Extremely premature birth bioethical decision-making supported by dialogics and pragmatism.

Moral values in healthcare range widely between interest groups and are principally subjective. Disagreements diminish dialogue and marginalize alternative viewpoints. Extremely premature births exemplify how discord becomes unproductive when conflicts of interest, cultural misunderstanding, constrained evidence review, and peculiar hierarchy compete without the balance of objective standards of reason. Accepting uncertainty, distributing risk fairly, and humbly acknowledging therapeutic limits are honorable traits, not relativism, and especially crucial in our world of constrained resources. We think dialogics engender a mutual understanding that: i) transitions beliefs beyond bias, ii) moves conflict toward pragmatism (i.e., the truth of any position is verified by subsequent experience), and iii) recognizes value pluralism (i.e., human values are irreducibly diverse, conflicting, and ultimately incommensurable). This article provides a clear and useful Point-Counterpoint of extreme prematurity controversies, an objective neurodevelopmental outcomes table, and a dialogics exemplar to cultivate shared empathetic comprehension, not to create sides from which to choose. It is our goal to bridge the understanding gap within and between physicians and bioethicists. Dialogics accept competing relational interests as human nature, recognizing that ultimate solutions satisfactory to all are illusory, because every choice has downside. Nurturing a collective consciousness via dialogics and pragmatism is congenial to integrating objective evidence review and subjective moral-cultural sentiments, and is that rarest of ethical constructs, a means and an end.

In-House, Overnight Physician Staffing: A Cross-Sectional Survey of Canadian Adult ICUs.

OBJECTIVES: Overnight physician staffing in the ICU has been recommended by the Society of Critical Care Medicine and the Leapfrog Consortium. We conducted a survey to review practice in the current era and to compare this with results from a 2006 survey. DESIGN: Cross-sectional survey. SETTING: Canadian adult ICUs. PARTICIPANTS: ICU directors. INTERVENTIONS: None. MEASUREMENT AND MAIN RESULTS: A 29-question survey was sent to ICU directors describing overnight staffing by residents, fellows, nurse practitioners, and staff physicians, as well as duty duration, clinical responsibilities, and unit characteristics. We established contact with 122 ICU directors, of whom 107 (88%) responded. Of the 107 units, 60 (56%) had overnight in-house physicians. Compared with ICUs without overnight in-house physician coverage, ICUs with in-house physicians were in larger hospitals (p < 0.0001), had more beds (p < 0.0001), had more ventilated patients (p < 0.0001), and had more admissions (p < 0.0001). Overnight in-house physicians were first year residents (R1) in 20 of 60 (33%), second to fifth year residents (R2-R5) in 46 of 60 (77%), and Critical Care Medicine trainees in 19 of 60 (32%). Advanced practice nurses provided overnight coverage in four of 107 ICUs (4%). The most senior in-house physician was a staff physician in 12 of 60 ICUs (20%), a Critical Care Medicine trainee in 14 of 60 (23%), and a resident (R2-R5) in 20 of 60 (33%). The duration of overnight duty was on average 20-24 hours in 22 of 46 units (48%) with R2-R5 residents and 14 of 19 units (74%) covered by Critical Care Medicine trainees. CONCLUSIONS: Variability of in-house overnight physician presence in Canadian adult ICUs is linked to therapeutic complexity and unit characteristics and has not changed significantly over the decade since our 2006 survey. Additional evidence about patient and resident outcomes would better inform decisions to revise physician scheduling in Canadian ICUs.

Autosomal dominant transmission of transient neonatal lactic acidosis: a case report.

BACKGROUND: Lactic acidosis is a common finding in neonates, in whom mitochondrial dysfunction is often secondary to tissue hypoperfusion, respiratory failure, and/or sepsis. Primary (non-physiological) lactic acidosis is comparatively rare, and suggests the presence of an inborn error of mitochondrial energy metabolism. Optimal medical management and accurate prognostication requires the correct determination of the etiology of lactic acidosis in a given patient. Unfortunately, genetic diagnoses are rare and highly variable for neonates presenting with primary lactic acidosis; individual case reports may offer the most promise for treatment considerations. The mitochondrion is a complex molecular machine incorporating the products of > 1000 distinct nuclear genes. Primary lactic acidoses are therefore characterized by high genetic heterogeneity and a specific genetic diagnosis currently remains out of reach in most cases. Most mitochondriopathies with neonatal onset follow autosomal recessive inheritance and carry a poor prognosis. Here we detail the case of a father and daughter with dominantly-inherited, resolving (i.e. transient) neonatal hyperlactatemia due to complex IV deficiency. We found no other published descriptions of benign transient complex IV deficiency with autosomal dominant inheritance. CASE PRESENTATION: Both individuals presented as neonates with unexplained, marked lactic acidosis suggesting a primary mitochondrial disorder. Within the first weeks of life, elevated blood lactate levels normalized. Their clinical and developmental outcomes were normal. Biochemical studies in the proband showed multiple abnormalities consistent with a complex IV respiratory chain defect. Cultured skin fibroblasts showed an elevated lactate-to-pyruvate ratio, deficient complex IV activity, and normal pyruvate dehydrogenase and pyruvate carboxylase activities. Whole-exome sequencing of the proband and both parents did not identify a causative mutation. CONCLUSION: We conclude that the proband and her father appear to have a dominant form of transient neonatal hyperlactatemia due to heterozygous changes in an as-yet unidentified gene. This transient neonatal complex IV deficiency should be considered in the differential diagnosis of primary neonatal hyperlactatemia; notable clinical features include autosomal-dominant inheritance and an apparently benign postnatal course. This report exemplifies the growing differential diagnosis for neonatal lactic acidosis and highlights the importance of both physician counselling and the use of family history in communicating with parents.

Should Extremely Premature Babies Get Ventilators During the COVID-19 Crisis?

In a crisis, societal needs take precedence over a patient's best interests. Triage guidelines, however, differ on whether limited resources should focus on maximizing lives or life-years. Choosing between these two approaches has implications for neonatology. Neonatal units have ventilators, some adaptable for adults. This raises the question of whether, in crisis conditions, guidelines for treating extremely premature babies should be altered to free-up ventilators. Some adults who need ventilators will have a survival rate higher than some extremely premature babies. But surviving babies will likely live longer, maximizing life-years. Empiric evidence demonstrates that these babies can derive significant survival benefits from ventilation when compared to adults. When "triaging" or choosing between patients, justice demands fair guidelines. Premature babies do not deserve special consideration; they deserve equal consideration. Solidarity is crucial but must consider needs specific to patient populations and avoid biases against people with disabilities and extremely premature babies.

A meta-analysis of neurodevelopmental outcomes at 4-10 years in children born at 22-25 weeks gestation.

AIM: To update our meta-analysis on neurodevelopmental disability rates in children born at 22-25 weeks gestation. The main outcome measure was rates of neurodevelopmental disability in survivors at age 4-10 years. METHODS: We used a peer-reviewed electronic and grey search to identify articles. Two authors independently reviewed cohorts published after May 2012 with: born ≥1995 in a developed nation; assessed at 4-10 years; prospective; >65% follow-up; definitions for neurodevelopmental disability as per the EPICure cohort; results reported by gestation. We contacted authors for clarification. Random effects meta-analysis was used to estimate pooled proportions of neurodevelopmental disability. Within each study, the absolute change in proportions with each week was estimated and then pooled. RESULTS: We reviewed 3980 records; 21 articles were assessed and six were included. With the previous 9 cohorts, the meta-analysis now contains 15. Rates of moderate-to-severe neurodevelopmental disability were as follows: 42% (95% CI 23,64%; I2 0%) at 22; 41% (95% CI 31,52%; I2 20%) at 23; 32% (95% CI 25,39%; I2 45%) at 24; 23% (95% CI 18,29%; I2 60%) at 25 weeks. The analysis shows a significant decrease in risk of moderate-to-severe neurodevelopmental disability between each week (8.1% (95% CI -11.8, -4.5%); I2 0%; p < 0.001). CONCLUSION: Physicians can use this high-quality data to support parents during decision-making.

Catch the moment: The power of turning mistakes into 'precious' learning opportunities.

We developed a series of small group workshops that aim to facilitate communication during very challenging ethically sensitive scenarios within a Neonatal-Perinatal Medicine (NPM) postgraduate curriculum at the University of Ottawa. These workshops are called Scenario-Oriented Learning in Ethics (SOLE). This educational intervention aims to focus attention on the learner's needs and to help them recognize, define, and view each communicative or behavioural mistake as an occasion to achieve a personal-defined learning goal in a controlled environment free of judgement. The goal of this commentary is to describe the importance of timely interruptions during the scenarios allowing mini concurrent-guided debriefing-feedback by focusing upon trainees' communication mistakes, utilizing them as valuable learning opportunities.

Shared decision making during antenatal counselling for anticipated extremely preterm birth.

OBJECTIVES: To explore health care providers' (HCPs) perceptions of using shared decision making (SDM) and to identify facilitators of and barriers to its use with families facing the anticipated birth of an extremely preterm infant at 22+0 to 25+6 weeks gestational age. STUDY DESIGN: Qualitative descriptive study design: we conducted interviews with 25 HCPs involved in five cases at a tertiary care centre and completed qualitative content analysis of their responses. RESULTS: Nine facilitators and 16 barriers were identified. Facilitators included: a correct understanding of this process and how to apply it, a belief that parents should be the decision makers in these situations, and a positive outlook toward using SDM during antenatal counselling. Barriers included: HCPs' misunderstandings of how and when to apply SDM during antenatal counselling, challenges using the process for cases at the lower end of the gestational age range, fear of the negative emotions and stress parents face when making decisions, and HCPs' uncertainty about their ability to properly apply SDM. CONCLUSIONS: This study identified facilitators and barriers to use of SDM during antenatal counselling for anticipated birth of extremely preterm infants that can be used to inform development of tailored strategies to facilitate future implementation of shared decision making in this area.

Needs assessment of ethics and communication teaching for neonatal perinatal medicine programs in Canada.

OBJECTIVE: To explore ethics education needs in Canadian Neonatal Perinatal Medicine (NPM) training programs. METHODS: A retrospective review of NPM trainees' performance at the National NPM Objective Structured Clinical Examination (OSCE) was undertaken for 2012 to 2017 and two distinct cross-sectional online surveys were carried out. One survey targeted recently graduated neonatologists (RGNs) who completed 2 years' training in a Canadian NPM program between 2010 and 2015; the other survey was sent to Canadian NPM training program directors (PDs). The domains of interest were: perception of education, ethics and communication topics, educational strategies, assessment of trainees' competencies, and barriers to neonatal ethics education. RESULTS: NPM trainees generally performed less well in stations involving ethics and communication relative to other domains on the National OSCE. Forty-seven RGNs (44.3%) and 12 PDs (92.3%) completed the survey. Over 90% of PDs and RGNs agreed on the importance of training in ethics and communication. Both groups highly valued training on topics related to communication. Preferred teaching strategies were experiential: observation and feedback. PDs mentioned the importance of using validated tools to regularly and formally assess trainees. They recognized challenges in regard to financial resources, physical space, and faculty training in patient-physician communication. CONCLUSIONS: National OSCE results indicate the need to improve neonatal ethics and communication training in Canadian NPM programs. RGNs and PDs identified important topics, as well as teaching and evaluation strategies. These results can be used to develop a training program for ethics and communication in NPM.

Antenatal Consultations at Extreme Prematurity: A Systematic Review of Parent Communication Needs.

OBJECTIVE: To synthesize and describe parental expectations on how healthcare professionals should interact with them during a peripartum, antenatal consultation for extremely preterm infants. STUDY DESIGN: For this systematic literature review with textual narrative synthesis, we included studies that explored parental perspectives regarding the antenatal consultation for an extremely preterm infant. Electronic searches of Medline, CINAHL, PsycInfo, and Embase were conducted, along with a search of the grey literature. Quality appraisal was conducted using the guide by Walsh and Downe. Two independent reviewers reviewed 783 titles, of which 130 abstracts then 40 full-text articles were reviewed. Final data abstraction includes 19 studies. We predetermined 6 topics of interest (setting, timing, preferred healthcare professional, information, resources, and parents-physician interaction) to facilitate thematic analysis. RESULTS: In consideration of the variability of parents' specific desires, six predetermined topics and additional overarching themes such as perception of support, degree of understanding, hope, spirituality, and decision-making influences emerged. Studies suggest the quality of the antenatal consultation is not purely about information content, but also the manner in which it is provided. Limitations include thematic analysis that can potentially lead to the exclusion of important nuances. Relevant studies may have been missed if published outside the healthcare literature. CONCLUSIONS: The findings may inform clinical practice guidelines. This paper includes suggested strategies related to parents' perspectives that may facilitate communication during antenatal consultation for an extremely preterm infant. These strategies may also support parental engagement and satisfaction.

Effect of an Educational Presentation about Extremely Preterm Infants on Knowledge and Attitudes of Health Care Providers.

Objective To determine healthcare providers' knowledge (HCP) about survival rates of extremely preterm infants (EPI) and attitudes toward resuscitation before and after an educational presentation and, to examine the relationship between knowledge and attitudes toward resuscitation. Study Design Participants completed a survey before and after attending a presentation detailing evidence-based estimates of survival rates and surrounding ethical issues. Respondents included neonatologists, obstetricians, pediatricians, maternal-fetal medicine specialists, trainees in pediatrics, obstetrics, neonatal-perinatal medicine and neonatal and obstetrical nurses. Results In total, 166 participants attended an educational presentation and 130 participants completed both pre- and postsurveys (response rate 78%). Prepresentation, for all gestations, ≤ 50% of respondents correctly identified survival/intact survival rates. Postpresentation, correct responses regarding survival/intact survival rates ranged from 49 to 86% (p < 0.001) and attitudes shifted toward being more likely to resuscitate at all gestations regardless of parental wishes. There was a weak-to-modest relationship (Spearman's coefficient 0.24-0.40, p < 0.001-0.004) between knowledge responses and attitudes. Conclusion Attendance at an educational presentation did improve HCP knowledge about survival and long term outcomes for EPI, but HCP still underestimated survival and were not always willing to resuscitate in accordance with parental wishes. These findings may represent barriers to some experts' recommendation to use shared decision-making with parents when considering the resuscitation options for their EPI.

An innovative on-call system for paediatric residency programs: The alternate night float.

BACKGROUND: Night-float systems, in which residents work consecutive nights, have been increasingly adopted in paediatric programs, but may be detrimental to residents' sleep and mood. OBJECTIVE: To describe the self-reported impact of a novel system consisting of two consecutive weeks of 16 h overnight shifts every second day that was piloted at the Children's Hospital of Eastern Ontario (Ottawa, Ontario). METHODS: A survey of 28 senior paediatric residents examined their experience with the alternate night-float system in three domains (patient care, resident professional development and well-being) and their comparison of the system with the traditional overnight on-call system. RESULTS: Twenty-six of 28 residents responded. Nearly all (96%) felt familiar with important details of inpatients and that handover was effective (92%). Results were mixed for professional development, with concerns about the quality of supervisors' feedback and perceived difficulty in attending daytime teaching. All residents believed that the night-float system provided a better learning experience compared with the traditional system. Less than 35% considered fatigue to be a notable problem, although 20% increased use of sleep aids or stimulants beyond their typical use. Ninety-six percent believed their workload was appropriate. All residents felt equally or less fatigued under the night-float system compared with the traditional system. Ninety-six percent recommended that the night-float model continue as the on-call system. CONCLUSIONS: This novel night-float system is an alternative method of providing paediatric inpatient night coverage because it meets duty hour regulations and has strong resident approval. Studies to examine its impact on residents and patient care in comparison with other systems are warranted.

HISTORIQUE: Les systèmes de garde de nuit, dans le cadre desquels les résidents travaillent plusieurs nuits consécutives, sont de plus en plus fréquents dans les programmes de pédiatrie, mais ils peuvent nuire au sommeil et à l'humeur des résidents. OBJECTIF: Décrire les répercussions autodéclarées d'un nouveau système constitué de deux semaines consécutives de quarts de nuit de 16 heures tous les deux jours, piloté à Ottawa, au Centre hospitalier pour enfants de l'est de l'Ontario. MÉTHODOLOGIE: Dans un sondage auprès de 28 résidents seniors en pédiatrie, les chercheurs ont examiné l'expérience de ces résidents au sein du système de garde de nuit tous les deux jours (soins aux patients, bien-être des résidents et perfectionnement professionnel) et les comparaisons que ces résidents ont faites avec le système de garde de nuit habituel. RÉSULTATS: Vingt-six des 28 résidents ont répondu. Presque la totalité (96 %) connaissait l'information importante sur les patients hospitalisés et trouvait le transfert des soins efficace (92 %). Les résultats étaient mitigés à l'égard du perfectionnement professionnel, car les résidents se préoccupaient de la qualité de la rétroaction des superviseurs et trouvaient difficile d'assister à l'enseignement pendant la journée. Tous les résidents trouvaient que le système de garde de nuit assurait une meilleure expérience d'apprentissage que le système habituel. Moins de 35 % considéraient la fatigue comme un problème notable, même si 20 % utilisaient plus d'aides au sommeil ou de stimulants qu'à l'habitude. De plus, 96 % trouvaient leur charge de travail adéquate. Tous les résidents se sentaient aussi fatigués ou moins fatigués dans le système de garde de nuit que dans le système habituel. Enfin, 96 % recommandaient d'adopter le modèle de garde de nuit comme système de garde. CONCLUSIONS: Ce nouveau système de garde de nuit est une autre méthode pour assurer les services nocturnes auprès des enfants hospitalisés. Il respecte la réglementation sur les heures de garde et est fortement approuvé par les résidents. Des études s'imposent pour en examiner les effets sur les résidents et les soins aux patients par rapport aux autres systèmes.

Teaching ethics in neonatal and perinatal medicine: What is happening in Canada?

Ethically challenging clinical situations are frequently encountered in neonatal and perinatal medicine (NPM), resulting in a complex environment for trainees and a need for ethics training during NPM residency. In the present study, the authors conducted a brief environmental scan to investigate the ethics teaching strategies in Canadian NPM programs. Ten of 13 (77%) accredited Canadian NPM residency programs participated in a survey investigating teaching strategies, content and assessment mechanisms. Although informal ethics teaching was more frequently reported, there was significant variability among programs in terms of content and logistics, with the most common topics being 'The medical decision making process: Ethical considerations' and 'Review of bioethics principles' (88.9% each); lectures by staff or visiting staff was the most commonly reported formal strategy (100%); and evaluation was primarily considered to be part of their overall trainee rotation (89%). This variability indicates the need for agreement and standardization among program directors regarding these aspects, and warrants further investigation.

On affronte souvent des situations cliniques difficiles sur le plan éthique en médecine néonatale et périnatale (MNP), qui se traduisent par un milieu complexe pour les stagiaires et par la nécessité de donner une formation en éthique pendant la résidence en MNP. Dans la présente étude, les auteurs ont mené un bref examen du milieu pour examiner les stratégies d'enseignement de l'éthique au sein des programmes de MNP canadiens. Dix des 13 programmes de résidence canadiens agréés en MNP (77 %) ont participé à un sondage sur les stratégies d'enseignement, le contenu et les mécanismes d'évaluation. Même si l'enseignement informel de l'éthique était signalé davantage, on constatait une importante variabilité entre les programmes en matière de contenu et de logistique, les sujets les plus fréquents étant « Le processus de prise de décision médicale : des considérations éthiques ¼ et « Examen des principes bioéthiques ¼ (88,9 % chacun), les conférences données par le personnel ou du personnel en visite étaient la stratégie officielle la plus courante (100 %) et l'évaluation était principalement considérée comme un élément de la rotation globale des stagiaires (89 %). Cette variabilité démontre que les directeurs de programmes doivent s'entendre et standardiser ces aspects de l'éthique, et elle justifie des examens plus approfondis.

How we teach ethics and communication during a Canadian neonatal perinatal medicine residency: an interactive experience.

BACKGROUND: Ethically challenging clinical situations frequently confront health care professionals in neonatology. These situations require neonatologists to exercise professionalism by communicating effectively throughout evolving physician-parent relationships in order to arrive at shared decisions for care that are in the best interest of the neonate and grounded solidly in ethical precepts. AIM: This article describes the process by which a well-delineated, interactive program to teach ethical reasoning and skillful communication with parents was implemented at the University of Ottawa, Canada. METHODS: A revised ethics program implemented in 2009 identified competencies that should be demonstrated at the end of the Neonatal-Perinatal Medicine (NPM) residency. Several seminars were refined while new workshops, problem-based learning in ethics, and a personal portfolio were added. RESULTS: All teaching strategies were well received based on the average level of satisfaction (5.8 out of 7, SD 0.4). We are now moving forward by formally assessing our program including the impact on knowledge acquisition and behavior. CONCLUSION: A dedicated, interactive competency-based neonatal ethics teaching program is vital to support NPM trainees in learning how to integrate ethical thinking with competencies in communication.

An e-Delphi study on mode of delivery and extremely preterm breech singletons.

OBJECTIVES: To understand clinicians' consensus on mode of delivery in extremely preterm breech infants; assess knowledge on neonatal outcomes and its impact on consensus. STUDY DESIGN: A two-round Delphi of obstetrical or neonatal care providers, recruited from national conferences and investigator networks. Round one assessed decision-making (vignettes), and knowledge; the second round reassessed vignettes after presenting outcome data. RESULTS: In round one (102 respondents), consensus (a priori, ≥75% agreement) was achieved in 4/13 vignettes: two when likely/very likely to offer Cesarean (26 and 27 weeks) and two for unlikely/very unlikely (23 weeks growth restriction, ± adverse features). Clinicians generally underestimated neonatal outcomes. In round two (87 respondents), three scenarios achieved consensus (likely/very likely to offer Cesarean at 25-27 weeks); in five other vignettes, not offering Cesarean was reduced in ≥15% of respondents. CONCLUSION: Limited consensus exists on extremely preterm breech mode of delivery, partly associated with neonatal outcome underestimation. GESTATIONAL AGE NOTATION: The authors follow the World Health Organization's notation on gestational age. Under this notation, the first day of the last menstrual period (LMP) is day 0 of week 0. Therefore, days 0-6 represent completed week 0, days 7-13 represent completed week 1 and so on.

Assessing shared decision making during antenatal consultations regarding extreme prematurity.

OBJECTIVE: To assess whether antenatal decisions regarding the neonatal care at birth for extremely preterm infants are more likely to be made when using shared decision-making (SDM)-style consultations compared to standard consultations. STUDY DESIGN: In 2015, we implemented a clinical practice guideline promoting SDM use within antenatal consultations in our single-centre university-based perinatal unit. We conducted a prospective cohort study with a retrospective chart review based on data collected from all pregnant women presenting to obstetrical triage between 22 + 0 and 25 + 6 weeks gestation between September 2015 and June 2018. RESULT: Two-hundred-and-seventeen cases presented; 137 received antenatal consultations with 82 (60%) being SDM-style. Decisions were frequently made (88%; 120/137) after the consultations, with no significant difference between consultation style (RR 1.08, 95% CI [0.95-1.26], p = 0.28). CONCLUSION: The provision of either an SDM-style or a standard antenatal consultation seemed to comparably facilitate the reaching of a care decision.

Overnight staffing in Canadian neonatal and pediatric intensive care units.

Aim: Infants and children who require specialized medical attention are admitted to neonatal and pediatric intensive care units (ICUs) for continuous and closely supervised care. Overnight in-house physician coverage is frequently considered the ideal staffing model. It remains unclear how often this is achieved in both pediatric and neonatal ICUs in Canada. The aim of this study is to describe overnight in-house physician staffing in Canadian pediatric and level-3 neonatal ICUs (NICUs) in the pre-COVID-19 era. Methods: A national cross-sectional survey was conducted in 34 NICUs and 19 pediatric ICUs (PICUs). ICU directors or their delegates completed a 29-question survey describing overnight staffing by resident physicians, fellow physicians, nurse practitioners, and attending physicians. A comparative analysis was conducted between ICUs with and without in-house physicians. Results: We obtained responses from all 34 NICUs and 19 PICUs included in this study. A total of 44 ICUs (83%) with in-house overnight physician coverage provided advanced technologies, such as extracorporeal life support, and included all ICUs that catered to patients with cardiac, transplant, or trauma conditions. Residents provided the majority of overnight coverage, followed by the Critical Care Medicine fellows. An attending physician was in-house overnight in eight (15%) out of the 53 ICUs, seven of which were NICUs. Residents participating in rotations in the ICU would often have rotation durations of less than 6 weeks and were often responsible for providing care during shifts lasting 20-24 h. Conclusion: Most PICUs and level-3 NICUs in Canada have a dedicated in-house physician overnight. These physicians are mainly residents or fellows, but a notable variation exists in this arrangement. The potential effects on patient outcomes, resident learning, and physician satisfaction remain unclear and warrant further investigation.

Therapeutic strategies, including a high surgical ligation rate, for patent ductus arteriosus closure in extremely premature infants in a North American centre.

OBJECTIVE: To document the rate of surgical ligation of a patent ductus arteriosus (PDA) in extremely premature infants who had received more than one course of indomethacin. Outcomes were compared among three subgroups (ligation, further indomethacin and no further treatment) of infants who received at least one course of indomethacin, and between two subgroups (one course of indomethacin and more than one course) among infants who underwent ligation. STUDY DESIGN: A retrospective chart review of all 23 weeks+0 days to 26 weeks+6 days' gestational age infants with a PDA born between 1994 and 2005 was performed. Secondary outcomes were compared among the subgroups. RESULTS: The final study population consisted of 196 extremely premature infants with a PDA. The rate of surgical ligation in the 88 infants who received more than one course of indomethacin was 64%. The ligation subgroup, in comparison with the no further treatment subgroup, spent a greater median time on mechanical ventilation (39 versus 29 days, P<0.001) and in hospital (115 versus 92 days P=0.002), while trending toward lower mortality (18% versus 40%, P=0.07). The PDA closed following the first course of indomethacin in only 20% of infants. CONCLUSIONS: A majority of extremely premature infants receiving more than one course of indomethacin underwent surgical ligation. Repeated indomethacin courses were generally well tolerated, but were mostly unsuccessful. Ligation appears to have potential risks and benefits. A randomized trial should be performed after studies define a hemodynamically significant PDA that will result in morbidity and/or mortality unless treated.

OBJECTIF: Étayer le taux de ligatures chirurgicales de persistances du canal artériel (PCA) chez des grands prématurés qui avaient reçu plus d'une série de traitement à l'indométhacine. Les chercheurs ont comparé les issues entre les trois sous-groupes (ligature, nouvelle série de traitement à l'indométhacine et aucun traitement supplémentaire) et les nourrissons qui avaient reçu au moins une série de traitement à l'indométhacine, ainsi qu'entre deux sous-groupes (une série de traitement à l'indométhacine et plus d'une dose) et les nourrissons qui avaient eu une ligature. MÉTHODOLOGIE: Les chercheurs ont procédé à l'analyse rétrospective des dossiers de tous les nourrissons de 23+0 à 26+6 semaines d'âge gestationnel ayant une PCA, qui étaient nés entre 1994 et 2005. Ils ont comparé les issues secondaires entre les sous-groupes. RÉSULTATS: La population finale à l'étude se composait de 196grands prématurés ayant une PCA. Le taux de ligatures chirurgicales chez les 88 nourrissons qui avaient reçu plus d'une série de traitement à l'indométhacine s'élevait à 64 %. Le sous-groupe ligaturé, par rapport au sous-groupe n'ayant pas reçu de traitement supplémentaire, présentait une durée médiane plus élevée sous ventilation mécanique (39 jours par rapport à 29, P<0,001) et d'hospitalisation (115 jours par rapport à 92, P=0,002), tout en manifestant une tendance vers une mortalité moins élevée (18 % par rapport à 40 %, P=0,07). La PCA s'est fermée après la première dose d'indométhacine chez seulement 20% des nourrissons. CONCLUSIONS: La majorité des grands prématurés qui avaient reçu plus d'une série de traitement à l'indométhacine ont subi une ligature chirurgicale. Les nouvelles séries de traitement à l'indométhacine étaient généralement bien tolérées, mais la plupart étaient sans effet sur la PCA. La ligature semble s'associer à des risques et bienfaits potentiels. Il faudrait procéder à un essai aléatoire après que des études auront défini une PCA significative sur le plan hémodynamique qui s'associe à une morbidité ou une mortalité à moins d'être traitée.

Survival after self-poisoning with sodium nitrite: A case report.

Sodium nitrite ingestion poses a considerable public health threat. The incidence of sodium nitrite self-poisoning in the United States has been trending upward since 2017. Our case report describes an intentional sodium nitrite ingestion with favorable outcomes. We highlight the proper treatment of this ingestion with intravenous methylene blue. Sodium nitrite is an oxidizing agent that is commonly found in processed meats, fish, and cheeses as a preservative, antimicrobial, and food coloring agent. It is an odorless, white crystalline powder that has been confused for table salt or granulated sugar. It has become more readily available in large quantities online. Unfortunately, online forums exist that detail how to dose sodium nitrite for suicide. Furthermore, it has been recently discussed in popular news streams after a celebrity died of an overdose. Sodium nitrite toxicity is capable of causing severe methemoglobinemia with high mortality. Prompt identification is crucial. We discuss the important implications in regard to media coverage, imitative suicide, and accessibility of sodium nitrite.