Frank Eifinger

Propofol as an induction agent for endotracheal intubation can cause significant arterial hypotension in preterm infants.

Background:  Propofol is gaining increasing popularity as induction agent for pediatric endotracheal intubation. Recently, propofol has been described for the first time as induction agent for endotracheal intubation in preterm neonates. Propofol seemed to be efficient, safe and ideally suited for the INSURE (Intubation SURfactant Extubation) procedure in preterm neonates. The purpose of this study was to document intubating conditions, vital signs, extubation times and outcome in preterm neonates receiving propofol as induction agent for the INSURE procedure.

Remifentanil for INSURE in preterm infants: a pilot study for evaluation of efficacy and safety aspects.

Aim:  To evaluate intubating conditions, extubation times and outcome in preterm infants receiving remifentanil as induction agent for the INSURE procedure.

No advanced retinopathy of prematurity stages 4 or 5 in a large high-risk German cohort.

Background Retinopathy of prematurity (ROP) remains a major cause of juvenile blindness. As screening recommendations are refined, decreasing gestational age (GA) and birth weight (BW) constitute an increasing risk for ROP. This retrospective case series reviews the screening results of a very immature cohort in Germany. Methods We conducted ROP screening according to the German guidelines of 1999: all preterm infants with a GA of <32 weeks and/or a BW of <1501 g, or with GA ≥32 weeks and postnatal oxygen treatment for >3 days, were assigned for screening. Dense laser coagulation was performed according to the current treatment criteria. Results All 767 consecutive inborn (patients born at the Department of Neonatology, University Hospital of Cologne, Germany) preterm infants of a tertiary medical centre of maximum care underwent complete screening from 2001 to 2009. The treatment incidence was 7.0%. No preterm infant developed stage 4/5 ROP. Mean GA and BW of untreated/treated preterm infants were 28.4/24.6 weeks and 1109/635 g, respectively. Increasing treatment incidence was associated with lower GA, but not with lower BW in logistic regression analysis. Conclusion In this very immature high-risk cohort, advanced stages 4 and 5 were avoided throughout 9 years of screening. We suggest three factors that contributed to this outcome: (1) strict adherence to current ROP screening and treatment guidelines; (2) prompt and very dense laser coagulation if necessary; and (3) a specialised neonatal intensive care unit with experience of very immature babies.

The anterior to midaxillary line between the 4th or 5th intercostal space (Buelau position) is safe for the use of thoracostomy tubes in preterm and term infants

Objectives:  Thoracostomy tubes are widely used in neonatology. Complications occurred significantly more frequently in infants, especially neonates, than in adults. Principally, the access is the modified Buelau position which takes place in the anterior axillary line at the 4th or 5th intercostal space above the margin of the ribs.

Neonatal Testicular Infarction—Possibly due to Compression of the Umbilical Cord?

Neonatal testicular infarction is a rare occurrence. We report on a newborn infant with bilateral testicular infarction. At birth, the uncut umbilical cord ran taut between the thighs making a complete loop around the genitals, compressing the testes. At the age of 6 hours, because of increasing agitation and the beginnings of scrotal discoloration, the infant was operated on, showing a bilateral testicular infarction potentially induced by strangulation of the twisted umbilical cord. Here, we discuss the clinical findings of neonatal testicular infarction and give advice as to the management of this serious complication with regard to the available published data.

Plasma fluoride concentrations during prolonged administration of isoflurane to a pediatric patient requiring renal replacement therapy.

SIR—This is a case report of prolonged isoflurane administration over 164 hours in a 2-year-old boy with acute sepsis-related renal failure and renal replacement therapy. As there are concerns and only limited data available on long-lasting inhalation of volatile anesthetic agents like isoflurane, we performed a study regarding the elimination of the inorganic fluoride. Levels were measured at least twice a day. Fluoride reached a maximum concentration of 34.23 lM and showed mean values of 27.2 ± 5 lM (mean ± SD). We did not observe any other side effects with regard to isoflurane administration. A 2-year-old boy was treated for purpura fulminans caused by pneumococcal sepsis. A severe septic shock and disseminated intravascular coagulation occurred rapidly. Acute renal failure occurred in the first day of sepsis. The boy was referred to this hospital on the second day of illness for renal replacement therapy and extracorporeal blood purification. Venovenous hemodialysis (VVHD) was performed from day 2 to 19. Sedation was started by a continuous infusion of midazolam and fentanyl after intubation on day 1. The sedative requirements were scored and doses had to be escalated gradually over the days (see Figure S1). Because of severe agitation, we decided to start sedation by continuous inhalation of isoflurane using the AnaConDaa device (Anaesthetic Conserving Device, Sedana Medical, Sweden) from day 11 to 18 (164 h). After obtaining written informed consent, the AnaConDaa device was installed at the proximal inspiratory limb of the breathing circuit rather than at the distal Y piece, to avoid added dead space as described previously (1). Inspiratory and expiratory gases were sampled at the proximal end of the endotracheal tube and analyzed online for isoflurane concentration (Vamos, Draeger, Germany). The expiratory gas was captured in a gas adsorber (Contrafluran, ZeoSys, Berlin, Germany). The assistant ventilation allowed spontaneous breathing using biphasic positive airway pressure support. After starting isoflurane, fentanyl infusion was decreased and continued at low doses (see Figure S1). Intermittent doses of fentanyl, s-ketamine, or piritramide were given. Additionally, a bolus of 0.3 ml isoflurane could be administered to the vaporizer by volumetric pump if necessary. For the time of isoflurane application, VVHD was performed daily (except day 16) using Fresenius FX40 dialyzers (surface area 0.6 m) with Fresenius 4008 machine. Mean treatment duration was 152 ± 45 min with a mean filtration volume of 616 ± 296 ml (36 ± 17 mlÆkg) and a processed blood volume of 8263 ± 2754 ml (486 ± 162 mlÆkg) (each mean ± SD). The isoflurane application (Forene, Abbott, Germany) was brought by volumetric pump system (Perfusor compact, Braun, Germany) to the AnaConDaa vaporizer. The inspiratory and expiratory isoflurane concentrations reached 0.6% isoflurane. The endtidal isoflurane concentration was set to a target value of 0.5–0.9%. The mean isoflurane application rate was 9.1 ± 1.1 mlÆh, the mean isoflurane inspiratory concentration was 0.71 ± 0.13%, and the mean isoflurane expiratory concentration was 0.7 ± 0.12% (each mean ± SD). Serum inorganic fluoride concentrations were measured twice daily from day 13 to 18, before and after each VVHD intervention. Fluoride reached maximum concentration of 34.23 lM on day 15 with mean values of 27.2 ± 5 lM (mean ± SD, day 13–18), see Figure 1. Inhalational sedation was discontinued after 164 h of isoflurane application. Five days after the end of

Anatomical investigations on intraosseous access in stillborns – Comparison of different devices and techniques

AIM Intraosseous (IO)-access plays an alternative route during resuscitation. Our study was performed to investigate the successful rate of IO-access in preterm and term stillborns using different devices and techniques. METHODS The cadavers used were legal donations. 16 stillborns, median: 29.2 weeks (IQR 27.2-38.4) were investigated. Two different needles (a: Butterfly needle, 21G, Venofix® Fa.Braun; b: Arrow®EZ-IO®15G, Teleflex, Dublin, Ireland) were used. Needles were inserted i: manually, using a Butterfly needle; ii: manually, using EZ-IO® needle or iii: using a battery-powered semi-automatic drill (Arrow®EZ-IO®). Spectral-CTs were performed. The diameter of the corticalis was determined from the CT-images. Successful hit rates with 95% confidence intervals (CI) and odds ratios between the three methods were estimated using a generalised linear mixed model (GLMM). RESULTS Estimated success rate was 61.1% (95%CI:39.7%-78.9%) for the Butterfly needle, 43.0% (95%CI:23.4%-65.0%) for hand-twisted EZ-IO® screwing and 39.7% (95%CI:24.1-57.7%) for the semi-automatic drill (Arrow®EZ-IO®), all referring to an average diameter of the corticalis of 1.2 mm. The odds of a correct position were 2.4 times higher (95%CI:0.8-7.6) when using the Butterfly needle than with the drill. In contrast, the odds of correct positioning when inserting the needle by hand were not significantly different from using the drill (odds ratio 1.1, 95%CI: 0.4-3.3). Neither of these effects nor the diameter of the corticalis with an odds ratio near one were significant in the model. Median diameter of the bone marrow cavity was 4.0 mm [IQR 3.3-4.7]. CONCLUSION Intraosseous access for premature and neonatal infants could be best achieved by using a manually twisted Butterfly needle.

Investigation of umbilical venous vessels anatomy and diameters as a guideline for catheter placement in newborns

Umbilical cord catheters (UCC) are important for the primary care of critically ill newborns. To analyze anatomical variations of the umbilical vein (UV) and its further course, we performed abdominal spiral‐CT examinations on stillborns. The aim of the study was to explore the high incidence of mal‐positioned UCCs and to improve their positioning. Eighteen stillborns were investigated (29.2 weeks ± 6.7 weeks (IQR)). CTs were performed using either air or contrast medium injection into the UV. We measured the diameter at the narrowest points of (i) the umbilical vein, (ii) the segmental portal vein, (iii) the left portal vein, (iv) the umbilical recess, and (v) the ductus venosus. The branching angles between (a) the umbilical vein and intrahepatic veins and (b) the ductus venosus and umbilical recess were measured. The diameter of the UV increases from 3.4 to 11 mm (median [IQR]:4.6 mm [4.2–6.9]: r2 = 0.64). The left portal vein has a larger diameter (3.6 mm [2.6–4.55]; r2 = 0.43) than the left segmental portal vein (2.3 mm [1.8–2.75]; r2 = 0.23). The diameter of the ductus venosus (2.5 mm [1.6–3.4]; r2 = 0.59) is half that of the umbilical recess (5.1 mm [3.3–6.2]; r2 = 0.43). The most obtuse angle is formed by the junction between the umbilical recess and ductus venosus (151° [133–159]; r2 = 0.001). The branch angle from the outgoing UV into the left portal vein is more obtuse (128° [123–144]; r2 = 0.0001) than that of the segmental portal vein (115° [105–119]; r2 = 0.0001). To avoid mal‐positioning, our data suggest the use of a soft catheter. The UV and its extensions are wide enough to admit a 4 Fr. catheter without complete obstruction. Clin. Anat. 31:269–274, 2018.

Neonatal mouse ileum: functional properties and protein composition of the contractile machinery

Background:Immature motility of the ileum may contribute to life-threatening diseases. Little is known about the normal biomechanics of the neonatal ileum in relation to the protein composition of its contractile machinery.Methods:We analyzed the tissue architecture, the biomechanics in intact and β-escin-permeabilized preparations, and the protein composition in neonatal (P0) and adult murine ileum.Results:Muscle thickness of the P0 ileum was −50% of the adult ileum and passive compliance was higher. Carbachol- and KCl-elicited contractions were tonic rather than phasic as in the adult. Ca2+ sensitivity was higher and relaxation rate was slower in β-escin-permeabilized P0 compared with adult ileum. The expression level of β-actin relative to α-actin was higher, and those of total actin, myosin, myosin light chain kinase, the catalytic subunit of myosin phosphatase and telokin were lower compared with the adult. The expression level of MYPT1 was similar, but P0 ileum expressed only the M133; the adult ileum also expressed the M130 isoform.Conclusion:The mechanical features and protein composition of the P0 ileum are similar to those of adult tonic smooth muscles. We propose that this is highly adaptive during fetal life allowing the small intestine to act predominantly as a container.Pediatric Research (2014); 76 3, 252–260. doi:10.1038/pr.2014.91

Length, weight and head circumference as reliable signs of maturity in a modern German birth collective

Signs of maturity such as weight, length and head circumference are still a measure used to investigate cases of suspected neonaticides as they help to differentiate between newborns born dead or alive. However, limit values for these signs have not changed for a long time. Our study considers whether limit values should have changed and which validity the current ones have. We investigated the cases of 3162 newborns, dividing them into a mature and an immature collective on the basis of the gestational week. Application of these signs of maturity (2500g, 48cm, 34cm) had a high predictive value concerning maturity (>99%), and even applying only one sign of maturity gave a predictive value over 97%. Clinically the mature collective showed a slightly lower rate of ventilation (2% compared to 2.4% for the non-mature collective). Coherences between maternal age/weight and postnatal ventilation could be shown. Coherences with reanimation could not be investigated since the case number was too low. Our results show that, for valid forensic investigation, these numeric signs of maturity have to be supplemented by further investigations and other influencing factors have to be considered. Therefore, clinical instruments such as the Petrussa-Index, clavicule length measuring and foot length measuring must be considered.