Original Article Neonatal Med 2016 February;23(1):8-15 http://dx.doi.org/10.5385/nm.2016.23.1.8 pISSN 2287-9412 . eISSN 2287-9803
Deaths in the Neonatal Intensive Care Unit between 2002 and 2014 Ga Young Park, M.D., and Sung Shin Kim, M.D. Department of Pediatrics, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Korea
ABSTRACT Purpose: To report the causes and patterns of death among infants admitted to our neonatal intensive care unit (NICU) over a 13-year period. In addition, we analyzed trends regarding the type of end-of-life care provided. Methods: All of the neonates who died at the Soonchunhyang University Bucheon Hospital between January 1, 2002, and December 31, 2014, were identified. The causes and circumstances of death were extracted from individual medical records. Trends in mortality were compared between two time periods: 2002 to 2007 and 2008 to 2014. Results: Of the 5,223 admissions to our NICU, 97 neonates died. The overall mortality rate was 1.9%. The most common cause of death was sepsis (15%). At a lower gesta tional age, infants died of extreme prematurity and complications of prematurity. Among term infants, the principal cause of death shifted to hypoxic ischemic ence phalopathy and asphyxia. A total of 63 infants (64.9%) received maximal intensive care, and 34 infants (35%) had redirection of intensive care. During this period, the proportion of death after redirection of care increased from 30.6% to 39.6%. Infants decided to forgo life-sustaining care before death had significantly lower gestational ages and lower birth weights (30.5 vs. 27.1 weeks, P=0.005; 1,528 vs. 1,063 g, P=0.025). Conclusion: Infection remained an important cause of death for neonate, particul arly for preterm infants. The proportion of infants who had redirectoin of care before death was increased, suggesting that quality-of-life should be considered an impor tant factor in the decision-making process for the infant, parents, and medical staff. Key Words: Intensive care units neonatal, Mortality, Infant, Terminal care
INTRODUCTION Infant and neonatal mortality rates are important indicators of the overall societal health of a country. Although advanced medical care over recent decades has resulted in significantly improved neonatal outcomes
1-4)
, neonatal mortality still represents a large
proportion of overall infant and childhood mortality. Understanding the causes and trends of deaths in neonatal intensive care units (NICUs) is important because the proportion of
Received: 2 October 2015 Revised: 24 December 2015 Accepted: 24 December 2015 Correspondence to: Sung Shin Kim, M.D., Ph.D. Department of Pediatrics, College of Medicine, Soonchunhyang University Bucheon Hospital 170 Jomaru-ro, Wonmi-gu, Bucheon 14584, Korea Tel: +82-32-621-5388 Fax: +82-32-621-5662 E-mail:
[email protected]
Copyright(c) By Korean Society of Neonatology. All right reserved. This is an Open-Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/ by-nc/4.0), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Neonatal Med 2016 February;23(1):8-15 http://dx.doi.org/10.5385/nm.2016.23.1.8
5,6)
postneonatal deaths has a major impact on infant mortality . Prematurity remains one of the major causes of neonatal death 7-9)
, but there have been important changes in the specific
causes of neonatal mortality
1. Cause of death Each deceased infant was assigned one main cause of death, based on the International Classification of Disease and Related th
10-14)
23)
Health Problems (10 revision)
.
9
and the previously validated
With improvements in the survival of very sick or extremely
Perinatal Society of Australia and New Zealand’s Neonatal
preterm neonates, neonatologists are confronted with end-
Death Classification . The investigators selected the primary
of-life decisions, such as extending maximal intensive care,
cause of death from a predefined list. Death from extreme pre
withholding care, or withdrawing care. The decision-making is
maturity was defined as newborns who died without a clearly
preceded by discussions between the medical staff and parents
identifiable primary cause other than extreme prematurity
to reach appropriate end-of-life answers for each infant
12,15-19)
24)
.
within the first 48 hour after birth in extremely low birth weight
However, decision-making practices vary widely between coun
infants (typically ≤24 weeks’ gestation or birth weight ≤600 g) .
12)
tries for many reasons including uncertainty of the prognosis in 17,19)
individual cases, and cultural and religious differences
.
Many studies on clinical outcomes for very low birth weight infants (VLBWIs) have been performed in Korea
20-22)
2. End-of-life To examine the circumstances of death, we categorized the
; however,
type of death in the following three groups: (1) Death despite
there are few studies that describe deaths in NICUs, and few re
ongoing maximal intensive care treatment; (2) Death while
ports concerning the type of death. Thus, we reported changes
withholding life-sustaining treatment (LST); and (3) Death
in the principal causes and patterns of death for all infants
while withdrawing LST in moribund infants. Infants who died
admitted to our NICU over a period of 13 years. We also review
despite ongoing maximal intensive care died on a ventilator.
ed the types of death that occured in the newborn infants.
Withholding intervention was defined as withholding poten tially LST including withholding cardiopulmonary resuscitation (CPR) and not making additional intensive care interventions,
MATERIALS AND METHODS
such as additional ventilator changes and the use of inotropics. Withdrawing intervention meant that all LSTs were discontinu
We performed a medical record review retrospectively in
ed. Because this study was aimed at newborn who admitted
the NICU of the Soonchunhyang University Bucheon Hospital
our NICU, all infants received resuscitation initially. Decisions
(South Korea) from January 2002 to December 2014. The
on whether or not the LST should be done were made in infants
retrospective chart reviews were approved by the institutional
of the dying. We considered withholding and withdrawal of LST
review board of the hospital. The NICU consists of 22 level III
as “redirection of care.” End-of life approaches were categorized
beds, increased from 17 beds in 2013, and handles 300 to 500
after a thorough review of each medical record by the authors.
admissions per year. The study included all newborns of any gestational age who were admitted to the NICU and died before
3. Statistical analysis
discharge. Stillborn infants were excluded. Infants were divided
Statistical analyses were performed with SPSS software 14.0
into two groups according to year of birth: (1) epoch I, from
(SPSS Inc., Chicago, IL, USA) using one-way analysis of vari
January 2002 to December 2007; and (2) epoch II, from January
ance. Student’s t-test was used to compare continuous variables
2008 to December 2014. In addition, infants were categorized
between groups, and χ tests were used for categorical variables.
based on gestational age at birth into five groups: (1) born ≤24
A P
