Shiv Sajan Saini

A comparison of two-fingers technique and two-thumbs encircling hands technique of chest compression in neonates.

Objective:To compare the proportion of correct placements (POCP) between ‘two-fingers’ and ‘two-thumbs’ techniques of chest compression among neonates of various gestations.Study Design:Two-fingers and two-thumbs spans of 32 adult rescuers were individually compared with the inter-nipple line to sterno-xiphoid junction distance of 39 neonates. ‘Correct placement’ was defined if two-fingers/two-thumbs span was equal to or less than the inter-nipple line to sterno-xiphoid junction distance. The POCPs was compared between two-fingers and two-thumbs methods of chest compression by the McNemar test among neonates and their various subgroups.Result:There were a total of 1248 comparisons. The POCPs with two-fingers and two-thumbs techniques were 6.7 and 77% in all neonates, 10.6 and 89.5% in full term and 1.2 and 59% in preterm neonates, respectively (P<0.001).Conclusion:Two-thumbs technique achieved higher POCPs and should be preferred over two-fingers technique among neonates.

Hemodynamic Changes in Preterm Neonates With Septic Shock: A Prospective Observational Study*

Objective: We evaluated hemodynamic changes in preterm neonates with septic shock using functional echocardiography and studied the effects of vasoactive drugs on hemodynamic variables. Design: Prospective observational study. Setting: Level III neonatal ICU. Subjects and Patients: We enrolled 52 preterm neonates with septic shock (shock group) and an equal number of gestation and postnatal age-matched healthy neonates (control group). Interventions: We measured functional hemodynamic variables (left and right ventricular output, ejection fraction, isovolumetric relaxation time, and early passive to late active peak velocity ratio) by echocardiography in the shock group during initial fluid resuscitation, before initiation of vasoactive drugs, and again 30–40 minutes after initiation of vasoactive drug infusion. Control group underwent a single assessment after enrollment. We compared various hemodynamic variables between shock group and control group using paired t test or Wilcoxon signed-rank test. Measurements and Main Results: The baseline left ventricular output was significantly higher in neonates with septic shock as compared with controls (median [interquartile range], 305 mL/kg/min [204, 393] vs 233 mL/kg/min [204, 302]; p < 0.001), but ejection fraction was similar between the two groups (55% ± 12% vs 55% ± 5%, p = 0.54). Other hemodynamic variables were comparable between the two groups. After vasoactive drug infusion, there was a significant increase in heart rate (152 ± 18 to 161 ± 18 beats/min, p ⩽ 0.001) and right ventricular output (median [interquartile range], 376 [286, 468] to 407 [323, 538] mL/kg/min; p = 0.018) compared with the baseline, but left ventricular output and ejection fraction did not change significantly. Conclusions: We found an elevated left ventricular output but normal ejection fraction in preterm neonates with septic shock. This suggests that septic shock in preterm neonates is predominantly due to vasoregulatory failure. Vasoactive drugs significantly increased right ventricular output, which was predominantly due to increase in heart rate.

Ringer’s lactate vs normal saline for children with acute diarrhea and severe dehydration: A double blind randomized controlled trial

ObjectiveWHO recommends Ringer’s lactate (RL) and Normal Saline (NS) for rapid intravenous rehydration in childhood diarrhea and severe dehydration. We compared these two fluids for improvement in pH over baseline during rapid intravenous rehydration in children with acute diarrhea.DesignDouble-blind randomized controlled trialSettingPediatric emergency facilities at a tertiary-care referral hospital.InterventionChildren with acute diarrhea and severe dehydration received either RL (RL-group) or NS (NS-group), 100 mL/kg over three or six hours. Children were reassessed after three or six hours. Rapid rehydration was repeated if severe dehydration persisted. Blood gas was done at baseline and repeated after signs of severe dehydration disappeared.Outcome MeasuresPrimary outcome was change in pH from baseline. Secondary outcomes included changes in serum electrolytes, bicarbonate levels, and base-deficit from baseline; mortality, duration of hospital stay, and fluids requirement.ResultsTwenty two children, 11 each were randomized to the two study groups. At primary end point (disappearance of signs of severe dehydration), the improvement in pH from baseline was not significant in RL-group [from 7.17 (0.11) to 7.28 (0.09)] as compared to NS-group [7.09 (0.11) to 7.21 (0.09)], P=0.17 (after adjusting for baseline serum Na/Cl). Among this limited sample size, children in RL group required less fluids [median 310 vs 530 mL/kg, P=0.01] and had shorter median hospital stay [38 vs 51 hours, P=0.03].ConclusionsThere was no difference in improvement in pH over baseline between RL and NS among children with acute diarrhea and severe dehydration.

Isotonic versus hypotonic fluid supplementation in term neonates with severe hyperbilirubinemia - a double-blind, randomized, controlled trial.

Aim:  To compare the incidence of hyponatremia in full‐term neonates with severe hyperbilirubinemia, receiving intravenous fluid supplementation with 0.2% saline in 5% dextrose versus 0.9% saline in 5% dextrose, to prevent blood exchange transfusion (BET).

Continuous positive airway pressure in preterm neonates: An update of current evidence and implications for developing countries

ContextContinuous Positive Airway Pressure (CPAP) is a cost-effective and minimal invasive respiratory support for the newborn.ObjectiveTo review the evidence related to various aspects of CPAP usage and its applicability for developing countries.Evidence AcquisitionWe conducted a literature search on PubMed, CENTRAL, and Cochrane Database of Systematic Reviews using the terms ‘CPAP’ OR ‘continuous positive airway pressure’ OR, non-invasive ventilation’ AND ‘newborn’ OR ‘neonate’ OR ‘infant’. We also searched the reference lists from the above articles and of review articles. Extracted manuscripts and reviews were analyzed and results related to various aspects of CPAP usage were summarized in narrative form.ResultsEarly use of CPAP with early rescue surfactant (InSurE) is the ideal approach for management of respiratory distress syndrome in preterm and extremely preterm infants. Delivery room CPAP is feasible and reduces the need for surfactant and mechanical ventilation by nearly 50%. Prophylactic surfactant for extreme preterms should be discouraged. Heated humidified high flow nasal cannula is best utilized for post-extubation respiratory support. The search for ideal interface still continues and binasal prongs or nasal masks are the good contenders. Evidence on the ideal CPAP delivery is still inconclusive.ConclusionsCPAP, if used early and judiciously, is an effective intervention and need immediate scaling-up in resource-limited settings. Future research should focus on the ideal interface and the CPAP delivery methods.

Off-label use of drugs in neonatal intensive care units

ObjectiveTo estimate proportion of off-label medication use in neonates and to evaluate evidence of efficacy and safety of these medications.MethodsChart audit in neonatal intensive care units of two institutions in Chandigarh, India.ResultsAmong 568 prescriptions in 156 neonates, 286 (50%) were off-label. Of these, 56% drugs were not approved for use in neonatal age group and 26% prescriptions were off-label for frequency, dose, indication, route or rate. Most common off-label drugs were anti-infective and antiepileptic. Despite lack of regulatory approval, one-third off-label drugs had level I-II evidence of safety and efficacy for use in neonates.ConclusionUse of off-label drugs is common in sick neonates.

Nasal Jet-CPAP (variable flow) versus Bubble-CPAP in preterm infants with respiratory distress: an open label, randomized controlled trial

Objective:To compare the failure rates between Jet continuous positive airway pressure device (J-CPAP-variable flow) and Bubble continuous positive airway device (B-CPAP) in preterm infants with respiratory distress.Study design:Preterm newborns <34 weeks gestation with onset of respiratory distress within 6 h of life were randomized to receive J-CPAP (a variable flow device) or B-CPAP (continuous flow device). A standardized protocol was followed for titration, weaning and removal of CPAP. Pressure was monitored close to the nares in both the devices every 6 hours and settings were adjusted to provide desired CPAP. The primary outcome was CPAP failure rate within 72 h of life. Secondary outcomes were CPAP failure within 7 days of life, need for surfactant post-randomization, time to CPAP failure, duration of CPAP and complications of prematurity. An intention to treat analysis was done.Results:One-hundred seventy neonates were randomized, 80 to J-CPAP and 90 to B-CPAP. CPAP failure rates within 72 h were similar in infants who received J-CPAP and in those who received B-CPAP (29 versus 21%; relative risks 1.4 (0.8 to 2.3), P=0.25). Mean (95% confidence intervals) time to CPAP failure was 59 h (54 to 64) in the Jet CPAP group in comparison with 65 h (62 to 68) in the Bubble CPAP group (log rank P=0.19). All other secondary outcomes were similar between the two groups.Conclusion:In preterm infants with respiratory distress starting within 6 h of life, CPAP failure rates were similar with Jet CPAP and Bubble CPAP.

Neonatal adrenal hemorrhage with intraperitoneal spill managed conservatively

A neonate presented with anemia, hyperbilirubinemia and bilateral flank fullness at 23 days of age. Ultrasound abdomen showed bilateral adrenal hemorrhage with intraperitoneal extension on the left side. This was managed nonoperatively and the hematoma resolved completely. Literature regarding this rare entity is described.

Clinical predictors of hospital admission in acute lower respiratory tract infection in 2 months to 2-year-old children.

Acute lower respiratory tract infections (ALRI) are a common cause of paediatric emergency visits in young children. We studied risk factors for hospitalization and developed a clinical score for predicting hospitalization among 2 months to 2‐year‐old children with ALRI.

Preterm Thrombocytopenia and Delay of Ductus Arteriosus Closure

OBJECTIVES: To evaluate whether preterm thrombocytopenia within 24 hours of birth is associated with delayed closure of patent ductus arteriosus (PDA) and higher proportion of hemodynamically significant PDA (Hs-PDA). METHODS: Neonates (gestation 260/7–336/7 weeks, age <24 hours) with known platelet count and PDA on echocardiogram were prospectively enrolled. Asphyxia, congenital infections, structural heart disease, major malformations and clinical sepsis were exclusions. Subjects were recruited in groups A (n = 35), B (n = 18), and C (n = 17) [platelet counts >150,000, 100,000-150,000 and <100,000 per μL respectively] and underwent daily echocardiography until first closure of PDA, death, or day 10. RESULTS: The primary outcome was time to first closure of PDA. Secondary outcomes included proportion with PDA at 72 hours and 7 days, Hs-PDA, and PDA needing treatment. In groups A, B, and C, median (first–third quartile) platelet counts (×100000/μL) were 2.28 (1.94–3.19), 1.25 (1.14–1.37), and 0.68 (0.54–0.83) and time to PDA closure was 2 (2–2), 2 (2–3), and 10 (6–10) days, respectively (log-rank test, P < .001). On Cox proportional hazard regression, platelet count (in multiples of 10 000 /μL) independently predicted time to PDA closure (adjusted hazard ratio: 1.045; 95% confidence interval: 1.019–1.07). On day 7, 47.1% neonates in group C had PDA and none in groups A and B (P < .001). CONCLUSIONS: Thrombocytopenia within 24 hours of birth independently predicts delayed PDA closure and PDA on day 7 in preterm neonates.