Neonatal Course Research Articles

Prehospital emergency obstetric and neonatal care train-the-trainers program in Rwanda.

To improve maternal mortality rates, our collaboration developed and implemented a context-specific, prehospital Emergency Obstetrics and Neonatal Course (EONC) and train-the-trainers program in Rwanda. Two cohorts of staff participated in the program-the SAMU emergency medical service and staff from district hospitals. A 2-day course was developed, consisting of skills stations, simulations, and didactics. A 50-question assessment was administered to both cohorts before and after the courses. Student's t test and matched paired t tests were used to evaluate the assessments through retrospective analysis of the data. EONC1 median scores were 60% versus 92% (pre vs post), using matched-pair analysis of 20 participants. EONC2 median scores were 52% versus 96% (pre vs post), using matched-pair analysis of participants. A one-way analysis of variance mean square analysis showed that regardless of the baseline level of training for each participant, all trainees reached similar post-course assessment scores (F(1) =8.35, P=0.0059). Optimal prehospital management of obstetric emergencies is essential to prevent needless mortality and morbidity. This study demonstrated that a context-appropriate prehospital obstetric and neonatal training program could be effectively developed and implemented for the SAMU team in Kigali, Rwanda.

Epilepsy-Related Outcomes in Children With Neonatal Cerebellar Injury.

Acute brain injury is a frequent perinatal neurologic complication that can involve the cerebellum. Although short-term outcomes of infants with neonatal cerebellar injury are well described, neurologic sequelae in older children are underreported. Here, we describe epilepsy-related outcomes in young children who suffered from neonatal cerebellar injuries. In-house automated software identified patients with neonatal brain injuries who were evaluated at our institution both as neonates (≤28 days) and as children (≥1 year). Neonatal hospital course, neuroimaging, and outcomes related to epilepsy were reviewed from the medical record. Patients were stratified into 2 groups based on neonatal brain injuries: those with cerebellar injury and those without cerebellar involvement. Of the 282 neonates followed through childhood over the decade-long study period, 33 (12%) experienced neonatal brain injury. All 33 cases involved supratentorial injury, and 5 (15%) also included cerebellar injury. The development of epilepsy was significantly less likely in the group with cerebellar involvement (40%) compared to that with cerebellar sparing (82%; P = 0.043). In some cases, children with cerebellum-sparing injuries required admission for seizure control and developed drug-resistant epilepsy as well as status epilepticus. These outcomes occurred less frequently in the group with cerebellar involvement. Epilepsy-related sequelae may occur less frequently when the cerebellum is involved in neonatal brain injury. Larger prospective studies are needed to clarify how cerebellocortical networks impact functional brain connectivity and epilepsy longitudinally.

Trichorhinopharyngeal Syndrome Type 1 and Trisomy 21: A Patient with 2 Genetic Mutations

Trichorhinophalangeal syndrome (TRPS) Type I is a rare, autosomal dominant genetic syndrome with a spectrum of characteristics affecting hair, craniofacial, and skeletal development. It was first described in 1966 by Giedion based on three main features of sparse hair, bulbous nasal tip, and short deformed fingers. TRPS Type I is generally associated with mutations or microdeletions in the TRPS1 gene on chromosome 8q23.3, with translocations on this chromosomal arm also reported. The prevalence of TRPS Type I is unknown due to varying and subtle presenting features. Approximately 100 cases of TRPS Type I and III and 100 cases of TRPS Type II have been described and published up until 2017. We describe the neonatal course of an infant with TRPS Type I and Trisomy 21, two chromosomal anomalies prenatally diagnosed. To our knowledge, this is the first report of TRPS with Trisomy 21.

Discrepancy Between Pre- and Postnatal Diagnoses of Congenital Heart Disease and Impact on Neonatal Clinical Course - A Retrospective Study at a Japanese Tertiary Institution.

Congenital heart disease (CHD) is often diagnosed prenatally using fetal echocardiography, but few studies have evaluated the accuracy of these fetal cardiac diagnoses in detail. We investigated the discrepancy between pre- and postnatal diagnoses of CHD and the impact of discrepant diagnoses. This retrospective study at a tertiary institution included data from the medical records of 207 neonates with prenatally diagnosed CHD admitted to the cardiac neonatal intensive care unit between January 2011 and December 2016. Pre- and postnatal diagnoses of CHD differed in 12% of neonates. Coarctation of the aorta and ventricular septal defects were the most frequent causes of discrepant diagnosis. Unexpected treatments were added to 38% of discrepant diagnostic cases. However, discrepant diagnoses did not adversely affect the clinical course. The 9% of the 207 neonates who required invasive intervention within 24 h of delivery were accurately diagnosed prenatally. Pre- and postnatal diagnoses differed in only a few neonates, with differences not adversely affecting the clinical course. Neonates who required invasive intervention immediately after delivery were accurately diagnosed prenatally. Prenatal diagnosis thus seems to contribute to improved prognosis in neonates with CHD.

Quality of life in school-age children with shunt implantation due to neonatal posthemorrhagic hydrocephalus

To assess the functional outcome in school-age children shunted in the neonatal period due to post-hemorrhagic hydrocephalus (PHH), using the HOQ-Spanish version (HOQ-sv), and to analyze predictors of quality of life in this group. A cross-sectional study was performed between 2015 and 2018. Parents of pediatric patients with PHH attending our neurosurgery outpatient clinic were invited to complete the HOQ-sv and to enroll in the study. Clinical variables regarding the patients' neonatal course and surgical outcome were recorded. A descriptive analysis was done, and independent variables related to the HOQ scores were studied in univariate and multivariate analyses with regression trees. The study comprised a total of 52 patients. The mean overall HOQ score was 0.67 (on a scale from 0 [worse] to 1 [best]). The quality of life for the PHH children at school age was related to perinatal factors (gestational age at birth, time until shunt surgery, length of hospitalization at the time of shunt implantation, and comorbidity), shunt complications (symptomatic overdrainage, number of shunt revisions, and shunt revisions related to infection during the first year after treatment), and clinical background (seizures, spasticity, Gross Motor Function Classification System level or visual impairment). HOQ dimension scores in school-age children shunted due to PHH in our center were similar to those of referral centers for other etiologies of pediatric hydrocephalus. Future goals should be the prevention of complications related to worse outcomes at the time of diagnosis and to try to improve shunt performance later.

PROGNOSTIC VALUE OF SERUM MAGNESIUM LEVEL AS A MARKER OF ENDOTHELIAL DYSFUNCTION IN PREMATURE BIRTH NEONATES

Optimal magnesium supply during pregnancy and overcoming magnesium deficiency is essential due to its physiological role in many metabolic processes. Metabolic transformations with magnesium are necessary for the vitamin D activation, energy supply for homocysteine restoration, and regulation of nitric oxide synthesis. Magnesium deficiency increases the risk of premature birth, and the diffusion of magnesium to the fetus increases precisely from the second trimester of pregnancy, therefore, its deficiency can adversely affect neonatal adaptation. The aim of this work was to investigate the relationship between the serum magnesium level and markers of endothelial dysfunction and the clinical features of the early neonatal period course. Results. The average level of serum magnesium in 58 premature birth neonates was 1.21 ± 1.09 mg/dl on the first day. A borderline low level of serum magnesium (less than 1.2 mg/dl) was found in 72.41% of the examined children. Statistical analysis did not reveal a relationship between the serum magnesium level on the first day after birth and the studied markers of endothelial dysfunction (eNOS gene variants, nitric oxide level). A positive correlation was found between serum magnesium level and Apgar scores in newborns. For nitric oxide, a negative correlation with the Apgar 2 score and a positive correlation with the degree of respiratory failure were found. Serum magnesium and nitric oxide levels in premature birth neonates measured on the first day after birth enable to assess the course of the antenatal period and to predict postpartum adaptation.

Transplacentally transmitted organophosphorous compound poisoning in a newborn : Acase report and narrative review of literature

Organophosphorous compound (OPC) poisoning in the newborn is a medical emergency but completely treatable condition. Early recognition and treatment is of paramount importance in preventing fatality. A newbornmale of severe perinatal asphyxia was admitted in our neonatal intensive care unit (NICU) with a history of maternal OPC poisoning 31 hours before delivery. We treated the case on urgent basis, had stormy neonatal course and finally baby went home safely. OPC poisoning in newborn is a rare occurrence in the tropics. We report a rare case of transplacentally transmission of OPC poisoning innewborn and it is going to be 3rd and latest such reported case across the world upon literature search.
 Bangladesh Crit Care J September 2020; 8(2): 120-123

False-negative joint aspiration of septic arthritis of the hip in neonates.

In neonates, timely detection of septic arthritis of the hip can be challenging. Joint aspiration can be a useful diagnostic procedure, but scanty fluid in a septic joint has been reported, leading false-negative results. This study aimed to investigate clinical course of neonates with septic arthritis of the hip despite initial negative findings on joint aspiration. The neonates who surgically treated for septic arthritis of the hip between 2003 and 2013 for septic arthritis of the hip despite initial negative joint aspiration were retrospectively reviewed. Clinical presentations, MRI, intraoperative findings, functional and radiographic outcomes were evaluated. Six neonates were included with a mean follow-up of 12 years (range 5-15 years). All patients showed negative results on joint aspirations performed with ultrasound guidance or fluoroscopy. The mean duration between the onset of symptoms and initial surgery was 15.2 days (range 4-25 days). Four patients (67%) had extracapsular abscesses that were connected to perforated joint capsules on MRI. Intraoperatively, all patients were found to have hip joint instability with a ruptured capsule. Five (83%) patients experienced a complicated recovery. Four patients required reconstructive hip surgery, or further procedures to correct leg length discrepancy. Neonates with false-negative aspiration typically had a delay in appropriate surgical treatment. These cases suggest that the absence of aspirable fluid contents in the hip joint does not rule out septic arthritis in neonates. Our findings highlight the importance of considering spontaneous hip joint capsular perforation as the cause of extra-articular drainage of pus and instability.

Subdural Hemorrhage in Asymptomatic Neonates: Neurodevelopmental Outcomes and MRI Findings at 2 Years.

Background Subdural hemorrhage (SDH) is thought to have a benign course in asymptomatic neonates. However, effects on neurodevelopmental outcomes have not been established. Purpose To evaluate neurodevelopmental outcomes, gray matter volumes, and MRI findings in asymptomatic neonates with SDH compared with control neonates. Materials and Methods This retrospective analysis was conducted between 2003 and 2016 and was based on data from the University of North Carolina Early Brain Development Study. Neurodevelopmental outcomes were evaluated at 2 years of age by using the Mullen Scales of Early Learning (MSEL). All infants were imaged with 3.0-T MRI machines and were evaluated for SDH at baseline (neonates) and at ages 1 and 2 years. Volumetric MRI for brain segmentation was performed at ages 1 and 2 years. A secondary analysis was performed in neonates matched 1:1 with control neonates. Differences in categorical variables were measured by using the Fisher exact test, and the t test was used for continuous variables. Results A total of 311 neonates (mean gestational age ± standard deviation, 39.3 weeks ± 1.5), including 57 with SDH (mean gestational age, 39.5 weeks ± 1.2), were evaluated. The subgroup included 55 neonates with SDH (mean gestational age, 39.6 weeks ± 1.2) and 55 matched control neonates (mean gestational age, 39.7 weeks ± 1.2). Fifty-five of 57 neonates with SDH (97%; 95% CI: 92, 100) were delivered vaginally compared with 157 of 254 control neonates (62%, 95% CI: 56, 68; P < .001). Otherwise, there were no differences in perinatal, maternal, or obstetric parameters. There were no differences in composite MSEL scores (115 ± 15 and 109 ± 16 at 2 years, respectively; P = .05) or gray matter volumes between the neonatal SDH group and control neonates (730 cm3 ± 85 and 742 cm3 ± 76 at 2 years, respectively; P = .70). There was no evidence of rebleeding at follow-up MRI. Conclusion Neurodevelopmental scores and gray matter volumes at age 2 years did not differ between asymptomatic neonates with subdural hemorrhage and control neonates. © RSNA, 2020 Online supplemental material is available for this article.

VP14.02: Machine learning‐based phenogrouping of third trimester echocardiography can predict the neonatal clinical course in fetuses with tetralogy of Fallot

VP14.02: Machine learning‐based phenogrouping of third trimester echocardiography can predict the neonatal clinical course in fetuses with tetralogy of Fallot

Knowledge of General Practitioner Doctors and Midwives Who Has and Has Not Attended Neonatal Resuscitation Course Has No Significant Difference

Introduction: Infant death is most prominent in the neonatal period. The success of neonatal resuscitation practice has many contributing factors. One of which is the health workers’ knowledge of the Neonatal Resuscitation Program (NRP) algorithm. Therefore, it is necessary to conduct studies to evaluate the health workers’ knowledge of the Neonatal Resuscitation Program who are educated in neonatal resuscitation course and has taken part in Neonatal Life Support practice in primary health care (PHC) Objective: This study aims to analyze the knowledge of general practitioners and midwives who has or has not attended in neonatal resuscitation course in Surabaya PHC Methods and Materials: this research is descriptive, cross-sectional research. All Basic Emergency Obstetric and Newborn Care (BEmONC) PHC in Surabaya which are Jagir PHC, Banyu Urip PHC, Medokan Ayu PHC, Tanah kali Kedinding PHC, Tanjungsari PHC, Balongsari PHC, Sememi PHC, Simomulyo PHC is included in this research from 2018 to 2019. A nine-item questionnaire referenced from The Textbook of Neonatal Resuscitation 7th Edition is given to ten respondents in each BEmONC PHC. Results and Discussion: from the total sample of 78 respondents, 32 (41,0%) receive a high score, 20 (25,7%) receive a middle score, and 26 (33,3%) receive a low score. The data shows that there is no significant score difference between respondents who has or has not participate in the NRP course (p=0,419). Conclusion: There is no correlation between difference knowledge midwives and general practitioners who had and had not attended neonatal resuscitation training at basic emergency obstetric and newborn care in public health center Surabaya.

NEONATAL OUTCOMES AFTER UTERUS TRANSPLANT- DUETS (DALLAS UTERUS TRANSPLANT STUDY)

Uterus transplantation is restoring fertility in women absolute uterine-factor infertility and allows them to experience gestation and childbirth. Limited data are available on the outcome of infants born after uterus transplantation. Our aim was to describe the hospital course and laboratory findings of the first 6 infants born in the Dallas UtErus Transplant Study (DUETS). Prospective review. Twenty women received a uterus transplant at Baylor University Medical Center in Dallas (a tertiary referral center) from 2016 to 2019 (NCT02656550). Based on the trial protocol, information about the first 6 infants delivered was collected in a prospective fashion, including infant demographics, hospital course, and laboratory values. Six infants were delivered, all by cesarean section, from mothers who had undergone uterus transplantation. All mothers had an immunosuppressive regimen and none experienced an episode of rejection during pregnancy. The infants had a median gestational age of 36.3 weeks (range 30.6–37.2 weeks) and median birthweight of 2890 g (range 1771–3140 g). APGAR scores were at least 7 at 1 minute and at least 8 at 5 minutes. All were appropriate size for gestational age. Two infants had complete blood counts with bandemia but negative blood cultures. Blood urea nitrogen and creatinine levels were within expected range. The 6 infants born from mothers with uterus transplants had a neonatal course that reflected the gestational age at delivery. No baby was born with an identified deformation or malformation attributed to the transplantation or immunosuppression. Despite exposure to a calcineurin inhibitor throughout pregnancy, there were no adverse effects on renal function. Longer follow-up and a larger number of infants are needed to confirm these observations.

Prenatally diagnosed vasa previa: association with adverse obstetrical and neonatal outcomes

Vasa previa represents a rare prenatal finding with potentially life-threatening risk to the fetus. This study aimed to describe the natural history of prenatally diagnosed vasa previa and evaluate the association between antenatally diagnosed vasa previa and adverse obstetrical and neonatal outcomes. This was a multicenter descriptive and retrospective study of patients diagnosed prenatally with vasa previa on transvaginal ultrasound in the New York City Maternal-Fetal Medicine Research Consortium centers between 2012 and 2018. Outcomes evaluated included persistence of vasa previa at the time of delivery, gestational age at delivery, indications for unplanned unscheduled delivery, and neonatal course. A total of 165 pregnancies with vasa previa were included, of which 16 were twin gestations. Forty-three cases (26.1%) were noted to resolve on subsequent ultrasound. Of the remaining 122 cases with persistent vasa previa, 46 (37.7%) required unscheduled delivery. Twin gestations were nearly 3 times as likely to require unscheduled delivery as singleton gestations (73.3% vs 25.2%; P<.001). Most infants (70%) were admitted to the neonatal intensive care unit. There was 1 neonatal death (0.9%) because of complications related to prematurity. Despite the low neonatal mortality rate with prenatal detection of vasa previa, one-third of patients required unscheduled delivery, and more than half of neonates experienced complications related to prematurity.

Video Laryngoscopy Improves the Success of Neonatal Tracheal Intubation for Novices but Not for Experienced Medical Staff.

Background: There is limited evidence on the use of video laryngoscopy (VL) in neonatal tracheal intubation (NTI) during neonatal resuscitation. In this study, we aimed to compare the difference between direct laryngoscopy (DL) and VL in NTI of trainees during neonatal resuscitation training.Materials and Methods: A prospective observational study was conducted during a neonatal resuscitation training course to examine three circumstances: NTI by experienced medical staff (EMS) and less-experienced medical staff (LEMS) in a neonatal resuscitation scenario; NTI by EMS and LEMS with an ongoing chest compression; and NTI by midwives who were novices in the procedure. The trainees were given scenarios or were shown demonstrations on newborn simulation manikins and were required to perform an NTI on a simulation manikin using DL and/or VL. The mean intubation time and success rate of intubation were measured.Results: The mean NTI time for EMS using VL (24.1 ± 7.2 s) was significantly longer than that using DL intubation (18.1 ± 6.9 s, P < 0.001), whereas there was no significant difference between using VL and DL for LEMS. EMS spent slightly less time on NTI than did LEMS using both VL and DL, but there were no statistically significant differences (both p > 0.05). The NTI success rate for EMS using VL (48.0%, 12/25) was significantly lower than that using DL (88.0%, 22/25, P = 0.004), while the NTI success rate for LEMS using VL (68.2%, 15/22 vs. 40.9%, 9/22) was higher than that using DL, but there was no statistical significance. When NTI was required with ongoing chest compressions, there was no significant difference in the mean NTI time and success rate between using VL and DL for EMS or LEMS. In the group of midwives who were novices in NTI, after they watched a demonstration teaching NTI, the intubation time using VL (19.6 ± 9.0 s) was significantly shorter than that using DL (28.0 ± 6.7 s, P < 0.001). The success rate of NTI using VL was significantly higher (96.2%; 25/26) than that using DL (69.2%; 18/26).Conclusion: The video laryngoscopy could be an effective training tool for inexperienced staff in developing the skill of tracheal intubation.

Outcomes Following Post-Hemorrhagic Ventricular Dilatation among Infants of Extremely Low Gestational Age

To assess outcomes following post-hemorrhagic ventricular dilatation (PHVD) among infants born at ≤26weeks of gestation. Observational study of infants born April 1, 2011, to December 31, 2015, in the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network and categorized into 3 groups: PHVD, intracranial hemorrhage without ventricular dilatation, or normal head ultrasound. PHVD was treated per center practice. Neurodevelopmental impairment at 18-26months was defined by cerebral palsy, Bayley Scales of Infant and Toddler Development, 3rd edition, cognitive or motor score <70, blindness, or deafness. Multivariable logistic regression examined the association of death or impairment, adjusting for neonatal course, center, maternal education, and parenchymal hemorrhage. Of 4216 infants, 815 had PHVD, 769 had hemorrhage without ventricular dilatation, and 2632 had normal head ultrasounds. Progressive dilatation occurred among 119 of 815 infants; the initial intervention in 66 infants was reservoir placement and 53 had ventriculoperitoneal shunt placement. Death or impairment occurred among 68%, 39%, and 28% of infants with PHVD, hemorrhage without dilatation, and normal head ultrasound, respectively; aOR (95% CI) were 4.6 (3.8-5.7) PHVD vs normal head ultrasound scan and 2.98 (2.3-3.8) for PHVD vs hemorrhage without dilatation. Death or impairment was more frequent with intervention for progressive dilatation vs no intervention (80% vs 65%; aOR 2.2 [1.38-3.8]). Death or impairment increased with parenchymal hemorrhage, intervention for PHVD, male sex, and surgery for retinopathy; odds decreased with each additional gestational week. PHVD was associated with high rates of death or impairment among infants with gestational ages ≤26weeks; risk was further increased among those with progressive ventricular dilation requiring intervention.

Early Neonatal Oxygen Exposure Predicts Pulmonary Morbidity and Functional Deficits at 1 Year

To evaluate the predictive value of cumulative oxygen exposure thresholds over the first 2 postnatal weeks, linking them to bronchopulmonary dysplasia (BPD) and 1-year pulmonary morbidity and lung function in extremely low gestational age newborns. Infants (N=704) enrolled in the Prematurity and Respiratory Outcomes Program, a multicenter prospective cohort study, that survived to discharge were followed through their neonatal intensive care unit hospitalization to 1-year corrected age. Cumulative oxygen exposure (OxygenAUC14) thresholds were derived from univariate models of BPD, stratifying infants into high-, intermediate-, and low-oxygen exposure groups. These groups were then used in multivariate logistic regressions to prospectively predict post-prematurity respiratory disease (PRD), respiratory morbidity score (RMS) in the entire cohort, and pulmonary function z scores (N=108 subset of infants) at 1-year corrected age. Over the first 14 postnatal days, infants exposed to high oxygen averaged ≥33.1% oxygen, infants exposed to intermediate oxygen averaged 29.1%-33.1%, and infants exposed to low oxygen were below both cutoffs. In multivariate models, infants exposed to high oxygen showed increased PRD and RMS, whereas infants exposed to intermediate oxygen demonstrated increased moderate/severe RMS. Infants in the high/intermediate groups had decreased forced expiratory volume at 0.5seconds/forced vital capacity ratio. OxygenAUC14 establishes 3 thresholds of oxygen exposure that risk stratify infants early in their neonatal course, thereby predicting short-term (BPD) and 1-year (PRD, RMS) respiratory morbidity. Infants with greater OxygenAUC14 have altered pulmonary function tests at 1year of age, indicating early evidence of obstructive lung disease and flow limitation, which may predispose extremely low gestational age newborns to increased long-term pulmonary morbidity. ClinicalTrials.gov: NCT01435187.

Unusual fetal ascites and spontaneous bladder rupture in a female fetus: a case report

BackgroundFetal bladder rupture causing urinary ascites is uncommon. It is generally related to invasive fetal medicine procedures or obstructive disorders such as in posterior urethral valves in male fetuses. An exceptional case of spontaneous bladder rupture in a female fetus occurred in a pregnant woman treated with high doses of opiates in an intensive care unit. This unusual obstetric situation leads to discussion of the possible causes of fetal bladder rupture, its management, and the pediatric prognosis.Case presentationWe report the case of a 30-year-old nulliparous black woman with a history of mesenteric cystic lymphangioma and multiple bowel resections leading to chronic malabsorption. During her pregnancy, our patient presented with an occlusive syndrome and major bilateral renal dilation. Urinary derivation resulted in iatrogenic bilateral ureteral perforation. Our patient thus presented with major uroperitoneum, bilateral pleural effusion and acute renal failure, treated by thoracic drainage and bilateral nephrostomy. Postoperative pain required treatment with level III analgesics. In this context, 5 days after morphine treatment introduction an enlarged fetal bladder was observed, followed 3 days later by voluminous fetal ascites. The diagnosis of spontaneous bladder rupture was suspected. After multidisciplinary discussion, expectant management was decided. At 31 weeks and 4 days gestation, our patient went into spontaneous labor with a subsequent vaginal delivery. The infant required resuscitation and paracentesis of ascites at birth. Her neonatal course was favorable with a simple urethral bladder drainage. Cystography at day 9 was normal. At 2 years of follow-up, the mother and the child have a normal course.ConclusionsAn iatrogenic origin of megacystis in a female fetus must be evoked in the event of maternal administration of high doses of opiates in the second part of her pregnancy. In our case, the megacystis was followed by spontaneous bladder rupture at 30 weeks of gestation, with a favorable maternal fetal issue.

A Case of a 33-Week Pregnant Woman with COVID-19 and Term Birth

In this case report, we present a pregnant woman diagnosed with COVID-19 at 33 weeks gestation and having a vaginal birth at term. The postpartum and neonatal courses were uncomplicated. Anti-SARS-CoV-2-IgG antibodies were detected in the neonate. A vaginal delivery in this case was safe with clinical diagnosis of COVID-19.

Association of chest tube position with phrenic nerve palsy after neonatal and infant cardiac surgery

BackgroundDiaphragm paralysis (DP) complicates the postoperative course of neonates and infants undergoing cardiac surgery. Events causing DP remain poorly understood, and preventive strategies remain elusive. This retrospective cohort analysis aims to test the hypothesis that chest tubes in contact with the phrenic nerve in the pleural apex may cause pressure palsy. MethodsIn late 2018, the chest tube positioning strategy was changed so as to avoid a putative “danger zone” configuration, defined as (1) the chest tube looping apicomedially at the level of the second right intercostal space, and (2) wedging of chest tube tip against pericardium. A preintervention and postintervention analysis of 531 patients from 2012 to 2019 was performed to evaluate any association of chest tube position or duration in place with DP. Univariable and multivariable analyses were carried out, with significance set a priori at P < .05. ResultsThe preintervention group comprised 488 patients, of whom 32 (6.6%) had RDP. The postintervention group comprised 43 patients, none of whom had DP. Multivariable analysis of the entire cohort revealed chest tube positioning in the danger zone as the only significant association with RDP (odds ratio, 4.22; 95% confidence interval, 1.57-11.33; P < .05). ConclusionsChest tubes that occupy the right superior pleural space are associated with increased risk of DP.

Clinical Risk Index for Babies (CRIB-II) Scoring System in Prediction of Mortality Risk in Preterm Neonates in the First 24 Hour

Background: The scoring systems evaluate neonatal outcomes based on perinatal factors in the Neonatal Intense Course Unit (NICU). Aim: This study aimed to predict mortality risk in preterm neonates for the first time, using the Clinical Risk Index for Babies (CRIB II). Method: This cross-sectional, descriptive-analytical, longitudinal study was conducted on 344 preterm neonates with the gestational age of 23-32 weeks and birth weight of 500-1500 g in a referral center in Tehran, Iran, from winter 2016 to spring 2017. Some neonatal variables were completed within the first 12 h of life, and the final scores were calculated based on CRIB II. Then, the correlation of these variables with mortality outcome was evaluated using logistic regression. Sensitivity, specificity, and positive and negative values were also calculated via SPSS software (version 23). Results: According to the results, 253 (73.57%) neonates, including 122 girls (48%), survived in the first 24 h after birth. The total CRIB II score in the surviving neonates was 6.1±2.6. The area under the receiver operating characteristic curve was estimated at 0.84 with the cut-off point of 8.5. In addition, the sensitivity, specificity, positive predictive value, and negative predictive value of the CRIB II system were obtained as 75%, 78%, 55%, and 89.5%, respectively. The results revealed a significant correlation between the CRIB II score and mortality outcome. In this regard, an increase in the CRIB score coincided with a 0.67 increase in the risk of death (OR=1.671, p <0.001). Implications for Practice: Based on the findings of the present study,CRIB II can be concluded to be an appropriate scoring system. Consequently, the result of this tool can be used for routine investigations.