Sequence of Multiple System Organ Failure in Preterm Neonate: A Retrospective Study

1
Sequence of Multiple System Organ Failure in
Pre-term Neonate A Retrospective Study

• Nursrath Habiba, Tetyana Vasylyeva, Kimberly
  Babiash, Jeff Low, Viet Do, Brianna Kirk, Olga
  Vasylyeva, Evanthia Biskinis, Mubariz Naqvi
• Department of Pediatrics, Texas Tech University
  Health Sciences Center at Amarillo, TX

2
Abstract

• There is not enough information to establish
  definitive criteria for diagnosis of Multiple
  System Organ Failure (MSOF) in neonates and
  particularly in pre-term newborns.
• Sequence of organ failure in neonates is not well
  understood as compared to the older children and
  the adult population.
• The purpose of our study was establish the
  sequence of organ failure in pre-term neonates.
• This is a retrospective study of 21 pre-term
  neonates (average gestational age of 27 weeks),
  admitted to Neonatal Intensive Care Unit of North
  West Texas Health System, Childrens Hospital
  (Amarillo, TX) between 2002 and 2004.
• The results showed that sequence of organ failure
  in preterm neonates is different from the term
  neonates . We found the hepatic system failed
  first, followed by respiratory, renal,
  hematological, and cardiac systems.
• Knowledge of definitive criteria and sequences
  could significantly improve early diagnostic and
  therapeutic intervention of MSOF.

3
Introduction

• Characteristics of neonatal MSOF are entirely
  different from MSOF from the older children and
  adults.
• More studies are needed in the neonatal
  population especially in pre-term newborns to
  understand the etiology and the disease process.
• The process begins as a healthy physiologic
  response to a variety of clinical insults,
  including infection, trauma, shock, asphyxia, and
  surgery.
• This response is known as systemic inflammatory
  response syndrome (SIRS) and is mediated by
  cytokines, complement factors, arachidonic acid
  metabolites, and the clotting cascade (1,2,3).
• Initial physiologic response becomes pathologic,
  as it spreads, and diffuse inflammation initiates
  tissue and end organ damage eventually leading to
  MSOF.
• Thus, SIRS leads to coagulopathy, hypotension,
  inadequate perfusion of peripheral tissues and
  organs, and, ultimately, organ failure and death
  (4).
• The anti-inflammatory/immunoparalytic phase of
  the SIRS following major insult is of utmost
  clinical importance in the neonate, as risk of
  infection is high ( 5, 6).

4
Introduction (Contd)

• The first pediatric study of MSOF done in 1986 by
  Wilkinson et al. suggested organ failure
  progresses in a different manner in neonates than
  in adults (7).
• The International pediatric sepsis consensus
  conference 2005 -Significant difference between
  criteria for SIRS in adult population, neonate
  and children (8).
• Highly important to define criteria for failure
  of each organ system (renal, hepatic,
  hematological, respiratory, and cardiovascular)
  in term neonates and pre-term newborns because
  physiology vastly differ from adults
• Subsequent retrospective chart review by Avanglu
  et al. defined criteria for neonatal MSOF and
  determined the sequence of organ failure. It
  started with renal failure, followed by
  microvascular, hematologic, hepatic, respiratory
  and cardiac failure (9).
• Before conclusive evidence of organ failure
  sequence can be drawn, unified criteria for MSOF
  must be identified in the preterm neonatal
  population.

5
Aim

• The purpose of our study was to identify
  criteria and establish the sequence of organ
  failure in pre-term neonates.

6
Materials And Methods

• Pre-term neonates (average gestational age of 27
  weeks) admitted to NICU of North West Texas
  Health System, Childrens Hospital (NWTH) at
  Amarillo, between 2002 and 2004.
• Retrospective study of chart review based upon
  clinical appearance of edema and decreasing urine
  output.
• We revised the criteria defined by Avanglu et al.
  (9) to be limited to parameters that were
  measured and recorded in our NICU.
• Data gathered included gestational age,
  birthweight, route of delivery, sex, cord pH,
  days spent in the NICU, race, age of death, and
  blood cultures.

7
Criteria for neonatal MSOF by Avanglu et al.
Inclusion At least 1 criteria in at least 2
organ systems. Sequence of organ failure
determined by the first to last organ system to
meet criteria.
8
Results

• Mean gestational age 27 weeks
• Mean Birth Weight 1022 Grams.
• 9 females and 12 males
• 10 hispanics, 1 African American, and 10
  caucasians.
• 13 cesarean section and 8 vaginal delivery.
• Average cord pH was 7.169.
• 6 survived MSOF with aggressive treatment and 14
  expired
• Average age of death was 31?25 days.
• The primary admitting diagnosis - prematurity,
  low birth weight respiratory distress.
• Average length of stay in the NICU 44?38.6 days.
• Average age of MSOF onset - day of life 14.
• 11 had sepsis with positive blood cultures.

9
The most common organisms cultured in order of
frequency
10
Results
11
Distribution of Avanglu et al MSOD criteria in
our neonate group ()
12
Sequence of MSOF from different studies
 
13
Discussion

• The mean gestational age of our group was 27
  weeks compared to 36.8 weeks in the Avanglu et
  al. study (9).
• Based on the prematurely of subjects respiratory
  failure presented earlier in the sequence.
• The respiratory consequences for survivors
  include the respiratory distress syndrome (11).
• Pneumonia and systemic infection are common in
  premature infants (12).
• Adequate ventilation, recognition of preventable
  risk factors and adoption of an appropriate
  ventilatory strategy, along with continuous real
  time monitoring, may help to minimise lung damage
  (13).

14
Discussion (Contd)

• Liver failure present as early as 2 day of life
  (14).
• Hepatic failure was measured by total bilirubin
  exceeding 6mg/dL (9).
• Difficult to distinguish pathologic versus
  nonpathologic jaundice of the pre-term newborn
  without looking at direct versus indirect
  hyperbilirubinemia.
• To better define hepatic failure , criteria
  should include upper limits of direct and
  indirect serum bilirubin levels.
•  

15
Discussion (Contd)

• To define renal failure, creatinine and urine
  output were used as indicators.
• All of our subjects had rising creatinine levels
  at some point in their stay.
• Urine output never below 1.0 cc/kg/hr.
• In 19 of 21 subjects, creatinine levels rose
  above 1.0 mg/dL without a corresponding decrease
  in urine output.
• In future, to define renal failure, urine output
  lt1ml/kg/hr should not be used as criteria.
• We believe urine output did not drop in relation
  to rising creatinine levels because many neonates
  in our NICU were on Furosemide which could have
  masked renal failures effect on urine output.

16
Discussion (Contd)

• As in previous studies, anemia was used as a
  criterion for hematologic failure.
• Anemia may be result of blood draws for daily lab
  work.
• platelets below 150,000/mm3 were used as a
  criterion for hematologic failure.
• Thrombocytopenia may be misrepresented by the
  hemodilution effects of blood transfusions with
  packed red blood cells.
•  

17
Conclusion

• The sequence and criteria of MSOF in pre-term
  neonates are different from term babies, older
  children and adults.
• Better defined criteria for pre-term newborn MSOF
  are needed, which would take into consideration
  physiology of pre-term babies and specifics of
  their care in NICU units.
• This would allow more accurate interpretation of
  lab values by helping one to know whether the
  abnormal test is a result of actual organ failure
  versus physiologic response versus iatrogenic
  causes (ie blood draw, transfusion, etc.).
• The early identification of SIRS risk factors,
  definitive criteria and knowledge of the
  sequences of failure could significantly
  contribute into prevention and treatment of MOSF.
•  

18
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