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Qiu Q, Yang Z, Zhang Y, Zeng W, Yang K, Liang C, Alifu A, Huang H, Chen J, Zhang M, Wu D, Guo X, Jin S, Lin Y, Chuo J, Zhang H, Song X, Iyer RS. Reducing postoperative hypothermia in infants: Quality improvement in China. Paediatr Anaesth 2024; 34:773-782. [PMID: 38775778 DOI: 10.1111/pan.14910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 04/16/2024] [Accepted: 04/17/2024] [Indexed: 07/05/2024]
Abstract
BACKGROUND Unintended postoperative hypothermia in infants is associated with increased mortality and morbidity. We noted consistent hypothermia postoperatively in more than 60% of our neonatal intensive care (NICU) babies. Therefore, we set out to determine whether a targeted quality improvement (QI) project could decrease postoperative hypothermia rates in infants. OBJECTIVES Our SMART aim was to reduce postoperative hypothermia (<36.5°C) in infants from 60% to 40% within 6 months. METHODS This project was approved by IRB at Guangzhou Women and Children's Medical Center, China. The QI team included multidisciplinary healthcare providers in China and QI experts from Children's Hospital of Philadelphia, USA. The plan-do-study-act (PDSA) cycles included establishing a perioperative-thermoregulation protocol, optimizing the transfer process, and staff education. The primary outcome and balancing measures were, respectively, postoperative hypothermia and hyperthermia (axillary temperature < 36.5°C, >37.5°C). Data collected was analyzed using control charts. The factors associated with a reduction in hypothermia were explored using regression analysis. RESULTS There were 295 infants in the project. The percentage of postoperative hypothermia decreased from 60% to 37% over 26 weeks, a special cause variation below the mean on the statistical process control chart. Reduction in hypothermia was associated with an odds of 0.17 (95% CI: 0.06-0.46; p <.001) for compliance with the transport incubator and 0.24 (95% CI: 0.1-0.58; p =.002) for prewarming the OR ambient temperature to 26°C. Two infants had hyperthermia. CONCLUSIONS Our QI project reduced postoperative hypothermia without incurring hyperthermia through multidisciplinary team collaboration with the guidance of QI experts from the USA.
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Affiliation(s)
- Qianqi Qiu
- Department of Anesthesiology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Zixin Yang
- Department of Neonatology, Beijing Children's Hospital, Beijing, China
| | - Yong Zhang
- Department of Anesthesiology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Wen Zeng
- Department of Neonatology, Chengdu Women's and Children's Central Hospital, Chengdu, China
| | - Kuiyan Yang
- Department of Neonatal Intensive Care Unit, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Cuiping Liang
- Department of Gastroenterology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Ailixiati Alifu
- Department of Cardiothoracic Surgery, Hainan Women and Children's Medical Center, Hainan, China
| | - Haibo Huang
- Department of Neonatology, The University of Hong Kong-Shenzhen hospital, Shenzhen, China
| | - Jun Chen
- Department of Neonatology, Foshan Women and Children's hospital, Guangdong, China
| | - Meixue Zhang
- Department of Operating Theatre, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Dongmei Wu
- Department of Surgical Neonatal Intensive Care Unit, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Xiaoping Guo
- Department of Neonatal Intensive Care Unit, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Saifen Jin
- Department of Operating Theatre, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Yuzhen Lin
- Department of Operating Theatre, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - John Chuo
- Department of Neonatology, Children's Hospital of Philadelphia, Pennsylvania, USA
| | - Huayan Zhang
- Department of Neonatology, Children's Hospital of Philadelphia, Pennsylvania, USA
- Department of Neonatology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Xingrong Song
- Department of Anesthesiology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Rajeev S Iyer
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania, Pennsylvania, USA
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Ambia AM, Duryea EL, Wyckoff MH, Tao W, McIntire DD, Seasely AR, Moussa M, Leveno KJ. A Randomized Trial of the Effects of Ambient Operating Room Temperature on Neonatal Morbidity. Am J Perinatol 2024; 41:e1553-e1559. [PMID: 36918157 DOI: 10.1055/a-2053-7242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
Abstract
OBJECTIVE Newborn hypothermia has been implicated in neonatal morbidity without randomized evidence that it compromises the infant. Our objective was to determine if a difference in operating room temperature at cesarean birth impacts neonatal morbidity. STUDY DESIGN Women undergoing cesarean delivery of a liveborn infant without major malformations were included. The institutional preexisting operating room temperature of 20°C (67°F) was compared with an experimental group of 24°C (75°F) by cluster randomization assigned on a weekly basis. Newborn hypothermia was defined as axillary temperature on arrival to the nursery of less than 36.5°C (<97.7°F). The primary outcome was a composite of neonatal morbidity including respiratory support, sepsis, hypoglycemia, and neonatal death. RESULTS Between November 2016 and May 2018, 5,221 women had cesarean deliveries at Parkland Hospital with 2,817 randomized to the standard care group and 2,404 to the experimental group. The rate of neonatal composite morbidity did not differ between the groups: standard care 398 (14%) versus experimental 378 (16%), p = 0.11. This was despite a significant decrease in the rate of neonatal hypothermia: standard care 1,195 (43%) versus experimental 414 (18%), p < 0.001. There was no difference in the composite outcome for preterm infants (<37 wk) between the groups: standard care 194 (49%) versus experimental 185 (54%), p = 0.25. CONCLUSION An 8°F increase in operating room temperature was significantly associated with a reduced rate of neonatal hypothermia, although this decrease was not associated with a significant improvement in neonatal morbidity. However, the increase in operating room temperature was met with resistance from obstetricians and operating room personnel. This trial is registered (registration no.: NCT03008577).
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Affiliation(s)
- Anne M Ambia
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Elaine L Duryea
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Myra H Wyckoff
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Weike Tao
- Division of Obstetric Anesthesia, Department of Anesthesia, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Donald D McIntire
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Angela R Seasely
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Moussa Moussa
- Parkland Health and Hospital System, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Kenneth J Leveno
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, Texas
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Ramaswamy VV, Dawson JA, de Almeida MF, Trevisanuto D, Nakwa FL, Kamlin COF, Trang J, Wyckoff MH, Weiner GM, Liley HG. Maintaining normothermia immediately after birth in preterm infants <34 weeks' gestation: A systematic review and meta-analysis. Resuscitation 2023; 191:109934. [PMID: 37597649 DOI: 10.1016/j.resuscitation.2023.109934] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 07/26/2023] [Accepted: 08/05/2023] [Indexed: 08/21/2023]
Abstract
AIM To evaluate delivery room (DR) interventions to prevent hypothermia and improve outcomes in preterm newborn infants <34 weeks' gestation. METHODS Medline, Embase, CINAHL and CENTRAL were searched till 22nd July 2022. Randomized controlled trials (RCTs), non-RCTs and quality improvement studies were considered. A random effects meta-analysis was performed, and the certainty of evidence was evaluated using GRADE guidelines. RESULTS DR temperature of ≥23 °C compared to standard care improved temperature outcomes without an increased risk of hyperthermia (low certainty), whereas radiant warmer in servo mode compared to manual mode decreased mean body temperature (MBT) (moderate certainty). Use of a plastic bag or wrap (PBW) improved normothermia (low certainty), but with an increased risk of hyperthermia (moderate certainty). Plastic cap improved normothermia (moderate certainty) and when combined with PBW improved MBT (low certainty). Use of a cloth cap decreased moderate hypothermia (low certainty). Though thermal mattress (TM) improved MBT, it increased risk of hyperthermia (low certainty). Heated-humidified gases (HHG) for resuscitation decreased the risk of moderate hypothermia and severe intraventricular hemorrhage (very low to low certainty). None of the interventions was shown to improve survival, but sample sizes were insufficient. CONCLUSIONS DR temperature of ≥23 °C, radiant warmer in manual mode, use of a PBW and a head covering is suggested for preterm newborn infants <34 weeks' gestation. HHG and TM could be considered in addition to PBW provided resources allow, in settings where hypothermia incidence is high. Careful monitoring to avoid hyperthermia is needed.
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Affiliation(s)
- V V Ramaswamy
- Ankura Hospital for Women and Children, Hyderabad, India
| | - J A Dawson
- Newborn Research Centre, The Royal Women's Hospital, Victoria, Australia
| | - M F de Almeida
- Universidade Federal de Sao Paulo, Escola Paulista de Medicina, Sao Paulo, Brazil
| | - D Trevisanuto
- Medical School, University of Padua, Azienda Ospedaliera Padova, Padua, Italy
| | - F L Nakwa
- Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - C O F Kamlin
- Newborn Research Centre, The Royal Women's Hospital, Victoria, Australia
| | - J Trang
- Queensland Children's Hospital, Queensland, Australia
| | - M H Wyckoff
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - G M Weiner
- Division of Neonatal-Perinatal Medicine, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI, USA
| | - H G Liley
- Faculty of Medicine and Mater Research, The University of Queensland, Australia.
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Shi Q, Zhang J, Fan C, Zhang A, Zhu Z, Tian Y. Factors influencing hypothermia in very low/extremely low birth weight infants: a meta-analysis. PeerJ 2023; 11:e14907. [PMID: 36846465 PMCID: PMC9948743 DOI: 10.7717/peerj.14907] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 01/25/2023] [Indexed: 02/22/2023] Open
Abstract
Introduction Previous studies have explored factors that influence the occurrence of hypothermia in very low/extremely low birth weight (VLBW/ELBW) infants, but the factors associated with hypothermia in VLBW or ELBW infants remain inadequately evaluated due to limited prospective data and inconsistency in study populations. Therefore, it is necessary to systematically evaluate the risk factors of hypothermia in VLBW/ELBW infants in order to provide a theoretical basis for clinical practice. Methods PubMed and other databases were used to search for case-control or cohort studies on factors influencing the occurrence of hypothermia in VLBW/ELBW infants. The search time was set from database creation to June 30th, 2022. Literature screening, quality evaluation, and data extraction were performed independently by two investigators according to predefined inclusion and exclusion criteria. Meta-analysis was performed using RevMan 5.3. Results A total of 10 papers were finally included in this study and 12 factors were established by meta-analysis: body weight (six papers), failure to keep warm in time (three papers), neonatal resuscitation (seven papers), gestational age (three papers), premature rupture of membranes (three papers), maternal combined complications (four papers), cesarean section (six papers), antenatal steroids (four papers), multiple birth (two papers), small for gestational age (two papers), 1 min Apgar score (three papers), and 5 min Apgar score (three papers). Since only one study included race, age (hour), socio-economic status, and spontaneous labor, these factors could not be fitted into RevMan 5.3 for the analysis. Conclusion Although there were differences in the study design of the included literature, the influencing factors described in each study were relatively similar. The influencing factors identified in this study may contribute to the construction of related intervention strategies for hypothermia in VLBW/ELBW infants.
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Affiliation(s)
- Qinchuan Shi
- Pediatric Surgery, Women’s Hospital of Nanjing Medical University, Nanjing Maternity and Child Health Care Hospital, Nanjing, Jiangsu, PR China
| | - Jingjing Zhang
- Obstetrics, Women’s Hospital of Nanjing Medical University, Nanjing Maternity and Child Health Care Hospital, Nanjing, Jiangsu, PR China
| | - Chong Fan
- Emergency Medicine, Women’s Hospital of Nanjing Medical University, Nanjing Maternity and Child Health Care Hospital, Nanjing, Jiangsu, PR China
| | - Aixia Zhang
- Nursing, Women’s Hospital of Nanjing Medical University, Nanjing Maternity and Child Health Care Hospital, Nanjing, Jiangsu, PR China
| | - Zhu Zhu
- Nursing, Women’s Hospital of Nanjing Medical University, Nanjing Maternity and Child Health Care Hospital, Nanjing, Jiangsu, PR China
| | - Yingying Tian
- Special Section, Women’s Hospital of Nanjing Medical University, Nanjing Maternity and Child Health Care Hospital, Nanjing, Jiangsu, PR China
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Sentilhes L, Schmitz T, Madar H, Bouchghoul H, Fuchs F, Garabédian C, Korb D, Nouette-Gaulain K, Pécheux O, Sananès N, Sibiude J, Sénat MV, Goffinet F. [The cesarean procedure: Guidelines for clinical practice from the French College of Obstetricians and Gynecologists]. GYNECOLOGIE, OBSTETRIQUE, FERTILITE & SENOLOGIE 2023; 51:7-34. [PMID: 36228999 DOI: 10.1016/j.gofs.2022.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To identify procedures to reduce maternal morbidity during cesarean. MATERIAL AND METHODS The quality of evidence of the literature was assessed following the GRADE® method with questions formulated in the PICO format (Patients, Intervention, Comparison, Outcome) and outcomes defined a priori and classified according to their importance. An extensive bibliographic search was performed on PubMed, Cochrane and EMBASE databases. The quality of the evidence was assessed (high, moderate, low, very low) and a (i) strong or (ii) weak recommendations or (iii) no recommendation were formulated. The recommendations were reviewed in two rounds with external reviewers (Delphi survey) to select the consensus recommendations. RESULTS Of the 27 questions, there was agreement between the working group and the external reviewers on 26. The level of evidence of the literature was insufficient to provide a recommendation on 15 questions. Preventing hypothermia is recommended to increase maternal satisfaction and comfort (weak recommendation) and to reduce neonatal hypothermia (strong recommendation). The quality of the evidence of the literature did not allow to recommend the skin disinfectant to be used nor the relevance of a preoperative vaginal disinfection nor the choice between the use or nonuse of an indwelling bladder catheterization (if micturition takes place 1 hour before the cesarean section). The Misgav-Ladach technique or its analogues should be considered rather than the Pfannenstiel technique to reduce maternal morbidity (weak recommendation) bladder flap before uterine incision should not be performed routinely (weak recommendation), but a blunt (weak recommendation) and cephalad-caudad extension of uterine incision (weak recommendation) should be considered to reduce maternal morbidity. Antibiotic prophylaxis is recommended to reduce maternal infectious morbidity (strong recommendation) without recommendation on its type or the timing of administration (before incision or after cord clamping). The administration of carbetocin after cord clamping does not significantly decrease the incidence of blood loss>1000 ml, anemia, or blood transfusion compared with the administration of oxytocin. Thus, it is not recommended to use carbetocin rather than oxytocin in cesarean. It is recommended that systematic manual removal of the placenta not to be performed (weak recommendation). An antiemetic should be administered after cord clamping in women having a planned cesarean under locoregional anaesthesia to reduce intraoperative and postoperative nausea and vomiting (strong recommendation) with no recommendation regarding choice of use one or two antiemetics. The level of evidence of the literature was insufficient to provide any recommendation concerning single or double-layer closure of the uterine incision, or the uterine exteriorization. Closing the peritoneum (visceral or parietal) should not be considered (weak recommendation). The quality of the evidence of the literature was not sufficient to provide recommendation on systematic subcutaneous closure, including in obese or overweight patients, or the use of subcuticular suture in obese or overweight patients. The use of subcuticular suture in comparison with skin closure by staples was not considered as a recommendation due to the absence of a consensus in the external review rounds. CONCLUSION In case of cesarean, preventing hypothermia, administering antiemetic and antibiotic prophylaxis after cord clamping are the only strong recommendations. The Misgav-Ladach technique, the way of performing uterine incision (no systematic bladder flap, blunt cephalad-caudad extension), not performing routine manual removal of the placenta nor closure of the peritoneum are weak recommendations and may reduce maternal morbidity.
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Affiliation(s)
- L Sentilhes
- Service de gynécologie-obstétrique, centre hospitalier universitaire de Bordeaux, Bordeaux, France.
| | - T Schmitz
- Service de gynécologie obstétrique, hôpital Robert-Debré, université Paris Diderot, AP-HP, Paris, France
| | - H Madar
- Service de gynécologie-obstétrique, centre hospitalier universitaire de Bordeaux, Bordeaux, France
| | - H Bouchghoul
- Service de gynécologie-obstétrique, centre hospitalier universitaire de Bordeaux, Bordeaux, France
| | - F Fuchs
- Service de gynécologie-obstétrique, centre hospitalier universitaire de Montpellier, Montpellier, France
| | - C Garabédian
- Service de gynécologie-obstétrique, centre hospitalier universitaire de Lille, Lille, France
| | - D Korb
- Service de gynécologie obstétrique, hôpital Robert-Debré, université Paris Diderot, AP-HP, Paris, France
| | - K Nouette-Gaulain
- Service d'anesthésie, centre hospitalier universitaire de Bordeaux, Bordeaux, France
| | - O Pécheux
- Service de gynécologie-obstétrique, centre hospitalier universitaire de Lille, Lille, France
| | - N Sananès
- Service de gynécologie-obstétrique, centre hospitalier universitaire de Strasbourg, Strasbourg, France
| | - J Sibiude
- Service de gynécologie-obstétrique, hôpital Louis-Mourier, AP-HP Louis-Mourier, Colombes, France
| | - M-V Sénat
- Service de gynécologie-obstétrique, hôpital Bicêtre, AP-HP Le Kremlin-Bicêtre, Paris, France
| | - F Goffinet
- Maternité Port-Royal, groupe hospitalier Cochin Broca, Hôtel-Dieu, université Paris-Descartes, AP-HP, Paris, France
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Abstract
Quality improvement has become a foundation of neonatal care. Structured approaches to improvement can standardize practices, improve teamwork, engage families, and improve outcomes. The delivery room presents a unique environment for quality improvement; optimal delivery room care requires advanced preparation, adequately trained providers, and carefully coordinated team dynamics. In this article, we examine quality improvement for neonatal resuscitation. We review the published literature, focusing on reports targeting admission hypothermia, delayed cord clamping, and initial respiratory support. We discuss specific challenges related to delivery room quality improvement, including small numbers, data collection, and lack of benchmarking, and potential strategies to address them including simulation, checklists, and state and national collaboratives. We examine how quality improvement can target equity in delivery room outcomes, and explore the impact of the COVID-19 pandemic on delivery room quality of care.
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Affiliation(s)
- Emily Whitesel
- Department of Neonatology, Beth Israel Deaconess Medical Center, Boston MA, United States; Division of Newborn Medicine, Harvard Medical School, Boston MA, United States.
| | - Justin Goldstein
- Department of Neonatology, Beth Israel Deaconess Medical Center, Boston MA, United States
| | - Henry C. Lee
- Department of Pediatrics, Stanford University School of Medicine, Stanford CA, United States
| | - Munish Gupta
- Department of Neonatology, Beth Israel Deaconess Medical Center, Boston MA, United States,Division of Newborn Medicine, Harvard Medical School, Boston MA, United States
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7
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Technology in the delivery room supporting the neonatal healthcare provider's task. Semin Fetal Neonatal Med 2022; 27:101333. [PMID: 35400603 DOI: 10.1016/j.siny.2022.101333] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Very preterm infants are a unique and highly vulnerable group of patients that have a narrow physiological margin within which interventions are safe and effective. The increased understanding of the foetal to neonatal transition marks the intricacy of the rapid and major physiological changes that take place, making delivery room stabilisation and resuscitation an increasingly complex and sophisticated activity for caregivers to perform. While modern, automated technologies are progressively implemented in the neonatal intensive care unit (NICU) to enhance the caregivers in providing the right care for these patients, the technology in the delivery room still lags far behind. Diligent translation of well-known and promising technological solutions from the NICU to the delivery room will allow for better support of the caregivers in performing their tasks. In this review we will discuss the current technology used for stabilisation of preterm infants in the delivery room and how this could be optimised in order to further improve care and outcomes of preterm infants in the near future.
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Nguyen L, Mitsakakis N, Sucha E, Lemyre B, Lawrence SL. Factors associated with hypothermia within the first 6 hours of life in infants born at ≥34 0 weeks' gestation: a multivariable analysis. BMC Pediatr 2022; 22:447. [PMID: 35879708 PMCID: PMC9316355 DOI: 10.1186/s12887-022-03512-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 07/21/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Lack of appropriate temperature management has been associated with significant adverse outcomes in preterm and low birthweight neonates. There is a lack of similar investigations in the late preterm (340-366) and term (≥370) neonate population. Our aim was to identify key risk factors as well as clinical outcomes associated with hypothermia in this population. METHODS A retrospective chart review was conducted at the Ottawa Hospital including all eligible infants ≥340 weeks' gestation over a one-month period in November 2020. Infant, maternal, and delivery room variables were collected, including prematurity, maternal temperature, delivery mode, birthweight, and premature rupture of membranes, as well as clinical outcomes such as NICU/SCN admission and length of stay. Regression models were generated, adjusted for covariates, and stepwise regression was performed. RESULTS Four hundred forty infants were included in the analysis; 26.8% (118/440) were hypothermic within 6 hours of delivery. In the multivariable analysis, prematurity, low 5 minute Apgar score (< 7) or need for resuscitation, maternal hypertension, and absence of premature rupture of membranes > 18 hours or suspected maternal infection were significantly associated with hypothermia within 6 hours of delivery (p < 0.05). Multivariable analysis of clinical outcomes demonstrated a significant association between hypothermia within 6 hours of delivery and NICU/SCN admission (OR = 2.87; 95% CI 1.36, 6.04), need for respiratory support or diagnosis of respiratory distress syndrome (OR = 3.94; 95% CI 1.55, 10.50), and length of stay (exp(β) = 1.20; 95% bootstrap CI 1.04, 1.37). CONCLUSIONS Our results suggest there are similar factors associated with hypothermia in our study population of infants born at ≥340 weeks' gestation compared to prior studies in preterm and low-birthweight infants. Furthermore, hypothermia is associated with higher risk of adverse outcomes, which highlights the need to prevent hypothermia in all newborns.
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Affiliation(s)
- Laura Nguyen
- Faculty of Medicine, University of Ottawa, 451 Smyth Rd, Ottawa, Ontario, Canada
| | - Nicholas Mitsakakis
- Children's Hospital of Eastern Ontario Research Institute, 401 Smyth Rd, Ottawa, Ontario, Canada
| | - Ewa Sucha
- Children's Hospital of Eastern Ontario Research Institute, 401 Smyth Rd, Ottawa, Ontario, Canada
| | - Brigitte Lemyre
- The Ottawa Hospital, General Campus, 501 Smyth Road, Ottawa, Ontario, Canada.,Department of Pediatrics, Children's Hospital of Eastern Ontario, 401 Smyth Rd, Ottawa, Ontario, K1H 8L1, Canada
| | - Sarah Linda Lawrence
- The Ottawa Hospital, General Campus, 501 Smyth Road, Ottawa, Ontario, Canada. .,Department of Pediatrics, Children's Hospital of Eastern Ontario, 401 Smyth Rd, Ottawa, Ontario, K1H 8L1, Canada.
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9
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Kato S, Iwata O, Iwata S, Yamada T, Tsuda K, Tanaka T, Saitoh S. Admission temperature of very low birth weight infants and outcomes at three years old. Sci Rep 2022; 12:11912. [PMID: 35831444 PMCID: PMC9279326 DOI: 10.1038/s41598-022-15979-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Accepted: 07/01/2022] [Indexed: 11/09/2022] Open
Abstract
The lower body temperature of preterm newborns at admission to neonatal intensive care units (NICUs) is inversely associated with their morbidities and mortalities before discharge. This retrospective cohort study aimed to determine whether admission rectal temperature in very low birth weight infants (VLBWIs) is independently associated with a composite outcome of death or moderate-to-severe neurodevelopmental impairments as defined by a performance developmental quotient of < 70 at three years of age. VLBWIs admitted to the NICU between April 2010 and March 2016 were assesed. Developmental assessment was completed in 216 newborns. Nine and two infants died before and after discharge, respectively. A higher admission temperature was associated with a lower incidence of death or moderate-to-severe neurodevelopmental impairments with adjustment for gestational age, sex, antenatal steroid use, Apgar score, severe intraventricular hemorrhage, and severe bronchopulmonary dysplasia (odds ratio [OR] 0.424; 95% confidence interval [CI] 0.250-0.717; p = 0.001). The admission temperature remained as an independent variable of adverse outcome at three years of age even when the study cohort was limited to surviving infants (OR 0.448; 95% CI 0.259-0.774; p = 0.004). Further studies are needed to assess whether avoiding low body temperature at admission results in better long-term neurodevelopmental outcomes in VLBWIs.
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Affiliation(s)
- Shin Kato
- Department of Pediatrics and Neonatology, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, 467-8601, Japan.
| | - Osuke Iwata
- Department of Pediatrics and Neonatology, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, 467-8601, Japan
| | - Sachiko Iwata
- Department of Pediatrics and Neonatology, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, 467-8601, Japan
| | - Takaharu Yamada
- Department of Pediatrics, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, Nagoya, Japan
| | - Kennosuke Tsuda
- Department of Pediatrics and Neonatology, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, 467-8601, Japan.,Department of Pediatrics, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, Nagoya, Japan
| | - Taihei Tanaka
- Department of Pediatrics, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, Nagoya, Japan
| | - Shinji Saitoh
- Department of Pediatrics and Neonatology, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, 467-8601, Japan
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10
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Bi SY, Yu YH, Li C, Xu P, Xu HY, Li JH, Liu QY, Li M, Liu XJ, Wang H. A standardized implementation of multicenter quality improvement program of very low birth weight newborns could significantly reduce admission hypothermia and improve outcomes. BMC Pediatr 2022; 22:281. [PMID: 35568937 PMCID: PMC9107002 DOI: 10.1186/s12887-022-03310-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Accepted: 04/27/2022] [Indexed: 11/12/2022] Open
Abstract
Background Admission hypothermia (AH, < 36.5℃) remains a major challenge for global neonatal survival, especially in developing countries. Baseline research shows nearly 89.3% of very low birth weight (VLBW, < 1500 g) infants suffer from AH in China. Therefore, a prospective multicentric quality improvement (QI) initiative to reduce regional AH and improve outcomes among VLBW neonates was implemented. Methods The study used a sequential Plan—Do—Study—Act (PDSA) approach. Clinical data were collected prospectively from 5 NICUs within the Sino-Northern Neonatal Network (SNN) in China. The hypothermia prevention bundle came into practice on January 1, 2019. The clinical characteristics and outcomes data in the pre-QI phase (January 1, 2018– December 31, 2018) were compared with that from the post-QI phase (January 1, 2019–December 31, 2020). Clinical characteristics and outcomes data were analyzed. Results A total of 750 in-born VLBW infants were enrolled in the study, 270 in the pre-QI period and 480 in the post- QI period, respectively. There were no significant differences in clinical characteristics of infants between these two phases. Compared with pre-QI period, the incidence of AH was decreased significantly after the QI initiative implementation in the post-QI period (95.9% vs. 71.3%, P < 0.01). Incidence of admission moderate-to-severe hypothermia (AMSH, < 36℃) also decreased significantly, manifesting a reduction to 38.5% in the post-QI (68.5% vs 30%, P < 0.01). Average admission temperature improved from after QI (35.5 \documentclass[12pt]{minimal}
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\begin{document}$$\pm$$\end{document}± 0.6℃, P < 0.01). There was no increase in proportion the number of infants with a temperature of > 37.5 °C or thermal burns between the two groups. The risk ratio of mortality in infants during the post-QI period was significantly lower in the post-QI period as compared to the pre-QI period [adjusted risk ratio (aRR): 0.26, 95% confidence interval (CI): 0.13–0.50]. The risk ratio of late-onset neonatal sepsis (LOS) also significantly lowered in the post-QI period (aRR: 0.66, 95% CI: 0.50–0.87). Conclusion Implementation of multicentric thermoregulatory QI resulted in a significant reduction in AH and AMSH in VLBW neonates with associated reduction in mortality. We gained a lot from the QI, and successfully aroused the attention of perinatal medical staff to neonatal AH. This provided a premise for continuous quality improvement of AH in the future, and might provide a reference for implementation of similar interventions in developing countries. Trial registration Trial registration number: ChiCTR1900020861. Date of registration: 21 January 2019(21/01/2019). Prospectively registered. Supplementary Information The online version contains supplementary material available at 10.1186/s12887-022-03310-5.
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Affiliation(s)
- Shu-Yu Bi
- Department of Neonatology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, 250021, Shandong, China
| | - Yong-Hui Yu
- Department of Neonatology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, 250021, Shandong, China. .,Department of Neonatology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, 250021, China.
| | - Cong Li
- Department of Neonatology, Liaocheng People's Hospital, Liaocheng, 252000, Shandong, China
| | - Ping Xu
- Department of Neonatology, Liaocheng People's Hospital, Liaocheng, 252000, Shandong, China
| | - Hai-Yan Xu
- Department of Neonatology, The First Affiliated Hospital of Shandong First Medical University, Jinan, 250014, Shandong, China
| | - Jia-Hui Li
- Department of Neonatology, The First Affiliated Hospital of Shandong First Medical University, Jinan, 250014, Shandong, China
| | - Qiong-Yu Liu
- Department of Neonatology, Women and Children's Healthcare Hospital of Linyi, Linyi, 276000, Shandong, China
| | - Min Li
- Department of Neonatology, Women and Children's Healthcare Hospital of Linyi, Linyi, 276000, Shandong, China
| | - Xin-Jian Liu
- Department of Neonatology, Hebei Petro China Central Hospital, Langfang, 065000, Hebei, China
| | - Hui Wang
- Department of Neonatology, Hebei Petro China Central Hospital, Langfang, 065000, Hebei, China
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11
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Whitesel E, Goldstein J, Lee HC, GuptaMMSc M. Quality Improvement for Neonatal Resuscitation and Delivery Room Care. SEMINARS IN SPINE SURGERY 2022:100961. [PMID: 35574250 PMCID: PMC9080026 DOI: 10.1016/j.semss.2022.100961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Quality improvement has become a foundation of neonatal care. Structured approaches to improvement can standardize practices, improve teamwork, engage families, and improve outcomes. The delivery room presents a unique environment for quality improvement; optimal delivery room care requires advanced preparation, adequately trained providers, and carefully coordinated team dynamics. In this article, we examine quality improvement for neonatal resuscitation. We review the published literature, focusing on reports targeting admission hypothermia, delayed cord clamping, and initial respiratory support. We discuss specific challenges related to delivery room quality improvement, including small numbers, data collection, and lack of benchmarking, and potential strategies to address them including simulation, checklists, and state and national collaboratives. We examine how quality improvement can target equity in delivery room outcomes, and explore the impact of the COVID-19 pandemic on delivery room quality of care.
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Affiliation(s)
- Emily Whitesel
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | | | - Henry C Lee
- Stanford University School of Medicine, Stanford, CA
| | - Munish GuptaMMSc
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
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12
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Liu J, Wu S, Zhu X. Advances in the Prevention and Treatment of Neonatal Hypothermia in Early Birth. Ther Hypothermia Temp Manag 2022; 12:51-56. [PMID: 35384724 DOI: 10.1089/ther.2021.0036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Neonates are vulnerable to hypothermia in the early postnatal period due to a low temperature environment, physiological function, and many other factors. In this article, the definition, occurrence status, related factors, hazards, and prevention strategies of neonatal hypothermia are reviewed. The interventions for hypothermia are mainly achieved through three processes, that is, intervention in the delivery room before and after birth, intervention on the way from the delivery room to the neonatal intensive care unit (NICU), and intervention after arrival at the NICU. Rewarming is the main intervention measure after the occurrence of hypothermia and slow rewarming is advocated, based on related studies of early neonatal cold injury syndrome and mild hypothermia treatment of hypoxic-ischemic encephalopathy. Rapid rewarming has been proposed in recent years but remains controversial. There are no detailed guidelines yet for rewarming for early neonatal hypothermia, and there is no precise definition of "rapid rewarming" and "slow rewarming" in terms of the rewarming rate.
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Affiliation(s)
- Jianhong Liu
- Department of Neonatology, Jingzhou Central Hospital, The Second Hospital of Yangtze University, Jingzhou, China
| | - Shanshan Wu
- Department of Neonatology, Jingzhou Central Hospital, The Second Hospital of Yangtze University, Jingzhou, China
| | - Xiaofang Zhu
- Department of Neonatology, Jingzhou Central Hospital, The Second Hospital of Yangtze University, Jingzhou, China
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13
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Heo JS, Kim SY, Park HW, Choi YS, Park CW, Cho GJ, Oh AY, Jang EK, Kim HS, Kim ARE, Hwang SO. 2020 Korean Guidelines for Cardiopulmonary Resuscitation. Part 8. Neonatal resuscitation. Clin Exp Emerg Med 2021; 8:S96-S115. [PMID: 34034452 PMCID: PMC8171175 DOI: 10.15441/ceem.21.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Accepted: 04/05/2021] [Indexed: 01/02/2023] Open
Affiliation(s)
- Ju Sun Heo
- Department of Pediatrics, Korea University College of Medicine, Seoul, Korea
| | - Su Yeong Kim
- Department of Pediatrics, Chung-Ang University College of Medicine, Seoul, Korea
| | - Hye Won Park
- Department of Pediatrics, Konkuk University School of Medicine, Seoul, Korea
| | - Yong-Sung Choi
- Department of Pediatrics, Kyung Hee University School of Medicine, Seoul, Korea
| | - Chan-Wook Park
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Korea
| | - Geum Joon Cho
- Department of Obstetrics and Gynecology, Korea University College of Medicine, Seoul, Korea
| | - Ah Young Oh
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Eun Kyung Jang
- Office of Patient Safety, Yonsei University Severance Hospital, Seoul, Korea
| | - Han-Suk Kim
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Ai-Rhan Ellen Kim
- Department of Pediatrics, Ulsan University College of Medicine, Seoul, Korea
| | - Sung Oh Hwang
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
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14
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Sprecher A, Malin K, Finley D, Lembke P, Keller S, Grippe A, Hornung G, Antos N, Uhing M. Quality Improvement Approach to Reducing Admission Hypothermia Among Preterm and Term Infants. Hosp Pediatr 2021; 11:270-276. [PMID: 33627479 DOI: 10.1542/hpeds.2020-003269] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Newborns, particularly premature newborns, are susceptible to hypothermia when transitioning from birth to admission to the NICU, potentially leading to increased mortality and morbidity. Despite attention to this issue, our rate of admission hypothermia was 39.8%. METHODS We aimed to reduce the rate of admission hypothermia for all inborn infants admitted to our institution to <10%. We undertook a quality improvement effort that spanned from 2013 through 2019 in our level IV NICU. Current state analysis involved investigating patient risk factors for hypothermia and staff understanding of hypothermia prevention. Improvement cycles included auditing processes, an in-hospital relocation of our NICU, expanded use of chemical heat mattresses and polyethylene bags, and staff education. Improvement was evaluated by using Shewhart control charts. RESULTS We demonstrated a reduction in admission hypothermia from 39.8% to 9.9%, which was temporally related to educational efforts and expanded use of chemical heat mattresses and polyethylene bags. There was not an increase in admission hyperthermia over this time period. We found that our group at highest risk of admission hypothermia was not our most premature cohort but those infants born between 33 and 36 6/7 weeks' gestation and those infants prenatally diagnosed with congenital anomalies. CONCLUSIONS Expanded use of polyethylene bags and chemical heat mattresses can improve thermoregulation particularly when combined with staff education. Although premature infants have been the focus of many hypothermia prevention efforts, our data suggest that older infants, and those infants born with congenital anomalies, require additional attention.
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Affiliation(s)
- Alicia Sprecher
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin; and
| | | | | | - Paula Lembke
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin; and
| | | | - Ann Grippe
- Children's Wisconsin, Milwaukee, Wisconsin
| | | | - Nicholas Antos
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin; and
| | - Michael Uhing
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin; and
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15
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Glenn T, Price R, Culbertson L, Yalcinkaya G. Improving thermoregulation in transported preterm infants: a quality improvement initiative. J Perinatol 2021; 41:339-345. [PMID: 32678317 PMCID: PMC7860135 DOI: 10.1038/s41372-020-0732-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 06/16/2020] [Accepted: 07/07/2020] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Increase the percentage of transported preterm or LBW infants with an admission temperature of 36.5-37.5 °C from 60 to 80% by December 2017. STUDY DESIGN We used the Model for Improvement with Plan-Do-Study-Act (PDSA) cycles. Interventions focused on awareness of temperature control in preterm infants, adequate monitoring, and maintaining normothermia. Interventions consisted of standardizing isolette temperature, use of chemical warming pack and plastic wrap, and feedback. Data were plotted on a p-chart and grouped by month. RESULT A total of 381 infants <37 weeks or <2.5 kg were transported from January 2016 to December 2019. At baseline 60% were admitted with a temperature within the range of 36.5-37.5 °C. Special cause variation was noted twice during the study period, initially to 80% in June 2018 and then to 96% in April 2019, without an increase in hyperthermia. CONCLUSION Multidisciplinary quality improvement efforts improved normothermia in vulnerable transported infants to 96%.
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Affiliation(s)
- Tara Glenn
- Department of Pediatrics, University Hospitals Rainbow Babies and Children's Hospital, Cleveland, OH, USA.
| | - Rhonda Price
- Department of Emergency Services, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Lauren Culbertson
- Department of Pediatrics, University Hospitals Rainbow Babies and Children’s Hospital, Cleveland, OH.,Department of Pediatrics, Oregon Health and Science University, Portland, OR
| | - Gulgun Yalcinkaya
- Department of Pediatrics, University Hospitals Rainbow Babies and Children’s Hospital, Cleveland, OH
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16
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Bruckner M, Mileder LP, Richter A, Baik-Schneditz N, Schwaberger B, Binder-Heschl C, Urlesberger B, Pichler G. Association between Regional Tissue Oxygenation and Body Temperature in Term and Preterm Infants Born by Caesarean Section. CHILDREN-BASEL 2020; 7:children7110205. [PMID: 33138154 PMCID: PMC7692110 DOI: 10.3390/children7110205] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 10/26/2020] [Accepted: 10/28/2020] [Indexed: 11/22/2022]
Abstract
Body temperature (BT) management remains a challenge in neonatal intensive care, especially during resuscitation after birth. Our aim is to analyze whether there is an association between the BT and cerebral and peripheral tissue oxygen saturation (crSO2/cTOI and prSO2), arterial oxygen saturation (SpO2), and heart rate (HR). The secondary outcome parameters of five prospective observational studies are analyzed. We include preterm and term neonates born by Caesarean section who received continuous pulse oximetry and near-infrared spectroscopy monitoring during the first 15 min, and a rectal BT measurement once in minute 15 after birth. Four-hundred seventeen term and 169 preterm neonates are included. The BT did not correlate with crSO2/cTOI and SpO2. The BT correlated with the HR in all neonates (ρ = 0.210, p < 0.001) and with prSO2 only in preterm neonates (ρ = −0.285, p = 0.020). The BT was lower in preterm compared to term infants (36.7 [36.4–37.0] vs. 36.8 [36.6–37.0], p = 0.001) and prevalence of hypothermia was higher in preterm neonates (29.5% vs. 12.0%, p < 0.001). To conclude, the BT did not correlate with SpO2 and crSO2/cTOI, however, there was a weak positive correlation between the BT and the HR in the whole cohort and a weak correlation between the BT and prSO2 only in preterm infants. Preterm neonates had a statistically lower BT and suffered significantly more often from hypothermia during postnatal transition.
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Affiliation(s)
- Marlies Bruckner
- Research Unit for Neonatal Micro- and Macrocirculation, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, 8036 Graz, Austria; (M.B.); (A.R.); (N.B.-S.); (B.S.); (C.B.-H.); (B.U.); (G.P.)
- Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, 8036 Graz, Austria
| | - Lukas P. Mileder
- Research Unit for Neonatal Micro- and Macrocirculation, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, 8036 Graz, Austria; (M.B.); (A.R.); (N.B.-S.); (B.S.); (C.B.-H.); (B.U.); (G.P.)
- Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, 8036 Graz, Austria
- Correspondence: ; Tel.: +43-316-385-81052; Fax: +43-316-385-13953
| | - Alisa Richter
- Research Unit for Neonatal Micro- and Macrocirculation, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, 8036 Graz, Austria; (M.B.); (A.R.); (N.B.-S.); (B.S.); (C.B.-H.); (B.U.); (G.P.)
| | - Nariae Baik-Schneditz
- Research Unit for Neonatal Micro- and Macrocirculation, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, 8036 Graz, Austria; (M.B.); (A.R.); (N.B.-S.); (B.S.); (C.B.-H.); (B.U.); (G.P.)
- Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, 8036 Graz, Austria
| | - Bernhard Schwaberger
- Research Unit for Neonatal Micro- and Macrocirculation, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, 8036 Graz, Austria; (M.B.); (A.R.); (N.B.-S.); (B.S.); (C.B.-H.); (B.U.); (G.P.)
- Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, 8036 Graz, Austria
| | - Corinna Binder-Heschl
- Research Unit for Neonatal Micro- and Macrocirculation, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, 8036 Graz, Austria; (M.B.); (A.R.); (N.B.-S.); (B.S.); (C.B.-H.); (B.U.); (G.P.)
- Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, 8036 Graz, Austria
| | - Berndt Urlesberger
- Research Unit for Neonatal Micro- and Macrocirculation, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, 8036 Graz, Austria; (M.B.); (A.R.); (N.B.-S.); (B.S.); (C.B.-H.); (B.U.); (G.P.)
- Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, 8036 Graz, Austria
| | - Gerhard Pichler
- Research Unit for Neonatal Micro- and Macrocirculation, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, 8036 Graz, Austria; (M.B.); (A.R.); (N.B.-S.); (B.S.); (C.B.-H.); (B.U.); (G.P.)
- Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, 8036 Graz, Austria
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17
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Perretta LJ, Spaight M, Yap V, Perlman J. Randomized Study of Delayed Cord Clamping of 30 to 60 Seconds in the Larger Infant Born Preterm. J Pediatr 2020; 224:153-157. [PMID: 32651013 DOI: 10.1016/j.jpeds.2020.04.058] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 04/10/2020] [Accepted: 04/23/2020] [Indexed: 10/23/2022]
Abstract
In a randomized study of infants born preterm (gestational age 28-34 6/7 weeks), we evaluated delayed cord clamping for 30 (n = 50) vs 60 (n = 55) seconds. The primary outcome of initial hematocrit differed by 2.8% (P = .006), being greater with 60 seconds. There were no differences in secondary outcomes and no adverse consequences between groups. These findings should serve as a stimulus to many centers that are reluctant to implement delayed cord clamping in this targeted larger premature population.
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Affiliation(s)
- Laura J Perretta
- Division of Newborn Medicine, Department of Pediatrics, New York Presbyterian-Weill Cornell Medicine, New York, NY
| | - Morgan Spaight
- Division of Newborn Medicine, Department of Pediatrics, New York Presbyterian-Weill Cornell Medicine, New York, NY
| | - Vivien Yap
- Division of Newborn Medicine, Department of Pediatrics, New York Presbyterian-Weill Cornell Medicine, New York, NY
| | - Jeffrey Perlman
- Division of Newborn Medicine, Department of Pediatrics, New York Presbyterian-Weill Cornell Medicine, New York, NY.
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18
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Bhatt DR, Reddy N, Ruiz R, Bustos DV, Peacock T, Dizon RA, Weerasinghe S, Braun DX, Ramanathan R. Perinatal quality improvement bundle to decrease hypothermia in extremely low birthweight infants with birth weight less than 1000 g: single-center experience over 6 years. J Investig Med 2020; 68:1256-1260. [PMID: 32690596 PMCID: PMC7525784 DOI: 10.1136/jim-2020-001334] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/25/2020] [Indexed: 11/11/2022]
Abstract
Normothermia (36.5°C–37. 5°C) at the time of admission to the neonatal intensive care unit (NICU) in extremely low birthweight (ELBW) infants (birth weight <1000 g) is associated with decreased morbidity and mortality, decreased length of stay and hospital costs. We designed a thermoregulation bundle to decrease hypothermia (<36.5°C) in ELBW infants with a multidisciplinary perinatal quality improvement initiative that included the following key interventions: dedicated delivery room (DR)/operating room (OR) for all preterm deliveries of ≤32 weeks with DR/OR temperature set 24/7 at 74°F by the hospital engineering staff, use of exothermic mattress, preheated radiant warmer set at 100% for heat prior to delivery, servo-controlled mode after the neonate is placed on the warmer, and use of plastic wrap, head cap and warm towels. A total of 200 ELBW infants were admitted to our NICU between January 1, 2014 and December 31, 2019. Hypothermia (<36.5°C) occurred in 2.5% of infants, normothermia (36.5°C–37.5°C) in 91% of infants and transitional hyperthermia (>37.5°C) in 6.5% of ELBW infants. No case of moderate hypothermia (32°C–36°C) was seen in our infants. Our target rate of less than 10% hypothermia was reached in ELBW infants over the last 2 years with no cases of moderate hypothermia in 6 years. Eliminating hypothermia among ELBW remains a challenge and requires team effort and continuous quality improvement efforts.
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Affiliation(s)
- Dilip R Bhatt
- Pediatrics/Neonatology, Kaiser Fontana Medical Center, Fontana, California, USA
| | - Nirupa Reddy
- Pediatrics/Neonatology, Kaiser Fontana Medical Center, Fontana, California, USA
| | - Reynaldo Ruiz
- Obstetrics, Kaiser Fontana Medical Center, Fontana, California, USA
| | - Darla V Bustos
- Neonatology, Kaiser Fontana Medical Center, Fontana, California, USA
| | - Torria Peacock
- Pediatrics/Neonatology, Kaiser Fontana Medical Center, Fontana, California, USA
| | - Roman-Angelo Dizon
- Pediatrics/Neonatology, Kaiser Fontana Medical Center, Fontana, California, USA
| | | | - David X Braun
- Pediatrics/Neonatology, Kaiser Fontana Medical Center, Fontana, California, USA
| | - Rangasamy Ramanathan
- Pediatrics/Division of Neonatology, LAC USC Medical Center, Los Angeles, California, USA
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19
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Merazzi D, Bresesti I, Tagliabue P, Valsecchi MG, De Lorenzo P, Lista G. Body temperature at nursery admission in a cohort of healthy newborn infants: results from an observational cross-sectional study. Ital J Pediatr 2020; 46:46. [PMID: 32293526 PMCID: PMC7157981 DOI: 10.1186/s13052-020-0810-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Accepted: 03/25/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Exposure to hypothermia is somehow unavoidable when a baby comes to life. This is the reason why any possible effort should be made by every caregiver involved during birth, from labour to transfer into the maternity ward, to reduce it. Hypothermia has widely shown to be related to several neonatal problems, and the risks are more relevant when the babies are born prematurely. METHOD An observational study was conducted in April 2016 to assess the current practises to avoid hypothermia at birth in 20 Italian neonatal units. Each unit introduced local improvements in clinical practice and the same observational study was repeated 1 year later. RESULTS A total of 4722 babies were analysed. An overall increase in adherence to local and international recommendations emerged from our study. Significant differences between 2016 and 2017 were found in regard to neonatal temperature at nursery entry (36.3 °C vs 36.5 °C, respectively, p < 0.0001), delayed cord clamping practice > 60″ (48.1% vs 68.1%, respectively, p < 0.0001) and skin-to-skin practice > 60' (56.3% vs 60.9, respectively, p = 0.03). Statistical correlations with the risk of hypothermia were found for delivery room (OR 0.88 (CI 95%0.83-0.94), p < 0.0001) and maternal temperature (OR 0.57 (CI 95% 0.48-0.67), p < 0.0001). CONCLUSION Periodical assessment of the delivery room practice has shown to be effective in improving adherence to the international recommendations. Relationship between neonatal hypothermia and several other variables including the delivery room and mother temperature underlines how neonatal thermoregulation starts immediately after birth. Hence, a multi-disciplinary approach is needed to provide the optimal environment for a safe birth.
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Affiliation(s)
| | - Ilia Bresesti
- Division of Neonatology, "V. Buzzi" Children's Hospital, ASST-FBF-Sacco, Milan, Italy.,Division of Pediatrics, "L. Sacco" Hospital, ASST-FBF-Sacco, Milan, Italy
| | - Paolo Tagliabue
- Division of Neonatology, "S. Gerardo" Hospital, MBBM Foundation, Monza, Italy
| | - Maria Grazia Valsecchi
- Center of Biostatistics for Clinical Epidemiology, School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Paola De Lorenzo
- Center of Biostatistics for Clinical Epidemiology and Pediatric Clinic, School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Gianluca Lista
- Division of Neonatology, "V. Buzzi" Children's Hospital, ASST-FBF-Sacco, Milan, Italy.
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20
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Donnellan D, Moore Z, Patton D, O'Connor T, Nugent L. The effect of thermoregulation quality improvement initiatives on the admission temperature of premature/very low birth-weight infants in neonatal intensive care units: A systematic review. J SPEC PEDIATR NURS 2020; 25:e12286. [PMID: 31909894 DOI: 10.1111/jspn.12286] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 12/12/2019] [Accepted: 12/16/2019] [Indexed: 12/22/2022]
Abstract
PURPOSE The purpose of this review was to ascertain the impact of thermoregulation quality improvement initiatives (QIs) on the admission temperatures of premature/very-low-birth-weight infants in neonatal intensive care units (NICUs). METHODS A systematic search of databases Cumulative Index to Nursing and Allied Health Literature, Medline, Embase, and the Cochrane library was carried out. Specific inclusion and exclusion criteria were adhered to, with no publication date limitations added. The chosen studies were examined for quality, data were extracted and analysed, before a narrative synthesis was performed. The last search occurred on January 7, 2019, with PRISMA flow diagrams completed for identified studies. RESULTS Ten studies of varying methodology design were included in this review. Variations of thermoregulation interventions were included in the 10 studies. Nevertheless, all of them demonstrated that admission temperature rates can be significantly improved by implementing a thermoregulation QI. The multidisciplinary team and ongoing education were seen as much needed components to the overall sustainability, and continuing success of the QI's. PRACTICAL IMPLICATIONS This systematic review determines that thermoregulation QIs can positively impact the admission temperatures of premature/very-low-birth-weight infants in the NICU. Prevention of hypothermia is aimed at reducing the risks of developing major neonatal morbidities. The pooling of the results from the 10 studies helps in the sharing of outcome measures and thus, improving quantitative synthesis. More frequent monitoring of the axillary temperature would help in preventing hypothermia and hyperthermia occurring. Ongoing education and staff training are essential for managing thermoregulation successfully. Examining the compliance rates to such quality initiatives, and the variations in interventions would benefit from further research to ensure better standardisation of clinical practice.
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Affiliation(s)
- Denise Donnellan
- Neonatal Intensive Care Unit, University Hospital Galway, Galway, Ireland
| | - Zena Moore
- School of Nursing and Midwifery, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Declan Patton
- School of Nursing and Midwifery, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Tom O'Connor
- School of Nursing and Midwifery, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Linda Nugent
- School of Nursing and Midwifery, Royal College of Surgeons in Ireland, Dublin, Ireland
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Boghossian NS, Geraci M, Lorch SA, Phibbs CS, Edwards EM, Horbar JD. Racial and Ethnic Differences Over Time in Outcomes of Infants Born Less Than 30 Weeks' Gestation. Pediatrics 2019; 144:peds.2019-1106. [PMID: 31405887 PMCID: PMC6813804 DOI: 10.1542/peds.2019-1106] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/15/2019] [Indexed: 01/07/2023] Open
Abstract
OBJECTIVES To examine changes in care practices over time by race and ethnicity and whether the decrease in hospital mortality and severe morbidities has benefited infants of minority over infants of white mothers. METHODS Infants 22 to 29 weeks' gestation born between January 2006 and December 2017 at a Vermont Oxford Network center in the United States were studied. We examined mortality and morbidity rate differences and 95% confidence intervals for African American and Hispanic versus white infants by birth year. We tested temporal differences in mortality and morbidity rates between white and African American or Hispanic infants using a likelihood ratio test on nested binomial regression models. RESULTS Disparities for certain care practices such as antenatal corticosteroids and for some in-hospital outcomes have narrowed over time for minority infants. Compared with white infants, African American infants had a faster decline for mortality, hypothermia, necrotizing enterocolitis, and late-onset sepsis, whereas Hispanic infants had a faster decline for mortality, respiratory distress syndrome, and pneumothorax. Other morbidities showed a constant rate difference between African American and Hispanic versus white infants over time. Despite the improvements, outcomes including hypothermia, mortality, necrotizing enterocolitis, late-onset sepsis, and severe intraventricular hemorrhage remained elevated by the end of the study period, especially among African American infants. CONCLUSIONS Racial and ethnic disparities in vital care practices and certain outcomes have decreased. That the quality deficit among minority infants occurred for several care practice measures and potentially modifiable outcomes suggests a critical role for quality improvement initiatives tailored for minority-serving hospitals.
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Affiliation(s)
- Nansi S. Boghossian
- Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina
| | - Marco Geraci
- Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina
| | - Scott A. Lorch
- Division of Neonatology, Department of Pediatrics, Children’s Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania;,Leonard Davis Institute of Health Economics, Wharton School, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ciaran S. Phibbs
- Health Economics Resource Center and Center for Implementation to Innovation, Veterans Affairs Palo Alto Health Care System, Menlo Park, California;,Perinatal Epidemiology and Health Outcomes Research Unit, Division of Neonatology, Department of Pediatrics, School of Medicine, Stanford University, Stanford, California
| | - Erika M. Edwards
- Vermont Oxford Network, Burlington, Vermont;,Department of Mathematics and Statistics, University of Vermont, Burlington, Vermont; and,Department of Pediatrics, College of Medicine, University of Vermont, Burlington, Vermont
| | - Jeffrey D. Horbar
- Vermont Oxford Network, Burlington, Vermont;,Department of Pediatrics, College of Medicine, University of Vermont, Burlington, Vermont
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Lee NH, Nam SK, Lee J, Jun YH. Clinical impact of admission hypothermia in very low birth weight infants: results from Korean Neonatal Network. KOREAN JOURNAL OF PEDIATRICS 2019; 62:386-394. [PMID: 31122009 PMCID: PMC6801200 DOI: 10.3345/kjp.2019.00206] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Accepted: 05/22/2019] [Indexed: 01/28/2023]
Abstract
BACKGROUND Preterm infants have difficulty maintaining body temperature after birth. However, clinical guidelines advocate that neonatal body temperature should be maintained at 36.5°C-37.5°C. PURPOSE We aimed to investigate the incidence of admission hypothermia in very low birth weight (VLBW) infants and to determine the association of admission temperature with in-hospital mortality and morbidities. METHODS A cohort study using prospectively collected data involving 70 neonatal intensive care units (NICUs) that participate in the Korean Neonatal Network. From registered infants born between January 2013 and December 2015, 5,343 VLBW infants born at less than 33 weeks of gestation were reviewed. RESULTS The mean admission temperature was 36.1°C±0.6°C, with a range of 31.9°C to 38.4°C. Approximately 74.1% of infants had an admission hypothermia of <36.5°C. Lower birth weight, intubation in the delivery room and Apgar score <7 at 5 minutes were significantly related to admission hypothermia. The mortality was the lowest at 36.5°C-37.5°C and adjusted odd ratios for all deaths increased to 1.38 (95% confidence interval [CI], 1.04-1.83), 1.44 (95% CI, 1.05-1.97) and 1.86 (95% CI, 1.22-2.82) for infants with admission temperatures of 36.0°C-36.4°C, 35.0°C-35.9°C, and <35.0°C, respectively. Admission hypothermia was also associated with high likelihoods of bronchopulmonary dysplasia, pulmonary hypertension, proven sepsis, pulmonary hemorrhage, air-leak, seizure, grade 3 or higher intraventricular hemorrhage and advanced retinopathy of prematurity requiring laser therapy. CONCLUSION A large portion of preterm infants in Korea had hypothermia at NICU admission, which was associated with high mortality and several important morbidities. More aggressive interventions aimed at reducing hypothermia are required in this high-risk population.
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Affiliation(s)
- Na Hyun Lee
- Department of Pediatrics, Inha University Hospital, Incheon, Korea
| | - Soo Kyung Nam
- Department of Pediatrics, Inha University Hospital, Incheon, Korea
| | - Juyoung Lee
- Department of Pediatrics, Inha University Hospital, Incheon, Korea.,Department of Pediatrics, Inha University College of Medicine, Incheon, Korea
| | - Yong Hoon Jun
- Department of Pediatrics, Inha University Hospital, Incheon, Korea.,Department of Pediatrics, Inha University College of Medicine, Incheon, Korea
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Abstract
The following guideline is designed to give recommendations for the routine care of all neonates immediately after delivery, and the resuscitation and delivery room approach of all high-risk infants in light of recent literature. The guideline has been prepared as three different parts. The first part is about routine procedures that have to be performed to all healthy term and preterm infants in delivery room care. The second part summaries the basic principles of resusucitation including the latest changes that were mentioned in the International Liaison Committee on Resuscitation (ILCOR)-2015 guideline. Recommendations about the delivery room management of rare clinical conditions have been discussed in the last part. The social, medical conditions, and the resourses of Turkey have also been taken into consideration in its preparation. We hope it will be useful for all pediatricians and neonatologists for use as a essential guideline in delivery room care.
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Affiliation(s)
- Nihal Oygür
- Division of Neonatology, Department of Pediatrics, Akdeniz University, Faculty of Medicine, Antalya, Turkey
| | - E Esra Önal
- Division of Neonatology, Department of Pediatrics, Gazi University, Faculty of Medicine, Ankara, Turkey
| | - Aysegül Zenciroğlu
- Health Sciences University Dr. Sami Ulus Gynecology, Obstetrics, Pediatrics SAUM Neonatology Clinic, Ankara, Turkey
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Caughey AB, Wood SL, Macones GA, Wrench IJ, Huang J, Norman M, Pettersson K, Fawcett WJ, Shalabi MM, Metcalfe A, Gramlich L, Nelson G, Wilson RD. Guidelines for intraoperative care in cesarean delivery: Enhanced Recovery After Surgery Society Recommendations (Part 2). Am J Obstet Gynecol 2018; 219:533-544. [PMID: 30118692 DOI: 10.1016/j.ajog.2018.08.006] [Citation(s) in RCA: 136] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Accepted: 08/01/2018] [Indexed: 12/12/2022]
Abstract
The Enhanced Recovery After Surgery Society guideline for intraoperative care in cesarean delivery will provide best practice, evidenced-based, recommendations for intraoperative care, with primarily a maternal focus. The "focused" pathway process for scheduled and unscheduled cesarean delivery for this Enhanced Recovery After Surgery cesarean delivery guideline will consider procedure from the decision to operate (starting with the 30-60 minutes before skin incision) through the surgery. The literature search (1966-2017) used Embase and PubMed to search medical subject headings including "cesarean section," "cesarean section," "cesarean section delivery," and all pre- and intraoperative Enhanced Recovery After Surgery items. Study selection allowed titles and abstracts to be screened by individual reviewers to identify potentially relevant articles. Metaanalyses, systematic reviews, randomized controlled studies, nonrandomized controlled studies, reviews, and case series were considered for each individual topic. Quality assessment and data analyses evaluated the quality of evidence and recommendations were evaluated according to the Grading of Recommendations, Assessment, Development and Evaluation system as used and described in previous Enhanced Recovery After Surgery Society guidelines. The Enhanced Recovery After Surgery cesarean delivery guideline/pathway has created a maternal focused pathway (for scheduled and unscheduled surgery starting from 30-60 minutes before skin incision to maternal discharge) with Enhanced Recovery After Surgery-directed preoperative elements, intraoperative elements, and postoperative elements. Specifics of the intraoperative care included the use of prophylactic antibiotics before the cesarean delivery, appropriate patient warming intraoperatively, blunt expansion of the transverse uterine hysterotomy, skin closure with subcuticular sutures, and delayed cord clamping. A number of specific elements of intraoperative care of women who undergo cesarean delivery are recommended based on the evidence. The Enhanced Recovery After Surgery Society guideline for intraoperative care in cesarean delivery will provide best practice, evidenced-based, recommendations for intraoperative care with primarily a maternal focus. When the cesarean delivery pathway (elements/processes) is studied, implemented, audited, evaluated, and optimized by maternity care teams, this will create an opportunity for the focused and optimized areas of care and recommendations to be further enhanced.
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Abstract
A high incidence of postnatal hypothermia has been reported in high-as well low-resource countries and it remains an independent predictor of neonatal morbidity and mortality, especially in very preterm infants in all settings. The temperature of newly born infants should be maintained between 36.5 and 37.5 °C after birth through admission and stabilization. Interventions to achieve this may include environmental temperature 23-25 °C, use of radiant warmers, exothermic mattresses, woollen or plastic caps, plastic wraps, humidified and heated gases. Skin-to-skin contact has been used, especially in low-resource settings. The combinations of these interventions applied to quality improvement initiatives, including staff training, use of checklists, and continuous feedback with the staff involved in the management of the neonate, are key factors to prevent heat loss from delivery room to admission to the neonatal intensive care unit. The admission temperature should be recorded as a predictor of outcomes as well as a quality indicator.
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Affiliation(s)
- Daniele Trevisanuto
- Department of Women's and Children's Health, Azienda Ospedaliera di Padova, University of Padua, Padua, Italy.
| | - Daniela Testoni
- Division of Neonatal Medicine, Escola Paulista de Medicina da Universidade Federal de São Paulo, São Paulo, Brazil
| | - Maria Fernanda B de Almeida
- Division of Neonatal Medicine, Escola Paulista de Medicina da Universidade Federal de São Paulo, São Paulo, Brazil
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Howes A, Keir A. Quality improvement effort to reduce hypothermia among high-risk infants on a mother-infant unit. Acta Paediatr 2018; 107:1837. [PMID: 29924896 DOI: 10.1111/apa.14413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Alexander Howes
- Department of Neonatal Medicine; Women's and Children's Hospital; North Adelaide SA Australia
| | - Amy Keir
- Department of Neonatal Medicine; Women's and Children's Hospital; North Adelaide SA Australia
- Healthy Mothers, Babies and Children Theme; South Australian Health and Medical Institute; North Adelaide SA Australia
- Robinson Research Institute; and the Adelaide Medical School; The University of Adelaide; North Adelaide SA Australia
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Lahana A, Delanaud S, Erbani R, Glusko-Charlet A, Durand E, Haraux E, Ghyselen L, Libert JP, Tourneux P. Warming the premature infant in the delivery room: Quantification of the risk of hyperthermia. Med Eng Phys 2018; 59:70-74. [PMID: 30131113 DOI: 10.1016/j.medengphy.2018.06.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Revised: 04/20/2018] [Accepted: 06/11/2018] [Indexed: 10/28/2022]
Abstract
AIM The efficacy and safety of three polyethylene bags commonly used to prevent hypothermia in premature infants was assessed. METHODS To simulate transfer from the delivery room to a secondary care unit, a thermally stable, bonneted mannequin (skin temperature: 34.4 °C) was placed in a climate chamber under different conditions: with a radiant warmer, with various polyethylene bags (open on one side, closed by a draw-string at the neck, or a "life support pouch" with several access points) or without a bag. RESULTS With the radiant warmer turned on, the mean reduction in heat loss from the nude mannequin was 50.8 ± 1.7% (p < 0.0001, vs. warmer off). The mean reduction in heat loss (vs. no bag) was 55.0 ± 0.9% for the drawstring bag, 49.0 ± 2.2% for the standard bag (p = 0.0001), and 48.1 ± 0.7% for the life support pouch (p = 0.006). When a radiant warmer + polyethylene bag were used, heat stress (body temperature: 38 °C) and severe hyperthermia (40 °C) occurred after 11 and 34 min, respectively. CONCLUSION Caution must be taken when using a radiant warmer and polyethylene bag with a premature infant. Heat stress can occur in only 11 min. Continuous body temperature monitoring is therefore required.
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Affiliation(s)
- Armand Lahana
- Réanimation Néonatale, Pôle Femme - Couple - Enfant, CHU, avenue René Laennec, F-80480, Amiens, France
| | | | - Romain Erbani
- Réanimation Néonatale, Pôle Femme - Couple - Enfant, CHU, avenue René Laennec, F-80480, Amiens, France
| | - Anaïs Glusko-Charlet
- Réanimation Néonatale, Pôle Femme - Couple - Enfant, CHU, avenue René Laennec, F-80480, Amiens, France
| | - Estelle Durand
- PériTox, UMI INERIS-01, UFR de Médecine UPJV, Amiens, France
| | - Elodie Haraux
- PériTox, UMI INERIS-01, UFR de Médecine UPJV, Amiens, France; Chirurgie viscérale pédiatrique, Pôle Femme - Couple - Enfant, CHU, Amiens, France
| | | | | | - Pierre Tourneux
- Réanimation Néonatale, Pôle Femme - Couple - Enfant, CHU, avenue René Laennec, F-80480, Amiens, France; PériTox, UMI INERIS-01, UFR de Médecine UPJV, Amiens, France.
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Choi HS, Lee SM, Eun H, Park M, Park KI, Namgung R. The impact of a quality improvement effort in reducing admission hypothermia in preterm infants following delivery. KOREAN JOURNAL OF PEDIATRICS 2018; 61:239-244. [PMID: 30130949 PMCID: PMC6107400 DOI: 10.3345/kjp.2018.61.8.239] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Revised: 11/01/2017] [Accepted: 11/08/2017] [Indexed: 11/27/2022]
Abstract
PURPOSE Hypothermia at admission is associated with increased mortality and morbidity in preterm infants. We performed a quality improvement (QI) effort to determine the impact of a decrease in admission hypothermia in preterm infants. METHODS The study enrolled very low birth weight (VLBW) infants born at Gangnam Severance Hospital between January 2013 and December 2016. This multidisciplinary QI effort included the use of occlusive wraps, warm blankets, and caps; the delivery room temperature was maintained above 23.0˚C, and a check-list was used for feedback. RESULTS Among 259 preterm infants, the incidence of hypothermia (defined as body temperature <36.0˚C) decreased significantly from 68% to 41%, and the mean body temperature on neonatal intensive care unit admission increased significantly from 35.5˚C to 36.0˚C. In subgroup analysis of VLBW infants, admission hypothermia and neonatal outcomes were compared between the pre-QI (n=55) and post-QI groups (n=75). Body temperature on admission increased significantly from 35.4˚C to 35.9˚C and the number of infants with hypothermia decreased significantly from 71% to 45%. There were no cases of neonatal hyperthermia. The incidence of pulmonary hemorrhage was significantly decreased (P=0.017). Interaction analysis showed that birth weight and gestational age were not correlated with hypothermia following implementation of the protocol. CONCLUSION Our study demonstrated a significant reduction in admission hypothermia following the introduction of a standardized protocol in our QI effort. This resulted in an effective reduction in the incidence of massive pulmonary hemorrhage.
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Affiliation(s)
- Han Saem Choi
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea
| | - Soon Min Lee
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea
| | - Hoseon Eun
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea
| | - Minsoo Park
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea
| | - Kook-In Park
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea
| | - Ran Namgung
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea
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Wilson E, Zeitlin J, Piedvache A, Misselwitz B, Christensson K, Maier RF, Norman M, Edstedt Bonamy AK. Cohort study from 11 European countries highlighted differences in the use and efficacy of hypothermia prevention strategies after very preterm birth. Acta Paediatr 2018; 107:958-966. [PMID: 29356061 DOI: 10.1111/apa.14230] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Revised: 09/18/2017] [Accepted: 01/16/2018] [Indexed: 01/22/2023]
Abstract
AIM This study investigated the different strategies used in 11 European countries to prevent hypothermia, which continues to affect a large proportion of preterm births in the region. METHODS We examined the association between the reported use of hypothermia prevention strategies in delivery rooms and body temperatures on admission to neonatal intensive care units (NICUs) in 5861 infants born at 22 + 0 to 31 +6 weeks of gestation. The use of plastic bags, wraps, caps, exothermic heat and mattresses was investigated. RESULTS The proportion of infants born in units that systematically used one or more hypothermia prevention strategies was 88.2% and 50.9% of those infants were hypothermic on admission to NICUs. Of the 9.6% born in units without systematic hypothermia prevention, 73.2% were hypothermic. Only 2.2% of infants were born in units with no reported prevention strategies. Lower gestational age increased the probability of hypothermia. No significant differences were found between the various hypothermia prevention strategies. Hyperthermia was seen in 4.8% of all admitted infants. CONCLUSION Very preterm infants had lower risks of hypothermia on NICU admission if the unit used systematic prevention strategies. All the strategies had similar effects, possibly due to implementation rather than a strategy's specific efficacy.
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Affiliation(s)
- Emilija Wilson
- Department of Clinical Science, Intervention and Technology; Karolinska Institutet; Stockholm Sweden
| | - Jennifer Zeitlin
- INSERM; Obstetrical, Perinatal and Paediatric Epidemiology Research Team; Centre for Epidemiology and Biostatistics (U1153); Paris-Descartes University; Paris France
| | - Aurélie Piedvache
- INSERM; Obstetrical, Perinatal and Paediatric Epidemiology Research Team; Centre for Epidemiology and Biostatistics (U1153); Paris-Descartes University; Paris France
| | | | - Kyllike Christensson
- Department of Women's and Children's Health; Karolinska Institutet; Stockholm Sweden
| | - Rolf F. Maier
- Children's Hospital; Philipps University; Marburg Germany
| | - Mikael Norman
- Department of Clinical Science, Intervention and Technology; Karolinska Institutet; Stockholm Sweden
- Department of Neonatal Medicine; Karolinska University Hospital; Stockholm Sweden
| | - Anna-Karin Edstedt Bonamy
- Department of Women's and Children's Health; Karolinska Institutet; Stockholm Sweden
- Clinical Epidemiology Unit; Department of Medicine Solna; Karolinska Institutet; Stockholm Sweden
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McCall EM, Alderdice F, Halliday HL, Vohra S, Johnston L. Interventions to prevent hypothermia at birth in preterm and/or low birth weight infants. Cochrane Database Syst Rev 2018; 2:CD004210. [PMID: 29431872 PMCID: PMC6491068 DOI: 10.1002/14651858.cd004210.pub5] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND Newborn admission temperature is a strong predictor of outcomes across all gestations. Hypothermia immediately after birth remains a worldwide issue and, if prolonged, is associated with harm. Keeping preterm infants warm is difficult even when recommended routine thermal care guidelines are followed in the delivery room. OBJECTIVES To assess the efficacy and safety of interventions designed for prevention of hypothermia in preterm and/or low birth weight infants applied within 10 minutes after birth in the delivery room, compared with routine thermal care or any other single/combination of intervention(s) also designed for prevention of hypothermia in preterm and/or low birth weight infants applied within 10 minutes after birth in the delivery room. SEARCH METHODS We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 5), MEDLINE via PubMed (1966 to 30 June 2016), Embase (1980 to 30 June 2016), and CINAHL (1982 to 30 June 2016). We also searched clinical trials databases, conference proceedings, and reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials. SELECTION CRITERIA Trials using randomised or quasi-randomised allocations to test interventions designed to prevent hypothermia (apart from 'routine' thermal care) applied within 10 minutes after birth in the delivery room for infants at < 37 weeks' gestation and/or birth weight ≤ 2500 grams. DATA COLLECTION AND ANALYSIS We used Cochrane Neonatal methods when performing data collection and analysis. MAIN RESULTS Twenty-five studies across 15 comparison groups met the inclusion criteria, categorised as: barriers to heat loss (18 studies); external heat sources (three studies); and combinations of interventions (four studies).Barriers to heat loss Plastic wrap or bag versus routine carePlastic wraps improved core body temperature on admission to the neonatal intensive care unit (NICU) or up to two hours after birth (mean difference (MD) 0.58°C, 95% confidence interval (CI) 0.50 to 0.66; 13 studies; 1633 infants), and fewer infants had hypothermia on admission to the NICU or up to two hours after birth (typical risk ratio (RR) 0.67, 95% CI 0.62 to 0.72; typical risk reduction (RD) -0.25, 95% CI -0.29 to -0.20; number needed to treat for an additional beneficial outcome (NNTB) 4, 95% CI 4 to 5; 10 studies; 1417 infants). Risk of hyperthermia on admission to the NICU or up to two hours after birth was increased in infants in the wrapped group (typical RR 3.91, 95% CI 2.05 to 7.44; typical RD 0.04, 95% CI 0.02 to 0.06; number needed to treat for an additional harmful outcome (NNTH) 25, 95% CI 17 to 50; 12 studies; 1523 infants), but overall, fewer infants receiving plastic wrap were outside the normothermic range (typical RR 0.75, 95% CI 0.69 to 0.81; typical RD -0.20, 95% CI -0.26 to -0.15; NNTH 5, 95% CI 4 to 7; five studies; 1048 infants).Evidence was insufficient to suggest that plastic wraps or bags significantly reduce risk of death during hospital stay or other major morbidities, with the exception of reducing risk of pulmonary haemorrhage.Evidence of practices regarding permutations on this general approach is still emerging and has been based on the findings of only one or two small studies.External heat sourcesEvidence is emerging on the efficacy of external heat sources, including skin-to-skin care (SSC) versus routine care (one study; 31 infants) and thermal mattress versus routine care (two studies; 126 infants).SSC was shown to be effective in reducing risk of hypothermia when compared with conventional incubator care for infants with birth weight ≥ 1200 and ≤ 2199 grams (RR 0.09, 95% CI 0.01 to 0.64; RD -0.56, 95% CI -0.84 to -0.27; NNTB 2, 95% CI 1 to 4). Thermal (transwarmer) mattress significantly kept infants ≤ 1500 grams warmer (MD 0.65°C, 95% CI 0.36 to 0.94) and reduced the incidence of hypothermia on admission to the NICU, with no significant difference in hyperthermia risk.Combinations of interventionsTwo studies (77 infants) compared thermal mattresses versus plastic wraps or bags for infants at ≤ 28 weeks' gestation. Investigators reported no significant differences in core body temperature nor in the incidence of hypothermia, hyperthermia, or core body temperature outside the normothermic range on admission to the NICU.Two additional studies (119 infants) compared plastic bags and thermal mattresses versus plastic bags alone for infants at < 31 weeks' gestation. Meta-analysis of these two studies showed improvement in core body temperature on admission to the NICU or up to two hours after birth, but an increase in hyperthermia. Data show no significant difference in the risk of having a core body temperature outside the normothermic range on admission to the NICU nor in the risk of other reported morbidities. AUTHORS' CONCLUSIONS Evidence of moderate quality shows that use of plastic wraps or bags compared with routine care led to higher temperatures on admission to NICUs with less hypothermia, particularly for extremely preterm infants. Thermal mattresses and SSC also reduced hypothermia risk when compared with routine care, but findings are based on two or fewer small studies. Caution must be taken to avoid iatrogenic hyperthermia, particularly when multiple interventions are used simultaneously. Limited evidence suggests benefit and no evidence of harm for most short-term morbidity outcomes known to be associated with hypothermia, including major brain injury, bronchopulmonary dysplasia, retinopathy of prematurity, necrotising enterocolitis, and nosocomial infection. Many observational studies have shown increased mortality among preterm hypothermic infants compared with those who maintain normothermia, yet evidence is insufficient to suggest that these interventions reduce risk of in-hospital mortality across all comparison groups. Hypothermia may be a marker for illness and poorer outcomes by association rather than by causality. Limitations of this review include small numbers of identified studies; small sample sizes; and variations in methods and definitions used for hypothermia, hyperthermia, normothermia, routine care, and morbidity, along with lack of power to detect effects on morbidity and mortality across most comparison groups. Future studies should: be adequately powered to detect rarer outcomes; apply standardised morbidity definitions; focus on longer-term outcomes, particularly neurodevelopmental outcomes.
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Affiliation(s)
- Emma M McCall
- Queen's University BelfastSchool of Nursing and MidwiferyMedical Biology Centre97 Lisburn RoadBelfastNorthern IrelandUK
| | - Fiona Alderdice
- Nuffield Department of Population Health, University of OxfordNational Perinatal Epidemiology UnitOxfordUK
| | - Henry L Halliday
- Retired Honorary Professor of Child Health, Queen's University Belfast74 Deramore Park SouthBelfastNorthern IrelandUKBT9 5JY
| | - Sunita Vohra
- University of AlbertaDepartment of Pediatrics8B19 11111 Jasper AvenueEdmontonABCanadaT5K 0L4
| | - Linda Johnston
- University of TorontoLawrence S Bloomberg Faculty of NursingHealth Sciences Building155 College StreetTorontoOntarioCanadaM5T 2S8
- Soochow UniversityTaipeiTaiwan
- The University of MelbourneMelbourneAustralia
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McGrory L, Owen LS, Thio M, Dawson JA, Rafferty AR, Malhotra A, Davis PG, Kamlin COF. A Randomized Trial of Conditioned or Unconditioned Gases for Stabilizing Preterm Infants at Birth. J Pediatr 2018; 193:47-53. [PMID: 29106924 DOI: 10.1016/j.jpeds.2017.09.006] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Revised: 08/07/2017] [Accepted: 09/06/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To determine whether the use of heated-humidified gases for respiratory support during the stabilization of infants <30 weeks of gestational age (GA) in the delivery room reduces rates of hypothermia on admission to the neonatal intensive care unit (NICU). STUDY DESIGN A multicenter, unblinded, randomized trial was conducted in Melbourne, Australia, between February 2013 and June 2015. Infants <30 weeks of GA were randomly assigned to receive either heated-humidified gases or unconditioned gases during stabilization in the delivery room and during transport to NICU. Infants born to mothers with pyrexia >38°C were excluded. Primary outcome was rate of hypothermia on NICU admission (rectal temperature <36.5°C). RESULTS A total of 273 infants were enrolled. Fewer infants in the heated-humidified group were hypothermic on admission to NICU (36/132 [27%]) compared with controls (61/141 [43%], P < .01). There was no difference in rates of hyperthermia (>37.5°C); 20% (27/132) in the heated-humidified group compared with 16% (22/141) in the controls (P = .30). There were no differences in mortality or respiratory outcomes. CONCLUSIONS The use of heated-humidified gases in the delivery room significantly reduces hypothermia on admission to NICU in preterm infants, without increased risk of hyperthermia. CLINICAL TRIAL REGISTRATION Australian and New Zealand Clinical Trials Register (www.anzctr.org.au) ACTRN12613000093785.
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Affiliation(s)
- Lorraine McGrory
- Department of Newborn Research, The Royal Women's Hospital, Melbourne, Australia; Department of Child Health, The University of Dundee, Dundee, United Kingdom.
| | - Louise S Owen
- Department of Newborn Research, The Royal Women's Hospital, Melbourne, Australia; The Murdoch Childrens Research Institute, Melbourne, Australia; Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Australia
| | - Marta Thio
- Department of Newborn Research, The Royal Women's Hospital, Melbourne, Australia; The Murdoch Childrens Research Institute, Melbourne, Australia; Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Australia
| | - Jennifer A Dawson
- Department of Newborn Research, The Royal Women's Hospital, Melbourne, Australia; The Murdoch Childrens Research Institute, Melbourne, Australia; Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Australia
| | - Anthony R Rafferty
- Department of Newborn Research, The Royal Women's Hospital, Melbourne, Australia
| | - Atul Malhotra
- Monash Newborn, Monash Children's Hospital, Melbourne, Australia; Department of Pediatrics, Monash University, Melbourne, Australia
| | - Peter G Davis
- Department of Newborn Research, The Royal Women's Hospital, Melbourne, Australia; The Murdoch Childrens Research Institute, Melbourne, Australia; Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Australia
| | - C Omar F Kamlin
- Department of Newborn Research, The Royal Women's Hospital, Melbourne, Australia; The Murdoch Childrens Research Institute, Melbourne, Australia; Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Australia
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Admission Temperature and Associated Mortality and Morbidity among Moderately and Extremely Preterm Infants. J Pediatr 2018; 192:53-59.e2. [PMID: 29246358 PMCID: PMC5808888 DOI: 10.1016/j.jpeds.2017.09.021] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Revised: 07/03/2017] [Accepted: 09/13/2017] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To evaluate the temperature distribution among moderately preterm (MPT, 29-33 weeks) and extremely preterm (EPT, <29 weeks) infants upon neonatal intensive care unit (NICU) admission in 2012-2013, the change in admission temperature distribution for EPT infants between 2002-2003 and 2012-2013, and associations between admission temperature and mortality and morbidity for both MPT and EPT infants. STUDY DESIGN Prospectively collected data from 18 centers in the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network were used to examine NICU admission temperature of inborn MPT and EPT infants. Associations between admission temperature and mortality and morbidity were determined by multivariable logistic regression. EPT infants from 2002-2003 and 2012-2013 were compared. RESULTS MPT and EPT cohorts consisted of 5818 and 3213 infants, respectively. The distribution of admission temperatures differed between the MPT vs EPT (P < .01), including the percentage <36.5°C (38.6% vs 40.9%), 36.5°C-37.5°C (57.3% vs 52.9%), and >37.5°C (4.2% vs 6.2%). For EPT infants in 2012-2013 compared with 2002-2003, the percentage of temperatures between 36.5°C and 37.5°C more than doubled and the percentage of temperatures >37.5°C more than tripled. Admission temperature was inversely associated with in-hospital mortality. CONCLUSIONS Low and high admission temperatures are more frequent among EPT than MPT infants. Compared with a decade earlier, fewer EPT infants experience low admission temperatures but more have elevated temperatures. In spite of a change in distribution of NICU admission temperature, an inverse association between temperature and mortality risk persists.
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Roehr CC, O'Shea JE, Dawson JA, Wyllie JP. Devices used for stabilisation of newborn infants at birth. Arch Dis Child Fetal Neonatal Ed 2018; 103:F66-F71. [PMID: 29079652 DOI: 10.1136/archdischild-2016-310797] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Accepted: 10/03/2017] [Indexed: 01/08/2023]
Abstract
This review examines devices used during newborn stabilisation. Evidence for their use to optimise the thermal, respiratory and cardiovascular management in the delivery room is presented. Mechanisms of action and rationale of use are described, current developments are presented and areas of future research are highlighted.
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Affiliation(s)
- Charles C Roehr
- Department of Paediatrics, Newborn Services, John Radcliffe Hospital, Oxford University Hospitals, NHS Foundation Trust, Oxford, UK
| | - Joyce E O'Shea
- Department of Neonatology, Royal Hospital for Children, Glasgow, UK
| | - Jennifer A Dawson
- Department of Newborn Research, The Royal Women's Hospital, Parkville, Victoria, Australia
| | - Jonathan P Wyllie
- Department of Neonatology, James Cook University Hospital, Middlesbrough, UK.,Resuscitation Council, London, UK.,University of Durham, Durham, UK
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Viaroli F, Cheung PY, O'Reilly M, Polglase GR, Pichler G, Schmölzer GM. Reducing Brain Injury of Preterm Infants in the Delivery Room. Front Pediatr 2018; 6:290. [PMID: 30386757 PMCID: PMC6198082 DOI: 10.3389/fped.2018.00290] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Accepted: 09/19/2018] [Indexed: 11/13/2022] Open
Abstract
Cerebrovascular injury is one of the major detrimental consequences of preterm birth. Recent studies have focused their attention on factors that contribute to the development of brain lesions immediately after birth. Among those factors, hypothermia and lower cerebral oxygen saturation during delivery room resuscitation and high tidal volumes delivered during respiratory support are associated with increased risk of severe neurologic injury. In preterm infants, knowledge about causes and prevention of brain injury must be applied before and at birth. Preventive and therapeutic approaches, including correct timing of cord clamping, monitoring of physiological changes during delivery room resuscitation using pulse oximetry, respiratory function monitoring, near infrared spectroscopy, and alpha EEG, may minimize brain injury, Furthermore, postnatal administration of caffeine or other potential novel treatments (e.g., proangiogenic therapies, antioxidants, hormones, or stem cells) might improve long-term neurodevelopmental outcomes in preterm infants.
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Affiliation(s)
- Francesca Viaroli
- Centre for the Studies of Asphyxia and Resuscitation, Royal Alexandra Hospital, Edmonton, AB, Canada.,Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Po-Yin Cheung
- Centre for the Studies of Asphyxia and Resuscitation, Royal Alexandra Hospital, Edmonton, AB, Canada.,Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Megan O'Reilly
- Centre for the Studies of Asphyxia and Resuscitation, Royal Alexandra Hospital, Edmonton, AB, Canada.,Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Graeme R Polglase
- The Ritchie Centre, Hudson Institute of Medical Research and Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
| | - Gerhard Pichler
- Department of Pediatrics, Medical University Graz, Graz, Austria
| | - Georg M Schmölzer
- Centre for the Studies of Asphyxia and Resuscitation, Royal Alexandra Hospital, Edmonton, AB, Canada.,Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
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Implementation of a multidisciplinary guideline improves preterm infant admission temperatures. J Perinatol 2017; 37:1242-1247. [PMID: 28726791 DOI: 10.1038/jp.2017.112] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Revised: 06/12/2017] [Accepted: 06/19/2017] [Indexed: 11/09/2022]
Abstract
BACKGROUND Hypothermia is a common problem in preterm infants immediately following delivery.Local problem:The rate of admission hypothermia in our neonatal intensive care unit (NICU) was above the rate of comparable NICUs in the Vermont Oxford Network. METHODS To reduce the rate of preterm admission hypothermia, a quality improvement (QI) project was implemented, utilizing the plan-do-study-act (PDSA) methodology. A guideline for delivery room thermoregulation management in <35-week infants at the University of Virginia was created and put into practice by a multidisciplinary team. INTERVENTIONS Clinical practice changes in the guideline included: increasing operating room temperatures, obtaining a 10-min axillary temperature, using an exothermic mattress for all infants <35 weeks, and using a polyethylene wrap for infants <32 weeks. RESULTS The baseline rate of hypothermia (<36.5 °CC) was 63%. Three PDSA cycles data were completed on 168 consecutive preterm births. The post-implementation rate of hypothermia (<36.5 °C) was reduced to 30% (P<0.001). The incidence of moderate hypothermia (< 36 °C) was reduced from a baseline of 29% to a rate of 9% (P<0.001). CONCLUSION Use of a multidisciplinary guideline to increase preterm NICU admission temperatures resulted in a decrease in hypothermic infants.
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Yip WY, Quek BH, Fong MCW, Thilagamangai, Ong SSG, Lim BL, Lo BC, Agarwal P. A quality improvement project to reduce hypothermia in preterm infants on admission to the neonatal intensive care unit. Int J Qual Health Care 2017; 29:922-928. [DOI: 10.1093/intqhc/mzx131] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Accepted: 09/25/2017] [Indexed: 11/14/2022] Open
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Abstract
Implementation of standardized practices in the delivery room fosters a safe environment to ensure that newborn infants are cared for optimally, whether or not they require extensive resuscitation. Quality improvement (QI) is an excellent methodology for implementation of standardized practices due to the multidisciplinary nature of the delivery room, complexity of tasks involved, and opportunities to track processes and outcomes. This article discusses how the delivery room is a unique environment and presents examples on how to approach delivery room QI. Key areas of potential focus for teams pursuing delivery QI include thermal regulation, optimizing respiratory support, and facilitating team communication.
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Affiliation(s)
| | - Henry C. Lee
- Department of Pediatrics, Stanford University, Stanford, CA 94305,California Perinatal Quality Care Collaborative, Stanford, CA 94305
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Delivery Room Quality Improvement Project Improved Compliance with Best Practices for a Community NICU. Sci Rep 2016; 6:37397. [PMID: 27869210 PMCID: PMC5116615 DOI: 10.1038/srep37397] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Accepted: 10/27/2016] [Indexed: 11/29/2022] Open
Abstract
A Quality Improvement bundle was implemented with the goal of standardizing the multidisciplinary approach to delivery room management. We used a Pre-Post Quality Improvement initiative with the following aims: (1) Placement of a functioning pulse oximeter by two minutes after birth, (2) Delayed intubation, (3) Normothermia on Neonatal Intensive Care Unit Admission, (4) Use of a pre-brief, debrief, and delivery room checklist. Data was collected for 548 infants, which represents every admission to the Palomar Rady Children’s Hospital Neonatal Intensive Care Unit during the 35 month study period from January 1, 2010 to November 30, 2012. The intervention began on May 1, 2011. The objective of increasing the frequency of each goal was met. A significant decrease in rates of retinopathy of prematurity in our post-intervention group was found. Odds ratio 0.00 (0.000, 0.696) p = 0.008. However, this was not confirmed in the multivariable analysis so should be interpreted with caution. This quality improvement project had a positive effect on newborn resuscitation at Palomar Medical Center.
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Nolan JP, Hazinski MF, Aickin R, Bhanji F, Billi JE, Callaway CW, Castren M, de Caen AR, Ferrer JME, Finn JC, Gent LM, Griffin RE, Iverson S, Lang E, Lim SH, Maconochie IK, Montgomery WH, Morley PT, Nadkarni VM, Neumar RW, Nikolaou NI, Perkins GD, Perlman JM, Singletary EM, Soar J, Travers AH, Welsford M, Wyllie J, Zideman DA. Part 1: Executive summary: 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Resuscitation 2016; 95:e1-31. [PMID: 26477703 DOI: 10.1016/j.resuscitation.2015.07.039] [Citation(s) in RCA: 138] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Wilson E, Maier RF, Norman M, Misselwitz B, Howell EA, Zeitlin J, Bonamy AK. Admission Hypothermia in Very Preterm Infants and Neonatal Mortality and Morbidity. J Pediatr 2016; 175:61-67.e4. [PMID: 27189680 DOI: 10.1016/j.jpeds.2016.04.016] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Revised: 03/22/2016] [Accepted: 04/07/2016] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To investigate the association between body temperature at admission to neonatal intensive care and in-hospital mortality in very preterm infants, stratified by postnatal age of death. Moreover, we assessed the association between admission temperature and neonatal morbidity. STUDY DESIGN In this cohort study from 19 regions in 11 European countries, we measured body temperature at admission for infants admitted for neonatal care after very preterm birth (<32 weeks of gestation; n = 5697) who were followed to discharge or death. Associations between body temperature at admission and in-hospital mortality and neonatal morbidity were analyzed by the use of mixed effects generalized linear models. The final model adjusted for pregnancy complications, singleton or multiple pregnancy, antenatal corticosteroids, mode of delivery, gestational age, infant size and sex, and Apgar score <7 at 5 minutes. RESULTS A total of 53.4% of the cohort had a body temperature at admission less than 36.5°C, and 12.9% below 35.5°C. In the adjusted model, an admission temperature <35.5°C was associated with increased mortality at postnatal ages 1-6 days, (risk ratio 2.41; 95% CI 1.45-4.00), and 7-28 days (risk ratio 1.79; 1.15-2.78) but not after 28 days of age. We found no associations between admission temperature and neonatal morbidity. CONCLUSION Admission hypothermia after very preterm birth is a significant problem in Europe, associated with an increased risk of early and late neonatal death.
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Affiliation(s)
- Emilija Wilson
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden; Department of Neonatal Medicine, Karolinska University Hospital, Stockholm, Sweden; Department of Gynecology and Obstetrics, Danderyd University Hospital, Stockholm, Sweden.
| | - Rolf F Maier
- Children's Hospital, Philipps University, Marburg, Germany
| | - Mikael Norman
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden; Department of Neonatal Medicine, Karolinska University Hospital, Stockholm, Sweden
| | | | - Elizabeth A Howell
- Department of Population Health Science & Policy, Icahn School of Medicine at Mount Sinai, New York, NY; Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY; Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Jennifer Zeitlin
- Inserm UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Center for Epidemiology and Statistics Sorbonne Paris Cité, Paris, France; DHU Risks in Pregnancy, Paris Descartes University, Paris, France
| | - Anna-Karin Bonamy
- Department of Women's and Children's Health and Clinical Epidemiology Unit, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden; Sachs' Children and Youth Hospital, Stockholm, Sweden
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Lambeth TM, Rojas MA, Holmes AP, Dail RB. First Golden Hour of Life: A Quality Improvement Initiative. Adv Neonatal Care 2016; 16:264-72. [PMID: 27391563 DOI: 10.1097/anc.0000000000000306] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Very low birth-weight (<1500 g) infants are vulnerable to their environment during the first hour after birth. We designed an evidence-based golden hour protocol (GHP) with a goal to stabilize and perform admission procedures within 1 hour of birth at a level IIIB neonatal intensive care unit (NICU). PURPOSE The aim of this quality improvement project was to ascertain whether an evidence-based GHP would improve care efficiency and short-term outcomes. METHODS Rapid cycles of change using Plan Do Study Act were utilized to document progress and gain knowledge during the quality improvement project. Measures were plotted with statistical process control methods (SPC), which analyzed improvement over time. RESULTS Both admission temperature and glucose-level means were within reference range throughout the project and predicted a stable process. We observed significantly decreased time to initiation of intravenous fluids and antibiotics. An upward trend of surfactant administration within the first 2 hours of life was also observed. IMPLICATIONS FOR PRACTICE The use of a GHP provided an organized approach to admission procedures and care. By using a checklist and recording intervention times, NICU caregivers were more aware of time management for each intervention and were able to decrease time to initiation of intravenous fluids and antibiotics. IMPLICATIONS FOR RESEARCH Future research should focus on establishing normal blood pressure ranges and safe pain management during the "golden hour" and beyond. Future quality improvement should focus on improving subsequent temperature and blood glucose levels after admission umbilical artery and venous catheter placement.
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Perlman J, Kjaer K. Neonatal and Maternal Temperature Regulation During and After Delivery. Anesth Analg 2016; 123:168-72. [DOI: 10.1213/ane.0000000000001256] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Duryea EL, Nelson DB, Wyckoff MH, Grant EN, Tao W, Sadana N, Chalak LF, McIntire DD, Leveno KJ. The impact of ambient operating room temperature on neonatal and maternal hypothermia and associated morbidities: a randomized controlled trial. Am J Obstet Gynecol 2016; 214:505.e1-505.e7. [PMID: 26874298 DOI: 10.1016/j.ajog.2016.01.190] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2015] [Revised: 01/11/2016] [Accepted: 01/14/2016] [Indexed: 10/22/2022]
Abstract
BACKGROUND Neonatal hypothermia is common at the time of cesarean delivery and has been associated with a constellation of morbidities in addition to increased neonatal mortality. Additionally, maternal hypothermia is often uncomfortable for the surgical patient and has been associated with intraoperative and postoperative complications. Various methods to decrease the rates of neonatal and maternal hypothermia have been examined and found to have varying levels of success. OBJECTIVE We sought to determine whether an increase in operating room temperature at cesarean delivery results in a decrease in the rate of neonatal hypothermia and associated morbidities. STUDY DESIGN In this single-center randomized trial, operating room temperatures were adjusted weekly according to a cluster randomization schedule to either 20°C (67°F), which was the standard at our institution, or 23°C (73°F), which was the maximum temperature allowable per hospital policy. Neonatal hypothermia was defined as core body temperature <36.5°C (97.7°F) per World Health Organization criteria. The primary study outcome was neonatal hypothermia on arrival to the admitting nursery. Measures of neonatal morbidity potentially associated with hypothermia were examined. RESULTS From February through July 2015, 791 women who underwent cesarean deliveries were enrolled, resulting in 410 infants in the 20°C standard management group and 399 in the 23°C study group. The rate of neonatal hypothermia on arrival to the admitting nursery was lower in the study group as compared to the standard management group: 35% vs 50%, P < .001. Moderate to severe hypothermia was infrequent when the operating room temperature was 23°C (5%); in contrast such hypothermia occurred in 19% of the standard management group, P < .001. Additionally, neonatal temperature in the operating room immediately following delivery and stabilization was also higher in the study group, 37.1 ± 0.6°C vs 36.9 ± 0.6°C, P < .001. We found no difference in rates of intubation, ventilator use, hypoglycemia, metabolic acidemia, or intraventricular hemorrhage. Fever (temperature >38.0°C or 100.4°F) on arrival to the admitting unit was uncommon and did not differ between the study groups. Maternal temperature on arrival to the operating room was not different between the 2 groups, however by delivery it was significantly lower in the standard management group, 36.2 ± 0.6°C vs 36.4 ± 0.6°C, P < .001. This effect persisted, as maternal temperature on arrival to the postoperative care area was lower in the standard management group, 36.1 ± 0.6°C vs 36.2 ± 0.6°C, P < .001, and the rate of hypothermia was higher, 77% vs 69%, P = .008. CONCLUSION A modest increase in operating room temperature at the time of cesarean reduces the rate of neonatal and maternal hypothermia. We did not detect a decrease in neonatal morbidity, but the power to detect a small change in these outcomes was limited.
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Affiliation(s)
- Elaine L Duryea
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX.
| | - David B Nelson
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Myra H Wyckoff
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX
| | - Erica N Grant
- Department of Anesthesia, University of Texas Southwestern Medical Center, Dallas, TX
| | - Weike Tao
- Department of Anesthesia, University of Texas Southwestern Medical Center, Dallas, TX
| | - Neeti Sadana
- Department of Anesthesia, University of Texas Southwestern Medical Center, Dallas, TX
| | - Lina F Chalak
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX
| | - Donald D McIntire
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Kenneth J Leveno
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX
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Wlodaver A, Blunt M, Satnes K, Escobedo M, Hallford G, Szyld E. A retrospective comparison of VLBW outcomes before and after implementing new delivery room guidelines at a regional tertiary care center. J Perinatol 2016; 36:182-5. [PMID: 26633146 DOI: 10.1038/jp.2015.187] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Revised: 10/23/2015] [Accepted: 10/28/2015] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To evaluate the impact of implemented protocol changes on delivery room interventions and very low birth weight (VLBW) health outcomes. STUDY DESIGN Retrospective study comparing birth characteristics, interventions and health outcomes of VLBW infants born in a tertiary care center before (calendar years 2008 to 2009) and after (calendar years 2012 to 2013) implementing new protocols using Chi-square analyses. RESULT Four hundred and nine were born before and 303 after changes were implemented. Postimplementation infants had more use of antenatal steroids (P=0.02), gestational age ⩽24 weeks (P=0.03) and birth weights between 501 and 750 g (P=0.04) and less oxygen administration (P=0.002), face mask ventilation (P=0.0001), surfactant use (P=0.0001), chest compressions (P=0.0001), intubation (P=0.002), epinephrine use (P=0.011), hypothermia (P=0.0001) and discharges home on supplemental oxygen (P=0.05). CONCLUSION Changes creating a new delivery team, adopting new delivery practice guidelines and updating delivery room equipment resulted in positive outcomes for delivery room practices and patient outcomes.
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Affiliation(s)
- A Wlodaver
- Department of Pediatrics, Neonatal-Perinatal Section, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - M Blunt
- Department of Pediatrics, Neonatal-Perinatal Section, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - K Satnes
- Department of Pediatrics, Neonatal-Perinatal Section, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - M Escobedo
- Department of Pediatrics, Neonatal-Perinatal Section, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - G Hallford
- Department of Pediatrics, Sections of Genetics and Neonatology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - E Szyld
- Department of Pediatrics, Neonatal-Perinatal Section, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
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Sensakovic WF, Agha A, Hough M, Rop B, Howley J, Donohoe A, Varich L. Impact of an Infant Transport Mattress on CT Dose and Image Quality. Acad Radiol 2016; 23:209-19. [PMID: 26625704 DOI: 10.1016/j.acra.2015.10.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Revised: 09/09/2015] [Accepted: 10/10/2015] [Indexed: 11/30/2022]
Abstract
RATIONALE AND OBJECTIVES Neonates are at increased risk for cold stress and hypothermia in cool environments. An infant transport mattress (ITM) is commonly used to increase neonate temperature during transport and has been used during CT scanning. This study determined the impact of an ITM on radiation dose and image artifacts during CT scanning. MATERIALS AND METHODS CT images from a single clinical patient scanned with an ITM were reviewed, and observations of image artifacts were recorded. A phantom was scanned with and without the ITM while varying tube-current modulation, reconstruction method, slice thickness, metal reduction algorithm, tube voltage, and tube current. The effects of the ITM on computed tomography dose index (CTDIvol), mean Hounsfield unit (HU), and HU standard deviation were recorded. RESULTS The clinical patient scan demonstrated significantly decreased mean HU and increased HU standard deviation. In the phantom, the ITM increased CTDIvol 27% and induced an artifact that decreased the mean HU by 3.5 HU and increased HU standard deviation by 4.6 HU. Angular tube-current modulation, strong iterative reconstruction, thick slices, metal artifact reduction, and high mA reduced the artifact. CONCLUSIONS Using ITM during CT scanning is not recommended given the relatively brief scanning time, increased dose, and induced image artifacts. Based on our results, several acquisition parameters may be altered to mitigate the image artifact if an ITM is required during scanning.
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Affiliation(s)
- William F Sensakovic
- Imaging Administration, Florida Hospital, 601 E. Rollins Street, Orlando, FL 32803.
| | - Ali Agha
- Imaging Administration, Florida Hospital, 601 E. Rollins Street, Orlando, FL 32803
| | | | - Baiywo Rop
- Radiology Residency, Florida Hospital, Orlando, Florida
| | | | | | - Laura Varich
- Imaging Administration, Florida Hospital, 601 E. Rollins Street, Orlando, FL 32803
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Hazinski MF, Nolan JP, Aickin R, Bhanji F, Billi JE, Callaway CW, Castren M, de Caen AR, Ferrer JME, Finn JC, Gent LM, Griffin RE, Iverson S, Lang E, Lim SH, Maconochie IK, Montgomery WH, Morley PT, Nadkarni VM, Neumar RW, Nikolaou NI, Perkins GD, Perlman JM, Singletary EM, Soar J, Travers AH, Welsford M, Wyllie J, Zideman DA. Part 1: Executive Summary: 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation 2016; 132:S2-39. [PMID: 26472854 DOI: 10.1161/cir.0000000000000270] [Citation(s) in RCA: 156] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Wyckoff MH, Aziz K, Escobedo MB, Kapadia VS, Kattwinkel J, Perlman JM, Simon WM, Weiner GM, Zaichkin JG. Part 13: Neonatal Resuscitation: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2016; 132:S543-60. [PMID: 26473001 DOI: 10.1161/cir.0000000000000267] [Citation(s) in RCA: 467] [Impact Index Per Article: 58.4] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Jang JH, Shin SH, Woo HK, Choi EK, Song IG, Shin SH, Kim EK, Kim HS. The Association between Admission Hypothermia and Neonatal Outcomes in Very Low Birth Weight Infants. NEONATAL MEDICINE 2016. [DOI: 10.5385/nm.2016.23.4.183] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Jin Hee Jang
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Seung Hyun Shin
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Hye Kyung Woo
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Eui Kyung Choi
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - In Gyu Song
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Seung Han Shin
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Ee-Kyung Kim
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Han-Suk Kim
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
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Wyllie J, Bruinenberg J, Roehr C, Rüdiger M, Trevisanuto D, Urlesberger B. Die Versorgung und Reanimation des Neugeborenen. Notf Rett Med 2015. [DOI: 10.1007/s10049-015-0090-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Wyckoff MH, Aziz K, Escobedo MB, Kapadia VS, Kattwinkel J, Perlman JM, Simon WM, Weiner GM, Zaichkin JG. Part 13: Neonatal Resuscitation: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care (Reprint). Pediatrics 2015; 136 Suppl 2:S196-218. [PMID: 26471383 DOI: 10.1542/peds.2015-3373g] [Citation(s) in RCA: 112] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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