Duration of mechanical ventilation and prediction of bronchopulmonary dysplasia and home oxygen in extremely preterm infants.

AIM: To determine whether the duration of invasive ventilation predicted the development of bronchopulmonary dysplasia (BPD) and need for discharge home on supplementary oxygen in extremely preterm infants. METHODS: Retrospective whole-population study of all infants <28 weeks of gestation admitted to a neonatal unit in England between 2014 and 2018. BPD development was defined as any respiratory support at 36 weeks postmenstrual age. The performance of the duration of mechanical ventilation to predict BPD or discharge home on oxygen was assessed by receiver operator characteristic curve analysis. RESULTS: The 11,806 infants had a median (IQR) gestational age of 26.0(24.9-27.1) weeks and birthweight of 0.81(0.67-0.96) kg. At discharge from neonatal care, 9,415 infants (79.7%) were alive. The incidence of BPD was 57.5% and of home oxygen 29.4%. Mechanical ventilation duration had areas under the curve of 0.793 and 0.703 in predicting BPD and home oxygen, respectively. Mechanical ventilation for >8 days predicted BPD development with 71% sensitivity and 71% specificity and mechanical ventilation for >10 days predicted discharge on home oxygen with 66% sensitivity and 65% specificity. CONCLUSION: In extremely preterm infants, the duration of invasive support predicted BPD and need for home oxygen with moderate sensitivity and specificity.

Tidal Volumes and Outcome of Extubation in Mechanically Ventilated Premature Infants.

OBJECTIVES: To compare the adjusted and unadjusted-for-weight tidal volume (VT) in ventilated prematurely born infants who were successfully extubated compared with the ones who failed extubation and explore the ability of VT to predict successful extubation. STUDY DESIGN: This is a two-center, prospective, observational, cohort study of ventilated infants born <32 weeks of gestational age (GA) at King's College Hospital and St George's University Hospital, London, United Kingdom between February and September 2018. Expiratory VT was recorded before extubation, and extubation was considered successful if the infants were not reintubated within 72 hours. RESULTS: Fifty-six (29 male) infants with a median (interquartile range) GA of 26 (25-29) weeks were studied. The infants who successfully extubated (N = 36) had a higher GA (27 [25-30] weeks) and VT (7.2 [4.8-9.5] mL) compared with the GA (25 [24-26] weeks) and VT (4.3 [4.0-5.5] mL) of the infants who failed extubation (p = 0.002 and p = 0.001, respectively). VT/kg was not different in infants who successfully extubated compared with the ones who failed extubation (p = 0.643). Following multivariate regression, VT was associated with extubation success (adjusted p = 0.022) and GA was not (adjusted p = 0.167). A VT > 4.5 mL predicted successful extubation with 82% sensitivity and 58% specificity (area under the curve = 0.786). CONCLUSION: Successful extubation was associated with higher unadjusted-for-weight VTs compared with failed extubation, and unadjusted VT predicted extubation outcome with moderate sensitivity and specificity.

Chronology and Determinants of Respiratory Function Changes Following Administration of Systemic Postnatal Corticosteroids in Extremely Preterm Infants.

OBJECTIVE: To describe the effect of systemic corticosteroids administered to treat evolving bronchopulmonary dysplasia on oxygen diffusion and ventilation efficiency. STUDY DESIGN: This was a retrospective cohort study of ventilated infants who received a 9-day course of dexamethasone in a tertiary neonatal unit. We calculated the transcutaneous oxygen saturation-to-fraction of inspired oxygen (FiO2) ratio (SFR), the ventilation perfusion ratio (VA/Q), and the ventilation efficiency index (VEI) before, during, and after the course of corticosteroids. The response to corticosteroids was calculated as the difference between the FiO2 percentage before starting steroids and the lowest FiO2 value during the course of steroid treatment. RESULTS: Seventy infants (38 males) with a median gestational age (GA) of 25.0 weeks (IQR, 24.3-26.0 weeks) and a median birth weight of 0.70 kg (IQR, 0.63-0.82 kg) were studied at a median postnatal age of 39 days (IQR, 29-48 days). The median SFR before treatment was 1.42 (IQR, 1.19-1.72), and the highest SFR was 2.35 (IQR, 1.87-2.83) after 9 days of treatment. The median VA/Q before treatment was 0.14 (IQR, 0.11-0.18) and was significantly higher at 72 hours after the start of treatment (0.22; IQR, 0.15-0.29; P < .001). The median VEI was 0.06 (IQR, 0.04-0.08) before treatment and was highest, 0.10 (IQR, 0.07-0.13) at 48 hours after starting treatment. The median rate of response to corticosteroids was 28% (IQR, 20%-37%). GA was significantly related to the response to corticosteroids (ρ = 0.283; P = .019). CONCLUSIONS: Oxygen diffusion continues to improve throughout the entire duration of a 9-day course of systemically administered corticosteroids in ventilated extremely preterm infants. More immature infants are less responsive to corticosteroids.

Prolonged ventilation and postnatal growth of preterm infants.

Background Extremely premature infants often need invasive respiratory support from birth, but have low nutritional reserves and high metabolic demands. Our aim was to determine if there was a relationship between prolonged ventilation and reduced postnatal growth in such infants. Methods A retrospective, observational study was undertaken. Data from infants born at less than 28 weeks of gestational age and ventilated for 7 days or more were collected and analysed including gestational age, gender, birth and discharge weight, birth and discharge head circumference, days of invasive mechanical ventilation and use of postnatal corticosteroids. The duration of invasive mechanical ventilation and the differences in weight (ΔWz) and head circumference (ΔHz) z-score from birth to discharge were calculated. Results Fifty-five infants were studied with a median [interquartile range (IQR)] gestational age at birth of 25.3 (24.3-26.7) weeks and birth weight of 0.73 (0.65-0.87) kg. The median duration of mechanical ventilation was 45 (33-68) days. Both ΔWz and ΔHz were significantly negatively correlated to the number of invasive mechanical ventilation days (P = 0.01 and P = 0.03, respectively), but not to the use of postnatal corticosteroids. Conclusion Poor postnatal growth is significantly negatively associated with a longer duration of mechanical ventilation in extremely prematurely born infants.

Small for gestational age and extremely low birth weight infant outcomes.

Background Small for gestational age (SGA) infants are less likely to develop respiratory distress syndrome (RDS), but more likely to develop bronchopulmonary dysplasia (BPD) and have a higher mortality. Our aim was to focus on outcomes of those with a birth weight less than or equal to 750 g. Methods The mortality, BPD severity, necrotising enterocolitis (NEC), home oxygen requirement and length of hospital stay were determined according to SGA status of all eligible infants in a 5-year period admitted within the first 24 h after birth. Results The outcomes of 84 infants were assessed, and 35 (42%) were SGA. The SGA infants were more mature (P<0.001), had a lower birth weight centile (P<0.001) and a greater proportion exposed to antenatal corticosteroids (P=0.022). Adjusted for gestational age (GA), there was no significant difference in mortality between the two groups (P=0.242), but a greater proportion of the SGA infants developed severe BPD (P=0.025). The SGA infants had a lower weight z-score at discharge (-3.64 vs. -1.66) (P=0.001), but a decrease in z-score from birth to discharge was observed in both groups (median -1.53 vs. -1.07, P=0.256). Conclusion Despite being more mature, the SGA infants had a similar mortality rate and a greater proportion developed severe BPD.

Deltoid muscle morphometry as an index of impaired skeletal muscularity in neonatal intensive care.

We hypothesised that extremely premature infants would have decreased muscle mass at term-corrected age compared to term-born infants and that the degree of reduced muscle mass acquisition would correlate with the duration of invasive mechanical ventilation. The MRI brain scans of infants admitted in the neonatal unit at King's College Hospital between 1 January 2010 and 1 June 2016 were retrospectively reviewed. The coronal cross-sectional area of the left deltoid muscle (DCSA) was measured in 17 infants born < 28 weeks of gestation and in 20 infants born at term. The prematurely born infants had a median (IQR) gestation age of 25 weeks (24-27) and the term infants 40 weeks (38-41). The duration of invasive mechanical ventilation for the prematurely born infants was 39 days (14-62) and that for the term infants 4 days (2-5), p < 0.001. DCSA was smaller in prematurely born infants (median 189, IQR 176-223 mm2) compared to term-born infants (median 302, IQR 236-389 mm2), p < 0.001. DCSA was related to gestation age (r = 0.545, p = 0.001), weight z-score at MRI (r = 0.658, p < 0.001) and days of invasive mechanical ventilation (r = - 0.583, p < 0.001). In conclusion, extremely premature infants studied at term had a lower muscle mass compared to term-born infants. CONCLUSION: Our results suggest that prolonged mechanical ventilation in infants admitted in neonatal intensive care is associated with reduced skeletal muscle mass acquisition. What is Known: • Prolonged mechanical ventilation in adult intensive care patients has been associated with skeletal muscle dysfunction and atrophy. • The cross-sectional area of the deltoid muscle has been used to evaluate muscle atrophy in infants with a previous branchial plexus birth injury. What is New: • Premature infants studied at term exhibit lower cross-sectional area of the deltoid muscle than their term counterparts. • Prolonged mechanical ventilation could be associated with skeletal muscle impairment.

Mortality and short-term morbidity in infants with exomphalos.

BACKGROUND: Infants with exomphalos major have a high mortality and morbidity. The aims of this study were to identify predictors of survival regardless of the size of the exomphalos, and to analyze morbidity in infants with exomphalos minor. METHODS: Patients were classified as having exomphalos major or minor based on whether the liver was in the exomphalos sac, and the size of the abdominal wall defect. The respiratory, gastrointestinal and surgical outcomes of 50 infants with exomphalos (including 27 with exomphalos major) were assessed. Receiver operating characteristic (ROC) curves were constructed to identify factors predictive of survival. RESULTS: No infant with exomphalos minor died; there were seven deaths in the exomphalos major group (P < 0.001). Infants with exomphalos minor who had chromosomal abnormalities (six had a genetic diagnosis of Beckwith-Wiedemann syndrome) developed severe respiratory distress or chronic respiratory morbidity. Nasogastric feeding at discharge was required in 37% of infants with exomphalos major and in 17% with exomphalos minor. Lower gestational age (area under the ROC curve [AUROC], 0.814) and birthweight (AUROC, 0.797), and longer duration of ventilation (AUROC, 0.853) and of supplementary oxygen (AUROC, 0.810) were predictive of mortality. CONCLUSIONS: Infants with exomphalos regardless of size can have chronic morbidity. Mortality is commonest in those with exomphalos major born at lower gestational age and birthweight.

Proportional assist versus assist control ventilation in premature infants.

During proportional assist ventilation (PAV), the applied pressure is servo-controlled based on continuous input from the infant's breathing. In addition, elastic and resistive unloading can be employed to compensate for the abnormalities in the infant's lung mechanics. The aim of this study was to test the hypothesis that in very prematurely born infants remaining ventilated beyond the first week, PAV compared to assist control ventilation (ACV) would be associated with superior oxygenation. A randomised crossover study was undertaken. Infants were studied for 4 hours each on PAV and ACV in random order; at the end of each 4-h period, the oxygenation index (OI) was calculated. Eight infants, median gestational age of 25 (range 24-33) weeks, were studied at a median of 19 (range 10-105) days. It had been intended to study 18 infants but as all the infants had superior oxygenation on PAV (p = 0.0039), the study was terminated after recruitment of eight infants. The median inspired oxygen concentration (p = 0.049), mean airway pressure (p = 0.012) and OI (p = 0.012) were all lower on PAV. CONCLUSION: These results suggest that PAV compared to ACV is advantageous in improving oxygenation for prematurely born infants with evolving or established BPD. WHAT IS KNOWN: During proportional assist ventilation (PAV), the applied pressure is servo controlled throughout each spontaneous breath. Elastic and resistive unloading can compensate for the infant's abnormalities in lung mechanics. WHAT IS NEW: In a randomised crossover study, infants with evolving/established BPD were studied on PAV and ACV each for 4 h. The oxygenation index was significantly lower on PAV in all infants studied.

Congenital diaphragmatic hernia-influence of fetoscopic tracheal occlusion on outcomes and predictors of survival.

UNLABELLED: The morbidity of infants with congenital diaphragmatic hernia (CDH) who had undergone foetal endoscopic tracheal occlusion (FETO) to those who had not was compared and predictors of survival regardless of antenatal intervention were identified. FETO was undertaken on the basis of the lung to head ratio or the position of the liver. A retrospective review of the records of 78 CDH infants was undertaken to determine the lung-head ratio (LHR) at referral and prior to birth, maximum oxygen saturation in the labour suite and neonatal outcomes. The 43 FETO infants were born earlier (mean 34 versus 38 weeks) (p < 0.001). They had a lower mean LHR at referral (0.65 versus 1.24) (p < 0.001) but not prior to birth and did not have a higher mortality than the 35 non-FETO infants. The FETO infants required significantly longer durations of ventilation (median: 15 versus 6 days) and supplementary oxygen (28 versus 8 days) and hospital stay (29 versus 16 days). Overall, the best predictor of survival was the OI in the first 24 h. CONCLUSION: The FETO group had increased morbidity, but not mortality. The lowest oxygenation index in the first 24 h was the best predictor of survival regardless of antenatal intervention. WHAT IS KNOWN: • Randomised controlled trials have demonstrated that foetal endotracheal occlusion (FETO) in high risk infants with congenital diaphragmatic hernia is associated with a higher survival rate. • Mortality is greater in foetuses who underwent FETO and delivered prior to 35 weeks of gestation. What is New: • Infants who had undergone FETO compared to those who had not had significantly longer durations of mechanical ventilation, supplementary oxygen and hospital stay. • Regardless of antenatal intervention, the lowest oxygenation index in the first 24 h was the best predictor of survival.

Mortality following congenital diaphragmatic hernia repair: the role of anesthesia.

BACKGROUND: Mortality following surgical repair of congenital diaphragmatic hernia (CDH) remains high. The volume and type of perioperative intravenous fluid administered, baro-trauma, oxygen toxicity, and the duration of anesthesia are thought to affect outcome in surgical populations. AIMS: The aim of this retrospective observational study was to determine whether the perioperative volume or type of fluids and/or the duration of anesthesia were associated with postoperative mortality and if mortality was predicted by the oxygenation index (OI) prior to or following CDH surgical repair. METHODS: The records of infants with a left-sided CDH and without other congenital anomalies, who underwent surgical repair between April 2009 and March 2015, were examined. The oxygenation index was used to "quantify" the severity of lung function abnormality and reported as the best OI on day 1 after birth (OIBEST ), the OI immediately prior to surgery (OIPRE ) and at 1, 6, 12, and 24 h postsurgery (OI1h , OI6h , OI12h , OI24h ), respectively. The change in the OI index (delta OI) was calculated by subtracting OIPRE from postoperative OIs. RESULTS: The records of 37 CDH infants (median gestational age 35.8, range 31.5-41.4 weeks) were assessed; six died postoperatively. Neither the duration of anesthesia, the volume of crystalloids or colloids administered, nor the peak inflation pressures used during surgical repair were significantly correlated with postoperative mortality. Neither fetal tracheal occlusion nor use of a parietal patch significantly influenced mortality. The postoperative OI1h , OI6h , OI12h showed weak evidence for a difference between survivors and nonsurvivors. An OI24h of ≥5.5 predicted mortality with 100% sensitivity (95% CI, confidence intervals (CI) 40-100) and 93.1% specificity (95% CI, 77-99). CONCLUSION: Neither the volume of intraoperative fluids administered nor the duration of anesthesia was associated with postoperative death. The OI 24 h postsurgery was the best predictor of an increased risk of mortality.

Outcomes of biventricular mechanical support patients discharged to home to await heart transplantation.

BACKGROUND: The use of left ventricular assist devices has grown rapidly in recent years for patients with end-stage heart failure. A significant proportion of patients require both left- and right-sided support with biventricular assist devices (BiVADs) as a bridge to transplantation. Traditionally, these patients have waited in the hospital until they receive a transplant. PURPOSE: The aim of this study was to characterize the clinical course of BiVAD patients discharged to home to await heart transplantation. METHODS: Between November 2009 and July 2011, 24 adult patients underwent Thoratec paracorporeal BiVAD placement at the University of California Los Angeles, all with an Interagency Registry for Mechanically Assisted Circulatory Support score 1 or 2. The disposition, complications, and rehospitalizations of these subjects were retrospectively reviewed. RESULTS: Fourteen of the 24 patients were successfully discharged to home, with a mean time of 60 ± 27 days from BiVAD implantation to discharge. Ninety-three percent (13/14) of the patients sent home went on to be transplanted. Eleven of the 14 (79%) came in from home to receive their transplant. The mean time from BiVAD implantation to transplantation was 100 ± 65 days. Of the 14 patients discharged to home, there were 18 readmissions in 8 patients. CONCLUSION: In this small single-center review, we found that complex medical patients with BiVADs can be discharged to home and can await a heart transplant from home under the close management of multidisciplinary acute care and outpatient teams.

READS: the rapid electronic assessment documentation system.

Patient documentation is time consuming and can detract from care. The authors report a novel computer programme that manipulates routinely collected information to quantify nursing workload, along with the reason for admission, functional status, estimates of in-hospital mortality and life expectancy. The programme stores information in a database, and produces a print-out in a situation/background/assessment/recommendation (SBAR) format. The average time taken to enter 629 patient encounters was 6.6 minutes. Pain was the most common presentation for low workload patients, while high workload patients often presented with altered mental status and reduced mobility. There was only a modest correlation between the risk of death and nursing workload. The programme measures nursing workload without further paperwork, and improves routine documentation with a legible brief report that is automatically generated. This report can be shared and provides data that is immediately available for day-to-day care, audit, quality control and service planning.

Mortality after 36 weeks postmenstrual age of extremely preterm infants in neonatal care: The impact of growth impairment and bronchopulmonary dysplasia.

BACKGROUND: A small group of extremely preterm infants survive to 36 weeks postmenstrual age (PMA), but die before discharge from neonatal care. AIMS: To investigate which epidemiological and clinical parameters were related to death after 36 weeks PMA in extremely preterm infants. STUDY DESIGN: Retrospective whole-population study. SUBJECTS: All infants born <28 weeks of gestation admitted to a neonatal unit in England between 2014 and 2018. OUTCOME MEASURES: Mortality after 36 weeks PMA and before discharge from neonatal care. Bronchopulmonary dysplasia (BPD) defined as any respiratory support at 36 weeks PMA. RESULTS: Death after 36 weeks PMA occurred in 156 of a total of 11.747 included infants (1.3 %) and at a median (IQR) age of 130 (93-164) days. A lower gestational age [Odds Ratio: 0.82, 95 % CI:0.72-0.94, adjusted p = 0.005], lower birth weight z-score [Odds Ratio: 0.45, 95 % CI:0.36-0.56, adjusted p < 0.001], greater absolute difference in weight z-score from birth to 36 weeks PMA [Odds Ratio: 0.46, 95 % CI:0.38-0.56, adjusted p < 0.001] were independently associated with death after 36 weeks PMA. A diagnosis of BPD [Odds Ratio: 4.57, 95 % CI:2.19-9.54, adjusted p < 0.001] and of necrotising enterocolitis requiring surgery [Odds Ratio: 2.81, 95 % CI:1.82-4.34, adjusted p < 0.001] were also independently associated with death after 36 weeks PMA. CONCLUSIONS: Mortality of extremely preterm infants after 36 weeks postmenstrual age is associated with lower gestational age and more impaired growth. The diagnoses of bronchopulmonary dysplasia and necrotising enterocolitis were associated with a higher risk of death after 36 weeks postmenstrual age and before discharge from neonatal care.

Multiprofessional cross-site working between a level 1 and a level 3 neonatal unit: a retrospective cohort study.

OBJECTIVE: To assess the association of short-term neonatal outcomes with cross-site working of multiple healthcare professional teams between a level 3 and a level 1 neonatal unit. DESIGN: Retrospective cohort study. SETTING: A level 1 neonatal unit in London. PATIENTS: All infants admitted to the neonatal unit, between 2010 and 2021. INTERVENTIONS: The clinical service was rearranged in 2014 with the introduction of cross-site working between the level 1 unit and a level 3 unit of neonatal doctors, nurses and allied healthcare professionals. MAIN OUTCOME MEASURES: Admission of infants with a temperature less than 36°C, length of stay and time to first consultation by a senior team member. RESULTS: A total of 4418 infants were admitted during the study period. The percentage of infants delivered at a gestation below 32 weeks was higher in the pre-cross-site period (8.9%) compared with the cross site period (3.6%, p<0.001). The percentage of infants with an Apgar score less than 8 at 10 min was higher in the pre-cross-site period (6.2%) compared with the cross-site period (3.4%, p=0.001). More infants were admitted with a temperature less than 36°C in the pre-cross site period (12.3%) compared with the cross site period (3.7%, p<0.001). The median (IQR) duration of time to first consultation by a senior team member was higher in the pre-cross-site period (1 (0.5-2.6) hours) compared with the cross-site period (0.5 (0.2-1.3) hours) (p<0.001). The median (IQR) length of stay was 4 (2-11) days in the pre-cross-site period and decreased to 2 (1-4) days in the cross-site period (p<0.001). CONCLUSIONS: Cross-site working was associated with lower rates of admission hypothermia, shorter duration of stay and earlier first senior consultation.

Assessing the impact of the COVID-19 pandemic on parental satisfaction in two European neonatal intensive care units.

BACKGROUND: Neonatal units across the world have altered their policies to prevent the spread of infection during the COVID-19 pandemic. Our aim was to report parental experience in two European neonatal units during the pandemic. METHODS: Parents of infants admitted to each neonatal unit were asked to complete a questionnaire regarding their experience during the COVID-19 pandemic. At King's College Hospital, UK (KCH), data were collected prospectively between June 2020 and August 2020 (first wave). At the Hospital Clínic Barcelona (HCM), data were collected retrospectively from parents whose infants were admitted between September 2020 and February 2021 (second and third wave). RESULTS: A total of 74 questionnaires were completed (38 from KCH and 36 from HCM). The parents reported that they were fully involved or involved in the care of their infants in 34 (89.4%) responses in KCH and 33 (91.6%) responses in HCM. Quality time spent with infants during the pandemic was more negatively affected at KCH compared with HCM (n=24 (63.2%) vs n=12 (33.3%)). Parents felt either satisfied or very satisfied with the updates from the clinical care team in 30 (79.0%) responses at KCH and 30 (83.4%) responses in HCM. The parents felt that the restrictions negatively affected breast feeding in six (15.8%) responses at KCH and two (5.6%) responses in HCM. Travelling to the hospital was reported overall to be sometimes difficult (39.2%); this did not differ between the two units (14 (36.8%) respondents at KCH and 15 (41.6%) from HCM). Furthermore, the self-reported amount of time spent giving kangaroo care also did not differ between the two countries. CONCLUSION: Restrictive policies implemented due to the COVID-19 pandemic had a negative impact on the perception of quality of time spent by parents with their newborns admitted to neonatal units.

Bronchopulmonary dysplasia and postnatal growth following extremely preterm birth.

OBJECTIVES: To report the current incidence of bronchopulmonary dysplasia (BPD) and to compare changes in weight and head circumference between infants who developed BPD and infants who did not. DESIGN: Retrospective, whole-population study. SETTING: All neonatal units in England between 2014 and 2018. PATIENTS: All liveborn infants born <28 completed weeks of gestation. INTERVENTIONS: The change in weight z-score (ΔWz) was calculated by subtracting the birthweight z-score from the weight z-score at 36 weeks postmenstrual age (PMA) and at discharge. The change in head circumference z-score (ΔHz) was calculated by subtracting the birth head circumference z-score from the head circumference z-score at discharge. MAIN OUTCOME MEASURE: BPD was defined as the need for any respiratory support at 36 weeks PMA. RESULTS: 11 806 infants were included in the analysis. The incidence of BPD was 57.5%, and 18.9% of the infants died before 36 weeks PMA. The median (IQR) ΔWz from birth to 36 weeks PMA was significantly smaller in infants who developed BPD (-0.69 (-1.28 to -0.14), n=6105) than in those who did not develop BPD (-0.89 (-1.40 to -0.33), n=2390; adjusted p<0.001). The median (IQR) ΔHz from birth to discharge was significantly smaller in infants who developed BPD (-0.33 (-1.69 to 0.71)) than in those who did not develop BPD (-0.61 (-1.85 to 0.35); adjusted p<0.001). CONCLUSIONS: Postnatal growth was better in infants diagnosed with BPD compared with infants without BPD possibly due to more aggressive nutrition strategies.

Premature infants with patent ductus arteriosus: Postnatal growth according to type of management.

BACKGROUND: Patent Ductus Arteriosus (PDA) is a common condition, affecting nearly half of infants born before 28 weeks' of gestation, and it has been associated with poor growth. It is not known if different treatment modalities are associated with more profound growth impairment. Our aim was to compare differences in weight gain at 36 weeks' corrected gestational age (CGA) in premature infants that received medical, surgical or conservative management for PDA. METHODS: We retrospectively reviewed notes of 208 infants born under 30 weeks' gestation with a diagnosis of PDA. Gestational age (GA) at birth, birth weight z-score, CGA and weight z-score at 36 weeks' CGA were collected. In our cohort, surgical closure was performed in infants who remained symptomatic after medical or conservative management. RESULTS: Ninety-four infants had medical, 56 surgical and 58 conservative management. Surgically managed infants had a lower median (IQR) GA [24.4 (24.0-26.1) weeks'] than medically [25.4 (24.6-26.5) weeks'] or conservatively managed [26.4 (25.4-28.1) weeks', p < 0.001] infants. There was no difference in birth weight z-scores across the groups. Surgically managed infants demonstrated a greater decrease in weight z-score [-2.24 (-2.89 to -1.53)] compared to medically [-1.79 (-2.45 to -1.35)] and conservatively [-1.57 (-1.99 to -1.28), p < 0.001] managed infants between birth and 36 weeks' CGA. After adjusting for GA at birth, definitive treatment modality was significantly related to change in weight z-score from birth to 36 weeks' CGA (adjusted p = 0.022). CONCLUSION: Premature infants with PDA who were managed surgically had a greater degree of faltering growth compared to those who were treated medically or conservatively.

Respiratory monitoring during less invasive surfactant administration in the delivery suite.

BACKGROUND: On the neonatal unit less invasive surfactant administration (LISA) reduces BPD and the need for mechanical ventilation. AIMS: To evaluate the feasibility of LISA in the delivery suite and to undertake respiratory function physiological monitoring before and after LISA. STUDY DESIGN: A prospective, observational cohort study was undertaken. A LISA simulation training programme was delivered. Then, LISA was undertaken in infants with respiratory distress maintained on continuous positive airway pressure (CPAP) in the delivery suite using videolaryngoscopic guidance without sedation. SUBJECTS: Thirty-eight infants with a median (IQR) gestational age of 31 + 5 weeks (30+3-33+4) and birth weight of 1.61 (1.42-1.90) kg had LISA in the delivery suite. OUTCOME MEASURES: Adverse effects of LISA and whether LISA resulted in changes in tidal and minute volumes, end tidal carbon dioxide (EtCO2) levels and the inspired oxygen concentration (FiO2). RESULTS: Respiratory function monitoring was available for 34 of the infants. LISA occurred at a median (IQR) interval of 18 (15-29) minutes after birth. The most common adverse events were desaturation (44.7%) and surfactant reflux (39.5%), both responded to either temporary suspension of LISA or slowing the speed of surfactant administration. Following LISA, there was a significant reduction in respiratory rate 2 min later (p < 0.001) and in the FiO2 2 h later (p < 0.001). CONCLUSIONS: LISA is feasible in the delivery suite after appropriate training of staff. It can be undertaken without serious adverse effects and results in a reduction in respiratory distress and improvement in oxygenation.

Introduction of 24 h Resident Consultant Cover in a Tertiary Neonatal Unit-Impact on Mortality and Clinical Outcomes.

BACKGROUND: We aimed to determine whether the introduction of 24 h cover by resident consultants in a tertiary neonatal unit affected mortality and other clinical outcomes. METHODS: Retrospective cohort study in a tertiary medical and surgical neonatal unit between 2010-2020 of all liveborn infants admitted to the neonatal unit. Out of hours cover was rearranged in 2014 to ensure 24 h presence of a senior trained neonatologist (resident consultant). RESULTS: In the study period, 4778 infants were included: 2613 in the pre-resident period and 2165 in the resident period. The median (IQR) time to first consultation by a senior member of staff was significantly longer in the pre-resident period [1.5 (0.6-4.3) h] compared to the resident period [0.5 (0.3-1.5) h, p < 0.001]. Overall, mortality was similar in the pre-resident and the resident periods (3.2% versus 2.3%, p = 0.077), but the mortality of infants born at night was significantly higher in the pre-resident (4.5%) compared to the resident period (2.5%, p = 0.016). The resident period was independently associated with an increased survival to discharge (adjusted p < 0.001, odds ratio: 2.0) after adjusting for gestational age, admission temperature and duration of ventilation. CONCLUSIONS: Following introduction of a resident consultant model the mortality and time to consultation after admission decreased.

Congenital diaphragmatic hernia in newborn infants: Variable endotracheal tube and umbilical venous catheter positions.

We reviewed the radiographs of 131 infants with congenital diaphragmatic hernia and report that the umbilical venous catheter usually deviates to the ipsilateral and the endotracheal tube to the contralateral side of the defect. The trachea and the umbilical vein, however, can be found on either side of the midline.