Dwell times and risk of non-elective removal of 1-French peripherally inserted central catheters according to catheter tip position in very preterm infants.

We investigated dwell times and risk of non-elective removal of 975 single-lumen 1-French peripherally inserted central catheters (1FR-PICC) according to tip position in a cohort of very preterm infants with a mean (SD) gestational age of 27+6 (2+1) weeks and a mean (SD) birth weight of 988 (294) g over an eight-year period. Infants with a 1FR-PICC inserted for continuous infusion of intravenous fluids within the first 30 days of life were eligible. Dwell times of PICC with elective versus non-elective removal, risk of non-elective removal of PICC according to tip position, and differences between upper versus lower limb catheter insertion were analysed. 33.8% PICC were removed non-electively. Median (IQR) dwell time was 193 (142-287) versus 154 (102-260) h for elective versus non-elective removal (p < 0.001). Non-elective removal was more common for lower limb insertion sites: 41 versus 31% (p = 0.002). PICC were significantly more likely to be removed non-electively when located in the axillary (odds ratio (OR) 2.08), cephalic (OR 8.93), external iliac (OR 4.99), and femoral (OR 10.31) vein. CONCLUSION: In this cohort, dwell times of 1FR-PICC lines removed non-electively were similar to 1.9- or 2.0FR-PICC. PICC tips positioned in the axillary, cephalic, external iliac, and femoral veins had a higher risk of non-elective removal. What is Known: •Peripherally inserted central catheters (PICC) are widely used in neonatal intensive care. •Previous studies focused on 2-French PICC and newborns of all gestational ages. What is New: •Dwell times of 1-French PICC removed non-electively were similar to 2-French PICC. •1-French PICC tips positioned more peripherally had a higher risk of non-elective removal.

BNP, troponin I, and YKL-40 as screening markers in extremely preterm infants at risk for pulmonary hypertension associated with bronchopulmonary dysplasia.

Bronchopulmonary dysplasia (BPD) is often complicated by pulmonary hypertension (PH). We investigated three biomarkers potentially suitable as screening markers for extremely preterm infants at risk of BPD-associated PH. In this prospective observational cohort study conducted in a tertiary neonatal intensive care unit, 83 preterm infants with BPD born <28-wk gestation and still inpatients at 36-wk corrected age received an echocardiogram and blood tests of B-type natriuretic peptide (BNP), troponin I, and YKL-40. Infants were analyzed according to echocardiographic evidence of tricuspid regurgitation (TR). Thirty infants had evidence of TR on echocardiogram at 36-wk corrected age. Infants with or without TR had similar baseline demographics: mean ± SD gestational age 261 ± 12 vs. 261 ± 11 wk and birth weight 830 ± 206 vs. 815 ± 187 g, respectively. There was no difference in duration of respiratory support. The right ventricular systolic pressure of infants with evidence of TR was 40 ± 16 mmHg. BNP was the only biomarker that proved to be significantly higher in infants with evidence of TR: median (interquartile range) serum level 54.5 (35-105) vs. 41.5 (30-59) pg/ml, P = 0.043. Subgroup analysis of infants with severe BPD requiring discharge on home oxygen or BPD-related mortality revealed similar results. There was no difference between groups for troponin I and YKL-40. In conclusion, increased serum levels of BNP were associated with evidence of TR at 36-wk corrected gestational age in extremely preterm infants, suggesting a potential role as a screening biomarker for BPD-associated PH.

Gentamicin trough levels using a simplified extended-interval dosing regimen in preterm and term newborns.

UNLABELLED: To evaluate a simplified gentamicin extended-interval dosing regimen in a large cohort of preterm and term newborns, we conducted a retrospective cohort study over a 4-year period. All inborn newborns who received gentamicin for the first episode of suspected or proven sepsis were eligible. Newborns received 4 mg/kg gentamicin intravenously 24-hourly, except for those at <28 weeks of gestation who received gentamicin 36-hourly. Trough levels were taken before the third dose and considered non-toxic if ≤2 µg/mL. Infants were analysed in gestational age subgroups: <28 weeks, 28-31 weeks, 32-35 weeks, 36-39 weeks and ≥40 weeks. Newborns who received indomethacin co-medication were analysed separately. Nine hundred ninety-three newborns, gestational age range 23(+2)-42(+1) weeks, birth weight range 397-5936 g, were included. The median (interquartile range (IQR)) gentamicin trough level for all newborns was 1.3 µg/mL (0.8-1.7). Ninety per cent of newborns had non-toxic trough levels. The incidence of trough levels >2 µg/mL was between 2.2 and 9.7 % in all subgroups except for infants born at 28-31 weeks of gestation, where 21.7 % of trough levels were >2 µg/mL. Indomethacin co-medication significantly increased the median gentamicin trough level in preterm infants at <32 weeks of gestation. CONCLUSION: This study demonstrates that simplified gentamicin dosage regimens are feasible. Prospective evaluations are required to establish safety profiles.

B-type and N-terminal pro-B-type natriuretic peptides are equally useful in assessing patent ductus arteriosus in very preterm infants.

AIM: B-type natriuretic peptide (BNP) and N-terminal pro-BNP (NTproBNP) have been shown to correlate with the size of the patent ductus arteriosus (PDA) in preterm infants. We investigated whether BNP or NTproBNP was more closely correlated with PDA size. METHODS: This prospective observational study included preterm infants born <32 weeks' gestation who had an echocardiogram performed within the first four days of life. Blood samples were taken simultaneously for BNP and NTproBNP measurements prior to echocardiographic examination. RESULTS: Of the 60 infants recruited, 58 had complete data sets. The cohort's mean and standard deviation (SD) gestational age was 27(+3) (2(+2)) weeks, the mean (SD) birthweight was 1032 (315) grams, and 46 (79.3%) infants had a PDA with a mean (SD) diameter of 3.2 (0.9) mm. Median and interquartile range (IQR) BNP levels were 486.5 (219-1316) pg/mL for infants with a PDA and 190 (95.5-514.5) pg/mL for infants without a PDA. Median (IQR) NTproBNP levels were 10 858.5 (6319-42 108) pg/mL for infants with a PDA and 7488 (3363-14 227.5) pg/mL for infants without a PDA. Both BNP (R = 0.35, p = 0.0066) and NTproBNP (R = 0.31, p = 0.018) were significantly correlated with PDA size. CONCLUSION: BNP and NTproBNP are similarly useful for assessing PDA size in preterm infants.

Unplanned extubation and subsequent trial of noninvasive ventilation in the neonatal intensive care unit.

OBJECTIVE: Unplanned extubation (UE) occurs as an infrequent complication of mechanical ventilation in the neonatal intensive care unit (NICU). Following UE, a trial of noninvasive ventilation (NIV) may be considered if a neonate is showing adequate respiratory effort. This study investigated the success and failure rate of NIV management of neonates experiencing UE. STUDY DESIGN: Retrospective single-center study of neonates experiencing UE in the NICU over a 9-year period. Reintubation within 12 hours of a trial of NIV following UE was defined as treatment failure. Short-term respiratory outcomes were analyzed for all infants plus the incidence of bronchopulmonary dysplasia for preterm infants born less than 32 weeks' gestation. RESULTS: A total of 43 patients were included. Of those, 30 infants were trialed on NIV following UE. Baseline demographics were similar between both the groups except for the oxygen requirement before UE. The NIV was successful in 20 and failed in 10 infants. Infants who failed a trial of the NIV were reintubated between 0.45 and 5.25 hours following UE. Respiratory outcomes in very preterm infants did not differ between groups. CONCLUSION: A trial of NIV may be considered as a treatment option in preterm and term newborns experiencing UE in the NICU.

Accuracy of infrared thermometers in very low birth weight infants and impact on newborn behavioural states.

AIM: To study the impact on newborn behavioural states and accuracy of three infrared thermometers compared with digital axillary thermometer measurements in very low birth weight infants. METHODS: Single-centre prospective observational study. Preterm infants born <1500-g birth weight were eligible. Infants were observed for pre-measurement behaviour state using a five-point neonatal behaviour observation tool. One infrared temperature was taken from each of the devices, followed by an axillary measurement. Further behaviour-state observations were recorded following infrared and axillary measurements. RESULTS: One hundred measurements were collected from each infrared device among a cohort of 42 very low birth weight infants. Only one infrared device showed satisfactory agreement with bias -0.071 (95% limits of agreement -0.68 to 0.54). The other two devices demonstrated poor agreement: bias -1.34; 95% limits of agreement -2.62 to -0.5 and bias -0.56; 95% limits of agreement -1.38 to 0.25. Neonatal behavioural scores showed only minimal changes when infrared measurements were performed but increased significantly following axillary measurements. The difference between the two modalities was statistically significant with a mean increase of 1.44 points following axillary measurements (95% confidence interval 1.21 to 1.67, P < 0.001). CONCLUSIONS: Temperature measurements taken with infrared thermometers demonstrated less disruption to preterm infants' behavioural state, however accuracy of devices varied.

Association of BNP, NTproBNP, and early postnatal pulmonary hypertension in very preterm infants.

OBJECTIVE: B-type natriuretic peptide (BNP) has been shown to correlate with pulmonary hypertension (PH) in term neonates with persistent pulmonary hypertension of the newborn or congenital diaphragmatic hernia, and in very preterm infants with bronchopulmonary dysplasia. This study investigated the potential association of BNP and N-terminal-pro-BNP (NTproBNP) and PH within the first 72 hr of life in very preterm infants. METHODS: Preterm infants <32 weeks gestational age who received an echocardiogram within the first 72 hr of life were eligible. BNP and NTproBNP were sampled at the time of the echocardiogram. Right ventricular systolic pressure (RVSP) was calculated as a surrogate marker of PH. Simple and multiple linear regression analysis was performed to examine associations and potential confounding factors. RESULTS: Sixty-one infants were included with a median (IQR) birth weight of 983 g (826-1,167) and a median (IQR) gestational age of 27(2) weeks (26(2) -28(6) ). There was no difference between BNP or NTproBNP levels for infants with or without measurable RVSP. There was no significant correlation of BNP and RVSP in multiple linear regression analysis (regression coefficient -0.0035 (95%CI: -0.020 to 0.013), P = 0.67). Also, NTproBNP and RVSP were not significantly correlated in multiple linear regression analysis (regression coefficient 0.0071 (95%CI: -0.019 to 0.033), P = 0.58). CONCLUSION: B-type natriuretic peptides did not correlate with RVSP in the early postnatal period of very preterm infants. Pediatr Pulmonol. 2016;51:820-824. © 2016 Wiley Periodicals, Inc.

Bronchopulmonary dysplasia in preterm infants managed with non-invasive ventilation or surfactant and a brief period of mechanical ventilation: a 6-year cohort study.

OBJECTIVE: Non-invasive ventilation (NIV) is increasingly used as first-line management of respiratory distress syndrome in preterm infants to avoid the lung-damaging effects of mechanical ventilation (MV). We hypothesised that even a short period of MV following surfactant treatment would increase the rate of bronchopulmonary dysplasia (BPD). METHODS: Retrospective study including preterm infants <30 weeks gestational age over a six-year period if they required surfactant followed by MV not longer than 24 h (SURF&MV group) or if managed exclusively with NIV (NIV group). Baseline and morbidity variables such as gestation, birth weight, sex, place of birth, antenatal steroids, sepsis, pneumothorax, intraventricular haemorrhage, necrotising enterocolitis, and patent ductus arteriosus were analysed in a multivariate model for potential confounding. RESULTS: 289 infants were included: 150 in the NIV group and 139 in the SURF&MV group. Seventeen infants in the NIV group and 23 in the SURF&MV group developed BPD (odds ratio: 1.55; 95% confidence interval (CI): 0.79-3.05; p = 0.202). After adjusting for potential confounders, the odds ratio was 1.09 for the SURF&MV group to develop BPD (95% CI: 0.52-2.28; p = 0.812). CONCLUSION: The rate of BPD did not differ between infants managed with NIV or with surfactant administration followed by ≤24 h of MV after adjusting for confounding factors.

The effect of sildenafil on evolving bronchopulmonary dysplasia in extremely preterm infants: a randomised controlled pilot study.

OBJECTIVE: Sildenafil has been shown to preserve alveolar growth and lung angiogenesis in a rat model of bronchopulmonary dysplasia. We conducted a proof-of-concept randomised controlled pilot study to assess the feasibility of oral sildenafil treatment in extremely preterm infants with evolving bronchopulmonary dysplasia. METHODS: Preterm infants <28 weeks gestational age were eligible if they were mechanically ventilated on day 7 of life. Infants were randomised to a 4-weeks course of either oral sildenafil (3 mg/kg/day) or placebo solution. Pre-discharge cardiorespiratory outcomes and medication side effects were collected. RESULTS: Twenty infants were randomised, 10 received sildenafil (mean gestational age 24 + 5 weeks (SD 4.9 days), mean weight 692 g (SD 98)) and 10 received placebo (mean gestational age 24 + 5 weeks (SD 6.5 days), mean weight 668 g (SD 147)). One infant in the sildenafil group did not receive treatment because of an early pneumoperitoneum. Two infants did not complete the study (transferred out). Of the remaining seven treated infants, three died (two from respiratory-related causes). One infant in the control group died from a non-respiratory cause. Sildenafil did not reduce length of invasive (median 688 versus 227 h) or non-invasive ventilation (median 1609 versus 1416 h). More infants in the sildenafil group required postnatal steroid treatment. One infant developed hypotension following sildenafil administration and was excluded after three doses. CONCLUSIONS: In this pilot study, oral sildenafil treatment did not improve any short-term respiratory outcomes in extremely preterm infants.