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Clinical practice guidelines are becoming pervasive in pediatrics and newborn medicine. They have spanned a wide range of primary care practice parameters from treating otitis media with effusion, to performing complex surgery for congenital heart disease, and management of respiratory distress syndrome and coordinating discharge from the neonatal intensive care unit. Administrators believe that using clinical practice parameters reduces health care costs, improves quality of care, and limits malpractice liability. Practice parameters and guidelines have grown in use because powerful interests-third-party payers, insurers, and health maintenance organizations, as well as hospital administrators bent on reducing variable costs of care and contracting for capitated care-champion their development, implementation, and monitoring. Economic credentialing of physicians with excessive variances without risk-adjusting for other than average patients is problematic and remains unchecked partly because of the fundamental characteristics of the evolving health care industry in which costs are more easily measured than quality. For highly autonomus physicians this standardization of medical decision making may represent a difficult transition into corporate practice by realigning traditional values of the doctor-patient relationship. However, because guidelines are almost certainly here to stay, pediatricians and neonatologists need to think critically about how their content and method of implementation, monitoring, and modification may influence medical teaching and decision making in the future. If guidelines are introduced primarily as a cost savings or containment tool that ignores the impact on the quality of care and restricts necessary care for infants and children, especially those with chronic illness or who are developmentally at risk, then neonatologists and pediatricians must be quick and determined to challenge the potentially damaging use of practice parameters or guidelines. Furthermore, there are many medicolegal implications of guideline implementation that may not favor physicians and leave to hospitals, insurers, and ultimately the courts decisions regarding evidence-based practice. In this review article, we pay special attention to the guidelines developed in newborn medicine. We discuss why and how guidelines are developed and critically evaluate the available evidence describing potential benefits and drawbacks of guidelines in general. There are legal implications to the implementation of guidelines, and guidelines may increase provider susceptibility to malpractice allegations. Neonatologists and pediatricians should critically analyze the following questions when guidelines are being developed: Are clinical practice parameters the most effective means to reduce the costs of health care, or improve the quality of health care services while reducing the need for and protecting physicians from malpractice suits? Or do clinical practice guidelines more closely resemble an audit system developed by health care organizations, insurers, and others including government-sponsored health care to appease powerful interests-with limited evidence for promise and perhaps potential negative cost, quality, and malpractice liability implications? In pediatric and newborn medicine there is limited evidence that guidelines have achieved the desired goals and further analysis of their process of care and the costs of implementation is warranted.
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PMID:Clinical practice guidelines in pediatric and newborn medicine: implications for their use in practice. 898 46

We report a surgical case of severe Ebstein's anomaly associated with pulmonary atresia in the neonate. The baby had remarkable cardiomegaly (CTR > or = 90%) soon after birth and presented severe respiratory distress. He underwent modified Starnes operation (closure of tricuspid valve using a perforated patch, enlargement of interatrial communication, modified Blalock shunt, and PDA ligation) at the age of 12 days. He survived the procedure and cardiopulmonary failure was improved. However, he died from arrhythmia on the 3rd postoperative day. We think this procedure is useful regard to improvement of cardiopulmonary failure due to this fatal congenital heart disease.
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PMID:[A surgical case of severe Ebstein's anomaly, pulmonary atresia in the neonate: experience of modified Starnes operation]. 918 47

Using information from our database, a review of mortality for the Newborn Intensive Care Unit at Providence Alaska Medical Center was conducted for 1987-1996. There has been a significant decline in mortality over the last decade (p = 0.003). An analysis of mortality by birthweight and gestational age groups demonstrated a decline in mortality (p = 0.005) for infants with birthweight < 2 kg and infants < or = 34 weeks gestation, but no change for infants > or = 2 kg and > or = 35 weeks gestation. As a result, larger and more mature babies now account for an increasing proportion of NICU deaths. For 1995 and 1996 the major contributors to mortality for the smaller neonates were respiratory distress syndrome and congenital and nosocomial sepsis/pneumonia. The major contributors to mortality for larger neonates were persistent pulmonary hypertension of the newborn, congenital heart disease, congenital diaphragmatic hernia, and primary birth asphyxia. A majority of deaths in the larger neonates were due to non-lethal causes. We contend that improved survival in the larger neonate is an important and achievable goal. The introduction of ECMO (Extracorporeal Membrane Oxygenation) for the NICU and a focused review of the neonatal cardiac program offers the best possible potential for achieving this goal.
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PMID:The next challenge for newborn intensive care in Alaska: improving the survival of the larger neonate. 947 9

A 1-month-old male infant with respiratory distress was referred to our hospital for operation of the ventricular septal defect. A chest roentgenogram demonstrated pulmonary emphysema especially in the right upper and middle lobes. At 3 months, a perimembranous ventricular septal defect was closed. But the infant could not be weaned from the ventilator. On the 21st postoperative day, a right upper and middle bilobectomy was performed. Three days later, he was weaned from the ventilator and the postoperative course was uneventful. The pathologic diagnosis revealed no bronchial cartilagenous abnormality. Infantile lobar emphysema of the right upper lobe with congenital heart disease is rather rare. We emphasize the need for lobectomy simultaneous with, secondary to, cardiac surgery in these cases.
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PMID:[An infant with lobar emphysema requiring lobectomy after ventricular septal defect closure]. 959 7

It has recently been recognized that neonates may develop pneumonia as a result of Legionella pneumophila. The objective of this study is to characterize the epidemiology, risk factors, diagnosis, clinical features, and outcome of neonatal legionellosis. Review of the literature revealed nine cases of neonatal Legionella infection. Five neonates were term infants and four were preterm. Eight had potential risk factors such as prematurity, congenital heart disease, bronchopulmonary dysplasia, or corticosteroid therapy. Diagnosis was proven by culture in all cases. The main presentation was acute respiratory distress requiring mechanical ventilation. In six infants, the infection had a fatal outcome, including five who were not treated with erythromycin. All the cases were nosocomial, and environmental Legionella was documented in five cases. As has been noted in adults and children with Legionella, early recognition and institution of appropriate therapy are the most important determinants of the prognosis.
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PMID:Legionella pneumonia in neonates: a literature review. 973 Jan 99

PDA (patent ductus arteriosus) is a common congenital heart disease. Usually surgical intervention through left thoracotomy or recently through video assisted thoracoscopy will be recommended if the preceding or intent medical treatment fails or is contraindicated. However, once surgical intervention is decided, various complications are still a real fear in the mind of the surgeon and the anesthesiologist, particularly if the infant is premature or very sick. Here we report an anesthetic management in a female preterm infant weighing 500 grams, who underwent PDA ligation. She was born at gestation age of 28 weeks at our hospital, and since her birth she was noted to have infant respiratory distress syndrome associated with renal dysfunction. She was admitted to the neonatal intensive care unit (NICU) straightaway. After thorough examination, a severe PDA was disclosed. The possibility of pulmonary hemorrhage and heart failure could be predicted in view of the large left to right shunt. Worst of all was that her poor renal function contradicted a medical treatment. So we decided to carry out the ligation procedure at once although she was premature and only 5 days old. The NICU was chosen as the operation theater for transferring concerns. General anesthesia was induced and maintained by atropine 0.01 mg, pancuronium 0.1 mg, fentanyl 2 micrograms, and ketamine 0.15 mg intravenously. Supplemental oxygen was given throughout the operation. The PDA was ligated through left thoracotomy and blood loss was minimal. The peri-operative course was uneventful. The patient recovered well following surgery and anesthesia.
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PMID:The anesthetic management of a preterm infant weighing 500 grams undergoing ligation of patent ductus arteriosus--a case report. 1041 Apr 9

Patency of the ductus arteriosus (DA) is maintained during gestation by locally produced and circulating prostaglandins (PGE's). As gestation proceeds, the ductus becomes less sensitive to dilating prostaglandins and more sensitive to constricting factors such as PGE's synthetase inhibitors. This case report describes a fetus at term (38 weeks) with signs of severe right ventricular failure due to constriction of DA. Maternal history documented 5 day assumption of a non-steroid antiinflammatory agent to relieve skeletal-muscle pain. Careful echocardiogram ruled out a structural heart disease, such as coarctation of the aorta. A gradient of 41 mmHg across the ductus was recorded. A cesarean section delivery was immediately undertaken. The 3.5 kg newborn delivered appeared to be in good health, with Apgar score of 8/9 at 1 and 5'. There were no signs of congestive heart failure and mild respiratory distress. An echocardiogram showed a dilated, well contractile right ventricle, with a pressure of 50 mmHg. DA was already closed. The fetal echocardiogram was the most relevant investigation in the decision-making process of this case treatment. Any different evaluation of this fetal heart, delaying the delivery would have very seriously compromised the survival of the fetus. Fetal echocardiography is the most important diagnostic tool in the evaluation of the fetal heart; non steroid antiinflammatory drugs to mother at term should be avoided or given with close echocardiographic assessment of DA patency.
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PMID:[Timely detection of premature closure of the ductus arteriosus in a full-term fetus. Important role of fetal echocardiography]. 1043 30

RSV is the most important respiratory pathogen in infants and young children. About 1% of primary RSV infections result in hospitalization. The virus is spread by large droplets of secretions or contact with contaminated secretions. Infants infected with RSV may demonstrate poor feeding, rhinorrhea, apnea, lethargy, wheezing, and respiratory distress. Diagnosis may be made by clinical signs and symptoms (especially those observed during epidemics), by chest radiographs showing hyperinflation, or by rapid antigen detection with immunofluorescence of nasopharyngeal aspirates. Risk factors for severe disease accompanied by complications include chronic heart disease, chronic lung disease, immunodeficiency, HIV, and prematurity. Immunity is incomplete and of short duration, and reinfection is common. Treatment remains supportive and consists of oxygen administration, hydration, and diligent monitoring. Use of corticosteroids, bronchodilators, antibiotics, and ribavirin is controversial and is dependent largely on physician preference. Use of ribavirin should be reserved for patients who have severe underlying conditions associated with increased mortality rates. Intravenous RSV Ig has been replaced by palivizumab, which is generally recommended for infants at high risk for severe RSV, including those with a history of prematurity and those with chronic lung disease.
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PMID:RSV infection in infants and young children. What's new in diagnosis, treatment, and prevention? 1060 68

In order to provide better understanding of the factors affecting the mortality of sick newborns in the Taipei metropolitan area, data of newborns admitted to the intensive care units (ICU) were analyzed retrospectively according to the hospital type of care. Fourteen of the 19 hospitals with an ICU admitting sick newborns joined the data collection: 3 were local hospitals, 7 were regional hospitals and 4 were medical centers. Perinatal and neonatal data of 1083 sick newborns were analyzed: 60% were premature newborns and 58% were male newborns. The maternal referral rate was 7.8% and the neonatal transport rate was 36.2%. Fifty-nine percent of very low birth-weight newborns and 66% of extremely low birth-weight (ELBW) newborns were admitted to the medical centers. The two most common illnesses were perinatal asphyxia and respiratory distress syndrome. About 40% needed assisted ventilation. There were higher incidence of maternal referral, fetal distress, resuscitation in the delivery room, perinatal asphyxia, and necrotizing enterocolitis; lower incidence of meconium aspiration syndrome, sepsis and pneumothorax in newborns admitted to the medical center than those newborns admitted to other hospitals. A total of 153 newborns (14%) died. The most common cause of death was sepsis (22.9%). Multivariate logistic regression analysis revealed that factors significantly related to the mortality were gestational age < 28 weeks, congenital anomaly, sepsis, resuscitation in the delivery room, neonatal transport, congenital heart disease, hospital type of care, ELBW, pneumothorax and high-risk pregnancy. The results of the study stress the importance of regionalization of perinatal and neonatal care, organization of neonatal transport system, newborn resuscitation training, infection control, and delicate ventilatory care in the further improvement of the outcome of sick newborns in the Taipei metropolitan area.
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PMID:Factors affecting the mortality of sick newborns admitted to intensive care units. 1091 May 91

Paralysis of the diaphragm may cause life-threatening respiratory distress in infants and young children because of paradoxical motion of the affected diaphragm and contralateral shift of the mediastinum during expiration. Phrenic nerve injury (PNI) may follow chest operations. 10 children with diaphragmatic paralysis and severe respiratory distress underwent plication of the diaphragm. Ages ranged from 14 days to 5 years. 9 had PNI after operations for congenital heart disease and 1 after resection of an intraspinal cervical lipoma. The right side was affected in 7, the left in 3. Indication for surgery was inability to wean from mechanical ventilation, which had ranged from 11 to 152 days (median 35). 8 underwent plication via a thoracic approach and 2 via an abdominal approach. There were no complications directly related to the operation. The interval from plication to weaning from mechanical ventilation ranged from 2 to 140 days (median 4). 1 patient died 2 hours after plication due to severe heart failure and 2 after prolonged hospitalization due to sepsis and multi-organ failure. 6 were extubated 2-8 days (median 4) after plication and 1 only after 40 days. Early diaphragmatic plication is simple and avoids more serious surgery. While effective in ventilator-dependent infants and young children, it should not be used in those with multi-organ failure. Early plication may prevent the complications of prolonged mechanical ventilation.
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PMID:[Plication of diaphragm for postoperative phrenic nerve injury in infants and young children]. 1095 18


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