- Neonatal-Perinatal Medicine
Clinical Associate Professor, Pediatrics - Neonatal and Developmental Medicine
Residency: UCSD Dept of Pediatrics (2008) CA
Board Certification: American Board of Pediatrics, Neonatal-Perinatal Medicine (2012)
Fellowship: Stanford University Neonatology Fellowship (2011) CA
Medical Education: Creighton University School of Medicine Registrar (2005) NE
Board Certification: American Board of Pediatrics, Pediatrics (2008)
Correlation of preterm infant illness severity with placental histology.
2016; 39: 61-9
A major goal of neonatal medicine is to identify neonates at highest risk for morbidity and mortality. Previously, we developed PhysiScore (Saria et al., 2010), a novel tool for preterm morbidity risk prediction. We now further define links between overall individual morbidity risk, specific neonatal morbidities, and placental pathologies.102 placentas, including 38 from multiple gestations, were available from the previously defined PhysiScore cohort (gestational age ≤ 34 weeks and birth weight ≤ 2000 g). Placentas were analyzed for gross and histologic variables including maternal malperfusion, amniotic fluid infection sequence, chronic inflammation, and fetal vascular obstruction. Risk as determined by PhysiScore and recorded neonatal morbidities were tested for statistical association with placental findings.In pair-wise correlations, respiratory distress syndrome, bronchopulmonary dysplasia, acute hemodynamic instability, post-hemorrhagic hydrocephalus, culture-positive sepsis, and necrotizing enterocolitis each significantly correlated with at least one placenta histology variable. Amniotic fluid infection sequence (p = 0.039), specifically the fetal inflammatory response (p = 0.017), correlated with higher PhysiScores (greater morbidity) but was not independent of gestational age and birth weight. In multivariate analyses correlating variables with all nine morbidities, gestational age (p < 0.001), placental size <10th percentile (p = 0.031), full thickness perivillous fibrin deposition (p = 0.001), and amniotic fluid infection sequence (umbilical arteritis, p = 0.031; ≥2 chorionic plate vessels with vasculitis, p = 0.0125), each were significant associations.Amniotic fluid infection sequence plays a significant role in neonatal morbidity. Less neonatal morbidity was observed in older and heavier infants and those with small placental size and full thickness perivillous fibrin deposition. The combined assessment of placental gross and histologic findings together with physiologic risk evaluation may allow more precise prediction of neonatal morbidity risk soon after delivery.
View details for DOI 10.1016/j.placenta.2016.01.012
View details for PubMedID 26992676
View details for PubMedCentralID PMC4819396
Using simulation to study difficult clinical issues: prenatal counseling at the threshold of viability across american and dutch cultures.
Simulation in healthcare
2014; 9 (3): 167-173
Prenatal counseling at the threshold of viability is a challenging yet critically important activity, and care guidelines differ across cultures. Studying how this task is performed in the actual clinical environment is extremely difficult. In this pilot study, we used simulation as a methodology with 2 aims as follows: first, to explore the use of simulation incorporating a standardized pregnant patient as an investigative methodology and, second, to determine similarities and differences in content and style of prenatal counseling between American and Dutch neonatologists.We compared counseling practice between 11 American and 11 Dutch neonatologists, using a simulation-based investigative methodology. All subjects performed prenatal counseling with a simulated pregnant patient carrying a fetus at the limits of viability. The following elements of scenario design were standardized across all scenarios: layout of the physical environment, details of the maternal and fetal histories, questions and responses of the standardized pregnant patient, and the time allowed for consultation.American subjects typically presented several treatment options without bias, whereas Dutch subjects were more likely to explicitly advise a specific course of treatment (emphasis on partial life support). American subjects offered comfort care more frequently than the Dutch subjects and also discussed options for maximal life support more often than their Dutch colleagues.Simulation is a useful research methodology for studying activities difficult to assess in the actual clinical environment such as prenatal counseling at the limits of viability. Dutch subjects were more directive in their approach than their American counterparts, offering fewer options for care and advocating for less invasive interventions. American subjects were more likely to offer a wider range of therapeutic options without providing a recommendation for any specific option.
View details for DOI 10.1097/SIH.0000000000000011
View details for PubMedID 24401918
The accuracy of human senses in the detection of neonatal heart rate during standardized simulated resuscitation: implications for delivery of care, training and technology design.
2013; 84 (3): 369-372
Auscultation and palpation are recommended methods of determining heart rate (HR) during neonatal resuscitation. We hypothesized that: (a) detection of HR by auscultation or palpation will vary by more than ± 15BPM from actual HR; and (b) the inability to accurately determine HR will be associated with errors in management of the neonate during simulated resuscitation.Using a prospective, randomized, controlled study design, 64 subjects participated in three simulated neonatal resuscitation scenarios. Subjects were randomized to technique used to determine HR (auscultation or palpation) and scenario order. Subjects verbalized their numeric assessment of HR at the onset of the scenario and after any intervention. Accuracy of HR determination and errors in resuscitation were recorded. Errors were classified as errors of omission (lack of appropriate interventions) or errors of commission (inappropriate interventions). Cochran's Q and chi square test were used to compare HR detection by method and across scenarios.Errors in HR determination occurred in 26-48% of initial assessments and 26-52% of subsequent assessments overall. There were neither statistically significant differences in accuracy between the two techniques of HR assessment (auscultation vs palpation) nor across the three scenarios. Of the 90 errors in resuscitation, 43 (48%) occurred in association with errors in HR determination.Determination of heart rate via auscultation and palpation by experienced healthcare professionals in a neonatal patient simulator with standardized cues is not reliable. Inaccuracy in HR determination is associated with errors of omission and commission. More reliable methods for HR assessment during neonatal resuscitation are required.
View details for DOI 10.1016/j.resuscitation.2012.07.035
View details for PubMedID 22925993
Comparing the utility of a novel neonatal resuscitation cart with a generic code cart using simulation: a randomised, controlled, crossover trial
BMJ QUALITY & SAFETY
2013; 22 (2): 124-129
To compare a novel neonatal resuscitation cart (NRC) to a generic code cart (GCC).A prospective, randomised, controlled, crossover trial was performed to compare the utility of the NRC with the GCC during simulated deliveries of extremely low birthweight infants and infants with gastroschisis. Fifteen subjects participated. Mean times and accuracy of equipment and supply retrieval were compared for each scenario using the Wilcoxon test.Mean acquisition times for the NRC were always faster (by 58% to 74%) regardless of scenario (p<0.01). Accuracy of equipment selection did not differ. Ease of use was judged using a Likert scale (1=easiest to use; 5=most difficult), with mean score for NRC 1.1 and GCC 3.7 (p<0.0001). All subjects rated the NRC as easier to use.The NRC was superior to the GCC in acquisition speed, supply selection and ease of use.
View details for DOI 10.1136/bmjqs-2012-001336
View details for PubMedID 23112286
Newborn with prenatally diagnosed choroidal fissure cyst and panhypopituitarism and review of the literature.
2011; 1 (2): 111-114
Little has been reported on fetal diagnosis of choroidal fissure cysts and prediction of the clinical complications that can result. We describe the case of a near-term male infant with prenatally diagnosed choroidal fissure cyst and bilateral clubfeet. His prolonged course in the neonatal intensive care nursery was marked by severe panhypopituitarism, late-onset diabetes insipidus, placement of a cystoperitoneal shunt, and episodes of sepsis. Postnatal genetic evaluation also revealed an interstitial deletion involving most of band 10q26.12 and the proximal half of band 10q26.13. The patient had multiple readmissions for medical and surgical indications and died at 6 months of age. This case represents the severe end of the spectrum of medical complications for children with choroidal fissure cysts. It highlights not only the importance of comprehensive evaluation and multidisciplinary management and counseling in such cases, but also the need for heightened vigilance in these patients.
View details for DOI 10.1055/s-0031-1293512
View details for PubMedID 23705098
- Newborn with Prenatally Diagnosed Choroidal Fissure Cyst and Panhypopituitarism and Review of the Literature AJP REPORTS 2011; 1 (2): 111–14
Comparison of Umbilical Venous and Intraosseous Access During Simulated Neonatal Resuscitation
2011; 128 (4): E954-E958
Emergent umbilical venous catheter (UVC) placement for persistent bradycardia in the delivery room is a rare occurrence that requires significant skill and involves space constraints. Placement of an intraosseous needle (ION) in neonates has been well described. The ION is already used in the pediatric population and is placed at an anatomic location distant from where chest compressions are performed. In this study we compared time to placement, errors in placement, and perceived ease of use for UVCs and IONs in a simulated delivery room.Forty health care providers were recruited. Subjects were shown an instructional video of both techniques and allowed to practice placement. Subjects participated in 2 simulated neonatal resuscitations requiring intravenous epinephrine. In 1 scenario they were required to place a UVC and in the other an ION. Scenarios were recorded for later analysis of placement time and error rate. Subjects were surveyed regarding the perceived level of difficulty of each technique.The average time required for ION placement was 46 seconds faster than for UVC placement (P < .001). There was no significant difference in the number of errors between UVC and ION placement or in perceived ease of use.In a simulated delivery room setting, ION placement can be performed more quickly than UVC insertion without any difference in technical error rate or perceived ease of use. ION insertion should be considered when rapid intravenous access is required in the neonate at the time of birth, especially by health care professionals who do not routinely place UVCs.
View details for DOI 10.1542/peds.2011-0657
View details for PubMedID 21930542
Integration of Early Physiological Responses Predicts Later Illness Severity in Preterm Infants
SCIENCE TRANSLATIONAL MEDICINE
2010; 2 (48)
Physiological data are routinely recorded in intensive care, but their use for rapid assessment of illness severity or long-term morbidity prediction has been limited. We developed a physiological assessment score for preterm newborns, akin to an electronic Apgar score, based on standard signals recorded noninvasively on admission to a neonatal intensive care unit. We were able to accurately and reliably estimate the probability of an individual preterm infant's risk of severe morbidity on the basis of noninvasive measurements. This prediction algorithm was developed with electronically captured physiological time series data from the first 3 hours of life in preterm infants (< or =34 weeks gestation, birth weight < or =2000 g). Extraction and integration of the data with state-of-the-art machine learning methods produced a probability score for illness severity, the PhysiScore. PhysiScore was validated on 138 infants with the leave-one-out method to prospectively identify infants at risk of short- and long-term morbidity. PhysiScore provided higher accuracy prediction of overall morbidity (86% sensitive at 96% specificity) than other neonatal scoring systems, including the standard Apgar score. PhysiScore was particularly accurate at identifying infants with high morbidity related to specific complications (infection: 90% at 100%; cardiopulmonary: 96% at 100%). Physiological parameters, particularly short-term variability in respiratory and heart rates, contributed more to morbidity prediction than invasive laboratory studies. Our flexible methodology of individual risk prediction based on automated, rapid, noninvasive measurements can be easily applied to a range of prediction tasks to improve patient care and resource allocation.
View details for DOI 10.1126/scitranslmed.3001304
View details for Web of Science ID 000288436900003
View details for PubMedID 20826840
View details for PubMedCentralID PMC3564961
Delivery Room Management of the Newborn
PEDIATRIC CLINICS OF NORTH AMERICA
2009; 56 (3): 515-?
Neonatal resuscitation is an attempt to facilitate the dynamic transition from fetal to neonatal physiology. This article outlines the current practices in delivery room management of the neonate. Developments in cardiopulmonary resuscitation techniques for term and preterm infants and advances in the areas of cerebral resuscitation and thermoregulation are reviewed. Resuscitation in special circumstances (such as the presence of congenital anomalies) are also covered. The importance of communication with other members of the health care team and the family is discussed. Finally, future trends in neonatal resuscitation are explored.
View details for DOI 10.1016/j.pcl.2009.03.003
View details for PubMedID 19501690