Day 1 :
Nassau University Medical Center, USA
Keynote: Early postnatal body weight changes in the extremely low birth weight infants (ELBW, birth weight < 1000 g): Clinical implications and determinants
Time : 09:05-09:45
Rita Verma Prasad is an attending neonatologist and Professor of Pediatrics at Nassau University Medical Center, NY, USA. She graduated from medical school in India at the top of her class of 210 students with honors. She worked at the State University of New York School of Medicine, Stony Brook; and at the University of Maryland School of Medicine as Associate Professor before joining Nassau University Medical Center. She has published over 90 peer reviewed manuscripts and abstracts and has presented her research at national and international meetings. She serves on the editorial board and is a manuscript reviewer for several journals. She is a member of the Neonatal- Perinatal, Critical Care and Epidemiology subcommittees of the American Academy of Pediatrics and is acknowledged for her contribution in making pediatrics and neonatology protocols for the academy. She has mentored many medical students, pediatric residents and neonatology fellows over the years.
Background: Early postnatal body weight changes (Δ bw) and their clinical implications are poorly understood in preterm infants. We investigated the relationships between Δ bw and body fluid metabolism dependent morbidities in ELBW infants, the population which has highest incidences of such morbidities. Δ bw were evaluated as maximum weight loss (MΔbw); and as daily body weight changes from birth weight (DΔ bw) during the first 15 days of life. The mother-infants' variables relevant to body fluid balance, namely, oxygen dependence on day 28 (BPD28), patent ductus arteriosus (PDA), intraventricular-periventricular hemorrhage (IVH), antenatal steroid (ANS) and gestational age (GA) were correlated with MΔbw and DΔ bw via Pearson's correlation coefficient and Pearson's partial correlation tests. The effects of MΔbw, as low (5-12% of birth weight) moderate (18.1-12%) and high (18-25%) were also assessed.
Results: MΔbw (n=102) was 14.2+/-5.4%. Day of life of MΔbw was 5.5+/-2.1 and that of surpassing birth weight 14.5+/-4.2. MΔbw correlated negatively with GA, ANS and pregnancy associated hypertension (PAH); and positively with BPD28, days on oxygen, fluid intake and urinary output in a GA dependent manner. MΔbw did not correlate with RDS, hypotension, PIE, IVH, PDA and hospital stay. DΔ bw correlated inversely with GA on days 1–8, and was associated with decreased risks for BPD28, PDA and IVH after controlling for GA. ANS decreased DΔ bw. Maternal diabetes mellitus (MDM) and PAH were not noted in mothers in high MΔbw group. 38% of mothers in low MΔbw group suffered from PAH.
Conclusion: MΔbw, governed by maturation, does not promote morbidities independent of GA within the range of 14.5+4.2%. DΔ bw is protective for PDA, BPD28 and IVH independent of GA. ANS decreases DΔbw, which correlates inversely with GA during the first week of life. MDM and PAH have implications in Δ bw in ELBW neonates.
Antwerp University Hospital, Belgium
Ludo Mahieu has his expertise in epidemiology and passion for clinical infectious diseases, hospital hygiene and wellbeing of the newborn. His open and contextual evaluation model based on responsive constructivists creates new pathways for improving healthcare. He has built predictive scores after years of experience in research, neonatology, teaching both in hospital and education institutions. The prediction is based on computer based weighting using multivariate analysis and more recently machinery learning which is a ethodology that utilizes artificial intelligence for evaluation: measurement, description and judgment. It allows for complex prediction.
Statement of the Problem: Neonatal Intensive Care Unit patients are at high risk for central line associated bloodstream infections (CLABSI). International guidelines, based on evidence based recommendations for the prevention of CLABSI, have been published. However, the guidelines are largely based on adult studies. Great variability in CLABSI infection rates among NICUs have been reported, probably because of differences in adherence to CLABSI prevention guidelines. The purpose of this study is to describe the variability of current prevention practices among Belgian NICUs and to identify areas for improvement and for further research.
Methodology & Theoretical Orientation: We surveyed NICU staff reporting to the National healthcare associated infection working group (NeoKISS) to assess strategies used to prevent CLABSI and also hygiene quality audit performance the NICUs. Each item was scored in accordance to the level of evidence of the 3 reference guidelines (SHEA/ EPIC3/ CDC).
Findings: Fourteen (73%) out of 19 NICUs did respond to the survey. The compliance to the CLABSI prevention items were 64%, 47% and 50% for the insertion items, maintenance items and hygiene quality items respectively. The variability between units was considerably with a SD of 8, 13 and 22 for insertion items, maintenance items and hygiene quality items.
Conclusion & Significance: The overall compliance to international guidelines for the prevention of CLABSI is low (57%) in Belgium. Especially, during maintenance of the central line there is room for improvement in infection prevention. Our survey underscores the need for standardization of central line care in Belgium and was able to define priorities for education.
Dhaka Shishu Children Hospital, Bangladesh
Mohammad Monir Hossain is currently working as Professor of Neonatal Medicine, NICU & Critical Care of Paediatrics at the Bangladesh Institute of Child Health (BICH) & Dhaka Shishu (Children) Hospital. He received his PhD from the University of Dhaka for his research work on neonate receiving intensive care in 2006. After his graduation (MBBS) in 1987, he completed Doctor of Medicine in Paediatrics (MD) in 1997. He became fellow (FCPS) of Bangladesh College of Physicians & Surgeons in 1999 and Royal College of Physicians and Surgeons of Glasgow (FRCP Glasg) in 2009, Royal College of Physicians of Edinburgh (FRCP Edin) in the same year and Royal College of Paediatric & Child Health (FRCPCH), UK in 2010. Since 2001 he has been serving as Assistant Professor, Associate Professor and Professor at Bangladesh Institute of Child Health & Dhaka Shishu (Children) Hospital. Professor Hossain has authored several publications in various journals and books. His publications reflect his research interests in critical care in neonatology. He was the Executive Editor of Bangladesh Journal of Child Health (BJCH).
Pulmonary hemorrhage (PH) is an acute, catastrophic event characterized by discharge of bloody fluid from the upper respiratory tract or the endotracheal tube. The hematocrit of the hemorrhagic fluid is often 15 to 20 percentage points below the venous hematocrit. The incidence of PH is 1 to 12 per 1,000 live births. PH occurs most commonly in the first few days after birth. Mortality rates as high as 50% have been reported. Prematurity is the factor most commonly associated with PH; other associated factors are those that predispose to perinatal asphyxia or bleeding disorders, including toxemia of pregnancy, maternal cocaine use, erythroblastosis fetalis, breech delivery, hypothermia, infection, Respiratory Distress Syndrome, administration of exogenous surfactant (in some studies) and ECMO. It is postulated that the infant suffers an asphyxial insult with resultant myocardial failure; this increases pulmonary microvascular pressure resulting in pulmonary edema. Subsequently, there is frank bleeding into the pulmonary interstitial and alveolar spaces. The typical presentation of the infant with PH is a premature infant who suddenly presents with frothy pink-tinged secretions from an ET. Over the next minutes to hours, the infant often requires increased ventilatory support and has increased work of breathing. As increasing amounts of blood are suctioned from the ET, PCO2 starts to rise, as does the need for oxygen. If the PH continues, the infant will develop apnea, generalized pallor, become cyanotic, with concomitant bradycardia and a drop in blood pressure. Chest radiography results are nonspecific. Based on severity and timing of the PH, the chest radiograph may have fluffy opacities, focal ground-glass opacities, or appear as a complete “white out” if the PH is massive. The immediate treatment of PH should include tracheal suction to ensure that blood clots have not obstructed the ET. The FiO2 should be increased as guided by the oxygen saturation of the infant. The standard therapy is to raise the positive end-expiratory pressure (PEEP) to 6 to 8 cm H2O. To decrease PH, the mean airway pressure should be increased in an attempt to reverse or slow down hemorrhagic pulmonary edema. In some cases, high-frequency oscillatory ventilation may be needed to increase the mean airway pressure. Endotracheal or nebulized epinephrine has been used in the treatment of PH because of its vasoconstrictive and inotropic effects. Immediate radiography of the chest should be obtained. Once the hemorrhage has resolved, the chest radiograph will show improvement within 24 to 48 hours. Because the radiographic appearance of PH is difficult to distinguish from pneumonia, therapy often includes antibiotics until infection is ruled out. An echocardiograph should be done to rule out left to right shunting through a PDA. In this setting, surgical treatment for PDA may be safer than medical treatment because the latter may exacerbate bleeding. Phytonadione (vitamin K) should be given to correct prothrombinemia. Based on an estimate of the volume of blood lost, packed red blood cells and platelets should be given after a complete blood count, prothrombin time, activated partial thromboplastin time, D-dimers, and fibrinogen are obtained. The administration of recombinant factor VII should be considered. Activated recombinant factor VII (rFVIIa) has been successfully used to treat severe PH refractory to conventional ventilator management in very low birth weight infants. Surfactant has also been used in the treatment of PH. with significant improvement in oxygenation index and no deterioration. Hemocoagulase has been reported as a new effective treatment for PH. by converting prothrombin to thrombin and fibrinogen to fibrin. Hence, it decreases bleeding time and enhances coagulation at sites of bleeding. The mainstay of treatment includes ventilation and vigorous resuscitation of a shocked and critically ill infant.
BP Koirala Institute of Health Sciences, Nepal
Shailesh Adhikary is a Professor of GI and a Laparoscopic Surgeon currently serving as a Clinical Teacher at the Community Based Medical College in Eastern Nepal and has published 57 papers, columns at national and international journals and social news magazines and is also contributing as an Editorial Board Member for Asian Journal of Surgery. He is also the Governor of Endoscopic Laparoscopic Surgeons of Asia (ELSA) and is working to promote the Minimal Access Surgery across Nepal and in Asia.
Penetrating or perforating abdominal or chest injuries are very uncommon in the pediatric age group and are associated with a high mortality. Impalement injuries are consequence of penetration by elongated, usually fixed objects through the body. The case study begins with a 10-year young child suffered from a penetrating injury to the left iliac fossa, when he had fallen from a coconut tree on to the sharp bamboo fence. The bamboo stick penetrated the abdominal wall, perforated the jejunal loops at two sites along with the fundus of stomach, the left diaphragm, upper lobe of the left lung and the bevelled end of the bamboo had exited at the neck after tearing apart the neck muscles and skin sweeping along with it, few scattered pieces of jejunal tissues which were seen lying alongside. He was brought to the hospital 5 hours after the accident. On arrival he was in agony, dehydrated and scored 15/15 on Glasgow scale, remained hemodynamically stable, saturation of 93% with oxygen supplement. On examination a 75x5cm bamboo stick was in situ, which entered 4cm medial to the left anterior superior iliac spine and exited 3cm above the skin at the posterior triangle of neck. Operation imaging modalities were followed by exploration via the left thoracoabdominal incision. The thorax, mediastinum and neck were assessed in the beginning and after confirming that no great vessels were at risk, the foreign body was then carefully removed. The perforated stomach, jejunum and diaphragm were repaired. The upper lobe of lung had to be resected. An abdominal drain and two intercostal drains were placed. The total operative time was 3.30 hours and the child were managed in intensive care for 4 days and was finally discharged after two weeks. A rare penetrating injury with damage to the multiple organs could be managed successfully possibly because of a teamwork: and also, due to some sensible move by the villagers as they did not try to fiddle around with the foreign body.