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ORIGINAL ARTICLE
Year : 2021  |  Volume : 26  |  Issue : 5  |  Page : 307-310
 

Evaluation of risk factors affecting outcome in outborn surgical neonates


1 Department of Pediatric Surgery, Chacha Nehru Bal Chikitsalaya, Delhi, India
2 Department of Pediatrics, Chacha Nehru Bal Chikitsalaya, Delhi, India

Date of Submission11-May-2020
Date of Decision22-Nov-2020
Date of Acceptance24-Jan-2021
Date of Web Publication16-Sep-2021

Correspondence Address:
Dr. Niyaz A Khan
Department of Pediatric Surgery, Chacha Nehru Bal Chiktsalaya, Delhi - 110 031
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiaps.JIAPS_149_20

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   Abstract 


Background: Mortality in surgical neonates contributes to neonatal mortality rates. The study was conceptualized to study clinical and nonclinical factors affecting mortality in surgical neonates so that timely intervention could result in improved survival of the neonates.
Materials and Methods: The study was initiated after approval from the institutional ethics committee and included 120 surgical neonates over a period of 18 months after obtaining consent from the parents/caregivers. Predesigned pro forma was used to record the details of antenatal care received, place of birth, travel history, maternal education and gestational age, and clinical condition at the time of admission. Values of biochemical tests such as serum electrolytes, serum creatinine, and arterial blood gasses were recorded. The need of inotrope support, blood or blood product transfusion, and postoperative ventilator support and intensive care unit (ICU) care was recorded. The results of the two groups, i.e., survivals and mortality, were compared. Outcome was recorded as mortality at 30 days or earlier.
Results: Irrespective of the surgical condition, the survival rate was significantly better in those babies who weighed more than 2.5 kg at the time of admission, had capillary refill time of <3 s, had serum ionized calcium levels more than 1 mmol/L, and did not require inotropes, blood or blood product transfusion, and postoperative ICU care and ventilator support. The place of birth, educational status of the mother, gestational age, and distance traveled for care had no statistically significant effect on survival.
Conclusion: There is a statistically significant correlation between the survival of the babies who weighed more than 2.5 kg and are more physiologically preserved at the time of admission. Mortality rates can be decreased by timely interventions to reduce the need of inotropes, blood or blood products, and ICU care and ventilator support during their postoperative recovery.


Keywords: Clinical, nonclinical parameters, outborn neonates, surgical neonates


How to cite this article:
Mohta A, Mishra A, Khan NA, Jajoo M, Neogi S, Sengar M, Gupta CR. Evaluation of risk factors affecting outcome in outborn surgical neonates. J Indian Assoc Pediatr Surg 2021;26:307-10

How to cite this URL:
Mohta A, Mishra A, Khan NA, Jajoo M, Neogi S, Sengar M, Gupta CR. Evaluation of risk factors affecting outcome in outborn surgical neonates. J Indian Assoc Pediatr Surg [serial online] 2021 [cited 2022 Jul 6];26:307-10. Available from: https://www.jiaps.com/text.asp?2021/26/5/307/326060





   Introduction Top


Approximately 4 million babies of the estimated 130 million infants born each year globally die within the first 28 days of life and nearly three-fourth of these deaths occur within the 1st week.[1] Surgical conditions not only account for a reasonable proportion of neonatal deaths but also lead to significant financial burden on health care.[2] Despite the efforts to reduce the neonatal mortality in the country,[3] the preadmission condition of the surgical neonates adversely affects the outcomes and thus the mortality rates. There has been a paucity of data in the country that focused on factors affecting outcome in surgical neonates. This study was conducted in an attempt to identify various preselected clinical and nonclinical factors likely to result in adverse outcomes after surgery.


   Materials and Methods Top


This prospective observational study was conducted at a tertiary care institute over a period of 18 months after obtaining approval from the institutional ethics committee. The institute does not have indoor obstetric facility, and all the patients operated were outborn. Patients were included in the study after obtaining written consent from the parent or available legally authorized representative. All the neonates admitted in the pediatric surgery department which required surgical intervention were considered for inclusion. Exclusion criteria included (a) refusing surgical intervention if it was needed, (b) left against medical advice, and (c) neonates requiring referral to another center for immediate management for conditions for which immediate logistics were not available at the institute.

Patient-related data were recorded in a predesigned pro forma. Demographic details recorded were age, sex, weight at admission, and gestational age of the baby. Clinical parameters included capillary refill time, total leukocyte count, serum levels of ionized calcium, need for inotropes during surgery, and duration of surgery. Other nonclinical parameters studied included mother's age and educational status, child's place of birth (home or hospital), and distance traveled to surgical center. The outcome parameter was survival at the time of discharge or at 30 days of life, whichever was later.

Statistical analysis

The data were tabulated using Microsoft Excel Sheet and analyzed using SPSS version 2015, IBM, Armonk, New York, USA. Chi-square test was used for quantitative data to arrive at P value, and a value of <0.05 was taken as significant.


   Results Top


Patients' characteristics and surgical profile

A total of 185 neonates presented with conditions needing surgical intervention, out of which 120 patients fulfilled the inclusion criteria, and were enrolled. Reasons for exclusions included (a) denial of consent for inclusion in the study (20), referral to other hospitals (25) on request, and refusal for surgery including left against medical advice (20). Neonatal surgical conditions encountered are summarized in [Table 1]. The mean age and weight of the patients was 6.21 ± 7.514 days and 2.56 ± 0.39 kg, respectively, and was comparable in the two groups. Majority of the patients operated had tracheoesophageal fistula (27.5%) followed by anorectal malformations. The survival rate among patients with admission weight more than 2.5 kg was 90% (56\62) versus 63.79% (37/58) in those with admission weight less than 2.5 kg (P = 0.001).
Table 1: Surgical conditions in study

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Nonclinical parameters

Nearly two-third of the babies were hospital delivered. The survival rate among hospital delivered patients was 74.36% (58/78) whereas those delivered at home had survival of 83.33% (35/42) (P = 0.261). The survival rate in those who traveled less than 60 km to reach our center had a survival which was clinically significant than those who traveled more than 60 km. The maternal age and their educational status had no significant difference in the primary outcome (P = 0.0348 and 0.667, respectively) [Table 2].
Table 2: Survival on clinical parameters

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Clinical parameters

The details of clinical parameters are summarized in [Table 3]. Capillary refill time, serum ionized calcium level at the time of admission, and need for inotropic support significantly correlated with the survival outcome (P = 0.0079, P = 0.04, and P = 0.00001, respectively).
Table 3: Clinical parameters

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   Discussion Top


Every newborn makes transition from placental physiology to self-dependent physiology. During this period, they have limited physiological reserves to handle the challenges of hypothermia, sepsis, hypoglycemia, hemodynamic instability, dyselectrolytemia, and acid–base imbalances. Surgery and anesthesia add to the vulnerability by burdening the already precarious physiology. Timely addressing the risk factors will prevent burden on health-care infrastructure. Although birth weight and gestational age have been known to have inverse correlation with survival, other factors have been less studied.

Statistically significant better survival was noted in those weighing 2.5 kg or more (P = 0.001). The birth weight/admission weight had a statistically significant association with survival among other studies also.[4],[5],[6],[7]

Maternal education and age may affect the neonatal survival as Elizabeth and Oyetunde[8] noted that higher maternal education leads to better health-seeking behavior, better reasoning and understanding, and better and early adoption of the knowledge for the benefit babies, and this resulted in statistically significant improved survival of the surgical neonate, however, we did not find a significant relationship between the two.

In our study, place of birth did not significantly affect the survival (hospital born n = 78, P = 0.261). The percentage survival of those born in the hospital was higher, possibly due to the fact that many of those, born at home, might have deteriorated clinically before reaching to the health-care facility. Only those babies who were physiologically robust could reach hospital. Sowande et al. did not find any association between place of delivery and survival.[4] Similar observations were made by Tandon et al. in their study of factors affecting survival of patients with tracheoesophageal fistula.[9] Higher mortalities among outborn neonates due to increased travel time and possible deterioration of the clinical condition during transportation were noted in the study conducted by Ugwu and Okoro.[7]

In our study, prolonged capillary refill time of more than 3 s and hypothermia at the time of admission had a statistically significant association with mortality (P = 0.0079). The total leukocyte count between 4000 and 19,000/mm3 and serum sodium levels did not affect survival significantly (P = 0.456 and P = 0.598, respectively). Serum ionized calcium levels more than 1 mmol/L were significantly associated with survival (P = 0.002). Manchanda et al. found a significant association of the high heart rate, higher respiratory rate, lower temperature, lower blood pressure, presence of respiratory distress, and lower urine output, with the mortality of the neonates. They also noted that lower platelet count, lower blood glucose levels, lower pH, lower bicarbonate levels, and raised C-reactive protein levels were significantly associated with mortality. Respiratory distress at presentation was the most important factor in overall mortality in their study. However, on multivariate analysis, they found only increased heart rate to be significantly associated with mortality.[10]

It was observed that the survival was significantly better statistically in the babies who did not require blood transfusion, inotropes during surgery, and postoperative ventilator support. There is limited literature available on these aspects of patient care. Sowande et al. have commented that mortality was higher in their facility due to lack of ventilator support.[4]

Another important factor, though not statistically significant, that affected the mortality rate adversely was distance traveled to reach our institution. Patients who traveled more had poorer results probably due to inadequate facilities for safe transport. It has been suggested that the increased mortality due to transport issues can be reduced by institutional deliveries, prereferral stabilization, prior communication, and adequate monitoring by trained personnel during transfer.[11]

One factor difficult to explain was the lower mortality rate in babies born by home delivery as compared to those who were hospital delivered. The possible reason for this could be that more complicated pregnancies were hospital delivered thus contributing to higher mortality. These factors could not be studied due to lack of necessary information from the attending caregivers.

Limitations of the study included (a) smaller number of participants due to limitation of time, (b) nonavailability of birth records and details of any prior hospital stay of some babies, and (c) logistics did not allow surgery on all the patients at our Institution and had to be referred elsewhere.


   Conclusion Top


That perioperative clinical factors were important in predicting the postoperative mortality in the surgical neonates and thus preoperative optimization can help reduce the mortality.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Bhatnagar SN, Sarin YK. Current trends in neonatal surgery in India. J Neonatal Surg 2012;1:18.  Back to cited text no. 1
    
2.
Gangopadhyay AN, Upadhyaya VD, Sharma SP. Neonatal surgery: A ten year audit from a university hospital. Indian J Pediatr 2008;75:1025-30.  Back to cited text no. 2
    
3.
Paul VK, Kumar R, Zodpey S. Towards single digit neonatal mortality rate in India. J Perinatol 2016;36:51-2.  Back to cited text no. 3
    
4.
Sowande OA, Ogundoyin OO, Adejuyigbe O. Pattern and factors affecting management outcome of neonatal emergency surgery in Ile-Ife, Nigeria. Surg Pract 2007;11:71-5.  Back to cited text no. 4
    
5.
Gizaw M, Molla M, Mekonnen W. Trends and risk factors for neonatal mortality in Butajira District, South Central Ethiopia, (1987-2008): A prospective cohort study. BMC Pregnancy Childbirth 2014;14:64.  Back to cited text no. 5
    
6.
Ilori IU, Ituen AM, Eyo CS. Factors associated with mortality in neonatal surgical emergencies in developing tertiary hospital in Nigeria. Open J Pediatr 2013;3:231-5.  Back to cited text no. 6
    
7.
Ugwu RO, Okoro PE. Pattern, outcome and challenges of neonatal surgical cases in a tertiary teaching hospital. Afr J Paediatr Surg 2013;10:226-30.  Back to cited text no. 7
[PUBMED]  [Full text]  
8.
Elizabeth UI, Oyetunde MO. Patterns of diseases and care outcomes of neonates admitted in special care baby unit of University College Hospital, Ibadan, Nigeria, from 2007 to 2011. IOSR J Nurs Health Sci 2015;4:62-71.  Back to cited text no. 8
    
9.
Tandon RK, Sharma S, Sinha SK, Rashid KA, Dube R, Kureel SN, et al. Esophageal atresia: Factors influencing survival – Experience at an Indian tertiary center. J Indian Assoc Pediatr Surg 2008;13:2-6.  Back to cited text no. 9
[PUBMED]  [Full text]  
10.
Manchanda V, Sarin YK, Ramji S. Prognostic factors determining mortality in surgical neonates. J Neonatal Surg 2012;1:3.  Back to cited text no. 10
    
11.
Jajoo M, Kumar D, Dabas V, Mohta A. Neonatal transport: The long drive has not even begun. Indian J Community Med 2017;42:244-5.  Back to cited text no. 11
[PUBMED]  [Full text]  



 
 
    Tables

  [Table 1], [Table 2], [Table 3]


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