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Mazur L, Veten A, Ceneviva G, Pradhan S, Zhu J, Thomas NJ, Krawiec C. Characteristics and Outcomes of Intrahospital Transfers from Neonatal Intensive Care to Pediatric Intensive Care Units. Am J Perinatol 2024; 41:e1613-e1622. [PMID: 37037202 DOI: 10.1055/s-0043-1768069] [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: 04/12/2023]
Abstract
OBJECTIVE Critically ill children may be transferred from the neonatal intensive care unit (NICU) to the pediatric intensive care unit (PICU) for further critical care, but the frequency and outcomes of this patient population are unknown. The aims of this study are to describe the characteristics and outcomes in patients transferred from NICU to PICUs. We hypothesized that a higher-than-expected mortality would be present for patients with respiratory or cardiovascular diagnoses that underwent a NICU to PICU transition and that specific factors (timing of transfer, illness severity, and critical care interventions) are associated with a higher risk of mortality in the cardiovascular group. STUDY DESIGN Retrospective analysis of Virtual Pediatric Systems, LLC (2011-2019) deidentified cardiovascular and respiratory NICU to PICU subject data. We evaluated demographics, PICU length of stay, procedures, disposition, and mortality scores. Pediatric Index of Mortality 2 (PIM2) score was utilized to determine the standardized mortality ratio (SMR). RESULTS SMR of 4,547 included subjects (3,607 [79.3%] cardiovascular and 940 [20.7%] respiratory) was 1.795 (95% confidence interval: 1.62-1.97, p < 0.0001). Multivariable logistic regression analysis demonstrated transfer age (cardiovascular: odds ratio, 1.246 [1.10-1.41], p = 0.0005; respiratory: 1.254 [1.07-1.47], p = 0.0046) and PIM2 scores (cardiovascular: 1.404 [1.25-1.58], p < 0.0001; respiratory: 1.353 [1.08-1.70], p = 0.0095) were significantly associated with increased odds of mortality. CONCLUSION In this present study, we found that NICU to PICU observed deaths were high and various factors, particularly transfer age, were associated with increased odds of mortality. While the type of patients evaluated in this study likely influenced mortality, further investigation is warranted to determine if transfer timing is also a factor. KEY POINTS · NICU patients may be transitioned to the PICU.. · NICU to PICU observed deaths were high.. · Transfer timing may be a factor..
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Affiliation(s)
- Lauren Mazur
- Department of Pediatrics, Penn State College of Medicine, Hershey, Pennsylvania
| | - Ahmed Veten
- Department of Pediatrics, Pediatric Critical Care Medicine, Penn State Hershey Children's Hospital, Hershey, Pennsylvania
| | - Gary Ceneviva
- Department of Pediatrics, Pediatric Critical Care Medicine, Penn State Hershey Children's Hospital, Hershey, Pennsylvania
| | - Sandeep Pradhan
- Department of Public Health Sciences, Pennsylvania State University College of Medicine, Hershey, Pennsylvania
| | - Junjia Zhu
- Department of Public Health Sciences, Pennsylvania State University College of Medicine, Hershey, Pennsylvania
| | - Neal J Thomas
- Department of Pediatrics, Pediatric Critical Care Medicine, Penn State Hershey Children's Hospital, Hershey, Pennsylvania
- Department of Public Health Sciences, Pennsylvania State University College of Medicine, Hershey, Pennsylvania
| | - Conrad Krawiec
- Department of Pediatrics, Pediatric Critical Care Medicine, Penn State Hershey Children's Hospital, Hershey, Pennsylvania
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Same baby, different care: variations in practice between neonatologists and pediatric intensivists. Eur J Pediatr 2022; 181:1669-1677. [PMID: 35006378 DOI: 10.1007/s00431-022-04372-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 12/20/2021] [Accepted: 01/02/2022] [Indexed: 11/03/2022]
Abstract
UNLABELLED The aim of the study was to identify and explore areas in neonatal care in which significant differences in clinical care exist, among neonatal intensive care (NICU) and pediatric intensive care (PICU) physicians. A questionnaire presenting three common scenarios in neonatal critical care-severe pneumonia, post-cardiac-surgery care, and congenital diaphragmatic hernia (CDH) was electronically sent to all PICU and NICU physicians in Israel. The survey was completed by 110 physicians. Significant differences were noted between NICU and PICU physicians' treatment choices. A non-cuffed endotracheal tube, initial high-frequency ventilation, and lower tidal volumes when applying synchronized-intermittent-mechanical-ventilation were selected more often by NICU physicians. For sedation/analgesia, NICU physicians treated as needed or by continuous infusion of a single agent, while PICU physicians more often chose to continuously infuse ≥ 2 medications. Fentanyl, midazolam, and muscle relaxants were chosen more often by PICU physicians. Morphine administration was similar for both groups. Treating CDH with pulmonary hypertension and systemic hypotension, NICU physicians more often began treatment with high dose dopamine and/or dobutamine, while PICU physicians chose low-dose adrenalin and/or milrinone. For vascular access NICU physicians chose umbilical lines most often, while PICU physicians preferred other central sites. CONCLUSION Our study identified major differences in respiratory and hemodynamic care, sedation and analgesia, and vascular access between NICU and PICU physicians, resulting from field-specific consensus guidelines and practice traditions. We suggest to establish joint committees from both professions, aimed at finding the optimal treatment for this vulnerable population - be it in the NICU or in the PICU. WHAT IS KNOWN • Variability in neonatal care between the neonatal and the pediatric intensive care units has been previously described. WHAT IS NEW • This scenario-based survey study identified major differences in respiratory and hemodynamic care, sedation and analgesia, and vascular access between neonatologists and pediatric intensivists, resulting from lack of evidence-based literature to guide neonatal care, field-specific consensus guidelines, and practice traditions. • These findings indicate a need for joint committees, combining the unique skills and literature from both professions, to conduct clinical trials focusing on these specific areas of care, aimed at finding the optimal treatment for this vulnerable population - be it in the neonatal or the pediatric intensive care unit.
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Pozzi N, Cogo P, Moretti C, Biban P, Fedeli T, Orfeo L, Gitto E, Mosca F. The care of critically ill infants and toddlers in neonatal intensive care units across Italy and Europe: our proposal for healthcare organization. Eur J Pediatr 2022; 181:1385-1393. [PMID: 35088115 PMCID: PMC8794634 DOI: 10.1007/s00431-021-04349-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 11/02/2021] [Accepted: 12/13/2021] [Indexed: 11/29/2022]
Abstract
UNLABELLED Numerous studies have shown that critically ill infants and toddlers admitted to paediatric intensive care units (PICUs) have a lower mortality than those admitted to adult ICUs. In 2014, there were only 23 registered PICUs in Italy, most of which were located in the north. For this reason, in Italy and elsewhere in Europe, some neonatal ICUs (NICUs) have begun managing critically ill infants and toddlers. Our proposal for healthcare organization is to establish "extended NICUs" in areas where paediatric intensive care beds are lacking. While some countries have opted for a strict division between neonatal and paediatric intensive care units, the model of "extended NICUs" has already been set up in Italy and in Europe. In this instance, the management of critically ill infants and toddlers undoubtedly falls upon neonatologists, who, however, must gain specific knowledge and technical skills in paediatric critical care medicine (PCCM). Postgraduate residencies in paediatrics need to include periods of specific training in neonatology and PCCM. The Italian Society of Neonatology's Early Childhood Intensive Care Study Group is supporting certified training courses for its members involving both theory and practice. CONCLUSION Scientific societies should promote awareness of the issues involved in the intensive management of infants and toddlers in NICUs and the training of all health workers involved. These societies include the Italian Society of Neonatology, the European Society of Paediatric and Neonatal Intensive Care, and the Union of European Neonatal and Perinatal Societies. They should also act in concert with the governmental institutional bodies to establish the standards for the "extended NICUs." WHAT IS KNOWN • The mortality of critically ill infants and toddlers admitted to PICUs is lower than that for those admitted to adult ICUs. • In Italy, there are only a handful of PICUs, located mainly in the north. WHAT IS NEW • Critically ill infants and small toddlers can be managed in "extended NICUs" in areas with a lack of paediatric intensive care beds. • "Extended NICUs" is our proposal for healthcare organization to compensate for the paucity of paediatric intensive care beds, but neonatologists must be trained to provide them with specific knowledge and technical skills in PCCM.
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Affiliation(s)
- Nicola Pozzi
- Neonatal Intensive Care Unit, Department of Maternal and Child Health, San Pio Hospital, Via dell'Angelo 1, Benevento, 83013, Italy.
| | - Paola Cogo
- Department of Medicine (DAME), Division of Pediatrics, S. Maria della Misericordia University Hospital, University of Udine, P.zzale S. Maria della Misericordia, 15, Udine, 33100 Italy
| | - Corrado Moretti
- Emeritus Consultant in Paediatrics, Policlinico Umberto I, Sapienza University, Rome, Italy
| | - Paolo Biban
- Department of Neonatal and Paediatric Critical Care, Verona University Hospital, Verona, Italy
| | - Tiziana Fedeli
- Neonatal Intensive Care Unit, Fondazione Monza e Brianza per il Bambino e la sua Mamma and Azienda Socio Sanitaria Territoriale-Monza, Monza, Italy
| | - Luigi Orfeo
- Neonatal Intensive Care Unit, San Giovanni Calibita Fatebenefratelli Hospital, Rome, Italy
| | - Eloisa Gitto
- Neonatal and Paediatric Intensive Care Unit, Department of Human Pathology in Adult and Developmental Age “Gaetano Barresi, ” University of Messina, Via Consolare Valeria, 1, Messina, 98125 Italy
| | - Fabio Mosca
- Neonatal Intensive Care Unit, Department of Clinical Science and Community Health, IRCCS Foundation Ca’ Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
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Scher MS. Neurologic Sequelae Associated with Hypertensive Disorders of Pregnancy. CHILDREN (BASEL, SWITZERLAND) 2021; 8:945. [PMID: 34828658 PMCID: PMC8617864 DOI: 10.3390/children8110945] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 10/05/2021] [Accepted: 10/13/2021] [Indexed: 11/23/2022]
Abstract
Hypertensive disorders of pregnancy (HDP) contribute to adverse gene-environment interactions prior to conception and continue throughout pregnancy. Embryonic/fetal brain disorders occur from interactions between genetic susceptibilities interacting with acquired diseases or conditions affecting the maternal/placental fetal (MPF) triad. Trimester-specific pathophysiological mechanisms, such as maternal immune activation and ischemic placental syndrome, contribute to adverse peripartum, neonatal and childhood outcomes. Two diagnostic approaches provide timelier diagnoses over the first 1000 days from conception until two years of age. Horizontal analyses assess the maturation of the triad, neonate and child. Vertical analyses consider systems-biology from genetic, molecular, cellular, tissue through organ networks during each developmental niche. Disease expressions associated with HDP have cumulative adverse effects across the lifespan when subjected to subsequent adverse events. Critical/sensitive periods of developmental neuroplasticity over the first 1000 days are more likely to result in permanent sequelae. Novel diagnostic approaches, beginning during pre-conception, will facilitate the development of effective preventive, rescue and reparative neurotherapeutic strategies in response to HDP-related trimester-specific disease pathways. Public health policies require the inclusion of women's health advocacy during and beyond their reproductive years to reduce sequelae experienced by mothers and their offspring. A lower global burden of neurologic disease from HDP will benefit future generations.
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Affiliation(s)
- Mark S. Scher
- Pediatrics and Neurology, Rainbow Babies and Children’s Hospital, Case Western Reserve University School of Medicine, Cleveland, OH 44106, USA;
- Department of Pediatrics, Division of Pediatric Neurology Fetal/Neonatal Neurology Program, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, USA
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Zuniga-Villanueva G, Widger K, Medeiros C, Trenholm M, Streuli JC. Specialized Pediatric Palliative Care in Neonates with Life-Limiting Illness: A Systematic Review. Am J Perinatol 2021; 38:e318-e329. [PMID: 32330969 DOI: 10.1055/s-0040-1710031] [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] [Indexed: 12/28/2022]
Abstract
OBJECTIVE The aim of this study is to assess the impact of specialized pediatric palliative care (PPC) on neonates with life-limiting conditions compared to standard care. STUDY DESIGN MEDLINE, PsycINFO, Cochrane Central Register of Controlled Trials, Web of Science, CINAHL, Scopus, and Embase databases were searched from January 2000 to September 2018. Randomized clinical trials, experimental or observational studies, and secondary administrative database analyses published in English, Spanish, French, and German were included. Two independent reviewers extracted data, and used the Newcastle-Ottawa Scale and the Cochrane Risk of Bias Tool for quality analysis. Discrepancies were resolved as a team. RESULTS From the 37,788 records obtained, only eight articles met the inclusion criteria. A meta-analysis was not possible due to the heterogeneity in how the outcomes were defined; however, a qualitative synthesis of the results was possible; organizing outcomes into eight different categories: psychological, social and spiritual support; communication; location of care; symptom management; bereavement care; predicted versus actual neonatal outcomes; and parental coping, stress, and satisfaction. CONCLUSION Specialized versus may have an impact on neonates with life-limiting conditions and their families. More studies that evaluate the impact of specialized versus in neonates with sound statistical analysis is warranted.
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Affiliation(s)
| | - Kimberley Widger
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada.,Pediatric Advanced Care Team, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Christina Medeiros
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Madeline Trenholm
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Jürg C Streuli
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada.,Department of Pediatrics, University Children's Hospital Zurich, Zurich, Switzerland
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Scher MS. "The First Thousand Days" Define a Fetal/Neonatal Neurology Program. Front Pediatr 2021; 9:683138. [PMID: 34408995 PMCID: PMC8365757 DOI: 10.3389/fped.2021.683138] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 05/27/2021] [Indexed: 01/11/2023] Open
Abstract
Gene-environment interactions begin at conception to influence maternal/placental/fetal triads, neonates, and children with short- and long-term effects on brain development. Life-long developmental neuroplasticity more likely results during critical/sensitive periods of brain maturation over these first 1,000 days. A fetal/neonatal program (FNNP) applying this perspective better identifies trimester-specific mechanisms affecting the maternal/placental/fetal (MPF) triad, expressed as brain malformations and destructive lesions. Maladaptive MPF triad interactions impair progenitor neuronal/glial populations within transient embryonic/fetal brain structures by processes such as maternal immune activation. Destructive fetal brain lesions later in pregnancy result from ischemic placental syndromes associated with the great obstetrical syndromes. Trimester-specific MPF triad diseases may negatively impact labor and delivery outcomes. Neonatal neurocritical care addresses the symptomatic minority who express the great neonatal neurological syndromes: encephalopathy, seizures, stroke, and encephalopathy of prematurity. The asymptomatic majority present with neurologic disorders before 2 years of age without prior detection. The developmental principle of ontogenetic adaptation helps guide the diagnostic process during the first 1,000 days to identify more phenotypes using systems-biology analyses. This strategy will foster innovative interdisciplinary diagnostic/therapeutic pathways, educational curricula, and research agenda among multiple FNNP. Effective early-life diagnostic/therapeutic programs will help reduce neurologic disease burden across the lifespan and successive generations.
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Affiliation(s)
- Mark S Scher
- Division of Pediatric Neurology, Department of Pediatrics, Fetal/Neonatal Neurology Program, Emeritus Scholar Tenured Full Professor in Pediatrics and Neurology, Case Western Reserve University School of Medicine, Cleveland, OH, United States
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Mahendra M, McQuillen P, Dudley RA, Steurer MA. Variation in Arterial and Central Venous Catheter Use in Pediatric Intensive Care Units. J Intensive Care Med 2020; 36:1250-1257. [PMID: 32969326 DOI: 10.1177/0885066620962450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Describe patient and hospital characteristics associated with Arterial Catheter (AC) or Central Venous Catheter (CVC) use among pediatric intensive care units (ICUs). DESIGN Hierarchical mixed effects analyses were used to identify patient and hospital characteristics associated with AC or CVC placement. The ICU adjusted median odds ratios (ICU-AMOR) for the admission ICU, marginal R2, and conditional intraclass correlation coefficient were reported. SETTING 166 PICUs in the Virtual PICU Systems (VPS, LLC) Database. PATIENTS 682,791 patients with unscheduled admissions to the PICU. INTERVENTION None. MEASURES AND MAIN RESULTS ACs were placed in (median, [interquartile range]) 8.2% [4.9%-11.3%] of admissions, and CVCs were placed in 14.9% [10.4%-19.3%] of admissions across cohort ICUs. Measured patient characteristics explained about 25% of the variability in AC and CVC placement. Higher Pediatric Index of Mortality 2 (PIM2) illness severity scores were associated with increased odds of placement (Odds Ratio (95th% Confidence Interval)) AC: 1.88 (1.87-1.89) and CVC: 1.82 (1.81-1.83) per 1 unit increase in PIM2 score. Primary diagnoses of cardiovascular, gastrointestinal, hematology/oncology, infectious, renal/genitourinary, rheumatology, and transplant were associated with increased odds of AC or CVC placement compared to a primary respiratory diagnosis. Presence of in-house attendings 24/7 was associated with increased odds of AC placement 1.32 (1.11-1.57). Admission ICU explained 4.9% and 3.5% of the variability in AC or CVC placement, respectively. The ICU-AMOR showed a patient would have a median increase in odds of 55% and 43% for AC or CVC placement, respectively, if the same patient moved from an ICU with lower odds of placement to an ICU with higher odds of placement. CONCLUSIONS Variation in AC or CVC use exists among PICUs. The admission ICU was more strongly associated with AC than with CVC placement. Further study is needed to understand unexplained variation in AC and CVC use.
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Affiliation(s)
- Malini Mahendra
- Division of Pediatric Critical Care, Department of Pediatrics, UCSF Benioff Children's Hospital, University of California, San Francisco, CA, USA.,Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, CA, USA
| | - Patrick McQuillen
- Division of Pediatric Critical Care, Department of Pediatrics, UCSF Benioff Children's Hospital, University of California, San Francisco, CA, USA
| | - R Adams Dudley
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of Medicine, University of Minnesota, MN, USA.,Center for Care Delivery and Outcomes Research, Minneapolis VAMC, MN, USA
| | - Martina A Steurer
- Division of Pediatric Critical Care, Department of Pediatrics, UCSF Benioff Children's Hospital, University of California, San Francisco, CA, USA
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Pozzi N, D'Angelo G, Gitto E. Why is "early childhood intensive care" an Italian association of neonatology study group? Ital J Pediatr 2019; 45:33. [PMID: 30841913 PMCID: PMC6404272 DOI: 10.1186/s13052-019-0626-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Accepted: 02/25/2019] [Indexed: 11/10/2022] Open
Abstract
To date, a large number of children are hospitalized inappropriately in adult intensive care units, where the minimum standards of care are not applied to young patients. It is well-known that the child is not a small adult. Recently it has been demonstrated that critically ill children hospitalized in pediatric intensive care receive higher quality of care, and have better outcomes, besides a lower mortality rate, compared to those admitted to adult intensive care units.We believe that the management of the critically ill child is an area of expertise of the neonatologist, who however must acquire specific skills and abilities of pediatric intensive medicine. The new idea of care is to offer in general hospitals 'broader' Neonatal Intensive Care Units, extended to infants and children in early childhood, based on territorial macro-areas and/or population of competence.
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Affiliation(s)
- Nicola Pozzi
- Neonatal and Pediatric Intensive Care Unit, Maternal and Child Department, San Pio Hospital, Benevento, Italy
| | - Gabriella D'Angelo
- Neonatal and Pediatric Intensive Care Unit, Department of Human Pathology in Adult and Developmental Age "Gaetano Barresi", University of Messina, Via Consolare Valeria, 1, 98125, Messina, Italy. .,Department of Clinical and Experimental Medicine, University of Messina, Via Consolare Valeria, 1, 98125, Messina, Italy.
| | - Eloisa Gitto
- Neonatal and Pediatric Intensive Care Unit, Department of Human Pathology in Adult and Developmental Age "Gaetano Barresi", University of Messina, Via Consolare Valeria, 1, 98125, Messina, Italy
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Snoep MC, Jansen NJ, Groenendaal F. Deaths and end-of-life decisions differed between neonatal and paediatric intensive care units at the same children's hospital. Acta Paediatr 2018; 107:270-275. [PMID: 28871637 PMCID: PMC5813263 DOI: 10.1111/apa.14061] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Revised: 03/28/2017] [Accepted: 08/31/2017] [Indexed: 11/30/2022]
Abstract
AIM We compared neonatal deaths and end-of-life decisions in a neonatal intensive care unit (NICU) and paediatric intensive care unit (PICU) in a Dutch tertiary children's hospital. SUBJECTS All 235 full-term infants who died within 28 days of life between 2003 and 2013 in the NICU (n = 199) and PICU (n = 36) were retrospectively studied. RESULTS The median length of stay was three days in the NICU and seven days in the PICU (p = 0.003). The main reasons for NICU stays were asphyxia (52.8%) and congenital malformations (42.2%), and in the PICU, they were congenital malformations (97.2%) and primarily cardiac problems (83.3%, p < 0.001). The median age of death was three days in the NICU and eight days in the PICU (p < 0.001), and mortality despite full intensive care treatment was 4.0% and 25.0%, respectively. Intensive treatment was discontinued because of poor survival chances in 25.1% of NICU and 52.8% of PICU cases (p < 0.001), and care was redirected because of expected poor quality of life in 70.9% and 22.2%, respectively. CONCLUSION Differences between the age at death and end-of-life decisions were found between full-term infants in the NICU and PICU in the same children's hospital. Underlying disorders and doctors' attitudes may have played a role.
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Affiliation(s)
- Maartje C. Snoep
- Department of Neonatology; The Wilhelmina Children's Hospital; University Medical Center Utrecht; Utrecht University; Utrecht the Netherlands
- Paediatric Intensive Care; The Wilhelmina Children's Hospital; University Medical Center Utrecht; Utrecht University; Utrecht the Netherlands
| | - Nicolaas J.G. Jansen
- Paediatric Intensive Care; The Wilhelmina Children's Hospital; University Medical Center Utrecht; Utrecht University; Utrecht the Netherlands
| | - Floris Groenendaal
- Department of Neonatology; The Wilhelmina Children's Hospital; University Medical Center Utrecht; Utrecht University; Utrecht the Netherlands
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