Ben Stenson

The International Liaison Committee on Resuscitation (ILCOR) consensus on science with treatment recommendations for pediatric and neonatal patients: Neonatal resuscitation

APPROXIMATELY 10% OF newborns require some assistance to begin breathing at birth, and about 1% require extensive resuscitation. Although the vast majority of newborn infants do not require intervention to make the transition from intrauterine to extrauterine life, the large number of births worldwide means that many infants require some resuscitation. Newborn infants who are born at term, had clear amniotic fluid, and are breathing or crying and have good tone must be dried and kept warm but do not require resuscitation. All others need to be assessed for the need to receive 1 or more of the following actions in sequence:

Treatment of Neonatal Sepsis with Intravenous Immune Globulin

BACKGROUND Neonatal sepsis is a major cause of death and complications despite antibiotic treatment. Effective adjunctive treatments are needed. Newborn infants are relatively deficient in endogenous immunoglobulin. Meta-analyses of trials of intravenous immune globulin for suspected or proven neonatal sepsis suggest a reduced rate of death from any cause, but the trials have been small and have varied in quality. METHODS At 113 hospitals in nine countries, we enrolled 3493 infants receiving antibiotics for suspected or proven serious infection and randomly assigned them to receive two infusions of either polyvalent IgG immune globulin (at a dose of 500 mg per kilogram of body weight) or matching placebo 48 hours apart. The primary outcome was death or major disability at the age of 2 years. RESULTS There was no significant between-group difference in the rates of the primary outcome, which occurred in 686 of 1759 infants (39.0%) who received intravenous immune globulin and in 677 of 1734 infants (39.0%) who received placebo (relative risk, 1.00; 95% confidence interval, 0.92 to 1.08). Similarly, there were no significant differences in the rates of secondary outcomes, including the incidence of subsequent sepsis episodes. In follow-up of 2-year-old infants, there were no significant differences in the rates of major or nonmajor disability or of adverse events. CONCLUSIONS Therapy with intravenous immune globulin had no effect on the outcomes of suspected or proven neonatal sepsis.

Increased 36 week survival with high oxygen saturation target in extremely preterm infants

The authors report pooled preliminary results from two trials of oxygen saturation (SpO2) targeting in infants born at less than 28 weeks of gestation.

Clinical Diagnosis of Pneumothorax Is Late: Use of Trend Data and Decision Support Might Allow Preclinical Detection

Pneumothorax in the newborn has a significant mortality and morbidity. Early diagnosis would be likely to improve the outlook. Forty-two consecutive cases of pneumothorax that developed after admission to a tertiary referral neonatal medical intensive care unit over 4 y from 1993 to 1996 were reviewed. The time of onset of the pneumothorax was determined by retrospective evaluation of the computerized trend of transcutaneous carbon dioxide (tcpCO2) and oxygen tensions. The timing of the occurrence in the notes and x-rays determined the time of clinical diagnosis noted at the time. The difference was the time the condition was undiagnosed. The overall mortality before discharge was 45% (19cases), four patients succumbing within 2 h. The median time (range) between onset of pneumothorax and clinical diagnosis was 127 min (45–660 min). In most cases, the endotracheal tube was aspirated and the transcutaneous blood gas sensor was repositioned, and in at least 40% of the cases, the baby was reintubated before the diagnosis was made. Reference centiles were constructed for level of tcpCO2 and slope of the trended tcpCO2 over various time intervals (in minutes) from 729 infants from 23 to 42 wk gestation who needed intensive care during the first 7 d of life from the same time period. The 5-min tcpCO2 trend slopes were compared in index and matched control infants. The presence of five consecutive and overlapping 5-min slopes greater than the 90th centile showed good discrimination for a pneumothorax (area under the receiver operating characteristic curve, 89%). We concluded that 1) the clinical diagnosis of pneumothorax was late, occurring when infants decompensate;2) trend monitoring of tcpCO2 might allow the diagnosis to be made earlier if used properly; and 3) use of reference centiles of the trended slopes of tcpCO2 might be used for automatic decision support in the future.

Oxygen targeting in preterm infants using the Masimo SET Radical pulse oximeter

Background A pretrial clinical improvement project for the BOOST-II UK trial of oxygen saturation targeting revealed an artefact affecting saturation profiles obtained from the Masimo Set Radical pulse oximeter. Methods Saturation was recorded every 10 s for up to 2 weeks in 176 oxygen dependent preterm infants in 35 UK and Irish neonatal units between August 2006 and April 2009 using Masimo SET Radical pulse oximeters. Frequency distributions of % time at each saturation were plotted. An artefact affecting the saturation distribution was found to be attributable to the oximeters internal calibration algorithm. Revised software was installed and saturation distributions obtained were compared with four other current oximeters in paired studies. Results There was a reduction in saturation values of 87–90%. Values above 87% were elevated by up to 2%, giving a relative excess of higher values. The software revision eliminated this, improving the distribution of saturation values. In paired comparisons with four current commercially available oximeters, Masimo oximeters with the revised software returned similar saturation distributions. Conclusions A characteristic of the software algorithm reduces the frequency of saturations of 87–90% and increases the frequency of higher values returned by the Masimo SET Radical pulse oximeter. This effect, which remains within the recommended standards for accuracy, is removed by installing revised software (board firmware V4.8 or higher). Because this observation is likely to influence oxygen targeting, it should be considered in the analysis of the oxygen trial results to maximise their generalisability.

Influence of erythromycin on establishment of feeding in preterm infants: observations from a randomised controlled trial.

AIM To determine the effect of erythromycin on the establishment of enteral feeding in ventilated infants <31 weeks gestation. METHODS Erythromycin was randomly allocated as an antimicrobial treatment for the first 7 days of life in 76 infants: 35 received erythromycin and 41 acted as controls. Feed toleration, time taken to establish full enteral feeding, vomiting, prescription of glycerine suppositories and occurrence of necrotising enterocolitis were recorded. RESULTS There were no significant differences between the groups for any of the outcomes. The infants treated with erythromycin reached full feeding at a median (quartile) age of 8 (5–12) days compared with 9 (6–14) days for controls. CONCLUSIONS Intravenous erythromycin in antimicrobial doses is unlikely to benefit the introduction of feeding in preterm infants.

Non‐invasive measurement of reduced ventilation:perfusion ratio and shunt in infants with bronchopulmonary dysplasia: a physiological definition of the disease

Background: An objective definition of bronchopulmonary dysplasia (BPD) is required to interpret trial outcomes and provide a baseline for prognostic studies. Current definitions do not quantify disease severity. The cardinal measures of impaired gas exchange are a reduced ventilation:perfusion ratio (VA:Q) and increased right to left shunt. These can be determined non-invasively by plotting arterial oxygen saturation (Spo2) against inspired oxygen pressure (PIo2). Aims: To describe the reduced VA:Q and shunt in infants with BPD and evaluate these as graded measures of pulmonary dysfunction. Methods: 21 preterm infants with BPD were studied. PIo2 was changed stepwise to vary Spo2 between 86% and 94%. Pairs of PIo2 and Spo2 data points for each infant were plotted and analysed to derive reduced VA:Q ratio and shunt. Results: In every infant, the Spo2 versus PIo2 curve was shifted to the right of the normal because of a reduced VA:Q. The mean (SD) shift was 16.5 (4.7) kPa (normal 6 kPa). Varying degrees of shunt were also present, but these were less important in determining Spo2 within the studied range. The degree of shift was strongly predictive of the PIo2 required to achieve any Spo2 within the range 86–94% (R2>0.9), permitting shift and VA:Q to be determined from a single pair of PIo2 and SpO2 values in this range. Conclusions: The predominant gas exchange impairment in BPD is a reduced VA:Q, described by the right shift of the Spo2 versus PIo2 relationship. This provides a simpler method for defining BPD, which can grade disease severity.

Arterial oxygen tension (Pao2) values in infants <29 weeks of gestation at currently targeted saturations

Background: Oxygen saturation (Spo2) monitors are commonly used to determine the need for supplemental oxygen. We aimed to describe the range of arterial oxygen tensions (Pao2) observed in preterm infants at saturation levels targeted in current trials. Methods: In a cohort of 98 consecutive infants born at <29 weeks’ gestation, the Pao2 from each arterial blood gas result during the first week of life (n = 2076) was matched to the Spo2 at time of sampling. The mean (95% CI) Pao2 was calculated for each saturation. Results: The 95% CI of Pao2 for the Spo2 range 85–95% was 3.8 to 8.9 kPa. The mean (95% CI) Pao2 at a saturation of 85% was 5.3 (3.8 to 6.8) kPa and at a saturation of 95% it was 7.2 (5.5 to 8.9) kPa. Conclusion: Saturations within the range 85–95% largely exclude hyperoxia in preterm infants <29 weeks’ gestation but permit Pao2 values far lower than those recommended in traditional guidelines.

Antenatal corticosteroid prescribing : setting standards of care

Objective Despite widespread recognition that prenatal administration of corticosteroids dramatically reduces perinatal mortality and morbidity, clinical practice in this area remains less than ideal. We therefore reviewed our practice to identify reasons for this and to determine attainable standards of care.

Randomised controlled trial of respiratory system compliance measurements in mechanically ventilated neonates

AIM To determine whether outcomes of neonatal mechanical ventilation could be improved by regular pulmonary function testing. METHODS Two hundred and forty five neonates, without immediately life threatening congenital malformations, were mechanically ventilated in the newborn period. Infants were randomly allocated to conventional clinical management (control group) or conventional management supplemented by regular measurements of static respiratory system compliance, using the single breath technique, with standardised management advice based on the results. RESULTS Fifty five (45%) infants in each group experienced one or more adverse outcomes. The median (quartile) durations of ventilation and oxygen supplementation were 5 (2–12) and 6 (2–34) days for the control group, and 4 (2–9) and 6 (3–36) days for the experimental group (not significant). On post-hoc secondary analysis, control group survivors were ventilated for 1269 days with a median (quartile) of 5 (2–13) days, and experimental group survivors were ventilated for 775 days with a median (quartile) duration of 3 (2–8) days (p=0.03). CONCLUSIONS Although primary analysis did not show any substantial benefit associated with regular measurement of static respiratory system compliance, this may reflect a type II error, and a moderate benefit has not been excluded. Larger studies are required to establish the value of on-line monitoring techniques now available with neonatal ventilators.