Effects of exogenous surfactant on neonates supported by extracorporeal membrane oxygenation.

OBJECTIVE: The purpose of this study was to evaluate the impact of exogenous surfactant on the duration of extracorporeal membrane oxygenation needed to support neonates. STUDY DESIGN: Retrospective case review. RESULTS: The duration of extracorporeal membrane oxygenation decreased from 112 +/- 43.3 hours to 76 +/- 17.9 hours. There was no difference in duration of mechanical ventilation, duration of supplemental oxygen, incidence of chronic lung disease, or length of hospital stay. CONCLUSION: Surfactant administered soon after initiation of extracorporeal membrane oxygenation results in a significant reduction in the duration of extracorporeal support for neonates.

Controlled prospective randomized comparison of high-frequency jet ventilation and conventional ventilation in neonates with respiratory failure and persistent pulmonary hypertension.

OBJECTIVE: The objective of this study was to evaluate the efficacy and safety of high-frequency jet ventilation in near-term and term neonates with persistent pulmonary hypertension. STUDY DESIGN: Subjects for this prospective, randomized, controlled comparison study were recruited from neonates treated in a level-three neonatal intensive care unit that accepts referrals for extracorporeal membrane oxygenation. RESULTS: In patients treated with high-frequency jet ventilation (n = 11) acute improvement in oxygenation (p = 0.008), ventilation (p < 0.001), and oxygen indices (p < or = 0.01) was demonstrated while stable peak and mean airway pressures were maintained. Control group patients receiving high-frequency positive pressure ventilation with a conventional ventilator required increasingly higher peak inspiratory pressures (p = 0.005) to maintain oxygenation, ventilation, and oxygen indices. There were no significant differences in survival without use of extracorporeal membrane oxygenation, nor were there differences in duration of oxygen therapy, ventilation, and hospitalization; need for extracorporeal membrane oxygenation; or incidence of chronic lung disease. CONCLUSIONS: High-frequency jet ventilation acutely improves oxygenation and ventilation without significantly increasing morbidity. Therefore high-frequency jet ventilation may be a useful adjunct for stabilization of the conditions of neonates with severe persistent pulmonary hypertension. Conclusions about the efficacy of high-frequency jet ventilation in improving survival without the need for extracorporeal membrane oxygenation await multicentered, collaborative investigations with large cohorts of patients.

Outcome of extracorporeal membrane oxygenation survivors at age two years: relationship to status at one year.

The objective of this study was to assess the respiratory, neurologic, and developmental status at age 2 years of children treated with extracorporeal membrane oxygenation (ECMO) as neonates. The study population comprised patients treated at a tertiary care neonatal unit and included in a high-risk follow-up program. Eighty-five consecutive patients were treated with ECMO between June 1987 and October 1990, of which 64 (75%) survived. Forty-eight (73%) of the survivors underwent evaluation of growth and respiratory status, neurologic examination, and psychometric testing at ages 1 and 2 years. At age 2 years, 21% of study patients had at least one abnormal growth parameter (weight or length < 5%, head circumference < 2%). Twenty-one percent required respiratory medications and two children had tracheostomies. Six percent had significant abnormalities on neurologic examination. Twenty-five percent scored between 70 and 85 on the mental or psychomotor scales (or both) of the Bayley Scales of Infant Development or the Stanford-Binet, and 12% scored less than 70. Seventy-three percent of children who scored 70 to 85 on one or both subscales of the Bayley Scales of Infant Development or the Stanford-Binet at 2 years had normal scores at 1 year, as did 50% with scores less than 70. Spearman rank analysis suggested a relationship between congenital diaphragmatic hernia, neonatal electroencephalogram, and computed tomography of the head and developmental status at age 2 years (p < 0.05). We conclude that children treated with ECMO are at significant risk for abnormalities in growth and neurodevelopmental and respiratory status at age 2 years, which may not be evident at earlier assessments. This highlights the need for continued follow-up.

Mortality prediction and interval until death in near-term and term neonates with respiratory failure.

Mortality risk indicators may be useful adjuncts to clinical judgment in considering the use of extraordinary and relatively high-risk treatments such as high-frequency ventilation, extracorporeal membrane oxygenation, and nitric oxide therapy. We retrospectively evaluated the reliability of published indications of high mortality, developed additional high-risk indicators, and determined the interval between the time when high-risk indicators were met and when death occurred in near-term and term neonates with respiratory failure. Patients were included in the analysis if they met the following criteria: > or = 35 weeks gestation, > or = 2 kg birth weight, < or = 7 days of age, and receiving a fraction of inspired oxygen of > or = 0.8 and mechanical ventilation. Patients were excluded if they had congenital heart disease, intracranial hemorrhage, untreatable bleeding diathesis, or lethal congenital anomaly. Fifteen patients in the 1980 to 1981 group and 41 patients in the 1985 to 1987 group met these criteria. We observed 100% mortality in our 1980 to 1981 patients who met previously published criteria predictive for > or = 80% mortality in near-term and term neonates with respiratory failure; however, mortality risk was 60% to 80% in the 1985 to 1987 group.(ABSTRACT TRUNCATED AT 250 WORDS)

Patent ductus arteriosus in neonates.

Patency of the ductus arteriosus is one of the more common problems of the neonate. Although the ductus arteriosus usually closes within the first days of life, persistent patency can complicate the clinical status of a newborn. The ductus arteriosus also may play a role in the pathophysiology of persistent pulmonary hypertension of the newborn and in some forms of congenital heart disease. Diagnosis of patent ductus arteriosus can be suspected clinically but should be verified by echocardiography before treatment. Accurate diagnosis, early intervention and proper treatment are necessary to decrease the immediate risks and minimize the potential for long-term complications.

Delayed surgical repair and ECMO improves survival in congenital diaphragmatic hernia.

One hundred ten infants with congenital diaphragmatic hernia (CDH) developed life-threatening respiratory distress in the first 6 hours of life. Associated anomalies were present in 33%. Twenty-eight of 65 infants (43%) treated before 1987 (pre-extracorporeal membrane oxygenation [ECMO] era) survived after immediate CDH repair, and mechanical ventilation with or without pharmacologic support. Only two of 16 (12.5%) infants requiring a prosthetic diaphragmatic patch survived. Since 1987, 31 of 46 (67.4%) infants with birth weight, gestational age, and severity of illness similar to the pre-1987 group survived. All patients were immediately intubated and ventilated. Seven (four with lethal chromosomal anomalies) infants died before treatment, and 30 stabilized (partial pressure of carbon dioxide [PCO2] < 50; partial pressure of oxygen [PO2] > 100; pH > 7.3) and underwent delayed CDH repair at 5 to 72 hours. Fifteen did well on conventional support and survived. Fifteen infants deteriorated after operation: 11 were placed on ECMO with eight survivors, and four infants were not considered ECMO candidates. Nine babies failed to stabilize initially and were placed on ECMO before CDH repair (alveolar-arterial gradient > 600 and oxygenation index > 40), and seven survived. The overall survival rate was 80% at 3 months in this ECMO-treated group. Early mortality was due to inability to wean from ECMO (one), intracranial hemorrhage (one), liver injury (one), and pulmonary hypoplasia (one). Nine of 11 babies requiring a prosthetic patch in the post-1987 ECMO group survived (81.8%). There were three late post-ECMO deaths (3 to 18 months) of right heart failure (two) and sepsis (one). Symptomatic gastroesophageal reflux occurred in nine cases, six requiring a fundoplication in the bypass babies. Recurrent diaphragmatic hernia occurred in nine cases (five ECMO). The overall survival rate was significantly improved in the delayed repair/ECMO group (67% versus 43%; p < 0.05) and was most noticeable in infants requiring a prosthetic diaphragm (81.2% versus 12.5%; p < 0.005). These data indicate that early stabilization, delayed repair, and ECMO improve survival in high-risk CDH. Early deaths are related to pulmonary hypertension and can be reversed by ECMO.

Pulmonary hypoplasia and persistent pulmonary hypertension: favorable clinical response to high-frequency jet ventilation.

Pulmonary hypoplasia in the neonate is frequently fatal. This article reports two neonates with a clinical diagnosis of pulmonary hypoplasia complicated by persistent pulmonary hypertension (PPHN). Though both infants were progressively worsening while receiving conventional mechanical ventilatory support, they survived when treated with high-frequency jet ventilation.

The use of bronchotomy and retrograde dilatation to repair acquired obliterative bronchial obstruction.

A case is presented of acquired obliterative mainstem bronchial obstruction with total ipsilateral lung atelectasis and contralateral lung hyperexpansion. The condition failed to improve after a suitable trial of positive airway pressure and medical management. Penetration of the obstructing lesion bia bronchotomy and a distal retrograde approach successfully opened the airway and the patient has been symptom-free for more than 9 months. This unique approach may be useful in other selected patients with similar acquired lesions.

Update on legal processes for adoption in Indiana.

In this article, we review the process of adoption in Indiana. Comments about the legal process, the right to know issue and the process of adoption from the viewpoint of the potential adoptive parents are discussed.

Rapid analysis of lymphocyte subsets in cord blood.

Several investigators have enumerated cellular populations in neonatal cord blood with variable results. In this study, the authors established reference ranges for lymphocyte subsets in cord blood from healthy newborns using a whole blood lysis technique on the Coulter Immunoprep Epics Leukocyte Preparation System (Coulter Immunology, Hialeah, FL). All analyses were performed on a flow cytometer by gating on forward angle versus 90 degrees light scatter. Lymphocytes demonstrated all surface markers examined, including T4, T8, T3, T11, B1, NKH-1, I3, and 4B4; 2H4 suppressor inducer lymphocytes were prominent in neonatal blood. The authors think this standardized system may be suitable for use in neonatal and pediatric patients because it quickly processes small aliquots of whole blood with minimal sample manipulation.

Congenital candida pneumonia and sepsis: a case report and review of the literature.

A term newborn with Candida albicans infection of the lungs and blood is described. Although no maternal risk factors were identified, this patient's rapid clinical deterioration and postmortem findings suggest congenital infection. Related cases in the literature are reviewed. This case suggests that a diagnosis of fungal pneumonia should be considered in any infant presenting with severe respiratory distress.

Culture medium oxygen tension affects fibronectin production in human adult and cord blood macrophages.

Varying culture medium oxygen tension from one-half to twice the normal concentration did not alter adult or cord blood monocyte-derived macrophage secretion of lysozyme or total protein. Lowering oxygen tension did result in significant increases in fibronectin concentration in both adult and cord blood macrophage culture supernatants. Dexamethasone (10(-7) M) completely blocked adult macrophage but had no effect on cord blood macrophage fibronectin release in response to lowering oxygen tension. These results indicate that human macrophages selectively regulate fibronectin production in response to changes in oxygen tension in vitro.

Vitamin E decreases superoxide anion production by polymorphonuclear leukocytes.

Pharmacologic serum levels of vitamin E administered to low birth weight infants predispose them to infectious complications. We studied in vitro the effect of vitamin E, its vehicle and buffer (Krebs Ringers phosphate glucose) on the ability of human polymorphonuclear leukocytes (PMN) to produce superoxide anion, an oxygen radical important for bacterial killing. We found that superoxide anion production after a 5-min exposure to phorbol myristate acetate was significantly decreased in vitamin E-treated PMN (76 +/- 15 nM/10(7) PMN) compared to vehicle-treated PMN (289 +/- 109 nM/10(7) PMN). We also found that significantly decreased superoxide anion production was associated with 5.0 and 10.0 mg/dl but not with 3.5 mg/dl vitamin E. Our results support the hypothesis that pharmacologic concentrations of vitamin E depress PMN oxidative activity.

Neonatal tracheobronchomegaly.

Tracheobronchomegaly is rarely reported in neonates. We present five cases of tracheobronchomegaly occurring in neonates receiving intensive ventilatory and oxygen support. Barotrauma is speculated to be the primary pathophysiologic factor in these cases.

Neonatal bacterial endocarditis of the pulmonary valve: report of two cases.

Bacterial endocarditis in the neonate is rare and fatal in the majority of reported cases. This article reports two neonates who survived bacterial endocarditis. One patient was infected with group B beta-hemolytic streptococcus (GBBS) while the second grew Streptococcus saluvarius from the blood.