Gonzalo Mariani

Randomized Trial of Early Bubble Continuous Positive Airway Pressure for Very Low Birth Weight Infants

OBJECTIVEnTo determine whether very low birth weight infants (VLBWIs), initially supported with continuous positive airway pressure (CPAP) and then selectively treated with the INSURE (intubation, surfactant, and extubation to CPAP; CPAP/INSURE) protocol, need less mechanical ventilation than those supported with supplemental oxygen, surfactant, and mechanical ventilation if required (Oxygen/mechanical ventilation [MV]).nnnSTUDY DESIGNnIn a multicenter randomized controlled trial, spontaneously breathing VLBWIs weighing 800-1500 g were allocated to receive either therapy. In the CPAP/INSURE group, if respiratory distress syndrome (RDS) did not occur, CPAP was discontinued after 3-6 hours. If RDS developed and the fraction of inspired oxygen (FiO(2)) was >0.35, the INSURE protocol was indicated. Failure criteria included FiO(2) >0.60, severe apnea or respiratory acidosis, and receipt of more than 2 doses of surfactant. In the Oxygen/MV group, in the presence of RDS, supplemental oxygen without CPAP was given, and if FiO(2) was >0.35, surfactant and mechanical ventilation were provided.nnnRESULTSnA total of 256 patients were randomized to either the CPAP/INSURE group (n = 131) or the Oxygen/MV group (n = 125). The need for mechanical ventilation was lower in the CPAP/INSURE group (29.8% vs 50.4%; P = .001), as was the use of surfactant (27.5% vs 46.4%; P = .002). There were no differences in death, pneumothorax, bronchopulmonary dysplasia, and other complications of prematurity between the 2 groups.nnnCONCLUSIONnCPAP and early selective INSURE reduced the need for mechanical ventilation and surfactant in VLBWIs without increasing morbidity and death. These results may be particularly relevant for resource-limited regions.

Nacimiento por cesárea al término en embarazos de bajo riesgo: efectos sobre la morbilidad neonatal

INTRODUCTIONnThe rate of cesarean delivery (CD) has significantly increased over the last years, even in low risk pregnancies. Our objective was to compare the neonatal morbidity rate in low risk term infants delivered by vaginal or CD.nnnDESIGNnProspective observational and analytical cohort study. Main outcome measures. Incidence of any neonatal morbidity and respiratory morbidity. Population and methods. Infants < or = 37 weeks born at the Hospital Italiano de Buenos Aires between December 2004 and July 2006 were eligible. Exclusion criteria included: any maternal related disorder, acute or chronic fetal distress, breech presentation in primiparous women, multiple pregnancies, intrauterine growth restriction and newborns with major malformations.nnnRESULTSnA total of 2021 infants were included, 1120 born vaginally and 901 by CD. Main indications for CD were failure to progress labor (46%) and previous CD (37%). Only 3% of CD was performed by maternal request. Any neonatal morbidity rate was 9% in infants born by CD and 6.6% in infants born vaginally (RR 1.36; 95%CI 1.01-1.8). Respiratory morbidity rate was 5.3% in infants born by CD and 3.1% in those born vaginally (RR 1.7; 95%CI 1.1-2.6). When stratified by gestational age, respiratory morbidity was higher only for infants < or =38 weeks (7.4% in CD vs. 2.1% in vaginal delivery; RR 3.5; 95%CI 1.5-8.1). Also, respiratory morbidity was higher in infants born < or =38 weeks by CD without labor vs. those with labor 10.5% and 3.9%, respectively (RR 1.35; 95%CI: 1.07-1.70). In a logistic regression analysis, CD and male sex were independently associated with higher respiratory morbidity. There were not significant differences in other morbidities. NICU admission was higher in infants born by CD (9.5% vs. 6.1%; RR 1.5; 95% CI: 1.1-2.1). Sixty-eight percent of the mothers from the CD group refereed having moderate to severe pain in the puerperium vs. 36% in the vaginal group (RR 1.9; 95% CI: 1.7-2.1). Exclusive breastfeeding at discharge was significantly lower in infants born by CD (90% vs. 96%; RR 0.94 95%CI 0.92-0.96).nnnCONCLUSIONSnLow risk CD at term was associated with a higher neonatal morbidity, NICU admission and maternal pain in the puerperium. It also reduces exclusive breastfeeding rate at discharge.

Early hypophosphatemia in preterm infants receiving aggressive parenteral nutrition.

Objective:To report the prevalence of hypophosphatemia during the first week of life in preterm infants receiving aggressive parenteral nutrition and to analyze population variables associated with severe hypophosphatemia.Study design:A retrospective cohort of 61 neonates below 1250u2009g birth weight consecutively born at Hospital Italiano de Buenos Aires exposed to high caloric and protein intake from the first day of birth. Primary outcome was hypophosphatemia (phosphate <4u2009mgu2009dl−1). A one-sample mean comparison test was used to compare our sample with a hypothesized population mean.Results:The prevalence of hypophosphatemia was 91% (95% confidence interval (CI) 82 to 97%). The mean phosphatemia value was 2.52u2009mgu2009dl−1 (95% CI 2.18 to 2.86), significantly different from the hypothesized population mean (P<0.001). Patients with severe hypophosphatemia (<2u2009mgu2009dl−1) were smaller. They presented with sepsis more frequently and received more vasoactive drugs and mechanical ventilation.Conclusion:The prevalence of hypophosphatemia in this group of preterm infants is high. The potential association with adverse clinical outcomes deserves further research.

Medication error in an extremely low birth weight infant: paracetamol overdose

Errors are part of human nature and are usually present in our actions. Medical errors occur quite often and can be serious. Medication errors are among the most frequent, especially in newborn infants because of the multiple steps that occur during the process of prescribing and administering drugs and because most drugs are not licensed for being used in newborn infants (off-label). The aim of this report is to describe a medication error in prescribing paracetamol for closing a patent ductus arteriosus in a preterm infant and to analyze its causes. A preterm female infant born at 27 weeks of gestational age with a birth weight of 750 g received paracetamol at 9 days old at a dose 20 times greater than required. The initial plasma level was 480 µg/mL. N-acetylcysteine was administered and her clinical outcome was satisfactory. Parents were notified of the event, which was recorded in the medical record and in the electronic error reporting system of the Hospital Italiano de Buenos Aires. We consider this report as an example that we are exposed to making mistakes and should maximize precautions to improve patient safety in neonatal units.

The rising incidence and impact of non-medically indicated pre-labour cesarean section in Latin America

In the poorest populations of the world the difficulties of performing a surgical procedure lead to extremely low cesarean section rates associated with very high perinatal mortality. Meanwhile the proportion of births by cesarean section has been increasing for several decades in many areas of the world, reaching alarmingly high rates especially in Latin America. This review aims to describe this secular trend. The causes of the increase in cesarean deliveries are analyzed with a multidimensional approach, trying to recognize the reasons behind the choice of the route of delivery. We are facing a shift in the guiding paradigm, leaving the classical biomedical one. Advantages and disadvantages of non-medically indicated cesarean section are being sought, comparing it with the results of vaginal delivery, with special emphasis on the short- and long-term morbidity of the newborn. Several variables involved in this controversial topic are considered, with the objective of stimulating critical thoughts about the medical, bioethical and social aspects of the increasing trend in the cesarean section rate.

Surfactant Administration through Laryngeal Mask Airway: A Randomized Controlled Study in Rabbits

Background Minimally invasive techniques for surfactant administration for infants with respiratory distress syndrome (RDS) of moderate severity have been proposed. The laryngeal mask airway (LMA) helps in securing the airway without the need of laryngoscopy, but still requires the use of positive pressure ventilation (PPV) to flush surfactant into the lungs. Objective This article compares the effectiveness of two techniques for LMA surfactant administration, instillation into the LMA lumen followed by PPV versus direct laryngeal instillation through a preinserted feeding tube inside the LMA during spontaneous respirations. Study Design This is a randomized controlled trial (RCT) of 18 rabbits with acquired respiratory distress after lung lavage. After surfactant was given, the rabbits remained on continuous positive airway pressure (CPAP). Gas exchange parameters were assessed at baseline and at 30 minutes and lung parenchyma pathology features were analyzed. Results Time required for surfactant administration, oxygenation improvement, and histopathologic findings did not differ between groups. The new technique decreased the need of PPV (p < 0.05). Conclusion In this animal model, surfactant administration through a preinserted feeding tube within the LMA lumen is safe and effective while providing the benefits of a minimally invasive approach. This technique reduces the need of PPV and may prevent its potential risks.

Permissive Hypercapnia in Neonates: Specific Experience and Limitations

Two decades ago, a consensus of experts on mechanical ventilation indicated that one of the potential strategies to reduce lung injury was to modify blood-gas targets to accept a higher-than-normal PaCO2 (Slutsky 1993). This approach to ventilator support has been called permissive hypercapnia, also termed controlled mechanical hypoventilation. In the past, many clinicians aimed to achieve PaCO2 levels of 40 mmHg or less in ventilated neonates. Experimental and clinical researches during the last two decades indicate that slightly higher PaCO2 levels may allow a reduction in ventilatory support and may reduce the risk for lung injury.

Two-by-two table contradicts study's conclusions on tongue colour.

To the Editor, I read with interest the paper by Dawson et al. (1) on how assessing the tongue colour of newborn infants may help to predict the need for supplemental oxygen in the delivery room. However, I am quite confused by the authors final conclusion. If I have understood the paper correctly, a blue tongue – a positive test result – means that the oxygen saturation level (SpO2) is below 70% and the newborn infant need supplemental oxygen. In contrast, the authors state in the final sentence of their paper that: When the tongue is pink, it is likely that the infant has an SpO2 of more than 70% and does not require supplemental oxygen. I disagree with this statement, having used the information provided in the paper to produce the two-by-two table (Table 1). The table shows that the tongue colour test had a sensitivity of 26% when it came to ruling out SpO2 < 70%, which means a high rate of falsenegative results.What the test doeshas, however, is high specificity, meaning that there would be very few false-positive results (4%) when the infants tongue was blue and the SpO2 was above 70%.

Randomized Trial of Different Methods to Reduce the Pain Response Associated with Blood Extraction in Term Neonates

Randomized Trial of Different Methods to Reduce the Pain Response Associated with Blood Extraction in Term Neonates