Michael Kornhauser

Effects of Multiple Ventilation Courses and Duration of Mechanical Ventilation on Respiratory Outcomes in Extremely Low-Birth-Weight Infants

IMPORTANCE Extubation failure is common in extremely preterm infants. The current paucity of data on the adverse long-term respiratory outcomes associated with reinitiation of mechanical ventilation prevents assessment of the risks and benefits of a trial of extubation in this population. OBJECTIVE To evaluate whether exposure to multiple courses of mechanical ventilation increases the risk of adverse respiratory outcomes before and after adjustment for the cumulative duration of mechanical ventilation. DESIGN, SETTING, AND PARTICIPANTS We performed a retrospective cohort study of extremely low-birth-weight (ELBW; birth weight <1000 g) infants born from January 1, 2006, through December 31, 2012, who were receiving mechanical ventilation. Analysis was conducted between November 2014 and February 2015. Data were obtained from the Alere Neonatal Database. EXPOSURES The primary study exposures were the cumulative duration of mechanical ventilation and the number of ventilation courses. MAIN OUTCOMES AND MEASURES The primary outcome was bronchopulmonary dysplasia (BPD) among survivors. Secondary outcomes were death, use of supplemental oxygen at discharge, and tracheostomy. RESULTS We identified 3343 ELBW infants, of whom 2867 (85.8%) survived to discharge. Among the survivors, 1695 (59.1%) were diagnosed as having BPD, 856 (29.9%) received supplemental oxygen at discharge, and 31 (1.1%) underwent tracheostomy. Exposure to a greater number of mechanical ventilation courses was associated with a progressive increase in the risk of BPD and use of supplemental oxygen at discharge. Compared with a single ventilation course, the adjusted odds ratios for BPD ranged from 1.88 (95% CI, 1.54-2.31) among infants with 2 ventilation courses to 3.81 (95% CI, 2.88-5.04) among those with 4 or more courses. After adjustment for the cumulative duration of mechanical ventilation, the odds of BPD were only increased among infants exposed to 4 or more ventilation courses (adjusted odds ratio, 1.44; 95% CI, 1.04-2.01). The number of ventilation courses was not associated with increased risk of supplemental oxygen use at discharge after adjustment for the length of ventilation. A greater number of ventilation courses did not increase the risk of tracheostomy. CONCLUSIONS AND RELEVANCE Among ELBW infants, a longer cumulative duration of mechanical ventilation largely accounts for the increased risk of chronic respiratory morbidity associated with reinitiation of mechanical ventilation. These results support attempts of extubation in ELBW infants receiving mechanical ventilation on low ventilator settings, even when success is not guaranteed.

Adverse neurodevelopmental outcome after extracorporeal membrane oxygenation among neonates with bronchopulmonary dysplasia.

OBJECTIVE The relationship between bronchopulmonary dysplasia (BPD) and neurodevelopmental outcome after extracorporeal membrane oxygenation (ECMO) has not been extensively reported. We compared the outcomes in a large series of infants with and without BPD after ECMO. STUDY DESIGN Hospital charts and follow-up records of 145 infants treated with ECMO (1985 through 1990) were reviewed. Complete long-term respiratory and follow-up outcome data were available in 64 infants. BPD occurred in 17 survivors; the remaining 47 did not have BPD. RESULTS Babies with BPD were more likely to have had respiratory distress syndrome. Mean (+/- SD) age at ECMO initiation was later for the BPD group (127+/-66 vs 53+/-39 hours, p < 0.001), and the duration of ECMO treatment was longer (192+/-68 vs 119+/-53 hours, p < 0.001). Bayley Scales of Infant Development scores at <30 months were lower in infants with BPD (p < 0.001), as were three of four Mullen Scales of Early Learning scores (> or = 30 months, p < 0.001 or p = 0.01). At 57+/-16 months 11 (64%) patients with BPD had mild neurologic disabilities, and 3 (18%) had severe disabilities. At a similar age (53+/-16 months, p = NS) 16 (34%) patients without BPD had mild disabilities, whereas 2 (4%) had severe disabilities (p < 0.01). CONCLUSIONS The occurrence of BPD after ECMO is associated with adverse neurodevelopmental outcome. Patients with BPD after ECMO merit close long-term follow-up.

Differences in short-term neonatal outcomes between discordant twins.

PURPOSETo evaluate short-term outcomes associated with discordant twin pairs admitted to the NICU. DESIGNA retrospective descriptive study comparing discordant twin pairs. SUBJECTSThree hundred eighty-four discordant twin pairs were included. Mean gestational age of the twin pairs was 32.6 weeks (range, 24–39). METHODSThe ParadigmHealth database was queried for all twin admissions from January 2001 to June 2004 admitted to 453 NICUs across the United States. Discordance was calculated for each twin set as defined as greater than 20% difference in birth weight. Exclusion criteria were death of a twin, congenital anomalies, or extracorporeal life support. MAIN OUTCOME MEASURESDemographics, respiratory needs, feeding characteristics, complications, and discharge needs. RESULTSA total of 384 discordant twin pairs met inclusion criteria. The larger twins required more ventilation/continuous positive airway pressure (55% vs 44%, P < .01) and/or oxygen therapy (50% vs 41%, P = .02) compared with smaller twins. Smaller twins reached full oral (PO) feeds an average of 0.6 weeks later than larger twins (P < .0001) but had more weight gain per day. Smaller twins transitioned to an open crib at lower weights but at slightly greater age. No differences were noted with necrotizing enterocolitis or apnea. Smaller twins had increased nosocomial infections. Mean length of stay was shorter (P = .0036) in the larger twin group. Only 33% of the twin pairs were discharged on the same day. CONCLUSIONSLarger twins had more acute respiratory issues but achieved certain milestones more rapidly with fewer complications, thus leading to earlier discharge compared with their smaller twin counterparts.

MATERNALLY-ADMINISTERED MAGNESIUM SULFATE (MgSO 4 ) DECREASES THE INCIDENCE OF SEVERE NECROTIZING ENTEROCOLITIS (NEC) IN PRETERM INFANTS: A PROSPECTIVE STUDY. † 1501

MATERNALLY-ADMINISTERED MAGNESIUM SULFATE (MgSO 4 ) DECREASES THE INCIDENCE OF SEVERE NECROTIZING ENTEROCOLITIS (NEC) IN PRETERM INFANTS: A PROSPECTIVE STUDY. † 1501

The Intensive Care Management of the Term Neonate: Are There Regional Differences in Outcome?

The Intensive Care Management of the Term Neonate: Are There Regional Differences in Outcome?

Do Regional Differences in Neonatal Critical Care Effect Length of Stay? 548

The practice patterns in neonatology are often a reflection of training programs, and care may be regionalized. Different styles of neonatal care may result in different outcomes and length of stay (LOS). We hypothesized that regional differences in neonatal practice exist, and that these differences result in variations in LOS.

Earlier Discharge Guidelines for Preterm Infants: Effectiveness of Widespread Insititution Through Case Management † 1158

Earlier Discharge Guidelines for Preterm Infants: Effectiveness of Widespread Insititution Through Case Management † 1158

Variations In The Day of The Week Discharge: An example of Unwarranted Variation? 1350

Discharge from an intensive care nursery should be dependent upon the infants clinical condition, and independent of the day of the week. We observed, however, that the timing of nursery discharge shows an uneven distribution across the days of the week, with the weekend discharge rates significantly lower than weekdays.

LONG-TERM NEUROPROTECTION BY MATERNALLY-ADMINISTERED MAGNESIUM SULFATE(MgSO4) IN PRETERM INFANTS IS RELATED TO INITIAL POST-NATAL SERUM MAGNESIUM LEVELS AND TO THE PRESENCE OF PRECEDING GRADE III/ IV INTRA

INTRODUCTION: The sole case-control trial delineating a reduction in cerebral palsy (CP) by maternally-administered MgSO4 did not address the effect of Gr III/IV ICH or CPVL. We have described a similar neuroprotective effect of MgSO4 in preventing long-term cerebral injury in preterm infants (CP, as well as scores > 2 SDs below the population mean on the Bayley Scales of Infant Development [BSID]). We speculated that the degree of neuroprotection may be related to maternal or initial neonatal serum magnesium (Mg) levels, to the duration of maternal therapy, or to the prior presence of Grade III or IV ICH or CPVL.METHODS: The mothers of 61 ventilated pre-term infants (< 33 wks GA) received MgSO4 prior to delivery. 39 of the surviving infants were old enough (mean age 27.7 mo.) to undergo neurodevelopmental testing and physical assessment for findings of CP. 32/39 had serum Mg levels drawn on day 1 and comprise the study population. We ascertained the duration of maternal MgSO4 therapy and their serum Mg levels prior to delivery. RESULTS:Table CONCLUSION: Initial neonatal serum Mg levels in preterm infants, as well as the preceding presence of Gr III/IV ICH or CPVL, directly correlate with long-term neuroprotection. The degree of neuroprotection by maternal MgSO4 beyond prevention of Gr III/IV ICH or CPVL is unclear.

EARLY INITIATION OF HIGH-FREQUENCY JET VENTILATION (HFJV) IN THE MANAGEMENT OF RESPIRATORY DISTRESS SYNDROME (RDS) IS ASSOCIATED WITHA GREATER RISK FOR ADVERSE OUTCOMES: A PROSPECTIVE, RANDOMIZED, CONTROLLED TRIAL

EARLY INITIATION OF HIGH-FREQUENCY JET VENTILATION (HFJV) IN THE MANAGEMENT OF RESPIRATORY DISTRESS SYNDROME (RDS) IS ASSOCIATED WITHA GREATER RISK FOR ADVERSE OUTCOMES: A PROSPECTIVE, RANDOMIZED, CONTROLLED TRIAL