NT-PROBNP as a screening tool for low-risk patent ductus arteriousus: a follow-up validation study.

The purpose of the study is to test whether NT-proBNP serves as a screening tool for low-risk patent ductus arteriosus and safely avoids routine early echocardiography. This is a prospective observational study in preterm infants ≤32 weeks of gestational age. Infants with ≥5100 pg/ml (positive screening) at 48-72 hours of life received comprehensive echocardiography and were treated according to shunt severity. Infants with NT-proBNP below 5100 pg/ml (negative screening) were managed expectantly. The main outcome was need for ductus treatment within the first 7 days of life. One hundred twenty-five infants were included; 82 had a negative NT-proBNP screening and 43 had a positive NT-proBNP screening. No infant (0%) with a negative screening was treated for ductus while 26 (60.4%) with a positive screening were treated (p < 0.001). NT-proBNP avoided a 65.6% of routine echocardiograms. NT-proBNP had an excellent performance to predict PDA treatment (AUC = 0.967).Conclusion: NT-proBNP at 48-72 hours of life has an excellent performance to detect low risk and avoids unnecessary echocardiograms. This may contribute to optimize PDA management in terms of resource utilization.

Early assessment of lung aeration using an ultrasound score as a biomarker of developing bronchopulmonary dysplasia: a prospective observational study.

The objective of this study was to assess the predictive value of a lung ultrasound (LUS) score in the development of moderate-severe bronchopulmonary dysplasia (sBPD). This was a prospective  observational diagnostic accuracy study in a third-level neonatal intensive care unit. Preterm infants with a gestational age below 32 weeks were included. A LUS score (range 0-24 points) was calculated by assessing aeration semiquantitatively (0-3 points) in eight lung zones on the 7th day of life (DOL) and repeated on the 28th DOL. ROC curves and logistic regression were used for analysis. Forty-two preterm infants were included. The LUS on the 7th DOL had an area under the receiver operating characteristic curve (AUROC) of 0.94 (95% CI: 0.87-1) for the prediction of sBPD (optimal cutoff of ≥8 points: sensitivity 93%, specificity 91%). The LUS score was independently associated with sBPD [OR 2.1 (95% CI: 1.1-3.9), p = 0.022, for each additional point in the score]. Conclusions: Lung aeration as assessed by LUS on the 7th DOL may predict the development of sBPD.

N-terminal-probrain natriuretic peptide as a biomarker of moderate to severe bronchopulmonary dysplasia in preterm infants: A prospective observational study.

OBJECTIVE: N-terminal-probrain natriuretic peptide (NT-proBNP) is a marker of hemodynamically significant patent ductus arteriosus (HsPDA) in preterm infants. In this study, we assessed whether NT-proBNP levels could predict the risk of moderate to severe bronchopulmonary dysplasia (BPD) and/or death. METHODS: This was an observational prospective study of preterm infants with GA ≤32 weeks. Infants who died within the first 48 h or who had major congenital malformations or incomplete information were excluded. NT-proBNP was determined at 48-96 h of life and at 5-10 days of life. The predictive capacity of NT-proBNP for the combined outcome of BPD and/or death was evaluated using receiver operator characteristic (ROC) curves and multivariate regression. RESULTS: Of the 125 eligible patients, 110 completed the analysis. Twenty-eight developed BPD (n = 15) and/or died (n = 13). Infants who developed BPD and/or died had higher NT-proBNP levels ​​at 48-96 h (26,848 ng/L, interquartile range [IQR] 7818-60,684 vs 3008 ng/L, IQR 1425-9876) and at 5-10 days (8849 ng/L, IQR 3796-19,526 vs 1427 ng/L, IQR 907-2889). The NT-proBNP levels at 5-10 days, but not at 48-96 h, were independently associated with BPD and/or death after adjustments for HsPDA and other confounders (OR = 3.36; 95%CI: 1.52-7.4, P = 0.006). For the prediction of this result, a cutoff of 3348 ng/L had a sensitivity and specificity of 82% and 83%, respectively (area under the curve [AUC] = 0.87; 95%CI: 0.79-0.95). CONCLUSION: The NT-proBNP levels at 5-10 days of life may identify preterm infants with an HsPDA who are at high risk of BPD or death and may be useful for individualized preventive and therapeutic strategies.

Early NT-proBNP levels as a screening tool for the detection of hemodynamically significant patent ductus arteriosus during the first week of life in very low birth weight infants.

OBJECTIVE: To assess whether early NT-ProBNP can identify the need for echocardiographic assessment of hemodynamically significant patent ductus arteriosus (HsPDA) in preterm infants. STUDY DESIGN: Prospective observational study of infants with a gestational age ≤32 weeks. Echocardiographic assessment and NT-proBNP measurement were performed at 48-96 h. ROC curves were generated to assess optimal cutoffs to detect HsPDA and predict the need for treatment. RESULTS: Eighty-five patients were included. HsPDA was present in 28 infants (37.6%), and 22 (25.8%) received treatment. The optimal NT-proBNP cutoff for the detection of HsPDA was 5099 pg/mL (sensitivity 94%, specificity 82%, area under the curve 0.941, P < 0.001). Only 1 child with NT-proBNP levels <5099 pg/mL was ultimately treated for PDA. NT-proBNP screening could have avoided 45 of 85 routine echocardiograms (53%). CONCLUSION: NT-proBNP screening at 48-96 h of life may identify preterm infants at low risk for HsPDA, improving PDA management.

[Impact of screening and treatment of low systemic blood flow in the prevention of severe intraventricular haemorrhage and/or death in pre-term infants]. / Impacto del cribado y tratamiento del bajo flujo sistémico en la prevención de hemorragia intraventricular grave y/o muerte en el prematuro.

OBJECTIVE: To assess the effect of a protocolised intervention for low systemic blood flow (SBF) in the occurrence of severe intraventricular haemorrhage (IVH) or death in pre-term infants. METHODS: A study with a quasi-experimental design with retrospective controls was conducted on pre-term infants of less than 30weeks of gestational age, born between January 2016 and July 2017, who were consecutively included in the intervention period. The control cohort included pre-term infants (born between January 2013 and December 2015) matched by gestational age, birth weight, and gender (two controls for each case). The cases of low SBF diagnosed according to functional echocardiography during the study period received dobutamine (5-10µg/kg/min) for 48hours. RESULTS: The study included 29 cases (intervention period) and 54 controls (pre-intervention period). Ten out of 29 (34.5%) infants received dobutamine for low SBF during the intervention period, with 3/29 (10.3%) cases of severe IVH and/or death compared to 17/54 (31.5%) in the control cohort (p=.032). There was an independent association between the intervention and a decreased occurrence of severe IVH/death after adjusting for confounding factors both in the logistic regression model [OR 0.11 (95%CI: 0.01-0.65), p=.015], as well as in the sensitivity analysis using inverse probability of treatment weighting [OR 0.23 (95%CI: 0.09-0.56); p=.001]. CONCLUSIONS: In this study with retrospective controls, a protocolised screening, and treatment for low SBF was associated with a decreased occurrence of severe IVH or death in preterm infants. Large, adequately powered trials, are needed in order to determine whether postnatal interventions directed at low SBF can improve neurological outcomes.

Ultrasound-Guided Cannulation of the Brachiocephalic Vein in Neonates and Preterm Infants: A Prospective Observational Study.

INTRODUCTION: Percutaneous central venous catheter (CVC) insertion is a challenging procedure in neonates, especially in preterm infants. OBJECTIVE: This study aims to describe the technical success and safety profile of ultrasound (US)-guided brachiocephalic vein (BCV) cannulation in neonates. METHODS: Prospective observational study. Neonates admitted to the neonatal intensive care unit (NICU) in whom US-guided cannulation of the BCV was attempted were eligible. Outcomes included first attempt success rate, the overall success rate, the number of attempts, the cannulation time, immediate mechanical complications, catheter indwelling days, and late complications. RESULTS: A total of 40 procedures in 37 patients were included. Median weight and age at the time of cannulation were 1.85 kg (0.76-4.8) and 13 days (3-31), respectively. First attempt and overall success rates were 29 (72.5%) and 38 (95%), respectively. No major complications were observed. Catheter-associated infection rate was 2.4/1,000 catheter days. There were no difference in outcomes between low weight preterm infants (<1.5 kg) and the rest of the cohort. There was no linear relationship between weight at time of insertion and the number of puncture attempts (r = 0.250; p = 0.154) or cannulation time (r = 0.257; p = 0.142). CONCLUSION: US-guided cannulation of the BCV may be considered in acutely ill neonates, including small preterm infants, who need a large bore CVC.

[Ultrasound-guided cannulation of the brachiocephalic vein in neonates and infants]. / Canalización del tronco braquiocefálico guiada por ecografía en neonatos y lactantes.

INTRODUCTION: Central venous catheter (CVC) insertion in neonates and small infants is a challenging and high risk procedure. Ultrasound (US) guided cannulation increases the success rate and reduces procedural-related complications. The internal jugular vein is the most frequent site for US-guided CVC insertion. However this approach is technically demanding in neonates and small infants. US-guided supraclavicular cannulation of the brachiocephalic vein (BCV) is a new approach that may be advantageous in case of difficult central venous catheterization. We present our preliminary experience with this technique in a case series of neonates and small infants. METHODS: Case series of neonates and small infants weighing less than 5kg, in whom US-guided supraclavicular cannulation of the BCV was attempted. A longitudinal "in plane" supraclavicular approach to the BCV was performed using a 12Hz linear or a 8Hz microconvex transducer. All cannulations were performed by the same operator, a pediatrician with previous experience in US-guided central venous catheterization. RESULTS: The study included 6 patients with a median (range) weight of 2.1 (0.94-4.1) kg and age of 1.9 (0.6-4) months. Two cases required 2 punctures, while cannulation was achieved at the first attempt in the remaining 4 cases. There were no procedural or catheter-related complications. CVCs were withdrawn after 9 (6-15) days. CONCLUSIONS: The US-guided supraclavicular approach to the BCV is a feasible and safe alternative in neonates and very small infants. More studies are needed to define the role of this new venous access before its routine application in daily practice.

Location of the Central Venous Catheter Tip With Bedside Ultrasound in Young Children: Can We Eliminate the Need for Chest Radiography?

OBJECTIVE: To compare the use of bedside ultrasound and chest radiography to verify central venous catheter tip positioning. DESIGN: Prospective observational study. SETTING: PICU of a university hospital. PATIENTS: Patients aged 0-14 who required a central venous catheter. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: Central venous catheter tip location was confirmed by ultrasound and chest radiography. Central venous catheters were classified as intra-atrial or extra-atrial according to their positions in relation to the cavoatrial junction. Central venous catheters located outside the vena cava were considered malpositioned. The distance between the catheter tip and the cavoatrial junction was measured. The time elapsed from image capture to interpretation was recorded. Fifty-one central venous catheters in 40 patients were analyzed. Chest radiography and ultrasound results agreed 94% of the time (κ coefficient, 0.638; p < 0.001) in determining intra-atrial and extra-atrial locations and 92% of the time in determining the diagnosis of central venous catheter malposition (κ coefficient, 0.670; p < 0.001). Chest radiography indicated a greater distance between the central venous catheter tip and the cavoatrial junction than measured by ultrasound, with a mean difference of 0.38 cm (95% CI, +0.27, +0.48 cm). Three central venous catheters were classified as extra-atrial by chest radiography but as intra-atrial by ultrasound. To locate the central venous catheter tip, ultrasound required less time than chest radiography (22.96 min [20.43 min] vs 2.23 min [1.06 min]; p < 0.001). CONCLUSIONS: Bedside ultrasound showed a good agreement with chest radiography in detecting central venous catheter tip location and revealing incorrect positions. Ultrasound could be a preferable method for routine verification of central venous catheter tip and can contribute to increased patient safety.

Ultrasound evaluation of lumbar spine anatomy in newborn infants: implications for optimal performance of lumbar puncture.

An ultrasound evaluation of lumbar spine anatomic landmarks relevant for lumbar puncture was performed in 199 newborn infants. Effects of 6 patient positions and gestational age on interspinous process distance, subarachnoid space width, predicted needle entry angle, and needle insertion depth were assessed. Our results identify optimized conditions for lumbar puncture: sitting the infant with hips flexed, a needle entry angle of 65-70 degrees, and proper needle insertion depth (calculated as 2.5 × weight in kilograms + 6 in millimeters).

Tracheal intubation of pediatric manikins during ongoing chest compressions. Does Glidescope® videolaryngoscope improve pediatric residents' performance?

UNLABELLED: Our objective was to test the ability of pediatric residents to intubate the trachea of infant and child manikins during continuous chest compressions (CC) by means of indirect videolaryngoscopy with Glidescope® versus standard direct laryngoscopy. A randomized crossover simulation trial was designed. Twenty-three residents trained to intubate child and infant manikins were eligible for the study. They were asked to perform tracheal intubation in manikins assisted by both standard laryngoscopy and Glidescope® while a colleague delivered uninterrupted chest compressions. In the infant cardiac arrest scenario, the median (IQR) total time for intubation was significantly shorter with the Miller laryngoscope [28.2 s (20.4-34.4)] than with Glidescope® [38.0 s (25.3-50.5)] (p = 0.021). The number of participants who needed more than 30 s to intubate the manikin was also significantly higher with Glidescope® (n = 13) than with the Miller laryngoscope (n = 7, p = 0.01). In the child scenario, the total time for intubation and number of intubation failures were similar with Macintosh and Glidescope® laryngoscopes. The participants' subjective difficulty of the procedure was similar for direct and videolaryngoscopy. CONCLUSION: In simulated infant and child cardiac arrest scenarios, pediatric residents are able to intubate the trachea during CC. The videolaryngoscope Glidescope® does not improve performance in this setting.