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Operieren auf der neonatologischen Intensivstation. Monatsschr Kinderheilkd 2021. [DOI: 10.1007/s00112-021-01300-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Joshi RK, Aggarwal N, Agarwal M, Joshi R. Anesthesia protocols for "bedside" preterm patent ductus arteriosus ligation: A single-institutional experience. Ann Pediatr Cardiol 2021; 14:343-349. [PMID: 34667406 PMCID: PMC8457282 DOI: 10.4103/apc.apc_41_21] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 06/25/2021] [Accepted: 07/11/2021] [Indexed: 12/02/2022] Open
Abstract
Background : Hemodynamically significant patent ductus arteriosus (PDA) is frequently encountered in preterm infants sometimes requiring surgical attention. Although PDA ligation is regularly performed in the operating room, conducting it at the bedside in a neonatal intensive care unit (NICU) and its anesthetic management remains challenging. Aim : We aim to discuss the anesthetic considerations in patients undergoing bedside PDA ligation and describe our experience highlighting the feasibility and safety of this procedure. Setting and Design : The study was conducted in the NICU in a tertiary care hospital; This was a retrospective, observational study. Methods : Preterm infants scheduled for bedside PDA ligation using a predefined anesthesia protocol between August 2005 and October 2020 were included. Statistical Analysis Used: Quantitative data were presented as median with interquartile range and categorical data were presented as numbers and percentage thereof. Results : Sixty-six premature infants underwent bedside PDA ligation. Thirty-day mortality was 4.5% (3 infants), but there were no procedural deaths. One (1.5%) patient had intraoperative endotracheal tube dislodgement. Three (4.5%) infants had postoperative pneumothorax requiring an additional chest tube insertion. Twenty-one (32%) patients required initiation of postoperative inotrope/vasodilator therapy within 6 h. Three postligation cardiac syndromes (≥ Grade-III mitral regurgitation with left ventricular dysfunction and hypotension) occurred. Conclusions : Although anesthesia for preterm neonates undergoing bedside PDA ligation poses unique challenges, it can be safely conducted by following a predetermined standardized anesthesia protocol. Its successful conduct requires utmost vigilance and pristine understanding of the principles of neonatal and cardiac care.
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Affiliation(s)
- Reena Khantwal Joshi
- Department of Pediatric Cardiac Sciences, Sir Ganga Ram Hospital, New Delhi, India
| | - Neeraj Aggarwal
- Department of Pediatric Cardiac Sciences, Sir Ganga Ram Hospital, New Delhi, India
| | - Mridul Agarwal
- Department of Pediatric Cardiac Sciences, Sir Ganga Ram Hospital, New Delhi, India
| | - Raja Joshi
- Department of Pediatric Cardiac Sciences, Sir Ganga Ram Hospital, New Delhi, India
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Garge S, Kakani N, Khan J. Surgery in the Neonatal Intensive Care Unit in Indian Scenario: Should It be "The New State of the Art" or Just "The Need of the Hour"? J Indian Assoc Pediatr Surg 2020; 25:368-371. [PMID: 33487939 PMCID: PMC7815018 DOI: 10.4103/jiaps.jiaps_165_19] [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: 09/24/2019] [Revised: 12/28/2019] [Accepted: 04/20/2020] [Indexed: 11/04/2022] Open
Abstract
Introduction: Critically ill surgical neonates are physiologically challenged and delicately poised on ventilator and inotropic support systems. They experience significant stress in the event of surgery. Shifting them poise further addition to this stress. We here share our experience of operating such surgical neonates for certain conditions in the neonatal intensive care unit (NICU). Methods: We retrospectively analyzed the data of operated patients in the NICU. We collected the demographic data, diagnosis, and preoperative stability of the patient, ventilator and inotropic requirements, need for extra anesthetic drugs, procedures performed, complications, and outcome. Operations were performed at bedside in the NICU in critically ill, unstable neonates who needed emergency surgery, neonates of very low birth weight (<1000 g), and neonates on special equipment such as high-frequency ventilators. We excluded minor routine procedures such as drain placement, central line placement, ventricular taps, incision and drainage, and intercostal drainage procedures. Results: We performed seven surgical procedures in the NICU. These included bowel resections and stoma creation, fistula ligation, lung biopsies, and ventricular reservoir placement. Gestational age ranged between 24 and 34 weeks (mean, 28 weeks). Birth weights ranged between 800 and 2500 g (mean, 1357 g). Age at surgery was between 2 and 18 days (mean, 10.2 days). All our patients were on inotropic support and were intubated and mechanically ventilated. Conclusion: Doing surgery for critically ill neonates in the NICU definitely has a place. It was the need of the hour based on the condition of the neonates; however, we feel that neonatal surgery in the NICU should be the norm as it can improve survival. Surgery in the NICU can give a fighting chance to these patients; however, operation theaters in the NICU would be an ideal setting.
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Affiliation(s)
- Saurabh Garge
- Department of General Surgery, Pediatric Surgery Unit, Amaltas Institute of Medical Sciences, Dewas, Madhya Pradesh, India
| | - Neha Kakani
- Department of Pediatrics, Amaltas Institute of Medical Sciences, Dewas, Madhya Pradesh, India
| | - Jafar Khan
- Indore Newborn Care Centre, Indore, Madhya Pradesh, India
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A comparison of postoperative outcomes with PDA ligation in the OR versus the NICU: a retrospective cohort study on the risks of transport. BMC Anesthesiol 2018; 18:199. [PMID: 30579349 PMCID: PMC6303951 DOI: 10.1186/s12871-018-0658-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2018] [Accepted: 12/03/2018] [Indexed: 12/04/2022] Open
Abstract
Background Although patent ductus arteriosus (PDA) ligations in the Neonatal Intensive Care Unit (NICU) have been an accepted practice, many are still performed in the Operating Room (OR). Whether avoiding transport leads to improved perioperative outcomes is unclear. Here we aimed to determine whether PDA ligations in the NICU corresponded to higher risk of surgical site infection or mortality and if transport was associated with worsened perioperative outcomes. Methods We performed a retrospective cohort study of NICU patients, ≤37 weeks post-menstrual age, undergoing surgical PDA ligation in the NICU or OR. We excluded any infants undergoing device PDA closure. We measured the incidence of perioperative hypothermia, cardiac arrest, decreases in SpO2, hemodynamic instability and postoperative surgical site infection, sepsis and mortality. Results Data was collected on 189 infants (100 OR, 89 NICU). After controlling for number of preoperative comorbidities, weight at time of procedure, procedure location and hospital in the mixed-effect model, no significant difference in mortality or sepsis was found (odds ratio 0.31, 95%CI 0.07, 1.30; p = 0.107, and odds ratio 0.40; 95%CI 0.14, 1.09; p = 0.072, respectively). There was an increased incidence of hemodynamic instability on transport postoperatively in the OR group (12.4% vs 2%, odds ratio 6.93; 95% CI 1.48, 35.52; p = 0.014). Conclusion PDA ligations in the NICU were not associated with higher incidences of surgical site infection or mortality. There was an increased incidence of hemodynamic instability in the OR group on transport back to the NICU. Larger multicenter studies following long-term outcomes are needed to evaluate the safety of performing all PDA ligations in the NICU. Keywords Patent ductus arteriosus, Newborn infant, Neonatal intensive care unit, Surgical wound infection, Postoperative period, Hemodynamics
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Safety and Efficacy of Bedside Percutaneous Endoscopic Gastrostomy Placement in the Neonatal Intensive Care Unit. J Pediatr Gastroenterol Nutr 2018; 67:40-44. [PMID: 29401084 DOI: 10.1097/mpg.0000000000001906] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVE The aim of the study is to describe the safety and efficacy of bedside percutaneous endoscopic gastrostomy (PEG) placement in a level 3 neonatal intensive care unit (NICU). METHODS A retrospective chart review was performed on 106 infants with a birthweight ≤6 kg receiving bedside PEG placement at Johns Hopkins All Children's Hospital between 2007 and 2013. Preprocedure, postprocedure, and demographic data were collected. The main safety outcome was postprocedure complication rate and the main efficacy outcome was time to initiate feeds and time on respiratory support. RESULTS The mean birth weight and mean gestational age of our population at the time of procedure were 2.2 kg and 33 weeks, respectively. There were 9 total complications (8.5%) with major complications being only 2 (1.8%). There were no instances of blood stream infections. The mean length of time to initiate feeds was 1.2 days (standard deviation [SD] = 1.2). Ninety-three percent of patients were extubated within 24 hours. CONCLUSIONS Bedside PEG placement is safe with minimal complications. It is associated with little need for ventilator support and allows for early re-initiation of feeds and early success at reaching goal feedings.
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Wang YL, Jeng SF, Tsao PN, Chou HC, Chen CY, Hsieh WS. Operating Room Within the Neonatal Intensive Care Unit--Experience of a Medical Center in Taiwan. Pediatr Neonatol 2015; 56:220-5. [PMID: 25500106 DOI: 10.1016/j.pedneo.2014.10.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2014] [Revised: 07/17/2014] [Accepted: 10/08/2014] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Most neonates who reside in the neonatal intensive care unit (NICU) and require surgery are transferred to the operating room (OR) or undergo bedside surgery. However, critically ill neonates who are transferred often encounter the risk of complications. An OR in our NICU was therefore launched in 2009. This study was to appraise the surgeries performed in the NICU OR and compare results with the traditional main OR outside the NICU. METHODS This was a retrospective study in the NICU of a tertiary center. Retrospective chart review was conducted for all neonates who underwent surgical procedures in the NICU OR and the main OR. The information regarding baseline characteristics, surgical procedures and duration, ventilator use, hypothermia, hyperglycemia, instrument dislocations, surgically related infection or complications, and outcomes was obtained. RESULTS There were a total of 65 patients in this study, 37 in the NCIU OR group and 28 in the main OR group. The presurgical mean airway pressure and the fraction of inspired oxygen (FiO2) were comparable between the two groups, but the postsurgical FiO2 was significantly lower in the NICU OR group (31.0%) than in the main OR group (40.9%; p = 0.027). Furthermore, the NICU OR group required a significantly shorter preoperation waiting time (34.4 minutes vs. 63.6 minutes, p = 0.001) and had a lower incidence of hypothermia than the main OR group (8.1% vs. 39.3%, p = 0.008). However, surgically related complications were similar between groups. CONCLUSION The OR within the NICU may reduce the risk of complications during transportation and provide continuity of care to critically ill neonates. It also decreases the disturbance to other NICU patients during operation.
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Affiliation(s)
- Ya-Lei Wang
- Department of Pediatrics, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan; Department of Pediatrics, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Suh-Fang Jeng
- School and Graduate Institute of Physical Therapy, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Po-Nien Tsao
- Department of Pediatrics, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Hung-Chieh Chou
- Department of Pediatrics, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Chien-Yi Chen
- Department of Pediatrics, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Wu-Shiun Hsieh
- Department of Pediatrics, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan.
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Wright NJ, Thyoka M, Kiely EM, Pierro A, De Coppi P, Cross KMK, Drake DD, Peters MJ, Curry JI. The outcome of critically ill neonates undergoing laparotomy for necrotising enterocolitis in the neonatal intensive care unit: a 10-year review. J Pediatr Surg 2014; 49:1210-4. [PMID: 25092078 DOI: 10.1016/j.jpedsurg.2014.01.052] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2013] [Revised: 01/06/2014] [Accepted: 01/30/2014] [Indexed: 11/19/2022]
Abstract
PURPOSE To evaluate outcomes in critically ill neonates with necrotising enterocolitis (NEC) undergoing a laparotomy in the neonatal intensive care unit (NICU). METHODS This is a retrospective review of neonates diagnosed with NEC who underwent a laparotomy on NICU between 2001 and 2011. Demographic, diagnostic, operative and outcome data were analysed. Nonparametric comparison was used. Data are reported as median (range). RESULTS 221 infants with NEC were referred for surgical evaluation; 182 (82%) underwent surgery; 15 (8%) required a laparotomy on NICU. Five had NEC totalis, 4 multifocal disease and 6 focal disease. Five had an open and close laparotomy, 8 stoma with/without bowel resection and 2 bowel resection and primary anastomosis. Ten (67%) died at a median of 6.5-hours (2-72) postoperatively; 2 died at 72 and 264-days. The 30-day mortality rate was higher (p=0.01) among infants undergoing a laparotomy on NICU (10/15; 67%) than in theatre (54/167; 32%). There was no significant difference in mean Paediatric Index of Mortality 2 Scores between survivors and nonsurvivors (p=0.55). Three (20%) infants remain alive with no or minimal disability at 1.4 (0.5-7.5) years. CONCLUSION Laparotomy for NEC on NICU is a treatment option for neonates who are too unstable to transfer to theatre. However, with 67% dying within 6.5-hours and a further 13% after months in hospital, we must consider whether surgery is always in their best interests. Development of a prediction model to help distinguish those at highest risk of long-term morbidity and mortality could help with decision making in this difficult situation.
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Affiliation(s)
- Naomi J Wright
- Paediatric Surgery Department, Great Ormond Street Hospital for Children, London, United Kingdom
| | - Mandela Thyoka
- Paediatric Surgery Department, Great Ormond Street Hospital for Children, London, United Kingdom
| | - Edward M Kiely
- Paediatric Surgery Department, Great Ormond Street Hospital for Children, London, United Kingdom
| | - Agostino Pierro
- Paediatric Surgery Department, Great Ormond Street Hospital for Children, London, United Kingdom
| | - Paolo De Coppi
- Paediatric Surgery Department, Great Ormond Street Hospital for Children, London, United Kingdom
| | - Kate M K Cross
- Paediatric Surgery Department, Great Ormond Street Hospital for Children, London, United Kingdom
| | - David D Drake
- Paediatric Surgery Department, Great Ormond Street Hospital for Children, London, United Kingdom
| | - Mark J Peters
- Paediatric Surgery Department, Great Ormond Street Hospital for Children, London, United Kingdom
| | - Joe I Curry
- Paediatric Surgery Department, Great Ormond Street Hospital for Children, London, United Kingdom.
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Neumann RP, von Ungern-Sternberg BS. The neonatal lung--physiology and ventilation. Paediatr Anaesth 2014; 24:10-21. [PMID: 24152199 DOI: 10.1111/pan.12280] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/18/2013] [Indexed: 12/22/2022]
Abstract
This review article focuses on neonatal respiratory physiology, mechanical ventilation of the neonate and changes induced by anesthesia and surgery. Optimal ventilation techniques for preterm and term neonates are discussed. In summary, neonates are at high risk for respiratory complications during anesthesia, which can be explained by their characteristic respiratory physiology. Especially the delicate balance between closing volume and functional residual capacity can be easily disturbed by anesthetic and surgical interventions resulting in respiratory deterioration. Ventilatory strategies should ideally include application of an 'open lung strategy' as well avoidance of inappropriately high VT and excessive oxygen administration. In critically ill and unstable neonates, for example, extremely low-birthweight infants surgery in the neonatal intensive care unit might be an appropriate alternative to the operating theater. Best respiratory management of neonates during anesthesia is a team effort that should involve a joint multidisciplinary approach of anesthetists, pediatric surgeons, cardiologists, and neonatologists to reduce complications and optimize outcomes in this vulnerable population.
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Affiliation(s)
- Roland P Neumann
- Department of Neonatal Intensive Care, Basel University Children's Hospital (UKBB), Basel, Switzerland
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Jenkins IA, Kelly Ugarte LR, Mancuso TJ. Where should we operate on the preterm neonate? Paediatr Anaesth 2014; 24:127-36. [PMID: 24289318 DOI: 10.1111/pan.12311] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/27/2013] [Indexed: 11/29/2022]
Abstract
The ideal venue for neonatal surgical procedures has been the subject of a contentious debate between the leading pediatric hospitals throughout the world. Bias toward the location of neonatal surgery tends to be based on institutional practices. The following opposing viewpoints from two leading pediatric institutions in the United Kingdom and the United States highlight the relevant issues.
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Affiliation(s)
- Ian A Jenkins
- Departments of Anesthesiology and Intensive Care, Bristol Royal Hospital for Children, Bristol, UK
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Bedside neonatal intensive care unit surgery- myth or reality! J Neonatal Surg 2013; 2:20. [PMID: 26023440 PMCID: PMC4420370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2012] [Accepted: 02/24/2013] [Indexed: 12/02/2022] Open
Abstract
Neonatal transport is associated with complications, more so in sick and unstable neonates who need immediate emergency surgery. To circumvent these problems, surgery in Neonatal intensive care unit (NICU) is proposed for these neonates. This article reviews the literature regarding feasibility of this novel concept and based on the generated evidence, suggest the NICU planners to always include infrastructure for this. Also neonatal surgical team can be developed that could be transported.
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Hall NJ, Stanton MP, Kitteringham LJ, Wheeler RA, Griffiths DM, Drewett M, Burge DM. Scope and feasibility of operating on the neonatal intensive care unit: 312 cases in 10 years. Pediatr Surg Int 2012; 28:1001-5. [PMID: 22907723 DOI: 10.1007/s00383-012-3161-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/01/2012] [Indexed: 11/29/2022]
Abstract
PURPOSE To report the scope, feasibility and learning experience of operating on neonates on the neonatal intensive care unit (NICU). METHODS (1) Review of all NICU operations performed by general neonatal surgeons over 10 years; (2) 6-month prospective comparison of procedures performed in NICU or operating room; (3) structured interviews with five surgeons with 1-13 years experience of operating on NICU. RESULTS 312 operations were performed in 249 infants. Median birth weight was 1,494 g (range 415-4,365), gestational age 29 weeks (22-42), and age at operation 25 days (0-163). Nearly half (147) were laparotomy for acute abdominal pathology in preterm, very low birth-weight infants There were no surgical adverse events related to location of surgery. Surgeon satisfaction with operating on NICU for this population was high (5/5). Several factors contribute to making this process a success. CONCLUSIONS This is the largest reported series of general neonatal surgical procedures performed on NICU. Operating on NICU is feasible and safe, and a full range of neonatal operations can be performed. It removes risks associated with neonatal transfer and is likely to reduce physiological instability. We recommend this approach for all ventilated neonates and urge neonatal surgeons to operate at the cotside of unstable infants.
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Affiliation(s)
- N J Hall
- Wessex Regional Centre for Neonatal Surgery, Department of Paediatric Surgery, Southampton University Hospitals NHS Trust, Mailpoint 44, Tremona Road, Southampton, SO16 6YD, UK.
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Ghallab A, El-Gohary Y, Redmond M, Corbally M. In-situ emergency pediatric surgery in the intensive care unit. Ir J Med Sci 2012; 182:33-6. [PMID: 22528250 DOI: 10.1007/s11845-012-0819-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2011] [Accepted: 03/26/2012] [Indexed: 10/28/2022]
Abstract
BACKGROUND The role of surgery in the intensive care unit (ICU) remains unclear. Although previous studies have not shown any increase in morbidity when operating on patients in the ICU for surgical procedures; there remains a reluctance to operate on sick patients in the ICU. AIM We did a retrospective study of critically ill children and neonates who underwent in-situ surgery (ISS) to further evaluate its safety and potential. Surgery was aided with the use of operative loupes and high-intensity headlight. METHODS The medical records of all patients who had undergone surgical procedures in the pediatric ICU over an 11-year period from January 1998 till December 2008 were retrospectively reviewed. We reviewed our experience looking specifically at wound infection rates along with other morbidities in 543 patients. RESULTS Our morbidities were comparable with that of operations performed in the operating theater, with low wound infection rates (1%) for all surgeries undertaken in the pediatric ICU. CONCLUSION ISS avoids the risks of transfer to the operative theater and the potential delays in theater access. Our results suggest that ISS in a tertiary-level pediatric surgical hospital is safe and does not impact adversely on clinical outcome.
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Affiliation(s)
- A Ghallab
- Division of Pediatric Surgery, Our Lady's Children's Hospital, Crumlin, Dublin 12, Ireland.
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Abstract
Congenital Diaphragmatic Hernia (CDH) is defined by the presence of an orifice in the diaphragm, more often left and posterolateral that permits the herniation of abdominal contents into the thorax. The lungs are hypoplastic and have abnormal vessels that cause respiratory insufficiency and persistent pulmonary hypertension with high mortality. About one third of cases have cardiovascular malformations and lesser proportions have skeletal, neural, genitourinary, gastrointestinal or other defects. CDH can be a component of Pallister-Killian, Fryns, Ghersoni-Baruch, WAGR, Denys-Drash, Brachman-De Lange, Donnai-Barrow or Wolf-Hirschhorn syndromes. Some chromosomal anomalies involve CDH as well. The incidence is < 5 in 10,000 live-births. The etiology is unknown although clinical, genetic and experimental evidence points to disturbances in the retinoid-signaling pathway during organogenesis. Antenatal diagnosis is often made and this allows prenatal management (open correction of the hernia in the past and reversible fetoscopic tracheal obstruction nowadays) that may be indicated in cases with severe lung hypoplasia and grim prognosis. Treatment after birth requires all the refinements of critical care including extracorporeal membrane oxygenation prior to surgical correction. The best hospital series report 80% survival but it remains around 50% in population-based studies. Chronic respiratory tract disease, neurodevelopmental problems, neurosensorial hearing loss and gastroesophageal reflux are common problems in survivors. Much more research on several aspects of this severe condition is warranted.
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Roussel A, Hascoet JM, Desandes R, Claris O, Vieux R. [Does the regional health care organization impact the outcome of infants born with congenital diaphragmatic hernia?]. Arch Pediatr 2011; 18:1062-8. [PMID: 21873038 DOI: 10.1016/j.arcped.2011.07.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2010] [Revised: 04/06/2011] [Accepted: 07/22/2011] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Congenital diaphragmatic hernia (CDH) is a serious pathology that requires optimal management in very specialized health centers. French medical care organization is regionally based. Hence, evaluating local practices may help deliver clear information to parents before delivery. The aim of this study was to analyze the neonatal characteristics and the postnatal outcome of infants affected with CDH, treated within two different French perinatal health care networks. PATIENTS AND METHODS Retrospective cohort study of infants with CDH, cared for in the Lorraine perinatal health care network (Réseau Périnatal Lorrain [RPL]) or at Édouard-Herriot Hospital (HEH) in Lyon, between 1997 and 2007. RESULTS One hundred and twenty-seven newborns were included, 44 in the RPL and 83 in Lyon. Prenatal diagnosis of CDH was similar in RPL and at HEH; 47.7% of infants with CDH died in RPL vs 36.1% in HEH (P=0.2). Surgery delayed for more than 24h was more frequent in RPL (68.6% vs 31.7%; P<0.001), with a postoperative mortality rate of 31.4% vs 15.9%; P=0.08. In RPL, specialized medical follow-up was rare (33.3% vs 100%; P<0.001), while psychomotor retardation was more frequent (33.3% vs 5.7%; P=0.002). CONCLUSION This study brings to light the diversity of care and outcome for infants affected with CDH in two French perinatal health care networks. These results may help improve both centers' practices. In Lorraine for instance, the follow-up of these vulnerable children can be improved.
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MESH Headings
- Algorithms
- Cohort Studies
- France/epidemiology
- Health Services
- Hernia, Diaphragmatic/complications
- Hernia, Diaphragmatic/diagnosis
- Hernia, Diaphragmatic/mortality
- Hernia, Diaphragmatic/surgery
- Hernias, Diaphragmatic, Congenital
- Humans
- Infant, Newborn
- Infant, Newborn, Diseases/diagnosis
- Infant, Newborn, Diseases/surgery
- Intensive Care, Neonatal
- Perinatal Care
- Postoperative Period
- Psychomotor Disorders/epidemiology
- Psychomotor Disorders/etiology
- Retrospective Studies
- Survival Rate
- Treatment Outcome
- Ultrasonography, Prenatal
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Affiliation(s)
- A Roussel
- Service de néonatalogie, soins intensifs et réanimation néonatale, maternité régionale universitaire de Nancy, 10, rue du Docteur-Heydenreich, 54042 Nancy cedex, France
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Shooman D, Portess H, Sparrow O. A review of the current treatment methods for posthaemorrhagic hydrocephalus of infants. Cerebrospinal Fluid Res 2009; 6:1. [PMID: 19183463 PMCID: PMC2642759 DOI: 10.1186/1743-8454-6-1] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2008] [Accepted: 01/30/2009] [Indexed: 11/10/2022] Open
Abstract
Posthaemorrhagic hydrocephalus (PHH) is a major problem for premature infants, generally requiring lifelong care. It results from small blood clots inducing scarring within CSF channels impeding CSF circulation. Transforming growth factor – beta is released into CSF and cytokines stimulate deposition of extracellular matrix proteins which potentially obstruct CSF pathways. Prolonged raised pressures and free radical damage incur poor neurodevelopmental outcomes. The most common treatment involves permanent ventricular shunting with all its risks and consequences. This is a review of the current evidence for the treatment and prevention of PHH and shunt dependency. The Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library) and PubMed (from 1966 to August 2008) were searched. Trials using random or quasi-random patient allocation for any intervention were considered in infants less than 12 months old with PHH. Thirteen trials were identified although speculative interventions were also evaluated. The literature confirms that lumbar punctures, diuretic drugs and intraventricular fibrinolytic therapy can have significant adverse effects and fail to prevent shunt dependence, death or disability. There is no evidence that postnatal phenobarbital administration prevents intraventricular haemorrhage (IVH). Subcutaneous reservoirs and external drains have not been tested in randomized controlled trials, but can be useful as a temporising measure. Drainage, irrigation and fibrinolytic therapy as a way of removing blood to inhibit progressive deposition of matrix proteins, permanent hydrocephalus and shunt dependency, are invasive and experimental. Studies of ventriculo-subgaleal shunts show potential as a temporary method of CSF diversion, but have high infection rates. At present no clinical intervention has been shown to reduce shunt surgery in these infants. A ventricular shunt is not advisable in the early phase after PHH. Evidence exists that pre-delivery corticosteroid therapy reduces mortality and IVH and there may be trends towards reduced disability in the short term. There is also evidence that postnatal indomethacin reduces IVH but with no effect on mortality or disability. Overall, there is still no definitive algorithm for the treatment of PHH or prevention of shunt dependence. New therapeutic approaches in neonatal care, including those aimed at pre-empting PHH, offer the best hope of improving neurodevelopmental outcomes.
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Affiliation(s)
- David Shooman
- Department of Neurosurgery, Wessex Neurological Centre, Southampton General Hospital, Tremona Road, Southampton, Hampshire, SO16 6YD, UK.
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Golombek S, Sola A, Baquero H, Borbonet D, Cabañas F, Fajardo C, Goldsmit G, Lemus L, Miura E, Pellicer A, Pérez J, Rogido M, Zambosco G, van Overmeire B. Primer consenso clínico de SIBEN: enfoque diagnóstico y terapéutico del ductus arterioso permeable en recién nacidos pretérmino. An Pediatr (Barc) 2008. [DOI: 10.1157/13128002] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Mallick MS, Jado AM, Al-Bassam AR. Surgical procedures performed in the neonatal intensive care unit on critically ill neonates: feasibility and safety. Ann Saudi Med 2008; 28:105-8. [PMID: 18398286 PMCID: PMC6074523 DOI: 10.5144/0256-4947.2008.105] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Transferring unstable, ill neonates to and from the operating room carries significant risks and can lead to morbidity. We report on our experience in performing certain procedures in critically ill neonates in the neonatal intensive care unit (NICU). We examined the feasibility and safety of such an approach. METHODS All surgical procedures performed in the the NICU between January 1999 and December 2005 were analyzed in terms of demographic data, diagnosis, preoperative stability of the patient, procedures performed, complications and outcome. Operations were performed at bedside in the NICU in critically ill, unstable neonates who needed emergency surgery, in neonates of very low birth weight (<1000 g) and in neonates on special equipment like high frequency ventilators and nitrous oxide. RESULTS Thirty-seven surgical procedures were performed including 12 laparotomies, bowel resections and stomies, 7 repairs of congenital diaphragmatic hernias, 4 ligations of patent ductus arteriosus, and various others. Birthweights ranged between 850 g and 3500 g (mean, 2000 g). Gestational age ranged between 25 to 42 weeks (mean, 33 weeks). Age at surgery was between 1 to 30 days (mean, 10 days). Preoperatively, 19 patients (51.3%) were on inotropic support and all were intubated and mechanically ventilated. There was no mortality related to surgical procedures. Postoperatively, one patient developed wound infection and disruption. CONCLUSION Performing major surgical procedures in the the NICU is both feasible and safe. It is useful in very low birth weight, critically ill neonates who have a definite risk attached to transfer to the operating room. No special area is needed in the the NICU to perform complication-free surgery, but designing an operating room within the the NICU would be ideal.
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Zaramella P, Freato F, Quaresima V, Ferrari M, Bartocci M, Rubino M, Falcon E, Chiandetti L. Surgical closure of patent ductus arteriosus reduces the cerebral tissue oxygenation index in preterm infants: a near-infrared spectroscopy and Doppler study. Pediatr Int 2006; 48:305-12. [PMID: 16732800 DOI: 10.1111/j.1442-200x.2006.02209.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND The aim of this study was to investigate the effects of patent ductus arteriosus (PDA) ligature on cerebral oxygen saturation, cerebral blood volume (CBV) and cerebral blood flow velocity by means of near-infrared spectroscopy (NIRS) and transcranial Doppler simultaneous examinations. METHODS This is an observational study considering 16 babies of gestational age 24-34 weeks diagnosed with PDA who underwent surgical ligation. The cerebral oxygen saturation, CBV and blood gases values were obtained 35 min before ligation, so also around the 14th and 27th min after the clip's insertion. RESULTS Cerebral oxygen saturation, measured as tissue oxygenation index (TOI), decreased significantly after PDA ligation from a basal value of 61.1 (3.8) before surgery to 56.6 (3.3) and 55.8 (2.6)%, for the 14th and 27th min, respectively (P<0.04). CBV before and after clipping was unvaried. A negative correlation was found between DeltapH and DeltaCBV after ligation (R=0.52, P=0.03), whilst a positive correlation was found between DeltaCBV and DeltaP(aCO2) (R=0.62, P=0.009). pH increased at the 27th min post-ligation. CONCLUSIONS NIRS is a tool for obtaining information on cerebral oxygen saturation and CBV changes during surgical PDA ligation at the bedside. A fall in TOI suggests an increased oxygen extraction during PDA surgery. The lack of increase in DeltaCBV or in diastolic flow velocity show that the PDA before the clipping did not limit cerebral blood flow, the drop in TOI suggests increased oxygen consumption over the clip and the need for accurate monitoring of oxygen utilization after the surgical treatment.
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MESH Headings
- Blood Flow Velocity/physiology
- Blood Volume/physiology
- Brain/metabolism
- Brain/physiopathology
- Cerebrovascular Circulation/physiology
- Ductus Arteriosus, Patent/diagnostic imaging
- Ductus Arteriosus, Patent/metabolism
- Ductus Arteriosus, Patent/surgery
- Follow-Up Studies
- Humans
- Infant, Newborn
- Infant, Premature
- Infant, Premature, Diseases/diagnostic imaging
- Infant, Premature, Diseases/metabolism
- Infant, Premature, Diseases/surgery
- Oxygen Consumption/physiology
- Spectroscopy, Near-Infrared
- Ultrasonography, Doppler, Transcranial
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Affiliation(s)
- Patrizia Zaramella
- Department of Paediatrics, Neonatal Intensive Care Unit, University of Padova, Padova, Italy.
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Rees CM, Hall NJ, Eaton S, Pierro A. Surgical strategies for necrotising enterocolitis: a survey of practice in the United Kingdom. Arch Dis Child Fetal Neonatal Ed 2005; 90:F152-5. [PMID: 15724040 PMCID: PMC1721850 DOI: 10.1136/adc.2004.051862] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Strategies for the surgical management of necrotising enterocolitis are various and controversial. OBJECTIVE To characterise variation in surgical management of this disease across the United Kingdom. METHODS Postal survey of 104 consultant paediatric surgeons with a 77% response rate. RESULTS Duration of antibiotic treatment (median 10 days, range 6-14), time until the start of enteral feeding (median 10 days, range 4-21), and absolute indications for surgery all vary between surgeons. Peritoneal drainage is used by 95% of surgeons. Forty two percent use it in neonates of all weights, whereas 36% restrict its use to those <1000 g. Peritoneal drainage is used for stabilisation by 95% and as definitive treatment by 58%. At laparotomy, operative procedures include diverting jejunostomy, resection and stoma, resection with primary anastomosis, and "clip and drop". All procedures are used in infants of all weights except resection and primary anastomosis, which is used predominantly in larger infants (55% in <1000 g; 77% in >1000g; p=0.005). Infants may be considered too unwell for peritoneal drainage by 11% of surgeons compared with 90% for laparotomy (p<0.0001). CONCLUSIONS There is considerable variation in surgical strategies for necrotising enterocolitis. Peritoneal drainage is used by most surgeons, with controversial indications and expectations. The use of resection and primary anastomosis is influenced by the weight of the neonate.
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Affiliation(s)
- C M Rees
- Department of Paediatric Surgery, Institute of Child Health, 30 Guilford Street, London WC1N 1EH, UK
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Mehta SK, Younoszai A, Pietz J, Achanti BP. Pharmacological closure of the patent ductus arteriosus. IMAGES IN PAEDIATRIC CARDIOLOGY 2003; 5:1-15. [PMID: 22368623 PMCID: PMC3232537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/29/2022]
Abstract
Pharmacological closure by indomethacin is customary if symptoms of PDA are not controlled adequately with fluid restriction and diuretics. Its use, however, requires a comprehensive clinical assessment of all the vital perinatal factors and a vigilant monitoring of the sick infant. Prophylactic use of indomethacin is discouraged. The decision to use pharmacological versus surgical treatment or both should be individualized based on evidence-based research and clinician's own experience. Surgical ligation remains the primary mode of therapy in cases of pharmacological treatment failure or recurrence.
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Affiliation(s)
- SK Mehta
- ,Contact information: Dr. Sudhir Ken Mehta, Chairman of Pediatrics, Department of Pediatrics and Pediatric Cardiology, Fairview Hospital, 18101 Lorain Avenue, Cleveland, Ohio 44111-5656 - USA Tel: 216-476-7236 Fax: 216-476-7021
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Maertzdorf WJ, Vles JSH, Beuls E, Mulder ALM, Blanco CE. Intracranial pressure and cerebral blood flow velocity in preterm infants with posthaemorrhagic ventricular dilatation. Arch Dis Child Fetal Neonatal Ed 2002; 87:F185-8. [PMID: 12390988 PMCID: PMC1721495 DOI: 10.1136/fn.87.3.f185] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
AIM To determine the volume of cerebrospinal fluid (CSF) that should be tapped in preterm infants with posthaemorrhagic ventricular dilatation as guided by intracranial pressure (ICP) and cerebral blood flow velocity (CBFV). METHODS The total number of measurements was 106 in 22 infants. Birth weights ranged from 630 to 2050 g, gestational age from 24.5 to 30.3 weeks, and age at insertion from 12 to 67 days. A subcutaneous ventricular catheter reservoir for repetitive CSF drainage was placed when the diameter of a ventricle was > 4 mm above the 97th centile. A volume of 5 ml/kg body weight was removed twice daily. ICP and CBFV were determined before and after CSF tapping. RESULTS If the ICP after tapping exceeded 7 cm H(2)O, tapping did not result in a significant improvement in CBFV. If the ICP before tapping was less than 6 cm H(2)O, tapping also had no effect on CBFV. Longitudinal studies in individual infants showed a slight correlation between ICP and CBFV. CONCLUSION Volume of repetitive CSF drainage in preterm infants with posthaemorrhagic ventricular dilatation guided by ICP and CBFV may be a useful technique. An ICP of about 6 cm H(2)O is the cut off point for CSF drainage.
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Affiliation(s)
- W J Maertzdorf
- Department of Neonatology, University Hospital Maastricht, The Netherlands.
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Koehne PS, Bein G, Alexi-Meskhishvili V, Weng Y, Bührer C, Obladen M. Patent ductus arteriosus in very low birthweight infants: complications of pharmacological and surgical treatment. J Perinat Med 2002; 29:327-34. [PMID: 11565202 DOI: 10.1515/jpm.2001.047] [Citation(s) in RCA: 76] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
AIMS To evaluate complications of surgical and pharmacological treatment of symptomatic patent ductus arteriosus (PDA) in very low birthweight (VLBW) infants. PATIENTS AND METHODS Of 931 VLBW infants consecutively admitted 1987-1998, a significant PDA prompted first-choice treatment by indomethacin in 101 infants, and surgery in 55 infants. PDA closed or became asymptomatic after indomethacin in 64 patients (63%), while 34 went on to surgery. PDA closure was achieved in all 61 infants after ligation and in 26 of 28 infants after clipping. RESULTS Transient renal impairment after indomethacin treatment was recorded in 40 of 101 infants (40%), compared to renal impairment in 9 of 55 infants (16%) undergoing surgery without prior indomethacin. No differences in necrotizing enterocolitis and intracranial hemorrhage rates were seen. Air leak occurred in 6 of 89 infants after surgery, two of which had fatal tension pneumothorax. Intraoperative hemorrhage requiring emergency transfusion occurred in 2 infants, wound infection occurred in 2 infants and phrenic palsy in one infant. Based on an intention-to-treat analysis, the overall fatality rates were 16 of 101 (16%) for indomethacin and 14 of 55 (25%) for surgery. CONCLUSIONS Despite the short-comings inherent to retrospective analyses, we propose that surgery should be reserved for infants not responding to pharmacological PDA closure.
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Affiliation(s)
- P S Koehne
- Departments of Neonatology and Pediatric Cardiology, Charité Virchow Hospital, Humboldt University, Department of Cardiovascular Surgery, German Heart Institute Berlin, Germany.
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Richardson DK, Zupancic JA, Escobar GJ, Ogino M, Pursley DM, Mugford M. A critical review of cost reduction in neonatal intensive care. I. The structure of costs. J Perinatol 2001; 21:107-15. [PMID: 11324356 DOI: 10.1038/sj.jp.7200502] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Neonatal intensive care is expensive. In the current era of intense cost containment in hospital care, neonatologists and hospital administrators are under intense pressure to find strategies for cost reduction for neonatal services. Few neonatal clinicians are trained in economics, management, or accounting, and few hospital administrators are familiar with neonatal intensive care. In this review, we describe the structure and sources of hospital costs and the accounting systems needed to isolate and measure such costs. We discuss where efficiencies might be found and consider specific issues in capitated settings such as health maintenance organizations in the United States, the Canadian health care system and the National Health System in the United Kingdom.
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Affiliation(s)
- D K Richardson
- Department of Neonatology, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215, USA
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Bruinsma N, Stobberingh EE, Herpers MJ, Vles JS, Weber BJ, Gavilanes DA. Subcutaneous ventricular catheter reservoir and ventriculoperitoneal drain-related infections in preterm infants and young children. Clin Microbiol Infect 2000; 6:202-6. [PMID: 11168108 DOI: 10.1046/j.1469-0691.2000.00052.x] [Citation(s) in RCA: 61] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVE In the period January 1990 to September 1997, 70 patients, aged under 6 years were treated for hydrocephalus with a subcutaneous ventricular catheter reservoir and/or a ventriculoperitoneal drain at the University Hospital of Maastricht. METHODS By means of a retrospective chart analysis, the number of shunt infections and related risk factors were analyzed. RESULTS Twenty-one patients (30%) developed one or more infections, with an infection rate of 15.2% per surgical event. For an implanted reservoir or drain, the infection rates were 15.9 and 16.4%, respectively. The study group consisted of 39 (55.7%) preterm infants (< 37 weeks) and 31 (44.3%) full-term infants (> or = 37 weeks), with infection rates of 33.3 and 25.8%, respectively. At the first surgical intervention 28 patients (40%) had a postmenstrual age less than 37 weeks, with an infection rate of 46.4%. At the time of surgery, 69.7% of the patients were aged less than 6 months, with an infection rate of 19.6%. The most frequent causative microorganism of the shunt infections was Staphylococcus epidermidis (42.1%). CONCLUSIONS Prematurity is an important risk factor for ventricular catheter reservoir and ventriculoperitoneal drain-related infections, especially for patients with a postmenstrual age of less than 37 weeks at their initial shunt placement and extreme low birth weight infants have a high risk for infection. In our opinion the use of adequate antibiotic prophylaxis and optimal infection control measures are necessary to keep the rate of infection as low as possible.
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Affiliation(s)
- N Bruinsma
- Department of Medical Microbiology, University Hospital Maastricht, Maastricht, The Netherlands
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