Administración de surfactante mediante técnica mínimamente invasiva en neonatos / Administration of Surfactants by Minimally Invasive Technique in Neonates

Introducción: La administración de surfactante pulmonar tradicionalmente se realiza mediante un tubo endotraqueal, pero desde hace años existen técnicas menos invasivas como la administración mediante másscara laríngea, aerosolización y cateterización traqueal. Objetivos: Demostrar la evolución de tres neonatos que recibieron surfactante pulmonar mediante una cateterización traqueal y describir la técnica empleada para su administración. Presentación de casos: Se atendieron tres recién nacidos de muy bajo peso al nacer, que ingresaron en la unidad de cuidados intensivos neonatales del Hospital General Docente Iván Portuondo, San Antonio de los Baños, con síndrome de dificultad respiratoria del prematuro. Todos se trataron con surfactante pulmonar exógeno, Surfacen®, el cual se administró mediante cateterización traqueal empleando un catéter umbilical. Se trata de una técnica mínimamente invasiva que se realizó sin dificultades y siempre en el primer intento. Los tres pacientes mostraron mejoría clínica, gasométrica y radiográfica con esta forma de administración y solo uno de ellos tuvo una complicación durante el proceder, que no constituyó una limitante para su realización. Este método permitió mantener una ventilación no invasiva, y fue innecesaria la intubación endotraqueal en los neonatos. Los profesionales encargados de la ejecución de esta técnica recibieron entrenamiento previo. Conclusiones: La administración mínimamente invasiva de surfactante pulmonar resultó un método eficaz con el que se consiguió la resolución total del cuadro de dificultad respiratoria en los neonatos. El procedimiento empleado permitió una administración rápida y segura del Surfacen®(AU)

Introduction: Pulmonary surfactant administration is traditionally performed by endotracheal tube, but for years there have been less invasive techniques such as administration by laryngeal mask, aerosolization and tracheal catheterization. Objectives: To demonstrate the evolution of three neonates who received pulmonary surfactant via tracheal catheterization and to describe the technique used for its administration. Case presentation: Three very low birth weight newborns were attended and admitted to the neonatal intensive care unit of Iván Portuondo General Teaching Hospital, at San Antonio de los Baños municipality, with preterm respiratory distress syndrome. All were treated with exogenous pulmonary surfactant, Surfacen®, which was administered by tracheal catheterization using an umbilical catheter. This is a minimally invasive technique that was performed without difficulty and always on the first attempt. The three patients showed clinical, gasometric and radiographic improvement with this form of administration and only one of them had a complication during the procedure, which did not constitute a limitation for its performance. This method allowed maintaining non-invasive ventilation, and endotracheal intubation was unnecessary in neonates. The professionals in charge of performing this technique received previous training. Conclusions: Minimally invasive administration of pulmonary surfactant was an effective method that achieved total resolution of respiratory distress in neonates. The procedure used allowed rapid and safe administration of Surfacen®(AU)

Effect of combined sedation using multiple drugs on inflammatory cytokines in patients with acute respiratory distress syndrome

Abstract he innate immune response plays an important role in the pathophysiology of acute respiratory distress syndrome (ARDS); however, no drug has been proven to be beneficial in the management of ARDS. Therefore, the aim of this study was to investigate the effects of using combined sedatives on systemic inflammatory responses in patients with ARDS. A total of 90 patients with ARDS and an intubation time of > 120 h were randomly divided into the propofol group (group P), midazolam group (group M), and combined sedation group (group U). Patients in groups P and M were sedated with propofol and midazolam, respectively, whereas patients in group U were sedated with a combination of propofol, midazolam, and dexmedetomidine. The dosage of sedatives and vasoactive drugs, duration of mechanical ventilation, and incidence of sedative adverse reactions were documented. The dosage of sedatives and vasoactive drugs, as well as the incidence of sedative adverse reactions in group U, was significantly lower than those in groups P and M. Similarly, the duration of mechanical ventilation in group U was significantly shorter than that in groups P and M. Hence, inducing sedation through a combination of multiple drugs can significantly reduce their adverse effects, improve their sedative effect, inhibit systemic inflammatory responses, and improve oxygenation in patients with ARDS

Ventilación mecánica no invasiva en ingresados en un centro provisional para pacientes con CO VID-19 moderada / Non-invasive mechanical ventilation in patients admitted to a provisional center for moderate COVID-19 patients

Introducción: La ventilación mecánica no invasiva es una alternativa ventilatoria para los casos con COVID-19. Objetivo: Describir las características y la evolución de la ventilación mecánica no invasiva en los pacientes egresados en el Centro Provisional para pacientes moderados con COVID-19 en Figali, Panamá. Métodos: Estudio descriptivo, retrospectivo, longitudinal. Incluyó a todos los pacientes adultos egresados entre junio y julio del 2021 que recibieron ventilación mecánica no invasiva. Se utilizó un cuestionario cuya fuente primaria fue la historia clínica individual digital. Se emplearon técnicas de la estadística descriptiva. Resultados: De 217 ingresados con COVID-19 moderado, 78 (35,9 por ciento) necesitaron ventilación mecánica no invasiva, iniciada con media al noveno día de síntomas y segundo después del ingreso. De estos, el 62,8 por ciento eran obesos y el 29,5 por ciento hipertensos. En el 56,4 por ciento, la frecuencia respiratoria ≥30 y la disminución de la razón PaO2/FiO2 fueron los indicadores principales que decidieron el inicio de la VMNI. Del total de ventilados, el 62,8 por ciento tuvo un síndrome de distrés respiratorio agudo moderado-grave y esto se relacionó con el fracaso de la ventilación. La ventilación fue exitosa en el 65,4 por ciento. La razón PaO2/FiO2 <150 (62,9 por ciento), la frecuencia respiratoria ≥30 (55,6 por cientpo y el agotamiento físico (51,85 por ciento), indicaron la falla de la ventilación. Conclusiones: La ventilación mecánica no invasiva es un proceder efectivo en pacientes con COVID-19 y distrés respiratorio moderado o severo; aunque su éxito se relaciona con las formas menos graves. La PaO2/FiO2 baja junto a la clínica, fueron indicadores clave para evaluar inicio, éxito o fracaso de la ventilación mecánica no invasiva; no así los valores de PaO2, PaCO2 y SpO2(AU)

Introduction: Non-invasive mechanical ventilation is a ventilatory alternative for COVID-19 cases. Objective: To describe the characteristics and evolution of non-invasive mechanical ventilation (NIMV) in patients discharged from Provisional Center for moderate COVID-19 patients in Figali, Panama. Methods: A descriptive, retrospective, longitudinal stu was carried out in all adult patients discharged from June to July 2021 and who received non-invasive mechanical ventilation. A questionnaire was used using the digital individual medical record as primary source. Descriptive statistics techniques were used. Results: 35.9percent of the patients (78/217) who were admitted required non-invasive mechanical ventilation on the ninth day of symptoms and the second day after admission. 62.8percent (49/78) were obese and 29.5percent (23/78) hypertensive. The respiratory rate ≥30 and the decrease in the PaO2/FiO2 ratio decided the begining of non-invasive mechanical ventilation in 56.4percent (78/217) of those admitted. 62.8percent (49/78) had moderate-severe acute respiratory distress syndrome, and the severity was related to ventilation failure out of the total number of ventilated patients. Ventilation was successful in 65.4percent (51/78). PaO2/FiO2 <150 (62.9percent), respiratory rate ≥30 (55.6percent) and physical exhaustion (51.85percent) decided ventilation failure. Conclusions: Non-invasive mechanical ventilation is an effective procedure in COVID-19 patients and moderate or severe respiratory distress; although its success is related to the less severe forms. Low PaO2/FiO2, together with symptoms, were key indicators to assess the begining, success or failure of NIMV; not so the values of PaO2, PaCO2 and SpO2(AU)

A pilot study of plasma interleukin-6 and interleukin-27 in differential diagnosis of acute respiratory distress syndrome and neonatal respiratory distress syndrome in preterm infants / 中国当代儿科杂志

OBJECTIVES@#To study the significance of interleukin-6 (IL-6) and interleukin-27 (IL-27) in the differential diagnosis of acute respiratory distress syndrome (ARDS) and neonatal respiratory distress syndrome (NRDS) in preterm infants.@*METHODS@#The preterm infants with the manifestation of respiratory distress who were treated in the Neonatal Diagnosis and Treatment Center, Children's Hospital of Chongqing Medical University, from March to November 2021, were enrolled in this prospective study. According to the diagnosis results, they were divided into two groups: ARDS group (n=18) and NRDS group (n=20). ELISA was used to measure the plasma levels of IL-6 and IL-27. The receiver operating characteristic (ROC) curve was used to analyze the value of each index in the diagnosis of ARDS.@*RESULTS@#The ARDS group had significantly higher plasma levels of IL-6 and IL-27 than the NRDS group (P<0.05). The ROC curve analysis showed that IL-6 had an area under the ROC curve (AUC) of 0.867 for the diagnosis of ARDS, with a sensitivity of 61.1% and a specificity of 95.0% at the cut-off value of 56.21 pg/mL. The ROC curve analysis also showed that IL-27 had an AUC of 0.881 for the diagnosis of ARDS, with a sensitivity of 83.3% and a specificity of 80.0% at the cut-off value of 135.8 pg/mL.@*CONCLUSIONS@#Plasma IL-6 and IL-27 can be used as biological indicators for early differential diagnosis of ARDS and NRDS in preterm infants.

Presentación de un caso novedoso de síndrome de dificultad respiratoria aguda neonatal con infección por SARS-CoV-2: posible transmisión perinatal / A novel case of neonatal acute respiratory distress syndrome with SARS-CoV-2 infection: potential perinatal transmission

La enfermedad por coronavirus de 2019 (COVID-19), causada por el coronavirus 2 del síndrome respiratorio agudo grave (SARS-CoV-2), se convirtió en la primera pandemia del siglo XXI. La infección por SARS-CoV-2 se transmite principalmente a través de las gotículas. Si bien se han informado algunos casos de transmisión perinatal, no es claro si estas infecciones fueron resultado de la vía de contagio transplacentario o transcervical o de la exposición ambiental. En este artículo, presentamos el caso de un recién nacido que falleció por síndrome de dificultad respiratoria aguda neonatal con compromiso pulmonar grave. El bebé nació por cesárea de una madre con una PCR positiva para COVID-19 y se detectó que tenía una PCR positiva para COVID-19 mediante un hisopado nasofaríngeo en el transcurso de las 24 horas posteriores al parto debido a una sospecha de transmisión transplacentaria del SARS-CoV-2 de la madre al feto.

Coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is the first pandemic of the 21st century. SARS-CoV-2 infection is mainly transmitted via droplets. Although some cases of peri-natal transmission have been reported, it is unclear whether these infections occurred via transplacental or transcervical routes or via environmental exposure. Herein, we present the case of a newborn who died with neo-natal acute respiratory distress syndrome exhibiting severe pulmonary involvement. The baby was born to a COVID-19 PCR (+) mother by C-section and was found to be COVID-19 PCR (+) from a nasopharyngeal swab sample tested within 24 hours of birth due to the suspected transplacental transmission of SARS-CoV-2 from the mother to the fetus.

Caracterização do comprometimento pulmonar associado à COVID-19 em pacientes com necessidade de ventilação mecânica / Characterization of pulmonary impairment associated with COVID-19 in patients requiring mechanical ventilation

RESUMO Objetivo: Detectar precocemente a instabilidade respiratória e hemodinâmica para caracterizar o comprometimento pulmonar em pacientes com COVID-19 grave. Métodos: Analisamos retrospectivamente os dados colhidos de pacientes com COVID-19 que apresentaram insuficiência respiratória aguda com necessidade de intubação e ventilação mecânica. Utilizamos a avaliação da termodiluição transpulmonar por meio do dispositivo PiCCO™. Foram coletados os dados demográficos, respiratórios, hemodinâmicos e ecocardiográficos dentro das primeiras 48 horas após a admissão. Para resumir os dados, utilizamos estatística descritiva. Resultados: Entre 22 de março e 7 de abril de 2020, foram admitidos 23 pacientes com COVID-19 grave. Foram monitorados com o dispositivo PiCCO™ 12 (22,6%) deles. Quando da admissão, o volume diastólico final global indexado era normal (média de 738,8mL ± 209,2) e, na hora 48, encontrava-se moderadamente aumentado (879mL ± 179), enquanto o índice cardíaco se achava abaixo do normal (2,84 ± 0,65). Todos os pacientes revelaram a presença de água extravascular pulmonar acima de 8mL/kg na admissão (17,9 ± 8,9). Não identificamos qualquer evidência de origem cardiogênica. Conclusão: No caso de pneumonia grave por COVID-19, o quadro hemodinâmico e respiratório é compatível com edema pulmonar sem evidência de origem cardiogênica, o que favorece o diagnóstico de síndrome do desconforto respiratório agudo.

ABSTRACT Objective: To detect early respiratory and hemodynamic instability to characterize pulmonary impairment in patients with severe COVID-19. Methods: We retrospectively analyzed data collected from COVID-19 patients suffering from acute respiratory failure requiring intubation and mechanical ventilation. We used transpulmonary thermodilution assessment with a PiCCO™ device. We collected demographic, respiratory, hemodynamic and echocardiographic data within the first 48 hours after admission. Descriptive statistics were used to summarize the data. Results: Fifty-three patients with severe COVID-19 were admitted between March 22nd and April 7th. Twelve of them (22.6%) were monitored with a PiCCO™ device. Upon admission, the global-end diastolic volume indexed was normal (mean 738.8mL ± 209.2) and moderately increased at H48 (879mL ± 179), and the cardiac index was subnormal (2.84 ± 0.65). All patients showed extravascular lung water over 8mL/kg on admission (17.9 ± 8.9). We did not identify any argument for cardiogenic failure. Conclusion: In the case of severe COVID-19 pneumonia, hemodynamic and respiratory presentation is consistent with pulmonary edema without evidence of cardiogenic origin, favoring the diagnosis of acute respiratory distress syndrome.

Perspective Covid-19 ARDS: challenges in care, recommendations & review of research / Covid-19: Desafíos, recomendaciones, revisión e investigación

Though physicians and care providers are familiar with the management of ARDS, however, when it occurs as a sequale of COVID-19, COVID-19 ARDS has different features and there remains uncertainty on the consensus of management. To answer this question on how it compares and contrasts with ARDS from other causes, we deliver a review of the published literature and our own clinical experience from managing patients with COVID-19 ARDS in DR Congo and India. A PubMed search was conducted on 05-7-2020 using the systematic review filter to identify articles that were published using MeSH terms COVID-19 and ARDS. Systematic reviews or meta-analyses were selected from a systematic search for literature containing diagnostic, prognostic and management strategies in MEDLINE/PubMed. Those were compared and reviewed to the existing practices by the various treating specialists and recommendations were made. Specifically, we discuss the COVID-19 ARDS, its risk factors and pathophysiology, lab diagnosis, radiological findings, rational of recommendation of drugs proposed so far, oxygenation and ventilation strategies and the psychological ramifications of the disease. Because of the high mortality in mechanically ventilated patients, the above recommendations and findings direct the potential for improvement in the management of patients with COVID-19 ARDS.

Aunque los médicos y los proveedores de atención están familiarizados con el manejo de ARDS, cuando ocurre una complicación de COVID-19, existe incertidumbre sobre el manejo y curso que va a seguir. Para responder a esta pregunta sobre cómo se compara y contrasta con el SDRA por otras causas, entregamos una revisión de la literatura publicada y nuestra propia experiencia clínica en el manejo de pacientes con SDRA COVID-19 en la República Democrática del Congo e India. Se realizó una búsqueda en PubMed el 05 de julio de 2020 utilizando el método sistemático con filtro de revisión para identificar artículos que se publicaron utilizando términos MeSH COVID-19 y SDRA. Se seleccionaron revisiones sistemáticas o metanálisis de una búsqueda sistemática de literatura que contenga diagnóstico, pronóstico y manejo estrategias en MEDLINE / PubMed. Aquellos fueron comparados y revisados para las prácticas existentes por los diversos especialistas en tratamiento y recomendaciones que fueron hechos. Específicamente, discutimos el ARDS COVID-19, sus factores de riesgo, fisiopatología, diagnóstico de laboratorio, hallazgos radiológicos, racionalidad de recomendación de los fármacos propuestos hasta el momento, las estrategias de oxigenación y ventilación y las complicaciones psicológicas de la enfermedad. Debido a la alta mortalidad de los paciente en ventilación mecánica las recomendaciones y los hallazgos anteriores se dirigen a la potencial de mejora en el manejo de pacientes con COVID-19.

Protocolo nacional de sedación y analgesia en UCI COVID-19 / National protocol for sedation and analgesia in ICU COVID-19

El presente documento tiene la finalidad de guiar a los médicos que manejan la unidad de cuidados intensivos en los Hospitales Temporales Nacionales que atienden pacientes con COVID-19 en cuanto a la aplicación de sedación y analgesia. Una adecuada sedoanalgesia y el uso de bloqueantes neuromusculares permitirán asegurar la provisión de ventilación mecánica protectora durante la inducción para intubación y el mantenimiento, limitar el desarrollo de lesión pulmonar por ventilación espontánea con una alta demanda respiratoria Incluye un Flujograma de Algoritmos de análogo sedación en el paciente crítico bajo ventilación mecánica

Perinatal outcomes of fetuses with early growth restriction, late growth restriction, small for gestational age, and adequate for gestational age / Resultados perinatais de fetos com restrição de crescimento precoce, restrição de crescimento tardia, pequenos para a idade gestacional e adequados para a idade gestacional

Abstract Objective To evaluate the association between early-onset fetal growth restriction (FGR), late-onset FGR, small for gestational age (SGA) and adequate for gestational age (AGA) fetuses and adverse perinatal outcomes. Methods This was a retrospective longitudinal study in which 4 groups were evaluated: 1 - early-onset FGR (before 32 weeks) (n=20), 2 - late-onset FGR (at or after 32 weeks) (n=113), 3 - SGA (n=59), 4 - AGA (n=476). The Kaplan-Meier curve was used to compare the time from the diagnosis of FGR to birth. Logistic regression was used to determine the best predictors of adverse perinatal outcomes in fetuses with FGR and SGA. Results A longer timebetween the diagnosis and birthwas observed forAGAthan for late FGR fetuses (p<0.001). The model including the type of FGR and the gestational age at birth was significant in predicting the risk of hospitalization in the neonatal intensive care unit (ICU) (p<0.001). The model including only the type of FGR predicted the risk of needing neonatal resuscitation (p<0.001), of respiratory distress (p<0.001), and of birth at<32, 34, and 37 weeks of gestation, respectively (p<0.001). Conclusion Fetal growth restriction and SGA were associated with adverse perinatal outcomes. The type of FGR at the moment of diagnosis was an independent variable to predict respiratory distress and the need for neonatal resuscitation. The model including both the type of FGR and the gestational age at birth predicted the risk of needing neonatal ICU hospitalization.

Resumo Objetivo Avaliar o efeito da restrição de crescimento fetal (RCF) precoce, RCF tardio, fetos pequenos constitucionais para idade gestacional (PIG) e fetos adequados para idade gestacional (AIG) sobre resultados adversos perinatais. Métodos Estudo longitudinal e retrospectivo, no qual foram avaliados quatro grupos: 1 - RCF precoce (< 32 semanas) (n=20), 2 - RCF tardio ( 32 semanas) (n=113), 3 - PIG (n=59), 4 - AIG (n=476). A curva de Kaplan-Meier foi utilizada para comparar o tempo entre o diagnóstico da RCF e o parto. Regressão logística foi utilizada para determinação dosmelhores previsores de resultados perinatais adversos entre os fetos com RCF e PIG. Resultados Os fetos AIGs apresentaram maior tempo entre o diagnóstico e parto, enquanto fetos RCF tardio apresentaram menor tempo (p<0,001). O modelo contendo tanto os tipos de RCF quanto a idade gestacional no momento do parto foi significativo em predizer o risco de internação na unidade de terapia intensiva (UTI) neonatal (p<0,001). O modelo incluindo apenas o tipo de FGR prediz o risco de ressuscitação neonatal (p<0,001), de desconforto respiratório (p<0,001) e de nascimento<32, 34 e 37 semanas de gestação, respectivamente (p<0,001). Conclusão Os desvios do crescimento, RCF e PIG, foram associados a resultados perinatais adversos. O tipo de RCF no momento do diagnóstico foi variável independente para predizer necessidade de reanimação neonatal e desconforto respiratório. O modelo que incluiu o tipo de FGR e idade gestacional no nascimento prediz o risco de necessitar de internação em UTI neonatal.

Dolor y variabilidad de la frecuencia cardíaca en recién nacidos prematuros que recibieron surfactante: un estudio piloto / Neonatal pain and heart rate variability in preterm infants treated with surfactant: a pilot study

Objetivo. Evaluar la percepción del dolor de recién nacidos prematuros a quienes se les administró surfactante mediante diferentes técnicas, utilizando la variabilidad de la frecuencia cardíaca (VFC).Métodos. Se aleatorizó a los recién nacidos que requirieron tratamiento con surfactante por SDR a los grupos INSURE o MIST. El análisis de la VFC se realizó con la tecnología NIPE para evaluar el componente parasimpático del sistema nervioso autónomo de los recién nacidos. Se registró la VFC antes, durante y después de administrar el surfactante. La evaluación del dolor se determinó con la escala PIPP. Resultados. Se incluyó a 14 recién nacidos en el estudio. Los grupos tenían características demográficas similares. Los puntajes de la escala PIPP no difirieron entre los grupos INSURE y MIST (p = 0,05). Se observó una diferencia estadísticamente significativa en la mediana de la VFC durante la administración del surfactante entre los grupos INSURE y MIST (52 frente a 56, p = 0,03). El análisis de la VFC fue similar entre los grupos antes y después de administrar el surfactante.Conclusión. La administración de surfactante mediante la técnica MIST podría ser más cómoda para los recién nacidos prematuros con SDR. No obstante, es necesario realizar otros estudios con series más importantes.

Objective. We aimed to assess the pain perception of preterm infants treated with different surfactant administration techniques by using heart rate variability (HRV).Methods. Preterm infants who required surfactant therapy for RDS were randomized to INSURE or MIST groups. HRV analysis was performed by Newborn Infant Parasympathetic Evaluation monitor. HRV was recorded before, during and after surfactant administration. Pain assessment was determined by Premature Infant Pain Profile (PIPP) score.Results. Fourteen infants were enrolled in the study. Demographic characteristics of the groups were similar. PIPP scores did not differ between INSURE and MIST groups (p = 0.05). Statistically significant difference in median HRV during surfactant administration was observed between INSURE and MIST groups (52 vs. 56, p = 0.03). HRV analysis was similar between groups before and after surfactant administration. Conclusion. Surfactant administration with MIST technique might be more comfortable for preterm infants with RDS. However further studies with larger series are needed.

Rapid diagnosis of respiratory distress syndrome by oral aspirate in premature newborns / Diagnóstico rápido da síndrome do desconforto respiratório por aspirado bucal em recém-nascidos prematuros

Abstract Objective: The stable microbubble test on gastric aspirate and on amniotic fluid has been used for the diagnosis of respiratory distress syndrome in the newborn. However, no study has performed this test on oral aspirates from premature infants. The objective of this study was to evaluate the performance of the stable microbubble test on oral aspirates from preterm newborns to predict respiratory distress syndrome. Method: This study included infants with gestational age <34 weeks. Oral fluids were obtained immediately after birth and gastric fluids were collected within the first 30 minutes of life. The samples were frozen and tested within 72 hours. Results: The sample was composed of paired aspirates from 64 newborns, who were divided into two groups: respiratory distress syndrome group (n = 21) and control group (n = 43). The median (interquartile range) of the stable microbubble count in the oral samples of infants with respiratory distress syndrome was significantly lower than that of infants who did not develop respiratory symptoms: respiratory distress syndrome group = 12 (8 -22) stable microbubbles/mm2; control group = 100 (48 -230) microbubbles/mm2 (p < 0.001). The correlation between microbubble count in gastric and oral aspirates was 0.90 (95% confidence interval = 0.85 -0.95; p < 0.001). Considering a cut-off point of 25 microbubbles/mm2, the sensitivity and the specificity of the stable microbubble test were 81.4% and 85.7%, respectively. Conclusion: The study suggests that the stable microbubble test performed on oral aspirate is a reliable alternative to that performed on gastric fluid for the prediction of respiratory distress syndrome in the newborn.

Resumo Objetivo: O teste das microbolhas estáveis no aspirado gástrico e no líquido amniótico foi usado no diagnóstico da síndrome do desconforto respiratório do recém-nascido. Contudo, nenhum estudo fez esse teste nos aspirados bucais de neonatos prematuros. O objetivo deste estudo foi avaliar o desempenho do teste das microbolhas estáveis em aspirados bucais de recém-nascidos prematuros para prever síndrome do desconforto respiratório. Método: Este estudo incluiu neonatos com idade gestacional < 34 semanas. Os fluidos orais foram obtidos imediatamente após o nascimento e os fluidos gástricos foram coletados nos primeiros 30 minutos de vida. As amostras foram congeladas e testadas em 72 horas. Resultados: A amostra foi composta de aspirados pareados de 64 recém-nascidos, divididos em dois grupos: grupo de síndrome do desconforto respiratório (n = 21) e grupo de controle (n = 43). A mediana (intervalo interquartil) da contagem das microbolhas estáveis nas amostras de fluido oral dos neonatos com síndrome do desconforto respiratório foi significativamente menor que a dos neonatos que não desenvolveram sintomas respiratórios: grupo de síndrome do desconforto respiratório = 12 (8-22) microbolhas estáveis/mm2; grupo de controle = 100 (48-230) microbolhas/mm2 (p < 0,001). A correlação entre a contagem das microbolhas nos aspirados gástricos e bucais foi 0,90 (intervalo de confiança de 95% = 0,85-0,95; p < 0,001). Considerando um ponto de corte de 25 microbolhas/mm2, a sensibilidade e a especificidade do teste das microbolhas estáveis foram 81,4% e 85,7%, respectivamente. Conclusão: O estudo sugere que o teste das microbolhas estáveis feito no aspirado bucal é uma opção confiável ao fluido gástrico para a predição da síndrome do desconforto respiratório do recém-nascido.

Preeclampsia grave de aparición precoz confirmada con biomarcador / Severe early-onset biomarker-confirmed preeclampsia

RESUMEN La aparición de preeclampsia antes de las 20 semanas de gestación es rara y generalmente se asocia con enfermedades trofoblásticas o con el síndrome antifosfolípido. Presentamos el caso de una paciente con preeclampsia severa asociada al síndrome de distress respiratorio del adulto (SDRA) de forma precoz en la semana 15 de gestación en ausencia de los trastornos antes mencionados. Su confirmación diagnóstica se realizó mediante el empleo del biomarcador sFlt-1/P1GF.

ABSTRACT The occurrence of preeclampsia before 20 weeks of gestation is rare and usually associated with trophoblastic diseases or antiphospholipid syndrome. We present the case of a patient with severe preeclampsia associated with adult respiratory distress syndrome early in week 15 of gestation in the absence of the aforementioned disorders. Its confirmation was carried out through the use of biomarker sFlt-1/P1GF.

Clinical utility of early amplitude integrated EEG in monitoring term newborns at risk of neurological injury / Utilidade clínica de um monitoramento por EEG de amplitude integrada precoce em recém-nascidos a termo com risco de lesão neurológica

OBJECTIVE: to test the clinical utility of an early amplitude-integrated electroencephalography (aEEG) to predict short-term neurological outcome in term newborns at risk of neurology injury. METHODS: this was a prospective, descriptive study. The inclusion criteria were neonatal encephalopathy, neurologic disturbances, and severe respiratory distress syndrome. Sensitivity, specificity, positive and negative predictive values, and likelihood ratio (LR) were calculated. Clinical and demographic data were analyzed. Neurological outcome was defined as the sum of clinical, electroimaging, and neuroimaging findings. RESULTS: ten of the 21 monitored infants (48%) presented altered short-term neurologic outcome. The aEEG had 90% sensitivity, 82% specificity, 82% positive predictive value, and 90% negative predictive value. The positive LR was 4.95, and the negative LR was 0.12. In three of 12 (25%) encephalopathic infants, the aEEG allowed for a better definition of the severity of their condition. Seizures were detected in eight infants (38%), all subclinical at baseline, and none had a normal aEEG background pattern. The status of three infants (43%) evolved and required two or more drugs for treatment. CONCLUSIONS: in infants with encephalopathy or other severe illness, aEEG disturbances occur frequently. aEEG provided a better classification of the severity of encephalopathy, detected early subclinical seizures, and allowed for monitoring of the response to treatment. aEEG was a useful tool at the neonatal intensive care unit for predicting poor short-term neurological outcomes for all sick newborn. .

OBJETIVO: testar a utilidade clínica do aEEG precoce em recém-nascidos a termo com risco delesão neurológica, para prever resultados neurológicos de curto prazo. MÉTODOS: estudo prospectivo e descritivo. Os critérios de inclusão foram encefalopatia neonatal, distúrbios neurológicos e bebês com SARA grave. Sensibilidade, especificidade, valor preditivo positivo e negativo e razão de verossimilhança foram calculados. Dados clínicos edemográficos foram analisados. O resultado neurológico foi definido como a soma de conclusões clínicas, de eletro e de neuroimagem. RESULTADOS: dentre os 21 neonatos monitorados, dez (48%) apresentaram resultado neurológico de curto prazo alterado. O aEEG apresentou sensibilidade de 90%, especificidade de 82%, valor preditivo positivo de 82% e valor preditivo negativo de 90%. A VR positiva foi de 4,95, e a RV negativa de 0,12. Em três dos 12 (25%) neonatos com encefalopatia foi possível definir melhora gravidade de sua condição pelo aEEG. Foram detectadas convulsões em oito neonatos (38%), todas subclínicas no início do estudo, e nenhum apresentou um padrão histórico normal no aEEG. O estado de três neonatos (43%) evoluiu e exigiu dois ou mais medicamentos para tratamento. CONCLUSÕES: em neonatos com encefalopatia ou outra doença grave, os distúrbios no aEEGocorrem com mais frequência. O aEEG forneceu uma classificação melhor da gravidade da encefalopatia, detectou convulsões subclínicas precoces e permitiu que fosse feito o monitoramento da resposta ao tratamento. O aEEG é uma ferramenta útil para prever resultados neurológicos de curto prazo em todos os bebês doentes na UTIN. .

Early Prophylactic versus Late Selective Use of Surfactant for Respiratory Distress Syndrome in Very Preterm Infants: A Collaborative Study of 53 Multi-Center Trials in Korea

Pulmonary surfactant (PS) therapy was proven to be highly successful for the treatment of respiratory distress syndrome in premature infants. As a results, early prophylactic (EP) PS therapy has been introduced recently in Europe, the US and Korea. However, no multi-center study was compared EP and late selective (LS) PS therapies in Korea. We performed a retrospective multi-center study to compare the outcomes of EP and LS PS therapies in very preterm infants. We analyzed clinical morbidity and mortality for 1,291 infants in 2010 (LS group) and 1,249 infants in 2011 (EP group); the infants were born <30 weeks of gestation and had birth weight < or =1,250 g, and were chosen from 53 neonatal intensive care units in Korea. Compared to the LS group (22.5%), the overall mortality was better in the EP group (19.9%) and there was no increased need for retreatment.There were additional benefits in the EP group such as fewer associated complications. To the best of knowledge, our study is the first nationwide Korean study to compare the outcomes of EP and LS therapies, and it provides evidences that EP PS therapy is important in very preterm infants to improve for survival and reduce morbidities.

Early Prophylactic versus Late Selective Use of Surfactant for Respiratory Distress Syndrome in Very Preterm Infants: A Collaborative Study of 53 Multi-Center Trials in Korea

Pulmonary surfactant (PS) therapy was proven to be highly successful for the treatment of respiratory distress syndrome in premature infants. As a results, early prophylactic (EP) PS therapy has been introduced recently in Europe, the US and Korea. However, no multi-center study was compared EP and late selective (LS) PS therapies in Korea. We performed a retrospective multi-center study to compare the outcomes of EP and LS PS therapies in very preterm infants. We analyzed clinical morbidity and mortality for 1,291 infants in 2010 (LS group) and 1,249 infants in 2011 (EP group); the infants were born <30 weeks of gestation and had birth weight < or =1,250 g, and were chosen from 53 neonatal intensive care units in Korea. Compared to the LS group (22.5%), the overall mortality was better in the EP group (19.9%) and there was no increased need for retreatment.There were additional benefits in the EP group such as fewer associated complications. To the best of knowledge, our study is the first nationwide Korean study to compare the outcomes of EP and LS therapies, and it provides evidences that EP PS therapy is important in very preterm infants to improve for survival and reduce morbidities.

[Comparative study of diagnostic value of gastric aspirate shakes test and lamellar body count for prediction of lung maturity in premature neonates]

Respiratory distress syndrome due to lack of enough surfactant in fetal lung tissue is a common cause of neonatal mortality. There are several laboratory methods to predict the amount of fetal lung surfactant. The purpose of this study was to compare lamellar body count test [Quantitative test] and gastric aspirate shake test [Qualitative test] for prediction of the amount of pulmonary surfactant in premature neonates. This descriptive- analytic study was performed between August 2012 and January 2013 for 6 months and included 150 premature infants with gestational age of less than 34 weeks, born in Imam Reza [AS] Hospital, in Kermanshah. In this study, both gastric aspirate shake test and lamellar body count test were performed for all infants simultaneously. Using nasogastric tube we aspirated at least 2.5 cc of gastric secretions within the first hour of birth. For gastric aspirate shake test we added 0.5 cc normal saline and 1cc 95% ethyl alcohol to 0.5 cc of amniotic fluid and shook the test tube well for 15 seconds. Then, we counted the bubbles formed on the surface of the test tube. A cell counter [Sysmex model Xt-1800i] was used to determine the lamellar body counts. We used ROC Curve and kappa coefficient for data analysis. Of 230 samples, 80 were excluded from the study because of contamination with blood or meconium. Finally, 150 samples were analyzed. 59 cases [39/3%] had respiratory distress syndrome. The respective values of sensitivity, specificity, positive and negative predictive values for diagnosis of respiratory distress syndrome were 62.7%, 100%, 80.5% and100% for gastric shake test, and 98.3%, 94.5%, 98.9% and 92.1% for lamellar body count test. Lamellar body count, is a useful test for screening of respiratory distress syndrome and gastric aspirate shake test is also a suitable test to rule out respiratory distress syndrome. By using these 2 tests, we can expect appropriate sensitivity and specificity in the diagnosis of respiratory distress syndrome

Síndrome de dificultad respiratoria agudo: revisión de causas, patogénesis y tratamiento / Acute respiratory distress syndrome: a review of causes, pathogenesis and treatment

El Síndrome de Dificultad Respiratrio Agudo (SDRA) es una patología pulmonar aguda, rápidamente progresiva, provocada por múltiples causas y con una alta morbimortalidad. Se caracteriza por una inflamación del conjunto alveolo-capilar resultando en una alteración de su permeabilidad y acumulación del material proteico de tipo exudativo dentro del alveolo por lo cual la capacidad de intercambio gaseoso entre el aire inspirado y la circulación sanguínea se ve comprometida. A pesar de constantes esfuerzos en afán de mejorar el tratamiento farmacológico, hasta la fecha no se ha logrado un resultado satisfactorio y el goal-standard del tratamiento sigue focalizado en el mantenimiento de un óptimo balance hídrico conjuntamente a una ventilación mecánica caracterizada por bajos volúmenes Tidales o Corrientes, una alta frecuencia respiratoria, baja presión Plateau, alto nivel de Presión Positiva Teleespiratoria PEEP (Positive End Expiratory Pressure) y todo esto para mantener valores adecuados de intercambio gaseoso sin provocar un baro y/o volutrauma.

Low Apgar scores at 5 minutes in a low risk population: maternal and obstetrical factors and postnatal outcome / Baixos índices de Apgar no quinto minuto de vida em população de baixo risco: fatores maternos e obstétricos e resultados pós-natais

OBJECTIVE: To evaluate the association between Apgar scores of less than seven at five minutes (AS5min < 7) and antenatal factors and postnatal outcomes. METHODS: A retrospective cohort and case-control study of 27,252 consecutive term newborns in a low risk obstetrical population between January 2003 and December 2010. Maternal and infant databases were reviewed from all cases with AS5min < 7 (n = 121; 0.4%) and 363 cases with AS5min > 7 at 5 minutes who were randomly selected by a computer program. The main outcomes were neonatal death, newborn respiratory distress, need for orotracheal intubation and neonatal intensive care unit (NICU), and hypoxic-ischemic-encephalopathy. RESULTS: After multiple regression analysis, repeated late decelerations on cardiotocography (OR: 2.4; 95% CI: 1.4-4.1) and prolonged second stage of labor (OR: 3.3; 95% CI: 1.3-8.3) were associated with AS5min < 7, as well as neonatal respiratory distress (OR: 3.0; 95% CI: 1.3-6.9), orotracheal intubation (OR: 2.5; 95% CI: 1.2-4.8), need for NICU (OR: 9.5; 95% CI: 6.7-16.8), and hypoxic-ischemic-encephalopathy (OR: 14.1; 95% CI: 3.6-54.7). No other antenatal factors were associated with AS5min < 7 (p > 0.05). CONCLUSION: Repeated late decelerations and prolonged second stage of labor in the low-risk population are predictors of AS5min < 7, a situation associated with increased risk of neonatal respiratory distress, need for mechanical ventilatory support and NICU, and hypoxic-ischemic-encephalopathy.

OBJETIVO: Avaliar a associação entre índice de Apgar menor que sete no 5º minuto, os fatores pré-natais e resultados pós-natais. MÉTODOS: Trata-se de estudo retrospectivo com 27.252 recém-nascidos em maternidade escola com população de baixo risco obstétrico, de janeiro de 2003 a dezembro de 2010. Prontuários de todos os casos com índice de Apgar < 7 no 5º minuto (n = 121; - 0,4%) e de 363 casos com Apgar > 7 no 5º minuto, escolhidos ao acaso, foram revisados. Os principais desfechos estudados foram: óbito neonatal, insuficiência respiratória neonatal, necessidade de intubação orotraqueal e de unidade terapia intensiva (UTI) neonatal e encefalopatia hipóxico-isquêmica. RESULTADOS: Após análise de regressão múltipla, desacelerações tardias (DIP II) (OR: 2,4; IC95%: 1,4-4,1) e período expulsivo prolongado (OR: 3,3; IC 95%: 1,3-8,3) se associaram com Apgar < 7 no 5º minuto; assim como com insuficiência respiratória ao nascimento (OR: 3,0; IC 95%: 1,3-6,9), intubação traqueal (OR: 2,5; IC 95%: 1,2-4,8), necessidade de UTI neonatal (OR: 9,5; IC 95%: 6,7-16,8) e encefalopatia hipóxico-isquêmica (OR: 14,1; IC 95%: 3,6-54,7). Nenhuma outra variável prénatal se associou com Apgar < 7 no 5º minuto (p < 0,05). CONCLUSÃO: DIP II e período expulsivo prolongado estão associados com Apgar < 7 no 5º minuto em população obstétrica de baixo risco; situação essa relacionada com maior risco de insuficiência respiratória no parto, necessidade de suporte ventilatório e encefalopatia hipóxico-isquêmica.