Arthur E. Kopelman

Use of Oxygen Cannulas in Extremely Low Birthweight Infants is Associated with Mucosal Trauma and Bleeding, and Possibly with Coagulase-negative Staphylococcal Sepsis

OBJECTIVE: We studied the association between the use of oxygen cannulas (OCs) and (1) nasal bleeding and (2) coagulase-negative staphylococcal sepsis (CNSS).STUDY DESIGN: Review of care sheets, with χ 2 or sign-test group comparisons.RESULTS: Infants treated with OCs were suctioned more frequently (2.6 vs 1.3 times per day, p<0.001), and had more bloody nasal secretions (34.6% vs 4.6%, p<0.05) that increased with increasing OC days. By 10 days, 90% of infants had experienced bloody secretions.CNSS occurred less often in infants treated with oxyhoods than those on OC or CPAP (1 of 13, 8%, vs 10 of 44, 23%), but the difference was not significant. Eight of the 10 CNSS episodes clustered within 3 and 7 days of starting CPAP or cannula treatments.CONCLUSION: OC use in extremely low birthweight infants is associated with nasal mucosal injury and bleeding. Studies are needed to see if use of OCs is a risk factor for CNSS.

Airway obstruction in two extremely low birthweight infants treated with oxygen cannulas.

Two extremely low birthweight (ELBW) infants developed airway obstruction while being treated with oxygen cannulas. We have previously shown that nasal mucosal injury from use of oxygen cannulas in ELBW infants increases nasal secretions and bleeding. Airway patency may be compromised when ELBW infants are treated with oxygen cannulas.

Meconium Pleuritis: Cytologic Diagnosis in A Neonate with Perforated Sigmoid Colon and Diaphragmatic Hernia

Meconium pleuritis developed in a neonate with a perforation of the sigmoid colon, through a diaphragmatic defect. The meconium released in the abdomen communicated with the right pleural space. The association of these defects is unusual, and the cytologic diagnosis of meconium pleuritis has not been previously reported.

Plasma prostaglandin E and F in preterm infants: Association with respiratory distress syndrome and patent ductus arteriosus

In order to determine if prostaglandin values correlate with gestational age, birth weight, postnatal age, or respiratory distress syndrome (RDS), we determined plasma prostaglandin F2α (PGFα) and prostaglandin E2 (PGE2) by specific radioimmunoassay in 34 samples from 27 preterm infants. Neither prostaglandin correlated with gestational age or with birth weight. PGF2α decreased (p < 0.3) with postnatal age. Values for PGF and PGE in each sample varied together (p < .01) but only PGF2α increased (p < .09) in infants with RDS. The highest PGF2α values occurred in infants with severe RDS, including four infants with patent ductus arteriosus (PDA). In contrast, plasma PGE2 was not elevated in infants with RDS or PDA.

Neonatologists, Pediatricians, and the Supreme Court Criticize the “Baby Doe” Regulations

Earlier we reported neonatologists’ reaction (Kopelman et al., 1988) to the controversial federal regulations governing the treatment of severely handicapped infants—the “Baby Doe” Regulations (DHHS, 1985). We found that the responding neonatologists were highly critical of these regulations, and that their concerns were similar to those expressed by the United States Supreme Court (Bowen v. Am. Hosp. Ass’n., 1986) in rejecting an earlier set of Baby Doe regulations (DHHS, 1984). This agreement among the neonatologists and legal authorities on the Supreme Court lead us to conclude that these regulations were ill-considered. Some have questioned, however, whether the neonatologists’ negative reaction to these rules as reported in our survey might be biased, since the regulations restrict their daily practice. Others question if neonatologists have an unrealistic, pessimistic picture of severely sick newborns’ prognoses, since they do not generally deal with older children. To help answer these questions, we now present the reaction of nonneonatologist pediatricians to these regulations. These data were collected at the same time as the reported survey. Their responses are similar to the neonatologists’ responses, undercutting both objections to the conclusions of our survey.

Dilemmas in the Neonatal Intensive Care Unit

It is now possible to predict with a high degree of certainty that no matter what care is given, some newborn infants will be severely retarded. Controversies about how best to treat these infants sometimes arise in my area of medicine, intensive care for the newborn. And, to put the issue in perspective, it is important to note that there may be a stark contrast between what one may feel should be done and what can be done under difficult circumstances and with limited resources. The number of beds or personnel available for neonatal intensive care is sometimes inadequate to serve these patients. How many beds or personnel there are affect the lives or well-being of these sick infants. But this is a funding decision. Ultimately, it is a political one, with which the medical profession has to live.

A Single Dose of Dexamethasone (Dex.) Given at Delivery to Infants < 28 Weeks Gestation Results in Improved Lung Function, Early Extubation, Higher BP and Less PDA |[dagger]| 1046

Study: We tested the hypothesis that a 0.2 mg/kg dex. dose at delivery improves lung function, increases BP and prevents IVH in .2. Results: Within hours of the dex. dose the Ventilation Index improved and the effect persisted as shown by the following p values: Table Mean BP was initially similar between groups, but in the dex. infants it became significantly higher on day 1 and remained higher (within the physiologic range) through day 6 (p<.025 on each day). The dex. infants had fewer PDAs (10/32 vs 18/31, p<.03), and fewer received indocin (10/32 vs 17/31, p <.06). At the study hospital where early extubation was practiced more dex. infants were extubated during the first week (10/22 vs 2/16, p <.03). There was no difference in IVH. No adverse effects occurred. Conclusion: A single 0.2 mg/kg dex. dose given at delivery to infants < 28 weeks gestation resulted in rapid improvements which lasted through the first week and included reduced ventilator settings and earlier extubations, higher BP and fewer PDAs.

Arterial and Cerebral Venous Blood Gases Differ in Acute Tension Pneumothorax

Tension pneumothorax (TP) complicates the course of respiratory distress syndrome in about 13% of low birth weight infants. If TP is accompanied by hypotension the majority of infants will develop large intraventricular hemorrhages or cerebral ischemic lesions. Severe TP likely produces cerebral ischemia as a consequence of systemic hypotension, but in a previous clinical study we did not demonstrate accompanying abnormalities in the arterial blood gases. Because of the possibility that arterial blood gases do not reflect tissue acid-base abnormalities during TP, this study was designed to compare sagittal sinus blood gases with arterial gases during and following recovery from severe TP in 5-7 day piglets.During a 4 minute TP mean blood pressure and common carotid blood flow dropped by 75% and 73%, respectively, and the electroencephalogram became isoelectric. Also sagittal sinus pCO2 rose (from 45.7 to 63.4 mmHg, P < 0.02) and pH fell (from 7.31 to 7.23, P < 0.02). During TP, end-tidal CO2 decreased (fr...

797 NEONATAL STABILIZATION AT COMMUNITY HOSPITALS IS IMPROVED BY OUTREACH EDUCATION: A PROSPECTIVE STUDY

We describe the first prospective evaluation of the effects of an outreach education program on pre-transport stabilization of sick neonates born in community hospitals. The relationship between the adequacy of stabilization and the timing of participation in a perinatal outreach program was studied.Information regarding stabilization procedures done by referring hospital personnel prior to the arrival of our transport team was recorded and expressed as the percentage of appropriate actions. Highly significant improvement was seen in these percentage scores in the six-month period following outreach education compared to the 12 months immediately preceding the educational program (mean post-outreach score 81%, n=58 transports versus pre-outreach score 68%, n=40, p < .001). In contrast, no spontaneous improvement with time (i.e. without outreach education) was seen during the two years prior to the program (mean pre-outreach score A 64%, n=3t, pre-outreach score B 68%, n=10, non-significant).This study shows that neonatal outreach education improves the stabilization of neonates in community hospitals and implies a beneficial effect on neonatal outcome.

1824 THE EMPTY THORAX: AN AVOIDABLE LETHAL FACTOR IN CONGENITAL DIAPHRAGMATIC HERNIA

In spite of sophistication in neonatal care, congenital diaphragmatic hernia (CDH) which presents within the first 24 hours of life has a high mortality (generally around 50%).The observation that neonates with CDH deteriorate several hours after surgery, frequently with a mediastinal shift, suggest that they may be dying of the empty thorax syndrome. When a patient is on positive pressure ventilation, insertion of a chest tube connected to a suction or a waterseal into the thoracic cavity, when there is no expandable lung, creates a vacuum and the mediastinum is shifted to that side.In addition to using currently accepted management, we used a modification of an infant chest bottle. A chest tube was connected to a bottle with a vent, but without a waterseal. This permitted evacuation of fluid but prevented mediastinal shifts.We treated a consecutive series of 11 infants with this approach, ten of which were symptomatic soon after birth. Three of these were moribund at the time of surgery and died. Seven of the remaining eight salvageable infants required surgery within 24 hours of life.Seven out of eight (87.5%) of the infants survived if they were considered potentially salvageable prior to surgery. The use of thoracic drainage with avoidance of the empty thorax syndrome appeared to play a significant role in obtaining these improved results.