Assessing Opportunities to Improve Sedation/Analgesia Use in Neonatal Patients on ECMO

Background: Sedation is used during ECMO to prevent agitation. Analgesia is used to dampen pain perception as neonatal procedural pain related stress is associated with later altered neurodevelopment with poorer perceptual reasoning and visual perception. Common sedatives/analgesics used during ECMO are opiates and benzodiazepines. Studies have shown that lipophilic drugs such as Fentanyl and Midazolam are significantly sequestered in the circuit suggesting opportunities to improve delivery for pain. Hypothesis and Methods: We hypothesized opportunities to improve sedation/analgesia drug treatment in ECMO patients. Using a retrospective analysis of all neonatal patients receiving ECMO between 2015-2020, we aimed to assess the relationship between sedative/analgesia type and dose and clinical complications. We identified patient demographics, medication type, dose used, days to wean, length of hospital stay, mortality, medical complications at discharge and MRI results. Results: 49 patients were included, mean gestational age 37.6 wks ±3.6. Seventeen (35%) infants died. Race was not associated with mortality. All patients received Fentanyl and Midazolam with one patient who also received Morphine infusion. Fentanyl and Midazolam dose during ECMO was associated with risk for oxygen at discharge 296 vs 517 mcg/kg/days for Fentanyl (p=0.04), and 358 vs 2598 mcg/kg/days for Midazolam (p=0.002) as well as need for feeding tube at discharge 272 vs 420 mcg/kg/days for Fentanyl (p=0.049) and 1.03 vs 1.60 mg/kg/days for Midazolam(p=0.04). Risk for abnormal MRI was increased with Fentanyl ECMO dose exposure (p=0.016). Male gender was associated with greater fentanyl dose exposure by 27% (p=0.038). Conclusion: Fentanyl and Midazolam increased dose exposure was associated with increased risk for later neurological clinical complications in infants undergoing ECMO. Further studies are needed to assess serum drug concentrations in ECMO patients to better understand development of drug tolerance, circuit sequestration and dose exposure to adjust the therapeutic range of sedation and analgesia use

VCU College of Humanities and Sciences Racial Equity Assessment

Racial equity is the process of ensuring that equal possible outcomes are available for every individual. At the College of Humanities and Sciences (CHS) an important goal is to ensure faculty and staff have access to the same opportunities, while accounting for those facing continued barriers. Following the establishment of the Inclusion, Diversity and Equity Committee, the current state of racial equity and the effectiveness of initiatives meant to correct for imbalance will be assessed

Predictors of Circuit Health in Neonatal Patients Receiving Extracorporeal Membrane Oxygenation

Background: Clot formation is the most common mechanical complication of ECMO and can lead to oxygenator failure and the need for subsequent circuit changes. The goals of this study were to identify early indicators of circuit failure to alert providers of ECMO circuit health. Hypothesis: We hypothesized that patient-specific circuit parameters can predict circuit health to identify risk of early circuit failure in neonate ECMO patients. Using a retrospective chart analysis ECMO flow parameters and clotting factors were identified during the 48 hours prior to ECMO circuit change through the 24 hours post circuit change. Statistical analysis included non-parametric Mann-Whitney U-test. Results: There was a significant increase in maximum and mean delta-p prior to need for circuit changes compared to those without (p=0.011 and p=0.0128 respectively) and a significant increase in the maximum RPM and mean RPM (p=0.0043 and p=0.0057 respectively). There was a significant increase in mean plasma free hemoglobin (hgb) (p=0.0209); however, the maximum plasma free hgb was not significant (p=0.0569). No differences were notable for sweep and venous pressure in those with circuit changes. Furthermore, clotting parameters were not found to be significant, including ACT, heparin, platelet count, fibrinogen, PT, PTT, INR, AT III (%), anti-Xa. Conclusion: Changes in Delta-p, RPM, and flow may be valuable predictors of early circuit impairment in neonates on ECMO. Sweep, venous pressure and clotting parameters may not reliable predictors of circuit health.https://scholarscompass.vcu.edu/gradposters/1167/thumbnail.jp

Predictors of Circuit Health in Neonatal Patients Receiving Extracorporeal Membrane Oxygenation (ECMO)

To identify predictors of neonatal ECMO circuit health, a retrospective analysis of circuit functional pressure and flow parameters as well as infant clotting values were collected 48 h prior to and 24 h post circuit change. Circuit impairment was defined as need for partial or total circuit change. Statistical analysis used multivariate statistics and non-parametric Mann–Whitney U-test with possible non-normality of measurements. A total of 9764 ECMO circuit and clotting values in 21 circuits were analyzed. Circuit delta-P mean, and maximum values increased from 8.62 to 48.59 mmHg (p \u3c 0.011) and 16.00 to 53.00 mmHg (p \u3c 0.0128) respectively prior to need for circuit change. Maximum and mean Pump Flow Revolutions per minute (RPM) increased by 75% (p \u3c 0.0043) and 81% (p \u3c 0.0057), respectively. Mean plasma free hemoglobin (pfHb) increased from 26.45 to 76.00 mg/dl, (p \u3c 0.0209). Sweep, venous pressure, and clotting parameters were unaffected. ECMO circuit delta-P, RPM, and pfHb were early predictors of circuit impairment

Fenton vs. Intergrowth-21st: Postnatal Growth Assessment and Prediction of Neurodevelopment in Preterm Infants

Although the survival rate of preterm infants has improved over the years, growth failure and associated impaired neurodevelopmental outcome remains a significant morbidity. Optimal nutrition plays an important role in achieving adequate postnatal growth. Accurate growth monitoring of preterm infants is critical in guiding nutritional protocols. Currently, there is no consensus regarding which growth assessment tool is suitable for monitoring postnatal growth of preterm infants to foster optimal neurodevelopmental outcomes while avoiding future consequences of aggressive nutritional approaches including increased risk for cardiovascular disease and metabolic syndrome. A retrospective single center cohort study was conducted to compare the performance of two growth-assessment tools, Fenton and Intergrowth-21st (IG-21st) in the classification of size at birth, identification of impaired growth and predicting neurodevelopment. A total of 340 infants with mean gestational age of 30 weeks were included. Proportion of agreement between the two tools for identification of small for gestational age (SGA) was high 0.94 (0.87, 0.1) however, agreement for classification of postnatal growth failure at discharge was moderate 0.6 (0.52, 0.69). Growth failure at discharge was less prevalent using IG-21st. There was significant association between weight-based growth failure and poor neurodevelopmental outcomes at 12 and 24 months of age

Ascorbic Acid and the Premature Infant

Little information exists about the plasma target nutritional needs of the >15 million premature infants <37 weeks gestation. Investigating ascorbic acid’s (AscA) role in infant health, our study details the relationship of infant characteristics and maternal health on infant plasma AscA level (pAscA) during postnatal development. Furthermore, we determined pAscA influence during the first week of life (EpAscA) with later infant morbidities. We hypothesize that pAscA is influenced by gestational organ immaturity, as well as maternal factors, with EpAscA associated with greater morbidity risk. We conducted a prospective longitudinal observational study of pAscA, demographics and hospital course detailed in infants ≤34 weeks. Sixty-three subjects were included, with >200 urine and plasma data points analyzed. Maternal smoking, exposure to magnesium sulfate (MgSO4) and advancing gestational and postnatal age were associated with lower pAscA. Non-white infants and those ≤30 weeks that developed bronchopulmonary dysplasia or retinopathy of prematurity had lower pAscA. Prenatal smoking, MgSO4, birth gestational age and race negatively influence pAscA. These results show prenatal and postnatal developmental factors influencing initial pAscA and metabolism, potentially setting the stage for organ health and risk for disease. Assessment of dietary targets may need adjustment in this population