Sabina Terzic

TRENDS AMONG NEONATOLOGISTS IN DECISION TO VENTILATEPRETERM INFANTS WITH PERMISSIVE HYPERCAPNIA

Introduction: Despite measures done to avoid neonatal respiratory distress syndrome, many prematurely born infants still suffer from this disease, they are artificially ventilated, or experience long term oxygen dependency and consequently have chronic lung disease/bronchopulmonary dysplasia. One of the proposed measures for shortening of mechanical ventilation is strategy of permissive hypercapnia. There are promising studies, but clear recommendations for this treatment option are still lacking.

Permissive hypercapnia in ventilated preterm infants: when is it safe to perform?

Introduction: In spite of measures to avoid invasive mechanical ventilation, many preterm infants are still artificially ventilated. The need for intubation and positive pressure ventilation is associated with so-called ventilator-induced lung injury (VILI) and bronchopulmonary dysplasia (BPD). A lot of strategies are made in order to minimise VILI. One of these strategies is the use of permissive hypercapnia, in which clinicians use more gentle ventilatory strategies and accept higher than “normal” alveolar partial pressure of carbon dioxide (PaCO2) values. Although there are promising studies about the use of permissive hypercapnia in preterm infants, we are still not sure if and when this mode of treatment is safe.Aim: The aim of this study is to investigate conditions in which permissive hypercapnia is safe to prematurely born infants regarding their survival.Methods: The present study was conducted in a tertiary research and educational hospital, NICU, Pediatric Clinic, Clinical Center University of Sarajevo (Sarajevo, Bosnia and Herzegovina). All infants had chest X-ray at admission, and were treated for respiratory distress syndrome (RDS) with nasal continuous positive airway pressure (nCPAP), conventional mechanical ventilation (CMV), or high frequency oscillatory ventilation (HFOV). At admission we registered data regarding birth weight (BW), gestational age in weeks (GW), Apgar score and prenatally given steroids. Inclusion criteria were fulfilled by 200 infants. According to their mean PaCO2, patients were divided into hypercapnia and normocapnia groups. We analyzed the outcome (survival) of these two groups.Results: The two groups didn’t differ regarding GW, prenatally given steroids, RDS severity, surfactant use, 1- and 5-minute Apgar score, nor according to their CRIB score. Groups had also similar survival. After performing ROC analysis we have found that infants born ≤ 27 GW and ≤ 1,000 g treated with permissive hypercapnia, and infants with normocapnia born ≤ 26 GW and ≤ 980 g, have a prediction of negative outcome regarding survival, with a high level of accuracy.Conclusions: This study shows that ventilation with permissive hypercapnia of preterm infants with RDS is not safe, considering survival in children with GW ≤ 27 and BW ≤ 1,000 g.

Pneumothorax in premature infants with respiratory distress syndrome: focus on risk factors

Introduction: Pneumothorax is a life threatening condition, more often seen in immature infants receiving mechanical ventilation. It carries a significant risk of death and impaired outcome. Objective: To determine predictive factors for the occurrence of pneumothorax in preterm infants with respiratory distress syndrome (RDS). Patients and methods: The present study was conducted in a tertiary research and educational hospital, NICU, Pediatric Clinic UKC Sarajevo, from January 2010 to December 2013. All infants had chest X-ray at admission, and were treated due to RDS with nasal continuous positive airway pressure (CPAP), mechanical ventilation, or high frequency oscillatory ventilation. At admission we registered data regarding birth weight, gestational age, Apgar score, prenatally given steroids. Inclusion criteria were fulfilled by 417 infants. Data about timing, circumstances, side and treatment of pneumothorax were gathered from medical records. Results: Mean birth weight was 1,477 g, mean gestational age 29.6 weeks. We report 98 infants who did not survive. We also report incidence of pneumothorax in 5% of the infants with RDS. In this study pneumothorax and non-pneumothorax groups didn’t differ regarding sex, gestational age (median 29 and 30) nor birth weight (p = 0.818). Apgar score at the 1 st and 5 th minute of life had no influence in genesis of pulmonary air leak, neither prenatally given steroids (p = 0.639), nor surfactant administration. There was a low coverage of preterm infants with prenatal steroids (overall 28.29%). We found that FiO 2 ≥ 0.4 in the first 12 hours of life, and need for mechanical ventilation are predicting factors for developing pneumothorax (p < 0.05). Conclusion: Together with mechanical ventilation, inspired fraction of oxygen higher than 40%, needed to provide adequate oxygenation in the first 12 hours of life in preterm infants, could be a predictive factor in selecting the highest risk babies for development of neonatal pneumothorax.

Palivizumab prophylaxis of RSV infections in Bosnia and Herzegovina

Background: Palivizumab is indicated for respiratory syncytial virus (RSV) prophylaxis in high-risk children. Methods: Observational study, based on 4 sites in Bosnia and Herzegovina (BH 365 (61.9%) infants in total were born before 33 weeks. Average gestational age of preterm infants enrolled for prematurity only was 30.2 ± 3.2 weeks; for preterm infants with BPD/CLD it was 28.3 ± 3.7 weeks. Overall average of palivizumab injections was 4.1 ± 1.0. Hospitalization rate related to severe lower respiratory infections (LRI) during the period of protection by palivizumab was 1.2%. Respiratory infections which deserved medical attention were observed in 3.7% infants included in palivizumab prophylaxis.Conclusion: RSV prophylaxis in B&H is provided systematically and successfully, following the national guidance established in 2009, with the aim of achieving a good cost-benefit ratio, with very low hospitalization rate for severe LRI in prophylaxed infants. New randomized controlled trials (RCTs) and American Academy of Pediatrics (AAP) guidance revised in 2014 will be taken into account in establishing a new national recommendation.

Neurodevelopmental outcome following therapeutic hypothermia for perinatal asphyxia

Studies are supporting neuroprotective benefi t of therapeutic hypothermia in term newborns with hypoxic-ischemic encephalopathy. We assessed survival and neurodevelopmental outcome of neonates subjected to the procedure and factors that may have infl uenced it. Newborns with gestational age of more than 36 weeks and less than 6 hours of age with moderate to severe asphyxi al encephalopathy underwent cooling protocol at a temperature of 33.5 °C for 72 hours and rewarming period of 6 hours. The outcome measures assessed were death and neurodevelopmental characteristics. Twenty-fi ve children were assessed during the period from October 2010 to October 2013. Median gestational age was 40 weeks, birth weight 3470 g, Apgar score 2/4 and pH on admission to the hospital 7.02. Four (16%) children died and two were lost for follow up. At the age of fi nal assessment, developmental cate gories of communication were normal in 68.4%, problem solving in 73.7%, personal-social in 68.4%, gross motor in 57.9%, and fimotor in 36.8% but with a high need of retesting in this area. Seven of 19 patients (36.8%) had completely normal results for all fi e categories, while three (15.8%) had abnormal results for all categories. None of the 18 parameters that were correlated with neurodevelopmental outcome showed statistical signifi cance. Amplitude integrated electroencephalography was done in ten patients and the most prominent fiwas discontinuous activity in eight patients. In conclusion, a relatively small number of patients and l imitations of this study design precluded any far-reaching conclusions, but we think that this method can provide better survival and less neurologic sequels in hypoxic-ischemic encephalopathy patients.