17-Hydroxyprogesterone in premature infants as a marker of intrauterine stress

Aims: Amniotic infection (AI) and preeclampsia (PE), which are commonly the reason for prematurity, inflict stress of different duration on immature fetuses. Whether chronic stress, as reflected by intrauterine growth retardation, influences the level of 17-OH progesterone (17-OHP), was not previously examined. Methods: We analyzed 17-OHP and TSH levels during neonatal screenings in the first hours of life of 90 premature infants born between 25 and 33weeks of gestation in infants with AI (n=37) or with PE (n=53). Control of acute stress parameters was derived from umbilical arterial cord blood pH and base excess (BE). Results: Mean 17-OHP levels of infants born to mothers with PE were 85.7nmol/L compared to 54.6nmol/L (P<0.001) in AI infants. 17-OHP was even higher when intrauterine growth restriction was present (99.8nmol/L). Antenatal steroids and mode of delivery did not significantly affect 17-OHP levels. Conclusions: Stress of relatively long duration, as in cases of PE, leads to a significant increase of 17-OHP level in preterm infants. The postnatal 17-OHP level may be considered as a measure for severity of intrauterine stress and might be used as an individualized indicator for earlier intensive car

Early enteral feeding in conservatively managed stage II necrotizing enterocolitis is associated with a reduced risk of catheter-related sepsis

Aims: To compare the effect of fasting period duration on complication rates in neonates managed conservatively for necrotizing enterocolitis (NEC) Bell stage II. Methods: We conducted a multicenter study to analyze retrospectively multiple data collected by standardized questionnaire on all admissions for NEC between January 2000 and December 2006. NEC was staged using modified Bell criteria. We divided the conservatively managed neonates with NEC Bell stage II into two groups (those fasted for 5days) and compared the complication rates. Results: Of the 47 conservatively managed neonates Bell stage II, 30 (64%) fasted for 5days (range 6-16days). There were no significant differences for any of the patient characteristics analyzed. One (3%) and four (24%) neonates, respectively, developed post-NEC bowel stricture. One (3%) and two neonates (12%) suffered NEC relapse. None and five (29%) neonates developed catheter-related sepsis. Conclusion: Shorter fasting after NEC appears to lower morbidity after the acute phase of the disease. In particular, shorter-fasted neonates have significantly less catheter-related sepsis. We found no benefit in longer fastin

Five-year experience of clinical ethics consultations in a pediatric teaching hospital

Our retrospective study presents and evaluates clinical ethics consultations (CECs) in pediatrics as a structure for implementing hospital-wide ethics. We performed a descriptive and statistical analysis of clinical ethics decision making and its implementation in pediatric CECs at Zurich University Children's Hospital. Ninety-five CECs were held over 5years for 80 patients. The care team reached a consensus treatment recommendation after one session in 75 consultations (89%) and on 82 of 84 ethical issues (98%) after two or more sessions (11 repeats). Fifty-seven CECs recommended limited treatment and 23 maximal treatment. Team recommendations were agreed outright by parents and/or patient in 59 of 73 consultations (81%). Initial dissensus yielded to explanatory discussion or repeat CEC in seven consultations (10%). In a further seven families (10%), no solution was found within the CEC framework: five (7%) required involvement of the child protection service, and in two families, the parents took their child elsewhere. Eventual team-parent/patient consensus was reached in 66 of 73 families (90%) with documented parental/patient decisions (missing data, n = 11). Patient preference was assessable in ten CECs. Patient autonomy was part of the ethical dilemma in only three CECs. The Zurich clinical ethics structure produced a 98% intra-team consensus rate in 95 CECs and reduced initial team-parent dissensus from 21 to 10%. Success depends closely on a standardized CEC protocol and an underlying institutional clinical ethics framework embodying a comprehensive set of transparently articulated values and opinions, with regular evaluation of decisions and their consequences for care teams and families

Five-year experience of clinical ethics consultations in a pediatric teaching hospital

Our retrospective study presents and evaluates clinical ethics consultations (CECs) in pediatrics as a structure for implementing hospital-wide ethics. We performed a descriptive and statistical analysis of clinical ethics decision making and its implementation in pediatric CECs at Zurich University Children's Hospital. Ninety-five CECs were held over 5years for 80 patients. The care team reached a consensus treatment recommendation after one session in 75 consultations (89%) and on 82 of 84 ethical issues (98%) after two or more sessions (11 repeats). Fifty-seven CECs recommended limited treatment and 23 maximal treatment. Team recommendations were agreed outright by parents and/or patient in 59 of 73 consultations (81%). Initial dissensus yielded to explanatory discussion or repeat CEC in seven consultations (10%). In a further seven families (10%), no solution was found within the CEC framework: five (7%) required involvement of the child protection service, and in two families, the parents took their child elsewhere. Eventual team-parent/patient consensus was reached in 66 of 73 families (90%) with documented parental/patient decisions (missing data, n = 11). Patient preference was assessable in ten CECs. Patient autonomy was part of the ethical dilemma in only three CECs. The Zurich clinical ethics structure produced a 98% intra-team consensus rate in 95 CECs and reduced initial team-parent dissensus from 21 to 10%. Success depends closely on a standardized CEC protocol and an underlying institutional clinical ethics framework embodying a comprehensive set of transparently articulated values and opinions, with regular evaluation of decisions and their consequences for care teams and families

Involvement of parents in critical incidents in a neonatal-paediatric intensive care unit

BACKGROUND: With more liberal visiting hours in paediatric intensive care practice, parents' presence at the bedside has increased. Parents may thus become involved in critical incidents as contributors or detectors of critical incidents or they may be affected by critical incidents. METHODS: Voluntary, anonymous, non-punitive critical incident reporting system. Parents' involvement in critical incidents has been evaluated retrospectively (January 2002 to August 2007). The reports were analysed regarding involvement of parents, age of child, unit (paediatric intensive care or intermediate neonatal nursery), critical incident severity, critical incident category, actual or potential harm to patient and/or parent (minor, moderate, major), delay between the critical incident and its detection, and implemented system changes. RESULTS: Overall, 2494 critical incidents have been reported. There were 101 critical incidents with parental involvement: parents as contributors to critical incident (18; 0.7%), parents discovering a critical incident (11; 0.4%), parents affected by critical incident (72; 2.9%). The most vulnerable categories regarding contribution and detection were drugs, line/drain disconnection, trauma and hygiene. Ten critical incidents precipitated by parents were of moderate severity and seven of potential major severity (six line/drain disconnections). The majority of the events (six) detected by parents were of potential moderate severity and four were of major severity. CONCLUSION: Because of their presence at the bedside, parents in the paediatric intensive care unit are inevitably involved in safety issues. It is not the parents' duty to guarantee the safety for their children, but parents should be encouraged to report anything that worries them. Only an established safety culture allows parents to articulate their concerns

Video Recordings to Analyze Preventable Management Errors in Pediatric Resuscitation Bay

OBJECTIVE In treating patients of different ages and diseases in the pediatric resuscitation bay, management errors are common. This study aimed to analyze the adherence to advanced trauma life support and pediatric advanced life support guidelines and identify management errors in the pediatric resuscitation bay by using video recordings. METHODS Video recording of all patients admitted to the pediatric resuscitation bay at University Children's Hospital Zurich during a 13-month period was performed. Treatment adherence to advanced trauma life support guidelines and pediatric advanced life support guidelines and errors per patient were identified. RESULTS During the study period, 128 patients were recorded (65.6% with surgical, 34.4% with medical diseases). The most common causes for admission were traumatic brain injury (21.1%), multiple trauma (20.3%), and seizures (14.8%). There was a statistically significant correlation between accurate handover from emergency medical service to hospital physicians and adherence to airway, breathing, circulation, and disability sequence (correlation coefficient [CC], 0.205; P = 0.021), existence of a defined team leader and adherence to airway, breathing, circulation, and disability sequence (CC, 0.856; P < 0.001), and accurate hand over and existence of a defined team leader (CC, 0.186; P = 0.037). Unexpected errors were revealed. Cervical spine examination/stabilization was omitted in 40% of admitted surgical patients, even in 20% of patients with an injury of spine/limbs. CONCLUSIONS Video recording is a useful tool to evaluate patient management in the pediatric resuscitation bay. Analyzing errors of missing the adherence to the guidelines helps to pay attention and focus on specific items to improve patient care

Strain-specific differences in lung tissue viscoelasticity of mechanically ventilated infant Sprague Dawley and Wistar rats

Rats are often used in ventilator-induced lung injury (VILI) models. However, strain-specific susceptibility for VILI has not been elucidated yet. The aim of this study was to demonstrate strain-specific differences in VILI in infant Sprague Dawley and Wistar rats. VILI was compared in two week old pups after 8 hours of protective or injurious ventilation. Pups were ventilated with tidal volumes (V$_{T}$) of ~7 mL/kg and positive end-expiratory pressures (PEEP) of 6 cmH$_{2}$O (V$_{T}$7 PEEP6) or with V$_{T}$ of ~21 mL/kg and PEEP 2 cmH$_{2}$O (V$_{T}$21 PEEP2). Interleukin-6, macrophage inflammatory protein-2 (MIP-2), inflammatory cells and albumin in bronchoalveolar lavage fluid (BALF), histology, and low-frequency forced oscillation technique (LFOT) and pressure-volume (PV) maneuvers were assessed. Alveolar macrophages, neutrophils, and MIP-2 derived from BALF revealed more pronounced VILI after V$_{T}$21 PEEP2 in both strains. LFOT and PV analyses demonstrated rat strain-specific differences both at baseline and particularly in response to V$_{T}$21 PEEP2 ventilation. Sprague Dawley rats showed higher airway and tissue resistance and elastance values with no difference in hysteresivity between ventilation strategies. Wister rats challenged by V$_{T}$21 PEEP2 experienced significantly more energy dissipation when compared with V$_{T}$7 PEEP6 ventilation. In conclusion, both rat strains are useful for VILI models and depend on ventilation strategy and selected strain. However, fundamental and time-dependent differences in respiratory system mechanics exist and reflect different lung tissue viscoelasticity. Hence, strain-specific characteristics of the respiratory system need to be considered when planning and interpreting VILI studies with infant rats

Early enteral feeding in conservatively managed stage II necrotizing enterocolitis is associated with a reduced risk of catheter-related sepsis

Aims: To compare the effect of fasting period duration on complication rates in neonates managed conservatively for necrotizing enterocolitis (NEC) Bell stage II. Methods: We conducted a multicenter study to analyze retrospectively multiple data collected by standardized questionnaire on all admissions for NEC between January 2000 and December 2006. NEC was staged using modified Bell criteria. We divided the conservatively managed neonates with NEC Bell stage II into two groups (those fasted for 5 days) and compared the complication rates. Results: Of the 47 conservatively managed neonates Bell stage II, 30 (64%) fasted for 5 days (range 6-16 days). There were no significant differences for any of the patient characteristics analyzed. One (3%) and four (24%) neonates, respectively, developed post-NEC bowel stricture. One (3%) and two neonates (12%) suffered NEC relapse. None and five (29%) neonates developed catheter-related sepsis. Conclusion: Shorter fasting after NEC appears to lower morbidity after the acute phase of the disease. In particular, shorter-fasted neonates have significantly less catheter-related sepsis. We found no benefit in longer fasting

Near-infrared spectroscopy measurements of cerebral oxygenation in newborns during immediate postnatal adaptation

OBJECTIVE: In view of growing concerns regarding the optimal supplementation of oxygen at birth, we measured cerebral oxygenation during the first minutes of life. STUDY DESIGN: Using near-infrared spectroscopy, changes in cerebral oxygenated hemoglobin (O(2)Hb), dexoxygenated hemoglobin (HHb), and tissue oxygenation index (TOI) were measured during the first 15 minutes of life in 20 healthy newborn infants delivered at term by elective cesarean section. RESULTS: O(2)Hb and TOI increased rapidly within the first minutes of life (median slope for O(2)Hb, 3.4 micromol/L/min; range, 1.4 to 20.6 micromol/L/min; median slope for TOI, 4.2 %/min; range, -0.4 to 27.3%/min), and cerebral HHb decreased (median slope, -4.8 micromol/L/min; range, -0.2 to -20.6 micromol/L/min). O(2)Hb, TOI, and HHb all reached a plateau within 8 minutes. CONCLUSIONS: A significant increase in cerebral O(2)Hb and TOI and a significant decrease in HHb occur during immediate adaptation in healthy term newborns, reaching a steady plateau at around 8 minutes after birth

Five-year experience of clinical ethics consultations in a pediatric teaching hospital

Our retrospective study presents and evaluates clinical ethics consultations (CECs) in pediatrics as a structure for implementing hospital-wide ethics. We performed a descriptive and statistical analysis of clinical ethics decision making and its implementation in pediatric CECs at Zurich University Children's Hospital. Ninety-five CECs were held over 5 years for 80 patients. The care team reached a consensus treatment recommendation after one session in 75 consultations (89 %) and on 82 of 84 ethical issues (98 %) after two or more sessions (11 repeats). Fifty-seven CECs recommended limited treatment and 23 maximal treatment. Team recommendations were agreed outright by parents and/or patient in 59 of 73 consultations (81 %). Initial dissensus yielded to explanatory discussion or repeat CEC in seven consultations (10 %). In a further seven families (10 %), no solution was found within the CEC framework: five (7 %) required involvement of the child protection service, and in two families, the parents took their child elsewhere. Eventual team-parent/patient consensus was reached in 66 of 73 families (90 %) with documented parental/patient decisions (missing data, n = 11). Patient preference was assessable in ten CECs. Patient autonomy was part of the ethical dilemma in only three CECs. The Zurich clinical ethics structure produced a 98 % intra-team consensus rate in 95 CECs and reduced initial team-parent dissensus from 21 to 10 %. Success depends closely on a standardized CEC protocol and an underlying institutional clinical ethics framework embodying a comprehensive set of transparently articulated values and opinions, with regular evaluation of decisions and their consequences for care teams and families