Christophe Milési

6 cmH2O continuous positive airway pressure versus conventional oxygen therapy in severe viral bronchiolitis: A randomized trial†

To compare the effects of nasal continuous positive airway pressure (nCPAP) and conventional oxygen therapy on the clinical signs of respiratory distress and the respiratory muscle workload in acute viral bronchiolitis.

High-flow nasal cannula: recommendations for daily practice in pediatrics.

High-flow nasal cannula (HFNC) is a relatively new device for respiratory support. In pediatrics, HFNC use continues to increase as the system is easily set up and is well tolerated by patients. The use of nasal cannula adapted to the infant’s nares size to deliver heated and humidified gas at high flow rates has been associated with improvements in washout of nasopharyngeal dead space, lung mucociliary clearance, and oxygen delivery compared with other oxygen delivery systems. HFNC may also create positive pharyngeal pressure to reduce the work of breathing, which positions the device midway between classical oxygen delivery systems, like the high-concentration face mask and continuous positive airway pressure (CPAP) generators. Currently, most of the studies in the pediatric literature suggest the benefits of HFNC therapy only for moderately severe acute viral bronchiolitis. But, the experience with this device in neonatology and adult intensive care may broaden the pediatric indications to include weaning from invasive ventilation and acute asthma. As for any form of respiratory support, HFNC initiation in patients requires close monitoring, whether it be for pre- or inter-hospital transport or in the emergency department or the pediatric intensive care unit.

Strategies to reduce curative antibiotic therapy in intensive care units (adult and paediatric)

Emerging resistance to antibiotics shows no signs of decline. At the same time, few new antibacterials are being discovered. There is a worldwide recognition regarding the danger of this situation. The urgency of the situation and the conviction that practices should change led the Société de Réanimation de Langue Française (SRLF) and the Société Française d’Anesthésie et de Réanimation (SFAR) to set up a panel of experts from various disciplines. These experts met for the first time at the end of 2012 and have since met regularly to issue the following 67 recommendations, according to the rigorous GRADE methodology. Five fields were explored: i) the link between the resistance of bacteria and the use of antibiotics in intensive care; ii) which microbiological data and how to use them to reduce antibiotic consumption; iii) how should antibiotic therapy be chosen to limit consumption of antibiotics; iv) how can antibiotic administration be optimized; v) review and duration of antibiotic treatments. In each institution, the appropriation of these recommendations should arouse multidisciplinary discussions resulting in better knowledge of local epidemiology, rate of antibiotic use, and finally protocols for improving the stewardship of antibiotics. These efforts should contribute to limit the emergence of resistant bacteria.

Nitrous oxide analgesia for intubating preterm neonates: a pilot study.

Aim: To evaluate the administration of an equimolar mixture of N2O and O2 for intratracheal intubation in preterm neonates with respiratory distress syndrome (RDS). Design: Prospective evaluation of N2O/O2 in premature neonates with RDS. Setting: Tertiary neonatal unit from March to August 2003. Patients: Twenty‐six of 79 neonates admitted for RDS within 48 h of birth. Intervention: N2O/O2 was administered until muscle tone was suppressed. Surfactant was given intratracheally. Patients were extubated as soon as possible. Main outcome measures: The time needed for N2O/O2 to suppress muscle tone, an evaluation of sedation/analgesia through movements of the limbs, and indicators of stress‐related haemodynamic change, all recorded by an independent observer. Results: In the 26 patients, gestational age was 30.5 (25th, 75th percentile: 30, 32) wk and median body weight was 1540 (1220, 1900) g. Postnatal age at intubation was 2 (2, 3) h. N2O/O2 administration time was 8 (6, 10) min (range 4–15 min). Sedation/analgesia was complete in 77% of patients. No significant differences between pre‐procedure and post‐procedure values were found for heart rate (p=0.29) or mean arterial blood pressure (p=0.13) (paired Wilcoxon test). Time needed for intubation was 30 (20, 37) s (range 10–60 s). Side effects included transient agitation (3/26) and retching (2/26). Extubation occurred 5 (5, 10) min (range 2–15 min) after surfactant instillation. Apnoeas occurred in 3/26 patients within 2 h after extubation. Two patients required reintubation to repeat surfactant administration within 24 h after extubation.

Haemodynamic features during high-frequency oscillatory ventilation in preterms.

Aim: To compare the haemodynamic status during high‐frequency oscillatory ventilation and conventional mechanical ventilation in very preterm infants with respiratory distress syndrome. Methods: Thirty‐two neonates of less than 30 wk gestation randomly assigned to high‐frequency oscillatory ventilation (n= 15) or conventional mechanical ventilation (n= 17) had three echocardiographies and one cerebral Doppler‐echography under the same ventilation during the first 48 h of life. Results: Mean airway pressure was 2 cm H2O higher in infants ventilated with high‐frequency oscillatory ventilation at the different echocardiographies. Comparable right ventricular indexes were observed in the two groups. Reduction of the ductus arteriosus diameter and ductal closure were significant only in neonates ventilated conventionally. Left ventricular performance and left ventricular contractility did not differ between the groups. The high‐frequency group had lower end diastolic velocity and a higher resistance index in the anterior cerebral artery.

Intubation in the delivery room: Experience with nasal midazolam ☆

BACKGROUND Neonates are often intubated in the delivery room (DR) without anesthesia because vascular access is impossible. AIMS To assess neonatal comfort and adverse events after use of nasal midazolam (nMDZ) for intubation in the DR. STUDY DESIGN Prospective data collection over 6months on the intubation of neonates with respiratory distress requiring tracheal instillation of surfactant. SUBJECTS Twenty-seven neonates with median (Q25-75) gestational age and birthweight of, respectively, 29 (27-33)weeks and 1270 (817-1942)g received a 0.1mg/kg dose of nMDZ, and intubation was performed at the onset of tonus resolution or apnea. OUTCOME MEASURES Comfort was assessed with a scale of hetero-pain assessment and electrical skin conductance monitoring. Continuous pulse oximetry was recorded in the first postnatal hour, with oscillometric blood pressure measurement every 10min. RESULTS Seventy percent of the patients required a single dose, with intubation performed 4.8 (3-9)min after administration. Combined electro-clinical assessment found adequate comfort during the procedure in 68% of neonates. Mean blood pressure decreased from 39 (34-44)mmHg before to 31 (25-33)mmHg 1h following nMDZ (p=0.011). CONCLUSION nMDZ provided rapid and effective sedation to intubate neonates in the DR but potentially exposed them to hypotension, thus requiring close hemodynamic monitoring.

Betamethasone Impairs Cerebral Blood Flow Velocities in Very Premature Infants with Severe Chronic Lung Disease

OBJECTIVE To assess betamethasone (BM) effects on the cerebral hemodynamics of neonates with severe chronic lung disease (CLD). STUDY DESIGN Intravenous BM was given once daily for 6 consecutive days to 12 infants (birth weight: 698 g [range, 650-884 g], gestational age: 25.3 weeks [range, 25-26.4 weeks]) at a postnatal age of 34 days (range, 28-36 days). Cerebral blood flow velocities (CBFVs) were recorded prospectively in the anterior cerebral artery (ACA) and the lenticulostriate artery (LSA) before, during, and after treatment, using Doppler flowmetry. RESULTS The decrease in systolic and diastolic velocities was maximum on the 5th day, reaching 32% (95% confidence interval [CI], 23%-42%) and 58% (95% CI, 39%-64%) from baseline in the ACA, and 44% (95% CI, 29%-50%) and 57% (95% CI, 33%-66%) in the LSA, respectively. The resistance index (RI) increased significantly in both arteries during treatment. Return to baseline values was observed after BM was stopped. The change in velocities and RI was independent of arterial blood gas and blood pressure variations. CONCLUSIONS BM decreased the CBFVs of premature infants, suggesting a vasoconstrictor effect in both superficial and deep arterial vessels. Caution is recommended when BM is used to treat preterm infants with severe CLD.

Syndrome hémolytique et urémique à pneumocoque : à propos de 2 cas

UNLABELLED Haemolytic and uremic syndrome (HUS) is the most frequent cause of pediatric acute renal failure. It occurs classically after a diarrhea due to Escherichia coli, seldom in the context of pneumococcus infection. HUS due to pneumococcus has epidemiologic, therapeutic and prognostic characteristics. OBSERVATIONS We report on the cases of 2 young girls who contracted pneumococcal HUS, one with meningitis and the other with pneumonia. Both were less than 2-year-old. Transfusions of washed blood cells were performed, and dialysis therapy was necessary for 6 days in one and 35 days in the other case. The 1st patient was hospitalised for 15 days and recovered completely in 8 months, the 2nd was hospitalised for 39 days and after 3 months still had renal insufficiency. DISCUSSION Pneumococcal HUS usually affects healthy children of under 24 months, and often requires dialysis therapy. All usually described serotypes of pneumococci are not included in Prevenar vaccine. The serotypes found in the 2 vaccinated young patients reported here were included in Pneumo23 but not in Prevenar vaccine. The use of washed blood products is preferable in case of blood transfusion, as the presence of plasma may prolong hemolysis through the action of a neuraminidase. The evolution of pneumococcal HUS, usually considered worse than that of the typical HUS, is similar if the last 30 cases described are considered. CONCLUSION Pneumococcal HUS is a disease that should be better known, whose incidence may be increasing. Prognosis improves if dialysis and antibiotics are started early. Antipneumococcal vaccination reduces the incidence of this disease.

Myocardial Adaptation to Anemia and Red Blood Cell Transfusion in Premature Infants Requiring Ventilation Support in the 1st Postnatal Week

Background: Although transfusion practice in very premature infants is becoming more restrictive, little is known about myocardial adaptation to anemia during the 1st postnatal week. Objectives: To determine the central hemodynamic effects of anemia and red blood cell transfusion in very preterm infants undergoing intensive care. Methods: Twenty-nine neonates of less than 30 weeks gestational age were treated for respiratory distress syndrome, following a strict protocol. Echocardiographies were performed at the 4th and 6th postnatal days, which corresponded to, respectively, just before and 48 h after an erythrocyte transfusion of 15 ml/kg in the 12 anemic infants. Results: Anemic infants had increased stroke volume [2.1 (1.8–2.3) vs. 1.5 (1.3–1.6) ml/kg] and left ventricular (LV) output [312 (271–345) vs. 206 (177–240) ml/min/kg]. The relationship of the heart rate-corrected velocity of circumferential fiber shortening to LV end-systolic meridional wall stress indicated a higher contractile state in the anemic infants, with a higher y-intercept (p = 0.03) and a steeper slope (p = 0.05) of the regression line than in the nonanemic patients. Posttransfusion, the stroke volume, LV output, shortening fraction, and contractile state decreased to the values observed in the nonanemic infants. Conclusions: Myocardial contractility was a major component of the circulatory adjustments in the anemic premature infants requiring ventilation support in the early neonatal period. Changes in LV performance associated with anemia were reversed by transfusion with no detrimental effect on right ventricular function, LV preload or the respiratory status of these patients.

Implementation of a neonatal pain management module in the computerized physician order entry system

BackgroundDespite the recommended guidelines, the neonatal management of pain and discomfort often remains inadequate. The purpose of the present study was to determine whether adding a pain and discomfort module to a computerized physician order entry (CPOE) system would improve pain and discomfort evaluation in premature newborns under invasive ventilation.MethodsAll newborns <37 weeks gestational age (GA) and requiring invasive ventilation were included in a prospective study during two 6-month periods: before and after the inclusion of the pain and discomfort evaluation module. The main outcome measure was the percentage of patients having at least one assessment of pain and discomfort per day of invasive ventilation using the COMFORT scale.ResultsA total of 122 patients were included: 53 before and 69 after the incorporation of the module. The mean age was 30 (3) weeks GA. After the module was included, the percentage of patients who benefited from at least one pain and discomfort assessment per day increased from 64% to 88% (p < 0.01), and the mean number (SD) of scores recorded per day increased from 1 (1) to 3 (1) (p < 0.01). When the score was not within the established range, the nursing staff adapted analgesia/sedation doses more frequently after module inclusion (53% vs. 34%, p < 0.001). Despite higher mean doses of midazolam after module introduction [47 (45) vs. 31 (18) μg/kg/hr, p < 0.05], the durations of invasive ventilation and hospital stay, and the number of nosocomial infections, were not significantly modified.ConclusionsAdding a pain and discomfort tool to the CPOE system was a simple and effective way to improve the systematic evaluation of premature newborns who required ventilatory assistance.