thANK U FR OPENING THIS DISCUSSION..YOU HAVE SEEN THE EXAMPLES OF IMROVISED CARE AND SURVIVAL IN OUR NICU..BUT THESE EXAMPLES NEEDS BAK UP DATA TO PROVE SO THAT THESE OUTCOMES CAN BE GENERALISE TO ALL nicu ADMISSIONS, BEFORE BEGINNING THE BIOSTATS LETS US FOCUS ON THE PORPOSE, AND THE PORPOSE IS A PROBLEM OUR COUNTRY FACING FOR MORE THAN A DECADE AND EVEN BEFORE. ON MY EXTREME RIGHT IS A DATA FROM NFHS 3 SHOWING VARIOUS MORTALITY INDICES IN INDIA, THE GREEN ONE IS U5 MORTALITY DEFINED AS A PROBABILITY OF U5 CHILD DYING IN GIVEN YEAR PER 1000 LIVE BIRTHS, IT IS SAID THAT U5 MORTALITY IS TOP MOARTALITY INDICATORS OF ALL AVAILABLE INDICES, MDG HAS CLEARCUT cut offs REGARDING U5M...OUR COUNTRY IS ALSO SIGNATURI AT INTERNATIONAL SUMMIT FOR MDG AND LOOK AT THE FIGURE, AS FOR AS OUR STATE IS CONCERNED OUR STATE IS AMONG 3 TOPPERS..AS I SAID GROSS DEVELOPMENT OF COUNTRY IS REFLECTED BY U5 MORTALITY. IF U SEE THE BAR DIAGRAM MAJOR CHUNK IS CONTRUBUTED BY NNM ALTHOUGH IT SEEMS TO BE INFANT MORT, THE MAJOR PART OF IT IS OCCUPIED BY NMR
STATS IS BORING THAT’S A COMMON CONCEPT , WE ALWAYS INTEND AND BELIEVE IN IMPROVISING BUT WE NEED TO KNOW WHETHER WE ARE ON RIGHT TRACK, WHETHER WE ARE REALLY IMPROVING OR JUST A FALSE SENSE THAT YES WE DID THIS, WE SAVED XYZ AND MOST IMORTANTLY THESE THINGS CANNOT never BE GENERALISED… BIOSTATS GIVES US OPPORTUNITY TO GO BAK IN THE PAST, HELP US THINK & REALISE WAT MISTAKES WE MADE, AND WHAT IS TO BE DONE FOR THESE. THE SOLE PORPOSE OF THIS PPT IS TO PRESENT IN FRONT OF U, THE CHANGES WE GONE THORUGH LAST 3 YEARS SINCE THE UNIT INCHRAGE TAKEN OVER THE ADMINISTRATION AT OUR NICU..ITS WITH HER EFFORT WE ARE ABLE TO KEEP EXACT DATA OF ALL OUR ADMISSIONS AND ANALYSE THE SAME FOR OUR AND COMMUNITY BENEFIT
Coming over to the vital parameters, Total live births, deaths of neonate and still birth, although the last one iS out of our area. In yeear 2012 we had 4100 live birth out of which we had 34 deaths,, just to mention neonatal death constitute of both early as well late nn deaths, the early deaths whithin 7 days and late from 7 to 28 days of life.. the most notorious are early nn deaths which constitute 90% burden out of wich most occur on day1…out of our 34 babies I hardly remember a neonate dying after 7 days of life IN OUR ICU LAST year ….the imp in knowing this is a potential to survive…the causes wich hit in early NN period are grosllymodifiAble and that’s where comes the opportunity to modify the death statastics. …will be further elaborating the importence of these in last few slides
This slide shows few success stories ofvery sick neonates in our icu…PREVIOUS slideS presented by shantanu depictshow we mastered essential new born care but at the same time, advance strategies were given equaLlmportencE AND THE RESULTS ARE HERENEONATAL VENTILATION IS COMPLEX AREA…NEEDS UNDERSTANDINg OF LOT MANY THINGS OTHER THAN just BASICS…JUST KNOWING THE SETTINGS DOES NOT SUFFICE BUT TAKING THE WHOLESOME CONTROLL OVER NEONATES PYSIOLOGY IS IMP. IN YEAR 2012 WE CONTD TO ADAPT NEWER VENTILATORY PROTOCOLS..WE GOT OUR OWN NICU BOOKLET FOR PRESSURE VOLUME LOOPS SO THAT ANYBODY AT ANY TIME CAN TROUBLESHOOT THE VENT.. THE YEAR STARTED WITH A BIGGEST SUCCESS OF BHUMI, all must have read in news papare , JUST 800 GRMS BABY 28 WEEKS CAN BE CALLED ABORTUS AS PER PREV DEFINITION. AND NOW SHE 1 YEAR OLD WITH NORMAL DEVELOPMENT STILL IN OUR FOLLOW UP., VERY HEALTHY AND NOBODY CAN EVEN IDENTIFY AMONG OTHER BABIES.
IN COMING SLIDES I WILL BE COMPARING THE PREVIOUS DATA FROM YR 2009 10 AND 11 WITH DATA SHOWN IN LAST 6 SLIDES,,,THE FIRST ONE IS NUMBER OF LIVE BIRTHS …3834 LIVE BIRTHS AS AGAINST 4100 IN 2012…MERE INCREMENT OF OUR YEARLY ADMISSIONS.
Lets see the male to feamle ratio…where in year 2009 we had 881 female for 1000 males in year 2012 we had 995 for 1000 males, nrhm cg pip 2011-12 data shows ratio of 990 females for 1000 males which exactly matches with ours….In india we had 989 for 1000 malesThe gap seems to be getting filled in year 2012 NRHM CG PIP 2011-12
COMING OVER to The neonatal m r , its not just a index but represent the overall health status of a institute its state and country. it not only represent overall status of maternal and neonatal care of a place but also economic growth and well beingIN YEAR 2012 WE HAD 34 DEATH AS AGAINST 170 DEATHS in 2009….. If u see the live birth in both these year we had more babies in 2012 and less deaths.If u see the linear graph at bottom the linear decrement in nmr from year 2010 onward and most imortantly its not a one point achievement but sustained over time as u ll see in next slides
Very low birth weght defined as less than 1500 grams… A second most common cause of nn mortality whatever be the cause may it be prematurity or growth failure, we at nicu constantly imrovised the survival, and the basic startegies were Again not very high figh but common things in pure form, as already discussed by shantanu…dedicated enbc, fedding asepsis…not for name sake but in true form.
substitution, of better modalities rather than being afraid of new thing, was one of major milestine in nicu, we replaced mach vent with cpap, it was not decrease in interventions, but justifiable decrease in mech vent, we sterted supporting babies with cpap even at o min of life, a very early support which decreased need for mech vent. Another big prob in neonate was establishmnet of iv access in fact if u ask me intubating is damn easire than putting angiocath, in previous year we use to use uvcfollwed by femoarl line, In recent years we adapted a substitution the picc, picc is very fragile catheter even not visible if see from a distance, a difficult procedure skill wise, but now at our icu we establised central access exclusively widpicc, if u serach databases the evidence has proven the incidence of sepsis with picc grossly less than central line and fairly less than angio, the second benefit is prevention of pain ,,no angiocath is viable in neonate for more than 48 hrs and repeated pricks has neg effect on neurodevelopment outcomes.
Second change in as for as intervention at nicu is conserned was decline in other invasive procedure, one of them is uAc, we used it for sampling for blood gases but from last two years we ADAPTED Pgi protocol FOR BLOOD GAS SAMPLING IN PLACE OF INDWELLING UAC AND IN FACT COMPLETELY STOPPED USING UAC IN YEAR 2012……we reached to 0 level uvc, AND this is also reduced by replacemnet of mach vent with bubble nasal cpapSecond one is ex trans, the theorotical mortality of this procedure is 1% and again comes with all dissadv of a blood transfusion...this is done for mx of hyperbilirubinemiawith less sepsis, better overall care and early initiation of phototherapy we reduced the incidence of development of severe hyperbilirubinemai needing exc…whereas in 2010 we had 20 exchanges, we had only 6 this year
The third change as for as procedural stats is concerned was adaptation of new modalities, beginning with surf therapy upto INSURE protocol …we now have fair exp and expertise in surf administartions, we have already presented in datails about surf therapy at our icuarround 8 mnthsbak along with evidences AND STATASTICS REGARDING SURVIVAL, FEELS very glad to tel the same video I SHOWN 8 MNTHS BAK, NOW is among the top three videos visited on youtube FOR SURF THERAPY.Neopuff is another thing we implemented as replacement for umbu bags ,, its ambu bag wcich can provide peep too….
Remaining four five slides will not take much timeone time improvement may be easy but sustaining the improvements always need perseverance with all time guidance form mam we have not only achieved but also maintained the standard in nicu,The slide shows trend of mortality in last 16 mnths, with TARGET achieved in 2011, maintained throUghout 2012, without a single upsurge and kept our fingers crossed for this year.
The slide shows same trend of persiverence for imroved survival and vlbw which is defined as and let me share that 1/3rd of them were elbw which means the babies counting less than 1000 grams, as u see we have just 26 survivals out of 50 in 20101 as against tremendous improv of and 42 survivalout of 54The slide shows than not only the quality was mainatained but imroved with each passing month
Finally where we stand in the country, the slide shows nmrindia cg and at our insttitute …32 35 and 8,,,seems like only digits but made a lot difference for many families which we served, we have set standard not only for our state but also for country as there are very few institutes with sane digitsIn fact Nmr of 8 can be compared to many developed countries, but its not all about comparision and show off ..the most imp part is we are contributing to decrease nmr at cg in way that we cater a large populaton here at our institute which in turn also contributing to decrease nmr of india to help us achieve the final wholesome target the MDR.
To summarise that we set a goal for ouselves, achieved with various strategies and maintained the same and will keep on the same waySlides has lot words like enbc pain mx but they are not for name sake, but the words are actual practices in the purest form, a true enbc we practising each and every day, pain management even the babies with simple caput we are taking care by using pcm, in fact now it’s a regular practice at our place.So just to mention the core strategies are followed by
Before going to actual statistic just a brief about neonatal unit and few success stories. Neonatal unit had total 26 beds, out of which 13 are for specialized care including 8 nicu beds and 5 for rooming in where mothers accompany their babies. 13 beds are for post resuscitation observational care we also use these beds as step down icu.
Babies requiring active resuscitation, meconium stained amniotic fluid, preterm lbw etc are admitted in nicu
In 2012 we had 89 twins, 3 triplet and 1 quadruplet. In year 2012 neonatal mortality of our institutional delivery decreased significantly. Major role in decreasing NMR was played by survival of VLBW babies i.e. wt less than 1500gms. Upto last year we had not saved baby less than 900 gm or less than 28 weeks of gestational age but this new year came with new hope for us.
In the month of January we had baby of bhoomi gestational age was 28 week 5 days birth weight was 820 gms. And it was the first child that we could save less than 900 gms. Mother conceived after 5 years of marriage after in vitro fertilisation. Mother was a booked case. It was one of the twin. Baby required active resuscitation in the form of bag and mask in labour room.
After initial resuscitation patient was stable. But then patient had recurrent apnea since 4th day of life instead of invasive mechanical ventilation we managed the child with bubble nasal cpap as u can see. During hospital stay euthermia was maintained minimal trophic feed were started on 3rd day and was on full feed on 15th day. Baby starts gaining weight from 10th day and patient was discharged on 23rd day, wt on discharge was 940gms
If you look, the risk of cerebral palsy in multiple fetus pregnancies parallels decreasing gestational age but at 6th month baby is doing well. There is no developmental delay, no evidence of retinopathy of prematurity or intraventricular hemorrhage
This year we had 3 triplet. Over all Incidence of triplet is 1 in 45000. before this year only 1 of triplet has been saved. This year out of 9 babies 8 survived and one died and that was hydrops. All are managed with only essential newborn care.
THIS YEAR WE HAD A QUADRUPLET, NATURALLY OCCURRING QUADRUPLET BIRTHS OCCUR IN APPROXIMATELY 1 PER 600,000 BIRTHS. USUALLY QUADRUPLET PREGNANCY OCCURS AFTER TREATMENT FOR INFERTILITY BUT HERE PREGNANCY OCCURRED WITHOUT ANY TREATMENT. MOTHER AND FATHER BOTH WERE TEACHER. MOTHER DELIVERED ALL BABIES BY NORMAL VAGINAL DELIVERY. GESTATIONAL AGE WAS 33WEEK 2 DAYS. 2 RESUSCITATOR WERE PRESENT DURING DELIVERY BUT ALL OF THEM REQUIRED ONLY ROUTINE RESUSCITATION.
All the babies were managed with only essential newborn care. feeding was started on first day itself. We encouraged and reinforced both mother and father for KMC. And discharged after 7 days of admission.
11 OUT OF 12 BABIES WERE SENT HOME HAPPILY AND ALL ARE ON FOLLOWUP REGULARLY. NONE OF THEM HAS EVIDENCE OF RETINOPATHY OR INTRAVENTRICULAR HEMORRHAGE. And its great pleasure to see smile on the face of mother while discharging the babies.
In this year we not only managed vlbw babies but also babies with various syndrome or metabolic disorder and surgical cases were diagnosed and referred to higher centre whenever required. Here is just a brief about some interesting cases.
This is case of apert syndrome. Note the characteristic ocular hypertelorism, down-slanting palpebralfissures,horizontal groove above the supraorbital ridge, break of the continuity of eyebrows, depressed nasal bridge, and short wide nose. syndactyly involving the second, third, fourth, and fifth fingers. Prevalence is estimated at 1 in 65,000 and it is an autosomal dominant disorder. Management is mostly supportive.
Poster of this case was presented in national genetic conference in month of November in raipur and it was awarded first prize. We suspected this as metabolic disorder from h/o previous issue with mental retardation and cerebral palsy and head circumference of this baby was 97thcentile for age. We investigated for metabolic screening from Sir ganga ram hospital and it turned out as glutaricacidemia. Ct is suggestive of prominent batwing appearance.it is autosomal recessive condition with inability to properly breakdown amino acid lysine and tryptophan
THERE WAS BABY WITH H/O MECONIUM ASPIRATION, PT WAS VENTILATED FOR 2 DAYS ON FOLLOW UP IN OPD PARENTS COMPLAINS OF HARD SUBCUTANEOUS NODULES ON BACK AS SHOWN IN PHOTOGRAPH . THE NODULES ARE ALSO PRESENT OVER EXTREMITIES, IN INVESTIGATION PATIENT HAD HYPERCALCEMIA AND USG WAS SUGGESTIVE OF NEPHROCALCINOSIS. THIS IS A CASE OF SUBCUTANEOUS FAT NECROSIS. VERY FEW CASES ARE REPORTED OF THIS ENTITY. MOSTLY SELF LIMITING CONDITION BUT MAY REQUIRE BISPHOSPHONATES FOR LIFE LONG.
Lets see some surgical cases. This patient requires special mention. Incidence of tof is 1 in 4500 live births and of H type of tof is 1% of total tof and generally it was diagnosed at the age of 1yr to one and half year and presents as recurrent respiratory infection, failure to gain wt. but we Suspected on day 1 and diagnosed on 3rd day of life. There is very nice video why we suspected it. We can see it at last if time permits. pt was also having congenital heart disease. Pt was operated on 5th day by pediatric surgeon.
Postoperatively pt was fine and discharged on 22nd day of life and at 3 month pt is alright.
Here first xray suggestive of air under diaphragm. In newborn period cause of pneumoperitonium is perforation in patients of necrotizing enterocolitis. But this was a case of spontaneous ilieal perforation in a full term baby and it is unusual presentation Second xray was suggestive of rtpneumothrax. Cause for pneumothorax in newborn is mostly iatrogenic after vigorous resuscitation . But in this case it was spontaneous pneumothorax and patient was absolutely normal after needle aspiration.
Lets see what we did to improve ourselves. In this period of 1year nothing fancy was done. We improve by giving importance to very small small things.
there are number of references in favor of early feeding. Journal of nutrition says that Early feeding not only decreases neonatal mortality but also influence the long term neurodevelopmental outcomes. We ensure early feeding as soon as possible. For feeding we practiced paladai instead of using ryles tube even in babies of 29 weeks. Exclusive Breast feeding was assured in case of term babies.
We enforce and encourage involvement of mother. Mothers participate in care of their babies since day one or two if child is stable. This helps in building the bonding between mother and child as well as confidence of mother and proper care of child after discharge.
role of KMC in reducing neonatal mortality and chances of sepsis is universally accepted fact. Initially mother gives intermittentkmcatleast for one hour and Gradually time is increased.
J Pediatr 2011 clearly says that Red blood cell transfusions are independently associated with intra-hospital mortality in very low birth weight preterm infants. And it is also a risk factor for development of retinopathy of prematurityNumber of blood transfusion decreased in this one year. now We are following strict guidelines for blood transfusion.
In this one year rate of proven bacterimia decreased significantly.Sepsis is one of the most common cause for mortality in neonates. We encourage and reinforce strict hand washing practices. All the procedures are done by wearing double gown. Preparation of iv fluid under lamilar flow helps in decreasing the infection. And if we look into our hospital data hand washing rate of NNU is highest i.e. upto 90%
Invasive procedures are decreased in this year. We use bubble nasal CPAP very frequently for assisted ventilation. We are also using cpap post extubation. Use of bubble cpap decreased the rate of extubation failure and also reduced the post neonatal morbidity. Strict policy for invasive mechanical ventilation was followed. As umbilical vein catheteristion is associated with increased risk of CRBSI, oozing from insertion site and portal vein fibrosis we increased use of Peripherally inserted central catheter.Actually implementation of all these policies is possible only because of immense effort from our unit in charge and seniors.
Technology really helped us. Good quality incubators helps in maintaining euthermic environment for vlbw babies and decreasing the insensible losses from skin. Specialised neonatal ventilator with facility of high frequency ventilation helped in ventilating the babies with hyline membrane disease and meconium aspiration syndrome. We have run this ventilator for period of 24 7 for 1 month continuously without any problem. Moniter and servo control also improves quality of patient care.
For us year ends with lesson. Before the month of december we are very reluctant for resuscitation of baby with gestational age less than 28 weeks because of very poor prognosis and increased incidence of morbidity. But last month had a baby with gestational of 27 week 2days with birth weight 850gms. Patient had occasional gasp. Patient was immidietlyintubated tube and mask ventilation done. Patient had respiratory distress after resuscitation which was managed with CPAP, temp maintainance and supportive care. There after patient was hemodynamically stable. Essential new born care was given. Patient had no complication during the hospital stay. And discharged on 12th day.
And finally to end with feed bak from our patients
dnbpaediatrics.blogspot.inREPORT CARD 2012 Dr Ajay Agade Dr Shantanu Gomase Moderator – Dr Subodh Saha Department of pediatrics J.L.N.H. & R.C. BHILAI
Early Childhood Mortality Rates 74 57 39 18 18 NN PN INFANT CHILD U5 MORTALITY MORTALITY MORTALITY MORTALITY MORTALITY 2005-06 National Family Health Survey (NFHS-3)More than half of deaths of children who die in the first five years of life occur in the firstmonth after birth
VITAL STATASTICS 2012TOTAL NEONATAL STILL BIRTHLIVE BIRTHS DEATHS • 4100 • 34 • 149 LIVE BIRTH VS NEONATAL DEATH 4100 LIVE BIRTH 34 DEATHS
PROCEDURAL STATASTICS Ventilation-Success stories 2012 Jan B/O Bhumi 28 wks 820 gms Feb B/O Sheshkumari 35 wks 900 gms March 4 out of 5 survived Apr B/O Geeta 1300 gms May 4 out of 6 survived June B/0 Savita twins 900 gms & 1000 gms (Both received surfactant) July B/0 Mariyana 2kg with MAS & B/O Pratima 30 wks August 6 out of 8 survived Sept B/0 Tarkeshwari IUGR, TEF repaired sent home 6 out of 6 survived Oct 9 out of 10 survived Nov B/0Tomeshwari with Diaphragmaic hernia Dec B/0 Priti 31 wks, B/o Sitarun nisha 35 wks, B/o Leelavati HIE grade 3
COMPARISION Live Births4100 4100400039003800 3834 LIVE BIRTH3700 3719 373836003500 2009-2010 2010-2011 2011-2012 2012-2013 dnbpaediatrics.blogspot.in
DEMOGRAPHIC COMPARISON Trend of Sex Distribution2500 2108 2171 2068 20542000 2075 1858 18541500 1801 MALES1000 FEMALES500 0 YEAR 2009 YEAR2010 YEAR2011 YEAR2012 dnbpaediatrics.blogspot.in
COMPARISION VLBW and their SurvivalYEAR 2010 YEAR 2011 YEAR 2012 TOTAL 93 TOTAL 98 TOTAL 106 SURVIVED 44 SURVIVED 76 SURVIVED 91 SURVIVAL OF VLBW VLBW SURVIVED 85% 77% 47% YEAR2010 YEAR2011 YEAR2012
COMPARISION Procedural Statistics Use of Newer Modalities SURFACTANT THERAPY87 Surfactant therapy65 INSURE protocol4 Nasal bubble CPAP32 PICC in place of UVC & Femoral1 Neopuff in place of Ambu bag0 YEAR2010 YEAR2011 YEAR2012 dnbpaediatrics.blogspot.in
SUSTAINING THE IMPROVEMENT Neonatal mortality8070605040302010 0 dnbpaediatrics.blogspot.in
NEONATAL MORTALITY THE TREND 35 30 25 20 32 35 15 10 5 8.35 0 INDIA CG OUR INSTITUTE dnbpaediatrics.blogspot.in
SETTING GOAL FOR OURSELVES ENBC ASEPSIS KMC ROOMING IN REDUCE NMR JUSTIFIABLE DECREASE IN INVASIVE PROCEDRE PAIN MANAGEMENT AT ITS BEST BETTER UNDERSTANDING OF NEONATAL VENTILATION IMBIBING NEWER MODALITIES OF MANAGEMENT
NNU Bed- 26Specialized care NICU bed- 8, Rooming In-5Observation- 13
“Delayed Breastfeeding Initiation Increases Risk of Neonatal Mortality" AAP, March 2006 “Early feeding is assiciated with reduced infection-specific neonatal mortality “ Am J Clin Nutr 2007;86:1126 –31“Early nutrition could also influence the long term neurodevelopmental outcomes” J Nutr. 1995;125:2212S–20S