Impact of catheterized ductal closure on renal and cerebral oximetry in premature neonates.

Percutaneous catheter-based closure is increasingly utilized in premature newborns. While near-infrared spectroscopy (NIRS) has been examined for assessment of interventional closure in surgical ligation, its application in percutaneous transcatheter closure remains unexplored. This study aims to assess cerebral and renal hemodynamic changes using NIRS during percutaneous closure compared to surgical closure in preterm infants. A prospective observational study enrolled preterm infants born at 32 weeks of gestation or less and diagnosed with hsPDA between January 2020 and December 2022. These infants received either surgical or catheter-based closure of the PDA. Cerebral and renal oxygen saturation was monitored using the INVOS 5100 device from 12 h before the intervention until 24 h after. Linear mixed-effects models were used to analyze time-dependent variables. Twenty-two patients were enrolled, with catheter-based closure performed in 16 cases and conventional surgery in 6 cases. Following ductal closure, a significant increase in renal and cerebral oximetry was observed alongside a decrease in renal and cerebral tissue oxygen extraction. These changes were particularly pronounced in the renal territory. No differences were detected between catheterization and surgical closure.   Conclusion: An improvement in cerebral and renal oximetry following hsPDA closure was observed. However, we did not identify differences in this pattern based on the type of interventional procedure for PDA, whether surgery or catheterization. What is Known: • The presence of a significant ductus is common in premature patients. Studies have shown that it affects cerebral and renal hemodynamics negatively, leading to decreased oximetry values in these areas. It has been reported that closure of the ductus, either pharmacologically or surgically, results in improved oximetry values. What is New: • This study assess the impact of percutaneous closure of ductus, revealing increased oximetry values in cerebral and renal territories without significant differences compared to surgical ligation. Notably, renal oximetry values showed a greater increase, underscoring the importance of multi-location monitoring.

Parent Perception of Child Safety following Admission to a Neonatal Unit.

OBJECTIVE: Parent partnership is a key aspect of neonatal hospital care. However, there is a lack of information regarding parents' perception of neonatal safety. This study explores parents' opinions on safety during their child's hospitalization to identify points for improvement. STUDY DESIGN: We used a questionnaire, validated by the Spanish National Healthcare Authorities, on perception of safety with respect to hospital health care. RESULTS: Thirty-seven parents of 20 newborns treated in the neonatal intensive care unit (NICU) and 139 parents of newborns in intermediate care (IC) participated in this study. With regard to overall perception of safety, more than 96% of parents felt "very safe" or "fairly safe." In the NICU, an area for improvement detected was to ask parents more often their opinion about the care or treatment provided to their child. In IC, three points for improvement were identified from the group of parents whose child was admitted directly to IC: the consistency of the information received, the request for consent for procedures, and the request for an opinion on their child's care and treatment. Only four parents reported that their child suffered an incident. Regarding incident management, parents were not completely satisfied with the information they received. CONCLUSION: To the best of our knowledge, this is the first study of parent perception of patient safety in a neonatal unit using a validated questionnaire. Our findings suggest that parents can provide valuable information on neonatal safety, which can then be used to identify areas for improvement. KEY POINTS: · There is a lack of information regarding parents' perception of neonatal safety.. · This study explores parent's opinion about safety of their child during the hospitalization.. · Our findings suggest that parents can provide valuable information to identify improvement areas..

Effect of a new respiratory care bundle on bronchopulmonary dysplasia in preterm neonates.

The development of devices that can fix the tidal volume in high-frequency oscillatory ventilation (HFOV) has allowed for a significant improvement in the management of HFOV. At our institution, this had led to the earlier use of HFOV and promoted a change in the treatment strategy involving the use of higher frequencies (above 15 Hz) and lower high-frequency tidal volumes (VThf). The purpose of this observational study was to assess how survival without bronchopulmonary dysplasia grades 2 and 3 (SF-BPD) is influenced by these modifications in the respiratory strategy applied to preterm infants (gestational age < 32 weeks at birth) who required mechanical ventilation (MV) in the first 3 days of life. We compared a baseline period (2012-2013) against a period in which this strategy had been fully implemented (2016-2017). A total of 182 patients were exposed to MV in the first 3 days of life being a higher proportion on HFOV at day 3 in the second period 79.5% (n 35) in 2016-2017 vs 55.4% (n 31) in 2012-2013. After adjusting for perinatal risk factors, the second period is associated with an increased rate of SF-BPD (OR 2.28; CI 95% 1.072-4.878); this effect is more evident in neonates born at a gestational age of less than 29 weeks (OR 4.87; 95% CI 1.9-12.48).Conclusions : The early use of HFOV combined with the use of higher frequencies and very low VT was associated with an increase in the study population's SF-BPD. What is Known: • High-frequency ventilation with volume guarantee improve ventilation stability and has been shown to reduce lung damage in animal models. What is New: • The strategy of an earlier use of high-frequency oscillatory ventilation combined with the use of higher frequencies and lower tidal volume is associated to an increase in survival without bronchopulmonary dysplasia in our population of preterm infants.

Electrical velocimetry for non-invasive monitoring of the closure of the ductus arteriosus in preterm infants.

Closure of a patent ductus arteriosus (PDA) in preterm infants modifies cardiac output and induces adaptive changes in the hemodynamic situation. The present study aims to analyze those changes, through a non-invasive cardiac output monitor based on blood electrical velocimetry, in preterm babies. A prospective observational study of preterm infants with a gestational age of less than 28 weeks, and a hemodynamic significant PDA, requires intravenous ibuprofen or surgical closure. All patients were monitored with electrical velocimetry before treatment and through the following 72 h. Two groups were defined, ibuprofen and surgical closure. Variations of cardiac output were analyzed from the basal situation and at 1, 8, 24, 48, and 72 h on each group. During a 12-month period, 18 patients were studied. The median gestational age in the ibuprofen group (12/18) was 26+5 weeks (25+5-27+3) with a median birth weight of 875 (670-1010) g. The cardiac output index (CI) value was 0.29 l/kg/min (0.24-0.34). Among the patients with confirmed ductus closure (50%), a significant CI decrease was shown (0.24 vs 0.29 l/kg/min; P 0.03) after 72 h (three ibuprofen doses). A statistically significant decrease in systolic volume (SVI) was found: 1.62 vs 1.88 ml/kg, P 0.03 with a decrease in contractility (ICON), 85 vs 140, P 0.02. The gestational age in the surgical group (6/18) was 25+2 weeks (24-26+3) with a median weight of 745 (660-820) g. All patients in this group showed a decrease in the immediate postoperative CI (1 h after surgery) 0.24 vs 0.30 l/kg/min, P 0.05, and a significant decrease in contractility (ICON 77 vs 147, P 0.03). In addition, a no statistically significant decrease in SVI (1.54 vs 1.83 ml/kg, P 0.06), as well as an increase in systemic vascular resistance (10,615 vs 8797 dyn/cm2, P 0.08), were detected. This deterioration was transient without significant differences in the remaining periods of time evaluated. CONCLUSION: The surgical closure of the PDA in preterm infants causes a transient deterioration of cardiac function linked to a documented decrease in the left ventricular output. The hemodynamic changes detected after pharmacological PDA closure are similar but those patients present a better clinical tolerance to changes in the cardiac output. What is Known: • Surgical ductus closure generates acute hemodynamic changes in cardiac output and left ventricular function. What is New: • The hemodynamic changes detected after pharmacological ductus closure are similar to those found in the surgical closure. Electrical velocimetry can detect those changes.

Prognostic relevance of early AKI according to pRIFLE criteria in children undergoing cardiac surgery.

BACKGROUND: Acute renal injury increases risk of death after cardiac surgery. The objective of the study was to evaluate the ability of the pediatric Risk, Injury, Failure, Loss, End-Stage Renal Disease (pRIFLE) criteria to characterize the development of postoperative renal damage in children after cardiopulmonary bypass (CPB) and to evaluate the relationship between the severity of kidney injury and mortality, pediatric intensive care unit (PICU) length of stay, and the duration of mechanical ventilation (MV). METHODS: In this retrospective study including children undergoing CPB surgery during a 3-year period in the PICU of a tertiary hospital, demographic, clinical, surgery-related, and postoperative clinical data were collected. Kidney damage was assessed with pRIFLE criteria. RESULTS: Four hundred and nine patients were included. Early acute kidney injury (AKI) was found in 82 patients (achieving categories Risk 44; Injury 16; Failure 22). Early AKI was associated with younger age (P = 0.010), longer CPB, deep hypothermic circulatory arrest (DHCA) use, ICU stay >12 days, MV >4 days, and death (P < 0.001). Controlling the effect of age, CPB, DHCA use, previous cardiac surgeries, and Risk Adjustment in Congenital Heart Surgery Surgical Severity Score (RACHS-1), early AKI development proved to predict ICU stay >12 days [odds ratio (OR) 3.5; 95% confidence interval (CI) 1.9-6.5, P < 0.001)] and need of MV >4 days (OR 5.1; 95% CI 2.6-10.2, P < 0.001). CONCLUSIONS: Early AKI when evaluated with the pRIFLE criteria can predict prolonged ICU stay, need of prolonged MV, and mortality.

Lung recruitment in neonatal high-frequency oscillatory ventilation with volume-guarantee.

BACKGROUND AND OBJECTIVES: The optimal lung volume strategy during high-frequency oscillatory ventilation (HFOV) is reached by performing recruitment maneuvers, usually guided by the response in oxygenation. In animal models, secondary spontaneous change in oscillation pressure amplitude (ΔPhf) associated with a progressive increase in mean airway pressure during HFOV combined with volume guarantee (HFOV-VG) identifies optimal lung recruitment. The aim of this study was to describe recruitment maneuvers in HFOV-VG and analyze whether changes in ΔPhf might be an early predictor for lung recruitment in newborn infants with severe respiratory failure. DESIGN AND METHODS: The prospective observational study was done in a tertiary-level neonatology department. Changes in ΔPhf were analyzed during standardized lung recruitment after initiating early rescue HFOV-VG in preterm infants with severe respiratory failure. RESULTS: Twenty-seven patients were included, with a median gestational age of 24 weeks (interquartile range [IQR]: 23-25). Recruitment maneuvers were performed, median baseline mean airway pressure (mPaw) was 11 cm H2 O (IQR: 10-13), median critical lung opening mPaw during recruitment was 14 cm H2 O (IRQ: 12-16), and median optimal mPaw was 12 cm H2 O (IQR: 10-14, p < 0.01). Recruitment maneuvers were associated with an improvement in oxygenation (FiO2 : 65.0 vs. 45.0, p < 0.01, SpO2/FiO2 ratio: 117 vs. 217, p < 0.01). ΔPhf decreased significantly after lung recruitment (mean amplitude: 23.0 vs. 16.0, p < 0.01). CONCLUSION: In preterm infants with severe respiratory failure, the lung recruitment process can be effectively guided by ΔPhf on HFOV-VG.

Target volume-guarantee in high-frequency oscillatory ventilation for preterm respiratory distress syndrome: Low volumes and high frequencies lead to adequate ventilation.

BACKGROUND AND OBJECTIVES: Respiratory distress syndrome (RDS) and ventilation-induced lung injury lead to significant morbidity in preterm infants. High-frequency oscillatory ventilation with volume-guarantee (HFOV-VG) has been used as a rescue therapy and might lead to lower rates of death and bronchopulmonary dysplasia, especially when using low tidal volumes and high frequencies. The aim of the study was to define HFOV-VG parameters leading to adequate ventilation in the first 72 h of preterm RDS using a low volume and high-frequency strategy. DESIGN AND METHODS: Retrospective cohort study in a tertiary-level neonatology unit. Infants <32 weeks with severe respiratory insufficiency needing HFOV-VG were included. Patients were ventilated following a standard mechanical ventilation aiming for low tidal volumes and high frequencies. Clinical data, perinatal characteristics and high-frequency parameters corresponding with adequate ventilation were recorded. RESULTS: 116 patients were included. Median gestational age was 25 weeks (interquartile range [IQR] = 24-27), median birth weight 724 g (IQR = 600-900 g). HFOV-VG was started at 2 h, median high-frequency tidal volume was 1.63 ml/kg (IQR = 1.44-1.84) and median frequency was 16 Hz (IQR = 15-18). Weight-adjusted tidal volumes did not depend on gestational age, antenatal corticosteroids nor chorioamnionitis, and were inversely correlated with frequencies (R 2 = -0.10, p = .001). CONCLUSION: HFOV-VG can reach adequate ventilation at high frequencies when using adequate volumes, providing a feasible ventilation strategy that might be of help in preterm infants with RDS.

New indicators for optimal lung recruitment during high frequency oscillator ventilation.

Previous research has demonstrated the potential benefit derived from the combination of high frequency oscillatory ventilation and volume guarantee mode (HFOV-VG), a procedure that allows us to explore and control very low tidal volumes. We hypothesized that secondary spontaneous change in oscillation pressure amplitude (∆Phf), while increasing the mean airway pressure (MAP) using HFOV-VG can target the lung recruitment. METHODS: A two-step animal distress model study was designed; in the first-step (ex vivo model), the animal's lungs were isolated to visually check lung recruitment and, in the second one (in vivo model), they were checked through arterial oxygen partial pressure improvement. Baseline measurements were performed, ventilation was set for 10 min and followed by bronchoalveolar lavage with isotonic saline to induce depletion of surfactant and thereby achieve a low compliance lung model. The high-frequency tidal volume and frequency remained constant and the MAP was increased by 2 cmH2 O (ex vivo) and 3 cmH2 O steps (in vivo) every 2 min. Changes in ΔPhf to achieve the fixed volume were recorded at the end of each interval to describe the maximum drop point as the recruitment point. RESULTS: Fourteen Wistar Han rats were included, seven on each sub-study described. After gradual MAP increments, a progressive decrease in ΔPhf related to recruited lung regions was visually demonstrated. In the in vivo model we detected a significant comparative decrease of ΔPhf, when measured against the previous value, after reaching a MAP of 11 cmH2 O up to 17 cmH2 O, correlating with a significant improvement in oxygenation. CONCLUSION: The changes in ∆Phf, linked to a progressive increase in MAP during HFOV-VG, might identify optimal lung recruitment and could potentially be used as an additional lung recruitment marker.

[Improving patient safety: Usefulness of safety checklists in a neonatal unit]. / Mejorando la seguridad del paciente: utilidad de las listas de verificación de seguridad en una unidad neonatal.

INTRODUCTION: Due to the complexity and characteristics of their patients, neonatal units are risk areas for the development of adverse events (AE). For this reason, there is a need to introduce and implement some tools and strategies that will help to improve the safety of the neonatal patient. Safety check-lists have shown to be a useful tool in other health areas but they are not sufficiently developed in Neonatal Units. MATERIAL AND METHODS: A quasi-experimental prospective study was conducted on the design and implementation of the use of a checklist and evaluation of its usefulness for detecting incidents. The satisfaction of the health professionals on using the checklist tool was also assessed. RESULTS: The compliance rate in the neonatal intensive care unit (NICU) was 56.5%, with 4.03 incidents per patient being detected. One incident was detected for every 5.3 checklists used. The most frequent detected incidents were those related to medication, followed by inadequate alarm thresholds, adjustments of the monitors, and medication pumps. The large majority (75%) of the NICU health professionals considered the checklist useful or very useful, and 68.75% considered that its use had managed to avoid an AE. The overall satisfaction was 83.33% for the professionals with less than 5 years working experience, and 44.4% of the professionals with more than 5 years of experience were pleased or very pleased. CONCLUSION: The checklists have shown to be a useful tool for the detection of incidents, especially in NICU, with a positive assessment from the health professionals of the unit.

[Stridor in neonates with hypoxic-ischaemic encephalopathy subject to selective cerebral or whole body hypothermia]. / Estridor en neonatos con encefalopatía hipóxico-isquémica sometidos a tratamiento con hipotermia cerebral selectiva o corporal total.

INTRODUCTION: Hypothermia treatment has improved the prognosis of asphyxiated neonates. Widely used, it has demonstrated to be safe without severe side effects. The aim of this article is to review the incidence of stridor amongst asphyxiated newborns treated with hypothermia in our unit. METHODS: Retrospective chart review of our patients. RESULTS: Stridor was presented in 7/75 (9.3%) of patients during hypothermia. Three received whole body hypothermia, 3 selective cerebral, and in one case both techniques were used. All cases required increased respiratory support. CONCLUSIONS: Different mechanisms may be responsible for the appearance of stridor in patients with hypoxic-ischaemic encephalopathy (HIE). In our series the incidence of stridor was similar for the two hypothermia devices. To better understand these possible side effects of hypothermia, further prospective studies (which should include laryngoscopy) are needed.