We identified significant differences in phlebotomy and transfusion practices between two NICUs. We found no differences in short-term outcome, suggesting that the additional use of blood in one of the NICUs was discretionary rather than necessary. Our multivariate models can be used to characterize and quantify transfusion and phlebotomy practices. By predicting which patients are likely to require multiple transfusions, clinicians can target patients for erythropoietin therapy and identify those patients for whom donor exposure can be reduced by a unit of blood for multiple use. The models may help in monitoring changes in practice as they occur.
Background. Low birth weight is a major determinant of neonatal mortality. Yet birth weight, even in conjunction with other demographic markers, is inadequate to explain the large variations in neonatal mortality between intensive care units. This variation probably reflects differences in admission severity. The authors have recently developed the Score for Neonatal Acute Physiology (SNAP), an illness severity index specific for neonatal intensive care, and demonstrated illness severity to be a major determinant of neonatal mortality. Objective. To define the relative contributions of birth weight and illness severity to the risk of neonatal mortality and to identify other significant independent risk factors. Methods. Logistic regression was used to analyze data from a cohort of 1621 consecutive admissions to three neonatal intensive care units (92 deaths), to test six alternative predictive models. The best logistic model was then used to develop a simple additive clinical score, the SNAP Perinatal Extension (SNAP-PE). Results. These analyses demonstrated that birth weight and illness severity are powerful independent predictors across a broad range of birth weights and that their effects are additive. Below 750 g, there is an interaction between birth weight and SNAP. Other factors that showed independent predictive power were low Apgar score at 5 minutes and small size for gestational age. Separate derivation and test samples were used to demonstrate that the SNAP-PE is comparable to the best logistic model and has a sensitivity and specificity superior to either birth weight or SNAP alone (receiver-operator characteristic area .92 ± .02) as well as excellent goodness of fit. Conclusion. This simplified clinical score provides accurate mortality risk estimates for application in a broad array of clinical and research settings.
Aim: Aim of the present study was to analyse the influence of postnatal age on peripheral oxygenation in healthy term neonates during the first week of life.Methods: Peripheral oxygenation was measured by means of near infrared spectroscopy (NIRS) in combination with the venous occlusion method. Measurements were performed by placing the NIRS optodes on the left forearm. Venous occlusions were obtained by a pneumatic cuff around the left upper arm. Central and peripheral temperatures were measured continuously, as well as by means of pulsoximetry heart rate and peripheral arterial oxygen saturation were measured continuously. Arterial blood pressure was measured before and after venous occlusions. Oxygen delivery (DO2), oxygen consumption (VO2), fractional oxygen extraction (FOE), and tissue oxygenation index (TOI) were analysed and compared to postnatal age.Results: 131 measurements were performed in 90 term neonates. Gestational age was 39,5ϩ/-1,1 weeks, birth weight 3364ϩ/-435 g, and postnatal age 46ϩ/-33 hours. Peripheral arterial oxygen saturation was 96,3ϩ/-1,8 %, heart rate 114ϩ/-11 /minute, mean arterial blood pressure 54,4ϩ/-6,8 mmHg, central temperature 37ϩ/-0,3 degree Celsius, and peripheral temperature 34,3ϩ/-1 degree Celsius. DO2 was 140ϩ/-74 mol/100ml/minute, VO2 46ϩ/-23 mol/100ml/minute, FOE 0,34ϩ/-0,11 and TOI 65ϩ/-6. DO2 was independent of age. VO2 and FOE increased with increasing age, whereas TOI decreased with increasing age.Conclusion: The present study in term neonates demonstrated changes in peripheral oxygenation in healthy term neonates during the first week of life. Reason for this observation seems to be changes in the peripheral muscular oxygen consumption. PATTERNS OF CHANGE IN FAMILY FUNCTION, RESOURCES, COPING AND PARENTAL DISTRESS IN MOTHERS AND FATHERS OF SICK NEW-BORNS OVER THE FIRST YEAR OF LIFE DEPARTMENT OF CLINICAL EPIDEMIOLOGY AND BIOSTATISTICS (CANADA)Background: Families of high risk infants are more likely to experience family dysfunction. Little is known about the pattern of family function, resources, coping and distress over time. Objective: To determine the pattern of change in family function, resources, coping and distress, as reported independently by mothers and fathers, over the first year following the birth of a sick newborn; and to determine the relationship among them.Design/Methods: Longitudinal design. Participants: 200 two-parent families of infants who required intensive care at birth were recruited from a regional tertiary centre. Information was obtained through well validated questionnaires at 4 points: in the NICU, and at 3, 6, and 12 months (mo) post-discharge. Of the 200 families recruited, there were 44 (22%) drop-outs over the length of the study; and 4 had incomplete data for a final sample of 152. Data analyses were based on analysis of variance with repeated measures.Results: Most changes occurred in the time period from NICU to 3 mo: 1) both mothers and fathers showed a significant decline in family function (pϽ.0001); 2) mothers showed a si...
Background. Clinicians' estimates of mortality risk in the neonatal intensive care unit (NICU) have implications for patient triage, transfer, initiation and termination of life support, and allocation of medical resources. The accuracy of these judgments has not been studied, nor the differences between nurses and attending physicians. Objectives. 1) evaluate the accuracy of subjective judgments of NICU unit mortality risk, 2) identify the key components of clinician judgments, 3) compare accuracy between attending physicians and nurses, and 4) examine the utility of combining an objectively computed risk and clinician judgments to improve predictions. Methods. We obtained estimates of mortality risk on 544 admissions to two NICUs on the day of admission from the attending physician and primary nurse. These were compared with an objective computed mortality risk based on birth weight and the Score for Neonatal Acute Physiology (SNAP) using a linear judgment analysis model, as well as with actual outcomes. Results. Physicians and nurses had good discriminating power with actual mortality rates ranging from 0% among low risk patients to 67% among those with the highest mortality estimates. Physicians had a tendency to overestimate mortality risk. Clinicians base their estimates on the same factors and similar judgment weights as the empiric mortality risk model (22% birth weight, 62% illness severity (SNAP), 13% low Apgar, and 3% for intrauterine growth restriction). Clinicians place additional emphasis on therapeutic as well as physiologic factors. When the computed risk and physician judgment were combined, both made significant contributions in a logistic mortality risk model. Conclusions. Clinician judgments of mortality risk are fairly accurate and similar to an objective illness severity index. This simple method provides insight into clinical decision making and has important applications in improving direct patient care, appropriate allocation of medical resources, and medical training.
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