Yaşar Demirelli

Intravenous Paracetamol for Patent Ductus Arteriosus in Premature Infants - A Lower Dose Is Also Effective

babies with hsPDA. The first patient was a 29-week premature infant (birth weight 1,045 g, postnatal age 3 days). Oral ibupro-fen was contraindicated in this patient due to suspected necrotizing enterocolitis (NEC). We started IV paracetamol with the dose regimen suggested by Oncel et al. [1] . After the first 4 doses, transaminase levels were checked and a significant increase was detected compared to pretreatment levels (aspartate aminotransferase (AST) 43 vs. 260 U/l, alanine aminotransferase (ALT) 11 vs. 180 U/l). The drug was ceased and transaminase levels normalized over the following 4 days. After this experience, we decreased each dose to 10 mg/kg (3 doses/day). An echocardiographic study was per-formed after each of the 3 doses. If the duc-tal shunt had disappeared, treatment was stopped, but if it persisted, an additional 3 doses were given, for a maximum of 4 days. In 6 additional patients, IV paracetamol was used with this dosing regimen. All were very low birth weight infants. The gesta-tional ages were <28 weeks (1 patient) and 28–31 weeks (5 patients). Oral ibuprofen could not be given to 2 patients due to Dear Sir, We read with great interest the recent article by Oncel et al. [1] entitled ‘Intrave-nous paracetamol treatment in the man-agement of patent ductus arteriosus in ex-tremely low birth weight infants’. It is the first study to report the results of intrave-nous (IV) paracetamol in premature in-fants where a 3-day treatment (15 mg/kg dose, 4 doses/day) is offered. In the case of treatment failure at the end of the third day, a second course is administered. Palmer et al. [2] reported the following dose regimen for IV acetaminophen to be safe in premature infants: 28–32 weeks, 10 mg/kg; 32–36 weeks, 12.5 mg/kg, and 36 weeks, 15 mg/kg. Although the gestational ages of the patients in the study of Oncel et al. [1] were low, they used a higher dose; no side effect related to IV paracetamol was re-ported. In our clinical practice, prematures with hemodynamically significant patent ductus arteriosus (hsPDA) and contraindi-cations for oral ibuprofen present a great challenge. For these patients, IV para ce ta-mol seems to be a good alternative. We ad-ministered IV paracetamol in 7 preterm

Intravenous paracetamol with a lower dose is also effective for the treatment of patent ductus arteriosus in pre-term infants.

INTRODUCTION Haemodynamically significant patent ductus arteriosus is a significant cause of morbidity and mortality in pre-term infants. This retrospective study was conducted to investigate the usefulness of lower-dose paracetamol for the treatment of patent ductus arteriosus in pre-term infants. MATERIALS AND METHODS A total of 13 pre-term infants who received intravenous paracetamol because of contrindications or side effects to oral ibuprofen were retrospectively enrolled. In the first patient, the dose regimen was 15 mg/kg/dose, every 6 hours. As the patient developed significant elevation in transaminase levels, the dose was decreased to 10 mg/kg/dose, every 8 hours in the following 12 patients. Echocardiographic examination was conducted daily. In case of closure, it was repeated after 2 days and when needed thereafter in terms of reopening. RESULTS A total of 13 patients received intravenous paracetamol. Median gestational age was 29 weeks ranging from 24 to 31 weeks and birth weight was 950 g ranging from 470 to 1390 g. The median postnatal age at the first intravenous paracetamol dose was 3 days ranging from 2 to 9 days. In 10 of the 13 patients (76.9%), patent ductus arteriosus was closed at the median 2nd day of intravenous paracetamol ranging from 1 to 4 days. When the patient who developed hepatotoxicity was eliminated, the closure rate was found to be 83.3% (10/12). CONCLUSION Intravenous paracetamol may be a useful treatment option for the treatment of patent ductus arteriosus in pre-term infants with contrindication to ibuprofen. In our experience, lower-dose paracetamol is effective in closing the patent ductus arteriosus in 83.3% of the cases.

Safety and Efficacy of Intravenous Colistin in Neonates With Culture Proven Sepsis.

Background: Although it is well described among adults, intravenous colistin use and its associated toxicities in newborns are poorly understood. Objectives: We present our experience of efficacy and safety of intravenous colistin in the treatment of sepsis in term and preterm neonates. Patients and Methods: The records of neonates who received colistin between January 2013 and February 2014 were retrospectively reviewed. All neonates with culture proven nosocomial infections due to multidrug resistant organisms and treated continuously with colistin for more than 72 hours were included in the study. Results: Patients were evaluated for clinical and microbiological response to the drug and its and side effects. Twelve newborn infants with mean 31.8 ± 3.5 weeks gestational age and median 1482 (810 - 3200) gram birth weight were included. 11/12 (91.7%) patients showed microbiological clearance with intravenous colistin. One patient who had recurrent cerebrospinal fluid positive culture was treated with intraventricular colistin. The major side effects observed was hyponatremia and hypokalemia in 2 (16.6%) patients, all infants required magnesium supplementation. Conclusions: Intravenous colistin administration appears to be safe and efficacious for multidrug-resistant gram-negative infections in neonates, including preterm infants. However, we believe that large prospective controlled studies are needed to confirm its efficacy and safety in neonates.

Evaluation of Premature Infants Hospitalized in Neonatal Intensive Care Unit between 2010-2012.

OBJECTIVE With continuing developments in the field of neonatology, survival rates of low birth weight and small for gestational age infants have increased, which in turn has brought important prematurity-related problems. The aim of this study was to evaluate retrospectively the prematurity problems that are the significant causes of morbidity and mortality. MATERIALS AND METHODS 613 premature infants hospitalized in the neonatal intensive care unit of Ataturk University Medical Faculty Hospital between January 2010 and January 2012 were included in this study. Infants were divided into groups according to their birth weight and gestational age. RESULTS 323 infants were male (52.6%) and 290 were female (47.4%). 63.9% of infants weighed ≥1500 grams, and 58.5% had a gestational age of ≥33 weeks. Respiratory distress syndrome (RDS) was detected in 249 (40.6%), bronchopulmonary dysplasia (BPD) in 124 (20.2%), necrotizing enterocolitis (NEC) in 41 (6.6%), retinopathy of prematurity (ROP) in 202 (32.9%), and intracranial hemorrhage (ICH) in 15 (2.4%). RDS, BPD, NEC, ROP, and ICH rates were inversely proportional to decreases in gestational age and birth weight, and were found to be statistically significant. CONCLUSION Mortality and morbidity rates were similar to the other data published from our country, but the rates were above those reported in developed countries. We believe that our morbidity and mortality rates can reach levels comparable to those of developed countries with improved antenatal care, regular follow-up of pregnancy and increased numbers of physicians and health care personnel per patient.

May we use ibuprofen as doses against courses in the treatment of patent ductus arteriosus in premature infants

Abstract Objective: We aimed to investigate the efficacy of ibuprofen doses in closing patent ductus arteriosus (PDA) and the possibility of reducing drug-related complications by reducing dose number. Methods: We performed a prospective study with 60 premature infants (≤33 weeks) who were treated with enteral ibuprofen for hsPDA. Echocardiographic examinations were performed before each dose. Treatment was stopped when PDA was closed and patients were followed for reopening and complications. Results: Rates of closure were 28.3%, 44.1%, 54.1%, 36.3%, 42.8% and 50.0% with the 1st, 2nd, 3rd, 4th, 5th and 6th doses. No closure was observed with 7th, 8th and 9th doses. Reopening was observed only in patients whose PDA closed with the 1st (3.3%), 2nd (1.6%) and 3rd (1.6%) doses. PDA diameters were higher in patients who required >4 doses. Complications were rare (6.6%) but unrelated with dose number. Conclusions: We conclude that it is possible to minimize ibuprofen exposure and achieve high closure rates of PDA in premature infants by performing echocardiography before each dose. PDA diameter should be used to estimate the duration of treatment. This approach is not effective in reducing complication rates and must be performed in attention to reopening especially for the first three doses.

Combined treatment with chlorhexidine and 0·9% saline in a newborn infant with an infected surgical wound

Newborns are more susceptible to infection; this makes proper wound care extremely important in them. Unfortunately, in spite of successful surgery, patients can die as a result of wound area infections. Herein, we report a case in which a combined therapy of chlorhexidine (a disinfectant) and saline (a cleansing agent used in wound care) was used effectively to treat the wound in a newborn infant with an antibiotic‐resistant, Gram‐negative, bacteria‐related surgical site infection.

Ecthyma gangrenosum in a preterm infant.

Dear Editors, Ecthyma gangrenosum (EG) is a rare infection that is characteristically seen in immunocompromised patients and presents as embolic lesions caused by Pseudomonas aeruginosa (1). This type of infection has distinct pathognomonic features along with a high mortality rate, but when recognised early, it can be successfully treated. The classic lesions associated with EG are composed of deep ulcers with ecchymotic, gangrenous centres, bright red areolae and typical raised, purplish, indurated and rolled-out edges (1,2). An infant born at the 28th gestational week with a birthweight of 1200 g was admitted to the neonatal intensive care unit of our facility because of a large teratoma in the sacrococcygeal region on the first postnatal day. A complete resection was performed on the third postnatal day, and the pathology results showed a grade three immature teratoma. Chemotherapy (cisplatin, bleomycin and etoposide) was started on the 24th postnatal day and continued for four cycles at 3-week intervals. When the patient reached the 60th postnatal day, which coincided with the end of the second course of chemotherapy, ulcerated lesions were found over the infant’s entire body (Figure 1). Blood and wound cultures were performed, and the results identified the presence of P. aeruginosa. Based on the antibiotic susceptibility of this bacterium, meropenem treatment was started, and a complete recovery was observed after 21 days of treatment. To date, very few cases of EG have been reported during the neonatal period (1–5). However, preterm infants are especially at risk because of their immature immune system (3). The chemotherapy treatment in conjunction with the infant’s prematurity facilitated the development of EG in our

The Use Of Low-dose Recombinant Tissue Plasminogen Activator To Treat A Preterm İnfant With An İntrauterine Spontaneous Arterial Thromboembolism

Neonatal thromboembolic events are rare, and only a few cases of intrauterine spontaneous arterial thromboembolisms have been reported in the literature. Thrombolytic therapy with recombinant tissue plasminogen activator is usually the preferred treatment because it has a short half-life, fewer systemic side effects, and a strong, specific affinity for fibrin. Protocols vary from center to center, but there is still no consensus regarding the proper dosage or treatment duration. Herein, we present the case of an intrauterine spontaneous arterial thromboembolism in a preterm infant that completely resolved after being treated with low-dose recombinant tissue plasminogen activator (0.02 mg/kg/h).

Cow’s Milk Allergy in Preterm Infant with Bronchopulmonary Dysplasia

Cows milk allergy is frequent in the first year of life. The symptoms may start during the first weeks of life, and may be cutaneous (50-60%), gastrointestinal (50-60%) or respiratory (20-30%), often involving more than one organ system. In this report, we describe a case of cows milk allergy in a preterm infant in whom rectal bleeding and respiratory symptoms resolved with the introduction of an extensively hydrolyzed formula. Occurrence of the respiratory symptoms of this disorder in a preterm infant with bronchopulmonary dysplasia may cause re-hospitalization after discharge.

Intraventricular Colistin Use in a Premature Infant with Cerebral Abscess and Ventriculitis

The treatment of multidrug-resistant Acinetobacter baumannii infections is a serious problem in neonatal Intensive Care Units. Colistin has been used successfully in the treatment of these infections. Due to the limited penetration of colistin into the cerebrospinal fluid, central nervous system infection due to A. baumannii necessitates intrathecal or intraventricular application. Here, we describe our experience with intravenous and intraventricular colistin administration in a premature infant (33 gestational weeks) with shunt infection and brain abscess. No side-effects related to the drug were observed. To the best of our knowledge, our patient is the first premature infant to undergo intraventricular colistin administration. Although the central nervous system infection in our patient was treated successfully, it is obvious that detailed prospective studies are required regarding colistin usage in neonates and especially in premature infants.