Javier Rodríguez-Fanjul

Lung Ultrasound as a Predictor of Mechanical Ventilation in Neonates Older than 32 Weeks

Background: The prognosis of neonatal respiratory distress may be difficult to estimate at admission. Lung ultrasound is a useful diagnostic tool that is quick, requires little training, and is radiation free. Objective: This study aims to analyze whether early lung ultrasound can predict respiratory failure. Methods: From January to December 2014, lung ultrasound was performed on neonates admitted with breathing difficulties if they were older than 32 weeks and not intubated. A neonatologist, not aware of the patients clinical condition, analyzed the stored ultrasound images. The findings were classified into the following 2 groups according to the potential risk of a bad respiratory outcome: low risk (normal or transient tachypnea of the newborn) or high risk (respiratory distress syndrome, meconium aspiration syndrome, pneumothorax, or pneumonia). A second investigator made the same classification after reading the chest X-rays. Respiratory failure was defined as a need for mechanical ventilation during the first day of life. Results: In total, 105 neonates were recruited (64.8% in the low-risk sonography group and 35.2% in the high-risk sonography group). Of those, 20% needed intubation, and this was more frequent in the high-risk group (relative risk = 17.5; 95% CI 4.3-70.9, p < 0.01). As predictors of respiratory failure, lung ultrasound and chest X-ray showed a high index of agreement (κ coefficient = 0.91; 95% CI 0.83-1, p < 0.01) and good accuracy (ultrasound: 95% sensitivity, 82.5% specificity, and a negative predictive value of 98.5%). Conclusions: Early lung ultrasound is a useful tool to determine which neonates admitted with respiratory distress will require mechanical ventilation. It may help the clinician to carrying out appropriate transfers.

Neuroprotection with Hypothermia and Allopurinol in an animal model of hypoxic-ischemic injury: Is it a gender question?

Background Hypoxic-ischemic encephalopathy (HIE) is one of the most important causes of neonatal brain injury. Therapeutic hypothermia (TH) is the standard treatment for term newborns after perinatal hypoxic ischemic injury (HI). Despite this, TH does not provide complete neuroprotection. Allopurinol seems to be a good neuroprotector in several animal studies, but it has never been tested in combination with hypothermia. Clinical findings show that male infants with (HI) fare more poorly than matched females in cognitive outcomes. However, there are few studies about neuroprotection taking gender into account in the results. The aim of the present study was to evaluate the potential additive neuroprotective effect of allopurinol when administrated in association with TH in a rodent model of moderate HI. Gender differences in neuroprotection were also evaluated. Methods P10 male and female rat pups were subjected to HI (Vannucci model) and randomized into five groups: sham intervention (Control), no treatment (HI), hypothermia (HIH), allopurinol (HIA), and dual therapy (hypothermia and allopurinol) (HIHA). To evaluate a treatment’s neuroprotective efficiency, 24 hours after the HI event caspase3 activation was measured. Damaged area and hippocampal volume were also measured 72 hours after the HI event. Negative geotaxis test was performed to evaluate early neurobehavioral reflexes. Learning and spatial memory were assessed via Morris Water Maze (MWM) test at 25 days of life. Results Damaged area and hippocampal volume were different among treatment groups (p = 0.001). The largest tissue lesion was observed in the HI group, followed by HIA. There were no differences between control, HIH, and HIHA. When learning process was analyzed, no differences were found. Females from the HIA group had similar results to the HIH and HIHA groups. Cleaved caspase 3 expression was increased in both HI and HIA. Despite this, in females cleaved caspase-3 was only differently increased in the HI group. All treated animals present an improvement in short-term (Negative geotaxis) and long-term (WMT) functional tests. Despite this, treated females present better long-term outcome. In short-term outcome no sex differences were observed. Conclusions Our results suggest that dual therapy confers great neuroprotection after an HI event. There were functional, histological, and molecular improvements in all treated groups. These differences were more important in females than in males. No statistically significant differences were found between HIHA and HIH; both of them present a great improvement. Our results support the idea of different regulation mechanisms and pathways of cell death, depending on gender.

Lung Ultrasound: A Useful Tool for the Follow-Up of Neonatal Localized Interstitial Emphysema

A 33-week-old girl was admitted to the neonatal intensive care unit because of respiratory distress. A ground glass appearance and air bronchograms were seen on the chest radiograph (Figure, 1a). Lung ultrasound showed an alveolar interstitial syndrome pattern: bilateral coalescent B-lines from the base to the apex and pleural thickness without spared areas (Figure, 1L and 1R). She required continuous positive airway pressure for 72 hours. After being asymptomatic for 1 week, she began to have tachypnea and subcostal retraction. Radiograph revealed an asymmetric inflation of both lungs with left-sided cystic lucencies (Figure, 2a). Lung ultrasound showed a normal pattern for the right lung, and on the left non-coalescent, vertically-oriented B-lines were seen (Figure, 2L and 2R). A thoracic computed tomography demonstrated localized interstitial emphysema of the left upper lobe (Figure, 3).

Procalcitonin Is a Better Biomarker than C-Reactive Protein in Newborns Undergoing Cardiac Surgery: The PROKINECA Study

Objectives To assess the kinetics of procalcitonin (PCT) and C-reactive protein (CRP) in newborns after cardiothoracic surgery (CS), with and without cardiopulmonary bypass, and to assess whether PCT was better than CRP in identifying sepsis in the first 72 hours after CS. Patients and Methods This is a prospective study of newborns admitted to the neonatal intensive care unit after CS. Interventions PCT and CRP were sequentially drawn 2 hours before surgery and at 0, 12, 24, 48, and 72 hours after surgery. Results A total of 65 patients were recruited, of which 14 were excluded because of complications. We compared the kinetics of PCT and CRP after CS in bypass and non-bypass groups without sepsis; there were no differences in the PCT values at any time (24 hours, P = 0.564; 48 hours, P = 0.117; 72 hours, P = 0.076). Thirty-five patients needed bypass, of whom four were septic (11.4%). Significant differences were detected in the PCT values on comparing the septic group to the nonseptic group at 48 hours after cardiopulmonary bypass (P= 0.018). No differences were detected in the CRP values in these groups. A suitable cutoff for sepsis diagnosis at 48 hours following bypass would be 5 ng/mL, with optimal area under the curve of 0.867 (confidence interval 0.709–0.958), P< 0.0001, and sensitivity and specificity of 87.5% (29.6–99.7) and 72.6% (53.5–86.4), respectively. Conclusions This is a preliminary study but PCT seems to be a good biomarker in newborns after CS. Values over 5 ng/mL at 48 hours after CS should alert physicians to the high risk of sepsis in these patients.

La ecografía pulmonar como herramienta para guiar la surfactación en neonatos prematuros

OBJECTIVES The aim of this study is to assess the usefulness of lung ultrasound (LUS) to estimate the endotracheal tube (ETT) depth position during the Intubation-Surfactant-Extubation (INSURE) procedure. MATERIAL AND METHODS The ETT insertion depth was estimated using the weight (insertion depth (cm)=weight (kg)+5.5). After intubation two independent neonatologists using bilateral auscultation or LUS checked the ETT depth. RESULTS Twelve newborns with respiratory distress syndrome were included. In two cases LUS helped to correctly replace the ETT. All the patients progressed well, with normal x-ray and LUS before discharge. CONCLUSIONS LUS appears to be a safe and non-invasive technique and is useful in clinical situations were x-ray is not routinely performed, as it is fast and radiation free.

Is Procalcitonin Useful in Pediatric Critical Care Patients

This review examines the use of procalcitonin in different clinical situations in the pediatric patient, with special emphasis on those requiring intensive care. We review the latest articles on its potency as a biomarker in both infectious processes at diagnosis and on the response to treatment.

Kinetics of Procalcitonin in Pediatric Patients on Extracorporeal Membrane Oxygenation

Objectives: To assess the kinetics of procalcitonin (PCT) and C-reactive protein (CRP) in pediatric patients who required extracorporeal membrane oxygenation (ECMO) and to analyze its relationship with morbidity and mortality. Patients and methods: Prospective observational study including pediatric patients who required ECMO. Both PCT and CRP were sequentially drawn before ECMO (P0) and until 72 hours after ECMO. Results: A total of 40 patients were recruited. Two cohorts were established based on the value of the P0 PCT (>10 ng/mL). Comparing the kinetics of PCT and CRP in these cohorts, the described curves were the expected for each clinical situation. The cutoff for P0 PCT to predict multiple organ dysfunction syndrome was 2.55 ng/mL (sensibility 83%, specificity 100%). Both PCT and CRP did not predict risk of neurologic sequelae or mortality in any group. Conclusions: Procalcitonin does not seem to be modified by ECMO and could be a good biomarker of evolution.

Patent Ductus Arteriosus Banding for Circular Shunting After Pulmonary Valvuloplasty

We report two cases of newborns with critical pulmonary stenosis having intact ventricular septum, who underwent pulmonary valve balloon valvuloplasty followed by banding of a patent ductus arteriosus. Transcatheter pulmonary valvuloplasty was performed one week after delivery. Following the procedure, both developed “circular shunting” as a consequence of left-to-right ductal flow and pulmonary regurgitation. This in turn caused increased blood flow into a dysfunctional right ventricle and low systemic cardiac output syndrome. The PDA banding was performed urgently as a rescue measure in order to restore systemic flow while still maintaining some duct-dependent pulmonary blood flow. This approach resolved the circular shunting. Outcome was favorable in both the patients.

Lung Ultrasound for Cardiogenic Shock in VA-ECMO

A neonate was referred with a diagnosis of refractory cardiogenic shock resulting from dilated myocardiopathy of unknown origin. Echocardiography showed dilation and severe dysfunction (left ventricular ejection fraction < 10%). Venoarterial extracorporeal membrane oxygenation (VA-ECMO) was started. Subsequent echocardiography showed persistence of dilatation of the left chambers (Figure 1A). Chest X-ray (Figure 1B) and lung ultrasound (Figure 2A) showed bilateral pulmonary edema (asterisks), indicated by the presence of B lines (hyperechogenic stripes perpendicular to the transducer and spreading from the pleural line across the screen) in the lung ultrasound (Figure 2A). Left heart decompression was performed by atrial balloon septostomy and the left atrium decreased in size (Figure 2B), with progressive recovery of ventricular function and resolution of pulmonary edema. Lung ultrasound was performed 48 hours after recovery of the pattern of normal pulmonary aeration, as indicated by chest X-ray (Figure 3A) and ultrasound, which showed the presence of A lines (hyperechogenic stripes parallel to the pleura) without the presence of B lines (arrows), a sign of normal pulmonary aeration (Figure 3B). The patient showed progressive improvement, and decannulation of ECMO was possible 7 days later. Echocardiography showed improvement in left ventricular function, with ejection fraction > 60%. This case illustrates the sensitivity and usefulness of chest ultrasound compared with chest X-ray for monitoring pulmonary edema as it reduces children’s exposure to ionizing radiation. Rev Esp Cardiol. 2018;71(5):393

Aortic thrombosis successfully treated with local recombinant tissue plasminogen activator in a newborn.

Arterial thrombosis in newborns varies depending on the location of the thrombus and can be a life-threatening emergency. We present a case of extensive aorta thrombosis with a left kidney thrombosis in a newborn successful treated with local recombinant tissue-type plasminogen activator.