ASSOCIATION OF PREOPERATIVE ANEMIA WITH POSTOPERATIVE MORTALITY IN NEONATES

Neonatal postoperative mortality is substantially higher than general pediatric patients. One study in 2005 reported a 30-day mortality rate for pediatrics as 41.6 per 10,000 operations versus 386.5 neonatal deaths per 10,000 operations.1 A new study has attempted to define the neonatal mortality in US hospitals and determine whether there are specific risk factors for neonates undergoing noncardiac surgery. Anemia is a known risk factor in the adult population but has not been studied in the neonatal population.

Data from the American College of Surgeons National Surgical Quality Improvement Program from the years 2012-2013 were utilized. All children with a document hematocrit value preoperatively were included. Exclusion criteria were patients who had a preoperative transfusion and neonates with congenital heart disease. A neonate was defined as an infant from 0 to 30 days of life. Anemia was defined as a hematocrit of less than 40%.

Neonates comprised 7% of the database (N = 2764), with 69.9% term or greater than 36 weeks' gestation. Eighty-five percent of the neonates weighed greater than 2 kg. In total, 3.4% of the neonates (n = 93) had postoperative in-hospital mortality as compared with 0.6% of all children 0 to 18 years of age. Preoperative hematocrits ranged from 24% to 52%, with a median of 38% in neonates. Neonates with preoperative anemia of less than 40% accounted for 32% (n = 892) of the neonates. The neonatal survivors accounted for 31% of neonates (n = 825) who had a hematocrit of greater than 40%. Sixty-seven (72%) of 93 neonates who died had a hematocrit of less than 40%. When controlling for other risk factors, a postoperative in-hospital mortality rate of neonates with hematocrits of less than 40% was 7.5% compared with neonates with hematocrits of greater than 40%, which was 1.4%. This is the first study to show an association between preoperative anemia and postoperative mortality in neonates.2

1. deBruin L, Pasma W, van der Werff D, et al. Perioperative hospital mortality at a tertiary paediatric institution. Br J Anaesth. 2015;115(4):608-615. [Context Link]

2. Goobie S, Faraoni D, Zurakowski J, DiNardo J. Association of preoperative anemia with postoperative mortality in neonates. JAMA Pediatr. 2016;170(9):855-862. [Context Link]

LANGUAGE OUTCOMES AT 36 MONTHS IN PREMATURELY BORN CHILDREN ARE ASSOCIATED WITH THE QUALITY OF DEVELOPMENTAL CARE IN NICUS

Preterm infants often have neurodevelopmental delays in language skills, especially in the areas of vocabulary and grammar. These delays have been reported in preschool-aged children. Impaired language skills have been reported in preterm infants without severe clinical complications. Less than optimal neonatal auditory and communicative experiences may be associated with language difficulties. Quality of care in the neonatal intensive care unit (NICU) may have a direct impact on the development of language skills.

A recent study1 evaluated the quality of care with respect to developmental care practices in 19 Italian NICUs with the preterm infants at 36 months of life. The Neonatal Adequate Care for Quality of Life (Neo-Acqua) Quality of Care questionnaire was utilized. Preterm infants were compared with a control cohort of term infants. Each group was assessed at 7 points in time from discharge until 84 months of life. Follow-up for language assessment was taken from the 36-month follow-up. Inclusion criteria for the preterm group were gestation age of 22 to 29.6 weeks and/or a birth weight between 401 and 1500 g. Exclusion criteria included major brain lesions (grade III or IV), periventricular leucomalacia greater than stage 1, retinopathy of prematurity greater than stage 2, documented hearing deficits, genetic syndromes, and/or major malformations. All infants in the full-term cohort were 37 weeks or greater and weighed at least 2500 g. All these infants were healthy and had no risk factors during pregnancy. The sample size included 111 preterm infants and 108 term infants.

Two indexes of developmental care were used to evaluate the NICU infants: the Infant Center Care (ICC) index and the Infant Pain Management (IPM) index. The ICC index included 4 items: (1) parent involvement; (2) kangaroo care as routine; (3) duration per day of kangaroo care (< or >45 minutes); and (4) nursing interventions such as containment, postural maneuvers, and reduction of disturbing tactile stimulation. The IPM includes 5 categories: (1) number of invasive procedures and nonpharmacological interventions were used; (2) number of invasive procedures where pharmacological interventions were used; (3) use of pharmacological analgesia or sedation for mechanical ventilation; (4) use of blood collection procedures, heal stick, or mechanical; and (5) use of pain score. The scores for both the IPM and ICC were calculated, and the NICUs were split into 2 levels, one being high-quality developmental care and low-quality developmental care.

There was no difference in the characteristic of the NICUs or for the infant's perinatal data. There was no significant difference in age, education, family, and BDI scores among the mothers in the low- or high-quality NICUS and the control group. There was significant difference between the 3 groups low, high, and control on word comprehension and sentence completion scores. Both low- and high-quality units scored lower than the control group. There was no difference among the groups for repetition and naming ability. Low developmental care units had significantly lower scores on sentence completion than the high-quality units. Low developmental quality units had lower scores than full-term infants on word completion. No significant difference in high-quality developmental care units and the control group in word and sentence completion. Infants in low-quality developmental care units showed worse receptive language skills. This study has demonstrated that developmental care procedures in the NICU are positively associated with language outcomes beyond infancy.

1. Montirosso R, Giusti L, DelPrete A, et al. Neo-Acqua Study Group. Language outcomes at 36 months in prematurely born children is associated with the quality of developmental care in NICUs. J Perinatol. 2016;36:768-774. [Context Link]

THE USE OF SHORT MESSAGE SERVICES (SMS) TO PROVIDE MEDICAL UPDATING TO PARENTS IN THE NICU

Long-term hospitalization of the premature infant is a very stressful time for parents. New technology is being used in the hospital in different areas. Recently, 1 neonatal intensive care unit decided to use short messaging services (SMS) to keep families up to date on their children's health status.1 Two questionnaires were given to both families and nursing at the initiation of the SMS study and at the conclusion. This study was conducted in a tertiary care unit of 49 beds, with 14 beds being intensive care unit and 35 step-down beds. SMS messages were sent every morning at 9:00 AM with a 1-sentence preface and a 1-sentence conclusion. Procedures for the day were included. No acute events or deterioration were sent via SMS. This information was delivered personally.

The pre-questionnaire results indicated that the families had a high degree of satisfaction of medical treatment, information provided, and communication with staff. The post-questionnaire results for families showed statistical improvement in physician availability and patience, as well as parenteral feeling of comfort in approaching physicians and nurses, and regularly receiving information regarding their children's medical status.

The nurse pre-questionnaire results indicated that 75.9% felt this SMS communication would add to their workload, 40.7% felt it would not be a user-friendly method of communication, and 33% felt it would not be a convenient method of communication. Post-questionnaire results indicated that only 51.4% of nurses felt it added to their workload, 17.6% felt it was not user-friendly, and only 1 nurse (3.1%) felt it was not a convenient method of communication.

Use of SMS highlights an easy and user-friendly modality for providing information to families. It is a complementary tool for encouraging and improving personal communication between staff and families.

Reference