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Papers by Bert Smit
Aim To study the hypothesis that high frequency ventilation (HFV) is an additional stressor compa... more Aim To study the hypothesis that high frequency ventilation (HFV) is an additional stressor compared to conventional ventilation (CV). Methodology A prospective explorative cohort study in a consecutive sample of 50 preterm infants (<37 gestational age) with Respiratory Distress Syndrome admitted to a Level III Neonatal Intensive Care Unit. During the first three days of ventilation stress was assessed by means of the Comfort scale (CS). Results 35 Infants received HFV and 15 CV. The HFV group was significantly younger (p = 0.003), had a significant lower birth weight (p = 0.017) and were significant more severely ill (p < 0.0001). Stress scores between groups were comparable, adjustment for baseline differences revealed no differences in scores during the first 3 days of ventilation. Of all CS assessments, 34.0% in the HFV group and 35.6% in the CV group indicated stress (score ≥ 20). Conclusion Stress during the first three days of mechanical ventilation using the CS did not reveal any difference between high frequency and conventional ventilated preterm infants. Routine use of sedatives seems insufficient to prevent high stress scores.
Obstetric Anesthesia Digest, 2009
Although elevated maternal temperature is known to be associated with intrauterine infection, inc... more Although elevated maternal temperature is known to be associated with intrauterine infection, increased risk of neonatal infection, and the use of epidural analgesia for labor, the exact range of normal maternal temperature during labor is not well described. This prospective cohort study examined the variations of normal maternal temperature in laboring women at a gestational age >36 weeks. Maternal rectal temperatures were measured in all laboring women at the authors’ institutions every 2 to 3 hours from admission until the beginning of the second stage and at 1-hour intervals postpartum.Womenwere excluded if scheduled for a planned cesarean delivery, if they presented in labor at full cervical dilation, or if the fetus was breech or had a serious congenital anomaly. Patients were separated into 2 groups. The study group (abnormal labor group) had factors associated with elevated maternal temperature, that is, admission to the delivery room Z6 hours before delivery, meconium-stained amniotic fluid, epidural analgesia, induction or augmentation of labor, rupture of membranes Z18 hours before birth, Z5 vaginal examinations, and operative delivery. Women in the normal labor group presented at Z37 week gestation, had spontaneous onset of labor, rupture of membranes <18 hours before birth, clear amniotic fluid, normal labor progress without the need for augmentation, epidural analgesia, or antibiotics, and also spontaneously delivered a healthy infant in normal condition. Intrauterine infection was deemed present if temperature was Z381C or Z381C along with fetal or maternal tachycardia, meconium-stained amniotic fluid, or maternal white blood cell count Z16 10/L. Women with infections were treated with intravenous amoxicillin or gentamicin until delivery. Data on 3052 of 3358 women were complete enough for analysis. Normal labor occurred in 843 women and abnormal labor in 2209 in whom a diagnosis of intrauterine infection during labor was made in 84 (2.7%). The mean temperature during labor in all patients increased from 37.11C [2 standard deviation (2-SD) 0.71C; 95% confidence interval (CI), 36.5-37.71C] at the beginning of labor to 37.41C (SD 1.21C; CI 36.4-38.21C ) after 22 hours. In the women having a normal labor, the mean temperature was 37.11C (CI, 36.4-37.71C); in those having an abnormal labor, the temperature was equal to the normal labor group during the first 3 hours of labor but then increased thereafter. For all measurements before delivery, mean temperature readings were similar for the normal and abnormal groups. Only 2% of women with normal labor had a temperature during labor higher than the upper 2-SD limit, whereas this occurred in 8% of those in the abnormal labor group. The regression coefficient for 2-SD was significantly higher in the abnormal labor group (0.0301C/h vs. the normal labor group 0.0081C/h). About 91% of those with an intrauterine infection diagnosis had a temperature above the 2-SD limit. Multivariate analysis demonstrated that a temperature higher than the 2-SD limit was associated with epidural analgesia [odds ratio (OR), 3.1; CI, 1.9-5.2], in hospital Z6 hours before delivery (OR, 3.1; CI, 1.9-5.4), meconium-stained fluid (OR, 2.0; CI, 1.2-3.1), and rupture of membranes Z18 hours before delivery (OR, 1.9; CI, 1.1-3.1). Temperature remained stable in the normal-labor group but slowly increased throughout labor in those with an abnormal labor. A circadian pattern was not found at the upper 2-SD limit and time of day is not relevant for classifying normal versus elevated temperature.
MCN: The American Journal of Maternal/Child Nursing, 2013
To prospectively evaluate hazards in the process of supplemental oxygen therapy in very preterm i... more To prospectively evaluate hazards in the process of supplemental oxygen therapy in very preterm infants hospitalized in a Dutch NICU. Methods: A Failure Mode and Effects Analysis (FMEA) was conducted by a multidisciplinary team. This team identifi ed, evaluated, and prioritized hazards of supplemental oxygen therapy in preterm infants. After accrediting "hazard scores" for each step in this process, recommendations were formulated for the main hazards. Results: Performing the FMEA took seven meetings of 2 hours. The top 10 hazards could all be categorized into three main topics: incorrect adjustment of the fraction of inspired oxygen (FiO 2), incorrect alarm limits for SpO 2 , and incorrect pulse-oximetry alarm limits on patient monitors for temporary use. The FMEA culminated in recommendations in both educational and technical directions. These included suggestions for (changes in) protocols on alarm limits and manual FiO 2 adjustments, education of NICU staff on hazards of supplemental oxygen, and technical improvements in respiratory devices and patient monitors. Conclusions: The FMEA prioritized fl aws in the process of supplemental oxygen therapy in very preterm infants. Thanks to the structured approach of the analysis by a multidisciplinary team, several recommendations were made. These recommendations are currently implemented in the study's center.
Archives of disease in childhood. Fetal and neonatal edition, Feb 10, 2018
To compare a low versus a higher threshold for intervention in preterm infants with posthaemorrha... more To compare a low versus a higher threshold for intervention in preterm infants with posthaemorrhagic ventricular dilatation. Multicentre randomised controlled trial (ISRCTN43171322). 14 neonatal intensive care units in six countries. 126 preterm infants ≤34 weeks gestation with ventricular dilatation after grade III-IV haemorrhage were randomised to low threshold (LT) (ventricular index (VI) >p97 and anterior horn width (AHW) >6 mm) or higher threshold (HT) (VI>p97+4 mm and AHW >10 mm). Cerebrospinal fluid tapping by lumbar punctures (LPs) (max 3), followed by taps from a ventricular reservoir, to reduce VI, and eventually a ventriculoperitoneal (VP) shunt if stabilisation of the VI below the p97+4 mm did not occur. VP shunt or death. 19 of 64 (30%) LT infants and 23 of 62 (37%) HT infants were shunted or died (P=0.45). A VP shunt was inserted in 12/64 (19%) in the LT and 14/62 (23%) infants in the HT group. 7/12 (58%) LT infants and 1/14 (7%) HT infants required shunt r...
To study the effect of L-thyroxine supplementation on neurologic maturation in very preterm infan... more To study the effect of L-thyroxine supplementation on neurologic maturation in very preterm infants with transient hypothyroxinemia.
Endoscopy, 2015
We thank Saliou and Baron for their comments. They state that microbial surveillance of endoscope... more We thank Saliou and Baron for their comments. They state that microbial surveillance of endoscopes by antegrade sampling with a sterile 0.9 % saline solution might be insufficient to reveal the microbial contamination. They also suggest the additional use of thiosulfate during sampling. Unfortunately, in the outbreak we described, the use of a thiosulfate-containing buffer would not have been able to detect the microbial contamination. As the manufacturer states, the elevator wire channel of the TJF-Q180V is sealed by an O-ring, which means that separate cleaning is no longer necessary. Moreover, this scope is also designed with a unique distal cap that is fixed, which impairs cleaning and disinfection in the spaces within this cap. Sampling of these spaces is only possible when using an ultrathin swab, as demonstrated in our study, which thereby revealed the VIM-2 producing Pseudomonas aeruginosa. However, we do agree with Saliou and Baron that the optimal sampling method for endoscopes is still under debate. At present, the use of sterile 0.9 % saline solution is recommended by the European Society of Gastrointestinal Endoscopy and the European Society of Gastroenterology and Endoscopy Nurses and Associates. Although the French guideline recommends the use of a tensioactive solution (e. g. Tween 80) to increase the detection of microorganisms, the use of sodium thiosulfate is not mentioned in this guideline. The combination of the narrow lumina of the endoscope and heavy contamination with blood, secretions, and microorganisms during its use, might promote the growth of biofilms in cases of insufficient (pre)cleaning. Once these biofilms occur, they are very resilient to physical removal by regular cleaning and are less susceptible to biocides. In a recent review, it was concluded that by ensuring prompt device cleaning and reprocessing, either by high-level disinfection or sterilization, and proper drying, biofilms will not have a chance to form [8]. Unfortunately, at present there is no evidence in the literature that a consensus on this matter has been reached. However, in light of recent reports of microbiological outbreaks after endoscopy, a reliable method of investigating microbial safety following high-level disinfection is urgently needed. The utility of sodium thiosulfate or another biofilm dissolver should be investigated in studies, led, ideally, by an international working group consisting of microbiologists and endoscopists. In addition, a consensus statement concerning the interpretation and action required from the data collected should become available and updated regularly. Saliou and Baron also stress the importance of endoscope drying in order to prevent bacterial proliferation. The importance of drying has been emphasized previously by Muscarella. As stated in our manuscript, at the Erasmus MC all endoscopes are dried and stored in a storage cabinet (WASSENBURG DRY 300; Wassenburg Medical Devices BV, Dodewaard, The Netherlands), unless immediate re-use (within 4 hours) is required. Therefore, bacterial proliferation during storage was not considered to be a possible cause of the VIM-2 producing P. aeruginosa outbreak.
Samenvatting Doel Voor pasgeborenen die intensieve zorg nodig hebben is sondevoeding vaak van lev... more Samenvatting Doel Voor pasgeborenen die intensieve zorg nodig hebben is sondevoeding vaak van levensbelang. Gebrek aan goede eenduidige richtlijnen voor het inbrengen en controleren van de sonde kan leiden tot onveilige situaties. Bij mechanisch beademde kinderen en kinderen met continuous positive airway pressure (CPAP) zou een verkeerde positie van de maagsonde ertoe kunnen leiden dat overtollige lucht niet goed kan worden afgevoerd. De volgende hypothese is getoetst: een betere positie van de maagsonde hangt positief samen met een geringere hoeveelheid lucht in de maag. Proefpersonen Een jaarcohort pasgeborenen met een voedingssonde, van een niveau IIIc neonatale intensive care unit (NICU). Design en Methode Retrospectief zijn op röntgenfoto’s van 326 pasgeborenen de positie van de sonde en de hoeveelheid lucht in de maag geclassifi ceerd. De demografi sche gegevens worden beschreven. Met Kendal’s T is de relatie tussen de positie van de sonde en de hoeveelheid lucht in de maag g...
Samenvatting De resultaten van een literatuuronderzoek naar de positionering van maagsondes en de... more Samenvatting De resultaten van een literatuuronderzoek naar de positionering van maagsondes en de controle daarvan laten zien dat het inbrengen van een maagsonde via de neus of de mond minder eenvoudig en veilig is dan over het algemeen wordt aangenomen. Beschreven worden de frequentie waarmee maagsondes verkeerd gepositioneerd zijn, factoren die de kans hierop vergroten en de problemen die hierdoor kunnen ontstaan. Vervolgens worden de meest gebruikte manieren van controleren van de positie van voedingssondes besproken, inclusief mogelijke alternatieven. Tot slot worden aanbevelingen voor de praktijk gedaan.
Endoscopy, 2015
Background and study aims: Infections are a recognized risk of endoscopic retrograde cholangiopan... more Background and study aims: Infections are a recognized risk of endoscopic retrograde cholangiopancreatography (ERCP). This paper reports on a large outbreak of VIM-2-producing Pseudomonas aeruginosa that was linked to the use of a recently introduced duodenoscope with a specific modified design (Olympus TJF-Q180V). Methods: Epidemiological investigations and molecular typing were executed in order to identify the source of the outbreak. Audits on implementation of infection control measures were performed. Additional infection control strategies were implemented to prevent further transmission. The design and the ability to clean and disinfect the duodenoscope were evaluated, and the distal tip was dismantled. Results: From January to April 2012, 30 patients with a VIM-2-positive P. aeruginosa were identified, of whom 22 had undergone an ERCP using a specific duodenoscope, the TJF-Q180V. This was a significant increase compared with the hospital-wide baseline level of 2 - 3 cases per month. Clonal relatedness of the VIM-2 P. aeruginosa was confirmed for all 22 cases and for the VIM-2 strain isolated from the recess under the forceps elevator of the duodenoscope. An investigational study of the new modified design, including the dismantling of the duodenoscope tip, revealed that the fixed distal cap hampered cleaning and disinfection, and that the O-ring might not seal the forceps elevator axis sufficiently. The high monthly number of cases decreased below the pre-existing baseline level following withdrawal of the TJF-Q180V device from clinical use. Conclusions: Duodenoscope design modifications may compromise microbiological safety as illustrated by this outbreak. Extensive pre-marketing validation of the reprocessability of any new endoscope design and stringent post-marketing surveillance are therefore mandatory.
Journal of neonatal-perinatal medicine, 2014
In multi-infusion IV therapy, the actual volume delivered to the neonate can vary over time. To r... more In multi-infusion IV therapy, the actual volume delivered to the neonate can vary over time. To reduce flow rate variability, check valves can be used. A check valve allows flow through the valve in only one direction. To evaluate flow rate variability in a low flow dual-infusion setup with and without check valves. The effect of changing the height of and adding syringes to the IV-administration set was tested with and without check valves in an in vitro dual-infusion setup with in-line flow meters. The pre-programmed flow rates were 2.5 and 0.1 ml/h. Twenty-four tests of 90 minutes were performed. Time to reach 75% of the pre-programmed 0.1 ml/h flow rate was >20 minutes. The highest total delivered volume during a test was (mean ± SD) 56 ± 8% of the expected delivery for tests without check valves, and diminished to 12 ± 24% of the expected delivery for check valves with a higher opening pressure. The actual flows and the total delivered volume in low flow dual-infusion setups...
Arch. Dis. Child.-Fetal Neonatal Ed., 2011
Clinical and Experimental Immunology - CLIN EXP IMMUNOL, 2000
Therapeutic Drug Monitoring, 1995
British Journal of Nutrition, 2007
Several studies have described reduced plasma concentrations of arginine, the substrate for nitri... more Several studies have described reduced plasma concentrations of arginine, the substrate for nitric oxide synthase (NOS) in infants with necrotizing enterocolitis (NEC). No information on the plasma concentrations of the endogenous NOS inhibitor asymmetric dimethylarginine (ADMA) in patients with NEC is currently available. We investigated whether plasma concentrations of arginine, ADMA, and their ratio differ between premature infants with and without NEC, and between survivors and non-survivors within the NEC group. In a prospective case–control study, arginine and ADMA concentrations were measured in ten premature infants with NEC (median gestational age 193 d, birth weight 968 g), and ten matched control infants (median gestational age 201 d, birth weight 1102 g), who were admitted to the Neonatal Intensive Care Unit. In the premature infants with NEC, median arginine and ADMA concentrations (μmol/l), and the arginine:ADMA ratio were lower compared to the infants without NEC: 21·...
Pediatric Anesthesia, 2013
Aim: To provide an overview of factors influencing the flow rate in intravenous (IV) therapy for ... more Aim: To provide an overview of factors influencing the flow rate in intravenous (IV) therapy for newborns. Methods: We conducted a review of the literature from 1980 to 2011 in PubMed and Web of Knowledge. Articles focusing on flow-rate variability and possible complications due to flow-rate variability were included. Results: Forty-one articles were selected for this review. IV therapy in (preterm) neonates is prone to significant start-up delays and flow-rate variability. The sudden changes in the volume delivered to (preterm) neonates may have serious consequences. Low preprogrammed flow rates, total compliance, and volume of the IV administration set, the presence or absence of antisiphon valves or inline filters and the vertical displacement of syringe pumps all contribute to flow-rate variability in IV therapy for neonates. Conclusions: Flow-rate variability in IV therapy and its clinical relevance are due to the preprogrammed flow rate, the hydrostatic pressure changes, the complete IV administration set compliance and the type of substances supplied to the patient. To improve IV therapy, the internal compliance of the complete IV administration set should be minimized and the highest possible preprogrammed flow rate should be used in combination with small syringes and low-resistance valves.
Nursing in Critical Care, 2013
Aims: This article aims (a) to get insight into intensive care nurses' most critical work-related... more Aims: This article aims (a) to get insight into intensive care nurses' most critical work-related incidents, (b) their reactions and coping and (c) perceived support, in a Dutch intensive care unit. Background: Research about the impact of critical incidents has largely been aimed at ambulance and emergency nurses; knowledge about intensive care nurses in this respect is scarce. Persistent stress reactions after critical incidents may cause symptoms of post-traumatic stress disorder, depression and anxiety. Unresolved problems may also cause poor behaviour towards patients. In response, nurses reduce work hours or even resign. Social support alleviates emotional problems, but little is known about actual support perceived. Design: This study is a qualitative explorative study. Method: Thematic analysis of semi-structured interviews was performed among a purposive sample of 12 intensive care nurses in a university hospital in The Netherlands. Findings: Four main themes have been identified in critical incidents: high emotional involvement in patient-related incidents (in contrast to major life-threatening events as such), avoidable incidents, substandard patient care and intimidation. Themes discerned in nurses' reactions after critical incidents were physical reactions, emotional reactions and cognitive/behavioural reactions. After critical incidents, nurses talked with colleagues, friends or relatives, but would have appreciated additional support. Conclusions: Incidents under emotionally demanding circumstances are among the most difficult situations, but may not be recognized as critical incidents by colleagues. Both adequate and inadequate coping strategies, with long-lasting problems after critical incidents, were reported. Feelings of anger, shame and powerlessness, may have hindered recovery. Talking to colleagues was perceived to be helpful, but intensive care nurses' need for support was insufficiently met. Relevance to clinical practice: Managers should acknowledge the effects of critical incidents on intensive care nurses and take preventive measures: reducing critical incidents, improving open communication, imposing a buddy-system for collegial support, and timely evaluating the necessity of professional help.
Aim To study the hypothesis that high frequency ventilation (HFV) is an additional stressor compa... more Aim To study the hypothesis that high frequency ventilation (HFV) is an additional stressor compared to conventional ventilation (CV). Methodology A prospective explorative cohort study in a consecutive sample of 50 preterm infants (<37 gestational age) with Respiratory Distress Syndrome admitted to a Level III Neonatal Intensive Care Unit. During the first three days of ventilation stress was assessed by means of the Comfort scale (CS). Results 35 Infants received HFV and 15 CV. The HFV group was significantly younger (p = 0.003), had a significant lower birth weight (p = 0.017) and were significant more severely ill (p < 0.0001). Stress scores between groups were comparable, adjustment for baseline differences revealed no differences in scores during the first 3 days of ventilation. Of all CS assessments, 34.0% in the HFV group and 35.6% in the CV group indicated stress (score ≥ 20). Conclusion Stress during the first three days of mechanical ventilation using the CS did not reveal any difference between high frequency and conventional ventilated preterm infants. Routine use of sedatives seems insufficient to prevent high stress scores.
Obstetric Anesthesia Digest, 2009
Although elevated maternal temperature is known to be associated with intrauterine infection, inc... more Although elevated maternal temperature is known to be associated with intrauterine infection, increased risk of neonatal infection, and the use of epidural analgesia for labor, the exact range of normal maternal temperature during labor is not well described. This prospective cohort study examined the variations of normal maternal temperature in laboring women at a gestational age >36 weeks. Maternal rectal temperatures were measured in all laboring women at the authors’ institutions every 2 to 3 hours from admission until the beginning of the second stage and at 1-hour intervals postpartum.Womenwere excluded if scheduled for a planned cesarean delivery, if they presented in labor at full cervical dilation, or if the fetus was breech or had a serious congenital anomaly. Patients were separated into 2 groups. The study group (abnormal labor group) had factors associated with elevated maternal temperature, that is, admission to the delivery room Z6 hours before delivery, meconium-stained amniotic fluid, epidural analgesia, induction or augmentation of labor, rupture of membranes Z18 hours before birth, Z5 vaginal examinations, and operative delivery. Women in the normal labor group presented at Z37 week gestation, had spontaneous onset of labor, rupture of membranes <18 hours before birth, clear amniotic fluid, normal labor progress without the need for augmentation, epidural analgesia, or antibiotics, and also spontaneously delivered a healthy infant in normal condition. Intrauterine infection was deemed present if temperature was Z381C or Z381C along with fetal or maternal tachycardia, meconium-stained amniotic fluid, or maternal white blood cell count Z16 10/L. Women with infections were treated with intravenous amoxicillin or gentamicin until delivery. Data on 3052 of 3358 women were complete enough for analysis. Normal labor occurred in 843 women and abnormal labor in 2209 in whom a diagnosis of intrauterine infection during labor was made in 84 (2.7%). The mean temperature during labor in all patients increased from 37.11C [2 standard deviation (2-SD) 0.71C; 95% confidence interval (CI), 36.5-37.71C] at the beginning of labor to 37.41C (SD 1.21C; CI 36.4-38.21C ) after 22 hours. In the women having a normal labor, the mean temperature was 37.11C (CI, 36.4-37.71C); in those having an abnormal labor, the temperature was equal to the normal labor group during the first 3 hours of labor but then increased thereafter. For all measurements before delivery, mean temperature readings were similar for the normal and abnormal groups. Only 2% of women with normal labor had a temperature during labor higher than the upper 2-SD limit, whereas this occurred in 8% of those in the abnormal labor group. The regression coefficient for 2-SD was significantly higher in the abnormal labor group (0.0301C/h vs. the normal labor group 0.0081C/h). About 91% of those with an intrauterine infection diagnosis had a temperature above the 2-SD limit. Multivariate analysis demonstrated that a temperature higher than the 2-SD limit was associated with epidural analgesia [odds ratio (OR), 3.1; CI, 1.9-5.2], in hospital Z6 hours before delivery (OR, 3.1; CI, 1.9-5.4), meconium-stained fluid (OR, 2.0; CI, 1.2-3.1), and rupture of membranes Z18 hours before delivery (OR, 1.9; CI, 1.1-3.1). Temperature remained stable in the normal-labor group but slowly increased throughout labor in those with an abnormal labor. A circadian pattern was not found at the upper 2-SD limit and time of day is not relevant for classifying normal versus elevated temperature.
MCN: The American Journal of Maternal/Child Nursing, 2013
To prospectively evaluate hazards in the process of supplemental oxygen therapy in very preterm i... more To prospectively evaluate hazards in the process of supplemental oxygen therapy in very preterm infants hospitalized in a Dutch NICU. Methods: A Failure Mode and Effects Analysis (FMEA) was conducted by a multidisciplinary team. This team identifi ed, evaluated, and prioritized hazards of supplemental oxygen therapy in preterm infants. After accrediting "hazard scores" for each step in this process, recommendations were formulated for the main hazards. Results: Performing the FMEA took seven meetings of 2 hours. The top 10 hazards could all be categorized into three main topics: incorrect adjustment of the fraction of inspired oxygen (FiO 2), incorrect alarm limits for SpO 2 , and incorrect pulse-oximetry alarm limits on patient monitors for temporary use. The FMEA culminated in recommendations in both educational and technical directions. These included suggestions for (changes in) protocols on alarm limits and manual FiO 2 adjustments, education of NICU staff on hazards of supplemental oxygen, and technical improvements in respiratory devices and patient monitors. Conclusions: The FMEA prioritized fl aws in the process of supplemental oxygen therapy in very preterm infants. Thanks to the structured approach of the analysis by a multidisciplinary team, several recommendations were made. These recommendations are currently implemented in the study's center.
Archives of disease in childhood. Fetal and neonatal edition, Feb 10, 2018
To compare a low versus a higher threshold for intervention in preterm infants with posthaemorrha... more To compare a low versus a higher threshold for intervention in preterm infants with posthaemorrhagic ventricular dilatation. Multicentre randomised controlled trial (ISRCTN43171322). 14 neonatal intensive care units in six countries. 126 preterm infants ≤34 weeks gestation with ventricular dilatation after grade III-IV haemorrhage were randomised to low threshold (LT) (ventricular index (VI) >p97 and anterior horn width (AHW) >6 mm) or higher threshold (HT) (VI>p97+4 mm and AHW >10 mm). Cerebrospinal fluid tapping by lumbar punctures (LPs) (max 3), followed by taps from a ventricular reservoir, to reduce VI, and eventually a ventriculoperitoneal (VP) shunt if stabilisation of the VI below the p97+4 mm did not occur. VP shunt or death. 19 of 64 (30%) LT infants and 23 of 62 (37%) HT infants were shunted or died (P=0.45). A VP shunt was inserted in 12/64 (19%) in the LT and 14/62 (23%) infants in the HT group. 7/12 (58%) LT infants and 1/14 (7%) HT infants required shunt r...
To study the effect of L-thyroxine supplementation on neurologic maturation in very preterm infan... more To study the effect of L-thyroxine supplementation on neurologic maturation in very preterm infants with transient hypothyroxinemia.
Endoscopy, 2015
We thank Saliou and Baron for their comments. They state that microbial surveillance of endoscope... more We thank Saliou and Baron for their comments. They state that microbial surveillance of endoscopes by antegrade sampling with a sterile 0.9 % saline solution might be insufficient to reveal the microbial contamination. They also suggest the additional use of thiosulfate during sampling. Unfortunately, in the outbreak we described, the use of a thiosulfate-containing buffer would not have been able to detect the microbial contamination. As the manufacturer states, the elevator wire channel of the TJF-Q180V is sealed by an O-ring, which means that separate cleaning is no longer necessary. Moreover, this scope is also designed with a unique distal cap that is fixed, which impairs cleaning and disinfection in the spaces within this cap. Sampling of these spaces is only possible when using an ultrathin swab, as demonstrated in our study, which thereby revealed the VIM-2 producing Pseudomonas aeruginosa. However, we do agree with Saliou and Baron that the optimal sampling method for endoscopes is still under debate. At present, the use of sterile 0.9 % saline solution is recommended by the European Society of Gastrointestinal Endoscopy and the European Society of Gastroenterology and Endoscopy Nurses and Associates. Although the French guideline recommends the use of a tensioactive solution (e. g. Tween 80) to increase the detection of microorganisms, the use of sodium thiosulfate is not mentioned in this guideline. The combination of the narrow lumina of the endoscope and heavy contamination with blood, secretions, and microorganisms during its use, might promote the growth of biofilms in cases of insufficient (pre)cleaning. Once these biofilms occur, they are very resilient to physical removal by regular cleaning and are less susceptible to biocides. In a recent review, it was concluded that by ensuring prompt device cleaning and reprocessing, either by high-level disinfection or sterilization, and proper drying, biofilms will not have a chance to form [8]. Unfortunately, at present there is no evidence in the literature that a consensus on this matter has been reached. However, in light of recent reports of microbiological outbreaks after endoscopy, a reliable method of investigating microbial safety following high-level disinfection is urgently needed. The utility of sodium thiosulfate or another biofilm dissolver should be investigated in studies, led, ideally, by an international working group consisting of microbiologists and endoscopists. In addition, a consensus statement concerning the interpretation and action required from the data collected should become available and updated regularly. Saliou and Baron also stress the importance of endoscope drying in order to prevent bacterial proliferation. The importance of drying has been emphasized previously by Muscarella. As stated in our manuscript, at the Erasmus MC all endoscopes are dried and stored in a storage cabinet (WASSENBURG DRY 300; Wassenburg Medical Devices BV, Dodewaard, The Netherlands), unless immediate re-use (within 4 hours) is required. Therefore, bacterial proliferation during storage was not considered to be a possible cause of the VIM-2 producing P. aeruginosa outbreak.
Samenvatting Doel Voor pasgeborenen die intensieve zorg nodig hebben is sondevoeding vaak van lev... more Samenvatting Doel Voor pasgeborenen die intensieve zorg nodig hebben is sondevoeding vaak van levensbelang. Gebrek aan goede eenduidige richtlijnen voor het inbrengen en controleren van de sonde kan leiden tot onveilige situaties. Bij mechanisch beademde kinderen en kinderen met continuous positive airway pressure (CPAP) zou een verkeerde positie van de maagsonde ertoe kunnen leiden dat overtollige lucht niet goed kan worden afgevoerd. De volgende hypothese is getoetst: een betere positie van de maagsonde hangt positief samen met een geringere hoeveelheid lucht in de maag. Proefpersonen Een jaarcohort pasgeborenen met een voedingssonde, van een niveau IIIc neonatale intensive care unit (NICU). Design en Methode Retrospectief zijn op röntgenfoto’s van 326 pasgeborenen de positie van de sonde en de hoeveelheid lucht in de maag geclassifi ceerd. De demografi sche gegevens worden beschreven. Met Kendal’s T is de relatie tussen de positie van de sonde en de hoeveelheid lucht in de maag g...
Samenvatting De resultaten van een literatuuronderzoek naar de positionering van maagsondes en de... more Samenvatting De resultaten van een literatuuronderzoek naar de positionering van maagsondes en de controle daarvan laten zien dat het inbrengen van een maagsonde via de neus of de mond minder eenvoudig en veilig is dan over het algemeen wordt aangenomen. Beschreven worden de frequentie waarmee maagsondes verkeerd gepositioneerd zijn, factoren die de kans hierop vergroten en de problemen die hierdoor kunnen ontstaan. Vervolgens worden de meest gebruikte manieren van controleren van de positie van voedingssondes besproken, inclusief mogelijke alternatieven. Tot slot worden aanbevelingen voor de praktijk gedaan.
Endoscopy, 2015
Background and study aims: Infections are a recognized risk of endoscopic retrograde cholangiopan... more Background and study aims: Infections are a recognized risk of endoscopic retrograde cholangiopancreatography (ERCP). This paper reports on a large outbreak of VIM-2-producing Pseudomonas aeruginosa that was linked to the use of a recently introduced duodenoscope with a specific modified design (Olympus TJF-Q180V). Methods: Epidemiological investigations and molecular typing were executed in order to identify the source of the outbreak. Audits on implementation of infection control measures were performed. Additional infection control strategies were implemented to prevent further transmission. The design and the ability to clean and disinfect the duodenoscope were evaluated, and the distal tip was dismantled. Results: From January to April 2012, 30 patients with a VIM-2-positive P. aeruginosa were identified, of whom 22 had undergone an ERCP using a specific duodenoscope, the TJF-Q180V. This was a significant increase compared with the hospital-wide baseline level of 2 - 3 cases per month. Clonal relatedness of the VIM-2 P. aeruginosa was confirmed for all 22 cases and for the VIM-2 strain isolated from the recess under the forceps elevator of the duodenoscope. An investigational study of the new modified design, including the dismantling of the duodenoscope tip, revealed that the fixed distal cap hampered cleaning and disinfection, and that the O-ring might not seal the forceps elevator axis sufficiently. The high monthly number of cases decreased below the pre-existing baseline level following withdrawal of the TJF-Q180V device from clinical use. Conclusions: Duodenoscope design modifications may compromise microbiological safety as illustrated by this outbreak. Extensive pre-marketing validation of the reprocessability of any new endoscope design and stringent post-marketing surveillance are therefore mandatory.
Journal of neonatal-perinatal medicine, 2014
In multi-infusion IV therapy, the actual volume delivered to the neonate can vary over time. To r... more In multi-infusion IV therapy, the actual volume delivered to the neonate can vary over time. To reduce flow rate variability, check valves can be used. A check valve allows flow through the valve in only one direction. To evaluate flow rate variability in a low flow dual-infusion setup with and without check valves. The effect of changing the height of and adding syringes to the IV-administration set was tested with and without check valves in an in vitro dual-infusion setup with in-line flow meters. The pre-programmed flow rates were 2.5 and 0.1 ml/h. Twenty-four tests of 90 minutes were performed. Time to reach 75% of the pre-programmed 0.1 ml/h flow rate was >20 minutes. The highest total delivered volume during a test was (mean ± SD) 56 ± 8% of the expected delivery for tests without check valves, and diminished to 12 ± 24% of the expected delivery for check valves with a higher opening pressure. The actual flows and the total delivered volume in low flow dual-infusion setups...
Arch. Dis. Child.-Fetal Neonatal Ed., 2011
Clinical and Experimental Immunology - CLIN EXP IMMUNOL, 2000
Therapeutic Drug Monitoring, 1995
British Journal of Nutrition, 2007
Several studies have described reduced plasma concentrations of arginine, the substrate for nitri... more Several studies have described reduced plasma concentrations of arginine, the substrate for nitric oxide synthase (NOS) in infants with necrotizing enterocolitis (NEC). No information on the plasma concentrations of the endogenous NOS inhibitor asymmetric dimethylarginine (ADMA) in patients with NEC is currently available. We investigated whether plasma concentrations of arginine, ADMA, and their ratio differ between premature infants with and without NEC, and between survivors and non-survivors within the NEC group. In a prospective case–control study, arginine and ADMA concentrations were measured in ten premature infants with NEC (median gestational age 193 d, birth weight 968 g), and ten matched control infants (median gestational age 201 d, birth weight 1102 g), who were admitted to the Neonatal Intensive Care Unit. In the premature infants with NEC, median arginine and ADMA concentrations (μmol/l), and the arginine:ADMA ratio were lower compared to the infants without NEC: 21·...
Pediatric Anesthesia, 2013
Aim: To provide an overview of factors influencing the flow rate in intravenous (IV) therapy for ... more Aim: To provide an overview of factors influencing the flow rate in intravenous (IV) therapy for newborns. Methods: We conducted a review of the literature from 1980 to 2011 in PubMed and Web of Knowledge. Articles focusing on flow-rate variability and possible complications due to flow-rate variability were included. Results: Forty-one articles were selected for this review. IV therapy in (preterm) neonates is prone to significant start-up delays and flow-rate variability. The sudden changes in the volume delivered to (preterm) neonates may have serious consequences. Low preprogrammed flow rates, total compliance, and volume of the IV administration set, the presence or absence of antisiphon valves or inline filters and the vertical displacement of syringe pumps all contribute to flow-rate variability in IV therapy for neonates. Conclusions: Flow-rate variability in IV therapy and its clinical relevance are due to the preprogrammed flow rate, the hydrostatic pressure changes, the complete IV administration set compliance and the type of substances supplied to the patient. To improve IV therapy, the internal compliance of the complete IV administration set should be minimized and the highest possible preprogrammed flow rate should be used in combination with small syringes and low-resistance valves.
Nursing in Critical Care, 2013
Aims: This article aims (a) to get insight into intensive care nurses' most critical work-related... more Aims: This article aims (a) to get insight into intensive care nurses' most critical work-related incidents, (b) their reactions and coping and (c) perceived support, in a Dutch intensive care unit. Background: Research about the impact of critical incidents has largely been aimed at ambulance and emergency nurses; knowledge about intensive care nurses in this respect is scarce. Persistent stress reactions after critical incidents may cause symptoms of post-traumatic stress disorder, depression and anxiety. Unresolved problems may also cause poor behaviour towards patients. In response, nurses reduce work hours or even resign. Social support alleviates emotional problems, but little is known about actual support perceived. Design: This study is a qualitative explorative study. Method: Thematic analysis of semi-structured interviews was performed among a purposive sample of 12 intensive care nurses in a university hospital in The Netherlands. Findings: Four main themes have been identified in critical incidents: high emotional involvement in patient-related incidents (in contrast to major life-threatening events as such), avoidable incidents, substandard patient care and intimidation. Themes discerned in nurses' reactions after critical incidents were physical reactions, emotional reactions and cognitive/behavioural reactions. After critical incidents, nurses talked with colleagues, friends or relatives, but would have appreciated additional support. Conclusions: Incidents under emotionally demanding circumstances are among the most difficult situations, but may not be recognized as critical incidents by colleagues. Both adequate and inadequate coping strategies, with long-lasting problems after critical incidents, were reported. Feelings of anger, shame and powerlessness, may have hindered recovery. Talking to colleagues was perceived to be helpful, but intensive care nurses' need for support was insufficiently met. Relevance to clinical practice: Managers should acknowledge the effects of critical incidents on intensive care nurses and take preventive measures: reducing critical incidents, improving open communication, imposing a buddy-system for collegial support, and timely evaluating the necessity of professional help.