Paolo Biban

Sustained Lung Inflation at Birth for Preterm Infants: A Randomized Clinical Trial

BACKGROUND: Studies suggest that giving newly born preterm infants sustained lung inflation (SLI) may decrease their need for mechanical ventilation (MV) and improve their respiratory outcomes. METHODS: We randomly assigned infants born at 25 weeks 0 days to 28 weeks 6 days of gestation to receive SLI (25 cm H2O for 15 seconds) followed by nasal continuous positive airway pressure (nCPAP) or nCPAP alone in the delivery room. SLI and nCPAP were delivered by using a neonatal mask and a T-piece ventilator. The primary end point was the need for MV in the first 72 hours of life. The secondary end points included the need for respiratory supports and survival without bronchopulmonary dysplasia (BPD). RESULTS: A total of 148 infants were enrolled in the SLI group and 143 in the control group. Significantly fewer infants were ventilated in the first 72 hours of life in the SLI group (79 of 148 [53%]) than in the control group (93 of 143 [65%]); unadjusted odds ratio: 0.62 [95% confidence interval: 0.38–0.99]; P = .04). The need for respiratory support and survival without BPD did not differ between the groups. Pneumothorax occurred in 1% (n = 2) of infants in the control group compared with 6% (n = 9) in the SLI group, with an unadjusted odds ratio of 4.57 (95% confidence interval: 0.97–21.50; P = .06). CONCLUSIONS: SLI followed by nCPAP in the delivery room decreased the need for MV in the first 72 hours of life in preterm infants at high risk of respiratory distress syndrome compared with nCPAP alone but did not decrease the need for respiratory support and the occurrence of BPD.

New cardiopulmonary resuscitation guidelines 2010: Managing the newly born in delivery room

Most newborns are born vigorous and do not require neonatal resuscitation. However, about 10% of newborns require some type of resuscitative assistance at birth. Although the vast majority will require just assisted lung aeration, about 1% requires major interventions such as intubation, chest compressions, or medications. Recently, new evidence has prompted modifications in the international cardiopulmonary resuscitation (CPR) guidelines for both neonatal, paediatric and adult patients. Perinatal and neonatal health care providers must be aware of these changes in order to provide the most appropriate and evidence-based emergency interventions for newborns in the delivery room. The aim of this article is to provide an overview of the main recommended changes in neonatal resuscitation at birth, according to the publication of the international Liaison Committee on Resuscitation (ILCOR) in the CoSTR document (based on evidence of sciences) and the new 2010 guidelines released by the European Resuscitation Council (ERC), the American Heart Association (AHA), and the American Academy of Pediatrics (AAP).

Procalcitonin for the diagnosis of early-onset neonatal sepsis: a multilevel probabilistic approach.

OBJECTIVESnTo compare the accuracy of procalcitonin (PCT) in early-onset neonatal sepsis (EOS) using standard cut-off values and a multilevel probabilistic approach.nnnDESIGN AND METHODSnA retrospective study of PCT was performed in 149 newborns at risk of EOS, including preterm or prolonged rupture of membranes, chorioamnionitis or maternal infection, GBS colonization and signs of fetal distress. PCT values were analysed according to time of assay, i.e. at birth and at 24 and 48 h. We estimated sensitivity, specificity, positive (LR+) and negative likelihood ratio (LR-), diagnostic odds ratio (DOR) and number needed to diagnose (NND) using traditional and optimal (derived from ROC analysis) PCT cut-off values.nnnRESULTSnUsing optimal cut-off, the LR+, DOR and NND at birth were 10, 18.9 and 2.2, at 24 h they were 5.3, 11.2 and 2.1, and at 48 h they were 5.6, 18.1 and 1.7, respectively. The multilevel analysis generated three post-test probabilities for each time of assay. At 24 h post-test probabilities of EOS were 78% for PCT >90, 11% for PCT 10.1-90 and 3% for PCT <10.1 mg/L, respectively. Similar results were found in the other time points, with a wide range of intermediate PCT concentrations that did not change the post-test probability.nnnCONCLUSIONSnThe multilevel probabilistic approach was more effective in assessing the diagnostic power of PCT in EOS, showing that a wide range of intermediate PCT values was not able to discriminate between presence and absence of infection.

Sustained lung inflation in the delivery room in preterm infants at high risk of respiratory distress syndrome (SLI STUDY): study protocol for a randomized controlled trial

BackgroundSome studies have suggested that the early sustained lung inflation (SLI) procedure is effective in decreasing the need for mechanical ventilation (MV) and improving respiratory outcome in preterm infants. We planned the present randomized controlled trial to confirm or refute these findings.Methods/DesignIn this study, 276 infants born at 25+0 to 28+6 weeks’ gestation at high risk of respiratory distress syndrome (RDS) will be randomized to receive the SLI maneuver (25 cmH2O for 15 seconds) followed by nasal continuous positive airway pressure (NCPAP) or NCPAP alone in the delivery room. SLI and NCPAP will be delivered using a neonatal mask and a T-piece ventilator.The primary endpoint is the need for MV in the first 72 hours of life. The secondary endpoints include the need and duration of respiratory support (NCPAP, MV and surfactant), and the occurrence of bronchopulmonary dysplasia (BPD).Trial registrationTrial registration number:NCT01440868

Understanding the private worlds of physicians, nurses, and parents: a study of life-sustaining treatment decisions in Italian paediatric critical care.

This study’s aim was to describe: (a) How life-sustaining treatment (LST) decisions are made for critically ill children in Italy; and (b) How these decisional processes are experienced by physicians, nurses and parents. Focus groups with 16 physicians and 26 nurses, and individual interviews with 9 parents were conducted. Findings uncovered the ‘private worlds’ of paediatric intensive care unit (PICU) physicians, nurses and parents; they all suffer tremendously and privately. Physicians struggle with the weight of responsibility and solitude in making LST decisions. Nurses struggle with feelings of exclusion from decisions regarding patients and families that they care for. Physicians and nurses are distressed by legal barriers to LST withdrawal. Parents struggle with their dependence on physicians and nurses to provide care for their child and strive to understand what is happening to their child. Features of helpful and unhelpful communication with parents are highlighted, which should be considered in educational and practice changes.

Postpneumonectomy-Like Syndrome in an Infant With Right Lung Agenesis and Left Main Bronchus Hypoplasia

We report a 1-year-old child born with agenesis of the right lung who sustained an episode of acute respiratory failure related to a postpneumonectomy-like syndrome, with severe mediastinal shift and subsequent stretching and stenosis of the left main bronchus. The insertion of an expandable prosthesis in the right empty pleural space markedly improved the patients clinical condition.

Neonatal resuscitation in the ward: the role of nurses.

Cardiopulmonary resuscitation (CPR) is necessary in about 1-2% of all newly born infants in their first minutes of life. However, CPR may also be needed in newborns beyond the time of birth, particularly in high risk categories of infants admitted in the NICU or in other less specialised units. In all these scenarios, the role of nurses is essential for several aspects, including early recognition of a deteriorating infant, with the aim to prevent cardiac arrest, as well as the starting of immediate basic life support manoeuvres at the bedside, whenever needed. Furthermore, nurses have a special part in family care during cardiopulmonary resuscitation.

Weaning newborn infants from mechanical ventilation

Invasive mechanical ventilation is a life-saving procedure which is largely used in neonatal intensive care units, particularly in very premature newborn infants. However, this essential treatment may increase mortality and cause substantial morbidity, including lung or airway injuries, unplanned extubations, adverse hemodynamic effects, analgosedative dependency and severe infectious complications, such as ventilator-associated pneumonia. Therefore, limiting the duration of airway intubation and mechanical ventilator support is crucial for the neonatologist, who should aim to a shorter process of discontinuing mechanical ventilation as well as an earlier appreciation of readiness for spontaneous breathing trials. Unfortunately, there is scarce information about the best ways to perform an effective weaning process in infants undergoing mechanical ventilation, thus in most cases the weaning course is still based upon the individual judgment of the attending clinician. Nonetheless, some evidence indicate that volume targeted ventilation modes are more effective in reducing the duration of mechanical ventilation than traditional pressure limited ventilation modes, particularly in very preterm babies. Weaning and extubation directly from high frequency ventilation could be another option, even though its effectiveness, when compared to switching and subsequent weaning and extubating from conventional ventilation, is yet to be adequately investigated. Some data suggest the use of weaning protocols could reduce the weaning time and duration of mechanical ventilation, but better designed prospective studies are still needed to confirm these preliminary observations. Finally, the implementation of short spontaneous breathing tests in preterm infants has been shown to be beneficial in some centres, favoring an earlier extubation at higher ventilatory settings compared with historical controls, without worsening the extubation failure rate. Further research is still required to identify the best practices capable to shorten the duration of mechanical ventilation in term and preterm infants, at the same time keeping to a minimum the risk of extubation failure. 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

A Case of Severe Methemoglobinemia in a Baby Fed Homemade Decoction of Silverbeet

This report describes a case of severe methemoglobinemia in a baby fed with a homemade decoction of silverbeet (Beta vulgaris L. var. cicla). Lay people and health professionals must be aware of possible risks associated with the use of folk herbal remedies in infants that, despite being natural, may be not as safe as claimed.

Should critically ill children be managed in paediatric intensive care units only

Dear Editor, We read with interest the article of Cogo et al. [1] recently published in Intensive Care Medicine. The authors report the outcome of 1,265 critically ill children admitted to 124 adult intensive care units (ICUs) in Italy between 2003 and 2007. By using the paediatric risk of mortality score (PRISM), they compare the standardized mortality ratios (SMRs) of the study group with that of a historical control group of 1,533 paediatric patients admitted to 26 Italian paediatric intensive care units (PICUs) between 1994 and 1995. The paper alludes to potential differences in the quality of care provided to critically ill children, once they are assisted outside of specialized units. By observing that the SMR in children admitted to adult ICUs was virtually identical to that reported 10 years earlier in paediatric ICUs, Cogo et al. [1] speculate that the performance of adult ICUs treating paediatric patients may be lower than that currently available in PICUs, suggesting a role for centralization of paediatric care in more specialized units. Indeed, requirements for high-quality care include adequate staff training and maintenance of their practical experience, especially in complex and heterogeneous patients such as critically ill children. These requirements are unlikely to be fulfilled in adult ICUs, particularly in those with few paediatric admissions and insufficient variation of case mix, where physicians and nurses may lack adequate paediatric exposure and training, to enable them to manage the complete age range of children requiring intensive care. Interestingly, in the study by Cogo et al., the average number of paediatric admissions was about 10/year in adult ICUs, whereas it was about 60/year in the historical group of PICUs. Actually, a possible relationship between patient volume and outcomes has been studied in different settings, including neonatology and paediatric cardiac surgery, generally documenting improved outcomes from greater volume [2, 3]. Recent studies in paediatric critical care have confirmed improved outcomes at high-volume centres. Tilford et al. [4] studied over 11,000 admissions in 16 PICUs and found a severity-adjusted odds ratio of 0.95/ 100 patients admitted per year as well as a decreased length of stay in highvolume units. In another study, involving 32 PICUs, high-volume units showed lower severity-adjusted mortality and shorter lengths of stay compared with low-volume units [5]. Indeed, if tertiary units are proven to have better outcomes than nontertiary units, then a programme of development of ‘‘regional’’ units for centralizing paediatric intensive care would be appropriate. However, although theoretically desirable, it may not be practical to refer all critically ill children to tertiary PICUs, particularly in very large countries or in healthcare systems lacking adequate transportation facilities. In fact, several countries, including many in the European area, still provide paediatric critical care trying to find a balance between available PICUs and adult ICUs with some paediatric commitment. Cogo et al. must be congratulated for their effort to bring our attention to such an important issue. Larger contemporaneous prospective studies will have to confirm their interesting observations.