Luigi Giannini

Nasal flow-synchronized intermittent positive pressure ventilation to facilitate weaning in very low-birthweight infants: Unmasked randomized controlled trial

Background: Nasal flow‐synchronized intermittent positive pressure ventilation (NFSIPPV) is a new non‐invasive ventilatory mode that delivers synchronized mechanical breaths through the nasal prongs. An unmasked, prospective randomized controlled trial was conducted to compare the efficacy of NFSIPPV and conventional nasal continuous positive airway pressure (NCPAP) in increasing the likelihood for successful extubation in very low‐birthweight infants.

Changes over time in delivery room management of extremely low birth weight infants in Italy

AIM To identify changes in practice between two historical periods (2002 vs. 2011) in early delivery room (DR) management of ELBWI in Italian tertiary centres. METHODS A questionnaire was sent to the directors of all Italian level III centres between April and August 2012. The same questionnaire was used in a national survey conducted in 2002. Among the participating centres, those that filled the questionnaire in both study periods were selected for inclusion in this study. RESULTS There was an 88% (n=76/86) and 92% (n=98/107) response rate in the 2 surveys, respectively. The two groups overlapped for 64 centres. During the study period, the use of polyethylene bags/wraps increased from 4.7% to 59.4% of the centres. The units using 100% oxygen concentrations to initiate resuscitation of ELBWI decreased from 56.2% to 6.2%. The approach to respiratory management was changed for the majority of the examined issues: positive pressure ventilation (PPV) administered through a T-piece resuscitator (from 14.0% to 85.9%); use of PEEP during PPV (from 35.9% to 95.3%); use of CPAP (from 43.1% to 86.2%). From 2002 to 2011, the percentages of ELBWI intubated in DR decreased in favor of those managed with N-CPAP; ELBWI receiving chest compressions and medications at birth were clinically comparable. CONCLUSIONS During the two study periods, the approach to the ELBWI at birth significantly changed. More attention was devoted to temperature control, use of oxygen, and less-invasive respiratory support. Nevertheless, some relevant interventions were not uniformly followed by the surveyed centres.

Oxygen administration for the resuscitation of term and preterm infants

Oxygen has been widely used in neonatal resuscitation for about 300 years. In October 2010, the International Liaison Committee on Neonatal Resuscitation released new guidelines. Based on experimental studies and randomized clinical trials, the recommendations on evaluation and monitoring of oxygenation status and oxygen supplementation in the delivery room were revised in detail. They include: inaccuracy of oxygenation clinical assessment (colour), mandatory use of pulse oximeter, specific saturation targets and oxygen concentrations during positive pressure ventilation in preterm and term infants. In this review, we describe oxygen management in the delivery room in terms of clinical assessment, monitoring, treatment and the gap of knowledge.

Delivery room management of extremely low birthweight infants shows marked geographical variations in Italy

To evaluate any geographical variations in practice and adherence to international guidelines for early delivery room management of extremely low birthweight (ELBW) infants in the North, Centre and South of Italy.

Central venous lines and how to manage them

The importance of vascular access in neonatal clinical practice is increasing, because of the survival of a larger number of premature babies, who require administration of long-term intravenous fluids and medications than in the past. In these newborn central venous lines are preferred to peripheral lines, particularly Peripherally Inserted Central Venous Catheter (PICC). Despite of the benefits of this device, PICC complications can negatively affect morbidity and mortality of the neonate. This article describes the principal strategies and recommendations for the success of the PICC insertion procedure and for its better management.

Flow-synchronized nasal intermittent positive pressure ventilation in the preterm infant: development of a project

This manuscript describes the experience of our team in developing a flow-triggered nasal respiratory support for the neonate and its related clinical applications. Although mechanical ventilation (MV) via an endotracheal tube has undoubtedly led to improvement in neonatal survival in the last 40 years, the prolonged use of this technique may predispose the infant to the development of many possible complications, first of all, bronchopulmonary dysplasia (BPD). Avoiding mechanical ventilation is thought to be a critical goal, and different modes of non invasive respiratory support may reduce the intubation rate: nasal continuous positive airway pressure (NCPAP), nasal intermittent positive pressure ventilation (NIPPV) and its more advantageous form, synchronized nasal intermittent positive pressure ventilation (SNIPPV). SNIPPV was initially performed by a capsule placed on the baby’s abdomen. To overcome the disadvantages of the abdominal capsule, our team decided to create a flow-sensor that could be interposed between the nasal prongs and the Y piece. Firstly we developed a hot-wire flow-sensor to trigger the ventilator and we showed that flow-SNIPPV can support the inspiratory effort in the post-extubation period more effectively than NCPAP. But, although accurate, the proper functioning of the hot-wire flow-sensor was easily compromised by secretions or moisture, and therefore we started to use as flow-sensor a simpler differential pressure transducer. In a following trial using the new device, we were able to demonstrate that flow-SNIPPV was more effective than conventional NCPAP in decreasing extubation failure in preterm infants who had been ventilated for respiratory distress syndrome (RDS). More recently we used flow-SNIPPV as the primary mode of ventilation, after surfactant replacement, reducing MV need and favorably affecting short-term morbidities of treated premature infants. We also successfully applied SNIPPV to treat apnea of prematurity (AOP). Finally, we developed a new shaped flow-sensor, which is smaller and lighter of the previous one and its reliability was tested using a simulated neonatal model. Proceedings of the 9 th International Workshop on Neonatology · Cagliari (Italy) · October 23 rd -26 th , 2013 · Learned lessons, changing practice and cutting-edge research

Electroencephalogram and magnetic resonance imaging comparison as a predicting factor for neurodevelopmental outcome in hypoxic ischemic encephalopathy infant treated with hypothermia

Hypoxic-ischemic encephalopathy (HIE) is an important cause of acute neurological damage in newborns at (or near) term. Several trials in recent years have shown that moderate hypothermia by total body cooling or selective head is an effective intervention to reduce mortality and major disability in infants survived a perinatal hypoxic-ischemic attack. Follow-up in these patients is very important to establish neurodevelopmental outcome, and specific markers can lead us to detect predicting sign for good or poor outcome. We reported a few cases of newborn with HIE treated with hypothermia, in whom the comparison between electroencephalogram (EEG) and magnetic resonance imaging (MRI) represents the first marker for neurodevelopment outcome prediction. The continuous EEG monitoring showed a depressed EEG activity with diffuse burst depression in 7 patients. No epileptic abnormalities were registered. In 10 out of 20 patients no abnormalities of the background activity and no epileptic abnormalities were observed. We found that a depressed EEG activity during the first 72 h of life and a diffused alteration of basal ganglia at MRI were correlated with a poor neurodevelopmental outcome at 18 months of follow-up.

Delivery room management of extremely low birth weight infants in Italy: comparison between academic and non-academic birth centres

Abstract Objective: International Guidelines provide a standardised approach to newborn resuscitation in the DR and, in their most recent versions, recommendations dedicated to management of ELBWI were progressively increased. It is expected that introduction in clinical practice and dissemination of the most recent evidence should be more consistent in academic than in non-academic hospitals. The aim of the study was to compare adherence to the International Guidelines and consistency of practice in delivery room management of extremely low birth weight infants between academic and non-academic institutions. Methods: A questionnaire was sent to the directors of all Italian level III centres between April and August 2012. Results: There was a 92% (n = 98/107) response rate. Apart from polyethylene wrapping to optimise thermal control, perinatal management approach was comparable between academic and non-academic centres. Conclusions: There were minor differences in management of extremely low birth weight infants between Italian academic and non-academic institutions, apart from thermal management. Although there was a good, overall adherence to the International Guidelines for Neonatal Resuscitation, temperature management was not in accordance with official recommendations and every effort has to be done to improve this aspect.

Delivery room management of extremely low birth weight infants in Italian level III hospitals

Results There was a 92% (n=98/107) response rate. Participating centers reported an overall number of 198.322 births during 2011, and of these, 1933 were ELBW infants. Northern and Central centers had a higher median of births and of ELBW infants than Southern centers. A provider skilled in neonatal resuscitation is present in high-risk deliveries in 46% of III level centers: this rate was higher in Northern (77.5%) than in Central (33.3%) and Southern (21.6%) centers. The team leader for neonatal resuscitation is generally a Pediatrician/ Neonatologist (67.2%). The median delivery room temperature was 24°C (IQR: 22–25). Only 18 centers (20.2%) achieved a delivery room temperature over 25°C. A polyethylene bag/wrap was used by 54 centers (55.1%). Most centers had a pulse oxymeter (91/98, 92.9%) available in delivery room and used saturation targets (82/98, 83.7%). In Northern regions, one centre (2.5%) said it used oxygen concentrations >40% to initiate positive pressure ventilation in ELBW infants. These proportions were higher in the Central (14.3%) and Southern (16.2%) areas. A T-piece device for positive pressure ventilation was widely used (77/97, 79.4%). The percentage of ELBW infants intubated at birth had a median of 60% (IQR: 40%–80%), with the highest values in Central group (median 66%, IQR: 50%–75%). A median of 13% (IQR: 5%–30%) of ELBW infants received chest compressions at birth in Italy.

Old and new strategies for the prevention of nosocomial infections

Nosocomial infections are a significant issue of public health. In Italy, the incidence of nosocomial infections range between 5 and 8% [1]; in Neonatal Intensive Care Unit (NICU) range between 7 and 24.5% [2]. Nosocomial infection in a newborn is defined as an infection arised after 48-72 hours of hospitalization. The extremely low birth weight (ELBW) neonates have an increased risk of developing infections (40%)[2], due to the immaturity of the immune system, the prolonged length of hospitalization and the frequent need for invasive procedures (central venous catheters - CVC, mechanical ventilation, parenteral nutrition, prolonged antibiotic therapies). In NICU, sepsis accounted for 45-55% of cases of nosocomial infections, followed by the lower respiratory tract infections (16-33%), skin and soft tissue infections (26.3%), urinary tract infections (8-19%) and meningitis (9.6%) [2]. The gram-positive bacteria are responsible for 65% of infections (Coagulase-negative Staphylococci - CoNS, Staphylococcus aureus and Enterococcus spp respectively in 50, 35 and 6% of cases), followed by Gram-negative bacteria (Klebsiella, Pseudomonas, E. Coli ) and fungi in 25% of cases each. Candida albicans is involved in 50% of cases of fungal infections. Viruses are accountable for epidemics in the NICU, but the incidence of viral infections is likely to be underestimated. The prevention of nosocomial infections is an essential element for the management of the newborns [3,4] and is based on strategies to reduce the risk factors related to the newborn (immune system, carefull skin care, etc.) and to improve the invasive care procedures (implementation and dissemination of guide lines for accurate and proper hand hygiene [4,5], for prevention of CVC related infections [4,6] and ventilator-associated pneumonia [7], promotion of enteral feeding with breast milk [8]). Not least, the need for accurate diagnostic strategies for early detection of neonatal infections and a rational use of antimicrobial therapies and antibiotic prophylaxis [9,10]. The new strategies of prophylaxis of infections involving the use of bioactive substances with anti-infective properties, such as lactoferrin [11]; the use of probiotics, which have recognized immunomodulatory and anti-infectious activities [12]; the prophylaxis with antifungal drugs [13]. Lastly, NICU should also meet specific criteria of organization, providing to maintain an adequate ratio nurses/beds, avoid overcrowding and understaffing, make easily available devices for hand washing, organize meetings for training/provide to caregivers regular feedback of performance data, plan continuous monitoring and a surveillance system of the rate of nosocomial infections and avoid preventive measures of unproven effectiveness.