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 In...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.
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. T...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.
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...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.
Schierholz E, Wetzel EA, Thomas AR
… +2 more, Kamath-Rayne BD, Reed DJW
Semin Perinatol
· 2024 Dec · PMID 39406611
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The Neonatal Resuscitation Program (NRP) is the most used resuscitation algorithm for infants requiring resuscitation in the neonatal intensive care unit (NICU). The population of infants cared for in the NICU is varied...The Neonatal Resuscitation Program (NRP) is the most used resuscitation algorithm for infants requiring resuscitation in the neonatal intensive care unit (NICU). The population of infants cared for in the NICU is varied and complex with resuscitation needs that may extend beyond the NRP algorithm. To provide resuscitation care that addresses these needs, institutions may choose to incorporate algorithms from the Pediatric Advanced Life Support or a "hybrid" approach that includes NRP. Limited evidence exists to support one algorithm or approach over another. In this article, we identify potential gaps in the application of using NRP or PALS in the NICU population, present select patient decompensations and discuss the resuscitation management approach using the NRP or PALS algorithms. Challenges associated with NICU resuscitation education will be explored as well as approaches to overcome some of the identified resuscitation education obstacles.
Semin Perinatol
· 2024 Nov · PMID 39358161
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Obstetric sepsis is a leading cause of maternal mortality and severe maternal morbidity in the United States. However, it is uncommon, and diagnosis and treatment are often delayed. This report summarizes recent work to...Obstetric sepsis is a leading cause of maternal mortality and severe maternal morbidity in the United States. However, it is uncommon, and diagnosis and treatment are often delayed. This report summarizes recent work to develop a patient-centered approach for the care of patients with obstetric sepsis. To support patients, educational materials to identify warning signs paired with advocacy tips are important. Following an adverse event, outlines and checklists for patient support are provided. These tools have been developed to address a variety of obstetric conditions and have utility beyond sepsis. On the clinical side, new data to establish a standardized approach to screening and diagnosis is covered in detail. This "two-step" approach has been supported by national obstetric organizations and has similarities to the algorithm used to screen neonates for term early onset sepsis. In addition, the approach for implementation of a sepsis care bundle by the California/Michigan Obstetric Sepsis Quality Collaborative is discussed.
Richardson BT, Cepin A, Grilo S
… +7 more, Moss RA, Moller MD, Brown S, Goffman D, Friedman A, Reddy UM, Hall KS
Semin Perinatol
· 2024 Nov · PMID 39341761
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Sepsis is the second leading cause of maternal death in the U.S. For racial and ethnic minoritized birthing people, especially those who are Black and living in underserved communities, labor and postpartum are particula...Sepsis is the second leading cause of maternal death in the U.S. For racial and ethnic minoritized birthing people, especially those who are Black and living in underserved communities, labor and postpartum are particularly vulnerable risk periods. To reduce sepsis-related morbidity and mortality and promote maternal health equity, community co-led, and co-designed interventions are urgently needed. In this commentary, we introduce the design and goals of our EnCoRe MoMS study as an exemplar for employing community based participatory research principals iteratively throughout the research process and integrated across all study aims. We also highlight our early lessons learned and recommendations for best practices. Our novel model and ongoing work have implications for scaling academic-community research partnerships for other causes of severe maternal morbidity and maternal health equity nationally.
Sepsis is a leading cause of maternal morbidity and mortality worldwide. Early recognition and treatment improve outcomes. Multiple sepsis diagnostic screening tools are available and may be used in clinical practice; ho...Sepsis is a leading cause of maternal morbidity and mortality worldwide. Early recognition and treatment improve outcomes. Multiple sepsis diagnostic screening tools are available and may be used in clinical practice; however, early thorough bedside evaluation of the patient is fundamental. Obstetricians should be able to recognize sepsis and promptly initiate potentially life-saving treatments, such as fluid resuscitation, vasopressors, broad-spectrum antibiotics, and early source control. It is recommended that obstetrical care, including delivery timing, not be altered solely due to the diagnosis of sepsis.
Obstetric sepsis is a significant cause of morbidity and mortality in pregnant people worldwide. Initial evaluation and timely intervention are crucial to improving outcomes for birthing persons and their newborns. While...Obstetric sepsis is a significant cause of morbidity and mortality in pregnant people worldwide. Initial evaluation and timely intervention are crucial to improving outcomes for birthing persons and their newborns. While many of the therapies and interventions for peripartum sepsis are consistent with the general population, there are considerations unique to pregnancy. Stabilization of the septic pregnant or immediately postpartum patient requires an understanding of the physiologic changes of pregnancy, hemodynamic changes during labor, and infections specific to pregnancy. We will review the interaction between pregnant physiology and sepsis pathophysiology, and how this can guide screening and diagnosis.
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 morbi...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.
Semin Perinatol
· 2024 Nov · PMID 39322442
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Sepsis remains a leading cause of mortality among pregnant and recently pregnant patients, rendering it a subject of vital importance to emergency clinicians in the US. However, death by sepsis has been found to be large...Sepsis remains a leading cause of mortality among pregnant and recently pregnant patients, rendering it a subject of vital importance to emergency clinicians in the US. However, death by sepsis has been found to be largely preventable with prompt and appropriate intervention. This narrative review provides a summary of the physiologic, epidemiologic, and systemic factors specific to obstetric sepsis that contribute to delays in diagnosis and treatment. Additionally, it provides a framework for emergency department providers to approach infection identification, antimicrobial selection, and appropriate resuscitation prior to disposition.
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 w...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.
The long-term consequences of obstetric sepsis have been a growing area of concern requiring attention. This narrative review summarizes the existing literature on the long-term sequelae of sepsis, with a focus on the an...The long-term consequences of obstetric sepsis have been a growing area of concern requiring attention. This narrative review summarizes the existing literature on the long-term sequelae of sepsis, with a focus on the antepartum and postpartum periods. In this article, we discuss risk factors for and epidemiology of post-sepsis syndrome (PSS) and related long-term medical conditions. We include recommendations for screening for PSS and management strategies involving multidisciplinary teams. PSS and other long-term medical and psychological sequelae of sepsis impact individuals and their communities greatly, including the obstetric population. There is a need for improved identification, management, and coordination of care for long-term complications of sepsis. Gaps in the literature for future study include identifying specific needs of the obstetric population in the weeks, months, and years following a sepsis event.
Social inequities and mental health are public health and medical conditions that are inextricably linked. Perinatal mental health is influenced by social, physical, and biological factors, with additional stressors rela...Social inequities and mental health are public health and medical conditions that are inextricably linked. Perinatal mental health is influenced by social, physical, and biological factors, with additional stressors related to pregnancy. The social determinants of health (SDOH) encompasses all conditions in which people live and grow, inclusive of cultural norms that reflect the diverse populations we serve. To best understand the mechanisms by which the SDOH affects perinatal mental health, we introduce the Urban Stress Model and describe the link between urban realities to stress response and potential mechanisms that link urban living to increased risk of adverse perinatal mental health. Given the increased diversity of patient populations, cultural considerations are paramount in understanding the utility and best practices in screening and interventions among ethnically diverse communities. Building on our Urban Stress Model and a structural determinants of health framework, we present examples of interventions to address the social inequities of perinatal mental health from the policy to community levels.
Perinatal mental health conditions affect up to 20 % of pregnant or postpartum individuals, and nearly 15 % of pregnant individuals meet criteria for substance use disorder (SUD). All providers taking care of pregnant or...Perinatal mental health conditions affect up to 20 % of pregnant or postpartum individuals, and nearly 15 % of pregnant individuals meet criteria for substance use disorder (SUD). All providers taking care of pregnant or postpartum individuals will encounter patients in these scenarios. Maternal Mortality Review Committees (MMRCs) have determined maternal mental health conditions, including SUD, to be the leading cause of preventable maternal death during pregnancy or in the first year postpartum. Lessons learned from MMRCs to prevent these deaths include the recommendation that screening and identification of mental health conditions need to be linked with evidence-based, patient-centered, and accessible treatments. Obstetricians and gynecologists, midwives, family medicine providers, and pediatricians, are in unique positions not only to screen and diagnose, but also to treat individuals with mental health concerns, including SUD, during pregnancy and postpartum.
Perinatal Mental Health Disorders (PMHDs) pose significant challenges to the well-being of perinatal individuals, infants, and families. Despite their prevalence and impact, PMHDs often go undetected and untreated due to...Perinatal Mental Health Disorders (PMHDs) pose significant challenges to the well-being of perinatal individuals, infants, and families. Despite their prevalence and impact, PMHDs often go undetected and untreated due to gaps in clinician education and training. This manuscript reviews the current state of perinatal mental health training, identifies emerging initiatives, and discusses innovative models of care aimed at enhancing the clinical preparedness of healthcare providers. Key findings highlight disparities in PMHD detection and treatment, the need for standardized education across disciplines, and the role of interdisciplinary collaboration in improving care outcomes. The manuscript emphasizes the urgency of prioritizing reproductive psychiatry education to mitigate the adverse effects of PMHDs on maternal and infant health. By standardizing education and fostering interdisciplinary collaboration, we can ensure that all perinatal individuals receive the care they need to thrive.
Perinatal mental health research typically focuses on the birthing parent's experiences and their influence on birth/child outcomes, while not considering non-birthing parents in similar depth. Non-birthing parents are a...Perinatal mental health research typically focuses on the birthing parent's experiences and their influence on birth/child outcomes, while not considering non-birthing parents in similar depth. Non-birthing parents are also at increased risk for mental illness during the perinatal period, and non-birthing parents' health and involvement affect the health of birthing people, fetuses, and newborns, necessitating greater understanding of non-birthing parents' contributions to family functioning. This review examines perinatal mental health disorders in non-birthing parents, their relationship quality with the birthing parent, and how the non-birthing parent's mental health and involvement affects the health outcomes of the birthing parent and the child. Recommendations are provided for healthcare professionals who work with perinatal patients and their families to engage non-birthing parents, learn about non-birthing parent health, and facilitate connections to care. By doing so, professionals working with perinatal patients can optimize health outcomes for their patients and the family as a whole.
Across the spectrum of perinatal mental illness, there exist a variety of effective treatments. However, the available treatments are not always matched to the presentation, resources, constraints, or values of each pati...Across the spectrum of perinatal mental illness, there exist a variety of effective treatments. However, the available treatments are not always matched to the presentation, resources, constraints, or values of each patient. Furthermore, provider, local, and systemic factors complicate access to current treatment options. New and emerging approaches offer the potential of more effective treatment for specific perinatal psychiatric disorders. From neuroactive steroid medications to accelerated psychotherapy interventions, recent innovations have demonstrated enhanced efficacy on a faster timeline. Optimally, these developments will also lower barriers to care but this is not necessarily true. We review novel and upcoming interventions across perinatal mental illness and place them in the context of existing treatments and common challenges.
Perinatal mental health models can broadly be described by scope and structure. Within these two broad domains lies an array of diverse methodologies that have attempted to increase access and coordination of care. These...Perinatal mental health models can broadly be described by scope and structure. Within these two broad domains lies an array of diverse methodologies that have attempted to increase access and coordination of care. These efforts have uncovered many opportunities that, if addressed, may improve our current parent and infant outcomes within our healthcare system and community. Furthermore, there are several opportunities that, if addressed, will result in more equitable, inclusive care. These include being attentive to the unique needs of vulnerable populations, emphasizing community efforts, and closing the current gaps in legislation.