Lung volume and cardiorespiratory changes during open and closed endotracheal suction in ventilated newborn infants.

OBJECTIVES: To compare change in lung volume (DeltaV(L)), using respiratory inductive plethysmography, time to recover pre-suction lung volume (t(rec)) and the cardiorespiratory disturbances associated with open suction (OS) and closed suction (CS) in ventilated infants. DESIGN: Randomised blinded crossover trial. SETTING: Neonatal intensive care unit. PATIENTS: Thirty neonates, 20 receiving synchronised intermittent mandatory ventilation (SIMV) and 10 high-frequency oscillatory ventilation (HFOV, four receiving muscle relaxant). INTERVENTIONS: OS and CS were performed, in random order, on each infant using a 6FG catheter at -19 kPa for 6 seconds and repeated after 1 minute. OUTCOME MEASURES: DeltaV(L), oxygen saturation (Spo(2)) and heart rate were continuously recorded from 2 minutes before until 5 minutes after suction. Lowest values were identified during the 60 seconds after suction. RESULTS: Variations in all measures were seen during CS and OS. During SIMV no differences were found between OS and CS for maximum DeltaV(L) or t(rec); mean (95% CI) difference of 3.5 ml/kg (-2.8 to 9.7) and 4 seconds (-5 to 13), respectively. During HFOV t(rec) was longer during OS by 13 seconds (0 to 27) but there was no difference in the maximum DeltaV(L) of 0.1 mV (-0.02 to 0.22). A small reduction in SpO(2) with CS in the SIMV group mean difference 6% (2.1 to 9.8) was the only significant difference in physiological measurements. CONCLUSIONS: Both OS and CS produced transient variable reductions in heart rate and Spo(2). During SIMV there was no difference between OS and CS in DeltaV(L) or t(rec). During HFOV there was no difference in DeltaV(L) but a slightly longer t(rec) after OS.

Systemic haemodynamics in infants with vein of Galen malformation: assessment and basis for therapy.

Systemic haemodynamics in three infants with severe cardiac failure secondary to vein of Galen malformation (VGAM) were studied using two-dimensional and Doppler echocardiography. In all cases, ventricular outputs were over two times normal and superior vena caval flows up to 10 times normal reflecting high flow through the low-resistance fistula. Severe pulmonary hypertension, right heart dilatation and retrograde flow in the descending aorta were uniformly present. Systemic blood flow below the head and neck was reduced resulting in metabolic acidosis at presentation. Two infants had patent arterial ducts, in which flow was entirely right to left and on entering the aorta passed predominantly retrogradely towards the VGAM. These findings provide a basis for understanding the pathophysiology of cardiac failure in VGAM and support treatment with pulmonary and systemic vasodilating agents.

Effects of open endotracheal suction on lung volume in infants receiving HFOV.

OBJECTIVE: To describe the pattern and magnitude of lung volume change during open endotracheal tube (ETT) suction in infants receiving high-frequency oscillatory ventilation (HFOV). DESIGN: Prospective observational clinical study. SETTING: Tertiary neonatal intensive care unit. PATIENTS AND PARTICIPANTS: Seven intubated and muscle-relaxed newborn infants receiving HFOV. INTERVENTIONS: Open ETT suction was performed for 6 s at -100 mmHg using a 6-F catheter passed to the ETT tip after disconnection from HFOV. The HFOV was then recommenced at the same settings as prior to ETT suction. MEASUREMENTS AND RESULTS: Change in lung volume (DeltaV (L)) referenced to baseline lung volume before suction was measured with a calibrated respiratory inductive plethysmography recording from 30 s before until 60 s after ETT suction. In all infants ETT suction resulted in significant loss of lung volume. The mean DeltaV (L) during suctioning was -13 ml/kg (SD 4 ml/kg) (p<0.0001 vs. baseline, repeated-measures ANOVA), with a mean 76.5% (SD 14.1%) of this volume loss being related to circuit disconnection. After recommencing HFOV lung volume was rapidly regained with mean DeltaV (L) at 60 s being 1 ml/kg (SD 4 ml/kg) below baseline (p>0.05, Tukey post-test). CONCLUSIONS: Open ETT suction caused a significant but transient loss of lung volume in muscle-relaxed newborn infants receiving HFOV.

Death in the neonatal intensive care unit: changing patterns of end of life care over two decades.

BACKGROUND: Death remains a common event in the neonatal intensive care unit, and often involves limitation or withdrawal of life sustaining treatment. OBJECTIVE: To document changes in the causes of death and its management over the last two decades. METHODS: An audit of infants dying in the neonatal intensive care unit was performed during two epochs (1985-1987 and 1999-2001). The principal diagnoses of infants who died were recorded, as well as their apparent prognoses, and any decisions to limit or withdraw medical treatment. RESULTS: In epoch 1, 132 infants died out of 1362 admissions (9.7%), and in epoch 2 there were 111 deaths out of 1776 admissions (6.2%; p<0.001). Approximately three quarters of infants died after withdrawal of life sustaining treatment in both epochs. There was a significant reduction in the proportion of deaths from chromosomal abnormalities, and from neural tube defects in epoch 2. CONCLUSIONS: There have been substantial changes in the illnesses leading to death in the neonatal intensive care unit. These may reflect the combined effects of prenatal diagnosis and changing community and medical attitudes.

Early intravenous nutrition for the prevention of neonatal jaundice.

BACKGROUND: The early institution of enteral feeding in the first few days of life is known to impact on the development of unconjugated hyperbilirubinaemia. However, the effect of early intravenous nutrition on neonatal jaundice remains unknown. OBJECTIVES: To determine the effect of early intravenous nutrition on neonatal jaundice. SEARCH STRATEGY: The standard search strategy of the Cochrane Neonatal Review Group was used including searches of the Cochrane Controlled Trials Register (Cochrane Library: Issue 3, 2002), MEDLINE (1966-December 2002), and EMBASE (1974-December 2002). SELECTION CRITERIA: Randomised or quasi-randomised controlled trials evaluating the effect of early intravenous nutrition on unconjugated bilirubin. DATA COLLECTION AND ANALYSIS: The search strategy identified no eligible studies, thus no data were collected. MAIN RESULTS: No studies were identified. REVIEWER'S CONCLUSIONS: Decisions regarding the institution of early intravenous nutrition must continue to be based upon factors others than its effect on neonatal jaundice.

Fibreoptic phototherapy for neonatal jaundice.

BACKGROUND: Phototherapy is used to treat newborn infants with hyperbilirubinaemia. Fibreoptic phototherapy is a new mode of phototherapy which is reported to lower serum bilirubin (SBR) while minimising disruption of normal infant care. OBJECTIVES: To evaluate the efficacy of fibreoptic phototherapy. SEARCH STRATEGY: The standard search strategy of the Cochrane Collaboration was used including searches of the Cochrane Controlled Trials Register, MEDLINE, EMBASE and discussion with experts in the field. SELECTION CRITERIA: Randomised or quasi-randomised controlled trials evaluating the efficacy of fibreoptic phototherapy in the management of newborn infants with hyperbilirubinaemia. DATA COLLECTION AND ANALYSIS: Thirty-one studies were identified of which 24 met inclusion criteria. They evaluated the efficacy of fibreoptic phototherapy in a number of different clinical situations and patient populations. MAIN RESULTS: Fibreoptic phototherapy was more effective at lowering SBR than no treatment but less effective than conventional phototherapy (percentage change in SBR after 24 hours of treatment: WMD -10.7%, 95%CI -18.14, -3.26 and WMD 3.59%, 95%CI 1.27, 5.92 respectively). Fibreoptic phototherapy was equally as effective as conventional phototherapy in preterm infants and when two fibreoptic devices were used simultaneously (change in SBR after 24 hours of treatment: WMD 1.7%, 95%CI -2.65, 6.05 and change in SBR per day over whole treatment period: WMD 2.82%, 95%CI -1.84, 7.48 respectively). A combination of fibreoptic and conventional phototherapy was more effective than conventional phototherapy alone (duration of phototherapy: WMD -12.51 hr, 95%CI -16.00, -9.02, meta-analysis affected by heterogeneity). No conclusion can be made on the superiority of one fibreoptic device over another as the two studies comparing them (one favouring BiliBlanket, the other finding no difference) did not contain a common outcome measure. REVIEWER'S CONCLUSIONS: Fibreoptic phototherapy has a place in the management of neonatal hyperbilirubinaemia. It is probably a safe alternative to conventional phototherapy in term infants with physiological jaundice. No trials have been identified which support the widely-held view that fibreoptic devices interfere less with infant care or impact less on parent-child bonding.

Upper cervical spinal cord injury in neonates: the use of magnetic resonance imaging.

Neonatal upper cervical spinal cord injury is associated with rotational forceps delivery and presents with quadriparesis and diaphragmatic paralysis. The underlying pathology determines neurologic outcome but is difficult to assess clinically or with simple radiographic techniques. We report 4 cases in which early magnetic resonance imaging demonstrated the extent and severity of the injury and guided management.

Novaco Anger Scale: reliability and validity within an adult criminal sample.

This study investigated the reliability and validity of the Novaco Anger Scale (NAS; Novaco, 1994) with two groups of correctional offenders, General Admissions and Violent Admissions. Predominantly White male offenders (N = 204), ranging in age from 18 to 69 years, participated in the study. One-month test-retest reliability for the General Admissions group ranged from .78 to .91 using both similar (paper-pencil) and dissimilar (computerized) retesting methods, with lower scores occurring on retest. Significantly lower scores were found for the Violent Admissions group as compared with the General Admissions group. Concurrent validity was examined in the Violent Admissions group using three anger/aggression measures and clinical ratings of eight anger dimensions. Stronger correlations with other similar anger measures than with negative affect indices revealed concurrent and discriminant validity. Implications for clinical use in an offender population are discussed.

The Criminal Sentiments Scale: predictive validity in a sample of violent and sex offenders.

This study investigated the predictive validity of the Criminal Sentiments Scale (CSS: Gendreau, Grant, Leipciger, & Collins, 1979) within a sample of violent and sex offenders using conviction and failure on conditional release as the criterion variables. The CSS was completed by 130 male offenders (65 sex offenders and 65 violent offenders) commencing a sentence of greater than two years in a Canadian federal institution. Average time at risk for the sample was 16 months. Arrest and conviction rates for violent offenders and sex offenders were 24.6% and 13.8% respectively, overall failure on release resulting in reincarceration was 41.5% and 18.5% respectively. The results showed no relationship between the CSS and recidivism or release failure. Implications for clinical use among this population of offenders are discussed.