Dr. Allen Cherer is a neonatal care expert with over 30 years of medical accomplishments to his name.


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Reducing Costs and Saving Lives

Sick newborns often rely on a ventilator to supply oxygen, and are tethered by a plastic endotracheal tube (ETT).  Often-times, this tube accidentally pops out.  This represents the fourth most common complication experienced by newborns in NICUs.  It can cause oxygen deficiency (hypoxia), high carbon dioxide levels in the blood, trauma to their airway, intraventricular hemorrhage, code events, and more.  “Unplanned extubations” also have the potential to nearly double the time of a hospital stay and increase the cost of care by $36,000 per patient.  Because of this, the Children’s National Health System’s NICU spearheaded a quality-improvement initiative to reduce the prevalence of unplanned extubations.

Many providers order a chest X-ray daily to verify the positioning of the ETT and prevent unplanned extubations.  However, this costs a lot of money, and potentially exposes infants to radiation.  Nobody needs to spend more money to expose themselves to more radiation, and that is particularly true for premature infants.  As part of their initiative, Children’s National has found that these same X-rays can be performed just twice weekly.  This sounds like a pretty simple initiative, but its consequences are surprisingly far-reaching: it lessens the chances of the breathing tube accidentally popping out, reducing radiation exposure, and saving roughly $1.6 million a year.  

The project started in July 2015, when Children’s National’s monthly X-ray expenditure was a whopping $289,520.  By the end of the year, that number had fallen down to $159,424, resulting in over $1 million in annual savings.  Within a month of implementation, unintended extubations dropped from 1.18 events per 100 ventilator days to .59.  Within five months, that number fell down .41.  Because of this initiative, unintended extubation rates at Children’s National are significantly lower than reported on various quality indices.  However, they don’t want to stop now, pledging to bring the rate down .3 events per 100 ventilator days.  I’m eager to see them reach their goal!

Pain in the NICU by dr. Allen Cherer

Pain in the NICU

When your child is placed in the Neonatal Intensive Care Unit (NICU), it’s an extremely stressful situation for everybody involved.  For parents, the stress of having their newborn in ICU is unimaginable.  But for the babies, maternal separation, noise, bright lights, procedures, and plenty of other operations make the experience overwhelming and extremely stressful in its own way, which can lead to various long-term consequences.  I recently read a very interesting blog post discussing why, and more importantly how, to deal with pain and stress in the NICU.    

It’s hard to imagine, but it was once believed that infants couldn’t feel pain.  Of course, we know now that that is hardly the case.  Although preterm infants have less localized and mature pain responses than their older counterparts, they still experience pain.  They often experience exaggerated pain responses, allodynia (pain from things that aren’t normally painful), and a longer latency in their responses.  The types of pain they experience include acute, postoperative, inflammatory, chronic, and visceral.  Pain experienced in these first stages of an infant’s life has potentially disastrous long-term consequences.  It may affect long-term memory, pain perception and responses, and possible alter social and cognitive development.  This is why understanding and addressing pain and stress in the NICU is so important.  

Stress and chronic pain is particularly difficult to assess, and is frequently superimposed by other types of pains.  When addressing acute pain due to procedures, it’s important to look at the procedure itself to see if it’s necessary, and also if you have access to local anesthetics.  Various sedatives, such as morphine, can be used for serious procedures, but each of these comes with its own set of long-term risks.  

Because of the stress and pain that comes with procedures, there’s been a movement to try and  limit the number of painful and stressful procedures.  There’s also been an effort to involve parents more to make the NICU environment less stressful.  This can involve swaddling, pacifiers, music, and family-centered care, all of which can reduce both stress and pain.  Because of this, parental participation, when combined with other methods, may be one of the safest options for the infant.  

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