Beate Grass

Infants born before 32 weeks of gestation are at high risk of developing intraventricular hemorrhage (IVH), which is associated with significant mortality and morbidity as well as long-term neurodevelopmental impairment. There is currently a lack of consensus regarding the impact of delivery mode on these infants. Therefore, the aim of this study was to determine the association between mode of delivery and the incidence of severe intraventricular hemorrhage (sIVH) in very to extremely preterm infants born before 32 weeks of gestation. This retrospective cohort study was conducted at the University Hospital Zurich, Switzerland, using integrated obstetric and neonatal databases. Live births born between 23 + 0 and 31 + 6 weeks from 2015 to 2023 were included. Confounders were selected a priori based on a direct acyclic graph, and severe IVH incidence was compared between vaginal and cesarean delivery using univariable and multivariable logistic regression models. A total of 683 infants were eligible for analysis. The proportion of children born by cesarean section was 77.5%. The incidence of sIVH in preterm infants delivered by cesarean section was 4.7% compared to 3.9% in vaginal deliveries. The univariable logistic regression analysis demonstrated no significant association between cesarean section and sIVH (OR 1.32, 95% CI 0.53-3.28, p = 0.529). In this cohort of very and extremely preterm infants, there was no significant association between the incidence of severe IVH and mode of delivery. These findings do not support cesarean sections as a preventive measure for sIVH and highlight the importance of optimizing pre-, peri-, and postnatal factors that impact haemodynamic stability.

Background/Objectives: Neonates with hypoxic–ischemic encephalopathy (HIE) are born in delivery facilities with different levels of neonatal care. The objective of this study was to investigate differences in the incidence of HIE and postnatal management between different levels of neonatal care in delivery facilities. Methods: This is a retrospective, multi-center cohort study of neonates with moderate-to-severe HIE receiving therapeutic hypothermia (TH) in the Canton of Zurich, Switzerland, registered in the Swiss National Asphyxia and Cooling Register between 2015 and 2023. Incidences of HIE receiving TH were calculated for all delivery facilities according to the national levels of neonatal care on site (Level I—basic; Level IIB—intermediate (no Level IIA facility in the Canton of Zurich); Level III—intensive neonatal care). Perinatal characteristics and variables on transport and outcomes were compared between neonates born in Level I and Level IIB facilities (the majority of the HIE population) and reported for neonates born in all other facilities (for completeness). Results: A total of 173 neonates (79 (45.7%) born in Level I; 80 (46.2%) in Level IIB; 9 (5.2%) in Level III; 5 (2.9%) in birthing centers) were admitted to a neonatal cooling center to receive TH. The average number of annual cases of HIE receiving TH per facility was 0.67 (0.11–1.50) in Level I and 2.22 (0.22–3.11) in Level IIB facilities (p = 0.088), respectively. There was no difference in Apgar score, worst pH (within 60 min after birth) and the severity of encephalopathy between neonates born in Level I and Level IIB facilities. Neonatal transport team requests were initiated earlier in Level I facilities (median 12 vs. 34 min of life, p < 0.001). There was no difference in age at initiation of TH (median 3 vs. 3 h, p = 0.431) and the time when target temperature was reached (median 4 vs. 4 h, p = 0.431) between neonates born in Level I and Level IIB facilities. Conclusions: The level of neonatal care available in delivery facilities influenced the management of neonates with HIE receiving TH.

The objective of this study was to assess the adherence to inclusion criteria for therapeutic hypothermia (TH) in neonates with hypoxic-ischemic encephalopathy (HIE) and to survey current attitudes on TH. This multicenter observational study therefore combined a retrospective analysis of the Swiss National Asphyxia and Cooling Register (2011–2023) and a prospective survey (2024) among neonatologists in the Canton of Zurich, Switzerland. A total of 456 neonates with HIE were registered in the Swiss National Asphyxia and Cooling Register in the Canton of Zurich, Switzerland, between 2011 and 2023. The rate of TH (52.6% [2011–2017] versus 52.0% [2018–2023]) as well as the incidence of off-protocol cooling remained stable over time ( p = 0.614). The survey response rate was 69.5% (57/82). Difficulties with clinical grading of encephalopathy were identified. Subjectively, respondents considered themselves more generous to initiate TH. In conclusion, register data reflected good adherence to inclusion criteria for TH. The survey confirmed willingness to consider TH in milder HIE cases. However, there was no drift in clinical practice—yet?

Background/Objectives: Hypoxic-ischemic encephalopathy (HIE) in late preterm and term neonates accounts for neonatal mortality and unfavorable neurodevelopmental outcomes in survivors despite therapeutic hypothermia (TH) for neuroprotection. The circumstances of death in neonates with HIE, including involvement of neonatal palliative care (NPC) specialists and neurodevelopmental follow-up at 18–24 months in survivors, warrant further evaluation. Methods: A retrospective multicenter cohort study including neonates ≥ 35 weeks gestational age with moderate to severe HIE receiving TH, registered in the Swiss National Asphyxia and Cooling Register between 2011 and 2021. Neurodevelopmental follow-up at 18–24 months in survivors was assessed. The groups of survivors and deaths were compared regarding perinatal demographic and HIE data. Prognostic factors leading to redirection of care (ROC) were depicted. Results: A total of 137 neonates were included, with 23 (16.8%) deaths and 114 (83.2%) survivors. All but one death (95.7%) occurred after ROC, with death on a median of 3.5 (2–6) days of life. Severe encephalopathy was indicated by a Sarnat score of 3 on admission, seizures were more frequent, and blood lactate values were higher on postnatal days 1 to 4 in neonates who died. Lactate in worst blood gas analysis (unit-adjusted odds ratio 1.25, 95% CI 1.02–1.54, p = 0.0352) was the only variable independently associated with ROC. NPC specialists were involved in one case. Of 114 survivors, 88 (77.2%) had neurodevelopmental assessments, and 21 (23.9%) of those had unfavorable outcomes (moderate to severe disability). Conclusions: Death in neonates with moderate to severe HIE receiving TH almost exclusively occurred after ROC. Parents thus had to make critical decisions and accompany their neonate at end-of-life within the first week of life. Involvement of NPC specialists is encouraged in ROC so that there is continuity of care for the families whether the neonate survives or not.

Background/Objectives: Hypoxic-ischemic encephalopathy (HIE) in (near)term neonates accounts for neonatal mortality and unfavorable neurodevelopmental outcome in survivors, despite therapeutic hypothermia (TH) for neuroprotection. The circumstances of death in neonates with HIE and involvement of neonatal palliative care (NPC) specialists warrant further evaluation. Methods: Retrospective multicenter cohort study including neonates ≥ 35 weeks gestational age with moderate to severe HIE receiving TH, registered in the Swiss National Asphyxia and Cooling Register between 2011 and 2021. Neurodevelopmental follow-up at 18-24 months in survivors was assessed. The groups of survivors and deaths were compared regarding perinatal demographic and HIE data. Prognostic factors leading to redirection of care (ROC) were depicted. Results: 137 neonates were included, 23 (16.8%) deaths and 114 (83.2%) survivors. All but one death (95.7%) occurred after ROC with death on median 3.5 (2-6) days of life. Severe encephalopathy indicated by Sarnat score 3 on admission and seizures were more frequent, and blood lactate values were higher on postnatal days 1 to 4 in neonates who died. Lactate in worst blood gas analysis (unit aOR 1.25, 95% CI 1.02-1.54, p=0.0352) was the only variable independently associated with ROC. NPC specialists were involved in one case. Of 114 survivors, 88 (77.2%) had neurodevelopmental assessments, and 21 (23.9%) of those had unfavorable outcome (moderate to severe disability). Conclusions: Death in neonates with moderate to severe HIE receiving TH almost exclusively occurred after ROC. Parents thus had to take critical decisions and accompany their neonate at end-of-life within the first week of life. To ensure continuity of care for the family, also beyond the death of the neonate, involvement of NPC specialists is encouraged in ROC.

Neonates with medical problems need transfer from the place of birth to a neonatal (intensive care) unit after birth by a specialized neonatal transport team. Neonatal transport is accompanied by a high emotional burden for the families due to spatial separation, uncertainty and care for the neonate. This survey of parents' needs was a quality control project of the neonatal transport team of the University Children's Hospital Zurich, Switzerland. The aim was to identify areas for improvement of family-centred care and to derive concrete suggestions for adjustments in the transport process. This single-center prospective cross-sectional study included parents of neonates transported between January 2021 and February 2022. Based on a literature review, an anonymous questionnaire was developed (mini-Delphi method) and conducted using an online survey tool. The survey results were analyzed descriptively. The response rate was 77% (168/217). The majority of parents agreed with the current procedures for neonatal transports and experienced the transport team as professional. There were no (emotional) support measures applied by the transport team which were not approved by the parents. Some parents suggested the following additions: the possibility of parental accompaniment during transport, contact by telephone on arrival at the destination hospital, and an improvement in the transmission of medical information, both prenatally and in the context of transport. There is potential for improvement in meeting parental needs during neonatal transport. Some parental suggestions can be implemented easily and cost-effectively. The importance of professional communication and situationally adapted information for parents was confirmed.

The Swiss National Asphyxia and Cooling Register was implemented in 2011. This study assessed quality indicators of the cooling process and (short-term) outcomes of neonates with hypoxic-ischemic encephalopathy (HIE) receiving therapeutic hypothermia (TH) longitudinally over time in Switzerland. This is a multicenter national retrospective cohort study of prospectively collected register data. Quality indicators were defined for longitudinal comparison (2011–2014 vs. 2015–2018) of processes of TH and (short-term) outcomes of neonates with moderate-to-severe HIE. Five hundred seventy neonates receiving TH in 10 Swiss cooling centers were included (2011–2018). Four hundred forty-nine (449/570; 78.8%) neonates with moderate-to-severe HIE received TH according to the Swiss National Asphyxia and Cooling Register Protocol. Quality indicators of processes of TH improved in 2015–2018 (compared with 2011–2014): less passive cooling ( p = 0.013), shorter time to reach target temperature ( p = 0.002), and less over- or undercooling ( p < 0.001). In 2015–2018, adherence to performing a cranial magnetic resonance imaging after rewarming improved ( p < 0.001), whereas less cranial ultrasounds were performed on admission ( p = 0.012). With regard to quality indicators of short-term outcomes, persistent pulmonary hypertension of the neonate was reduced ( p = 0.003), and there was a trend toward less coagulopathy ( p = 0.063) in 2015–2018. There was no statistically significant change in the remaining processes and outcomes. The Swiss National Asphyxia and Cooling Register is well implemented with good overall adherence to the treatment protocol. Management of TH improved longitudinally. Continuous reevaluation of register data is desirable for quality assessment, benchmarking, and maintaining international evidence-based quality standards.

Background: Connection and opening a syringe infusion pump to a central venous line can lead to acute anterograde or retrograde fluid shifts depending on the level of central venous pressure. This may lead to bolus events or to prolonged lag times of intravenous drug delivery, being particularly relevant when administering vasoactive or inotropic drugs in critically ill patients using microinfusion. The aim of this study was to assess the effect of syringe pump positioning at different vertical heights on start‐up fluid delivery before versus after purging and connection the pump to the central venous catheter.Methods: This in vitro study measured ante‐ and retrograde infusion volumes delivered to the central venous line after starting the syringe pump at a set infusion rate of 1 mL/h. In setup one, the pump was first positioned to vertical levels of +43 cm or –43 cm and then purged and connected to a central venous catheter. In setup two, the pump was first purged and connected at zero level and secondarily positioned to a vertical level of +43 cm or –43 cm. Central venous pressure was adjusted to 10 mmHg in both setups.Results: Positioning of the pump prior to purging and connection to the central venous catheter resulted in a better start‐up performance with delivered fluid closer to programmed and expected infusion volumes when compared to the pump first purged, connected, and then positioned. Significant backflow volumes were observed with the pump purged and connected first and then positioned below zero level. No backflow was measured with the pump positioned first below zero level and then purged and connected.Conclusions: Syringe infusion pump assemblies should be positioned prior to purging and connection to a central venous catheter line when starting a new drug, particularly when administering highly concentrated vasoactive or inotropic drugs delivered at low flow rates.

Background and Objectives: The purpose of the study is to assess parental experiences of therapeutic hypothermia for moderate to severe hypoxic-ischemic encephalopathy with the goal of improving local clinical practice guidelines and fostering family-integrated care in neonates with hypoxic-ischemic encephalopathy. Methods: This single-center retrospective cross-sectional study included neonates and their parents registered in the Swiss National Asphyxia and Cooling Register between 2011 and 2021. Based on a literature review, an anonymous survey of parents of neonates with hypoxic-ischemic encephalopathy was developed and conducted using an online survey tool. Descriptive statistics were used to analyze the survey results. Results: The overall response rate to this survey was 64% (46/72). Sufficient information about hypoxic-ischemic encephalopathy was reported by 78% (36/46) of parents and sufficient information about the process of therapeutic hypothermia by 87% (40/46) of parents. The majority of parents indicated the need for, and at least a satisfactory perception of, professional (91%; 42/46) and emotional (87%; 40/46) support. Parents identified fostering family involvement and regular family communication that focuses on family integrated care as areas for improvement. Conclusions: There is still an unmet need for multidisciplinary teams to provide professional, empathetic, high quality, and family-integrated care to families with a neonate receiving therapeutic hypothermia for moderate or severe hypoxic-ischemic encephalopathy.