POINT-OF-CARE TESTING
We have all been at the bedside of an infant, critically ill and deteriorating. Some of us remember the days where we would draw laboratory results or obtain radiographs and wait hours, not minutes, for critical results. Gone are the days we stood at the bedside wringing our hands in frustration, waiting for the information to aid our clinical decision-making. Today, we have x-ray machines that show images while we wait, improved monitoring equipment that provides continuous physiology monitoring of our patients, and point-of-care laboratory testing that produce data in minutes, not hours.
Multiple tests are conducted at the bedside in the neonatal intensive care unit (NICU). We depend on point-of-care testing for immediate results that have shown improvement in our patient care outcomes.1 Most of these testing methods are not new to bedside care providers. Common examples include serum electrolytes, lactate levels, hemoglobin/hematocrit, ionized calcium, blood gas analysis, glucose, hemocult, and gastric Ph. In addition to point-of-care testing, most NICUs are supported by 24-hour ancillary services such as radiology, laboratory, and blood banks. The access to needed information and intervention supports our ability to provide neonatal care. Not everyone practices in this world. When you are in a rural location or radiology is delayed, there may be a need to reach for the newest member of the point-of-care family, bedside ultrasonography.
Point-of-care ultrasonography (POCUS) is most commonly used in the NICU to diagnose pneumothorax, which occurs in approximately 9.2% of extremely low birth-weight infants.1 Although this diagnosis can be made clinically through auscultation and/or transillumination, there is a margin of error in the smallest of infants. Increased morbidity and mortality have been linked to treatment delay. Ultrasonography has demonstrated a high level of accuracy in detecting pneumothorax, reducing time of diagnosis and treatment.1
This technology is not new to the adult world but has recently gained attention in pediatric and neonatal units.2 Some of us are familiar with ultrasound technology use during percutaneous peripheral central catheter placement.3 In the pediatric intensive care units and emergency departments, this technology has been used to successfully identify the correct needle placement for a lumbar puncture and/or drainage of pleural effusions.4,5 Can you imagine this technology in the delivery room during resuscitation of an infant who requires urgent drainage of bilateral plural effusions?
Common barriers to POCUS in the NICU have been identified. These include equipment cost, training, and maintaining proficient users within the unit personnel. Although still debated, the most realistic training method for POCUS occurs during neonatal nurse practitioner and fellowship programs, with neonatologists and/or radiologists directing ongoing training. Proficiency would be maintained similar to other neonatal procedures, utilizing simulation or skills laboratories. It has been suggested that neonatologists who were once trained with transillumination are retiring and the new generation of neonatal providers are supportive of learning and teaching the most reliable method of diagnosis. In the future, we may be supplying central POCUS equipment on the code cart instead of transilluminators.
1. Raimondi F, Rodriquez-Fanjul J, Aversa S, et al Lung ultrasound for diagnosing pneumothorax in the critically ill neonate. J Pediatr. 2016;175:74-78. [Context Link]
2. Nguyen J, Aminovin R, Ramanathan R, Noori S. The state of point-of care ultrasonography use and training in neonatal-perinatal medicine and pediatric critical care medicine fellowship programs. J Perinatol. 2016;36:972-976. [Context Link]
3. Nguyen J. Ultrasonography for central catheter placement in the neonatal intensive care unit-a review of utility and practicality. Am J Perinatol. 2016;33:525-530. [Context Link]
4. Moore CL, Copel JA. Point-of-care ultrasonography. N Engl J Med. 2011;364:749-757. [Context Link]
5. McLario DJ, Sivitz AB. Point-of-care ultrasound in pediatric clinical care. JAMA Pediatr. 2015;169:594-597. [Context Link]
HOT OFF THE PRESS: HEPATITIS B IMMUNOPROPHYLAXIS RECOMMENDATIONS
The Advisory Committee on Immunization Practices (ACIP) has just released the "Updated Recommendations for Hepatitis B Virus Infection Prevention for Neonatal Patients."1 These recommendations include:
1. Universal hepatitis B vaccination within 24 hours of birth for medically stable infants weighing 2000 g or more.
2. Testing hepatitis B surface antigen (HBsAg)-positive pregnant women for hepatitis B virus deoxyribonucleic acid (HBV DNA).
3. Postvaccination serologic testing for those infants whose mothers' HBsAg status remains unknown.
4. Single-dose revaccination for infants born to HBsAg-positive women not responding to the initial vaccine series.
5. Removal of permissive language for delaying the birth dose until after hospital discharge (this recommendation has the greatest impact on those working in level I/level II nurseries).
The ACIP recommendations mirror the most recent American Academy of Pediatrics (AAP) policy statement, which states, "The first dose of the hepatitis B vaccine should be given within the first 24 hours of life."2
The AAP reported 1000 new cases of perinatal hepatitis B infection annually in the United States.2 Neonates who contract hepatitis B at birth or during the first year of life have a 90% risk to develop chronic hepatitis B.2 Immunoprophylaxis following perinatal transmission has implications for care delivery in nurseries and the NICU. The AAP and the Centers for Disease Control and Prevention recommend "administration of appropriate post exposure immunoprophylaxis with hepatitis B vaccine and immune globulin as a method of transmission prevention."2,3 Prevention of perinatal hepatitis B relies on the proper and timely identification of infants born to mothers who are HBsAg positive and/or those mothers with unknown hepatitis B status.3
The newest AAP recommendations, which were published in September 2017,2 align with the ACIP recommendations listed earlier.1 The change to neonatal practice specifically surrounds the "removal of permissive language for delaying the birth dose of hepatitis B vaccine and, for all medically stable infants weighing greater than or equal to 2,000 grams."1,2 No longer should we wait until the first pediatric visit following hospital discharge. In addition, the AAP endorses the recommendation for giving the birth vaccine within the first 24 hours of life to further reduce the incidence of perinatal hepatitis B transmission.2 These recommendations will likely alter the conversations we have with our parents during postdelivery and discharge care.
1. Abara WE, Qaseem A, Schillie S, McMahon BJ, Harris AM. High Value Care Task Force of the American College of Physicians and the Centers for Disease Control and Prevention. Hepatitis B vaccination, screening, and linkage to care: best practice advice from the American College of Physicians and the Centers for Disease Control and Prevention. Ann Intern Med. 2017;167(11):794-804. doi:10.7326/M17-1106.
2. AAP Committee on Infectious Diseases and Committee on Fetus and Newborn. Elimination of perinatal hepatitis B: providing the first vaccine dose within 24 hours of birth. Pediatrics. 2017;140(3):1-5.
3. Centers for Disease Control and Prevention, Division of Viral Hepatitis. Surveillance for viral hepatitis-United States 2014. https://www.cdc.gov/hepatitis/statistics/2014surveillance. Revised September 26, 2016. Accessed on January 16, 2018.