High frequency oscillatory ventilation for respiratory failure due to RSV bronchiolitis.

OBJECTIVE: To describe the time course of high frequency oscillatory ventilation (HFOV) in respiratory syncytial virus (RSV) bronchiolitis. DESIGN: Retrospective charts review. SETTING: A tertiary paediatric intensive care unit. PATIENTS AND PARTICIPANTS: Infants with respiratory failure due to RSV infection. INTERVENTION: HFOV. MEASUREMENTS AND RESULTS: Pattern of lung disease, ventilatory settings, blood gases, infant's vital parameters, sedation and analgesia during the periods of conventional mechanical ventilation (CMV, 6 infants), after initiation of HFOV (HFOVi, 9 infants), in the middle of its course (HFOVm), at the end (HFOVe) and after extubation (Post-Extub) were compared. All infants showed a predominant overexpanded lung pattern. Mean airway pressure was raised from a mean (SD) 12.5 (2.0) during CMV to 18.9 (2.7) cmH(2)O during HFOVi (P < 0.05), then decreased to 11.1(1.3) at HFOVe (P < 0.05). Mean FiO(2) was reduced from 0.68 (0.18) (CMV) to 0.59 (0.14) (HFOVi) then to 0.29 (0.06) (P < 0.05) at HFOVe and mean peak to peak pressure from 44.9 (12.4) cmH(2)O (HFOVi) to 21.1 (7.7) P < 0.05 (HFOVe) while mean (SD) PaCO(2) showed a trend to decrease from 72 (22) (CMV) to 47 (8) mmHg (HFVOe) and mean infants respiratory rate a trend to increase from 20 (11) (HFOVi) to 34 (14) (HFOVe) breaths/min. With usual doses of sedatives and opiates, no infant was paralysed and all were extubated to CPAP or supplemental oxygen after a mean of 120 h. CONCLUSION: RSV induced respiratory failure with hypercapnia can be managed with HFOV using high mean airway pressure and large pressure swings while preserving spontaneous breathing.

National ethical directives and practical aspects of forgoing life-sustaining treatment in newborn infants in a Swiss intensive care unit.

QUESTION UNDER STUDY: How do actual aspects of forgoing life supporting therapy (LST) in newborn infants compare with national ethical directives in a Swiss intensive care unit? METHODS: A prospective set of data on deaths after forgoing LST over a three year period in a single intensive care unit is analysed in view of the directives issued by the Swiss Academy for Medical Sciences (SAMS). RESULTS: Thirty-four newborn infants died after a decision to forgo LST, 21 after withdrawing and 13 after withholding. The decision making process was confined to the caregivers' team. Parents rarely initiated the discussion but participated in all decisions and were considered as willing in 32% and consenting in 68%. Futility was invoked in 79% of cases and poor developmental outcome in 21%. Respiratory support was forgone in 59%, circulatory support in 6% and both in 35%. The mother assisted the child at the time of death in 91%. At that time, 82% of infants were receiving opiates and 18% benzodiazepines, some in a higher than usual dose. Death occurred at a median of 13 (25-75% = 6-25) minutes after withdrawing LST and 70 (27.5-147.5) after withholding (p <0.001) without correlation with the dose of analgesic or sedative administered. None of these observations obviously departed from the Swiss ethical directives. CONCLUSIONS: Practices surrounding forgoing LST in newborn infants in a Swiss intensive care unit match ethical directives. Factors leading to occasional use of unusually high dose of analgesic and sedative drugs remain to be identified.

Intravenous adenosine for refractory pulmonary hypertension in a low-weight premature newborn: a potential new drug for rescue therapy.

OBJECTIVES: To use intravenous adenosine as a rescue therapy for neonatal refractory pulmonary hypertension in a low-weight premature infant. STUDY LINE: We report the successful use of a continuous intravenous adenosine infusion in a 1150-g premature baby with severe persistent pulmonary hypertension, refractory to classic management with high-frequency oscillatory ventilation, oxygen therapy and inhaled nitric oxide. RESULTS: Adenosine infusion had a dramatic effect allowing for a rapid weaning of oxygen, ventilatory variables, and nitric oxide. CONCLUSIONS: Although experience with continuous adenosine infusion is still at an early stage, it might be worth considering its administration as a rescue therapy or even as an alternative to extracorporeal membrane oxygenation.

Successful local low-dose urokinase treatment of acquired thrombosis early after cardiothoracic surgery.

BACKGROUND AND OBJECTIVE: Recent surgery (

Innate immune deficiency of extremely premature neonates can be reversed by interferon-γ.

BACKGROUND: Bacterial sepsis is a major threat in neonates born prematurely, and is associated with elevated morbidity and mortality. Little is known on the innate immune response to bacteria among extremely premature infants. METHODOLOGY/PRINCIPAL FINDINGS: We compared innate immune functions to bacteria commonly causing sepsis in 21 infants of less than 28 wks of gestational age, 24 infants born between 28 and 32 wks of gestational age, 25 term newborns and 20 healthy adults. Levels of surface expression of innate immune receptors (CD14, TLR2, TLR4, and MD-2) for Gram-positive and Gram-negative bacteria were measured in cord blood leukocytes at the time of birth. The cytokine response to bacteria of those leukocytes as well as plasma-dependent opsonophagocytosis of bacteria by target leukocytes was also measured in the presence or absence of interferon-γ. Leukocytes from extremely premature infants expressed very low levels of receptors important for bacterial recognition. Leukocyte inflammatory responses to bacteria and opsonophagocytic activity of plasma from premature infants were also severely impaired compared to term newborns or adults. These innate immune defects could be corrected when blood from premature infants was incubated ex vivo 12 hrs with interferon-γ. CONCLUSION/SIGNIFICANCE: Premature infants display markedly impaired innate immune functions, which likely account for their propensity to develop bacterial sepsis during the neonatal period. The fetal innate immune response progressively matures in the last three months in utero. Ex vivo treatment of leukocytes from premature neonates with interferon-γ reversed their innate immune responses deficiency to bacteria. These data represent a promising proof-of-concept to treat premature newborns at the time of delivery with pharmacological agents aimed at maturing innate immune responses in order to prevent neonatal sepsis.

Population based age stratified morbidities of premature infants in Switzerland.

OBJECTIVE: To provide population-based, gestational age (GA) stratified incidence of mortality and morbidities. METHODS: Population-based prospective observational study of infants born between 23 0/7 and 31 6/7 weeks GA in the years 2000-2004 in all Swiss neonatal intensive care units. Outcomes measured were: mortality, severe intraventricular haemorrhage (IVH), periventricular leukomalacia (PVL), necrotizing enterocolitis (NEC), moderate/severe bronchopulmonary dysplasia (BPD) and free of major complications. RESULTS: Mortality was 19% of 3083 infants. Mortality (95% CI) decreased from 95% (88%, 99%) at 23 weeks to 3% (2%, 5%) at 31 weeks. Short-term survival free of major complications was 66% (65%, 68%) overall and increased from 2%(0%, 9%) to 89% (87%, 92%). Rate of IVH was 8% (7%, 9%), PVL 2% (2%, 3%), NEC 3% (3%, 4%) and BPD 11% (10%, 12%). Males had more IVH than females (9% vs. 6%). Antenatal steroids were associated with lower mortality (11% vs. 18%) and IVH (5% vs. 12%). Odds of free of major complications (OR, 95%CI) were positive for female gender 1.2 (1.0, 1.5), steroids 1.3 (1.1, 1.5), multiple gestation 1.3 (1.0, 1.6), not small for gestational age 2.7 (2.0, 3.5), and each additional week of GA 1.6 (1.5, 1.7). CONCLUSION: Mortality and incidence of morbidities known to influence outcome show a weekly decline with increasing gestational age, except for PVL. Gestational age stratified data are a key component for prenatal counselling.

Surfactant use based on the oxygenation response to lung recruitment during HFOV in VLBW infants.

PURPOSE: Early lung recruitment (ELR) during high-frequency oscillatory ventilation (HFOV) in combination with prophylactic surfactant use has been reported to reduce mortality, improve respiratory outcomes, and reduce the need for repeated surfactant dosing, suggesting that surfactant might be used more selectively in very low birth weight (VLBW) infants on HFOV than generally recommended. We report our first experience from such a selective early rescue use of surfactant in VLBW infants on HFOV. METHODS: After a deliberate ELR maneuver and "optimal" continuous distending pressure (CDP) finding during HFOV, used as primary ventilation mode for VLBW infants with respiratory distress syndrome (RDS), surfactant was only given when an unsatisfactory oxygenation response to lung recruitment (as defined by CDP x FiO(2) > 5) was observed. RESULTS: Out of 144 VLBW infants on HFOV, 84 (58.3%) received surfactant and 60 (41.7%) did not. Duration of required oxygen supplementation (37.4 +/- 44.9 vs. 46.2 +/- 35.4 days; P = 0.031) and respiratory support (i.e., n-CPAP and/or mechanical ventilation; 22.3 +/- 19.3 vs. 38.2 +/- 24.3 days; P = 0.001) was shorter for infants who did not receive surfactant than for those who did. The incidence and severity of bronchopulmonary dysplasia was similar in both groups, and there was no difference in survival rates between groups. Subgroup analysis for infants of less than 28 weeks of gestation revealed similar results. CONCLUSIONS: First intention HFOV combined with an early attempt at lung volume optimization might allow surfactants to be used more selectively (in relation to disease severity) in VLBW infants presenting with RDS at birth without negatively influencing the outcome.

Incidence of early neonatal mortality and morbidity after late-preterm and term cesarean delivery.

OBJECTIVE: To determine the age-stratified risk of intrapartum and neonatal mortality as well as morbidities of clinical relevance after elective cesarean delivery (ECD). METHODS: This work was a cohort study including 56 549 prospectively recorded late-preterm and term deliveries. We analyzed the effect of cesarean delivery (CD) before the onset of labor on the following multiple neonatal outcomes before hospital discharge, compared with planned vaginal delivery (PVD) and emergency CD: mortality, birth depression, special care admission, and respiratory morbidity. We adjusted for confounders by multivariate analysis and stratified the risk according to gestational age (GA). RESULTS: Mortality and morbidities had a strong GA-related trend with the lowest incidences consistently found between 38 and 40 weeks of gestation independent of delivery mode. Compared with infants delivered via PVD, infants delivered via ECD had significantly higher rates of mortality (adjusted risk ratio [aRR]: 2.1), risk of special care admission (aRR: 1.4), and respiratory morbidity (aRR: 1.8) but not of depression at birth (aRR: 1.1). Compared with emergency CD, newborns delivered via ECD had less depression at birth (aRR: 0.6) and admission to special care (aRR: 0.8), but mortality (aRR: 0.8) and respiratory morbidity (aRR: 1.0) rates were similar. CONCLUSIONS: Gestational age-specific risk estimates are lowest between 38 and 40 weeks and should be included in the informed-consent process. The information should also be used to allow for appropriate preparation with respect to adequate staff and equipment. ECD is consistently associated with increased intrapartum and neonatal mortality, risk of admission, and respiratory morbidity compared with PVD and has no advantage over emergency CD in terms of mortality. Neonatal morbidities are lower after ECD than emergency CD only with term births. Our data provide evidence that ECD should not be performed before term.

Effect of crew resource management training in a multidisciplinary obstetrical setting.

OBJECTIVE: To assess the effect of a Crew Resource Management (CRM) intervention specifically designed to improve teamwork and communication skills in a multidisciplinary obstetrical setting. METHOD: Design--A before-and-after cross-sectional study designed to assess participants' satisfaction, learning and change in behaviour, according to Kirkpatrick's evaluation framework for training programmes. Setting--Labour and delivery units of a large university-affiliated hospital. Participants--Two hundred and thirty nine midwives, nurses, physicians and technicians from the department of anaesthesia, obstetrics and paediatrics. Intervention--All participants took part in a CRM-based training programme specifically designed to improve teamwork and communication skills. Principal measures of outcome-We assessed participants' satisfaction by means of a 10-item standardized questionnaire. A 36-item survey was administered before and after the course to assess participants' learning. Behavioural change was assessed by a 57-item safety attitude questionnaire measuring staff's change in attitude to safety over 1 year of programme implementation. RESULTS: Most participants valued the experience highly and 63-90% rated their level of satisfaction as being very high. Except for seven items, the 36-item survey testing participants' learning demonstrated a significant change (P<0.05) towards better knowledge of teamwork and shared decision making after the training programme. Over the year of observation, there was a positive change in the team and safety climate in the hospital [odds ratio (OR) 2.9, 95% confidence interval (CI) (1.3-6.3) to OR 4.7, 95% CI (1.2-17.2)]. **There was also improved stress recognition [OR 2.4, 95% CI (1.2-4.8) to OR 3.0, 95% CI (1.0-8.8)]. CONCLUSION: The implementation of a training programme based on CRM in a multidisciplinary obstetrical setting is well accepted and contributes to a significant improvement in interprofessional teamwork.

Mechanical support availability in pediatric cardiac surgery: program size should not matter.

Intractable heart failure may require Extracorporeal Life Support (ECLS) techniques for rescue therapy. Nevertheless, in many small to middle-sized centers in Europe, this valuable resource is not available. In our University pediatric intensive care unit 0.9% of 1360 open-heart surgical patients required mechanical assistance over the latest 9 years with a survival rate of 69.2% and low residual morbidity. This favorable overall outcome suggests that regardless of the program size, it is possible to ensure the availability of efficient mechanical assistance that appears to be fundamental in a center performing surgery for complex congenital or acquired cardiac diseases.

Stepping up versus standard doses of erythropoietin in preterm infants: a randomized controlled trial.

In this study, it is hypothesized that a planned increase in the dose of recombinant human erythropoietin (rh-EPO) can prevent transfusion in very low birth weight infants. Two different regimens of rh-EPO were administrated, one consisting in increasing dosage up to 5000 U/kg/wk, according to the individual reticulocytes response, and the second in a standard therapy of 1250 U/kg/wk. Fifty-one infants participated. Despite a significant higher reticulocytosis, the study was prematurely terminated due to the results of an interim analysis showing that transfusion was not avoided by increasing the rh-EPO. No significant differences were found between the two regimens concerning transfusion rate, volume transfused, gain in weight, and adverse effects. Progressive titration of rh-EPO to improve the biological response does not leave premature infants free of transfusion.

Home-based versus hospital-based postnatal care: a randomised trial.

OBJECTIVE: To compare a shortened hospital stay with midwife visits at home to usual hospital care after delivery. DESIGN: Randomised controlled trial. SETTING: Maternity unit of a Swiss teaching hospital. POPULATION: Four hundred and fifty-nine women with a single uncomplicated pregnancy at low risk of caesarean section. METHODS: Women were randomised to either home-based (n= 228) or hospital-based postnatal care (n= 231). Home-based postnatal care consisted of early discharge from hospital (24 to 48 hours after delivery) and home visits by a midwife; women in the hospital-based care group were hospitalised for four to five days. MAIN OUTCOME MEASURES: Breastfeeding 28 days postpartum, women's views of their care and readmission to hospital. RESULTS: Women in the home-based care group had shorter hospital stays (65 vs 106 hours, P < 0.001) and more midwife visits (4.8 vs 1.7, P < 0.001) than women in the hospital-based care group. Prevalence of breastfeeding at 28 days was similar between the groups (90%vs 87%, P= 0.30), but women in the home-based care group reported fewer problems with breastfeeding and greater satisfaction with the help received. There were no differences in satisfaction with care, women's hospital readmissions, postnatal depression scores and health status scores. A higher percentage of neonates in the home-based care group were readmitted to hospital during the first six months (12%vs 4.8%, P= 0.004). CONCLUSIONS: In low risk pregnancies, early discharge from hospital and midwife visits at home after delivery is an acceptable alternative to a longer duration of care in hospital. Mothers' preferences and economic considerations should be taken into account when choosing a policy of postnatal care.