NEONATOLOGY TODAY

News and Information for BC/BE Neonatologists and Perinatologists

Volume 3 / Issue 12 December 2008 Neonatal Cardiac Emergencies: Management Strategies IN THIS ISSUE By P. Syamasundar Rao, MD base status and treatment of metabolic aci- dosis with sodium bicarbonate (NaHCO3) Neonatal Cardiac and management of respiratory acidosis Emergencies: Management Strategies INTRODUCTION with suction, intubation, assisted ventilation by P. Syamasundar Rao, MD as deemed necessary, are important and Page 1 Emergencies of life-threatening nature involv- should be diligently undertaken in all pa- ing the cardiovascular system in the neonate tients. In most cyanotic defects FIO2 of Perspectives on Safety: are many and complex. Successful man- no more than 40% is necessary because of Identifying Adverse Events agement depends upon prompt and accurate fixed intracardiac shunting. In certain cya- Not Present on Admission: diagnosis of the problem in order to institute notic heart defects (CHDs), for example, Can We Do It?. Hypoplastic Left Heart Syndrome, 100% by James M. Naessens, ScD appropriate therapeutic measures and refer- FIO2 may be detrimental to the patient by Page 8 ral to a specialized treatment center, if nec- essary. These situations may manifest increasing the pulmonary flow at the ex- themselves as severe cyanosis, heart fail- pense of systemic perfusion. Specific meas- DEPARTMENTS ure, lethargy and lack of spontaneous ures depend on the diagnosis and will dis- movement or (Table I). The pur- cussed here-under. Medical News, Products and pose of this presentation is to draw attention Information to cardiac emergencies in neonates and to NEONATAL CYANOSIS Page 6 discuss their management. Cyanosis is an important manifestation of NEONATOLOGY TODAY GENERAL MANAGEMENT severe CHD in the neonate, as has been alluded to by a number of cardiologists [1-5]. Editorial and Subscription Offices 16 Cove Rd, Ste. 200 During the process of identification and Central cyanosis is manifested by bluish Westerly, RI 02891 USA work-up, prevention of hypothermia, mainte- discoloration of mucous membranes and is www.NeonatologyToday.net nance of neutral thermal environment, moni- generally more difficult to identify in the toring for and prompt treatment of hypogly- neonate than in older subjects. The ready availability of pulse oxymeters makes the Neonatology Today (NT) is a cemia and hypocalcaemia, monitoring acid- monthly newsletter for BC/BE neo- confirmation of cyanosis easier than obtain- natologists and perinatologists that ing blood gas analysis. The methods to dis- provides timely news and informa- tinguish cardiac from non-cardiac cyanosis tion regarding the care of newborns Table I. List of Cardiac Emergencies in and the diagnosis and treatment of and steps used to formulate a cardiac diag- premature and/or sick infants. the Neonate nosis are discussed elsewhere [5] and are © 2008 by Neonatology Today beyond the scope of this presentation, ex- ISSN: 1932-7129 (print); 1932- 1. Cyanosis in the newborn cept to state that evaluation of pulmonary 7137 (online). Published monthly. 2. Congestive heart failure blood flow by chest X-ray is useful in cate- All rights reserved. 3. Lethargy and lack of spontaneous gorization of CHD babies, especially prior to Statements or opinions expressed in movement echocardiographic and/or angiographic stud- Neonatology Today reflect the views ies. of the authors and sponsors, and 4. are not necessarily the views of Neonatology Today.

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Decreased Pulmonary Vascular Markings If the cause of cyanosis is secondary to pulmonary atresia with intact ventricular septum or critical pulmonary stenosis, transcatheter ra- Neonates with severe cyanosis and decreased pulmonary diofrequency perforation of the atretic pulmonary valve [8,13-15] or bal- vascular markings on chest roentgenogram are likely to have loon pulmonary valvuloplasty [16-20], respectively may be undertaken. severe right ventricular outflow tract obstruction and may have ductal dependant (Table II-A). Increased Pulmonary Vascular Markings The ductus may be kept open by an infusion of prostaglandin E1 (PGE1). Various cardiac defects with ductal-dependent Cyanotic neonates with increased pulmonary flow may have transpo- pulmonary blood flow in which prostaglandin is useful are sition of the great arteries, Hypoplastic Left Heart Syndrome, coarcta- listed in Table II-A. The current recommendations are for in- tion of the and multiple left-to-right shunts. fusion of PGE1 at a dose of 0.05 to 0.1 mcg/kg/min intrave- nously. Although PGE1 has been used in infants beyond the In infants with severe cyanosis and increased pulmonary blood flow first month of life, it is most likely to be effective the earlier in on chest X-ray, the cause of cyanosis is likely to be transposition of life it is begun. It appears that a small ductus can be dilated, the great arteries. Initially starting PGE1 to open the ductus to improve but an already closed ductus may be difficult to reopen. Side mixing may be undertaken followed by balloon atrial septostomy effects include apnea (10%), elevation of temperature (10%), [21,22]. Within the next few days arterial switch procedure [23] may be muscular twitching, and severe flushing. The side effects performed. have not posed substantial management problems; however, the infant should be watched for apnea. Once the O2 satura- Infants with mild cyanosis and increased pulmonary blood flow on chest tions improve, the PGE1 dose should be weaned down to X-ray are likely to have signs of congestive heart failure. The treatment 0.025 to 0.03 mcg/Kg/min; this is particularly useful in pre- of congestive heart failure, including administration of inotropic agents, venting apnea and need for endotrachial ventilation. The ma- diuretics and after-load reducing agents is similar to that of older chil- jor benefit of prostaglandin use lies in its keeping infants in a dren [24] and will not be discussed, except to state that the neonatal reasonable condition while the infant is being transferred to a myocardial development is incomplete [25], and that the myocardial tertiary care institution. Also, well-planned catheterization and response to pre-load and after-load manipulations and inotropic agents angiography, as well as palliative or corrective , can is suboptimal. In conditions in which perfusion to the body (Table II-B) is be performed with relative safety because of higher PO2 and ductal dependent, administration of PGE1 is necessary. The dosage and correction of metabolic acidosis. No more than 40% of hu- administration of PGE1 are the same as described above. Once the midified oxygen is necessary in infants with cyanotic congeni- infant is stabilized, the lesions require surgical intervention. tal heart disease since they have fixed intracardiac right to left shunt. Once the diagnosis is established by echo-Doppler Pulmonary Venous Congestion and/or studies, a permanent way to provide pulmonary blood flow should be considered. In pa- Majority of patients with severe pulmonary venous congestion on tients whose cardiac defect could not be corrected in the chest X-ray are likely to have infra-diaphragmatic type total anomalous neonatal period, a Blalock-Taussig shunt [6] is performed; pulmonary venous connection and require emergent surgical correc- most surgeons perform a modified Blalock-Taussig shunt [7] tion to include anastomosis of the common pulmonary with the using an interposition Gore-Tex graft between right or left left . subclavian arteries to the ipsilateral . An alternative approach is to keep the ductus open by placing a If the cause of cyanosis is persistent fetal circulation, it should be stent in it [8-11]. Based on our experience and that of others treated accordingly. Once the specific defect is diagnosed, the treat- [8-12], implantation of stent into the ductus is technically de- ment is based on the identified defect and is discussed in detail else- manding but a feasible procedure. Stenting the ductus arte- where [26]. riosus [8-12] is an attractive non-surgical option, but because of limited experience, it is not currently a first-line therapeutic CONGESTIVE HEART FAILURE option. Congestive heart failure in the neonate is usually associated with in- creased pulmonary blood flow and is more common with complex heart Table II. Ductal-dependent Cardiac Defects defects such as Swiss-cheese type of ventricular septal defect, double inlet left (single ventricle), double outlet right ventricle and tri- A. Ductal-dependent pulmonary flow cuspid atresia with a large ventricular septal defect, all without associ- • Pulmonary atresia or critical stenosis with intact ated pulmonary stenosis. Initially, aggressive anti-congestive measures ventricular septum should be instituted. If ductal dependent systemic circulation is present (Table II-B), PGE infusion should be started as detailed in the preced- • Pulmonary atresia with ventricular septal defect 1 ing sections. Because most of these defects can’t be corrected in the • Severe Tetralogy of Fallot neonatal period despite recent advances in open heart surgery, surgical • Tricuspid atresia constriction or banding of the pulmonary artery [27] is useful in this sub- • Complex cyanotic heart disease with pulmonary atresia group of patients. Banding not only improves congestive heart failure, but or severe stenosis also helps achieve normal pulmonary artery pressure so that bidirectional Glenn and Fontan procedures [28] can be safely performed later in the • Ebstein’s anomaly of the tricuspid valve subgroup of patients who have single ventricle physiology. If associated • Hypoplastic right ventricle aortic coarctation is present, the aortic obstruction must also be relieved.

B. Ductal-dependent systemic flow LETHARGY AND LACK OF SPONTANEOUS MOVEMENT • Hypoplastic Left Heart Syndrome Lethargy and lack of spontaneous movement are associated with sep- • Severe coarctation of the aorta sis in the newborn. It may also be seen in CHD babies who have severe • Interrupted aortic arch hypoxemia associated with severe obstruction to pulmonary blood flow

www.NeonatologyToday.net December 2008 4 NEONATOLOGY TODAY

(Table II-A), inadequate mixing in transposition of the great arteries with intact ventricular septum or poor systemic perfusion (Table II- B). Appropriate cultures and antibiotic treatment should be promptly instituted while investigating cardiac causes which may be ad- dressed as detailed in the two preceding sections.

ARRHYTHMIA

A number of arrhythmias may occur in the neonate and the most common rhythm disturbance, supra-ventricular tachycardia (SVT) will be discussed.

SVT is one of the most frequent symptomatic arrhythmias in the neonate. It may also occur in fetal life, causing fetal hydrops. The majority of these episodes are in neonates without any other as- sociated heart defects. The heart rate is very high in neonates (220 to 280 beats per minutes). The QRS complexes are narrow (Figure 1) although wider complexes may be seen when aberrant ventricular conduction is present. The presentation of the condi- tion may simply be an increased heart rate observation by the caregiver or parents, or more serious symptoms and signs of heart failure may be observed by the patient’s physician. Figure 1. Electrocardiogram of an infant with supraventricular tachycardia. Note the heart rate is approximately 260 beats per Management of Acute Episode minute and the QRS duration is very short and no definitive P waves were seen. In neonates with moderate to severe heart failure, hypotension, shock, pallor, or decreased level of consciousness (neonates may have only irritability, tachypnea, and poor feeding), syn- in the past, and is no longer the drug of choice because of delay chronized direct current (DC) with 0.5 to 2 Watt- in achieving conversion, narrow range of therapeutic to toxic second/kg should be attempted [29]. The DC conversion should effect and concern of producing more serious arrhythmia if Wolf- be synchronized to the peak of R wave, avoiding the vulnerable Parkinson-White (WPW) Syndrome is present. period of re-polarization. Adequate sedation should precede cardioversion. An alternative treatment is intravenous adeno- Prevention of Recurrence sine; this is not well studied for this purpose, however. Continu- ous ECG monitoring during the conversion is mandatory. Trans- In neonates and infants, oral digoxin (10 mcg/Kg/day in two di- venous or esophageal overdrive pacing with a pacing rate at 10- vided doses) for 6-12 months may be effective in preventing 15% shorter than SVT cycle length may be effective. The latter, recurrence of SVT. In the presence of WPW syndrome, digoxin however, requires pediatric or pediatric electrophysi- should not be used. Propranolol 1-4 mg/kg/day by mouth in 3 to ology expertise and such pacing is rarely required in the neo- 4 divided doses may be given in the presence of WPW Syn- nate. drome. Occasionally, both drugs may be required to prevent recurrence. Some authorities suggest that the effectiveness of If the neonate is in mild or no heart failure, simulation of diving these drugs in preventing recurrences is no better than no reflex by sudden or unexpected placement of ice bag (crushed treatment. ice and water in glove) or cold, wet cloth on face for 15 seconds may be effective. Rectal stimulation by using a rectal thermome- Flecanide, sotalol and amiodarone either alone or in combination, ter is another way of eliciting vagal stimulation (carotid massage have been used with varying degrees of efficacy and may be tried or eye-ball massage is not recommended in the neonate). If if recurrences are problematic despite treatment with digoxin and these maneuvers are not successful in averting the SVT, adeno- propranolol. is rarely, if ever, necessary sine 100 mcg/kg by rapid IV push may be used [30.31]. If not in the neonate. effective, increase doses by increments of 50 mcg/kg until con- version (maximum dose of 250 to 350 mcg/kg). Verapamil REFERENCES 0.1-0.2 mg/kg by very slow intravenous injection may be given in children and is not recommended in infants less than 1 year. If 1. Lees MH. Cyanosis of the newborn infant: Recognition and all the above fail, DC cardioversion or esophageal overdrive clinical management. J Pediat 1970; 77: 484-98. should be instituted. Digoxin was the most frequently used drug

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www.NeonatologyToday.net NEONATOLOGY TODAY 5 December 2008

2. McNamara DG. Management of congenital heart disease: 21. Rashkind WJ, Miller WW. Creation of an Role of the pediatrician and recommendations to pediatric without thoracotomy. J Am Med Assoc 1966; 196: 991-2. training programs. Pediat Clinics North Am 1971; 18: 1191- 22. Rao PS. Role of Interventional Cardiology In Neonates: Part I. 1205. Non-Surgical Atrial Septostomy. Neonatology Today 2007; 2(9) 3. Rao PS and Strong WB. Early Identification of the Neonate :9-14, with Heart Disease. J Med Assoc Georgia 1974: 63: 430-3. 23. Jatene AD, Fontes VF, Paulista PP, et al. Anatomic correction 4. Rowe RD, Freedom RM, Mehrizi A. The neonate with con- of transposition of the great vessels. J Thorac Cardiovasc Surg genital heart disease. W.B. Saunders Co, Philadelphia 1981. 1976; 72: 364-70. 5. Rao PS. An approach to the diagnosis of cyanotic neonate for 24. Rao PS. Congenital heart disease. In: Rakel RE (Ed), Conn’s the primary care provider. Neonatology Today 2007; 2: 1-7. Current Therapy, 1989. Philadelphia, WB Saunders Co., 6. Blalock A, Taussig HB. The surgical treatment of malforma- 1989. pp.201-13. tions of the heart in which there is pulmonary stenosis or pul- 25. Rao PS. Fetal and neonatal circulations. In: Kambam J (Ed), monary atresia. J Am Med Assoc 1945; 128: 189-94. Cardiac Anesthesia for Infants and Children. St. Louis, Mosby, 7. de Leval MR, McKay R, Jones M, et al. Modified Blalock- 1993, pp. 10-19. Taussig shunt. Use of subclavian artery orifice as flow regula- 26. Rao PS. Principles of Management of the Neonate with Con- tor in prosthetic systemic-pulmonary artery shunts. J Thorac genital Heart Disease Neonatology Today 2007; 2(8) :1-10. Cardiovasc Surg 1981; 81: 112-9. 27. Muller WH, Jr, Damman JF, Jr. The treatment of certain con- 8. Gibbs JL, Rothman MT, Rees MR, et al. Stenting of the arterial genital malformations of the heart by the creation of pulmonary duct: a new approach to palliation for pulmonary atresia. Br stenosis to reduce and excessive Heart J 1992; 67: 240-5. pulmonary blood flow: A preliminary report. Surg Gynecol Ob- 9. Siblini G, Rao PS, Singh GK, et al. Transcatheter management stet 1952; 95: 213-9. of neonates with pulmonary atresia and intact ventricular sep- 28. Fontan F, Baudet E. Surgical repair of tricuspid atresia. Thorax tum. Cathet Cardiovasc Diagn 1997; 42: 395-402. 1971; 26: 240-8. 10. Schneider M, Zartner P, Sidiropoulos A, et al. Stent implanta- 29. Kugler, JD, Danford, DA. Management of infants, children, and tion of the arterial duct in newborns with duct-dependent circu- adolescents with paroxysmal supraventricular tachycardia. J lation. Eur Heart J 1998; 19: 1401-9. Pediatr 1996; 129: 324-38. 11. Alwi M, Choo KK, Latiff HA, et al. Initial results and medium- 30. Muller, G, Deal, BJ, Benson, DW Jr. "Vagal maneuvers" and term follow-up of stent implantation of patent ductus arteriosus adenosine for termination of atrioventricular reentrant tachy- in duct-dependent pulmonary circulation. J Am Coll Cardiol. cardia. Am J Cardiol 1994; 74: 500-3. 2004; 44: 438-45. 31. Overholt, ED, Rheuban, KS, Gutgesell, HP, Lerman, BB. Use- 12. Gibbs JL, Orhan U, Blackburn MEC, et al. Fate of stented arte- fulness of adenosine for arrhythmias in infants and children. rial duct. Circulation 1999; 99: 2621-5. Am J Cardiol 1988; 61: 336-40. 13. Latson LA. Nonsurgical treatment of a neonate with pulmo- nary atresia and intact ventricular septum by transcatheter NT puncture and balloon dilatation of the atretic valve membrane. Am J Cardiol 1991; 68: 277-9. 14. Rosenthal E, Qureshi SA, Tynan M, et al. Radiofrequency- assisted balloon dilatation in patients with pulmonary valve atresia and intact ventricular septum. Br Heart J 1993; 69: 347-51. 15. Justo RN, Nykanen DG, Williams WG, et al. Transcatheter perforation of the right ventricular outflow tract as initial therapy for pulmonary valve atresia and intact ventricular septum in the newborn. Cathet Cardiovasc Diagn 1997; 40: 408-13. 16. Rao PS and Brais M. Balloon pulmonary valvuloplasty for con- genital cyanotic heart defects. Am Heart J 1988; 115: 1105-10. 17. Zeevi B, Keane JF, Fellows KE, et al. Balloon dilatation of P. Syamasundar Rao, MD critical pulmonary stenosis in the first week of life. J Am Coll Professor and Director Cardiol 1988; 11: 821-9. Division of Pediatric Cardiology 18. Rao PS. Technique of balloon pulmonary valvuloplasty in the UT-Houston Medical School neonate (Letter). J Am Coll Cardiol 1994; 23: 1735. 6431 Fannin, Suite 3.132 19. Rao PS. Balloon valvuloplasty in the neonate with critical Houston, TX 77030 USA pulmonary stenosis (Editorial). J Am Coll Cardiol 1996; 27: Phone: 713-500-5738; Fax: 713-500-5751 479-80. 20. Jureidini SB, Rao PS. Critical pulmonary stenosis in the neo- E-mail: [email protected] nate: role of transcatheter management. J Invasive Cardiol 1996; 8: 326-31.

www.NeonatologyToday.net December 2008 6 NEONATOLOGY TODAY

Medical News, Products and Information

Mattel Children's Hospital UCLA Launches Program in collaboration with industry and enable the rapid commercializa- Nanopediatrics tion of discoveries in nanosystems.

Newswise - Mattel Children's Hospital UCLA announced the For additional information, visit: www.nanopediatrics.ucla.edu. launch of the Mattel UCLA NanoPediatrics Program, which will explore the future of personalized medicine for children, includ- ing the opportunities and risks involved. The program is one of Increased Rate of Hemangiomas Linked to Rise in Number the world's first dedicated solely to nanomedicine and pediatric of Low Birth-Weight Infants in US patients. Newswise - Low birth weight is the most significant factor for the "Why develop a nanopediatrics program? Because children are development of infantile hemangiomas, a common birthmark, not small adults," said Dr. Edward McCabe, Physician-in-Chief according to a new study by researchers at The Medical College of Mattel Children's Hospital and founding director of the new of Wisconsin and Children's Research Institute. program. "We know that drugs affect children - they metabolize, excrete and may even utilize, developmentally, specific recep- The study, led by Beth Drolet, MD, Professor of Dermatology tors - differently than adults. and Pediatrics at the Medical College and medical director of pediatricdermatology and birthmarks and vascular anomalies "Unless children are included as a research priority for the appli- clinic at Children's Hospital of Wisconsin, was published in the cation of nanotechnology, then we will simply be applying ap- November 2008 issue of The Journal of Pediatrics. proaches developed for adults. This flawed strategy will place children at risk, as opposed to a program in which children will "Hemangiomas are benign tumors composed of blood vessels. be the focus from the outset." Our institution has seen a dramatic increase in the number of infants Nanotechnology involves manipulating atoms and molecules to presenting for care with hemangiomas. We believe the results of create tiny devices, smaller than one-thousandth the diameter of this study provide an explanation for this emerging pediatric a human hair (a nanometer is one-billionth of a meter). It is an- health issue," says Dr. Drolet. ticipated that nanomedicine, fueled by nanotechnology, will en- able more personalized medical care that will be both predictive While factors such as being female, Caucasian and premature and preventive. birth have been previously identified as risk factors for heman- giomas, Dr. Drolet's study found that low birth weight was the While considerable attention has been paid to nanomedicine, most statistically significant risk factor. UCLA's nanopediatrics program, initially organized in May 2008, may be the first initiative to examine the promises and risks of "For every 1.1 pound decrease in birth weight, the risk of he- nanodiagnostics and nanotherapeutics for children in a formal mangioma increased by nine-fold," says Dr. Drolet. and organized manner. Recently, there has been an increase in the US of infants born Created thanks to a generous $1.8 million gift from the Mattel under 5.5 pounds. In 2005, 8.2% of infants born in the US Children's Foundation, the program will support a nanopediatrics weighed less than 5.5 pounds. This is the highest percentage research core and pilot funding for projects that will potentially recorded since 1968 and is higher than the rate in most industri- enable investigators to obtain grants from the National Institutes alized countries. of Health. Additionally, a dramatic increase in low birth weight has been "The Mattel Children's Foundation is excited to support this found in white, non-Hispanic infants. Low birth weight has in- groundbreaking program in nanopediatrics, which can potentially creased 38% since 1990 in this group. revolutionize the research and treatment of illnesses that affect young patients," said Kevin Farr, Chairman of the foundation "This study reaffirms several known risk factors for infantile he- and Chief Financial Officer of Mattel Inc. "Our philanthropic vi- mangiomas, specifically: female gender, white, non-Hispanic sion is to make a meaningful difference, one child at a time, and race/ethnicity, and prematurity," says Dr. Drolet. "But the link to we believe that the nanopediatrics program at Mattel Children's low birth weight may explain why physicians believe more in- Hospital UCLA will bring new technologies and treatments to fants are developing hemangiomas. Based on low birth weight better the lives of children battling for their health." statistics, we estimate that the incidence of infantile hemangio- mas has increased by 40% in the last 20 years." Projects currently underway at UCLA include the development and application of nanodiagnostic tools such as DNA-based The researchers compared 420 children who had been diag- newborn screening tests for genetic abnormalities, the develop- nosed with infantile hemangiomas at Children's Hospital of Wis- ment of a new generation of nanodevices for the treatment of consin and the University of California - San Francisco Medical children with genetic diseases and cancer, and the investigation Center (UCSF), with 353 children less than two years old who of the use of nanoparticles for diagnostic imaging both during had been diagnosed with skin anomalies other than infantile pregnancy and after birth. hemangioma.

The Mattel UCLA NanoPediatrics Program will partner with the Dr. Drolet and co-investigator, Dr. Ilona Frieden, Professor of California NanoSystems Institute (CNSI) at UCLA, an integrated Dermatology and Pediatrics at UCSF, formed a 10-member re- research center established in 2000, to encourage university

www.NeonatologyToday.net NEONATOLOGY TODAY 7 December 2008 search consortium to better study ways to prevent and treat in- tient monitors. An optional fantile hemangiomas. camera also allows the recording and display of Earlier studies by the research consortium identified other risk patient video. factors for developing hemangiomas, including increased ma- ternal age, maternal history of infertility, and assisted reproduc- The CNS Monitor can com- tive technologies. Children born to women who had experienced pute and display amplitude- a miscarriage are also more likely to develop hemangiomas. integrated EEG (aEEG), as Additionally, 33% of infants with hemangiomas had the disorder well as other specialized in their family histories. EEG metrics including Spectral Edge Frequency, While hemangiomas are amongst the most common birthmarks, Inter-Burst Interval, Percent their cause is not known. Infantile hemangiomas are not visible Suppression, Percent at birth, but become evident within the first few weeks of life. Asymmetry, and frequency Because of this, they are less likely to be recorded in typical band power percentages. birth defect registries. Hemangiomas may result in permanent Multiple display types and scarring or other medical issues that require treatment. parameters can be com- bined onto one screen, "The finding that a significantly higher percentage of children enabling the comparison of with infantile hemangiomas had a positive family history sug- EEG parameters with a gests at least some genetic predisposition," says Dr. Drolet. patient’s vital signs and other measurements. All There are currently no FDA-approved medical therapies for the collected data is time- treatment of infantile hemangiomas. Most treatments are limited, synchronized, and can be due to increasing the potential risk of scarring. archived to a CD, DVD, USB drive, or to a network "We urgently need further research to evaluate existing medica- location for later review. tions so that more evidence-based approaches to management can be established," says Dr. Drolet. The user interface and monitoring features are "Our study also underscores the need for continuing education similar to a bedside patient of providers caring for children in distinguishing benign heman- monitor, making the CNS giomas from those with the greatest potential for complications Monitor easy to use by clinical personnel. The use of monitoring and need for treatment." “Protocols” within the system help to step the user through the monitoring process, and also enable the customization of data The study was funded by the Dermatology Foundation, The displays and recorded parameters. Context-sensitive reference American Skin Association, and Children's Research Institute. information about device setup and operation may be accessed for assistance during the monitoring session.

Day One Medical Announces Launch of Advanced Brain By using the CNS Monitor, physicians and clinical staff will be Monitor for Critical Care able to simultaneously view, analyze, and record EEG (including video) along with vital signs measurements in order to assess Day One Medical has announced the release of its first product the status of a patient’s brain function. offering, The Component Neuromonitoring SystemTM (CNS Monitor), an easy-to-use neurological monitoring system with The CNS Monitor was developed by Moberg Research, Inc. and advanced functionality. The CNS Monitor has received 510(k) will be sold for neonatal care applications through Day One clearance from the US Food and Drug Administration (FDA), Medical, LLC. Moberg Research performs research, product and is available for purchase. Day One Medical will be featuring development, and services in the areas of neurological monitor- the CNS Monitor at the upcoming International Conference on ing, informatics, and medical education. Day One Medical pro- Brain Monitoring & Neuroprotection in the Newborn in Orlando vides products for neonatal care and brain assessment and is on February 20 – 22, 1009. an affiliate of Moberg Research, Inc.

The CNS Monitor is a portable neurological data collection For more information, contact: Damon Lees, Day One Medical, system. It can perform simplified EEG monitoring using just LLC, 224 S. Maple Way, Ambler, PA 19002 USA; Tel: (215) 283- one or two channels, or can be used for full-array EEG moni- 0860. www.dayonemedical.com. toring with up to 16 electrodes. It can collect, store, and dis- play vital signs and other measurements from a variety of pa-

             

          

www.NeonatologyToday.net December 2008 8 NEONATOLOGY TODAY

Perspectives on Safety: Identifying Adverse Events Not Present on Admission: Can We Do It?

the time of admission is critical. This article will explore how well By James M. Naessens, ScD our present instruments perform in this key area.

Will POA Coding Enable the Identification of Adverse Events This article was originally published in AHRQ WebM&M (Morbid- Through Billing Data? ity and Mortality Rounds on the Web) [http://webmm.ahrq.gov] , and is reprinted here with permission. Citation: Naessens JM. Even with the new POA codes, a number of issues must still be Identifying adverse events not present on admission: can we do considered: it [Perspective]? AHRQ WebM&M [serial online]. October 2008. Available at: Variation in POA Coding http://webmm.ahrq.gov/perspective.aspx?perspectiveID=66.© 2008 Agency for Healthcare Research and Quality (AHRQ). All Several studies have shown that identifying whether a condition rights reserved.” was present on admission is not an exact science. In our early work in assessing inter-rater reliability of determining the timing of Interest is growing in the use of existing data sources to identify an illness or complication based on blinded review of the medical opportunities to improve the delivery and safety of medical care, record, we found that agreement differed across disease type. to measure and compare quality and patient safety, and even to There was more agreement on the timing of myocardial infarct, change provider incentives through pay for performance initia- stroke, and pulmonary embolism (kappa>0.8) than on the timing of tives. The Agency for Healthcare Research and Quality's (AHRQ) renal failure, decubitus ulcer, and pneumonia (kappa from 0.58 to Patient Safety Indicators (PSIs) (based on ICD-9-CM diagnosis 0.73) [11]. A Canadian study found agreement between routinely codes from hospital billing data) were developed to screen for abstracted data and chart review to be poor (kappa<0.5) for seven potential complications and medical mishaps [1,2]. Groups rang- conditions, moderate (0.5

Given the increasing focus on hospital quality measurement, ac- Variation is not only evident across institutions on POA coding; curately identifying adverse events and comorbidities present at there are substantial differences in diagnosis coding practices. Romano and colleagues [15] found that half of the difference in

Type to enter text The 4th International Conference on Neonatal Brain Monitoring and Neuroprotection in the Newborn February 20-22, 2009

Disney’s Yacht and Beach Club, Lake Buena Vista, FL www.cme.hsc.usf.edu/brain09

www.NeonatologyToday.net NEONATOLOGY TODAY 9 December 2008 postoperative (after back surgery) complication rates observed Multiple studies [7,13], including our examination of hospitaliza- across hospitals was attributed to variations in the collection, cod- tions in 2005 [6], have shown that the vast majority of patients ing, and reporting of diagnosis codes. Furthermore, the study with diagnoses coded as not present on admission appear to found that hospitals with higher-than-expected rates of complica- have relatively minor problems with no diagnosis-related group tions reported twice as thoroughly as hospitals with fewer compli- (DRG) or severity changes. While efforts should be made to re- cations than expected, clear evidence of a reporting bias. duce all adverse events, the severity of the problem should be considered for public reporting or pay for performance. Other limitations in the use of administrative diagnostic data in- clude the incomplete collection of conditions due to restrictions on Interpretation: Adverse Event Versus Medical Error the number of secondary diagnosis fields [1]. In our experience with Minnesota's mandatory reporting of the National Quality Fo- How will the identification of adverse events be interpreted? Not all rum list of serious adverse events, we reported "unstageable" adverse events are preventable. In their assessment of the pediat- pressure ulcers in addition to stage 3 or 4 ulcers acquired after ric PSIs, Scanlon and colleagues [17] classified each event into admission. However, only 25% of the last 16 reported patients three classes: preventable, nonpreventable, and uncertain. They had an ICD-9-CM secondary diagnosis code of a pressure ulcer found that the extent of cases that were clearly "nonpreventable" (codes 707.00–707.09). These patients typically have multiple ranged from about 20%–80%, and clear preventability never ex- morbidities and long hospitalizations. Our administrative system ceeded 52%. Studies have also suggested that sicker patients are has a limitation of 15 diagnoses, and it is possible that the decubi- at higher risk of adverse events. We found higher rates of hospital- tus ulcer was identified by the coder, but was not placed high acquired conditions among hospital transfers and among enough on the list of possible diagnoses to be captured in our physician-referred versus self-referred or primary care patients [6]. repository. Current risk adjustment methods for PSIs may not be adequate for appropriate interpretation. Hughes [18] calls for efforts to separate Limitations in ICD-9-CM Coding System "preventable" adverse events from events that result from underly- ing disease factors or are expected sequelae of treatment. It is There are issues about the granularity and coverage of our current unlikely that this can be done with only administrative data. In our coding system; hence the plans to eventually shift to ICD-10. In own review of PSIs, we have seen substantial differences of opin- their study of PSIs in the Veterans Health Administration system, ions depending on the background and experience of the re- Rosen and colleagues [16] noted that adverse events from surgery viewer. are more amenable to ICD-9-CM coding than other types of events. Incentives—DRG Creep in Reverse? Differentiation of the Trivial from the Catastrophic Based on the experience with the introduction of DRGs and the The presence of a hospital-acquired condition provides little in- proliferation of software to help "optimize" the coding of hospital formation about the seriousness of an adverse event. Even after discharges, coding and reporting practices for conditions not pre- eliminating cases with POA conditions, review of cases coded sent on admission can be expected to change. As Iezzoni [14] with hemorrhage and/or hematoma or cases coded with acciden- points out, an unintended consequence is that tying penalties in tal puncture and laceration identified a range of conditions from payment to the presence of a diagnosis code creates financial blood use within expected norms and incidental lysis of adhesions incentives to underreport those codes. (both relatively trivial procedures) to life-threatening situations. Summary

Echoing others, we must proceed with caution [6,7,14,17]. It is “Interest is growing in the use of likely that POA coding will ultimately enhance the value of admin- istrative data in identifying hospital adverse events, but not with- existing data sources to identify out further review and refinement. Today, however, the variability of thoroughness of reporting and accuracy of coding across insti- opportunities to improve the delivery tutions, combined with the low percentage of hospital-acquired and safety of medical care, to measure conditions deemed "preventable," still limit the use of diagnoses from billing data as a source of quality measurement for public and compare quality and patient safety, reporting and pay for performance. and even to change provider incentives Acknowledgments through pay for performance The author thanks Monica Van Such for editorial suggestions, and initiatives.” Sara Hobbs Kohrt for her manuscript preparation support.

Reach BC / BE Neonatologists and Perinatologists

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www.NeonatologyToday.net December 2008 10 . NEONATOLOGY TODAY . © 2008 by Neonatology Today References indicators for flagging complications in ISSN: 1932-7129 (print); 1932-7137 (online). administrative data. J Clin Epidemiol. Published monthly. All rights reserved. 1. Zhan C, Miller MR. Administrative data 2004;57:366-372. Publishing Management based patient safety research: a criti- 13. Zhan C, Elixhauser A, Friedman B, Tony Carlson, Founder & Editor cal review. Qual Safe Health Care. Houchens R, Chiang YP. Modifying [email protected] 2003;12:ii58-ii63. DRG-PPS to include only diagnoses Richard Koulbanis, Publisher & Editor-in-Chief 2. Patient Safety Indicators Overview. present on admission: financial impli- [email protected] Rockville, MD: AHRQ Quality Indicators, cations and challenges. Med Care. John W. Moore, MD, MPH, Medical Editor/ Agency for Healthcare Research and 2007;45:288-291. Editorial Board Quality; February 2006. Available at: 14. Iezzoni LI. Finally present on admis- [email protected] http://www.qualityindicators.ahrq.gov/ sion but needs attention. Med Care. Editorial Board psi_overview.htm. 2007;45:280-282. Dilip R. Bhatt, MD 3. Barron WM, Krsek C, Weber D, 15. Romano PS, Chan BK, Schembri ME, Barry D. Chandler, MD Cerese J. Critical success factors for Rainwater JA. Can administrative data Anthony C. Chang, MD performance improvement programs. be used to compare postoperative K. K. Diwakar, MD Jt Comm J Qual Patient Saf. complication rates across hospitals? Philippe S. Friedlich, MD 2005;31:220-226. Med Care. 2002;40:856-867. Lucky Jain, MD 4. Iezzoni LI. Risk Adjustment for Meas- 16. Rosen AK, Rivard P, Zhao S, et al. Patrick McNamara, MD uring Health Care Outcomes. Ann Evaluating the patient safety indica- David A. Munson, MD Arbor, MI: Health Administration tors: how well do they perform on Vet- Michael A. Posencheg, MD DeWayne Pursley, MD, MPH Press; 1994. ISBN: 156793207X. erans Health Administration data? Joseph Schulman, MD, MS 5. Naessens JM, Huschka TR. Distin- Med Care. 2005;43:873-884. Alan R. Spitzer, MD guishing hospital complications of care 17. Scanlon MC, Harris JM Jr, Levy F, Gautham Suresh, MD from pre-existing conditions. Int J Qual Sedman A. Evaluation of the agency Leonard E. Weisman, MD Health Care. 2004;16:i27-i35. for healthcare research and quality Stephen Welty, MD 6. Naessens JM, Campbell CR, Berg B, pediatric quality indicators. Pediatrics. Williams AR, Culbertson R. Impact of 2008;121:e1723-e1731. FREE Subscription - Qualified Professionals diagnosis-timing indicators on meas- 18. Hughes JS, Averill RF, Goldfield NI, et Neonatology Today is available free to quali- ures of safety, comorbidity, and case al. Identifying potentially preventable fied medical professionals worldwide in neo- natology and perinatology. International edi- mix groupings from administrative complications using a present on ad- tions available in electronic PDF file only; data sources. Med Care. mission indicator. Health Care Financ North American edition available in print. 2007;45:781-788. Rev. 2006;27:63-82. Send an email to: [email protected]. 7. Bahl V, Thompson MA, Kau TY, Hu Include your name, title(s), organization, ad- HM, Campbell DA Jr. Do the AHRQ NT dress, phone, fax and email. patient safety indicators flag conditions that are present at the time of hospital Contacts and Other Information admission? Med Care. For detailed information on author submis- 2008;46:516-522. sion, sponsorships, editorial, production and sales contact, send an email to 8. Coffey R, Milenkovic M, Andrews RM. [email protected]. The Case for the Present-on-Admission (POA) Indicator. Rockville, MD: Agency To contact an Editorial Board member, send for Healthcare Research and Quality; an email to: [email protected] putting 2006. HCUP Methods Series Report the Board member’s name on the subject line No. 2006-01. Available at: and the message in the body of the email. We http://www.hcup-us.ahrq.gov/reports/ will forward your email to the appropriate person. 2006_1.pdf. James M. Naessens, ScD 9. Present on Admission (POA) Indicator Sponsorships and Recruitment Advertising Assistant Professor For information on sponsorships or recruitment Reporting by Acute Inpatient Prospec- Health Care Policy & Research advertising call Tony Carlson at 301.279.2005 tive Payment System (IPPS) Hospi- Pavilion 3 or send an email to [email protected]. tals: Present on Admission (POA) Mayo Clinic Indicator Reporting and Hospital- Rochester, MN 55905 Meetings, Conferences and Symposiums Acquired Conditions (HAC). Baltimore, If you have a symposium, meeting or confer- MD: Center for Medicare & Medicaid [email protected] ence, and would like to have it listed in Neo- Services; 2007. Available at: natology Today, send an email to: http://www.cms.hhs.gov/HospitalAcq [email protected]. Include the meet- Cond/Downloads/poa_fact_sheet.pdf ing name, dates, location, URL and contact name. 10. The Leapfrog Hospital Survey. Leap- Usage of Probiotics in the NICU Survey frog Group Web site. Available at: Corporate Offices https://leapfrog.medstat.com/(S(lqmy Neonatal nurse practitioner students 9008 Copenhaver Drive, Ste. M sk3rvjx41055ps15f055))/index.aspx. at Creighton University in Omaha, Potomac, MD 20854 USA 11. Naessens JM, Brennan MD, Boberg Nebraska, are conducting a survey Tel:+1.301.279.2005; Fax: +1.240.465.0692 CJ, et al. Acquired conditions: an regarding the Usage of Probiotics in improvement to hospital discharge the NICU for their graduate research Editorial and Subscription Offices abstracts. Qual Assur Health Care. project. They would greatly appreciate 16 Cove Road, Ste. 200 1991;3:257-262. your participation in the survey - Westerly, RI 02891 USA 12. Quan H, Parsons GA, Ghali WA. 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