How doctors communicated with parents in a neonatal intensive care: Communication and ethical issues.

AIM: Doctors have a moral and legal obligation to keep patients and their families informed, and this is an integral part of care. We explored the communication strategies used by doctors when they spoke to parents in a French neonatal intensive care unit (NICU). METHODS: This was a single-centre qualitative pilot study carried out from October 2015 to January 2016. We asked five doctors (three female) to audiotape their discussions with the parents of newborn infants during their NICU stay. The doctors' mean age was 43 years, and they had a mean of 14 years of NICU experience. Each discussion was subjected to thematic content analysis. RESULTS: We analysed 40 discussions carried out between doctors on 26 newborn infants. Five communication strategy themes emerged: building understanding, how the communication was constructed, the role of the doctor, and of the parents, in the overall care of the newborn infant and how the information given to the parents developed over time. CONCLUSION: Analysing the content of the information discussed with parents provided us with the opportunity to understand the communication and ethical issues surrounding the delivery of information in a NICU. This could be used to improve future discussions between doctors and parents.

Generalized arterial calcification of infancy with a novel ENPP1 mutation: a case report.

BACKGROUND: Generalized Arterial Calcification of Infancy (GACI) is a heritable ectopic mineralization disorder resulting in diffuse arterial calcifications and/or stenosis, mostly caused by mutations in the ENPP1 gene. Here we present a case report of GACI in a male infant with a new familial mutation of the ENPP1 gene and the clinical outcome after biphosphonates therapy. CASE PRESENTATION: The clinical presentation was characterized by a severe early-onset of hypertension refractory to multiple therapy. To investigate this atypical hypertension, a renal Doppler ultra-sonography was performed and diffuse echo-bright arteries were detected; then a low-dose whole-body computed tomography demonstrated extensive arterial calcifications, suggesting GACI. A novel homozygous mutation c.784A > G (p.Ser262Gly) was detected in the ENPP1 gene. The infant was administered four courses of bisphosphonates: arterial calcifications were found to decrease but severe refractory hypertension was persistent. Although GACI can be a rapidly fatal illness and frequently results in death in infancy, the patient was 24 months of age at the time of writing this report. CONCLUSIONS: Three points of interest: the first one is to remind clinicians of this rare and atypical etiology in neonates with severe hypertension and in fetuses with cardiomyopathy and non-immune hydrops fetalis. The second point is the identification of a novel mutation in the ENPP1 gene associated with a clinical presentation of GACI. The third point is the fairly favourable outcome of our patient after bisphosphonates therapy, with calcifications regression but not hypertension.

Comparison of a high-flow humidified nasal cannula to nasal continuous positive airway pressure in children with acute bronchiolitis: experience in a pediatric intensive care unit.

UNLABELLED: The objective of the current study is to compare the use of a nasal continuous positive airway pressure (nCPAP) to a high-flow humidified nasal cannula (HFNC) in infants with acute bronchiolitis, who were admitted to a pediatric intensive care unit (PICU) during two consecutive seasons. We retrospectively reviewed the medical records of all infants admitted to a PICU at a tertiary care French hospital during the bronchiolitis seasons of 2010/11 and 2011/12. Infants admitted to the PICU, who required noninvasive respiratory support, were included. The first noninvasive respiratory support modality was nCPAP during the 2010/11 season, while HFNC was used during the 2011/2012 season. We compared the length of stay (LOS) in the PICU; the daily measure of PCO2 and pH; and the mean of the five higher values of heart rate (HR), respiratory rate (RR), FiO2, and SpO2 each day, during the first 5 days. Thirty-four children met the inclusion criteria: 19 during the first period (nCPAP group) and 15 during the second period (HFNC group). Parameters such as LOS in PICU and oxygenation were similar in the two groups. Oxygen weaning occurred during the same time for the two groups. There were no differences between the two groups for RR, HR, FiO2, and CO2 evolution. HFNC therapy failed in three patients, two of whom required invasive mechanical ventilation, versus one in the nCPAP group. CONCLUSION: We did not find a difference between HFNC and nCPAP in the management of severe bronchiolitis in our PICU. Larger prospective studies are required to confirm these findings.

Long Term Neurodevelopmental Outcomes after Sevoflurane Neonatal Exposure of Extremely Preterm Children: A Cross-Sectional Observationnal Study.

Sevoflurane, a volatile anesthetic, is used when extremely preterm neonates (EPT) undergo painful procedures. Currently, no existing studies analyze sevoflurane's long-term effects during the EPT's immediate neonatal period. Our primary objective was to compare the EPT's neurocognitive development regardless of any sevoflurane exposure prior to 45 weeks corrected gestational age (GA). We analyzed those live discharges, less than 28 weeks GA, who were either exposed, unexposed, and/or multiply exposed to sevoflurane before 45 weeks GA. All data were obtained from a cross-sectional multicenter study (GPQoL study, NCT01675726). Children, both exposed and non-exposed to sevoflurane, were sampled using a propensity-guided approach. Neurological examinations (Touwen), cognitive and executive functions (WISC IV, NEPSY, Rey figure), and assessments when the children were between 7 and 10 years old, were correlated to their neonatal sevoflurane exposure. There were 139 children in the study. The mean gestational age was 26.2 weeks (±0.8) GA and the mean birth weight was 898 g (±173). The mean age of their evaluation was 8.47 years old (±0.70). Exposure to sevoflurane to the mean corrected age 27.10 (3.37) weeks GA had a significant correlation with cerebral palsy (adjusted odds ratio (aOR): 6.70 (CI 95%: 1.84-32.11)) and other major disorders (cerebral palsy and/or severe cognitive retardation) (aOR: 2.81 [95% CI: 1.13-7.35]). Our results demonstrate the possibility of long-term effects on EPT infants who had a sevoflurane exposure before 45 weeks corrected GA. However, these results will require further confirmation by randomized controlled trials.

Sevoflurane for central catheter placement in neonatal intensive care: a randomized trial.

OBJECTIVE: To compare the efficacy and safety of sevoflurane deep sedation with glucose and nonnutritive sucking (GNNS) in reducing the duration of the procedure and in preventing pain-related effects during peripherally inserted central catheter (PICC) placement. BACKGROUND: PICC placement in neonatal intensive care is a delicate and stressful procedure that requires pain prevention. GNNS has been recommended in this situation but remain often inefficient. METHODS: We designed a randomized controlled study in a sixteen-bed pediatric and neonatal unit in a tertiary hospital. Fifty-nine neonates at >28 weeks of gestation with continuous positive airway pressure or invasive mechanical ventilation and requiring PICC placement were included. Patients were randomized to receive inhaled sevoflurane (IS) or glucose and non-nutritive sucking (GNNS). Procedural duration and conditions, hemodynamic and respiratory parameters, occurrence of movements and complications were compared (http://clinicaltrials.gov trial register no. NCT00420693). RESULTS: The two groups had similar demographics. There were no between-group differences in procedural duration (P = 0.84) despite greater immobility in IS group (P = 0.017). IS was also associated with fewer episodes of hypertension (P = 0.003), tachycardia (P < 0.001), and bradycardia (P = 0.02). Occurrences of hypotension were not different between the groups (P = 0.06). The GNNS group showed more desaturation during the 4 h after the procedure (P = 0.03). Complications during intensive care stay did not differ between groups. CONCLUSION: Inhaled sevoflurane does not make easier catheters placement but prevent pain-related symptoms. Because sevoflurane is responsible for hypotension, it requires careful monitoring and treatment adaptation.

Airway humidification with a heat and moisture exchanger in mechanically ventilated neonates : a preliminary evaluation.

OBJECTIVE: We set out to evaluate the efficacy of passive inspiratory gas conditioning in mechanically ventilated neonates and compared it with that of a heated humidifier (HH). DESIGN: Prospective, randomized, controlled study. SETTING: Neonatal and pediatric intensive care unit. PATIENTS: Fourteen mechanically ventilated neonates nursed in incubators. INTERVENTIONS: The HH was set to deliver a temperature of 37 degrees C and an absolute humidity of 40 mgH(2)O/l at the incubator entrance. Inspired temperature (T degrees ) and absolute humidity (AH) were measured by the psychometric method, transpulmonary pressure (Tpres) by means of a differential pressure transducer. Measurements were performed at 5, 10, and 15 min. MEASUREMENTS AND RESULTS: The values of T degrees were significantly higher using the HH (34.6+/-1.6 degrees C) than the heat and moisture exchanger (HME) (33.8+/2.3, p<0.001). The values of AH were significantly higher using the HH (36.6+/-2.5 mgH(2)O/l) than the HME (32.4+/-2.8 mgH(2)O/l, p<0.001). No significant changes were observed in transpulmonary pressure. A significant positive correlation was observed between incubator temperature and the temperature delivered by the HH (R(2)=0.61, p<0.001). CONCLUSIONS: The use of HMEs in neonates made it possible to achieve an absolute humidity of 28 mgH(2)O/l or more and a temperature of 30 degrees C or more. Higher values are obtained using a HH.

Tunneled central venous catheter for neonates: A simple technique for prolonged indwelling central catheters in intensive care.

OBJECTIVE: To describe and evaluate a new technique to insert a 24-gauge Silastic catheter in a central vein with a subcutaneous tunneled catheter in newborns after peripherally inserted central catheter (PICC) insertion failure. DESIGN: Retrospective chart review. SETTING: Pediatric and neonatal intensive care unit. PATIENTS: Twenty-nine newborns in whom a new technique was used to insert a prolonged indwelling jugular, femoral, or subclavian Silastic tunneled central catheter. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: This new technique was used in 29 newborns between January 1, 2004, and December 31, 2005. The mean gestational age was 34 +/- 5 wks with a mean weight of 2440 +/- 1101 g. Thirty-four insertion attempts were carried out. Access sites were internal jugular (28 of 34), femoral (three of 34) or subclavian (three of 34) vein. In five cases, catheter insertion failed. Pneumothorax occurred two times, and no other serious complication were observed. CONCLUSIONS: This technique is an interesting alternative when PICC insertion is not possible.

Colony morphology switching of Candida lusitaniae and acquisition of multidrug resistance during treatment of a renal infection in a newborn: case report and review of the literature.

Candida lusitaniae is an emerging opportunistic pathogen which exhibits an unusual antifungal susceptibility pattern. We describe a case of fatal renal infection due to C. lusitaniae in a very low birth weight neonate who was treated with short courses of fluconazole given alternately with amphotericin B. A colony morphology switching was detected on the standard primary culture medium by changes in colony size. Switching was shown to affect deeply the susceptibility to amphotericin B. Afterwards, the switched phenotype developed a cross resistance to fluconazole and itraconazole. Several issues raised by this case are discussed in the light of an extensive review of the literature. Our observations point out the importance of both the detection of colony morphology switching and the close monitoring of antifungal susceptibility in the management of infections due to C. lusitaniae. A judicious therapeutic strategy should prevent the acquisition of multidrug resistance during antifungal therapy.

Comparison of ultrasound and X-ray in determining the position of umbilical venous catheters.

OBJECTIVE: Thoraco-abdominal X-ray (TAX) is the most frequent used method to determine the route and tip position (TP) of umbilical venous catheters (UVCs). The aim of this study was to compare ability of TAX and ultrasonography (US) to determine UVC route and TP. PATIENTS AND METHODS: All neonates requiring UVC or admitted to our Paediatric and Neonatal Intensive Care with UVC were included in this prospective study. Catheter position was controlled by TAX and interpreted by the physician in charge of the patient. US examinations were performed by a paediatric radiologist blinded to TAX result. The UVC route (central or not central) and TP determined by each method were compared to the "actual UVC route and TP", as determined by senior paediatric radiologist and neonatologist referents joint interpretation of TAX and US results. RESULTS: Sixty-one UVCs were assessed in 60 neonates of mean gestational age of 34.7±4.2 weeks. To determine catheter route, sensitivity and specificity were respectively 96.4% and 93.9% for US and 92.8% and 78.8% for TAX. To determine catheter tip position, sensitivity and specificity were respectively 93.3% and 95.6% for US and 66.7% and 63.0% for TAX (p<0.001). Failure of TAX to define UVC tip position increased with birth weight (p<0.005). CONCLUSION: TAX and US are reliable in determining UVC route (central or not) but US examination is superior to TAX in determining UVC TP.

Acute leukoencephalopathy after buprenorphine intoxication in a 2-year-old child.

Leukoencephalopathies have been reported after heroin inhalation or ingestion, and buprenorphine injection, but the physiopathology remains unclear. We report here the first case of leukoencephalopathy caused by buprenorphine ingestion in a 2-year-old child who was admitted for coma and fever. Due to technical problems, the toxicology screen was delayed, and infectious disease was first suspected. A brain MRI found bilateral and symmetric white matter damages in the cerebral hemispheres and the cerebellum. Rapid recovery and positive toxicology screen for buprenorphine on day 4 confirmed the diagnosis of acute intoxication.

Terlipressin as rescue therapy for refractory pulmonary hypertension in a neonate with a congenital diaphragmatic hernia.

We report the case of a 38-week gestational age neonate, with isolated congenital diaphragmatic hernia presenting with refractory persistent pulmonary hypertension, systemic hypotension, and hypoxemia, resistant to usual therapeutics. Arginine vasopressin is responsible for systemic vasoconstriction and decreases pulmonary hypertension. We theorized that terlipressin, its long-acting analogue, could have the same properties. We used terlipressin as rescue therapy after parental and local ethics committee acceptance. After a bolus of terlipressin 20 µg/kg and continuous infusion at a rate of 5 µg/kg per hour, blood oxygen saturation improved from 75% to 98%, oxygen requirements fell from fraction of inspired oxygen 100% to 40%, and mean arterial pressure rose from 28 to 46 mm Hg, allowing a decrease of vasopressor infusion. Terlipressin may be useful in the management of neonates with congenital diaphragmatic hernia and refractory pulmonary hypertension.

Randomized controlled trial of sevoflurane for intubation in neonates.

BACKGROUND: Our aim was to determine whether sevoflurane can be used with safety and efficacy for anesthesia during intubation in term and preterm neonates in a prospective randomized-controlled nonblinded study in a tertiary neonatal intensive care unit. METHODS: Thirty-three neonates were randomly allocated to receive sevoflurane (inspired concentrations varying from 2% to 5%) or no medication (preoxygenation with 100% oxygen alone) before intubation. Minute by minute heart rate (HR), mean arterial blood pressure, SpO(2) and number of episodes of bradycardia (HR < 100 b.min(-1)) and desaturation (SpO(2) < 85% for >30 s) were noted from 5 min before to 10 min after intubation. Operator experience, ease and number of attempts were noted. RESULTS: No major adverse events were noted in the study group compared with the control group [hypotension (37.5% vs 37.5%, NS), number of desaturations [37.5% vs 44.5%, NS)]. Hypertension (25%, vs 56.3%P = 0.04) and incidence of bradycardias (8.3% vs 44.4%, P < 0.01) were greater in the control group. Intubation was easier in the study group: no movements: 95.5% vs 28% (P < 0.005); good glottis visualization: 73% vs 33% (P = 0.013). The failure rate was lower in the study group (25% vs 39%), but this difference was not statistically significant. CONCLUSION: Anesthesia for intubation with sevoflurane in neonates is well tolerated, even in the less mature. It facilitates the conditions for intubation and leads to fewer adverse events. Other studies are necessary to confirm these preliminary results.

Isovolume hypertonic solutes (sodium chloride or mannitol) in the treatment of refractory posttraumatic intracranial hypertension: 2 mL/kg 7.5% saline is more effective than 2 mL/kg 20% mannitol.

OBJECTIVE: To evaluate the clinical benefit of increasing the osmotic load of the hypertonic solution administered for the treatment of refractory intracranial hypertension episodes in patients with severe head injury. DESIGN: Prospective, randomized study. SETTINGS: A trauma center in a university hospital. PATIENTS: Twenty consecutive patients with head trauma and persistent coma who required infusions of an osmotic agent to treat episodes of intracranial hypertension resistant to well-conducted standard modes of therapy were studied. Intracranial hypertension was considered refractory when it persisted despite deep sedation, optimal hemodynamic status, and, in some patients, drainage of cerebral spinal fluid. INTERVENTIONS: Patients were randomly assigned to receive isovolume infusions of either 7.5% hypertonic saline solution (2400 mOsm/kg/H(2)O) or 20% mannitol (1160 mOsm/kg/H(2)O). The patients were given 2 mL/kg (body weight) of either solution, i.e., 361 +/- 13 mOsm of saline or 175 +/- 12 mOsm of mannitol per injection. MEASUREMENTS AND MAIN RESULTS: The main variables studied were the number and the duration of episodes of intracranial hypertension per day during the study period, which was stopped after the last episode of intracranial hypertension was recorded from intracranial pressure monitoring or after the allocated treatment failure. Patients in the HHS group were monitored for 7 +/- 5 days and those in the mannitol group for 7 +/- 6 days (not significant). The rate of failure for each treatment was also evaluated. Failure was defined as the persistence of intracranial hypertension despite two successive infusions of the same osmotic agent. The mean number of osmotic solute infusions was 3.7 +/- 5.3 in the mannitol group and 3.3 +/- 4.1 in the hypertonic saline solution group (not significant). The mean number (6.9 +/- 5.6 vs. 13.3 +/- 14.6 episodes) of intracranial hypertension episodes per day and the daily duration (67 +/- 85 vs. 131 +/- 123 min) of intracranial hypertension episodes were significantly lower in the hypertonic saline solution group (p <.01). The rate of clinical failure was also significantly lower in the hypertonic saline solution group: 1 of 10 patients vs. 7 of 10 patients (p <.01). CONCLUSION: In this study, when a hypertonic solute was required for the treatment of refractory intracranial hypertension episodes in patients with severe head trauma, increasing the osmotic load by giving 2 mL/kg (body weight) of 7.5% saline (361 +/- 13 mOsm) was more effective than giving 2 mL/kg (body weight) of 20% mannitol (175 +/- 12 mOsm). Within the limitations of the present study, these data suggest that giving 2 mL/kg hypertonic saline solution (approximately 480 mOsm/70 kg body weight) is an effective and safe initial treatment for intracranial hypertension episodes in head-trauma patients when osmotherapy is indicated.

Randomized clinical trial of extended use of a hydrophobic condenser humidifier: 1 vs. 7 days.

OBJECTIVE: To determine whether extended use (7 days) would affect the efficiency on heat and water preservation of a hydrophobic condenser humidifier as well as the rate of ventilation-acquired pneumonia, compared with 1 day of use. DESIGN: Prospective, controlled, randomized, not blinded, clinical study. SETTING: Twelve-bed intensive care unit of a university hospital. PATIENTS: One hundred and fifty-five consecutive patients undergoing mechanical ventilation for > or = 48 hrs. INTERVENTIONS: After randomization, patients were allocated to one of the two following groups: a) heat and moisture exchangers (HMEs) changed every 24 hrs; b) HMEs changed only once a week. Devices in both groups could be changed at the discretion of the staff when signs of occlusion or increased resistance were identified. MEASUREMENTS AND MAIN RESULT: Efficient airway humidification and heating were assessed by clinical variables (numbers of tracheal suctionings and instillations required, peak and mean airway pressures). The frequency rates of bronchial colonization and ventilation-acquired pneumonia were evaluated by using clinical and microbiological criteria. Endotracheal tube occlusion, ventilatory support variables, duration of mechanical ventilation, length of intensive care, acquired multiorgan dysfunction, and mortality rates also were recorded. The two groups were similar at the time of randomization. Endotracheal tube occlusion never occurred. In the targeted population (patients ventilated for > or = 7 days), the frequency rate of ventilation-acquired pneumonia was 24% in the HME 1-day group and 17% in the HME 7-day group (p > .05, not significant). Ventilation-acquired pneumonia rates per 1000 ventilatory support days were 16.4/1000 in the HME 1-day group and 12.4/1000 in the HME 7-day group (p > .05, not significant). No statistically significant differences were found between the two groups for duration of mechanical ventilation, intensive care unit length of stay, acquired organ system derangements, and mortality rate. There was indirect evidence of very little, if any, change in HME resistance. CONCLUSIONS: Changing the studied hydrophobic HME after 7 days did not affect efficiency, increase resistance, or altered bacterial colonization. The frequency rate of ventilation-acquired pneumonia was also unchanged. Use of HMEs for > 24 hrs and up to 7 days is safe.