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Predictors of death including quality of positive pressure ventilation during newborn resuscitation and the relationship to outcome at seven days in a rural Tanzanian hospital.

ABSTRACT: BACKGROUND:Effective positive pressure ventilation (PPV) of non-breathing newborns is crucial in facilitating cardio-respiratory adaptation at birth. Identifying predictors of death in newborns receiving PPV is important in order to facilitate preventative strategies. OBJECTIVE:The objective of this study was to determine the perinatal predictors of death including the quality of PPV administered among admitted newborns. METHODS:An observational study of admitted newborns who received PPV after birth was conducted. Research assistants observed all deliveries and recorded perinatal events on data collection forms. Measured heart rate (HR) and ventilation parameters were then compared between newborns who died and survivors. RESULTS:Newborns (n = 232) were studied between October 2014 and November 2016. Newborns who died (n = 53) compared to survivors (n = 179) had more fetal heart rate (FHRT) abnormalities (12/53 vs 19/179; p = 0.03); lower initial HR (<100 beats/minute) at start of PPV (44/48 vs 77/139; p<0.001); and a longer time for HR to increase >100 beats/minute from birth (180 vs 149 seconds; p = 0.07). Newborns who died compared to survivors took longer time (14 vs 4 seconds; p = 0.008) and more inflations (7 vs 3; p = 0.006) to achieve an expired volume (Vt) of 6 ml/kg, respectively. Median delivered Vt during the first 60 seconds of PPV was less in newborns who died compared to survivors (5 vs 6 ml/kg; p = 0.12). Newborns who died proceeded to severe encephalopathy (15/31 vs 1/59; p<0.001) compared to survivors. CONCLUSION:Depressed newborns who proceeded to death compared to survivors, exhibited delayed HR response to PPV which may partly reflect FHRT abnormalities related to interruption of placental blood flow, and/or a timely delay in establishing adequate Vt. Depressed newborns progressed to moderate/severe encephalopathy. Improving FHRT monitoring to identify fetuses at risk for expedited delivery, coupled with optimizing delivery room PPV might decrease mortality in this setting.

SUBMITTER: Moshiro R

PROVIDER: S-EPMC6097682 | biostudies-literature | 2018

REPOSITORIES: biostudies-literature

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Predictors of death including quality of positive pressure ventilation during newborn resuscitation and the relationship to outcome at seven days in a rural Tanzanian hospital.

Moshiro Robert R Perlman Jeffrey M JM Kidanto Hussein H Kvaløy Jan Terje JT Mdoe Paschal P Ersdal Hege L HL

PloS one 20180817 8

<h4>Background</h4>Effective positive pressure ventilation (PPV) of non-breathing newborns is crucial in facilitating cardio-respiratory adaptation at birth. Identifying predictors of death in newborns receiving PPV is important in order to facilitate preventative strategies.<h4>Objective</h4>The objective of this study was to determine the perinatal predictors of death including the quality of PPV administered among admitted newborns.<h4>Methods</h4>An observational study of admitted newborns w ...[more]

PMID: 30118519

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Project description:ObjectivesGlobally, perinatal mortality remains high, especially in sub-Saharan countries, mainly because of inadequate obstetric and newborn care. Helping Babies Breathe (HBB) resuscitation training as part of a continuous quality improvement (CQI) programme may improve outcomes. The aim of this study was to describe observed changes in perinatal survival during a 6-year period, while adjusting for relevant perinatal risk factors.SettingDelivery rooms and operating theatre in a rural referral hospital in northern-central Tanzania providing comprehensive obstetric and basic newborn care 24 hours a day. The hospital serves approximately 2 million people comprising low social-economic status.ParticipantsAll newborns (n=31 122) born in the hospital from February 2010 through January 2017; 4893 were born in the 1-year baseline period (February 2010 through January 2011), 26 229 in the following CQI period.InterventionsThe HBB CQI project, including frequent HBB training, was implemented from February 2011. This is a quality assessment analysis of prospectively collected observational data including patient, process and outcome measures of every delivery. Logistic regression modelling was used to construct risk-adjusted variable life adjusted display (VLAD) and cumulative sum (CUSUM) plots to monitor changes in perinatal survival (primary outcome).ResultsDuring the 6-year CQI period, the unadjusted number of extra lives saved according to the VLAD plot was 150 despite more women admitted with pregnancy and labour complications and more caesarean deliveries. After adjusting for these risk factors, the risk-adjusted VLAD plot indicated that an estimated 250 extra lives were saved. The risk-adjusted CUSUM plot confirmed a persistent and steady increase in perinatal survival.ConclusionsThe risk-adjusted statistical process control methods indicate significant improvement in perinatal survival after initiation of the HBB CQI project with continuous focus on newborn resuscitation training during the period, despite a concomitant increase in high-risk deliveries. Risk-adjusted VLAD and CUSUM are useful methods to quantify, illustrate and demonstrate persistent changes in outcome over time.

Project description:Introduction:Maternal and perinatal mortality is still a major public health challenge in Tanzania, despite the ongoing government efforts to improve maternal and newborn care. Among the contributors to these problems is the high magnitude of severe maternal outcomes (maternal near-miss). The current study, therefore, aimed to identify the magnitude and predictors of maternal and perinatal mortality among women with severe maternal outcomes admitted to Dodoma Regional Referral Hospital. Methods:A retrospective cross-sectional study was conducted from October 2015 to January 2016 at Dodoma Regional Referral Hospital in Dodoma City. All maternal deaths and maternal near-misses based on WHO criteria were included in this study. Three outcome variables have been identified: maternal mortality, perinatal mortality, and neonatal complications. To examine the predictors for the three predetermined outcome variables, the three logit models each containing unadjusted and adjusted findings were fitted. A P-value less than 0.05 was considered indicative of statistically significant. Results:A total of 3600 pregnant women were admitted for obstetric reasons during the mentioned period. 140 of them were diagnosed with severe maternal outcomes; hence, they were included in this study. The severe maternal outcome incidence ratio was 40.23 per 1000 live births, the institutional maternal mortality ratio was 459.77 per 100000 live births, and the perinatal mortality rate was 10.83 per 1000 total births. Most of the maternal morbidity and mortality were due to direct causes in which postpartum hemorrhage and hypertensive disorders were the leading causes. In adjusted analysis, per-protocol management, maternal age, and mode of birth were predictors of maternal mortality, perinatal mortality, and neonatal complications, respectively. Conclusion:Establishing and strengthening obstetric ICUs will help reduce maternal mortality as the response time from the onset of obstetric complications, while the provision of high-quality care will be substantially reduced. Furthermore, the study recommends regular provision of in-service refresher training to emphasize the practice and compliance of per-protocol case management through a team approach in order to reduce the burden of maternal and perinatal mortality in Tanzania.

Project description:RationaleAlthough noninvasive positive pressure ventilation (NIPPV) is increasingly used in acute respiratory distress syndrome (ARDS) to avoid invasive mechanical ventilation (IMV), the data supporting its benefit for this indication are lacking.ObjectivesTo analyze the all-cause in-hospital mortality rate and length of stay (LOS) for ARDS patients who received NIPPV in the United States (US) compared to those who were initially intubated. Our secondary outcome of interest was to determine the predicting factors for NIPPV failure.MethodsWe used the 2016 National Inpatient Sample database to identify 4,277 adult records with ARDS who required positive pressure ventilation. We divided the cohort into initial treatment with IMV or NIPPV. Then, the NIPPV group was further subdivided into NIPPV failure or success. We defined NIPPV failure as same-patient use of NIPPV and IMV either on the same day or using IMV at a later date. We analyzed the in-hospital mortality, LOS, and NIPPV failure rate. Linear regression of log-transformed LOS and logistic regression of binary outcomes were used to test for associations.ResultsThe NIPPV success group had the lowest mortality rate (4.9% [3.8, 6.4]) and the shortest LOS (7 days [6.6, 7.5]). The NIPPV failure rate was 21%. Sepsis, pneumonia, and chronic liver disease were associated with higher odds of NIPPV failure (adjusted OR: 4.47, 2.65, and 2.23, respectively). There was no significant difference between NIPPV failure and IMV groups in-hospital mortality (26.9% [21.8, 32.8] vs. 25.1% [23.5, 26.9], p=0.885) or LOS (16 [14, 18] vs. 15.6 [15, 16.3], p=0.926).ConclusionsNIPPV success in ARDS exhibits significantly lower hospital mortality rates and shorter LOS compared with IMV, and NIPPV failure exhibits no significant difference in hospital mortality or LOS compared with patients who were initially intubated. Therefore, an initial trial of NIPPV may be considered in ARDS. Sepsis, pneumonia, and chronic liver disease were associated with higher odds of NIPPV failure; these factors should be used to stratify patients to the most suitable ventilation modality.

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Predictors of death including quality of positive pressure ventilation during newborn resuscitation and the relationship to outcome at seven days in a rural Tanzanian hospital.

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Predictors of death including quality of positive pressure ventilation during newborn resuscitation and the relationship to outcome at seven days in a rural Tanzanian hospital.

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