IMPLEMENTATION OF BEST PRACTICE STRATEGIES TO DECREASE UNPLANNED - PDF document

IMPLEMENTATION OF BEST PRACTICE STRATEGIES TO DECREASE UNPLANNED EXTUBATIONS IN THE NEONATE Purpose: Unplanned extubations (UEX) are a serious and potentially life-threatening event for a neonate. UEX leads to emergent, less-controlled endotracheal re- intubations.Repeated intubations increase the risk of ventilator associated pneumonia, tracheal injury, and may prolong length of stay. A number of factors increase the risk of UEXs. These include lack of adequate sedation; type of tube stabilization used, and lack of vigilance by staff. Method: A prospective cohort quality study was designed to consider the impact of modifying these factors and implementing a sequence of best practice strategies. Three leading factors were defined: stabilization of endotracheal tube (ETT), sedation for intubated patients, and personnel at the bedside. Strategies were developed to address these factors: 1) A six month trial of three different stabilization techniques; 2) Sedation guideline implemented, for patients who self extubated and required re-intubation within 48hrs ( scheduled sedation, 1mcg/Kg Fentanyl Q4, 1 mcg/kg Fentanyl q2 hrs PRN); 3) Intubated patients required two personnel at the bedside during care or procedures. Patients requiring intubation from February 2010 to present were included in this 5 year quality study. A tracking tool was developed and data collected included: patient data were protocols followed, circumstances and personnel present for UEX and level of sedation. Results : Baseline data indicated an UEX rate of 4.5/100 ventilator days. Following the implementation of three standards of care practice changes we saw the following decrease in the UEX rate: 1) Standardized Taping to 2.4/100 ventilator days; 2) Standard sedation to 1.7/100 ventilator days; 3) Adequate personnel at the bedside to 0.4/100 ventilator days. Conclusion: UEXs continued to occur despite the implementation of standardized taping. It was determined that lack of sedation and the absence of adequate number of personnel at bedside during procedures and care time contributed to UEXs. After the implementation of Sedation Guidelines and standardizing personnel at the bedside during procedures, we experienced additional decrease in the UEXs rate. Care time, procedures, and sedation are coordinated by nursing and respiratory therapy Qshift. We continue to evaluate and track UEXs as part of our ongoing quality initiatives.

Pulmonary Arterioles and Terminal Bronchioles have Persistent Muscularization in the Lung of Former Preterm Lambs H Emerson*, J Orchard*, MJ Dahl, L Dong, Z Wang, DM Null, BA Yoder, and KH Albertine * Equal first authors (both 2 nd -year medical students)

Disclosure Statement Hal eigh Emerson does not have anything to disclose

Worrisome Long-Term Outcomes  Bronchopulmonary dysplasia (BPD) is a major pediatric public health problem  Cause: Premature birth and respiratory failure ● Requires ventilation with oxygen-rich gas  Potential life-long consequences ● Pulmonary hypertension ● Hyperreactive airways

Pulmonary Hypertension and BPD  2-year mortality rate of 33 to 48%  Pathology and pathophysiology ● Lower density of pulmonary microvessels ● Thicker walls of pulmonary arterioles ● Hypoxic vasoconstriction and increased pulmonary vascular resistance ● Hypertrophy and/or enlargement of the right atrium and ventricle Khemani et al, Pediatrics 120:1260-1269, 2007 Del Cerro et al, Pediatr Pulmonol 49:49-59, 2014 Baker et al, Pediatr Allergy Immunol Pulmonol 27:8-16, 2014

Pulmonary Arteriole (PA) Muscularization in Preterm Lambs Term Reference Preterm IMV 21d PA PA

Muscularization Persists from Fetal Anatomy Pulmonary 20 Arterioles Smooth Muscle Area 10 External Diameter 0 Fetal Newborn 128d 1d 21d References Mean ± SD; n=4 to 5 per group Bland et al., Pediatr Res 4 8:64-74, 2000

Muscularization Persists from Fetal Anatomy Pulmonary 20 Arterioles Smooth Muscle Area 10 External Diameter 0 Fetal Newborn Preterm 128d 1d 21d 21d IMV References Mean ± SD; n=4 to 5 per group Bland et al., Pediatr Res 4 8:64-74, 2000

Pulmonary Vascular Resistance Did Not Decrease Postnatally Term Preterm Reference 21d IMV Not ventilated n=7 n=10 40 Pulmonary Vascular 20 Resistance (mmHg/(L/min) 0 1 3 1 3 Week Week Mean ± SD Bland et al., Pediatr Res 4 8:64-74, 2000

Hyper-Reactive Airways and BPD  Recurrent wheezing and asthma  Mechanisms underlying these respiratory morbidities remain poorly understood ● Our previous studies of chronically ventilated preterm lambs provide mechanistic insights Jaakkola et al., J Allergy Clin Immunol 118:823-830, 2006 Walter et al., Am J Respir Crit Care Med 180:176-180, 2009

Terminal Bronchiole (TB) Muscularization in Preterm Lambs Term Reference Preterm IMV 21d TB TB

Increased Muscularization of Airways Terminal Bronchioles 0.20 Smooth Muscle Area 0.10 External Diameter 0 Term Preterm Reference 21d Mean ± SD, n=5 Bland et al., AJRCCM 172:899-906, 2005

Hypothesis  Invasive intermittent mandatory ventilation immediately after preterm birth will lead to ● Persistent muscularization of pulmonary arterial vessels ● Increased muscularization of airways ● later in life

Study Groups  Former preterm ventilated lambs ● 3 months (2 months corrected postnatal age) ● 6 months (5 months corrected postnatal age)  Term, age-matched, unventilated control lambs ● 2 months ● 5 months ● Pair-fed, based on milk volume taken by the former preterm lambs

Modified Our Preterm Lamb Model  Wean preterm lambs from ventilation support ● Based on clinical assessment of neurodevelopmental outcomes at 2 and 6 years corrected postnatal age ● Recovered preterm lambs for 2 or 5 months, respectively, after term gestation, based on anthropomorphic characteristic

Postnatal Age Equivalence Characteristic Humans Sheep Weaning 2 years 2 months

Postnatal Age Equivalence Characteristic Humans Sheep Weaning 2 years 2 months Interpolated * 6 years 5 months * Puberty onset in sheep occurs at ~8 months of age

Former Preterm Protocol Antenatal Steroids Delivered at ~128 days (Term is ~150 days) Intubated and treated with surfactant and caffeine citrate Intermittent mandatory ventilation (IMV) 3 days Extubated Less-invasive HFNV for 3 days Removed from ventilation support Fostered for 3 months or 6 months

Management of Preterm Lambs  Physiologic targets for oxygenation and ventilation ● PaO 2 60 to 80 mmHg ● PaCO 2 45 to 60 mmHg (pH 7.25 to 7.45)  Antibiotics  Sedation  Glucose: 60-80 mg/dL  Enteral feeding, using ewe’s colostrum and milk ● Term control lambs were pair-fed

Structural Analyses  Formalin-fixed, paraffin-embedded lung tissue sections ● Alpha smooth muscle actin localization  Quantitative histology ● Measure calibrated area of smooth muscle ● Pulmonary arterioles (PA) ● Independent landmark for same generation (~16 th ) ● Terminal bronchioles (TB)

Other Analyses  Heart ● Weight ● Ventricular free wall thickness  Airway resistance and hyper-reactivity

Persistent Muscularization of PAs 5 months 2 months Term Control Former Preterm

Persistent Muscularization of PAs 4000 * * Smooth Muscle Area 2000 ( μ m 2 ) 0 Former Term Former Term PT Control PT Control Mean ± SD, n=5 2 mo 2 mo 5 mo 5 mo * p<0.05 compared to the matched term control

Increased Heart-to-Body Weight Ratio 6 * Heart Weight 3 Body Weight 0 Former Term Former Term PT Control PT Control Mean ± SD, n=5 2 mo 2 mo 5 mo 5 mo * p<0.05 compared to matched term control

Thicker Right Ventricular (RV) Free Wall * 6 RV Free Wall Thickness 3 (mm) 0 Former Term PT Control Mean ± SD, n=5 2 mo 2 mo * p<0.05 compared to matched term control

Thicker Right Ventricular (RV) Free Wall * 6 RV LV Free Wall Thickness 3 (mm) 0 Former Term Former Term PT Control PT Control Mean ± SD, n=5 2 mo 2 mo 2 mo 2 mo * p<0.05 compared to matched term control

Increased Airway Resistance 3.0 (n=2) Airway * 1.5 Resistance (cmH 2 O/Liter/sec/Kg) 0 Former Term Former Term Mean ± SD, n=5 PT Control PT Control * Different from matched term 2 mo 2 mo 5 mo 5 mo control, p<0.05

Increased Muscularization of TBs 5 months 2 months Term Control Former Preterm

Increased Muscularization of TBs 8000 * * Terminal Bronchiole Smooth 4000 Muscle Area ( μ m 2 ) 0 Former Term Former Term Mean ± SD, n=5 PT Control PT Control * Different from matched term 2 mo 2 mo 5 mo 5 mo control, p<0.05

Long-Term Airways Hyperreactivity, 5 mo Former PT 3d IMV lambs, DOL 119 (~6 yr of age in humans) Airway Resistance 150 Former PT Weaned 100 cmH 2 O LPS T Control 50 0 10 min 100 min 10 min 100 min Baseline Methacholine Baseline Methacholine (15 mg/Kg) (30 mg/Kg) Average (n=3)

Summary for PAs Pulmonary Arterioles (PAs) Former Smooth Heart-to-Body RV Free Wall Preterm Muscle Wt Ratio Thickness Lambs Thickness 2 months * Not Different 5 months * Not done * Corrected postnatal age

Summary for PAs Pulmonary Arterioles (PAs) Former Smooth Heart-to-Body RV Free Wall Preterm Muscle Wt Ratio Thickness Lambs Thickness 2 months * Not Different 5 months * Not done * Corrected postnatal age