Showing posts with label NICU. Show all posts
Showing posts with label NICU. Show all posts

Wednesday, April 8, 2015

A Fork In The Road: Two Cases, Two Families, and Divergent Paths

By: Joann Schulte  DO, MPH; Editorial Board Member

      “It depends.” That's an answer you've probably heard from your parents growing up and is a phrase you've used with your own children. The circumstances of what you got to do as an adolescent or what you permit your children to do figure into the decisions made.
      “It depends” applies in medical ethical dilemmas as well. How the impact of family circumstances can shape medical decision making is well illustrated in the Ethics Rounds article “
Two babies, same prognosis, different parental choices” presented this month in Pediatrics. Antommaria et al. (doi: 10.1542/peds.2013-4044) described different decisions in the same NICU concerning two different families and their respective infants with the same medical problem. Both families had premature infants born with esophageal atresia with tracheoesophageal fistula. Each infant failed extubation and would have been maintained on long-term mechanical ventilation for months or years. In both cases, the NICU staff recommended long-term mechanical ventilation. One infant was born at 33 weeks to an Amish family who declined additional care and requested only comfort care. The other infant was a twin born at 31 weeks whose postoperative repair was complicated by cardiac tamponade and an unclear neuro-developmental future. That family agreed with the NICU staff and accepted the recommendation for long-term ventilation.
      The authors describe the NICU staff as being troubled by the different decisions made by parents in two different babies and reviewed the circumstances of the two families. The ethics experts discussed circumstances of the Amish family in detail, including the fact that the members of the religion rely on community support for care of such children and live in circumstances where electricity for a ventilator is not available. The other family decided to accept the recommendation of the NICU and agreed to the mechanical ventilation of their child for a prolonged period with no guaranteed outcome. 
       This Ethics Rounds article deals with the issues from the perspectives of the NICU staff.  Ethics issues and decision making are increasingly becoming a joint venture between the families involved and the NICU staff.   I’d like to know more about how families cope with the long-term, chronic consequences they face in caring for a child who is heavily dependent on medical technology.  What’s the impact on a marriage or on other children?  The issues of medical technology raise ethical issues about care that have to be re-evaluated periodically.  This ethics article  about two preterm infants with the same condition is an important  step in thinking about this  issue.

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Monday, March 9, 2015

A NICU Study on Inhaled Nitric Oxide And The Influence of Best Practice Guidelines: Do They Make A Difference?

          When our journal or other journals publish evidence-based reliable and valid recommendations against use of a therapeutic agent, we hope that such recommendations will be applied to actual practice—but sadly that is often not the case. 
     A classic example is captured in an article by Ellsworth et al. (doi:10.1542/peds.2014-3290) on off-label use of inhaled nitric oxide (iNO) for use in persistent pulmonary hypertension and respiratory failure in preterm infants. The authors used a large clinical database to look at iNO use among all neonates in multiple neonatal intensive care units across the country before and after the publication of a National Institutes of Health (NIH) consensus statement that found no benefit in the drug and discouraged its use. 
     Nonetheless in the two years following publication of this NIH statement, iNO use continued to rise. Yet the drug is not benign and comes with risks –both medical and economic. 
Just why some neonatologists are not paying attention to the NIH consensus statement is the subject of an accompanying commentary by Drs. Finer and Evans (doi:10.1542/peds.2015-0144).  Both the article and the commentary make for important reading even if you are not a neonatologist because of the lessons one can learn in trying to turn theory into practice when it comes to using or in this case not using a treatment regimen.  
Relying on past experience rather than keeping up with the scientific literature is a formula for anything but success—and this article may help you understand the import of lifelong learning so as to continue to improve how you care for patients post-residency training.  Read the study and commentary and then share with us whether you have used published guidelines or recommendations to change the way you practice by responding to this blog, or via an e-letter or our Facebook or Twitter sites.

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Wednesday, January 14, 2015

Treating Jaundice in the NICU and Lowering Cases of Readmission

By: Beth Tarini, Editorial Board Member

 Courtesy of Jim Champion
Jaundice continues to vex those who care for newborns.  The majority of babies are jaundiced to some degree.but must don't need treatment. The challenge is to identify those that need treatment without over treating the healthy or overlooking those that need treatment.

In years past, conversations about jaundiced newborns focused on our vigintiphobia – our fear that a bilirubin level of 20 mg/dL would lead to kernicterus unless treated with exchange transfusion.  Now our conversations focus on the effect of early discharge after birth.  According to the AAP, early discharge is defined as less than 48 hours for vaginal birth and more than 96 hours for Caesarean section. (1)  The conundrum is that the greatest risk for severe jaundice occurs at a time after “early discharge” babies have left the hospital.  This can create a challenge for monitoring babies – especially if they don’t have timely follow-up with a healthcare provider after discharge.

The debate over whether early discharge increases the readmission rate for jaundice among newborns is ongoing.  To this debate, Dr. Lain et al. (doi:10.1542/peds.2014-2388) add data based on the first population-based study of the issue.  The study, conducted in Australia from 2001-2010, examined the readmission rate for over 780,000 newborns, looking specifically at how factors such as gestational age might influence the readmission rate.  The authors found that 0.8% of all the infants studied were readmitted for jaundice.   However, those at highest risk for readmission were infants born early term (37 & 38 weeks gestation) and discharged less than 48 hours [aOR 9.43 (95% CI: 8.34-10.67) and 4.05 (95% CI: 3.62-4.54) respectively]. 

What is the reason for these findings?  One theory is that early discharge causes jaundice among this subset of newborns.  However, since this is a cohort study, these findings are associative and should not be viewed as causal.  It is also possible that early term infants are followed more closely after early discharge, which increases their chance of being identified as having an elevated bilirubin, which leads to a readmission.  In this study, we don’t know the bilirubin level that prompted the readmission.  We are left to assume that the level required treatment.

What can we do with these data?  Well, the authors themselves admit that prolonging the hospital stay is unlikely to be an economical viable solution.  It would mean that we would have to keep over 80 infants in the hospital longer just to prevent one admission.  Also noted is that unlike the U.S., Australia does not have universal bilirubin screening guidelines prior to discharge.  It would be interesting to see if these findings persist in those countries that have universal bilirubin screening.  Of course, as we already know, universal screening has been associated with increased use of phototherapy and increased readmission rates, likely due, in part, to over treatment (2).

So, in some ways, the more the conversation about jaundice has changed, the more it has stayed the same.  While we are not talking about vigintiphobia, we are still talking about fear - fear of kernicterus in the shadow of early hospital discharge.

1:American Academy of Pediatrics.Committee on Fetus and Newborn.Hospital stay for
healthy term newborns. Pediatrics.2010 Feb;125(2):405-9. doi:10.1542/peds.2009-3119.

2:Kuzniewicz MW, Escobar GJ, Newman TB. Impact of universal bilirubin screening on severe hyperbilirubinemia. Pediatrics. 2009 Oct;124(4):1031-9. Oct;124(4):1031-9. 

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