Rita Saldanha

The Baby Doe Rule: Still a Threat

Current federal policy, as reflected in the final Baby Doe rule, will have a chilling effect on the ability of doctors to care appropriately for severely disabled infants. The policy threatens to prolong life unjustifiably for such infants. It will force physicians to violate a duty to do no harm without compensating benefit. And it raises serious problems for the just distribution of health care.

Cerebrospinal Fluid Lactate Dehydrogenase in Neonatal Intracranial Hemorrhage

Cerebrospinal fluid (CSF) lactate dehydrogenase (LDH) was measured in 54 neonates with intracranial hemorrhage and compared with 82 control, 27 traumatic lumbar puncture, seven meningitis, and 30 asphyxiated newborns. Hospital data, neonatal outcomes, and long-term neurodevelopmental follow-up results were reviewed. CSF LDH was not significantly affected by traumatic lumbar puncture but was elevated in proportion to the severity of CNS hemorrhage as scored by computerized to mography. LDH was also significantly associated with subsequent seizures and hydrocephalus and abnormal long-term developmental outcome.

1824 THE EMPTY THORAX: AN AVOIDABLE LETHAL FACTOR IN CONGENITAL DIAPHRAGMATIC HERNIA

In spite of sophistication in neonatal care, congenital diaphragmatic hernia (CDH) which presents within the first 24 hours of life has a high mortality (generally around 50%).The observation that neonates with CDH deteriorate several hours after surgery, frequently with a mediastinal shift, suggest that they may be dying of the empty thorax syndrome. When a patient is on positive pressure ventilation, insertion of a chest tube connected to a suction or a waterseal into the thoracic cavity, when there is no expandable lung, creates a vacuum and the mediastinum is shifted to that side.In addition to using currently accepted management, we used a modification of an infant chest bottle. A chest tube was connected to a bottle with a vent, but without a waterseal. This permitted evacuation of fluid but prevented mediastinal shifts.We treated a consecutive series of 11 infants with this approach, ten of which were symptomatic soon after birth. Three of these were moribund at the time of surgery and died. Seven of the remaining eight salvageable infants required surgery within 24 hours of life.Seven out of eight (87.5%) of the infants survived if they were considered potentially salvageable prior to surgery. The use of thoracic drainage with avoidance of the empty thorax syndrome appeared to play a significant role in obtaining these improved results.

BRAIN SPECIFIC CREATINE KINASE IS NOT ASSOCIATED WITH SHORT-TERM NEUROLOGICAL OUTCOME IN VLBW INFANTS

Perinatal asphyxia and intracranial hemorrhage are known to be major determinants of neurodevelopmental outcome in VLBW neonates, but specific and accurate predictors are not well established. Recent investigations have indicated that serum creatine kinase isoenzyme BB (CK-BB) levels are associated with outcome.In this prospective study serum samples were obtained at 24 ± 4 hours in 83 preterm infants ≤ 32 weeks gestation. Cord blood was also available for analysis in 38 of them. Total CK and CK-BB by electrophoresis were determined on each of the samples. Mortality, cranial ultrasound scores on days 1 and 3, the presence of seizures within the first 2 weeks, abnormal neurological status (Sarnat Score) during the first 2 weeks, Parmalee neurological exam score at the time of discharge, and the presence of hydrocephalus were measured as short-term outcomes.Using a non-parametric test for association (Kendalls tau), no associations were found between CK-BB values in either cord blood or 24 hour samples and any of the above parameters. Thus, CK-BB is not associated with short-term neurological status. Follow-up is underway to evaluate whether CK-BB may predict long-term neurodevelopmental outcome.

THE USE OF CEREBRAL ARTERY PULSATILITY INDEX TO PREDICT NEUROLOGIC OUTCOME

Decreased blood flow velocity (increased pulsatility index, PI) in the anterior cerebral arteries (ACA) has been reported in preterm infants with intraventricular hemorrhage. From Feb. 1982 to Aug. 1983, we prospectively evaluated PI, cranial ultrasound and neurologic status (Sarnat Score), in 60 infants ⩽32 weeks gestation on days 1, 3 and 7 and then weekly until discharge, to determine their correlation with PI. PI was calculated from the tracings obtained by doppler ultrasound by the method described by Bada et al. Survival, neurologic status (Sarnat Score), cranial ultrasound, occurrence of seizures, and discharge neurologic examination (Parmalee exam) were assessed.Mean B.Wt. was 1151 grams (640-1750) and mean GA was 30.1 weeks (26-32). There were 31 males and 29 females. Mean Apgar Score at 1 minute was 4.7 and at 5 minutes was 6.6. Forty-two of the infants were inborn.The maximum PI recorded on day 1 correlated negatively with B.Wt. (p<0.05) and positively with mortality (p<0.06), occurrence of seizures (p<0.05) and development of hydrocephalus (p<0.06). There was no correlation between PI done at any time and GA, neurologic status (Sarnat Score), cranial ultrasound or discharge neurologic examination.Decreased cerebral blood flow velocity (high PI) is correlated with mortality, occurrence of seizures and later development of hydrocephalus. Follow-up of these infants is pending.

CSF LACTATE DEHYDROGENASE PREDICTS SEVERE NEONATAL INTRAVENTRICULAR HEMORRHAGE

CSF LDH is elevated in neonatal IVH and may arise from cerebral injury (Engelke, 1983). To test the value of CSF LDH in detecting cerebral injury, a prospective study was carried out in 57 neonates ≤ 32 weeks gestation. Total CSF LDH and its isoenzymes were measured on admission and cranial ultrasound (US) was performed on day 1 and 3. Ultrasounds were graded normal, small-moderate IVH, moderate-large IVH with ventricular dilation or parenchymal extension. There was a significant correlation of CSF LDH with severity of US hemorrhage (p<.02), although CSF red and white cell counts and glucose did not correlate with IVH. Comparing patients with large IVH and ventricular dilation or parenchymal extension vs patients with normal US or small IVH, mean CSF LDH was 169 v. 49 U/L. LDH isoenzyme 2 also correlated with severity of IVH (p<.01).Elevated CSF LDH was also significantly related to mortality (p<.04). Mean LDH in patients who died compared to survivors was 174 v. 48 U/L. In addition, elevated LDH isoenzyme 1 correlated with mortality (p<.02).In conclusion, our results show an increase in CSF LDH in patients with IVH and ventricular dilation or parenchymal hemorrhage, which may reflect cerebral infarction. Elevated CSF LDH also correlated with risk of death. Follow-up testing will assess its predictive value for long term neurodevelopmental handicap.

A-NEONATAL STATUS SCORE OF TRANSPORTED NEWBORNS AS A PREDICTOR OF TERM MORBIDITY AND MORTALITY

A Neonatal Status Score (NSS) was used to evaluate neonates at the referring hospital (T1). Temperature, heart rate, blood pressure, response to noxious stimuli and dextrostix were scored 0-2, 0 being the worst score. The same items were scored again after arrival back at our hospital (T2).Two hundred and five infants were transported between Sept., 1980 and Dec., 1982. The mean NSS at T1 was 12.3 and at T2 was 13.7. T2 was significantly higher than T1 (p<0.001). There was a strongly positive correlation between the NSS (at either T1 or T2) and survival (p<0.001 for each). There was no correlation between the NSS at T1 and neurologic morbidity (ICH, seizures, hydrocephalus, or abnormal neurologic examination at discharge). A low score at T2 correlated with the occurrence of seizures.One hundred sixty-three transports were done by neonatal nurse clinicians and 42 by residents. There was no difference in the NSS before or after transport between infants transported by neonatal nurse clinicians or residents, suggesting that they performed comparably with equivalently sick patients.The NSS is easily scored and is an accurate predictor of mortality. As an objective measure of an infants condition and risk of mortality prior to transport, the NSS can be used to compare the prognosis of groups of infants transported or treated in different ways.

1574 CEREBROSPINAL FLUID LACTATE DEHYDROGENASE IN INTRA-VENTRICULAR HEMORRHAGE OF THE PREMATURE

Intraventricular hemorrhage (IVH) has been found to occur in as many as 50% of premature infants, but its presence does not correlate well with symptoms or with cerebrospinal fluid values. CSF lactate dehydrogenase (LDH) is elevated in adults with intracranial hemorrhage (Henry, 1979). The usefulness of CSF LDH as a possible indicator of the presence and severity of IVH was evaluated in 22 premature neonates, 10 of whom had IVH by computerized tomography (CT) scan. (3 Gr.I, 3 Gr.II, 1 Gr.III, 3 Gr.IV)Spinal fluid LDH was significantly greater in the group with IVH, p<0.001 by the Mann-Whitney rank test. There was no overlap in the LDH values between the IVH and no IVH groups.In addition, the LDH values correlated well with the grade of IVH on CT scan. Other CSF and clinical parameters were analyzed and will be discussed. It is suggested that spinal fluid LDH may provide an index of the presence and severity of IVH in the newborn.