[Neonatal extracorporeal membrane oxygenation: 9 years of experience]. / Oxigenación por membrana extracorpórea neonatal: 9 años de experiencia.

INTRODUCTION: Extracorporeal membrane oxygenation (ECMO) is a rescue therapy for reversible respiratory or cardiac diseases. Neonatal pathologies requiring this technique are different from the ones found later in life. OBJECTIVES: To review the main causes requiring ECMO in the neonatal period, to compare the clinical course depending on the initial illness and to identify the sequelae attributable to this technique. MATERIAL AND METHOD: A retrospective review of clinical records of all neonatal patients that received ECMO support in our centre. RESULTS: 45 neonatal ECMO were performed in our unit between January 2001 and June 2009. Forty techniques were due to respiratory failure, 2 secondary to haemodynamic shock and 3 secondary to sepsis. Veno-venous cannulation was used initially in 24 patients (53.3%). The length of technique varied depending on the underlying disease. Patients with congenital diaphragmatic hernia were in ECMO for longer periods. The overall survival to the technique was 86.3% (38/44 patients), also with differences among diseases. Extracorporeal support was withdrawn in 4 children because of a diagnosis of an irreversible pathology and one because of massive brain haemorrhage. No serious adverse outcomes attributable to the technique were found among survivors. CONCLUSIONS: Survival among newborns supported with ECMO in our hospital is similar to that recorded by the ELSO in 2004, although we use veno-venous cannulation in more than a half of the patients. The percentage of moderate to severely impaired neurodevelopmental outcome among survivors after this technique was low.

Summary of recommendations and key points of the consensus of Spanish scientific societies (SEPAR, SEMICYUC, SEMES; SECIP, SENEO, SEDAR, SENP) on the use of non-invasive ventilation and high-flow oxygen therapy with nasal cannulas in adult, pediatric, and neonatal patients with severe acute respiratory failure. / Sumario de las recomendaciones y puntos clave del Consenso de las Sociedades Científicas Españolas (SEPAR, SEMICYUC, SEMES; SECIP, SENeo, SEDAR, SENP) para la utilización de la ventilación no invasiva y terapia de alto flujo con cánulas nasales en el paciente adulto, pediátrico y neonatal con insuficiencia respiratoria aguda grave.

Non-invasive respiratory support (NIRS) in adult, pediatric, and neonatal patients with acute respiratory failure (ARF) comprises two treatment modalities, non-invasive mechanical ventilation (NIMV) and high-flow nasal cannula (HFNC) therapy. However, experts from different specialties disagree on the benefit of these techniques in different clinical settings. The objective of this consensus was to develop a series of good clinical practice recommendations for the application of non-invasive support in patients with ARF, endorsed by all scientific societies involved in the management of adult and pediatric/neonatal patients with ARF. To this end, the different societies involved were contacted, and they in turn appointed a group of 26 professionals with sufficient experience in the use of these techniques. Three face-to-face meetings were held to agree on recommendations (up to a total of 71) based on a literature review and the latest evidence associated with 3 categories: indications, monitoring and follow-up of NIRS. Finally, the experts from each scientific society involved voted telematically on each of the recommendations. To classify the degree of agreement, an analogue classification system was chosen that was easy and intuitive to use and that clearly stated whether the each NIRS intervention should be applied, could be applied, or should not be applied.

Summary of recommendations and key points of the consensus of Spanish scientific societies (SEPAR, SEMICYUC, SEMES; SECIP, SENEO, SEDAR, SENP) on the use of non-invasive ventilation and high-flow oxygen therapy with nasal cannulas in adult, pediatric, and neonatal patients with severe acute respiratory failure.

Non-invasive respiratory support (NIRS) in adult, pediatric, and neonatal patients with acute respiratory failure (ARF) comprises two treatment modalities, non-invasive mechanical ventilation (NIMV) and high-flow nasal cannula (HFNC) therapy. However, experts from different specialties disagree on the benefit of these techniques in different clinical settings. The objective of this consensus was to develop a series of good clinical practice recommendations for the application of non-invasive support in patients with ARF, endorsed by all scientific societies involved in the management of adult and pediatric/neonatal patients with ARF. To this end, the different societies involved were contacted, and they in turn appointed a group of 26 professionals with sufficient experience in the use of these techniques. Three face-to-face meetings were held to agree on recommendations (up to a total of 71) based on a literature review and the latest evidence associated with 3 categories: indications, monitoring and follow-up of NIRS. Finally, the experts from each scientific society involved voted telematically on each of the recommendations. To classify the degree of agreement, an analogue classification system was chosen that was easy and intuitive to use and that clearly stated whether the each NIRS intervention should be applied, could be applied, or should not be applied.

[Respiratory care in neonatal intensive care units. Situation in the year 2005]. / Asistencia respiratoria en las unidades de cuidados intensivos neonatales en España: situación en 2005.

AIM: To learn the characteristic of the neonatal intensive care units (NICUs) that offer neonatal respiratory assistance in Spain. MATERIAL AND METHOD: A structured survey was developed and sent to all Spanish neonatal units to learn about the respiratory care offered in 2005. RESULTS: A total of 96 Units answered the survey, with an estimated representatively of 63%, with a range from 3 to 92%, depending on the geographical area. Level IIIc Units were in the upper range. Answer the survey 26 units type IIb (27%), 16 IIIa (17%), 40 IIIb (42%) and 14 IIIc (14%). The total number of level III NICU beds was 541 (1.2 beds per 1000 livebirths; range, 0.7-1.7). The mean number of beds per NICU was 4.1 in level IIIa Units, 2.8 in those IIIb and 14.6 in type IIIc NICUs. In level III NICUs, the bed per physician ratio was 2.4 and that of beds per registered nurse was 2.8 (2.2 in level IIIc NICUs). There were a total 13,219 admissions, 54% of those needed mechanical ventilation (36% in IIIa and 65% in level IIIc NICUs). Oxygen blenders for resuscitation at birth were available in 42% of level IIIb and IIIc NICUs. NICUs had one neonatal ventilator per bed, and 63% of units had high frequency ventilation available. All units had nasal-CPAP systems, 25% of level IIIa Units, 58% IIIb and 64% of those type IIIc had systems for nasal ventilation. All level IIIc and 93% of level IIIb NICUs were able to provide inhaled nitric oxygen therapy. Four NICUS offered ECMO. CONCLUSIONS: The mean number of NICU beds per 1000 livebirths is within the lower limits of those been recommended, and there were wide variations among different geographical areas. A 54% of those babies admitted to NICUs required mechanical ventilation. The mean number of NICU beds per registered nurse was 2.8. There was an adequate number of neonatal ventilators (one per bed) and 63% were able to provide HFV. All NICUs hand n-CPAP systems.

[Lung ultrasound as a tool to guide the administration of surfactant in premature neonates]. / La ecografía pulmonar como herramienta para guiar la surfactación en neonatos prematuros.

OBJECTIVES: The aim of this study is to assess the usefulness of lung ultrasound (LUS) to estimate the endotracheal tube (ETT) depth position during the Intubation-Surfactant-Extubation (INSURE) procedure. MATERIAL AND METHODS: The ETT insertion depth was estimated using the weight (insertion depth (cm)=weight (kg)+5.5). After intubation two independent neonatologists using bilateral auscultation or LUS checked the ETT depth. RESULTS: Twelve newborns with respiratory distress syndrome were included. In two cases LUS helped to correctly replace the ETT. All the patients progressed well, with normal x-ray and LUS before discharge. CONCLUSIONS: LUS appears to be a safe and non-invasive technique and is useful in clinical situations were x-ray is not routinely performed, as it is fast and radiation free.

[Recommendations for respiratory support in the newborn (iii). Surfactant and nitric oxide]. / Recomendaciones para la asistencia respiratoria en el recién nacido (iii). Surfactante y óxido nítrico.

The recommendations included in this document will be part a series of updated reviews of the literature on respiratory support in the newborn infant. These recommendations are structured into twelve modules, and in this work module 7 is presented. Each module is the result of a consensus process including all members of the Surfactant and Respiratory Group of the Spanish Society of Neonatology. They represent a summary of the published papers on each specific topic, and of the clinical experience of each one of the members of the group.

[Recommendations for neonatal transport]. / Recomendaciones sobre transporte neonatal.

During pregnancy, it is not always possible to identify maternal or foetal risk factors. Infants requiring specialised medical care are not always born in centres providing intensive care and will need to be transferred to a referral centre where intensive care can be provided. Therefore Neonatal Transport needs to be considered as part of the organisation of perinatal health care. The aim of Neonatal Transport is to transfer a newborn infant requiring intensive care to a centre where specialised resources and experience can be provided for the appropriate assessment and continuing treatment of a sick newborn infant. Intrauterine transfer is the ideal mode of transport when the birth of an infant with risk factors is diagnosed. Unfortunately, not all problems can be detected in advance with enough time to safely transfer a pregnant woman. Around 30- 50% of risk factors will be diagnosed during labour or soon after birth. Therefore, it is important to have the knowledge and resources to resuscitate and stabilise a newborn infant, as well as a specialised neonatal transport system. With this specialised transport it is possible to transfer newly born infants with the same level of care that they would receive if they had been born in a referral hospital, without increasing their risks or affecting the wellbeing of the newborn. The Standards Committee of the Spanish Society of Neonatology reviewed and updated recommendations for intrauterine transport and indications for neonatal transfer. They also reviewed organisational and logistic factors involved with performing neonatal transport. The Committee review included the type of personnel who should be involved; communication between referral and receiving hospitals; documentation; mode of transport; equipment to stabilise newly born infants; management during transfer, and admission at the referral hospital.

[Health care levels and minimum recommendations for neonatal care]. / Niveles asistenciales y recomendaciones de mínimos para la atención neonatal.

A policy statement on the levels of care and minimum recommendations for neonatal healthcare was first proposed by the Standards Committee and the Board of the Spanish Society of Neonatology in 2004. This allowed us to define the level of care of each center in our country, as well as the health and technical requirements by levels of care to be defined. This review takes into account changes in neonatal care in the last few years and to optimize the location of resources. Facilities that provide care for newborn infants should be organized within a regionalized system of perinatal care. The functional capabilities of each level of care should be defined clearly and uniformly, including requirements for equipment, facilities, personnel, ancillary services, training, and the organization of services (including transport) needed to cover each level of care.

[Bronchopulmonary dysplasia: definitions and classifications]. / Displasia broncopulmonar: definiciones y clasificación.

Bronchopulmonary dysplasia is the most common sequelae related to very low birth weight infants, mostly with those of extremely low birth weight. Even with advances in prevention and treatment of respiratory distress syndrome associated with prematurity, there is still no decrease in the incidence in this population, although a change in its clinical expression and severity has been observed. There are, however, differences in its frequency between health centres, probably due to a non-homogeneously used clinical definition. In this article, the Committee of Standards of the Spanish Society of Neonatology wishes to review the current diagnosis criteria of bronchopulmonary dysplasia to reduce, as much as possible, these inter-centre differences.

[Extracorporeal membrane oxygenation: indications and recommendations on when to refer patients to a specialized unit]. / Oxigenación por membrana extracorpórea (ECMO). Indicaciones y guías para el contacto con una unidad de ECMO.

Extracorporeal membrane oxygenation (ECMO) is a highly complex technique of extracorporeal support that has been available in Spain since 1997 and is now provided by three centres. This article aims to detail the guidelines and indications for neonatal and pediatric ECMO in severe cardiorespiratory failure and to provide information on when to contact the referral centres when treating patients who may need this treatment.

[Attitude towards parents after the death of their newborn infant in a neonatal unit]. / Atención a los padres de recién nacidos fallecidos en neustra unidad neonatal.

We have analyzed the neonatology team's actions, as well as the parent's reactions, after the death of a newborn baby in the Intensive Care Unit. A questionnaire was drawn-up and sent to 180 parents of decreased newborn babies in order to get to know their opinions about certain aspects related to their experience in the hospital. Only 49 out of the 180 (27.2%) questionnaires were sent back. From their answers, we would like to stress their positive opinion regarding both the medical care (95%) and the information that they received (93%). The suggestion that the hospital should have a trained team of trained professionals available to provide psychological support in such situations was made in 95.9% of the questionnaires. This analysis has justified changes in our team's procedure when confronted with newborn deaths.

[Congenital diaphragmatic hernia: evaluation of two ways of management]. / Hernia diafragmática congénita: análisis de dos formas de tratamiento.

OBJECTIVE: The aim of this study was to analyze the treatment and evolution of congenital diaphragmatic hernia in the last 16 years, distinguishing two ways of management, and to look for parameters that can predict the evolution. MATERIALS AND METHODS: Between 1978 and 1994, 29 cases of congenital diaphragmatic hernia were treated in our NICU. During the first period (1978-1988) 17 cases (group 1) were treated after birth as a surgical emergency. In the second period (1989-1994), preoperative stabilization was performed before surgery (12 cases, group 2). Two cases of group 2 were excluded because of the association of other malformations that were the cause of death. RESULTS: Both groups were similar in gestational age, birth weight and Apgar score at 5 minutes. Overall mortality was 48.1% (47.0% in group 1 and 50.0% in group 2). No infants with PaCO2 greater than 40 mmHg and OI greater than 40 or VEI over 1,000 survived. CONCLUSION: Despite preoperative stabilization, there is no difference in the mortality rate of the two groups. With congenital diaphragmatic hernia, as with other entities of low incidence, collaborative studies are needed to obtain enough cases to analyze the results more precisely.

[Neonatal endocarditis due to staphylococcus aureus as a complication of neonatal sepsis]. / Endocarditis neonatal por Staphylococcus aureus como complicación de sepsis neonatal.

We present the case of a newborn with bacterial endocarditis with mitral valve involvement as a complication of late-onset sepsis due to Staphylococcus aureus with associated pyelonephritis and meningitis. The diagnosis was confirmed by echocardiogram and blood culture with growth of S. aureus. Treatment was medical and surgical. Neonatal bacterial endocarditis is extremely difficult to diagnose. The signs and symptoms are usually nonspecific and cannot be distinguished from those of sepsis or congenital heart disease. Consequently, a high degree of suspicion is needed for the early diagnosis of this condition. Echocardiography should be performed in children who present sepsis and heart murmur and even in those with staphylococcemia (sepsis due to S. aureus) without associated heart murmur. This investigation enables an early diagnosis of endocarditis to be made and appropriate treatment to be given without having to wait for the development of signs and symptoms that frequently go undetected.

[Cutaneous colonization by Malassezia spp. in neonates]. / Colonización cutánea neonatal por Malassezia spp.

BACKGROUND: Malassezia spp. is a lipophilic yeast considered to be a normal component of the human skin flora. It has been associated with sepsis in patients receiving intravenous infusion of lipid emulsions through central venous catheters (CVC). Current evidence indicates a high rate of skin colonization in healthy adults, in contrast with the low rate of colonization in prepubertal children. Of note is the high prevalence of colonized infants in the neonatal intensive care unit (NICU). METHODS: We performed a prospective open observational study of colonization in all infants admitted to the NICU during a nine-month period (October 1997-June 1998). Length of stay in the unit, birthweight and the use of CVC for parenteral fat infusion were evaluated. RESULTS: Seventy-seven neonates were included in the study. The mean length of stay in the NICU was 24 days. A total of 63.6 % weighed less than 2,500 g at birth and 72 % were given parenteral nutrition supplemented with fat emulsion through a CVC. The overall rate of colonization in the unit was 41.5 and 75 % of the patients became colonized within the first two weeks of admission. CONCLUSIONS: These data emphasize the need for preventive measures to reduce the transmission of these yeasts in the NICU and to prevent the occurrence of neonatal sepsis due to Malassezia spp. in immunologically immature infants.