Two parenteral amino acid solutions and plasma levels of amino acids in the neonate: A randomized trial.

OBJECTIVE: In neonates on total parenteral nutrition (TPN), amino acids may be a risk factor for developing total parenteral nutrition-associated cholestasis (TPNAC). We aimed, first, to compare methionine, cysteine, and taurine plasma levels between neonates on TPN who were receiving an intravenous amino acid solution based on a breast milk aminogram and those on an intravenous solution of pediatric amino acids based on an umbilical cord aminogram, and second, to determine the frequency of TPNAC. METHODS: A double-blind randomized controlled trial was conducted. Ninety-four neonates with a birthweight of 1000g or more and a gestational age of 30 wk or older were admitted and enrolled. Blood samples were obtained at 0, 7, and 14 d of TPN, and plasma amino acid concentrations were determined by ultra-high-resolution liquid chromatography. Continuous variables were compared using the Wilcoxon rank-sum test or Student's t test; categorical variables were compared using the Fisher exact test. RESULTS: Thirty-five neonates completed the study (Primene, n = 14; TrophAmine, n = 21). On day 14, methionine plasma concentrations were significantly lower in the Primene group than in the TrophAmine group (27 µmol/L versus 32.9 µmol/L, P = 0.044); the taurine concentration was significantly higher in the same group (72.4 µmol/L versus 45.3 µmol/L, P < 0.0001). There were no differences in TPNAC incidence. CONCLUSIONS: Administering an intravenous solution of pediatric amino acids based on the umbilical cord aminogram yielded a higher taurine and lower methionine plasma concentration than did administering a similar solution based on the breast milk aminogram.

Unsuspected Lung Pathology in Autopsies of Children with Cancer.

BACKGROUND: Although pulmonary involvement is common in patients with cancer, its frequency and nature is seldom reported in the medical literature. OBJECTIVE: To determine the frequency and type of lung pathological conditions revealed by autopsy in children with cancer. METHODS: All reports from autopsies performed in children with cancer from 1989 to 2012 in a pediatric hospital were reviewed. RESULTS: In the analyzed period, 118 autopsies (10.2% of all autopsies) corresponded to children who died with cancer; 76 had complete information and were included in the analysis. Children were seen in the Hematology (41 cases) or the Oncology (35 cases) services. Their median age at decease was 7 years (range, 15 days to 16.1 years) and 46.1% were females. Main diagnoses were acute lymphoblastic (31 patients) or myeloblastic (10 patients) leukemias and tumors of the central nervous system (12 patients). A pathological respiratory condition was diagnosed antemortem in 31 (40.8%) patients, and at autopsy in 62 (81.6%) cases. Omitted diagnoses occurred in 58 (76.3%) children, being pneumonia (24 cases) and pulmonary hemorrhage (23 cases) the most frequent omissions. Nine patients had clinically unsuspected tumor infiltration or metastases. CONCLUSIONS: In these children with cancer, more than 80% of autopsies revealed some lung pathology, mainly of infectious or hemorrhagic nature. Thus, pulmonary involvement should be investigated in all children with cancer in a timely and intentional manner.

Enteral Docosahexaenoic Acid Reduces Analgesic Administration in Neonates Undergoing Cardiovascular Surgery.

BACKGROUND: Neonates undergoing surgery require analgesic medication to ameliorate acute pain. These medications produce negative side effects. Docosahexaenoic acid (DHA) has an antinociceptive effect in animals, but this has not been evaluated in human neonates. We evaluated the DHA effect on cumulative dose and duration of analgesics administered to neonates undergoing cardiovascular surgery. METHODS: A secondary analysis was performed with data from a clinical trial, in which enteral DHA was administered perioperatively compared with sunflower oil (SO). Present study assessed the antinociceptive effect of DHA by measuring the cumulative dose and duration of analgesics administered during postoperative stay in a neonatal intensive care unit. Multivariate linear regression models were performed. RESULTS: Seventeen neonates received DHA and 18 received SO in the control group. Compared with the control group, the DHA group received lower cumulative dose (14.6 ± 2.2 vs. 25.2 ± 4.8 µg/kg, p = 0.029) and shorter duration of buprenorphine (2 days (1-8) vs. 4.5 days (1-12); p = 0.053). After adjusting for confounders, the DHA group received significantly lesser buprenorphine (ß = -27 µg/kg, p = 0.028; R2 model = 0.90) for shorter duration (ß = -9 days, p = 0.003; R2 model = 0.94). No differences in fentanyl or ketorolac were detected. CONCLUSIONS: Buprenorphine administration was reduced in neonates who received DHA, suggesting that DHA likely has analgesic effects.

Frecuencia de lesión de la vía aérea identificada por broncoscopia en recién nacidos con intubación endotraqueal prolongada en una unidad de cuidados intensivos neonatales de tercer nivel / Frequency and type of airway injury identified by bronchoscopic examination in newborns with prolonged endotracheal intubation in a neonatal intensive care unit

Introducción. La intubación endotraqueal y la ventilación mecánica son recursos que se utilizan frecuentemente en la Unidad de Cuidados Intensivos Neonatales. Sin embargo, se ha observado que elevan significativamente la mortalidad, dado que se presentan complicaciones. Por tanto, el objetivo de este trabajo fue reportar la frecuencia y el tipo de lesiones de la vía aérea en recién nacidos con intubación endotraqueal prolongada a quienes se les realizó broncoscopia. Métodos. Se incluyeron 150 recién nacidos con tiempo de intubación endotraqueal ≥ 5 días a quienes se les realizó broncoscopia. Se registraron las siguientes variables: edad gestacional, peso al nacer, indicación de la intubación, tamaño del tubo endotraqueal, número de reintubaciones, tiempo de intubación, indicación de la broncoscopia, hallazgos de la broncoscopia, tipo de tratamiento y número de broncoscopias. Resultados. La principal indicación de la broncoscopia fue la atelectasia persistente o recidivante. Del total de los pacientes, 96% presentaron alguna alteración de la vía aérea. Predominaron las lesiones inflamatorias (67.3%), seguidas de malacia (39.3%) y estenosis (28.7%). Las estructuras anatómicas más afectadas fueron los bronquios (31.6%), la laringe (24%) y la tráquea (22%). En 126 pacientes se indicó tratamiento médico; los esteroides se utilizaron con mayor frecuencia. Además del tratamiento médico, a 21 pacientes (14%) se les realizó dilatación bajo broncoscopia y a 7 (4.6%), traqueostomía. Conclusiones. Las lesiones más frecuentes fueron de tipo inflamatorio. La atelectasia persistente fue la principal manifestación clínica, por lo que se sugiere considerarla para que, durante la exploración broncoscópica, se descarte lesión de la vía aérea en recién nacidos con intubación endotraqueal prolongada.

Background. Endotracheal intubation and mechanical ventilation are frequently use resources in the Neonatal Intensive Care Unit. Higher mortality has been observed as a result of complications. We undertook this study to report the frequency and type of airway injury in newborns with prolonged endotracheal intubation who underwent bronchoscopy examination. methods. Newborns (n = 150) who were intubated endotracheally for ≥ 5 consecutive days and who underwent bronchoscopy were included. We recorded the following variables: gestational age, birth weight, indications for intubation, size of endotracheal tube, number of reintubations, intubation length, indication for bronchoscopy, bronchoscopic findings, type of treatment for airway injury, and number of bronchoscopies. Results. The main indication for bronchoscopy was atelectasis (persistent and/or recurrent); 96% of newborns had at least one injury. The most frequent were inflammatory type (67.3%), malacia (39.3%), and stenosis (28.7%). The most injured anatomic structures were the bronchi (31.6%), larynx (24%), and trachea (22%). For 126 patients, primary medical treatment was steroids. For 21 patients (14%), dilatation was performed under bronchoscopy; and for 7 (4.6%) patients, tracheostomy was performed. Conclusions. The most frequent injuries were inflammatory-type. Persistent atelectasis was the principal clinical manifestation; therefore, it should be considered as an indication of bronchoscopic exploration to identify airway injury in newborns with prolonged endotracheal intubation.

Correlación entre el gasto y el aporte de energía en neonatos hospitalizados en una unidad de cuidados intensivos / Correlation between energy consumption and intake in infants hospitalized in an intensive care unit

Introducción. Una alimentación adecuada es esencial en el manejo del niño en estado crítico. Este estudio analiza la correlación entre el aporte total de energía (ATE) y el gasto energético total (GET) de pacientes hospitalizados en una Unidad de Cuidados Intensivos Neonatales (UCIN), considerando si nació pretérmino (PT), recibió alimentación parenteral (AP), o tratamiento quirúrgico (TQ). Métodos. Estudio transversal con 29 pacientes evaluados después de alcanzar estabilidad hemodinámica y ventilatoria. El GET se estimó mediante calorimetría indirecta, y el ATE sumando la energía administrada por vía enteral y parenteral. El análisis estadístico incluyó correlación de Spearman, U Mann-Whitney, prueba exacta de Fisher y regresión múltiple. Resultados. Catorce pacientes nacieron PT, y 21 recibieron TQ. Al momento del estudio, 14 recibían AP y 63% estaban desnutridos. El ATE fue mayor para los PT (P =0.022), los de AP (P =0.038) y los de TQ (P =0.046); el GET fue mayor en los PT (P =0.003). La correlación entre GET y ATE fue significativa sólo para alimentación enteral (r =0.518, P =0.046). El ATE fue inadecuado en 85.1% de los pacientes. Conclusiones. El ATE para niños atendidos en la UCIN parece ser inadecuado cuando se calcula por ecuaciones; se sugiere utilizar la determinación del gasto energético por calorimetría indirecta por lo menos en pacientes bajo el régimen de AP total.

Introduction. An adequate feeding is essential in the management of critically ill infants. This study analyzes the association between total energy intake (TEI) and total energy consumption (TEC) of patients hospitalized in a neonatal intensive care unit (NICU) taking into account whether were born preterm (PT), received parenteral nutrition (PN), or underwent surgical treatment (ST). Methods. A cross-sectional design including 29 patients hospitalized in a NICU after hemodynamic and ventilatory stability was conducted. TEC was determined by indirect calorimetry and TEI by the summation of the energy administered by enteral and parenteral pathways. The statistical analysis included, Spearman correlation, U Mann-Whitney test, exact Fisher test, and multiple regression. Results. Fourteen patients were born PT, 21 underwent ST; 14 were under PN regime at the moment of the study and 63% were undernourished. TEI was higher in PT (P =0.022), PN (P =0.038), and ST (P =0.046) patients; TEC was greater only in PT infants (P =0.003). TEC correlated with TEI only in patients receiving enteral nutrition (r=0.518, P =046). TEI was inadequate in 85.1% of the patients. Conclusion. The amount of energy administered to patients hospitalized in the NICU is inadequate when it is estimated by standardized equations. We suggest determining TEC by indirect calorimetry at least in patients under total PN.