ratio (OR) and mean difference (MD) with 95% confidence intervals (CIs) to evaluate the risk factors and influence of surgical site wound infections in neonates undergoing surgery. Surgical site wound infections had significantly higher mortality with OR value 2.03 at 95% CI 1.40-2.95 with P-value <0.001, the longer length of hospital stay (MD, 31.88; 95% CI, 18.17-45.59, P < 0.001), and lower birthweight of neonates (MD, -0.30; 95% CI, -0.53 to -0.07, P = 0.01) compared with neonates with no surgical site wound infections undergoing surgery. However, no remarkable change was observed with surgical site wound infections in the gestational age at birth of neonates (MD, -0.70; 95% CI, -1.46 to 0.05, P = 0.07), and the preoperative antibiotic prophylaxis (OR, 1.28; 95% CI, 0.57-2.87, P = 0.55) compared with no surgical site wound infections for neonates undergoing surgery. Surgical site wound infections had significantly higher mortality, a longer length of hospital stay, and lower birthweight of neonates. However, they had no statistically significant difference in the gestational age at birth of neonates and the preoperative antibiotic prophylaxis compared with no surgical site wound infections for neonates undergoing surgery. Furthermore, evidence is needed to confirm the outcomes.
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Affiliation(s)
- Mohamed A Abdelgawad
- Department of Pharmaceutical Chemistry, College of Pharmacy, Jouf University, Sakaka, Saudi Arabia
| | - Della G T Parambi
- Department of Pharmaceutical Chemistry, College of Pharmacy, Jouf University, Sakaka, Saudi Arabia
| | - Mohammed M Ghoneim
- Department of Pharmacy Practice, Faculty of Pharmacy, AlMaarefa University, Ad Diriyah, Saudi Arabia
| | - Nasser Hadal Alotaibi
- Department of clinical pharmacy, College of pharmacy, Jouf university Sakaka, Al Jouf, Saudi Arabia
| | | | - Abdullah S Alanazi
- Department of clinical pharmacy, College of pharmacy, Jouf university Sakaka, Al Jouf, Saudi Arabia.,Health sciences research unit, Jouf university, Sakaka, Saudi Arabia
| | - Ahmed Hassan
- Clinical Pharmacy Department, Faculty of Pharmacy, University of Sadat City (USC), Sadat City, Egypt
| | - Sara M Tony
- Clinical pharmacy department, Beni-suef specialized hospital, Beni-Suef, Egypt
| | - Mohamed Ea Abdelrahim
- Department of Clinical Pharmacy, Faculty of Pharmacy, Beni-Suef, Beni-Suef University, Beni-Suef, Egypt
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Del Bigio JZ, Tannuri ACA, Falcão MC, de Carvalho WB, Matsushita FY. Gastroschisis and late-onset neonatal sepsis in a tertiary referral center in Southeastern Brazil. J Pediatr (Rio J) 2022; 98:168-174. [PMID: 34153237 PMCID: PMC9432041 DOI: 10.1016/j.jped.2021.05.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 05/03/2021] [Accepted: 05/03/2021] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVES To analyze late-onset sepsis and to describe the etiological agents in newborns with gastroschisis. METHODS A retrospective cohort, including newborns with gastroschisis whose admissions occurred in the period between January 2012 to December 2018 in a tertiary referral center. Maternal and newborn characteristics, surgical procedures and evolution in hospitalization were verified. A bivariate analysis was performed with patients with proven late-onset neonatal sepsis and according to the simple or complex gastroschisis category, the prevalent microorganisms in positive cultures were identified, statistical tests were carried out and the significance level adopted was p < 0,05. Results are presented in proportions, averages and standard deviation or medians. The level of significance adopted was p < 0.05. RESULTS 101 newborns were analyzed, 45 (44.5%) were confirmed late-onset sepsis. The median birth weight was 2285+498 grams, and the gestational age was 35.9 +1.74weeks. The incidence of complex gastroschisis was 17.8%, the hospitalization time was 48.2+29.67 days and mortality was 9.9%. The newborns were divided into 2 groups: Group 1: late-onset sepsis (44.6%), and Group 2: no late-onset sepsis. The presence of complex gastroschisis was a factor associated with infection (p < 0.009). Fasting time (p < 0.001), parenteral nutrition time (p < 0.001), time to achieve full diet (p < 0.001), and hospitalization stay (p < 0.001) were higher in group 2. Gram-positive were the most frequent (51.1%), followed by Gram-negative (20%), and fungi (4.4%). CONCLUSIONS Newborns with gastroschisis have a higher risk of evolving with late-onset sepsis, despite this study did not calculate the risk of sepsis statistically, and the main germs detected by cultures were gram-positive bacteria, specifically Staphylococcus epidermidis.
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Affiliation(s)
- Juliana Zoboli Del Bigio
- Universidade de São Paulo, Faculdade de Medicina, Instituto da Criança e do Adolescente, Unidade de Terapia Intensiva Neonatal, São Paulo, SP, Brazil.
| | - Ana Cristina Aoun Tannuri
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Pediatria, Divisão de Cirurgia Pediátrica, São Paulo, SP, Brazil
| | - Mário Cícero Falcão
- Universidade de São Paulo, Faculdade de Medicina, Instituto da Criança e do Adolescente, Unidade de Terapia Intensiva Neonatal, São Paulo, SP, Brazil
| | - Werther Brunow de Carvalho
- Universidade de São Paulo, Faculdade de Medicina, Instituto da Criança e do Adolescente, Unidade de Terapia Intensiva Neonatal, São Paulo, SP, Brazil
| | - Felipe Yu Matsushita
- Universidade de São Paulo, Faculdade de Medicina, Instituto da Criança e do Adolescente, Unidade de Terapia Intensiva Neonatal, São Paulo, SP, Brazil
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Ting JY, Autmizguine J, Dunn MS, Choudhury J, Blackburn J, Gupta-Bhatnagar S, Assen K, Emberley J, Khan S, Leung J, Lin GJ, Lu-Cleary D, Morin F, Richter LL, Viel-Thériault I, Roberts A, Lee KS, Skarsgard ED, Robinson J, Shah PS. Practice Summary of Antimicrobial Therapy for Commonly Encountered Conditions in the Neonatal Intensive Care Unit: A Canadian Perspective. Front Pediatr 2022; 10:894005. [PMID: 35874568 PMCID: PMC9304938 DOI: 10.3389/fped.2022.894005] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 06/13/2022] [Indexed: 11/29/2022] Open
Abstract
Neonates are highly susceptible to infections owing to their immature cellular and humoral immune functions, as well the need for invasive devices. There is a wide practice variation in the choice and duration of antimicrobial treatment, even for relatively common conditions in the NICU, attributed to the lack of evidence-based guidelines. Early decisive treatment with broad-spectrum antimicrobials is the preferred clinical choice for treating sick infants with possible bacterial infection. Prolonged antimicrobial exposure among infants without clear indications has been associated with adverse neonatal outcomes and increased drug resistance. Herein, we review and summarize the best practices from the existing literature regarding antimicrobial use in commonly encountered conditions in neonates.
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Affiliation(s)
- Joseph Y Ting
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada.,Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Julie Autmizguine
- Division of Infectious Diseases, Department of Pediatrics, Université de Montreal, Montreal, QC, Canada.,Department of Pharmacology and Physiology, Université de Montréal, Montreal, QC, Canada
| | - Michael S Dunn
- Division of Neonatology, Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | - Julie Choudhury
- Department of Pharmacy, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Julie Blackburn
- Department of Microbiology, Infectious Diseases and Immunology, Université de Montreal, Montreal, QC, Canada
| | - Shikha Gupta-Bhatnagar
- Division of Neonatology, Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Katrin Assen
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Julie Emberley
- Division of Neonatology, Department of Pediatrics, University of Manitoba, Winnipeg, MB, Canada
| | - Sarah Khan
- Department of Microbiology, McMaster University, Hamilton, ON, Canada
| | - Jessica Leung
- Department of Pediatrics, University of Massachusetts, Worcester, MA, United States
| | - Grace J Lin
- School of Medicine, Queen's University, Kingston, ON, Canada
| | | | - Frances Morin
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Lindsay L Richter
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Isabelle Viel-Thériault
- Division of Infectious Diseases, Department of Pediatrics, CHU de Québec-Université Laval, Québec, QC, Canada
| | - Ashley Roberts
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Kyong-Soon Lee
- Division of Neonatology, Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | - Erik D Skarsgard
- Division of Pediatric Surgery, Department of Surgery, University of British Columbia, Vancouver, BC, Canada
| | - Joan Robinson
- Division of Infectious Diseases, Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Prakesh S Shah
- Division of Neonatology, Department of Pediatrics, University of Toronto, Toronto, ON, Canada
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Kapapa M, Rieg T, Serra A. Does meconium contaminated amniotic fluid affect intestinal wall thickness and functional outcome in patients with anterior abdominal wall defects? Afr J Paediatr Surg 2022; 19:46-51. [PMID: 34916352 PMCID: PMC8759423 DOI: 10.4103/ajps.ajps_8_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Gastroschisis (GS) and omphalocele (OC) are congenital abdominal wall defects, the main difference between is the direct exposure of intestinal loops in amniotic fluid in children with a GS. This leads to a reduced primary closure rate and a higher number of intraoperative abnormalities and post-operative complications. AIMS AND OBJECTIVES We analysed abdominal wall defect patients over an 11-year period, aiming to assess the influence of meconium-contaminated amniotic fluid. This study has different objectives to show the consequence of functional outcome of abdominal wall defects (AWD) children in reliance to colour of amniotic fluid, to assess the effect of reduced bowel exposure time to meconium contaminated amniotic fluid on edematous inflammatory thickening of the bowel loops, to show an positively influence in the number of primary AWD closures, to demonstrate a reduced incidence of post-natal complications and to verify a better outcome of OC children because of failing exposure to amniotic fluid. METHODS A retrospective, observational case-control design was used to compare GS (n = 36) and OC (n = 18) children. Physical data, colour of amniotic fluid, pre- and perinatal problems, operative complications and surgical technique, post-operative complications, duration of intensive care unit (ICU) stay, mechanical ventilation, parenteral nutrition, commencement of oral feeding and total hospital stay were collected. Data were analysed with descriptive methods, t-test and non-parametric tests such as Wilcoxon and Kruskal-Wallis were performed in addition to the analysis of variance, including post hoc testing accepting a confidence interval of 95% (P < 0.05) by using IBM SPSS software, version 23 (IBM, Illinois, USA). RESULTS Rate of meconium-contaminated amniotic fluid is significantly higher in GS compared to OC (P < 0.001), delivery problems such as congenital infections are also significantly higher (P < 0.001), this yields in significantly more bowel loops anomalies and problems during surgery (P < 0.036) but had no significant influence on primary abdominal wall closures rate (P = 0.523). The post-surgical outcome of OC was significantly better as compared to GS. Within the GS, those with swollen intestines had significantly longer ICU stays (P = 0.045) due to extended mechanical ventilation (P = 0.007), parenteral nutrition (P = 0.011) and delayed initiation of oral feeding (P < 0.001. Same results were found for the duration of ICU stay (P = 0.008), mechanical ventilation (P = 0.006), parenteral nutrition (P = 0.011) and delayed initiation of oral feeding (P < 0.001) in secondary closures as compared to primary abdominal wall closures in the GS group. CONCLUSIONS Worsen functional short-term outcome of GS children was directly addicted to meconium contamination of amniotic fluid due to swollen intestines and because of this more post-surgical problem including significantly extended hospital stays were observed.
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Affiliation(s)
- Melanie Kapapa
- Department of Surgery, Division of Pediatric Surgery, University Ulm Medical Centre, Eythstrasse, Ulm, Germany
| | - Teresa Rieg
- Department of Gynaecology and Obstetrics, Hospital Heidenheim, Heidenheim an der Brenz, Germany
| | - Alexandre Serra
- Department of Surgery, Division of Pediatric Surgery, University Ulm Medical Centre, Eythstrasse, Ulm, Germany
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10
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Al Maawali A, Skarsgard ED. The medical and surgical management of gastroschisis. Early Hum Dev 2021; 162:105459. [PMID: 34511287 DOI: 10.1016/j.earlhumdev.2021.105459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Gastroschisis (GS) is a full-thickness abdominal wall defect in which fetal intestine herniates alongside the umbilical cord into the intrauterine cavity, resulting in an intestinal injury of variable severity. An increased prevalence of gastroschisis has been observed across several continents and is a focus of epidemiologic study. Prenatal diagnosis of GS is common and allows for delivery planning and treatment in neonatal intensive care units (NICUs) by collaborative interdisciplinary teams (neonatology, neonatal nursing and pediatric surgery). Postnatal treatment focuses on closure of the defect, optimized nutrition, complication avoidance and a timely transition to enteral feeding. Babies born with complex GS are more vulnerable to complications, have longer and more resource intensive hospital stays and benefit from standardized care pathways provided by teams with expertise in managing infants with intestinal failure. This article will review the current state of knowledge related to the medical and surgical management and outcomes of gastroschisis with a special focus on the role of the neonatologist in supporting integrated team-based care.
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Affiliation(s)
| | - Erik D Skarsgard
- Department of Surgery, British Columbia Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada.
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11
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Behram M, Oğlak SC, Özaydın S, Çaypınar SS, Gönen İ, Tunç Ş, Başkıran Y, Özdemir İ. What is the main factor in predicting the morbidity and mortality in patients with gastroschisis: delivery time, delivery mode, closure method, or the type of gastroschisis (simple or complex)? Turk J Med Sci 2021; 51:1587-1595. [PMID: 33550767 PMCID: PMC8283496 DOI: 10.3906/sag-2011-166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Accepted: 02/06/2021] [Indexed: 11/06/2022] Open
Abstract
Background/aim There are numerous debates in the management of gastroschisis (GS). The current study aimed to evaluate perinatal outcomes and surgical and clinical characteristics among GS patients based on their type of GS, abdominal wall closure method, and delivery timing. Materials and methods This study was a retrospective analysis of prospectively collected data of 29 fetuses with GS that were prenatally diagnosed, delivered, and managed between June 2015 and December 2019 at the Obstetrics and Pediatric Surgery Clinics of Kanuni Sultan Süleyman Training and Research Hospital. Results Twenty-three of the patients had simple GS, and six of them had complex GS. The reoperation requirement, number of operations, duration of mechanical ventilation, time to initiate feeding, time to full enteral feeding, total parenteral nutrition (TPN) duration, TPN-associated cholestasis, wound infection, sepsis, and necrotizing enterocolitis were significantly lower in the simple GS group than in the complex GS group. The mean hospital length of stay was 3.5 times longer in the complex GS group (121.50 ± 24.42 days) than in the simple GS group (33.91 ± 4.13 days, p = 0.009). There were no cases of death in the simple GS group. However, two deaths occurred in the complex GS group. Conclusion This study indicated that simple GS, compared with complex GS, was associated with improved neonatal outcomes. We suggest that the main factor affecting the patients’ outcomes is whether the patient is a simple or complex GS rather than the abdominal wall closure method.
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Affiliation(s)
- Mustafa Behram
- Department of Perinatology, Health Sciences University, Kanuni Sultan Süleyman Training and Research Hospital, İstanbul, Turkey
| | - Süleyman Cemil Oğlak
- Department of Obstetrics and Gynecology, Health Sciences University, Gazi Yaşargil Training and Research Hospital, Diyarbakır, Turkey
| | - Seyithan Özaydın
- Department of Pediatric Surgery, Health Sciences University, Kanuni Sultan Süleyman Training and Research Hospital, İstanbul, Turkey
| | - Sema Süzen Çaypınar
- Department of Perinatology, Health Sciences University, Kanuni Sultan Süleyman Training and Research Hospital, İstanbul, Turkey
| | - İlker Gönen
- Department of Neonatology, Health Sciences University, Kanuni Sultan Süleyman Training and Research Hospital, İstanbul, Turkey
| | - Şeyhmus Tunç
- Department of Obstetrics and Gynecology, Health Sciences University, Gazi Yaşargil Training and Research Hospital, Diyarbakır, Turkey
| | - Yusuf Başkıran
- Department of Perinatology, Health Sciences University, Kanuni Sultan Süleyman Training and Research Hospital, İstanbul, Turkey
| | - İsmail Özdemir
- Department of Perinatology, Health Sciences University, Kanuni Sultan Süleyman Training and Research Hospital, İstanbul, Turkey
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12
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Abstract
BACKGROUND Neonates with abdominal wall defects are at an increased infection risk because of the defect itself and prolonged neonatal intensive care unit (NICU) stays. Antibiotic prophylaxis until closure of the defect is common. However, infection risk and antibiotic use have not been well quantified in these infants. METHODS A retrospective cohort study of infants with abdominal wall defects (gastroschisis and omphalocele) admitted to a single-center NICU from 2007 to 2018. Demographic and clinical information, including microbiologic studies, antibiotic dosing and surgical care, were collected. Antibiotic use was quantified using days of therapy (DOT) per 1000 patient-days. Sepsis was defined as culture of a pathogen from a normally sterile site. RESULTS Seventy-four infants were included; 64 (86%) with gastroschisis and 10 (14%) with omphalocele. Median day of closure was 8 days [interquartile range (IQR) 6-10, range 0-31]. All infants received ≥1 course of antibiotics; median antibiotic DOT/infant was 24.5 (IQR 18-36) for an average of 416.5 DOT per 1000 patient-days. Most antibiotic use was preclosure prophylaxis (44%) and treatment of small intestinal bowel overgrowth (24%). Suspected and proven infection accounted for 26% of all antibiotic use. Skin and soft tissue infection (13/74, 18%) and late-onset sepsis (11/74, 15%) were the most common infections; 2 infants had sepsis while on antibiotic prophylaxis. All infants survived to discharge. CONCLUSIONS Most antibiotic use among infants with abdominal wall defects was prophylactic. Infection on prophylaxis was rare, but 35% of infants had infection after prophylaxis. Improved stewardship strategies are needed for these high-risk infants.
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13
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Martins BMR, Abreu I, Méio MDB, Moreira MEL. Gastroschisis in the neonatal period: A prospective case-series in a Brazilian referral center. J Pediatr Surg 2020; 55:1546-1551. [PMID: 32467036 DOI: 10.1016/j.jpedsurg.2020.04.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 04/19/2020] [Accepted: 04/20/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND/PURPOSE Gastroschisis is increasing in incidence and has low mortality and high morbidity. We describe the clinical and surgical characteristics of gastroschisis patients in a Brazilian referral center. METHODS Single-center prospective case series of gastroschisis patients. The following two groups were formed depending on the intestinal characteristics: simple and complex patients. RESULTS In total, 79 patients were enrolled, 89% of whom were classified as simple and 11% as complex. The baseline characteristics were similar between the groups, with the exception of the illness severity score. The complex group had a significantly smaller defect size, more reoperations and worse clinical outcomes than the simple group, with the initiation of feeding taking 1.5 times longer, the duration of total parenteral nutrition taking twice as long, and the length of hospitalization being 2.5 times longer; the complex group also included all the deaths that occurred. Overall, the survival rate was 96%. Patients who underwent the sutureless technique had significantly fewer wound infections and a decreased duration of mechanical ventilation than sutured patients. CONCLUSIONS This study provides a comprehensive picture of gastroschisis during the neonatal period in a Brazilian referral center, emphasizing the significantly higher risk for morbidity and mortality among complex patients than among simple patients and the few advantages of the sutureless technique over the sutured technique in terms of closing the defect. TYPE OF STUDY Prognostic. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Bianca M R Martins
- Department of Surgery, Surgical NICU, Instituto Fernandes Figueira - Fundação Oswaldo Cruz, FIOCRUZ, Rio de Janeiro, Brazil.
| | - Isabel Abreu
- Department of Surgery, Surgical NICU, Instituto Fernandes Figueira - Fundação Oswaldo Cruz, FIOCRUZ, Rio de Janeiro, Brazil
| | - Maria Dalva B Méio
- Clinical Research Unit, Instituto Fernandes Figueira - Fundação Oswaldo Cruz, FIOCRUZ, Rio de Janeiro, Brazil
| | - Maria Elisabeth L Moreira
- Clinical Research Unit, Instituto Fernandes Figueira - Fundação Oswaldo Cruz, FIOCRUZ, Rio de Janeiro, Brazil
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14
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Modi N, Ashby D, Battersby C, Brocklehurst P, Chivers Z, Costeloe K, Draper ES, Foster V, Kemp J, Majeed A, Murray J, Petrou S, Rogers K, Santhakumaran S, Saxena S, Statnikov Y, Wong H, Young A. Developing routinely recorded clinical data from electronic patient records as a national resource to improve neonatal health care: the Medicines for Neonates research programme. PROGRAMME GRANTS FOR APPLIED RESEARCH 2019. [DOI: 10.3310/pgfar07060] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Background
Clinical data offer the potential to advance patient care. Neonatal specialised care is a high-cost NHS service received by approximately 80,000 newborn infants each year.
Objectives
(1) To develop the use of routinely recorded operational clinical data from electronic patient records (EPRs), secure national coverage, evaluate and improve the quality of clinical data, and develop their use as a national resource to improve neonatal health care and outcomes. To test the hypotheses that (2) clinical and research data are of comparable quality, (3) routine NHS clinical assessment at the age of 2 years reliably identifies children with neurodevelopmental impairment and (4) trial-based economic evaluations of neonatal interventions can be reliably conducted using clinical data. (5) To test methods to link NHS data sets and (6) to evaluate parent views of personal data in research.
Design
Six inter-related workstreams; quarterly extractions of predefined data from neonatal EPRs; and approvals from the National Research Ethics Service, Health Research Authority Confidentiality Advisory Group, Caldicott Guardians and lead neonatal clinicians of participating NHS trusts.
Setting
NHS neonatal units.
Participants
Neonatal clinical teams; parents of babies admitted to NHS neonatal units.
Interventions
In workstream 3, we employed the Bayley-III scales to evaluate neurodevelopmental status and the Quantitative Checklist of Autism in Toddlers (Q-CHAT) to evaluate social communication skills. In workstream 6, we recruited parents with previous experience of a child in neonatal care to assist in the design of a questionnaire directed at the parents of infants admitted to neonatal units.
Data sources
Data were extracted from the EPR of admissions to NHS neonatal units.
Main outcome measures
We created a National Neonatal Research Database (NNRD) containing a defined extract from real-time, point-of-care, clinician-entered EPRs from all NHS neonatal units in England, Wales and Scotland (n = 200), established a UK Neonatal Collaborative of all NHS trusts providing neonatal specialised care, and created a new NHS information standard: the Neonatal Data Set (ISB 1595) (see http://webarchive.nationalarchives.gov.uk/±/http://www.isb.nhs.uk/documents/isb-1595/amd-32–2012/index_html; accessed 25 June 2018).
Results
We found low discordance between clinical (NNRD) and research data for most important infant and maternal characteristics, and higher prevalence of clinical outcomes. Compared with research assessments, NHS clinical assessment at the age of 2 years has lower sensitivity but higher specificity for identifying children with neurodevelopmental impairment. Completeness and quality are higher for clinical than for administrative NHS data; linkage is feasible and substantially enhances data quality and scope. The majority of hospital resource inputs for economic evaluations of neonatal interventions can be extracted reliably from the NNRD. In general, there is strong parent support for sharing routine clinical data for research purposes.
Limitations
We were only able to include data from all English neonatal units from 2012 onwards and conduct only limited cross validation of NNRD data directly against data in paper case notes. We were unable to conduct qualitative analyses of parent perspectives. We were also only able to assess the utility of trial-based economic evaluations of neonatal interventions using a single trial. We suggest that results should be validated against other trials.
Conclusions
We show that it is possible to obtain research-standard data from neonatal EPRs, and achieve complete population coverage, but we highlight the importance of implementing systematic examination of NHS data quality and completeness and testing methods to improve these measures. Currently available EPR data do not enable ascertainment of neurodevelopmental outcomes reliably in very preterm infants. Measures to maintain high quality and completeness of clinical and administrative data are important health service goals. As parent support for sharing clinical data for research is underpinned by strong altruistic motivation, improving wider public understanding of benefits may enhance informed decision-making.
Future work
We aim to implement a new paradigm for newborn health care in which continuous incremental improvement is achieved efficiently and cost-effectively by close integration of evidence generation with clinical care through the use of high-quality EPR data. In future work, we aim to automate completeness and quality checks and make recording processes more ‘user friendly’ and constructed in ways that minimise the likelihood of missing or erroneous entries. The development of criteria that provide assurance that data conform to prespecified completeness and quality criteria would be an important development. The benefits of EPR data might be extended by testing their use in large pragmatic clinical trials. It would also be of value to develop methods to quality assure EPR data including involving parents, and link the NNRD to other health, social care and educational data sets to facilitate the acquisition of lifelong outcomes across multiple domains.
Study registration
This study is registered as PROSPERO CRD42015017439 (workstream 1) and PROSPERO CRD42012002168 (workstream 3).
Funding
The National Institute for Health Research Programme Grants for Applied Research programme (£1,641,471). Unrestricted donations were supplied by Abbott Laboratories (Maidenhead, UK: £35,000), Nutricia Research Foundation (Schiphol, the Netherlands: £15,000), GE Healthcare (Amersham, UK: £1000). A grant to support the use of routinely collected, standardised, electronic clinical data for audit, management and multidisciplinary feedback in neonatal medicine was received from the Department of Health and Social Care (£135,494).
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Affiliation(s)
- Neena Modi
- Department of Medicine, Imperial College London, London, UK
| | - Deborah Ashby
- Imperial Clinical Trials Unit, Imperial College London, London, UK
| | | | - Peter Brocklehurst
- Birmingham Clinical Trials Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | | | - Kate Costeloe
- Centre for Genomics and Child Health, Queen Mary University of London, London, UK
| | | | - Victoria Foster
- Department of Social Sciences, Edge Hill University, Ormskirk, UK
| | - Jacquie Kemp
- National Programme of Care, NHS England, London, UK
| | - Azeem Majeed
- School of Public Health, Imperial College London, London, UK
| | | | - Stavros Petrou
- Division of Health Sciences, University of Warwick, Coventry, UK
| | - Katherine Rogers
- School of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK
| | | | - Sonia Saxena
- School of Public Health, Imperial College London, London, UK
| | | | - Hilary Wong
- Department of Paediatrics, University of Cambridge, Cambridge, UK
| | - Alys Young
- School of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK
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15
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Abstract
Infection following surgical procedures leads to increased morbidity and mortality in all populations. Guidelines to aid providers in the proper use of prophylactic antibiotics exist for adults, but are rare in the neonatal surgical population. A recent emphasis on appropriate antibiotic stewardship had led to the development of more guidelines without a coincident increase in surgical site infection. Robust data from randomized, controlled trials, however, remain sparse.
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Affiliation(s)
- Carrie Laituri
- Joe DiMaggio Children's Hospital, Memorial Healthcare System, Hollywood, FL, USA
| | - Meghan A Arnold
- Department of Surgery, Section of Pediatric Surgery, University of Michigan, Ann Arbor, MI, USA.
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16
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Abstract
The expected outcome of gastroschisis has evolved from an almost certain death of the child prior to the use of parenteral nutrition to almost certain survival. The primary goal of the surgical intervention is return of eviscerated contents into the abdominal cavity. The optimal surgical technique is dependent on the status of the intestine and the accommodation of abdominal domain. In this review, the various surgical techniques for management are discussed as they have evolved. Ironically, a minimalist surgical intervention originally practiced due to the poor expected outcome is now being adopted as a minimalist surgical approach for abdominal wall closure associated with an expected excellent outcome.
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Affiliation(s)
- Mikael Petrosyan
- Children's National Health System, George Washington University Medical Center, United States
| | - Anthony D Sandler
- Children's National Health System, George Washington University Medical Center, United States.
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17
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Mansfield SA, Ryshen G, Dail J, Gossard M, McClead R, Aldrink JH. Use of quality improvement (QI) methodology to decrease length of stay (LOS) for newborns with uncomplicated gastroschisis. J Pediatr Surg 2018; 53:1578-1583. [PMID: 29291893 DOI: 10.1016/j.jpedsurg.2017.11.061] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Revised: 10/26/2017] [Accepted: 11/30/2017] [Indexed: 11/25/2022]
Abstract
PURPOSE Gastroschisis is a congenital defect of the abdominal wall leading to considerable morbidity and long hospitalizations. The purpose of this study was to use quality improvement methodology to standardize care in the management of gastroschisis that may contribute to length of stay (LOS). METHODS A gastroschisis quality improvement team established a best-practice protocol in order to decrease LOS in infants with uncomplicated gastroschisis. The specific aim was to decrease median LOS from a baseline of 34days. We used statistical process control charts including rational subgroup analysis to monitor LOS. RESULTS From December 2008 to December 2016, 119 patients with uncomplicated gastroschisis were evaluated. Retrospective data were obtained on 25 patients prior to protocol implementation. Ninety-four patients with uncomplicated gastroschisis comprised the prospective process stage. The median LOS for this retrospective cohort was 34days (IQR: 30.5-50.5), while the median LOS for the prospective cohort following implementation of the protocol decreased to 29days (IQR: 23-43). CONCLUSIONS With the use of quality improvement methodology, including standardization of care and a change in surgical approach, the median LOS for newborns with uncomplicated gastroschisis at our institution decreased from 34days to 29days. LEVEL OF EVIDENCE 3.
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Affiliation(s)
- Sara A Mansfield
- Department of General Surgery, The Ohio State University College of Medicine, Columbus, OH
| | - Gregory Ryshen
- Quality Improvement Services, Nationwide Children's Hospital, Columbus, OH
| | - James Dail
- Quality Improvement Services, Nationwide Children's Hospital, Columbus, OH
| | - Mary Gossard
- Division of Neonatology, Nationwide Children's Hospital, Columbus, OH
| | - Richard McClead
- Department of Pediatrics, Division of Neonatology, The Ohio State University College of Medicine, Nationwide Children's Hospital, Columbus, OH
| | - Jennifer H Aldrink
- Department of Surgery, Division of Pediatric Surgery, The Ohio State University College of Medicine, Nationwide Children's Hospital, Columbus, OH.
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18
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Haddock C, Al Maawali AG, Ting J, Bedford J, Afshar K, Skarsgard ED. Impact of Multidisciplinary Standardization of Care for Gastroschisis: Treatment, Outcomes, and Cost. J Pediatr Surg 2018; 53:892-897. [PMID: 29499843 DOI: 10.1016/j.jpedsurg.2018.02.013] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Accepted: 02/01/2018] [Indexed: 10/18/2022]
Abstract
BACKGROUND/PURPOSE Elimination of unnecessary practice variation through standardization creates opportunities for improved outcomes and cost-effectiveness. A quality improvement (QI) initiative at our institution used evidence and consensus to standardize management of gastroschisis (GS) from birth to discharge. METHODS An interdisciplinary team utilized best practice evidence and expert opinion to standardize GS care. Following stakeholder engagement and education, care standardization was implemented in September 2014. A comparative cohort study was conducted on consecutive patients treated before (n=33) and after (n=24) standardization. Demographic, treatment, and outcome measures were collected from a prospective GS registry. Direct costs were estimated, and protocol compliance was audited. RESULTS BW, GA, and bowel injury severity were comparable between groups. Key practice changes were: closure technique (pre-88% primary fascial, post-83% umbilical cord flap; p<0.001), closure location (pre-97% OR, post-67% NICU; p<0.001), and GA avoidance (pre-0%, post-48%; p<0.001). Median post-closure ventilation days were shorter (pre-4, post-1; p<0.001), and SSI rates trended lower (pre-21%, post-8%; p=0.3) in the post-implementation group with no differences in TPN days or LOS. No significant difference was seen in average per-patient costs: pre-$85,725 ($29,974-221,061), post-$76,329 ($14,205-176,856). CONCLUSION Care standardization for GS enables practice transformation, cost-effective outcome improvement, and supports an organizational culture dedicated to continuous improvement. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Candace Haddock
- Division of Pediatric Surgery, Department of Surgery, British Columbia Children's Hospital, University of British Columbia. Vancouver, BC, Canada
| | - Al Ghalgya Al Maawali
- Division of Pediatric Surgery, Department of Surgery, British Columbia Children's Hospital, University of British Columbia. Vancouver, BC, Canada
| | - Joseph Ting
- Division of Neonatology, Department of Pediatrics, British Columbia Children's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Julie Bedford
- Department of Quality and Safety, British Columbia Children's Hospital, Vancouver, BC, Canada
| | - Kourosh Afshar
- Division of Pediatric Urology, Department of Surgery, British Columbia Children's Hospital; Department of Urologic Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Erik D Skarsgard
- Division of Pediatric Surgery, Department of Surgery, British Columbia Children's Hospital, University of British Columbia. Vancouver, BC, Canada.
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Haddock C, Skarsgard ED. Understanding gastroschisis and its clinical management: where are we? Expert Rev Gastroenterol Hepatol 2018; 12:405-415. [PMID: 29419329 DOI: 10.1080/17474124.2018.1438890] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Gastroschisis is the commonest developmental defect of the anterior abdominal wall in both developed and developing countries. The past 30 years have seen transformational improvements in outcome due to advances in neonatal intensive care and enhanced integration between the disciplines of maternal fetal medicine, neonatology and pediatric surgery. A review of gastroschisis, which emphasizes its epidemiology, multidisciplinary care strategies and contemporary outcomes is timely. Areas covered: This review discusses the current state of knowledge related to prevalence and causation, and postulated embryopathologic mechanisms contributing to the development of gastroschisis. Using relevant, current literature with an emphasis on high level evidence where it exists, we review modern techniques of prenatal diagnosis, pre and postnatal risk stratification, preferred timing and method of delivery, options for abdominal wall closure, nutritional management, and short and long term clinical and neurodevelopmental follow-up. Expert commentary: This section explores controversies in contemporary management which contribute to practice and cost variation and discusses the benefits of novel nutritional therapies and care standardization that target unnecessary practice variation and improve overall cost-effectiveness of gastroschisis care. The commentary concludes with a review of fertile areas of gastroschisis research, which represent opportunities for knowledge synthesis and further outcome improvement.
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Affiliation(s)
- Candace Haddock
- a Department of Surgery , British Columbia Children's Hospital , Vancouver , Canada
| | - Erik D Skarsgard
- a Department of Surgery , British Columbia Children's Hospital , Vancouver , Canada
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20
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Williams SL, Leonard M, Hall ES, Perez J, Wessel J, Kingma PS. Evaluation of Early Onset Sepsis, Complete Blood Count, and Antibiotic Use in Gastroschisis. Am J Perinatol 2018; 35:385-389. [PMID: 29084414 PMCID: PMC5842123 DOI: 10.1055/s-0037-1607420] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Gastroschisis is a congenital defect in which the abdominal viscera herniate through the abdominal wall. In this population, antibiotics are often initiated immediately following delivery; however, this may be unnecessary as infections typically develop as a consequence of chronic issues in gastroschisis. The objective of this study was to evaluate the incidence of culture positive early onset sepsis, the reliability of the immature to mature neutrophil count (I:T) ratio as an infectious biomarker, and antibiotic use in infants with gastroschisis. STUDY DESIGN This retrospective chart review analyzed clinical data from 103 infants with gastroschisis and 103 weight-matched controls that were evaluated for early onset infection. RESULTS Compared with the control group, there was a significantly increased percentage of infants with an I:T ratio > 0.2 in the gastroschisis group (43% vs. 12%, p < 0.001) and an increased percentage of infants exposed to greater than 5 days of antibiotics regardless of their I:T ratio (75% vs. 6%, p < 0.001). There were no episodes of culture positive early onset sepsis in either group. CONCLUSION Our results indicate that I:T ratio is not a reliable marker of infection in gastroschisis, and suggest that empiric septic evaluation and antibiotic use, immediately following delivery in gastroschisis infants, may be unnecessary.
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Affiliation(s)
- Sadie L Williams
- The Perinatal Institute, Section of Neonatology, Perinatal and Pulmonary Biology Cincinnati Children’s, Hospital Medical Center, Cincinnati, Ohio
| | - Matthew Leonard
- The Perinatal Institute, Section of Neonatology, Perinatal and Pulmonary Biology Cincinnati Children’s, Hospital Medical Center, Cincinnati, Ohio
| | - Eric S Hall
- The Perinatal Institute, Section of Neonatology, Perinatal and Pulmonary Biology Cincinnati Children’s, Hospital Medical Center, Cincinnati, Ohio
| | - Jose Perez
- Winnie Palmer Hospital, Mednax Health Partner Solutions, Orlando, Florida
| | - Jacqueline Wessel
- Division of Nutrition Therapy, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Paul S Kingma
- The Perinatal Institute, Section of Neonatology, Perinatal and Pulmonary Biology Cincinnati Children’s, Hospital Medical Center, Cincinnati, Ohio,Cincinnati Fetal Center, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
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21
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Statnikov Y, Ibrahim B, Modi N. A systematic review of administrative and clinical databases of infants admitted to neonatal units. Arch Dis Child Fetal Neonatal Ed 2017; 102:F270-F276. [PMID: 28087722 DOI: 10.1136/archdischild-2016-312010] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Revised: 12/14/2016] [Accepted: 12/17/2016] [Indexed: 11/04/2022]
Abstract
OBJECTIVES High quality information, increasingly captured in clinical databases, is a useful resource for evaluating and improving newborn care. We conducted a systematic review to identify neonatal databases, and define their characteristics. METHODS We followed a preregistered protocol using MesH terms to search MEDLINE, EMBASE, CINAHL, Web of Science and OVID Maternity and Infant Care Databases for articles identifying patient level databases covering more than one neonatal unit. Full-text articles were reviewed and information extracted on geographical coverage, criteria for inclusion, data source, and maternal and infant characteristics. RESULTS We identified 82 databases from 2037 publications. Of the country-specific databases there were 39 regional and 39 national. Sixty databases restricted entries to neonatal unit admissions by birth characteristic or insurance cover; 22 had no restrictions. Data were captured specifically for 53 databases; 21 administrative sources; 8 clinical sources. Two clinical databases hold the largest range of data on patient characteristics, USA's Pediatrix BabySteps Clinical Data Warehouse and UK's National Neonatal Research Database. CONCLUSIONS A number of neonatal databases exist that have potential to contribute to evaluating neonatal care. The majority is created by entering data specifically for the database, duplicating information likely already captured in other administrative and clinical patient records. This repetitive data entry represents an unnecessary burden in an environment where electronic patient records are increasingly used. Standardisation of data items is necessary to facilitate linkage within and between countries.
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Affiliation(s)
- Yevgeniy Statnikov
- Neonatal Data Analysis Unit, Section of Neonatal Medicine, Department of Medicine, Imperial College London, Chelsea & Westminster Hospital campus, London, UK
| | - Buthaina Ibrahim
- Section of Neonatal Medicine, Department of Medicine, Imperial College London, Chelsea & Westminster Hospital campus, London, UK
| | - Neena Modi
- Section of Neonatal Medicine, Department of Medicine, Imperial College London, Chelsea & Westminster Hospital campus, London, UK
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22
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Abstract
PURPOSE OF REVIEW The diagnosis and treatment of gastroschisis spans the perinatal disciplines of maternal fetal medicine, neonatology, and pediatric surgery. Since gastroschisis is one of the commonest and costliest structural birth defects treated in neonatal ICUs, a comprehensive review of its epidemiology, prenatal diagnosis, postnatal treatment, and short and long-term outcomes is both timely and relevant. RECENT FINDINGS The incidence of gastroschisis has increased dramatically over the past 20 years, leading to a renewed interest in causation. The widespread availability of maternal screening and ultrasound results in very high rates of prenatal diagnosis, which enables evaluation of the optimal timing and mode of delivery. The preferred method of surgical closure continues to be an issue of debate among pediatric surgeons, whereas postsurgical treatment seeks to expedite the initiation and progression of enteral feeding and minimize complications. A small subset of babies with complex gastroschisis leading to intestinal failure benefit from the knowledge and expertise of dedicated interdisciplinary teams, which seek to bring novel therapies and improved clinical outcomes. SUMMARY The opportunities to increase the knowledge of causation, and identify best practices leading to improved outcomes, drive the ongoing need for collaborative clinical research in gastroschisis.
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Youssef F, Gorgy A, Arbash G, Puligandla PS, Baird RJ. Flap versus fascial closure for gastroschisis: a systematic review and meta-analysis. J Pediatr Surg 2016; 51:718-25. [PMID: 26970850 DOI: 10.1016/j.jpedsurg.2016.02.010] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Accepted: 02/07/2016] [Indexed: 11/17/2022]
Abstract
BACKGROUND Flap closure represents an alternative to fascial closure for gastroschisis. We performed a systematic review and meta-analysis of outcomes comparing these techniques. METHODS A registered systematic review ( PROSPERO CRD42015016745) of comparative studies was performed, querying multiple databases without language or date restrictions. Gray literature was sought. Outcomes analyzed included: mortality, ventilation days, feeding parameters, length of stay (LOS), wound infection, resource utilization, and umbilical hernia incidence. Multiple reviewers independently assessed study eligibility and literature quality. Meta-analysis of outcomes was performed where appropriate (Revman 5.2). RESULTS Twelve studies met inclusion criteria, of which three were multi-institutional. Quality assessment revealed unbiased patient selection and exposure, but group comparability was suboptimal in four studies. Overall, 1124 patients were evaluated, of which 350 underwent flap closure (210 immediately; 140 post-silo). Meta-analysis revealed no significant differences in mortality, LOS, or feeding parameters between groups. Flap patients had less wound infections (OR 0.40 [95%CI 0.22-0.74], P=0.003). While flap patients had an increased risk of umbilical hernia, they were less likely to undergo repair (19% vs. 41%; P=0.01). CONCLUSIONS Flap closure has equivalent or superior outcomes to fascial closure for patients with gastroschisis. Given potential advantages of bedside closure and reduced sedation requirements, flap closure may represent the preferred closure strategy.
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Affiliation(s)
- Fouad Youssef
- The Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital of the McGill University Health Centre, Montreal, Quebec, Canada, H4A 3J1
| | - Andrew Gorgy
- The Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital of the McGill University Health Centre, Montreal, Quebec, Canada, H4A 3J1
| | - Ghaidaa Arbash
- The Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital of the McGill University Health Centre, Montreal, Quebec, Canada, H4A 3J1
| | - Pramod S Puligandla
- The Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital of the McGill University Health Centre, Montreal, Quebec, Canada, H4A 3J1
| | - Robert J Baird
- The Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital of the McGill University Health Centre, Montreal, Quebec, Canada, H4A 3J1.
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Abstract
There are unique challenges to antimicrobial stewardship in neonatal intensive care units (NICUs). Diagnosis of infection is difficult as neonates can have nonspecific signs and symptoms. Between and within NICUs, significant variation exists in the treatment duration of suspected sepsis and pneumonia. Development of multidisciplinary teams and meaningful metrics are essential for sustainable antibiotic stewardship. Potential stewardship interventions include optimizing culturing techniques, guiding empiric therapy by NICU-specific antibiograms, using ancillary laboratory tests, and promptly discontinuing therapy once infection is no longer suspected. Use of large neonatal databases can be used to benchmark antibiotic use and conduct comparative effectiveness research.
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Affiliation(s)
- Joseph B Cantey
- Division of Pediatric Infectious Disease, Department of Pediatrics, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA; Division of Neonatal/Perinatal Medicine, Department of Pediatrics, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA.
| | - Sameer J Patel
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago Northwestern University Feinberg School of Medicine, 225 East Chicago Avenue, Box 20, Chicago, Illinois 60611-2605, USA
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25
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Schlueter RK, Azarow KS, Hines AG, Varman M, Abdessalam SF, Raynor SC, Cusick RA. Identifying strategies to decrease infectious complications of gastroschisis repair. J Pediatr Surg 2015; 50:98-101. [PMID: 25598102 DOI: 10.1016/j.jpedsurg.2014.10.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2014] [Accepted: 10/06/2014] [Indexed: 11/18/2022]
Abstract
PURPOSE We describe the infectious complications of gastroschisis in order to identify modifiable factors to decrease these complications. METHODS Data from 155 gastroschisis patients (2001-2013) were reviewed. Complicated gastroschisis (intestinal atresia, necrotic bowel, or perforation) were excluded, leaving 129 patients for review. Patient demographics, surgical details, postoperative infections and complications, and length of stay were reviewed. We used CDC definitions of infectious complications. RESULTS The average gestational age of patients was 35.97weeks. Silos were used in 46% of patients (n=59) for an average of 7.4days. Thirty-one patients (24%) acquired an infection within the first 60days of life. Patients who developed an infection were born earlier in gestation (P=0.02), weighed less (P=0.01), required silos more often (P=0.01), and received a sutured repair (P=0.04). Length of stay of patients with an infection was longer than in patients without infection (P=0.01). CONCLUSIONS Infectious complications following gastroschisis repair are common. Subsets of gastroschisis patients at increased risk of infection include patients with silos, preterm delivery, low birth weight, and sutured repair. Based on our findings, our recommendation would be to carry gastroschisis patients to term and advocate against the routine use of silos, reserving their use for those cases when primary closure is not possible.
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Affiliation(s)
- Rachel K Schlueter
- University of Nebraska Medical Center and Children's Hospital, Omaha, NE, USA
| | - Kenneth S Azarow
- University of Nebraska Medical Center and Children's Hospital, Omaha, NE, USA; Oregon Health Sciences University Department of Surgery, Portland, OR, USA
| | - Andrea Green Hines
- University of Nebraska Medical Center and Children's Hospital, Omaha, NE, USA
| | - Meera Varman
- Creighton University Pediatric Infectious Diseases, Omaha, NE, USA
| | - Shahab F Abdessalam
- University of Nebraska Medical Center and Children's Hospital, Omaha, NE, USA
| | - Stephen C Raynor
- University of Nebraska Medical Center and Children's Hospital, Omaha, NE, USA
| | - Robert A Cusick
- University of Nebraska Medical Center and Children's Hospital, Omaha, NE, USA.
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Segal I, Kang C, Albersheim SG, Skarsgard ED, Lavoie PM. Surgical site infections in infants admitted to the neonatal intensive care unit. J Pediatr Surg 2014; 49:381-4. [PMID: 24650461 PMCID: PMC5756080 DOI: 10.1016/j.jpedsurg.2013.08.001] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2013] [Revised: 07/31/2013] [Accepted: 08/02/2013] [Indexed: 01/30/2023]
Abstract
BACKGROUND Surgical interventions are common in infants admitted to the neonatal intensive care unit (NICU). Despite our awareness of the broad impact of surgical site infection (SSI), there are little data in neonates. Our objective was to determine the rate and clinical impact of SSI in infants admitted to the NICU. METHODS Provincial population-based study of infants admitted to a tertiary care NICU. SSI, explicitly defined, was included if it occurred within 30 days of a skin/mucosal-breaking surgical intervention. RESULTS Among 724 infants who underwent 1039 surgical interventions very low birth weight (VLBW) infants were over-represented. The overall SSI rate was 4.3 per 100 interventions [CI 95% 3.2 to 5.7], up to 19 per 100 dirty interventions (wound class 4) [CI 95% 4.0 to 46]. Rates were higher in infants following gastroschisis closure (13 per 100 infants [CI 95% 5.8 to 24]), whereas they were generally low following a ligation of a ductus arteriosus. Infants with SSI required longer hospitalization after adjusting for co-morbidities (p<0.001). CONCLUSIONS Data from this relatively large contemporary study suggest that SSI rates in the NICU setting are more comparable to the pediatric age group. However, VLBW infants and those undergoing gastroschisis closure represent high risk groups.
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Affiliation(s)
- Ilan Segal
- Children’s & Women’s Health Centre of British Columbia, Vancouver BC, Canada V6H 3N1,Department of Pediatrics, University of British Columbia, 2329 West Mall Vancouver BC, V6T 1ZA
| | - Christine Kang
- Children’s & Women’s Health Centre of British Columbia, Vancouver BC, Canada V6H 3N1
| | - Susan G. Albersheim
- Children’s & Women’s Health Centre of British Columbia, Vancouver BC, Canada V6H 3N1,Department of Pediatrics, University of British Columbia, 2329 West Mall Vancouver BC, V6T 1ZA,Child & Family Research Institute, 950 west 28th Avenue, Vancouver BC V5Z4H4
| | - Erik D. Skarsgard
- Children’s & Women’s Health Centre of British Columbia, Vancouver BC, Canada V6H 3N1,Department of Pediatrics, University of British Columbia, 2329 West Mall Vancouver BC, V6T 1ZA,Department of Surgery, University of British Columbia, 2329 West Mall Vancouver BC, V6T 1ZA
| | - Pascal M. Lavoie
- Children’s & Women’s Health Centre of British Columbia, Vancouver BC, Canada V6H 3N1,Department of Pediatrics, University of British Columbia, 2329 West Mall Vancouver BC, V6T 1ZA,Child & Family Research Institute, 950 west 28th Avenue, Vancouver BC V5Z4H4
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Cavalcante MB, de Lima FJB, Okoba W, Oliveira-Filho FJ, Sbragia L, Magalhães PJC, de Souza MHLP, Melo-Filho AA. Gastric contractility in experimental gastroschisis. J Pediatr Surg 2013; 48:326-32. [PMID: 23414860 DOI: 10.1016/j.jpedsurg.2012.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2012] [Accepted: 11/12/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND/PURPOSE The mechanism of fetal gastric dilation in gastroschisis is controversial. This study was designed to characterize changes in the contractile profile of strips of stomach from rats following experimental gastroschisis. METHODS Pregnant Wistar rats were operated on day 18.5. Fetuses were divided into three groups: gastroschisis (G), sham (S), and control (C). On day 21.5, gastric fundus and antrum strips were obtained and suspended to a force transducer connected to a digital data acquisition system. They were submitted to increasing concentrations of carbachol (CCh) and weighed at the end of each procedure. Frequency and amplitude of each contraction were evaluated. RESULTS Under basal conditions, spontaneous oscillatory contractions of antrum and fundus strips of G, S, and C were similar (P>0.05; ANOVA). However, cumulative concentrations of CCh (0.01-100 μM) produced different effects in all groups and were characterized by a significant increase in amplitude and frequency of spontaneous contractions in antral smooth muscle and a sustained increase in tonus in fundic strips. Upon analysis, no significant difference in frequency or amplitude was noted in antral tissues comparing C to G and to S (P>0.05). No significant contractility difference was noted in fundic smooth muscle (comparing all groups, P>0.05), with the CCh-induced curve following a typical sigmoidal format, dependent on increasing concentrations (P<0.001). CONCLUSIONS Gastric contractile responses to CCh are preserved in experimental gastroschisis. These results do not support the theory that gastric dilation occurs secondary to intestinal inflammation alone.
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Affiliation(s)
- Marcelo B Cavalcante
- Department of Physiology and Pharmacology, Medical School, Federal University of Ceará, Fortaleza, Ceará, Brazil
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