Gastroschisis Challenges North and South: Challenges in Brazil

Summary Slides: Gastroschisis Challenges North and South: Brazil

Challenges

• No specific plan for care existed
• Prenatal diagnosis was uncommon
• Most neonates were outborn and transferred
• Children were treated in Adult Intensive Care Unit
• Staged repair was the main technique
• Prior to 1995, we had complications as intestinal fistulae secondary to inadequate prosthesis as silo
• Mortality was high (one of every three babies with gastroschisis died)
• Babies with gastroschisis were often admitted to the Hospital in a delayed manner, sometimes up to 3 days after birth, with a clinical picture of dehydration, hypothermia or sepsis

Improvement Measures Implemented

• Eight targeted interventions were enacted in 2002
• Multidisciplinary effort (pediatric surgeons, neonatologists, obstetricians, and nurses)
• Literature review to delineate best practices in the care
• Two events in the University Hospital (HC-UFMG) – funding by Federal Government
• Expansion of the Fetal Medicine Center
• Inauguration of the Pediatric Intensive Care Unit
• The elements of the care package were:
  • Prenatal diagnosis
  • Inborn delivery
  • Monitored hydration to avoid electrolyte disturbances
  • Placement of PICC line for TPN (replaced cut-downs)
  • Early closure
  • Primary repair, when possible
  • Measurement of bladder pressure (to avoid abdominal compartment syndrome)
  • Early initiation of enteral feedings

Outcomes After Improvement Measures

• 156 newborns were treated for gastroschisis
• 35 (22.4%) and 121 (77.6%) before and after 2002, respectively.
• The number of patients treated increased progressively:
  • 35 from 1989 to 2001 (2.69 cases/year)
  • 50 from 2002 to 2007 (8.33 cases/year)
  • 71 from 2008 to 2013 (11.83 cases/year)
• Mortality decreased from 34.3% before 2002 to 24.8% (p =0.27)
• Median Hospital Stay for survivors decreased from 52 to 37 days (p= 0.057)
• Patients treated after 2002 had:
  • Higher rates of prenatal diagnosis (90.9% versus 60.0%, p < 0.001)
  • Delivery at a tertiary center (90.9% versus 62.9%, p < 0.001)
  • Early closure (65.3% versus 33.3%, p = 0.001)
  • Primary repair (55.4% versus 31.4%, p = 0.013)
  • Monitoring of bladder pressure (62.0% versus 2.9%, p = 0.001)
  • PICC placement (71.1% versus 25.7%, p < 0.001)
  • Early initiation of enteral feeding (54.5% versus 20.0%, p < 0.001)
  • Shorter duration of MV (median 7 versus 12 days, p=0.011)
  • Lower rates of electrolyte disturbances (53.7% versus 85.7%, p = 0.001).