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Matabele MN, Cheng C, Venkatesh M, Barr S, Ellefson J, Beninati M, Lobeck IN, Puricelli MD. Perinatal airway management in neonatal goiter: A healthcare cost and utilization project (HCUP) kids' inpatient database analysis. Int J Pediatr Otorhinolaryngol 2023; 175:111767. [PMID: 37931498 PMCID: PMC10841841 DOI: 10.1016/j.ijporl.2023.111767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 09/14/2023] [Accepted: 10/20/2023] [Indexed: 11/08/2023]
Abstract
INTRODUCTION Fetal goiter is a rare congenital disorder that can present with life-threatening neonatal airway obstruction. Lifesaving and function-preserving airway management strategies are available, but routine delivery affords a limited window for intervention. Accordingly, fetal goiter is reported among the most common indications for ex-utero intrapartum treatment (EXIT). While EXIT prolongs the window for airway intervention to benefit the neonate, it elevates the risk to the pregnant person and requires extensive resources; therefore, data to guide ideal treatment selection are essential. This study aims to compare perinatal airway interventions between individuals with a birth hospitalization discharge diagnosis (BHDD) of goiter and the general population. MATERIALS AND METHODS Individuals with and without BHDD of goiter were identified in the Healthcare Cost and Utilization Project (HCUP) Kids' Inpatient Database from 2000 to 2019. The frequency of airway interventions on day of life (DOL) 0 or 1 were compared using the Rao-Scott chi-square test. Additionally, gestational age, type of intervention, complications, mortality, birth weight, and length of stay were examined for the goiter cohort. RESULTS Two-hundred eighty-seven weighted cases of goiter were identified in the study period. The population was 61 % male, 55 % White, and median birthweight was 3.3 kg. The median length of stay was 4.3 days, and average total charges were $42,332. Airway intervention on DOL 0 or 1 was performed in 16.9 % of individuals with goiter compared to 1.6 % in neonates without goiter (p < 0.001). Interventions in the goiter cohort included endotracheal intubation in 16 % of cases, laryngoscopy/bronchoscopy in 1-5% of cases, and tracheostomy in <1 % of cases. Fewer than 1 % of individuals undergoing intubation additionally had mass decompression/resection on DOL 0 or 1. No neonates received extracorporeal membrane oxygenation cannulation or cardiopulmonary resuscitation. Hypoxic encephalopathy occurred in <1 % of cases, among which endotracheal intubation was the only airway intervention performed. There were no mortalities among neonates with goiter. CONCLUSION Individuals with BHDD of goiter receive significantly higher rates of perinatal airway intervention. In most cases, endoscopic interventions alone were sufficient to avoid hypoxic neurological complications. These findings contribute to data to aid in clinical counseling and empower patients to make informed decisions according to their values and treatment goals.
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Affiliation(s)
- Maya N Matabele
- University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Christie Cheng
- Department of Otolaryngology, University of Michigan, Ann Arbor, MI, USA
| | - Manasa Venkatesh
- Department of Surgery Statistical Analysis and Research Programming Core, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Samantha Barr
- University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Johanna Ellefson
- University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Michael Beninati
- Division of Maternal-Fetal Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Inna N Lobeck
- Division of Pediatric Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Michael D Puricelli
- Division of Otolaryngology Head and Neck Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.
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Joshi D, Stellon M, Antony K, Beninati M, Luks FI, Puricelli M, Lobeck IN. Indications, Resource Allocation, and Outcomes Associated with Ex-Utero Intrapartum Treatment Procedures: A North American Fetal Therapy Network Survey. Fetal Diagn Ther 2023; 50:376-386. [PMID: 37339615 PMCID: PMC10614236 DOI: 10.1159/000531615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 06/13/2023] [Indexed: 06/22/2023]
Abstract
INTRODUCTION Neonates with cardiorespiratory compromise at delivery are at substantial risk of hypoxic neurologic injury and death. Though mitigation strategies such as ex-utero intrapartum treatment (EXIT) exist, the competing interests of neonatal beneficence, maternal non-maleficence, and just distribution of resources require consideration. Due to the rarity of these entities, there are few systematic data to guide evidence-based standards. This multi-institutional, interdisciplinary approach aims to elucidate the current scope of diagnoses that might be considered for such treatments and examine if treatment allocation and/or outcomes could be improved. METHODS After IRB approval, a survey investigating diagnoses appropriate for EXIT consultation and procedure, variables within each diagnosis, occurrence of maternal and neonatal adverse outcomes, and instances of suboptimal resource allocation in the last decade was sent to all North American Fetal Treatment Network center representatives. One response was recorded per center. RESULTS We received a 91% response rate and all but one center offer EXIT. Most centers (34/40, 85%) performed 1-5 EXIT consultations per year and 17/40 (42.5%) centers performed 1-5 EXIT procedures in the last 10 years. The diagnoses with the highest degree of agreement between centers surveyed to justify consultation for EXIT are head and neck mass (100%), congenital high airway obstruction (90%), and craniofacial skeletal conditions (82.5%). Maternal adverse outcomes were noted in 7.5% of centers while neonatal adverse outcomes in 27.5%. A large percentage of centers report cases of suboptimal selection for risk mitigation procedures and several centers experienced adverse neonatal and maternal outcomes. CONCLUSION This study captures the scope of EXIT indications and is the first to demonstrate the mismatch in resource allocation for this population. Further, it reports on attributable adverse outcomes. Given suboptimal allocation and adverse outcomes, further examination of indications, outcomes, and resource use is justified to drive evidence-based protocols.
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Affiliation(s)
- Devashish Joshi
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA,
| | - Michael Stellon
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Kathleen Antony
- Department of Obstetrics and Gynecology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Michael Beninati
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
- Department of Obstetrics and Gynecology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Francois I Luks
- Department of Surgery, Alpert Medical School, Brown University, Providence, Rhode Island, USA
| | - Michael Puricelli
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Inna Neyman Lobeck
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
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Puricelli MD, Danielsen BM, Van Beek-King J, Wraight CL, Stewart KS, Beninati M, Lobeck IN, Iruretagoyena JI. Taking the Natural Exit: Opportunities for Treatment Rightsizing in Fetal Head and Neck Mass. Journal of Diagnostic Medical Sonography 2022. [DOI: 10.1177/87564793221100275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Fetal head and neck masses, when present, may cause neonatal airway obstruction at birth and associated morbidity and mortality. Escalated maternal treatment intensity such as surgical laryngoscopist/airway surgeon attended delivery and ex utero intrapartum treatment can mitigate the neonatal risk, however, increase maternal risk for complications. Accordingly, accurate prediction of the potential neonatal benefit and maternal risk is essential. Serial third-trimester sonographic features suggestive of more severe airway obstruction may justify more aggressive intervention in the right patient. This case study presents a 23-year-old G1P0 with a fetus predicted to have reduced perinatal airway risk based upon serial third-trimester ultrasound findings. Treatment was de-escalated, and the patient was successfully managed. Collaborative data collection aimed at treatment rightsizing across neonatal, maternal, and systematic domains will support ideal allocation.
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Affiliation(s)
- Michael D. Puricelli
- Division of Otolaryngology, University of Wisconsin–Madison School of Medicine and Public Health, University of Wisconsin–Madison, Madison, WI, USA
| | - Brodey Matthew Danielsen
- University of Wisconsin–Madison School of Medicine and Public Health, University of Wisconsin–Madison, Madison, WI, USA
| | - Jessica Van Beek-King
- Division of Otolaryngology, University of Wisconsin–Madison School of Medicine and Public Health, University of Wisconsin–Madison, Madison, WI, USA
| | - C. Lydia Wraight
- Division of Neonatology, University of Wisconsin–Madison School of Medicine and Public Health, University of Wisconsin–Madison, Madison, WI, USA
| | - Katharina S. Stewart
- Division of Maternal-Fetal Medicine, University of Wisconsin–Madison School of Medicine and Public Health, University of Wisconsin–Madison, Madison, WI, USA
| | - Michael Beninati
- Division of Maternal-Fetal Medicine, University of Wisconsin–Madison School of Medicine and Public Health, University of Wisconsin–Madison, Madison, WI, USA
- Division of Acute Care and Regional General Surgery, University of Wisconsin–Madison School of Medicine and Public Health, University of Wisconsin–Madison, Madison, WI, USA
| | - Inna N. Lobeck
- Division of Pediatric Surgery, University of Wisconsin–Madison School of Medicine and Public Health, University of Wisconsin–Madison, Madison, WI, USA
| | - J. Igor Iruretagoyena
- Division of Maternal-Fetal Medicine, University of Wisconsin–Madison School of Medicine and Public Health, University of Wisconsin–Madison, Madison, WI, USA
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Jacobson J, Antony K, Beninati M, Alward W, Hoppe KK. Use of dexamethasone, remdesivir, convalescent plasma and prone positioning in the treatment of severe COVID-19 infection in pregnancy: A case report. Case Rep Womens Health 2020; 29:e00273. [PMID: 33262932 PMCID: PMC7687655 DOI: 10.1016/j.crwh.2020.e00273] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 11/16/2020] [Accepted: 11/18/2020] [Indexed: 02/07/2023] Open
Abstract
Severe infection with COVID-19 virus in pregnancy offers unique management challenges for the obstetrician and critical care specialist. We report the case of a woman at 26 weeks of gestation with acute respiratory distress syndrome secondary to COVID-19 infection treated with dexamethasone, remdesivir, convalescent plasma and mechanical ventilation. Cesarean delivery was performed at 29 weeks due to worsening maternal status. This case offers insight into the assessment and successful use of treatment strategies, including dexamethasone, remdesivir, convalescent plasma, early prone positioning, conservative fluid management, permissive hypoxia and low tidal volume parameters with ventilator support for pregnancies affected by severe COVID-19 infection. Dexamethasone offers maternal and fetal benefits in severe COVID-19 infection. Lung protective ventilator settings can be used in pregnancy in COVID-related acute respiratory distress syndrome. Use of prone positioning for improved ventilation is well tolerated in pregnancy. Fetal heart rate tracing is a clinical indicator of maternal oxygenation status. Permissive hypoxia can be used to prevent barotrauma and advance fetal maturity.
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Affiliation(s)
- Jennifer Jacobson
- Department of Obstetrics and Gynecology, School of Medicine and Public Health, University of Wisconsin, Madison, WI, United States of America
- Corresponding author.
| | - Kathleen Antony
- Department of Obstetrics and Gynecology, School of Medicine and Public Health, University of Wisconsin, Madison, WI, United States of America
| | - Michael Beninati
- Department of Obstetrics and Gynecology, School of Medicine and Public Health, University of Wisconsin, Madison, WI, United States of America
| | - William Alward
- Department of Pulmonology and Critical Care, School of Medicine and Public Health, University of Wisconsin, Madison, WI, United States of America
| | - Kara K. Hoppe
- Department of Obstetrics and Gynecology, School of Medicine and Public Health, University of Wisconsin, Madison, WI, United States of America
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Hamel MS, Kanno L, Has P, Beninati M, Rouse DJ, Werner EF. 44: Randomized controlled trial of intrapartum glucose management in women with gestational diabetes: NCT02596932. Am J Obstet Gynecol 2019. [DOI: 10.1016/j.ajog.2018.11.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Seferovic MD, Pace RM, Meyer KM, Beninati M, Chu DM, Liu X, Li F, Aagaard K. 113: Taxonomic changes of placental microbes with bacterial-metabolized ursodeoxycholic acid treatment in IHCP is indicative of a functional placental microbiome. Am J Obstet Gynecol 2018. [DOI: 10.1016/j.ajog.2017.10.524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Seferovic MD, Beninati M, Chu D, Ma J, Liu X, Li F, Aagaard K. 697: IHCP is associated with the taxonomical and functional makeup of the placental microbiome. Am J Obstet Gynecol 2017. [DOI: 10.1016/j.ajog.2016.11.431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Abstract
BACKGROUND Intensive care unit (ICU) patients comprise a small proportion of patients in the hospital but consume a disproportionate amount of hospital resources. In our cost-conscious environment, it becomes necessary to address the overall performance of our ICUs. This study was designed to analyze survival among trauma ICU (TICU) patients with a length of stay (LOS) >1 month. METHODS We retrospectively reviewed the prospectively collected Trauma Registry Database between January 1, 1995, and January 1, 2005, in an adult TICU from a Level I trauma center. Data on demographics, mechanism of injury, Injury Severity Score (ISS), LOS, and in-hospital survival was collected. Descriptive statistics were calculated and student's t test and comparison of proportions were performed where appropriate. Logistic regression was performed to analyze independent predictors of mortality with significance when p < 0.05. RESULTS The initial cohort consisted of 3,556 patients with a mean LOS of 9.8 days (range, 0-274 days). Sixty-nine percent were men, mean age was 44.3 years (range, 0-104 years), and mean ISS was 18 (range, 0-75). The mechanism of injury was blunt trauma in 75%, burns in 15%, and penetrating trauma in 10%. Overall survival was 87%. A total of 339 patients had a LOS >1 month. There was no difference in survival between patients with a LOS <1 month and those with a LOS >1 month (87.1% versus 86.7%). Patients >50 years old (n = 1,251) had a longer LOS (12.5 versus 8.4 days; p < 0.001) and increased mortality (22.1% versus 8.0%; p < 0.001). Age remained an independent predictor of mortality when controlling for ISS. CONCLUSION In our TICU population, extended LOS did not preclude a significant chance of survival. Patients >50 years old had longer LOS and increased mortality. This suggests that the utilization of resources in patients with a prolonged LOS is reasonable and justified.
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Affiliation(s)
- Vincent Trottier
- Division of Trauma and Surgical Critical Care, University of Miami, Leonard Miller School of Medicine, Jackson Memorial Hospital, Ryder Trauma Center, Miami, Florida 33101, USA
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