Albert Akierman

Evaluation of the effectiveness of the standardized neonatal resuscitation program.

OBJECTIVE: To determine if health care personnel trained in the Neonatal Resuscitation Program (NRP) used the NRP guidelines in the resuscitation of newborn babies. To determine differences between self-reporting and documentation of resuscitation in medical records.STUDY DESIGN: Using a validated questionnaire, individuals participating in resuscitation of newborns voluntarily phoned and answered questions on an Interactive Voice Response (IVR) system. The study was undertaken in level II hospitals in Southern Alberta with 7500 deliveries per year.RESULTS: Of the 5155 babies delivered during the study, 16% required resuscitation (bag and mask ventilation 10.6%, intubation for meconium or intermittent positive pressure ventilation, IPPV, 3.6%, cardiac massage, CM, 0.3%, epinephrine 0.1%, naloxone 6.9%). Of babies whose interventions could be assessed, bag and mask was correct in 99%, endotracheal intubation for IPPV in 100%, and CM in 100%. Only 75% of babies had meconium managed correctly and 92% had naloxone administered according to guidelines. There were more instances where IVR (48) reported a procedure, which was not charted versus charted and not reported by IVR (21). Educational needs identified by IVR included skills of resuscitation and NRP indications for management.CONCLUSION: Bag and mask ventilation and intubation for neonatal resuscitation are more common than previously reported. Management of the meconium-stained baby and use of naloxone require further education. Compared to charts, use of IVR system allows more complete documentation with rationale of interventions and identification of continuing educational needs.

Severe Congenital Chylothorax Treated With Octreotide

We report a neonate with severe congenital chylothorax. Subcutaneous octreotide was added to the standard treatment regime. The chylothorax resolved with no observed side effects.

Extended interval dosing of gentamicin in premature neonates ≤ 28-week gestation

Aim:  To evaluate an extended interval dosing (EID) regimen of gentamicin in neonates ≤28‐week gestation.

Non-Rotavirus infection causing apnea in a neonate

Apnea in a premature infant is not always due to immaturity and caffeine is not always the answer. We report a case of apnea in a preterm infant who presented at two weeks of life with increase in frequency of apnea that did not respond to caffeine. Family history was significant for diarrhea in a sibling. Stool PCR was positive for Norovirus Genogroup II. Enteric isolation was instituted and the apnea resolved spontaneously with conservative management. Re-emergence of apnea or persistent apnea necessitates further investigation to elucidate the etiology.

Carboxyhemoglobin levels in umbilical cord blood of women with pre-eclampsia and intrauterine growth restriction

Abstract Objective: Pre-eclampsia (PE) and intrauterine growth restriction (IUGR) are associated with abnormal placentation. Heme oxygenase (HO) and carbon monoxide (CO) are involved in normal placental development and function and vasomotor control in the placenta. The objective of our study was to measure CO levels, as assessed by carboxyhemoglobin (COHb) levels in the umbilical cord arterial blood of women with PE, normotensive IUGR (<10th percentile for birth weight), and normotensive pregnancies with appropriate-for-gestational age (AGA) infants. Design and methods: We prospectively analyzed COHb levels in the umbilical arterial blood of women with PE, normotensive IUGR, and normotensive AGA pregnancies. Exclusion criteria included cigarette smoke exposure, hemolytic disorders, a positive direct anti-globulin test, chronic hypertension, fever, and any significant medical illness. COHb levels were measured using the ABL 725 blood gas analyzer. Results: There were 41 women in the normotensive AGA group, 42 in the PE group, and 36 in the normotensive IUGR group. Maternal age, mode of delivery, gravidity, parity, and gender of the infants were similar in the three groups. Gestational age and birth weight were significantly higher in the normotensive AGA group compared with the other two groups. COHb levels were significantly lower in the PE group compared with the normotensive AGA group (0.38±0.06% vs. 0.77±0.11%, P<0.05). COHb levels, although lower in the normotensive IUGR group compared with the normotensive AGA group, did not reach statistical significance. Conclusion: Our data suggests the HO-CO system may have a role in the pathogenesis of PE. We also, for the first time, provide information on umbilical arterial COHb levels in normotensive IUGR pregnancies.

Extended-interval gentamicin administration in neonates: an over-simplified approach

We read with interest the paper by El-Chaar et al on a simplified approach to extended interval dosing (EID) of gentamicin in neonates. We are pleased to see others recognize the benefits of using EID in neonates and approaching it in such a practical way. Our present practice is to adjust dosing intervals in neonates on EID using a single level drawn at 22 h post dose; we have validated this method in neonates less than and greater than 7 days of age and have found it a very effective and practical method. Our first concern with the authors’ approach is the very broad gestational age groupings. Maturation of nephrons occurs between 34 to 36 weeks, and the rate at which neonatal renal function increases ex utero is inversely related to the gestational age at birth. Because of this, the broad gestational age categories used in this study may not accurately account for these differences in renal function. For the authors’ dosing recommendation to be extended to infants of all gestational ages (GA), a much more detailed examination using smaller GA subgroups is required. The authors’ own data showing a higher rate of Cmin values 42 mg l − 1 in Group 1 supports this. In addition, the authors do not consider postnatal age in their suggested dosing scheme. Renal function changes rapidly over the first few weeks of life, and a lack of consideration of this in dosing aminoglycosides most certainly will render any dosing scheme inaccurate. There is a wide range of postnatal ages in the study groups (particularly in Group 1) and this most certainly will have created variability in the pharmacokinetic parameters of the study subjects. While the low rate of elevated Cmin values42 mg l 1 is reassuring, the authors may be missing a group of individuals in whom trough levels are undetectable for a prolonged period of time and may benefit from q24h dosing. For these reasons, we feel that the study results do not clarify the question of dosing for a 24-week GA infant in the first week of life compared with an ex 28-week infant with a corrected gestational age of 32 weeks or compared with a term infant on day 1 of life. The elevated mean AUC values and low percentage of target AUC values suggests that the values achieved in these groups may require closer examination for trends related to corrected gestational age and/or postnatal age. Dosage modifications in 24% of Group 1 study arm patients and 40% of Group 2 study arm patients raised further concern for adopting this proposed ‘simplified approach’ to EID gentamicin. It was good to see the positive safety outcomes reported by the authors, and we share the frustration when trying to determine clinical efficacy in this population.

Evolution of empiric vancomycin dosing in a neonatal population

BackgroundIn 2014, we assessed the effectiveness of our neonatal vancomycin empirical dosing regimen (15–45 mg/kg/day) which led to development of a revised regimen (20–60 mg/kg/day).ObjectiveTo validate the revised empirical vancomycin dosage regimen in achieving target troughs.MethodsThe primary outcome of this multicenter retrospective before-and-after cohort study was the proportion of neonates in the present cohort achieving trough levels below, at or above target (<10, 10–20 and >20 mg/L). Secondary outcomes included difference between cohorts (historical and present) in mean troughs and proportion of patients achieving target levels.ResultsOut of 118 participants, 63 (53.39%) achieved target troughs, 44 (37.29%) had below target troughs and 11 (9.32%) reached above target levels. Mean trough levels and proportion of patients achieving target levels were higher in the present versus historical cohort (p < 0.01 for all comparisons).ConclusionsThe revised empiric dosing regimen was more effective in achieving target serum trough concentrations.

Eosinophilic pustular folliculitis in a premature infant: Case report and literature review

A 10 week old preterm infant was noted to have a vesiculo-pustular eruption on the face and scalp with an erythematous base. Initially the lesions were thought to be secondary to herpes simplex virus infection. However, skin biopsy confirmed the diagnosis of eosinophilic pustular folliculitis (EPF). This idiopathic skin disorder is rarely seen in neonates. To our knowledge this is the first reported case of EPF in a preterm infant.