Seminars in perinatology最新文献

For the purposes of this review, obstetric sepsis refers to sepsis (from all causes, including non-obstetric such as pneumonia) in pregnant or postpartum patients, which was previously described as maternal sepsis. Obstetric sepsis poses a significant threat to pregnant, birthing, and postpartum individuals, contributing prominently to maternal mortality and morbidity despite being largely preventable¹. In response to identified gaps in sepsis management, particularly the lack of specific protocols tailored to obstetric populations, New York-Presbyterian undertook a system-wide initiative to implement a comprehensive sepsis bundle. This initiative included the development of new criteria for identifying sepsis in obstetric patients, the creation of electronic medical record (EMR) alerts aligned with obstetric-specific indicators, and the establishment of a structured sepsis management algorithm. The project involved collaboration across eight hospital campuses within the New York-Presbyterian system, aiming to standardize and improve the early recognition and treatment of sepsis in maternal care. Key components included rigorous data analysis to select appropriate sepsis criteria, simulation-based training to familiarize clinical teams with the new algorithm, and continuous refinement of alert systems to mitigate alarm fatigue and enhance responsiveness. Post-implementation evaluation revealed a significant reduction in preventable morbidity related to sepsis, accompanied by the identification of additional gaps in fever and chorioamnionitis management. These findings prompted the development of new clinical guidelines to further enhance patient safety. Challenges encountered included adapting sepsis criteria to balance sensitivity and specificity, as well as integrating trauma-informed care principles into clinical practice. This project underscores the effectiveness of tailored quality improvement efforts in maternal health, emphasizing the critical role of proactive interventions in enhancing patient outcomes and safety within obstetric settings. Ongoing efforts focus on monitoring process metrics through a dedicated sepsis dashboard and advancing education on trauma-informed care principles, highlighting the continued commitment to sustained improvement in maternal health outcomes.

Obstetric sepsis is a leading cause of preventable maternal morbidity and mortality. Pregnant and postpartum patients in rural settings experience disproportionate rates of sepsis and other forms of severe maternal morbidity. Although there have been recent advances in addressing preventable morbidity and mortality from sepsis in the general adult population, combating excess rates of sepsis in the obstetric population, particularly among rural patients, will require targeted clinical and policy interventions.

Severe morbidity and mortality associated with sepsis in obstetric care occur even among those presumed to be at low risk, are highly preventable and deserve critical public health prioritization. Continued research is warranted that focuses on the development and performance assessment of screening tools, standardizing diagnostic criteria, and understanding how to implement and sustain quality improvement practices to support timely recognition and treatment, as well as equitable healthcare practices to improve maternal outcomes across diverse populations.

Resuscitation of an infant with surgical complications includes both perioperative and post-operative management. In most cases this requires a multidisciplinary approach to achieve the best outcomes. Challenges include immediate expert management at infant delivery with the use of protocolized care, available anesthesia expertise, close monitoring of electrolytes with prompt attention to fluid status, and meticulous pain management. In this review, we will address contemporary research and ongoing challenges associated with resuscitation. We will make recommendations for effective resuscitation of this vulnerable and unique population from premature infant to term infant with complex surgical needs.

Neonatal intensive care unit resuscitative care continually evolves and increasingly relies on data. Data driven precision resuscitation care can be enabled by leveraging informatics tools and artificial intelligence. Despite technological advancements, these data are often underutilized due to suboptimal data capture, aggregation, and low adoption of artificial intelligence and analytic tools. This review describes the fundamentals and explores the evidence behind informatics and artificial intelligence tools supporting neonatal intensive care unit resuscitative care, training and education. Key findings include the need for effective interface design for accurate data capture followed by storage and translation to wisdom using analytics and artificial intelligence tools. This review addresses the issues of data privacy, bias, liability and ethical frameworks when adopting these tools. While these emerging technologies hold great promise to improve resuscitation, further study of these applications in neonatal population and awareness of informatics and artificial intelligence principles among clinicians is imperative.

Acute respiratory compromise (ARC) is a significant and frequent emergency in the Neonatal Intensive Care Unit (NICU), characterized by absent, agonal, or inadequate respiration that necessitates an immediate response. The primary etiologies of ARC in neonates can be categorized into upper and lower airway issues, disordered control of breathing, and lung tissue disease. ARC events are particularly dangerous as they compromise oxygen delivery and carbon dioxide removal, potentially leading to cardiopulmonary arrest. Approximately 1 % of NICU admissions experience cardiopulmonary arrest, and ARC is the primary cause of most events. This article provides a comprehensive review of the etiologies of ARC, including anatomical abnormalities, syndromic disorders, airway obstruction, and pulmonary diseases such as bronchopulmonary dysplasia and pneumonia. Management strategies include the use of continuous positive airway pressure, positive pressure ventilation, and advanced interventions like extracorporeal membrane oxygenation (ECMO) in cases of severe respiratory distress. Additionally, quality improvement initiatives aimed at reducing incidents such as unplanned extubations (UE) are discussed, along with emergency responses to ARC, which often require multidisciplinary collaboration and advanced airway management. The article emphasizes the importance of preparedness, training, and structured emergency protocols to ARC in the NICU to optimize patient care.

Cardiopulmonary resuscitation is a critical component of neonatal care. While the basic principles of resuscitation are consistent across different settings, the specific challenges and resources available in the delivery room and the Neonatal Intensive Care Unit (NICU) vary significantly. Understanding the differences between these settings is essential for optimizing resuscitation outcomes. This article explores four key areas of difference-environment and equipment, team composition and roles, care protocols and practices, and patient population and condition-and how they impact neonatal resuscitation efforts. By examining these differences, healthcare neonatal care teams can better prepare for the specific resuscitation needs in each setting, ultimately improving neonatal survival and long-term health outcomes.

Metabolic emergencies in neonates can present with nonspecific signs and symptoms. Sudden acute deterioration in a neonate should prompt consideration of metabolic disease. Common metabolic emergencies in the Neonatal Intensive Care Unit (NICU) include hypoglycemia, hyperammonemia, hyperbilirubinemia, metabolic acidosis, adrenal insufficiency, and electrolyte imbalances. These emergencies often require prompt recognition and intervention to prevent serious complications. Appropriate management depends on the diagnosis. However, initial resuscitation and stabilization can be started without a definitive diagnosis. Confirmatory testing and long-term management vary by condition and should be guided by symptoms and endocrinologist input.

Post-cardiac arrest syndrome is a unique pathophysiologic condition that is well-described in adult and pediatric populations. Early, goal-directed care after cardiac arrest can mitigate ongoing injury, improve clinical outcomes, and prevent re-arrest. There is a paucity of evidence about post-cardiac arrest care in the NICU, however, pediatric principles and guidelines can be applied in the NICU in the appropriate clinical context.

It is not uncommon for a patient to experience hemodynamic instability following birth. This is due to the fact that the transitional period requires dramatic cardiorespiratory changes. When it goes well, improved lung compliance and successful transition to the postnatal circulation is seen. However, it is highly beneficial that clinicians have a solid understanding of all of the required changes, the unique aspects of the neonatal myocardium, and the influence of cardiovascular disease on normal adaptive mechanisms. In this manuscript, we will review the physiology of the normal postnatal circulatory adaptation, the unique characteristics of the neonatal myocardium and how it behaves in states of altered loading conditions, and the impact of hemodynamic disease states on health and wellbeing during the immediate postnatal time-period.