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Veronica Franco, MD, MSPH

• Director of the Exercise Physiology/Metabolic
• Exercise Testing Program, Assistant Professor of Clinical
• Medicine, The Ohio State University

Patients can Other causes for reduced cerebral function should be sought and appear to otherwise be improving clinically at the time it develops medications buy lumigan master card. Pulmonary oedema can occur in both falciparum and Cerebral malaria is more common in children and non-immune vivax malaria medicine keppra 3ml lumigan. Mortality can be as high as 40% in children medications that cause hyponatremia order lumigan cheap, who are also at a greater risk of developing neurological sequelae (10%) medicine 832 lumigan 3 ml discount. Such Abnormal breathing patterns can be due to efects on the respiratory sequelae include hemiparesis, cerebellar ataxia, cortical blindness, centre. Patients may have a superadded chest infection due to hypotonia, mental retardation and cerebral palsy. Determine the degree of anaemia alongside the clinical picture Confrm with arterial blood gas results where possible. Consider and consider transfusion if the haematocrit is <25%, or when and treat bacterial infection and the impact of a reduced level of hypovolaemic shock is present. Children with a hyperdynamic circulation may need this is much less common than in adults. In anaemic children, dyspnoea is more commonly related to plasma transfusions may be required in the presence of coagulopathy. Increased FiO2 and hypoglycaemia positive end expiratory pressure may be required. It should be suspected in all those with a reduced conscious level, circulatory collapse and may present with coma or convulsions. Seek possible Hypoglycemia contributes to central nervous system dysfunction infection sites, including respiratory tract, urinary tract, meningitis and associated neurological defcits in survivors of cerebral malaria. Correct hypovolaemia and commence broad spectrum antibiotics, ideally after blood cultures are sent. Myocardial Fluid and electrolyte disturbance, metabolic acidosis function is often well preserved, however there is potential for Tere is often evidence of hypovolaemia and dehydration. Lactic acidosis is mainly due to reduced oxygen delivery to tissues caused by hypovolaemia, Preoperative assessment of hydration is important, with identifcation sequestration, and anaemia. Contributing factors include parasite and treatment of hypovolaemia, as well as sepsis and shock. Consider anaerobic glycolysis, impaired hepatic and renal function with fuid therapy, possible blood transfusion and potential inotropes. In children with Children with severe anaemia may present with tachycardia and 1 severe malaria, lactate level >5mmol. Children with acute renal haematological disturbances tubular dysfunction may have raised potassium levels. Children and non hyperpyrexia immune patients with high parasite loads are at the greatest risk. It relates to an may be gastric/duodenal ulceration, malabsorption and an increase increase in splenic clearance of platelets. Serum bilirubin and liver enzymes may bleeding occurs in < 10%, with the greatest risk among non-immune be elevated, although less than with viral hepatitis. Rapid deterioration is much more likely in Acute renal failure usually occurs in adults. Anaesthesia and surgery should be avoided in the child occasionally a polyuria may be found. Principles and Practice of at a greater risk of developing the condition, especially if receiving Infectious Diseases (7th Edition) New York: Churchhill Livingstone oxidant drugs such as primaquine and sulphonamides. In; Eddlestone M, Davidson R, Wiklinson R, to be associated with severe disease, particularly in children and Perini S. In endemic areas, and in the partially York: Oxford University Press, 2005: pp 9-37. Vulnerability is highest in the frst 28 days respiratory symptoms of bronchospasm, wheeze, cough and respiratory distress. In 2010 it was estimated that throughout the world 21, 000 children under the age of fve died pneUmonia every day, with a total of 7. Other signifcant bacteria include Pneumonia continues to be to pneumonia, which is more than those caused by 1, 2 Staphylococcus aureus and Klebsiella pneumoniae. Fungal infections such as pneumocystis the risk of a child dying under the developing world, particularly in Africa and South jiroveci are important to consider in the child with the age of fve is 18 times East Asia. Poverty contributes study investigating the aetiology of pneumonia in approach, as for any acutely ill to increasing susceptibility through risk factors such 9 child as malnutrition, inadequate sanitation, and reduced children. Neonates are also Supplementary oxygen saves is responsible for almost half of deaths due to acute at risk of blood borne infection at or shortly after extra lives. Non-exclusively breast fed infants are 15 Specialist Registrar Pneumonia is an acute lower respiratory tract infection times more likely to die from pneumonia, and sufer in Anaesthesia that presents with symptoms of cough, fever, and more frequent and severe infections than exclusively Worcester Royal Hospital difculty breathing. The Global Action Plan for chronic condition, patients often present with acute Leeds General Infrmary the Prevention and Control of Pneumonia presents exacerbations related to infective or non-infective a framework to reduce pneumonia morbidity and triggers (physical exertion, allergens, irritants or cold 7 Oliver Ross mortality through three facets: weather). Protection strategies include the provision of Anaesthetist Bronchiolitis is an acute, communicable condition a healthy living environment to enhance natural Southampton mainly afecting infants between 3-6 months of age. Prevention includes using immunisation against high-income countries, refecting increasing atopic sensitization. Haemophilus infuenzae B, Streptococcus pneumoniae, Prevalence is increasing in developing countries, possibly as a result measles and pertussis. As with many diseases, this is hampered by poverty, poor education and limited access to 3. Evidence shows BronchiolitiS mortality can be reduced through: Bronchiolitis predominantly afects infants under six months old. While environment and addressing risk factors in a similar manner to those most of the 180, 000 annual deaths from asthma are in patients over for pneumonia. Prevalence of asthma is already high in been shown to reduce the length of illness, reduce hospital stay and intensive care admissions. As the child recovers, switch to oral antibiotics to occur more commonly in viral pneumonia, but do not rely on this (amoxicillin or ampicillin), and ensure that the child completes to direct treatment. Clinical deterioration or failure to improve by 48 hours should prompt a When a child presents with symptoms of pneumonia, triage by change in antibiotics (to chloramphenicol). Seek specifc signs and plus gentamicin is preferable to chloramphenicol in treating severe symptoms, in particular pneumonia in children between one month and fve years of age in a low-resource setting. Other signs of severe reliable supply of electricity and many rural health facilities may difculty in breathing are grunting with each breath, nasal faring need to use cylinder supply. Children with very severe pneumonia will have to transport to remote areas so that shortages occur frequently. Normal values in children14, 19, 26 neonate infant Small child adolescent heart rate 110-150 100-150 80-120 60-100 respiratory rate 30-40 25-35 25-30 15-20 oxygen Saturation 88% at sea level Altitude greater than 2500m: SpO2 > 87% Altitude less than 2500m: SpO2 > 90% Systolic Blood pressure (lower limit, 65-75 70-80 (65+2 x age) 90 mmhg) table 3.

Anaphylaxis to chlorhexidine has been exposure in those with previously documented anaphylaxis to either reported in those with a known allergy to chlorhexidine treatment jones fracture cheap lumigan 3ml online, but where agent medicine 3605 generic lumigan 3 ml otc. Fortunately medications not to take with grapefruit generic 3ml lumigan otc, anaphylactic reactions to other broad-spectrum the presence of chlorhexidine was not recognised 9 treatment issues specific to prisons order lumigan 3 ml without a prescription, for instance in a antibiotics such as clindamycin and gentamicin are rare. The egg-based its presentation and severity and so a high index of suspicion is constituent of propofol is a highly purifed phosphatide, lecithin, required. The vast majority of anaphylactic between propofol and egg allergy has not been demonstrated. Symptoms and Manufacturers suggest a cautious approach is best in those with egg signs evolve within seconds or minutes of allergen exposure. The related anaphylaxis, but propofol has been widely administered to 16 chief difculty in managing perioperative anaphylaxis has often egg allergic patients without incident. Clinical criteria for diagnosing anaphylaxis (adapted bronchospasm and hypotension. In the absence of anaphylaxis is highly likely when any one of the following three skin manifestations the diagnosis can be overlooked in favour of criteria is met: an alternative event. Acute onset of illness (minutes to several hours) with involvement be missed as access for examination is limited by surgical drapes or of the skin, mucosal tissue, or both. Two or more of the following that occur rapidly after exposure to in children, only found in between a quarter and a third of cases. Gastrointestinal symptoms such as abdominal pain, nausea, vomiting hypotonia [collapse] syncope, incontinence) and diarrhoea may also be seen in non-anaesthetised children. Reduced blood pressure after exposure to a known allergen for that following these criteria will identify over 90% of reactions, that patient (minutes to several hours) leading to early treatment and thus improved outcome. Many nations adopt those produced by their own national societies and expert panels. Diferential diagnosis of anaphylaxis clinical staf are aware and have access to the guideline. A rapid decision is needed as to whether the surgical procedure is able to continue. Although adrenaline can be infused peripherally initially, it Tese are simple measures to implement. Tese can be instituted should be administered via a central venous catheter if possible. Adrenaline acts on alpha and beta adrenoreceptors efect and should be considered if hypotension is unresponsive to and increases systemic vascular resistance, coronary perfusion adrenaline. Specialised equipment, monitoring and appropriately pressure, cardiac contractility whilst causing bronchodilatation and trained staf are required if a vasopressor infusion is used: the child inhibiting infammatory mediator release. Mortality can be high in this patient group, even in Adrenaline 1:1000, at a dose of 0. Some algorithms have simplifed adrenaline dosing to include Secondary management EpiPen use, with a range of 150micrograms (0. Some guidelines omit them entirely as there is a lack of strong doses indicated until clinical improvement is achieved. Intravenous methylprednisolone should be available to allow for any developing laryngeal oedema and (1mg. Surgical cricothyroidotomy may be required if route is still available, prednisolone 1mg. Biphasic reactions can occur in up to 20% of cases, with most occurring in the frst Breathing 6 hours. Treatment with a nebulised beta-2 agonist, those patients who have delayed administration of adrenaline, or such as salbutamol 2. A recently published systematic anaesthetised patient is described elsewhere (page 61 and reference review showed that there is no good quality evidence to support the 21). Give further fuids titrated to multiple drugs and potential causative allergens in a brief period. This increases venous return, and is Specialist laboratory assays are required to confrm the diagnosis. The half-life of tryptase is approximately 2 hours; levels increase after Manage fuid resistant hypotension with an adrenaline infusion mast cell activation, peaking rapidly and falling again. Epidemiology of anaphylaxis: fndings of the American to determine baseline tryptase levels and allow interpretation of the College of Allergy, Asthma and Immunology Epidemiology of Anaphylaxis Working Group. Trends in national incidence, lifetime prevalence and adrenaline prescribing for Patients who have experienced anaphylaxis under anaesthesia should anaphylaxis in England. Fatalities due to Make detailed records of all drugs, timings and events surrounding anaphylactic reactions to food. Paediatrics 2003; 111(6 injections can be used to look for signs of sensitisation. Anaphylaxis during and many commonly used antibiotics, but this is often only available anaesthesia: results of a 12 year survey at a French paediatric in specialist laboratories. Risk of administering cephalosporin antibiotics to patients with histories of penicillin allergy. Anesth Analg 2011; 113(1): symposium on the defnition and management of anaphylaxis; 140-4. Latex allergy in children; Organisation survey on the global availability of essentials modalities and prevention. Anaesthesia Tutorial of the Week 95(2008) Susara Ribbens Correspondence email: susara@btinternet. Gastric lavage is also estimated 350 000 people died from unintentional contra-indicated in the ingestion of hydrocarbons poisoning in 2002. Accidental poisoning occurs (risk of aspiration and chemical pneumonitis) and most often in the age group 1-5 years, although less corrosives. Summary More than 94% of fatal poisonings occur in low-and with a long half life (anticonvulsants, digoxin, middle-income countries. The complications of gastric Prevention of childhood lavage include aspiration pneumonia, hypoxia, poisoning is vital. It may also induce of medications, child safe of child-proof containers for household chemicals and charcoal bezoars that may cause intestinal cabinets and containers, medicines play a key role in prevention. Activated charcoal can cause serious blister packaging and complications if aspirated. Most paediatric (Toxic plants, insect and snake bites are not discussed cases are not severe. Remove contaminated clothing and wash patient Recognition of potentially more information) with soap and water. Send samples for lab investigation (urea, appropriate early treatment General principleS electrolytes, blood glucose. Aggressive A history of poisoning usually makes the diagnosis aspirates should be saved for later toxicology supportive care is essential. Sources on information are common and include internet-based information databases 10. Specifc antidotes should be given as per such as the International Programme on Chemical instruction by Poison Centre. Commonly, they cause nausea, Susara Ribbens De Vos contraindicated with volatile substances. Consider gastric emptying and administration of bleach is unlikely to cause serious problems. Aspiration pneumonitis occurs Tere is a worrying recent increase in oesophageal injury associated in 12-40% of patients. Tere may be wheeze, coarse crackles as well as signs of Ingestion of small quantities of strong alkalis such as drain cleaner respiratory distress (intercostals and subcostal retraction).

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In this case symptoms cervical cancer order lumigan with american express, platelets from partially mismatched donors may provide adequate responses medicine stick generic lumigan 3ml on-line. These platelets should be irradiated to prevent transfusion-associated graft-versus-host dis ease (Wang et al symptoms to pregnancy cheap 3ml lumigan with amex. In patients with cancer medicine cabinet shelves lumigan 3 ml without a prescription, decreased red blood cell production typically is caused by the disease process or myelosup pressive therapy. One unit of red blood cells generally will increase hema tocrit by 3% and hemoglobin by 1 g/dl in a nonbleeding patient weighing 70 kg. Transfusion of packed red blood cells is used most often because it can provide more than 70% of the hematocrit of whole blood and one-third of the plasma (Rodriguez, 2018), thus minimizing fuid overload issues. As with any therapy, individual patient assessment is taken into consideration, including pulmonary or cardiac issues. Human plasma, which is derived from whole blood products or plasma pheresis, is used to correct coagulopathy. Typically, plasma is infused quickly so that the max imum plasma level is reached before any metabolic changes occur (Rodri guez, 2018). Cryo is prepared by slowly thawing fresh frozen plasma to form an insoluble precipitate. Other proteins in the concentrate include fbronectin, immunoglobulin G, immunoglobulin M, and albumin (Nascimento, Good nough, & Levy, 2014). The indirect plasmin inhibitors, tranexamic acid and aminocaproic acid, have also been used to decrease bleeding by reducing fbrinolysis. These agents have been shown to decrease blood loss and subsequent transfusions with no increased risk of venous thromboembolism. Aminocaproic acid may be taken orally or intravenously, whereas tranexamic acid is only available intravenously (Mon troy et al. Patients who have small bowel dis ease or resection or biliary obstruction are prone to defciencies of these clotting factors. Vitamin K therapy is effective if a defciency of these fac tors or excessive warfarin therapy is implicated in bleeding in a patient with Copyright 2018 by Oncology Nursing Society. The preferred route to administer vitamin K is oral, which reduces the potential for additional bleeding or infection in an already com promised patient (Hull & Garcia, 2017). Vasopressin acts by causing severe splenic arteriolar constriction, which reduces blood fow, thus aiding in plug formation in the affected vessel. It is less effective in bleeding that is not arteriolar and requires close monitoring in an intensive care unit (Cagir, Chico, Cirin cione, & Manas, 2017). Mechanical measures can be used to manage active bleeding, including applying direct steady pressure to the site of bleeding or, if the bleeding site is not directly exposed, inserting a balloon catheter or nasal packing, especially when dealing with epistaxis. It is very important that extreme care is taken when removing or replacing packing to avoid disturbing the clot that has formed (Rodriguez, 2018). If the bleeding is from peripheral phlebotomy sites or central venous catheter sites, hemostatic bioabsorb able dressings can be applied to stop it (Rodriguez, 2018). Other usable topical agents include absorbable gelatin, collagen, cellulose, fbrin seal ants, and alginates (Agrawal, Soni, Mittal, & Bhatnagar, 2014; Boateng & Catanzano, 2015). When minor vascular bleeding caused by damaged capillaries is evi dent, it is imperative to treat the underlying malignancy. Oral sup plements are safe and can correct anemia within six weeks, but therapy may need to continue for up to six months for the iron stores to be ade quately replaced (Barragan-Ibanez, Santoyo-Sanchez, & Ramos-Penafel, 2016). Nursing Management Nurses play a key role in the prevention and management of bleeding in patients with cancer and must be able to recognize the early signs and symp toms of bleeding through astute observation and physical assessment. Table 1-4 provides an overview of the clinical assessments and nursing interven tions in the care of patients who have active bleeding or are at risk for bleed ing. Vital signs, hemodynamic status, oxygenation, and fuid status are closely monitored in patients at risk for bleeding. All unnecessary proce dures should be avoided, including intramuscular injections, subcutaneous injections, rectal temperatures and suppositories, and indwelling catheters. Injections sites could put patients at risk for hematomas and lead to infec tion. If an injection must be given, the smallest gauge needle should be used and direct pressure applied for several minutes. Nursing Management of Patients With Actual or Potential Bleeding System Clinical Assessment Nursing Management Content not available for preview. Nursing Management of Patients With Actual or Potential Bleeding (Continued) System Clinical Assessment Nursing Management Content not available for preview. Nurses must ensure that patients with a risk for bleeding who present with a cough have an antitussive medication ordered. Medications with codeine are recommended to help minimize the induction of bleeding related to coughing. Bowel strain from constipation could result in bleeding, so laxatives and stool softeners should be used. Gentle dress ing removal; use of nonadherent dressings, moist wound products, and multiple-layer dressings; and minimal dressing changes and packing can reduce bleeding from wounds (Abdelrahman & Newton, 2011). Patient and Caregiver Education Because bleeding is a very common and potentially fatal event in patients with cancer, it is imperative that nurses instruct patients and care givers on strategies to help prevent bleeding and what to do if it occurs. Nurses should instruct patients to do an environmental check at home to identify and remove bump and fall risks such as throw rugs, to remove clutter from rooms and pathways, and to ensure the patient wears shoes or slippers at all times to minimize the potential for injury. To maintain good skin integrity, nurses should teach patients to use lotion that pre vents dryness and breaks in skin and to avoid the use of adhesive tape, which causes skin trauma; only paper tape should be used. The mouth and gums of thrombocytopenic patients are susceptible to injury; there fore, patients should apply nonpetroleum lubricant to the lips and gums to keep them moist and use a soft-bristled toothbrush to avoid trauma. Patients should avoid substances that can irritate the tissues of the mouth and gums, including hot and spicy foods, alcoholic beverages, and mouth washes that contain alcohol. To prevent bleeding from the nose, patients should be taught to clean the nostrils with a cotton swab or tissue and to avoid vigorous nose blowing (Healthwise Staff, 2016). The use of saline nose drops and sprays, as well as a small amount of moisturizing ointment, such as petroleum jelly, inside the nostrils, will help to prevent nosebleeds (Healthwise Staff, 2016). Bleeding events can be very distressing for patients and caregivers, so excellent communication should be maintained with the care team, and a plan should be developed in case an acute bleeding episode takes place. Instruction to put patients in a lateral position for comfort and to avoid suffocation in the case of a massive bleed is critical (von Gunten & Buckholz, 2017). Newer therapies, including thalidomide, lenalido mide, and bevacizumab, are associated with higher rates of venous thromboembolism. Therapy with low-molecular-weight heparin or vitamin K antagonists may continue indefnitely for patients with active cancer. Early recog nition and initiation of appropriate treatment are crucial to patient outcome. Those at risk are considered for pharmacologic prophylaxis, balancing the risk of venous thromboem bolism with the increased risk of bleeding. Sorensen, Mel lemkjaer, Steffensen, Olsen, and Nielsen frst described this fnding in 1998, and other landmark studies have since confrmed this relationship (Lee & Levine, 2003; White et al. In addition, 62% of the patients with known cancers and 70% of the patients with newly diagnosed cancers already had metastatic disease. In this study, the odds of cancer were nearly fve times higher for patients with idiopathic thrombosis than for those with secondary thrombosis. However, vascular toxicity, particularly thromboem bolism, is a specifc adverse effect of antiangiogenic drugs. Risk Factors and Etiology Thrombophilia is the general term for a condition where the blood has an increased tendency to form clots. These include Prior venous thromboembolism mutations in factor V Leiden Pulmonary disease and prothrombin G20210A and Renal insuficiency defciencies of natural anticoag Disease Bladder ulants protein C, protein S, and related Brain antithrombin (Lijfering et al. Non-Hodgkin lymphoma Kidney Lung Disease-Related Risk Ovary Factors Pancreas Stomach Disease-related factors include the site, stage, and duration of Treatment Antiangiogenesis agents the cancer.

This problem can be minimized by con sistent use of simplified language on written documents symptoms 10 days before period 3 ml lumigan sale, such as consent forms and patient instructions symptoms multiple myeloma buy 3ml lumigan otc, and in face-to-face conversation medications not to crush order lumigan amex. Whenever necessary medicine mound texas buy cheap lumigan on line, interpreter services must be provided to assist with important discussions if patients are not fluent in English or if they are sensory impaired. Reasonable steps are required to ensure meaningful access to interpreter services, includ ing hiring interpreters as office or hospital staff, using appropriate community resources, or using translation telephone services. Accountability Accountability for actions is a fundamental principle of health care provision applicable to all components of a health care delivery system and is a valuable attribute of professional practice that benefits all patients. This accountability includes, but is not limited to , the care of individual patients by individual health care providers. Patients and their support systems have a shared part nership for their health care. Within the perinatal health care delivery system, accountability and responsibility must be required equally of all participants, including patients, families, perinatal health care programs and systems, gov ernment agencies, insurers, and health maintenance organizations, all of whose actions and policies influence the delivery of patient care and, thereby, influence outcomes. Accountability includes developing meaningful quality improvement programs, monitoring medical errors, and working to ensure patient safety. Access to high quality care for all patients is a responsibility that requires a coordinated system with involvement, commitment, and account ability of all parties. Integrated perinatal care programs can be extended to encompass preconception evaluation and early pregnancy risk assessment in both ambulatory and hospital-based settings. Preconception Care Preconception care aims to promote the health of women of reproductive age before conception and improve pregnancy outcomes. Integrated perinatal health care programs and systems should place additional emphasis on pre conception care through educational programs. Health care providers in various disciplines (eg, internal medicine, family medicine, and pediatrics) should be made aware of preconception care recommendations and guidelines. Clinical details of preconception care for perinatal health care providers are presented in Chapter 5. Ambulatory Prenatal Care the goals for the coordination of ambulatory prenatal care are to provide appropriate care for all women, to ensure good use of available resources, and to improve the outcome of pregnancies. As recommended by the March of Dimes Foundation in the second edition of Toward Improving the Outcome of Pregnancy, prenatal care can be delivered more effectively and efficiently by defining the capabilities and expertise (basic, specialty, and subspecialty) of health care providers and ensuring that pregnant women receive risk appropriate care (Table 1-1). Early and ongoing risk assessment should be an integral component of perinatal care. Early identification of high-risk pregnancies allows prevention and treatment of conditions associated with maternal and fetal morbidity and mortality. The content and timing of prenatal care should be varied according to the needs and risk status of the woman and her fetus. Use of community-based risk assessment tools, such as a standardized prenatal record (see also Appendix A), by all health care providers within a regionalized perinatal care system helps to ensure the integration of care delivery and appropriate implementation of risk assessment and intervention activities. All prenatal health care providers should be able to identify a full range of medical and psychosocial risks and either provide appropriate care or make appropriate referrals (see also Appendix B and Appendix C). Prenatal care may involve the services of many types of health care provid ers, including the early involvement of pediatricians and neonatologists as well 8 Guidelines for Perinatal Care as other pediatric subspecialists (eg, cardiologists, surgeons, and geneticists). A consultation with a neonatologist and other appropriate specialists to discuss the pediatric implications with the mother and her partner is particularly important when fetal risks or problems have been identified. Since then, financial and marketing pressures, as well as com munity demands, have led some hospitals to raise their perinatal care service level designation without attention to regional coordination concerns. This tendency conflicts with the traditional concept of regionalized organization, in which single subspecialty care centers had the sole capability to provide com plex patient care and usually, but not always, assumed regional responsibilities for transport, outreach education, research, and quality improvement for a specific population or geographic area. Attempts to share regional responsibilities among hospitals have not been uniformly successful. Currently, some hos pitals capable of delivering specialty-level obstetric services also provide some elements of neonatal intensive care; such disproportionate service capability is not encouraged. This imbalance or lack of coordination in the provision of ser vices may be a product of a growing competitive health care market and efforts by insurers and health plans to control the costs of health care. Such competi tive forces frequently have led to the unnecessary duplication of services within a single community or geographic region, with the potential to result in poorer patient outcomes and, ironically, increased cost. Systematic review of the published literature over the past three decades demonstrates improved neonatal and posthospital discharge survival among very low birth weight and very preterm infants born in hospitals with neonatal intensive care units. Careful documentation of birth-weight specific neonatal Organization of Perinatal Health Care 9 mortality rates by hospital of birth has shown that the chance of survival of premature, very low birth weight infants is highest when births occur in hospitals with higher volume neonatal intensive care units. In addition, multiple reports regarding the outcomes of neonatal surgery support the concentration of resources and patients in a few highly specialized centers for neonatal sur gery. Given the weight of the evidence, it must be emphasized that inpatient perinatal health care services should be organized within individual regions or service areas, in such a manner that there is a concentration of care for the highest-risk pregnant women and their fetuses and neonates who require the highest level of perinatal care. The determination of the appropriate level of care to be provided by a given hospital should be guided by prevailing local and state health care regulations, national professional organization guidelines, and identified regional perinatal health care service needs. However, state and regional authorities should work with multiple hospitals, clinics, and transportation service providers to deter mine the appropriate population-based needs in a coordinated system of care. Currently, substantial variation exists among states in the provision of level of care definitions, functional criteria, and regulatory influence. The expected capabilities of basic, specialty, and subspecialty levels of inpa tient perinatal health care services are listed in Table 1-2. Whereas the previous system proposed by the March of Dimes applied to both obstetric and neonatal care, the capabilities outlined in Table 1-2 focus on obstetric care. Table 1-3 outlines the revised and expanded classification system for neonatal care pub lished in 2012 by the American Academy of Pediatrics. In general, each hospital should have a clear understanding of the cat egories of perinatal patients that can be managed appropriately in the local facility and those that should be transferred to a higher-level facility. Preterm labor and impending delivery at less than 32 weeks of gestation usually war rant maternal transfer to a facility with neonatal intensive care. In some states, because of geographic distances or demographics, hospitals may be approved for a level of neonatal care higher than that for the perinatal service as a whole. In such circumstances, transfer to a facility with a higher level of perinatal care may be appropriate. Capabilities of Health Care Providers in Hospitals Delivering Basic, Specialty, and Subspecialty Perinatal Care* (continued) Level of Care Capabilities Health Care Provider Types Regional Provision of comprehensive perinatal All subspecialty health care subspecialty health care services at and above providers, plus other subspecialists, perinatal health those of subspecialty care facilities. The expanded neonatal care classification system, which is illustrated in Table 1-3, builds on the previous categories of basic, specialty, subspecialty, and regional subspecialty perinatal care. Although no similar expanded classification system currently exists for obstetric care, women should ideally give birth in an obstetric unit within a facility that provides the level of neonatal care that her newborn is expected to require. Although the American Academy of Pediatrics uses both functional and numerical designations to describe levels of neonatal care, for the purpose of clarity in this book, functional designations will be used to denote levels of perinatal care and numerical designations will be used to denote levels of neonatal care. Level I Neonatal Care Level I neonatal care units offer a basic level of newborn care to infants at low risk. These units have personnel and equipment available to perform neonatal 14 Guidelines for Perinatal Care resuscitation at every delivery and to evaluate and provide routine postnatal care for healthy term newborn infants. In addition, level I neonatal units have personnel who can care for physiologically stable infants, who are born at or beyond 35 weeks of gestation, and can stabilize ill newborn infants, who are born at less than 35 weeks of gestation, until they can be transferred to a facility where the appropriate level of neonatal care is provided. These situations usually occur as a result of relatively uncomplicated preterm labor or preterm rupture of membranes. Referral to a higher level of care should occur for all infants when needed for subspecialty surgical or medical intervention.