Renaud Mesnage

Validation of a neonatal pain scale adapted to the new practices in caring for preterm newborns

Background Neonatal pain assessment generally requires access to facial expression. Improved neonatology practices, such as greater protection against bright lights and non-invasive mask ventilation, have made facial observation more difficult. Objective To validate a ‘faceless’ acute neonatal pain scale (FANS), which does not depend on facial expression. Methods In a prospective, multicentre study, 24–40-week-old neonates were videotaped during a painful procedure (heel prick). Three investigators then scored the pain using FANS and a previously validated scale: DAN (Douleur aiguë du Nouveau-né). FANS is based on assessment of limb movement, cry and autonomic reaction. Reliability was assessed by inter-rater agreement and internal consistency (Cronbachs α). Validity was evaluated by agreement between scales (intraclass correlation coefficient (ICC)). The Wilcoxon test evaluated the FANS score differences between conditions. Results are expressed as medians (25th and 75th percentiles). Ranges are presented for outcome parameters. Results From April 2006 to September 2007, 53 preterms of 32 (30–35) gestational weeks and 1500 (1000–2200) g were observed. Cronbachs α was 0.72. The ICC was 0.92 (0.9–0.98) for inter-rater agreement and 0.88 (0.76–0.93) for agreement between scales. Conclusion FANS, which is reliable and valid, is the first scale to score pain in preterm newborns when facial expression is not accessible.

Intubation in the delivery room: Experience with nasal midazolam ☆

BACKGROUND Neonates are often intubated in the delivery room (DR) without anesthesia because vascular access is impossible. AIMS To assess neonatal comfort and adverse events after use of nasal midazolam (nMDZ) for intubation in the DR. STUDY DESIGN Prospective data collection over 6months on the intubation of neonates with respiratory distress requiring tracheal instillation of surfactant. SUBJECTS Twenty-seven neonates with median (Q25-75) gestational age and birthweight of, respectively, 29 (27-33)weeks and 1270 (817-1942)g received a 0.1mg/kg dose of nMDZ, and intubation was performed at the onset of tonus resolution or apnea. OUTCOME MEASURES Comfort was assessed with a scale of hetero-pain assessment and electrical skin conductance monitoring. Continuous pulse oximetry was recorded in the first postnatal hour, with oscillometric blood pressure measurement every 10min. RESULTS Seventy percent of the patients required a single dose, with intubation performed 4.8 (3-9)min after administration. Combined electro-clinical assessment found adequate comfort during the procedure in 68% of neonates. Mean blood pressure decreased from 39 (34-44)mmHg before to 31 (25-33)mmHg 1h following nMDZ (p=0.011). CONCLUSION nMDZ provided rapid and effective sedation to intubate neonates in the DR but potentially exposed them to hypotension, thus requiring close hemodynamic monitoring.

Betamethasone Impairs Cerebral Blood Flow Velocities in Very Premature Infants with Severe Chronic Lung Disease

OBJECTIVE To assess betamethasone (BM) effects on the cerebral hemodynamics of neonates with severe chronic lung disease (CLD). STUDY DESIGN Intravenous BM was given once daily for 6 consecutive days to 12 infants (birth weight: 698 g [range, 650-884 g], gestational age: 25.3 weeks [range, 25-26.4 weeks]) at a postnatal age of 34 days (range, 28-36 days). Cerebral blood flow velocities (CBFVs) were recorded prospectively in the anterior cerebral artery (ACA) and the lenticulostriate artery (LSA) before, during, and after treatment, using Doppler flowmetry. RESULTS The decrease in systolic and diastolic velocities was maximum on the 5th day, reaching 32% (95% confidence interval [CI], 23%-42%) and 58% (95% CI, 39%-64%) from baseline in the ACA, and 44% (95% CI, 29%-50%) and 57% (95% CI, 33%-66%) in the LSA, respectively. The resistance index (RI) increased significantly in both arteries during treatment. Return to baseline values was observed after BM was stopped. The change in velocities and RI was independent of arterial blood gas and blood pressure variations. CONCLUSIONS BM decreased the CBFVs of premature infants, suggesting a vasoconstrictor effect in both superficial and deep arterial vessels. Caution is recommended when BM is used to treat preterm infants with severe CLD.

Staphylococcus aureus in a neonatal care center: methicillin-susceptible strains should be a main concern

BackgroundIn the context of a methicillin-susceptible Staphylococcus aureus (MSSA) outbreak, we aimed to improve our knowledge of S. aureus (SA) epidemiology in the neonatal care center (NCC) of a tertiary care teaching hospital.MethodsWe performed a complete one-year review of SA carrier, colonized or infected patients. Monthly prevalence and incidence of SA intestinal carriage, colonization and infection were calculated and the types of infection analysed. During the MSSA outbreak, strains were studied for antimicrobial resistance, content of virulence genes and comparative fingerprint in Pulsed-Field Gel Electrophoresis. Hand hygiene and catheter-related practices were assessed by direct observational audits. Environmental investigation was performed in search of a SA reservoir.ResultsEpidemiological analyses showed 2 or 3 prevalence peaks on a background of SA endemicity. In the NCC, during 2009, overall MSSA prevalence did not decrease below 5.5%, while mean MRSA prevalence was about 1.53%. Analysis of infection cases revealed that the outbreak corresponded to the emergence of catheter-related infections and was probably related to the relaxation in infection control practices in a context of high colonization pressure. Health care workers’ white coats appeared as a potential environmental reservoir that could perpetuate SA circulation in the ward.ConclusionThis report emphasizes the importance of integrating MSSA along with methicillin-resistant SA in a program of epidemiological surveillance in the NCC.

Can a clinical decision rule help ductus arteriosus management in preterm neonates

Aim:  Patent ductus arteriosus (DA) occurs frequently in premature neonates with respiratory distress syndrome. We assessed a combination of clinical, biological and echocardiographic parameters to derive a decision rule for selecting candidates for treatment based on the criteria in use in our unit.

Validation of nosocomial infection in neonatology: A new method for standardized surveillance

BACKGROUND Nosocomial infections (NIs) are a leading cause of mortality and morbidity in premature infants. We present a new method for detecting and confirming NIs in a neonatal intensive care unit. METHODS Newborns with birth weight < 1,500 g or gestational age (GA) < 33 weeks were included prospectively over 2 years in a single-center tertiary neonatal intensive care unit. The computerized physician order entry system (CPOE) generated alerts when antibiotics were prescribed for at least 5 consecutive days and these cases were reviewed by an expert group following international recommendations. RESULTS Four hundred sixty-one neonates were included, with a mean GA of 30 weeks (range, 26-32 weeks) and mean birth weight 1,270 g (range, 950-1600 g). The CPOE flagged 158 cases of potential NI, 85.1% of which were classified as true NI and 14.9% of which were false positive. Incidence and device-associated nosocomial bloodstream infection rates were 21.9% and 10.8 per 1,000 central venous catheter days, respectively. GA ≤ 28 weeks (odds ratio, 2.18; 95% confidence interval, 1.2-4) and > 7 central venous catheter days (odds ratio, 1.47; 95% confidence interval, 1.3-1.7) were independently associated with the risk of nosocomial bloodstream infection. CONCLUSION Combining CPOE and interdisciplinary review may improve the accuracy of NI recording in a neonatal intensive care unit.

Limitation et arrêt des thérapeutiques actives en néonatologie

* Auteur correspondant. e-mail : m-vidal@chu-montpellier.fr La moitie des deces en reanimation neonatale resulte d’une decision medicale de limitation ou arret des therapeutiques actives (LATA). La refl exion ethique accompagne depuis sa creation la pratique de la neonatologie. La loi du 22 avril 2005, dite loi Leonetti, lui a donne un cadre legal. Les principales dispositions de cette loi sont : l’interdiction d’euthanasie, l’interdiction de l’obstination deraisonnable et l’autorisation de soulager la souffrance au risque d’abreger la vie. L’article 9 mentionne la possibilite par le medecin de limiter ou d’arreter un traitement inutile apres avoir respecte une procedure collegiale et consulte la famille. La decision, motivee, doit etre inscrite dans le dossier medical [1]. L’objectif de ce travail etait l’evaluation des pratiques professionnelles concernant la fi n de vie en reanimation neonatale au sein du service de neonatologie du CHU de Montpellier. Nous avons etudie la mise en œuvre des decisions de LATA autant dans leurs aspects clinique, ethique que legal. Nous avons egalement evalue l’impact de la loi Leonetti sur nos pratiques.