Chronic lung injury from prolonged mechanical ventilation after premature birth inhibits the normal postnatal decrease in pulmonary vascular resistance (PVR) and leads to structural abnormalities of the lung circulation in newborn sheep. Compared with normal lambs born at term, chronically ventilated preterm lambs have increased pulmonary arterial smooth muscle and elastin, fewer lung microvessels, and reduced abundance of endothelial nitric oxide synthase. These abnormalities may contribute to impaired respiratory gas exchange that often exists in infants with chronic lung disease (CLD). Nitric oxide inhalation (iNO) reduces PVR in human infants and lambs with persistent pulmonary hypertension. We wondered whether iNO might have a similar effect in lambs with CLD. We therefore studied the effect of iNO on PVR in lambs that were delivered prematurely at approximately 125 days of gestation (term = 147 days) and mechanically ventilated for 3 wk. All of the lambs had chronically implanted catheters for measurement of pulmonary vascular pressures and blood flow. During week 2 of mechanical ventilation, iNO at 15 parts/million for 1 h decreased PVR by approximately 20% in 12 lambs with evolving CLD. When the same study was repeated in eight lambs at the end of week 3, iNO had no significant effect on PVR. To see whether this loss of iNO effect on PVR might reflect dysfunction of lung vascular smooth muscle, we infused 8-bromo-guanosine 3',5'-cyclic monophosphate (cGMP; 150 microg. kg(-1). min(-1) iv) for 15-30 min in four of these lambs at the end of week 3. PVR consistently decreased by 30-35%. Lung immunohistochemistry and immunoblot analysis of excised pulmonary arteries from lambs with CLD, compared with control term lambs, showed decreased soluble guanylate cyclase (sGC). These results suggest that loss of pulmonary vascular responsiveness to iNO in preterm lambs with CLD results from impaired signaling, possibly related to deficient or defective activation of sGC, the intermediary enzyme through which iNO induces increased vascular smooth muscle cell cGMP and resultant vasodilation.
Background Feeding dysfunction is a common consequence of prematurity and illness in neonates, often requiring supplemental nasogastric (NG) or gastrostomy (GT) feeding tubes. A standardized approach to the discharge of infants receiving home enteral nutrition (HEN) is currently lacking. Methods The Home Enteral Feeding Transitions (HEFT) program was developed to identify patients eligible for HEN and create a standard discharge process. A structured tool helped determine discharge timing and route, and a dedicated outpatient clinic was created for infants discharged on HEN. Demographic, inpatient, and outpatient data were prospectively collected and compared with a historical cohort. Results A total of 232 infants discharged from our neonatal intensive care unit (NICU) over 9 months met inclusion criteria. Ninety‐eight (42%) were discharged with HEN, 68 NG and 30 GT, compared with 134 (58%) receiving full oral feeds. This represented a 10% increase in HEN utilization (P = 0.003) compared with our historical control group. Median HEN length of stay was 31.5 days compared with our historical average of 41 days (P = 0.23). Frequency of emergency department visits and admissions because of HEN was unchanged postintervention. Parents were satisfied (8.6/10), and 98% said they would choose HEN again. The median time to NG discontinuation after discharge was 13.5 days, with an estimated cost savings of $2163 per NICU day. Conclusion Our program is the first of which we know to use a standard care‐process model to guide the decision‐making and utilization of HEN at NICU discharge. HEFT shows that HEN at NICU discharge can be safe and effective, with high parental satisfaction.
BackgroundThe present study evaluated the effectiveness of a multidisciplinary earlier discharge model for neonates receiving home enteral nutrition (HEN).MethodsA retrospective data review and analysis was performed on 183 patients discharged out of the neonatal intensive care unit (NICU) receiving partial oral feeds (PO) and partial HEN from September 2016 to March 2018. These patients were followed in a multidisciplinary clinic led by a pediatric gastroenterologist, a neonatal feeding therapist, and a pediatric dietitian. Demographics and data were recorded for patients at discharge, and then chart reviews were performed for additional data.ResultsOf 182 patients, 121 (67%) weaned off HEN with a median time to full PO at 79 days (interquartile range [IQR] 15, 247) and had median PO intake of 20% (0, 43) at time of discharge. When comparing patients who gained 100% PO vs patients who did not wean off HEN, the weaned group consisted of 88% nasogastric tubes, with median time off feeds at 27 days (IQR 8, 79) and median PO intake of 29% (11, 50) at discharge. Only 13% of the cohort had an emergency room or hospital admission, which corresponds to 1.6 and 0.8 events, respectively, per 500 tube days specifically due to HEN complications.ConclusionsOur study supports that NICU patients with feeding dysfunction can effectively and safely discharge home earlier while receiving HEN. Our data suggest that a dedicated outpatient clinic can facilitate effective tube weaning in a majority of neonates with complex medical diseases with low rates of adverse events.
ObjectiveDetermine the detection rate from an expanded targeted early cytomegalovirus (CMV) testing program implemented from a large healthcare system (Intermountain Healthcare, IHC).Study DesignRetrospective review.SettingTertiary medical center.MethodsAn electronic system was modified to include indications for testing whenever a provider placed an order for CMV testing. A retrospective analysis of this database was performed.ResultsFrom March 1, 2021 to August 31, 2022, there were 3450 (8.8%) patients who underwent CMV testing out of 39,245 total live births within the IHC system. Since the formal implementation of this program in 2019, annual CMV testing has increased almost 10‐fold: 2668 CMV tests were performed in 2021 compared to 289 CMV tests in 2015. The most frequent indication for congenital CMV (cCMV) testing was small for gestational age (SGA) (68.2%), followed by macrocephaly (13.5%), an abnormal hearing test (5.0%), and microcephaly (4.4%). Fourteen cCMV‐infected infants were diagnosed all of them meeting the criteria for symptomatic cCMV. The most common indication resulting in a positive diagnosis was those who presented with SGA (n = 10 patients). The positivity rate would result in a prevalence of 35.7 symptomatic cCMV cases diagnosed per 100,000 live births, numbers comparable to those expected for universal cCMV screening.ConclusionAn expanded targeted early cCMV testing program may improve detection rates of symptomatic cCMV cases and should be considered as a feasible alternative approach to universal or hearing‐targeted early CMV testing.
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