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"Kent, Alison"
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Reducing device-related pressure injuries in high-risk neonates receiving nasal continuous positive airway pressure: a quality improvement study
ObjectiveNeonates requiring Non-InVasive respiratory Support (NIVS) are at high risk of device-related pressure injury (DRPI), with incidence rates of 20%–60% in extremely premature infants. Over a 4-year period, our team undertook a Quality Improvement Project to review aspects of the clinical management of NIVS: types of interfaces, introduction of hydrocolloid dressing and the development and implementation of nasal injury care plan (NICP) to reduce DRPI in high-risk neonates.DesignA prospective descriptive study was completed in three stages: trial of nCPAP interfaces, preintroduction NICP (2016–2018), post-NICP (2018–2020) and (2021–2022) to measure sustainability of implementation. Data included: gestational age (GA), birth weight, NIVS days, incidence, grade and day of DRPI. Statistical analysis of incidence rate ratio was completed between pre and postgroups.SettingAustralian neonatal intensive care unit.PatientsAll neonates ≤32 weeks requiring nCPAP.InterventionsEvaluation of types of interfaces, introduction of hydrocolloid dressing and the development and implementation of NICPMain outcome measures: incidence and severity of DRPI.ResultsTotal DRPI recorded in all CPAP babies pre/post NICP were (59/659 (9.0%), 26/574 (4.5%), p=0.0032, respectively). Analysis showed DRPI incidence rates per 1000 NIVS days ((10.6, 5.5), p=0.0001, respectively). 75 (88%) of DRPI occurred in the ≤32 week group of neonates requiring NIVS. Review of babies ≤32 weeks across the three intervals showed significant improvement with time (55 (19%); 27 (13%); 19 (9%), p=0.0001).ConclusionsPreferred nCPAP interface, nasal dressing and NICP have reduced the incidence and severity of DRPI in the NICU.
Journal Article
Neonatal hypertension: an educational review
Hypertension is encountered in up to 3% of neonates and occurs more frequently in neonates requiring hospitalization in the neonatal intensive care unit (NICU) than in neonates in newborn nurseries or outpatient clinics. Former NICU neonates are at higher risk of hypertension secondary to invasive procedures and disease-related comorbidities. Accurate measurement of blood pressure (BP) remains challenging, but new standardized methods result in less measurement error. Multiple factors contribute to the rapidly changing BP of a neonate: gestational age, postmenstrual age (PMA), birth weight, and maternal factors are the most significant contributors. Given the natural evolution of BP as neonates mature, a percentile cutoff of 95% for PMA has been the most common definition used; however, this is not based on outcome data. Common causes of neonatal hypertension are congenital and acquired renal disease, history of umbilical arterial catheter placement, and bronchopulmonary dysplasia. The treatment of neonatal hypertension has mostly been off-label, but as evidence accumulates, the safety of medical management has increased. The prognosis of neonatal hypertension remains largely unknown and thankfully most often resolves unless secondary to renovascular disease, but further research is needed. This review discusses important factors related to neonatal hypertension including BP measurement, determinants of BP, and management of neonatal hypertension.
Journal Article
Incidence of neonatal hypertension from a large multicenter study Assessment of Worldwide Acute Kidney Injury Epidemiology in Neonates—AWAKEN
BackgroundHypertension occurs in up to 3% of neonates admitted to the Neonatal Intensive Care Unit (NICU), and is a potentially under-recognized condition. The aim of this study was to examine the incidence of documented and undiagnosed hypertension from the 24-center Assessment of Worldwide Acute Kidney Injury Epidemiology in Neonates (AWAKEN) database, and to assess risk factors for hypertension according to gestational age.MethodsDiagnosed hypertension was documented if an infant had a discharge diagnosis of hypertension and/or discharged on antihypertensive medications. Undiagnosed hypertension was defined when infants did not have a diagnosis of hypertension, but >50% of the lowest mean, diastolic and systolic blood pressure recordings were >95th percentile for gestational age.ResultsOf the 2162 neonates enrolled in the study, hypertension was documented in 1.8%. An additional 3.7% were defined as having undiagnosed hypertension. There was a significant correlation with neonatal hypertension and acute kidney injury (AKI). Additional risk factors for neonatal hypertension were hyperbilirubinaemia, Caucasian race, outborn, vaginal delivery, and congenital heart disease. Protective factors were small for gestational age, multiple gestations, and steroids for fetal maturation.ConclusionsNeonatal hypertension may be an under-recognized condition. AKI and other risk factors predispose infants to hypertension.
Journal Article
Determinants of Neonatal Blood Pressure
Blood pressure (BP) measurements have been increasingly used across neonatal intensive care units to determine and monitor hemodynamic status in neonates. A number of studies have attempted to derive normative blood pressure data in both preterm and term infants. However, this still remains a complex process, as several maternal and neonatal factors influence neonatal blood pressure. Maternal conditions, including hypertension and preeclampsia, seem to have some impact on neonatal BP, while maternal drugs, in particular antenatal steroids, seem to have a strong influence. Among the neonatal factors, gestational age, post-conceptual age and weight seem to have the strongest influence. The paucity of data on the short and long term effects of maternal conditions and medication on neonatal BP requires further research.
Journal Article
670nm Photobiomodulation as a Novel Protection against Retinopathy of Prematurity: Evidence from Oxygen Induced Retinopathy Models
To investigate the validity of using 670nm red light as a preventative treatment for Retinopathy of Prematurity in two animal models of oxygen-induced retinopathy (OIR).
During and post exposure to hyperoxia, C57BL/6J mice or Sprague-Dawley rats were exposed to 670 nm light for 3 minutes a day (9J/cm²). Whole mounted retinas were investigated for evidence of vascular abnormalities, while sections of neural retina were used to quantify levels of cell death using the TUNEL technique. Organs were removed, weighed and independent histopathology examination performed.
670 nm light reduced neovascularisation, vaso-obliteration and abnormal peripheral branching patterns of retinal vessels in OIR. The neural retina was also protected against OIR by 670 nm light exposure. OIR-exposed animals had severe lung pathology, including haemorrhage and oedema, that was significantly reduced in 670 nm+OIR light-exposed animals. There were no significance differences in the organ weights of animals in the 670 nm light-exposed animals, and no adverse effects of exposure to 670 nm light were detected.
Low levels of exposure to 670 nm light protects against OIR and lung damage associated with exposure to high levels of oxygen, and may prove to be a non-invasive and inexpensive preventative treatment for ROP and chronic lung disease associated with prematurity.
Journal Article
Neonatal hypoxic ischemic encephalopathy increases acute kidney injury urinary biomarkers in a rat model
Hypoxic ischemic encephalopathy (HIE) is associated with acute kidney injury (AKI) in neonates with birth asphyxia. This study aimed to utilize urinary biomarkers to characterize AKI in an established neonatal rat model of HIE. Day 7 Sprague–Dawley rat pups underwent HIE using the Rice–Vannucci model (unilateral carotid ligation followed by 120 mins of 8% oxygen). Controls included no surgery and sham surgery. Weights and urine for biomarkers (NGAL, osteopontin, KIM‐1, albumin) were collected the day prior, daily for 3 days post‐intervention, and at sacrifice day 14. Kidneys and brains were processed for histology. HIE pups displayed histological evidence of kidney injury including damage to the proximal tubules, consistent with resolving acute tubular necrosis, and had significantly elevated urinary levels of NGAL and albumin compared to sham or controls 1‐day post‐insult that elevated for 3 days. KIM‐1 significantly increased for 2 days post‐HIE. HIE did not significantly alter osteopontin levels. Seven days post‐start of experiment, controls were 81.2% above starting weight compared to 52.1% in HIE pups. NGAL and albumin levels inversely correlated with body weight following HIE injury. The AKI produced by the Rice–Vannucci HIE model is detectable by urinary biomarkers, which can be used for future studies of treatments to reduce kidney injury.
Although animal models of brain injury resulting from HIE are well established, the kidney injury that occurs is not well studied. This study aims to characterize AKI in an established rat model of HIE and track injury progression using sensitive urinary biomarkers. This provides an experimental approach utilizable for testing effectiveness of therapies that treat AKI.
Journal Article
Humidification Practices of Extremely Preterm Neonates: A Clinical Survey
Extremely preterm neonates are at risk of morbidity and mortality related to their underdeveloped skin barrier. Humidified incubators are typically used in their care, but there is a paucity of literature to inform the standardization of specific evidence-based humidification practices in the NICU. A brief, voluntary, anonymous survey was distributed to our home institution and numerous national and international external institutions. Survey questions pertained to institutional humidification guidelines and were qualitatively analyzed. We received 89 responses from the home institution and 42 responses from the external institutions. Within the home institution, despite the presence of a guideline, individual practitioners reported varying practices in the starting levels of humidity and length of time spent in humidity. The results also demonstrated significant variability in individual humidification practices between the external institutions. There is no standard humidification guideline for extremely preterm neonates being cared for in the NICU. Further research is required to provide appropriate evidence on which to base clinical guidelines for the management of extremely preterm neonates to prevent morbidity and mortality in this population.
Journal Article
A pilot randomised clinical trial of 670 nm red light for reducing retinopathy of prematurity
BackgroundPhotobiomodulation by 670 nm red light in animal models reduced severity of ROP and improved survival. This pilot randomised controlled trial aimed to provide data on 670 nm red light exposure for prevention of ROP and survival for a larger randomised trial.MethodsNeonates <30 weeks gestation or <1150 g at birth were randomised to receive 670 nm for 15 min (9 J/cm2) daily until 34 weeks corrected age. Data collected: placental pathology, growth, days of respiratory support and oxygen, bronchopulmonary dysplasia, patent ductus arteriosus, necrotising enterocolitis, sepsis, worst stage of ROP, need for laser treatment, and survival.ResultsEighty-six neonates enrolled—45 no red light; 41 red light. There was no difference in severity of ROP (<27 weeks—p = 0.463; ≥27 weeks—p = 0.558) or requirement for laser treatment (<27 weeks—p = 1.00; ≥27 weeks—no laser treatment in either group). Survival in 670 nm red light treatment group was 100% (41/41) vs 89% (40/45) in untreated infants (p = 0.057).ConclusionRandomisation to receive 670 nm red light within 24–48 h after birth is feasible. Although no improvement in ROP or survivability was observed, further testing into the dosage and delivery for this potential therapy are required.
Journal Article
Using Serum Cystatin C to Predict Acute Kidney Injury Following Infant Cardiac Surgery
Acute kidney injury (AKI) following cardiopulmonary bypass (CPB) is associated with increased morbidity and mortality. Serum Cystatin C (CysC) is a novel biomarker synthesized by all nucleated cells that may act as an early indicator of AKI following infant CPB. Prospective observational study of infants (< 1 year) requiring CPB during cardiac surgery. CysC was measured at baseline and 12, 24, 48, and 72 h following CPB initiation. Each post-op percent difference in CysC (e.g. %CysC
12h
) from baseline was calculated. Clinical variables along with urine output (UOP) and serum creatinine (SCr) were followed. Subjects were divided into two groups: AKI and non-AKI based upon the Kidney Disease Improving Global Outcomes (KDIGO) classification. AKI occurred in 41.9% (18) of the 43 infants enrolled. Patient demographics and baseline CysC levels were similar between groups. CysC levels were 0.97 ± 0.28 mg/L over the study period, and directly correlated with SCr (
R
= 0.71,
p
< 0.0001). Although absolute CysC levels were not significant between groups, the %CysC
12h
was significantly greater in the AKI group (AKI: − 16% ± 22% vs. Non-AKI − 28% ± 9% mg/L;
p
= 0.003). However, multivariate analysis demonstrated that a lower UOP (Odds Ratio:0.298; 95% CI 0.073, 0.850;
p
= 0.02) but not %CysC
12h
was independently associated with AKI. Despite a significant difference in the %CysC
12h
, only UOP was independently associated with AKI. Larger studies of a more homogenous population are needed to understand these results and to explore the variability in this biomarker seen across institutions.
Journal Article