Steven L. Goldman

Decreased mortality rate among small premature infants treated at birth with a single dose of synthetic surfactant: A multicenter controlled trial

To determine whether a single prophylactic dose of synthetic surfactant would reduce mortality and morbidity rates, we performed a randomized, controlled trial of Exosurf Neonatal at 19 hospitals in the United States. The Exosurf preparation (5 ml/kg) was instilled into the endotracheal tube of premature infants weighing 700 to 1100 gm during mechanical ventilation, as soon as practical after birth. Control infants were treated with air (5 ml/kg). Dose administration was performed in secrecy by clinicians who did not reveal for 2 years what they had instilled. A total of 222 infants received air and 224 received the synthetic surfactant; 36 infants with congenital pneumonia or malformations were excluded from the primary efficacy analysis. By the age of 28 days, there were 44 deaths in the air group and 27 deaths in the surfactant group (p = 0.022). By the age of 1 year after term there were 61 deaths in the air group and 35 deaths in the surfactant group (p = 0.002). Although there was no reduction in the incidence of respiratory distress syndrome, a significant reduction in the number of deaths attributed to respiratory distress syndrome, a significant reduction in the incidence of pulmonary air leaks, and significantly lower requirements for oxygen and mean airway pressure indicated that lung disease was less severe in the Exosurf-treated infants. There were no significant differences in the incidence of complications such as bronchopulmonary dysplasia, intraventricular hemorrhage, patent ductus arteriosus, necrotizing enterocolitis, and infection. The results indicate that a single prophylactic dose of Exosurf, in high-risk premature infants treated soon after birth, reduces the number of deaths from respiratory distress syndrome and the overall mortality rate.

Jaundice meter: Evaluation of new guidelines

The correlation of transcutaneous bilirubin measurements with serum bilirubin concentrations is not good enough to allow for accurate prediction of the serum values. To impose the jaundice meters potential clinical usefulness, we evaluated 344 paired jaundice meter-serum bilirubin measurements in 125 infants, using new guidelines from the marketing company which were designed to identify which infants require serum bilirubin determinations rather than to predict the actual bilirubin values. Use of the new guidelines correctly assessed the need for serum determinations in most infants, but false positives and, more importantly, false negatives (missed high serum values) did occur.

Automated method for exchange transfusion: A new modification

THE TECHNIQUE OF EXCHANGE TRANSFUSION has undergone significant metamorphosis since it was first described in 1925 by Hart, 1 who used the longitudinal sinus via the anterior fontanel and the saphenous vein for exsanguination and transfusion, respectively. Diamond et al} improved the technique, using a plastic catheter in the umbilical vein. Since 1951 several modifications of the Diamond single-site technique and of the original two-site technique have been described in attempts to avoid some real and potential problems. We describe our preliminary experience with a modification (devised by H.C.T.) of the two-site technique that has several important benefits. METHODS We modified a volumetric infusion pump (Harvard, Model 2681) to accommodate two syringes, one of which infuses while the other withdraws (Figure). Both syringe plungers are attached to the same driving element of the pump, so that any change in volumes in the syringes must be opposite but of identical magnitude. Two sites for exchange are necessary: exsanguination via an umbilical vessel or peripheral arterial catheter (radial); infusion through the umbilical or peripheral vein. We found it useful to place a syringe containing heparinized saline just proximal to both the infusion and exsanguination sites, to flush the sites if necessary. The exchange is done in cycles consisting of 50 ml infused and 50 ml removed. One syringe and the tubing leading to the infusion site are filled with transfusion blood; the other syringe remains empty with its plunger in maximally. The infusion pump is set to run at approximately 70 to 100 ml/kg/hr. Once the pump is turned on, one syringe begins to infuse 50 ml blood and the other withdraws an equal volume. When the infusion syringe is empty, the pump is switched off, the blood in the exsanguination syringe is discarded, the infusion syringe is refilled, the pumps driving element is returned to the original position, and another cycle can begin. If there is any delay

DETECTION OF SEIZURE ACTIVITY IN THE PARALYZED NEONATE

In experimental animals neurologic damage may occur during seizure activity whether the seizure is accompanied by motor activity and hypoxemia or whether the animal is paralyzed and normoxemic. These findings suggest that it may be important to detect seizure activity in the paralyzed neonate. Nine infants who were mechanically ventilated and paralyzed with pancuronium had their condition diagnosed as seizure activity. Vital signs were continuously monitored and six infants had either oxygen saturation or transcutaneous oxygen measured during seizure activity. For the group as a whole, rhythmic fluctuations in vital signs, cardiac rhythm, and oxygenation occurred every four minutes (range one to seven minutes) and lasted two minutes (range one to four minutes). In seven patients whose seizures were not accompanied by cardiac arrhythmias the following mean increases were noted: systolic arterial blood pressure, 15 mm Hg (range 7 to 36 mm Hg); heart rate, ten beats per minute (-11 to 30/min); oxygen saturation, 12% (range 4% to 20%); and transcutaneous oxygen, 31 mm Hg (range 14 to 45 mm Hg). Seizures in the two patients with cardiac arrhythmias were accompanied by a decrease in systolic arterial blood pressure of 27 mm Hg (range 15 to 40 mm Hg) and in oxygen saturation of 24% (range 20% to 28%). The presence of rhythmic fluctuation in vital signs and oxygenation should alert the physician to the possibility of seizure activity in the paralyzed neonate.