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AimsCritical or High Level Incidents are unfortunately a part and parcel of clinical care, which we all strive to eliminate or at very least minimise. In most units, when they occur, an incident form is submitted online by the clinical staff involved. An investigation may be carried out, and the individuals involved receive feedback. Often, incidents recur due to poor awareness of past events, as disseminating information to different clinical teams is challenging.To enhance awareness of NICU High Level Incidents, this large neonatal intensive care unit has sought out novel ways to disseminate feedback on incidents occurring, to improve clinical practice and maximise learning from adverse events or near misses. As part of improving knowledge of HLIs and the investigation outcomes, a middle-grade Risk Management role was created in May of this year, alongside the corresponding senior nursing roles.MethodsSince commencement of this QI initiative, the named Risk registrar acts as a liaison doctor, disseminating feedback on a weekly basis to the medical team, through (P) production, email and discussion at communication meetings. Information given highlights recurrent themes, near misses and the learning points from recent HLIs. In tandem, nursing teams receive similar feedback about incidents relevant to the care that they provide.ResultsIn this 60-cot unit, 40 to 60 critical incidents are reported each month, demonstrating our culture of openness and education. Since May 2017, Messages of the Week have focused around medication errors (prescribing and administration), inter-specialty communication, discharge planning, documentation and WBITs (wrong blood in tubes.) There is a significant improvement in reported awareness of HLIs at all grades.ConclusionAs we strive to improve the quality of care that we provide for our NICU babies and their families, we must continue to explore novel methods of enhancing education and communication within our teams. With challenges in shift working and high turnover of staff in large neonatal units, disseminating a clinical risk Message of the Week to front-line medical and nursing staff is an effective way to ensure lessons are learnt from adverse events. more...

BackgroundFlow-cycled ventilation may allow more consistent tidal volume delivery with a decreased mean airway pressure and shorter inspiratory times, mimicking physiological breathing. However, questions still exist regarding its tolerance by preterm infants across different pressure settings.AimTo establish whether flow-cycled pressure-support ventilation (PSV), as a sole ventilatory modality, is well-tolerated by preterm infants across different pressures, and leads to more consistent tidal volumes with a lower mean airway pressure compared with time-cycled pressure-limited synchronised intermittent mandatory ventilation (SIMV).MethodsStable preterm infants (below 32 weeks’ gestation) with respiratory distress syndrome, from one tertiary neonatal unit over a 3 month period, with parents’ consent, underwent a randomised short-term cross-over trial on day 1 of life, of 1 hour epochs, exposed to two different levels of PSV, followed by two further 1 hour epochs on PSV and SIMV, with equal peak pressure settings. Physiological observations were recorded every 15 min, along with breath-by-breath mean airway pressure, tidal volume and calculated inspiratory time data, and blood gas analysis after each epoch. Mann Whitney U test was used to assess differences across the ventilatory settings.ResultsSix preterm infants met the inclusion criteria, with gestation age ranging from 24 to 28 weeks’ gestation, birth weight 532–1156 grams. The different pressure settings on PSV were well-tolerated with no significant physiological disturbance. There was no significant difference in minute ventilation or pCO2(p=0.70) across the two levels of pressure-support. A trend for a higher respiratory rate was seen with the lower pressure setting. The tidal volumes achieved were significantly more consistent (p<0.001), with shorter inspiratory times (0.07–0.20 (PSV) vs 0.37–0.4 (SIMV); p<0.001) and lower mean airway pressure (5–7 (PSV) vs 7–12 (SIMV); p<0.001) on flow-cycled compared with time-cycled ventilation.ConclusionFlow-cycled ventilation as a sole ventilatory modality is well-tolerated by preterm infants with a stable respiratory drive and may be advantageous in meeting ventilatory requirements with a lower mean airway pressure, reducing potential ventilator-associated lung injury. more...

AimNeonatal haemochromatosis is a rare clinical condition to present with acute liver failure in newborn period. This causes congenital cirrhosis or acute liver failure with and without iron overload and siderosis. Aim is to discuss their clinical presentations, diagnosis, response to treatment and outcome of infants with neonatal Haemochromatosis (NH) from a tertiary neonatal unit.MethodsReview of local database registry and notes of babies who are diagnosed with NH in our neonatal unit.ResultsThree babies have been diagnosed with NH. Two babies are from same family and are siblings. All babies were born preterm around 33 weeks. Two babies had IUGR at birth. The median birth weight is 1700 grams. Two babies presented with acute liver failure and coagulopathy from birth and one baby presented with sepsis and liver failure in second week of life. They all had deranged liver function tests, coagulopathy with increased PT/APTT. All had elevated ferritin and alpha feto protein. Ultrasound of the abdomen showed irregular nodules and a heterogeneous echo texture of the liver. All three babies had abnormal head scans with bilateral intraventricular haemorrhages and increased white matter echogenicities. Salivary gland biopsy on one of the siblings showed iron deposition which confirmed NH. This infant had double volume exchange therapy and immunoglobulin and the liver functions are returning to normal. Two babies passed away with multi organ failure Post-mortem examination showed extrahepatic siderosis.ConclusionNeonatal haemochromatosis is a rare condition due to maternal alloimmunity resulting in fetal liver injury. Early diagnosis and early treatment is crucial for survival.Identification of infants with NH is important as treatment is available and effective for subsequent pregnancies.Pre-natal diagnosis can be made by recognising the nodular liver and hydrops on fetal US and MR.IVIG therapy during pregnancy (18 weeks GA onwards) and after birth is shown to be effective in preventing the need of liver transplant, reduces mortality and even full recovery in some cases. more...