RESUMEN
This case series aimed to characterize the clinical features, management, and outcomes of apnea in infants with trisomy 18. Participants in this study were infants with trisomy 18 who were born alive and admitted to the neonatal intensive care unit in Kyushu University Hospital from 2000 to 2018. Retrospective analysis was performed on clinical data recorded in our department. Twenty-seven infants with trisomy 18 were admitted to our hospital during the study period, of which 25 (nine males, 16 females) were enrolled as eligible participants in this study. Among them, 14 started presenting with apnea from median 3.5 days of age (range 0-47d). In these infants with apnea, eight received respiratory support of positive pressure ventilation (PPV). The 1-year survival rate of infants in the PPV group was higher than that of non-PPV-supported infants (5 out of 8 vs 0 out of 6 infants). Five PPV-supported infants received a diagnosis of epilepsy, which was controlled by antiepileptic drugs. Postnatal respiratory intervention provides better prognosis in infants with trisomy 18. Improved survival leads to accurate diagnosis and treatment of apneic events in association with epilepsy. WHAT THIS PAPER ADDS: Respiratory support is effective against apnea in infants with trisomy 18. Intervention with ventilation provides a higher chance of prolonged survival. Improved survival leads to the accurate diagnosis and treatment of epilepsy-associated apnea.
Asunto(s)
Apnea , Epilepsia , Unidades de Cuidado Intensivo Neonatal , Evaluación de Resultado en la Atención de Salud , Respiración con Presión Positiva , Síndrome de la Trisomía 18 , Apnea/diagnóstico , Apnea/etiología , Apnea/mortalidad , Apnea/terapia , Epilepsia/diagnóstico , Epilepsia/mortalidad , Epilepsia/terapia , Femenino , Humanos , Lactante , Recién Nacido , Masculino , Estudios Retrospectivos , Síndrome de la Trisomía 18/complicaciones , Síndrome de la Trisomía 18/diagnóstico , Síndrome de la Trisomía 18/mortalidad , Síndrome de la Trisomía 18/terapiaRESUMEN
OBJECTIVE: To characterize the epidemiology of Car Seat Tolerance Screening (CSTS) failure and the association between test failure and all-cause 30-day postdischarge mortality or hospital readmission in a large, multicenter cohort of preterm infants receiving neonatal intensive care. STUDY DESIGN: This retrospective cohort study used the prospectively collected Optum Neonatal Database. Study infants were born at <37 weeks of gestation between 2010 and 2016. We identified independent predictors of CSTS failure and calculated the risk-adjusted odds of all-cause 30-day mortality or hospital readmission associated with test failure. RESULTS: Of 7899 infants cared for in 788 hospitals, 334 (4.2%) failed initial CSTS. Greater postmenstrual age at testing and African American race were independently associated with decreased failure risk. Any treatment with an antacid medication, concurrent use of caffeine or supplemental oxygen, and a history of failing a trial off respiratory support were associated with increased failure risk. The mean adjusted post-CSTS duration of hospitalization was 3.1 days longer (95% CI, 2.7-3.6) among the infants who failed the initial screening. Rates of 30-day all-cause mortality or readmission were higher among infants who failed the CSTS (2.4% vs 1.0%; P = .03); however, the difference was not significant after confounder adjustment (OR, 0.38; 95% CI, 0.11-1.31). CONCLUSION: CSTS failure was associated with longer post-test hospitalization but no difference in the risk-adjusted odds for 30-day mortality or hospital readmission. Whether CSTS failure unnecessarily prolongs hospitalization or results in appropriate care that prevents adverse postdischarge outcomes is unknown. Further research is needed to address this knowledge gap.
Asunto(s)
Apnea/diagnóstico , Sistemas de Retención Infantil/efectos adversos , Unidades de Cuidado Intensivo Neonatal , Tamizaje Masivo , Apnea/etiología , Apnea/mortalidad , Hospitalización , Humanos , Recién Nacido , Recien Nacido Prematuro , Estudios Retrospectivos , Factores de RiesgoRESUMEN
PURPOSE: To report the clinical characteristics of abusive head trauma (AHT) in Taiwan and identify the risk factors associated with mortality of these patients. METHODS: Children with clinically diagnosed AHT from January 1, 2000, to October 31, 2015 were reviewed. The demographic data, clinical features, and associated retinal and radiologic findings were analyzed. The multivariable logistic regression model analysis was performed to identify the risk factors associated with in-hospital mortality. RESULTS: A total of 75 children were included. The mean age was 7.31 ± 6.57 months (range, 1-36 months). Retinal hemorrhages were detected in 69 children with AHT (92%). The majority of retinal hemorrhages were characterized by hemorrhagic numbers higher than ten (74.7%), multi-layered (54.7%), and extension beyond the posterior pole to the peripheral retina (73.3%). Twenty children (26.7%) had macular retinoschisis. As a direct result of AHT, ten children died in the hospital (13.3%). Logistic regression showed that respiratory distress or apnea (adjusted odds ratio [OR] = 22.46; 95% confidence interval [CI], 2.24-225.33; P = .0082), vomiting (adjusted OR = 11.94; 95% CI, 1.31-108.403; P = .0276), retinal finding of macular retinoschisis (adjusted OR = 8.9; 95% CI, 1.01-78.65; P = .0493), and the presence of subarachnoid hemorrhage (SAH) (adjusted OR = 15.17; 95% CI, 1.40-64.84; P = .0255) were independently associated with mortality. CONCLUSIONS: Respiratory distress or apnea, vomiting, SAH, and macular retinoschisis are independently associated with mortality in abusive head trauma. A complete ophthalmologic examination with the immediate visualization of intraocular injury should be performed to clarify the likelihood of child abuse and predict a potential poor neurologic outcome.
Asunto(s)
Maltrato a los Niños/diagnóstico , Traumatismos Craneocerebrales/diagnóstico , Mortalidad Hospitalaria , Apnea/diagnóstico , Apnea/mortalidad , Maltrato a los Niños/mortalidad , Preescolar , Traumatismos Craneocerebrales/mortalidad , Femenino , Humanos , Lactante , Masculino , Pronóstico , Síndrome de Dificultad Respiratoria del Recién Nacido/diagnóstico , Síndrome de Dificultad Respiratoria del Recién Nacido/mortalidad , Hemorragia Retiniana/diagnóstico , Hemorragia Retiniana/mortalidad , Retinosquisis/diagnóstico , Retinosquisis/mortalidad , Estudios Retrospectivos , Factores de Riesgo , Taiwán/epidemiologíaRESUMEN
AIM: To conduct a systematic review to evaluate the effectiveness of home monitoring devices in the prevention of sudden infant death syndrome (SIDS). METHODS: Systematic literature review to June 30, 2010. RESULTS: Eleven unique studies were identified. Only one of these studies involved a comparison of home monitoring with a control intervention and so could be deemed level I evidence. The remaining studies constituted level III evidence. CONCLUSIONS: There is no high-level evidence that home monitoring may be of use in preventing SIDS; further research is needed.
Asunto(s)
Atención Domiciliaria de Salud , Muerte Súbita del Lactante/prevención & control , Apnea/diagnóstico , Apnea/mortalidad , Bradicardia/diagnóstico , Bradicardia/mortalidad , Estudios de Cohortes , Humanos , Lactante , Monitoreo Fisiológico/instrumentación , Ensayos Clínicos Controlados Aleatorios como Asunto , Medición de RiesgoRESUMEN
Intermittent hypoxia (IH) occurs in many pathological conditions including recurrent apneas. Hypoxia-inducible factors (HIFs) 1 and 2 mediate transcriptional responses to low O(2). A previous study showed that HIF-1 mediates some of the IH-evoked physiological responses. Because HIF-2alpha is an orthologue of HIF-1alpha, we examined the effects of IH on HIF-2alpha, the O(2)-regulated subunit expression, in pheochromocytoma 12 cell cultures. In contrast to the up-regulation of HIF-1alpha, HIF-2alpha was down-regulated by IH. Similar down-regulation of HIF-2alpha was also seen in carotid bodies and adrenal medullae from IH-exposed rats. Inhibitors of calpain proteases (ALLM, ALLN) prevented IH-evoked degradation of HIF-2alpha whereas inhibitors of prolyl hydroxylases or proteosome were ineffective. IH activated calpain proteases and down-regulated the endogenous calpain inhibitor calpastatin. IH-evoked HIF-2alpha degradation led to inhibition of SOD2 transcription, resulting in oxidative stress. Over-expression of transcriptionally active HIF-2alpha prevented IH-evoked oxidative stress and restored SOD2 activity. Systemic treatment of IH-exposed rats with ALLM rescued HIF-2alpha degradation and restored SOD2 activity, thereby preventing oxidative stress and hypertension. These observations demonstrate that, unlike continuous hypoxia, IH leads to down-regulation of HIF-2alpha via a calpain-dependent signaling pathway and results in oxidative stress as well as autonomic morbidities.
Asunto(s)
Apnea/enzimología , Factores de Transcripción con Motivo Hélice-Asa-Hélice Básico/metabolismo , Calpaína/metabolismo , Estrés Oxidativo , Procesamiento Proteico-Postraduccional , Animales , Apnea/mortalidad , Sistema Nervioso Autónomo/efectos de los fármacos , Sistema Nervioso Autónomo/patología , Señalización del Calcio/efectos de los fármacos , Proteínas de Unión al Calcio/metabolismo , Calpaína/antagonistas & inhibidores , Hipoxia de la Célula/efectos de los fármacos , Regulación hacia Abajo/efectos de los fármacos , Activación Enzimática/efectos de los fármacos , Humanos , Subunidad alfa del Factor 1 Inducible por Hipoxia/metabolismo , Masculino , Oligopéptidos/administración & dosificación , Oligopéptidos/farmacología , Estrés Oxidativo/efectos de los fármacos , Células PC12 , Unión Proteica/efectos de los fármacos , Procesamiento Proteico-Postraduccional/efectos de los fármacos , Ratas , Ratas Sprague-Dawley , Superóxido Dismutasa/antagonistas & inhibidoresRESUMEN
BACKGROUND: Improvements in technology play an important role in caring for critically ill patients. One example is the advance in ventilator design to facilitate triggering of mechanical breaths. Minimal changes in circuit flow unrelated to respiratory effort can trigger a ventilator breath and may mislead caregivers in recognizing brain death. METHODS: We observed patients with devastating brain injuries in a mixed medical/surgical intensive care unit (ICU) with a high clinical suspicion for brain death including the absence of cranial nerve function with apparent spontaneous breathing during patient-triggered modes of mechanical ventilation. Further clinical observation for spontaneous respirations was assessed upon removal of ventilatory support. RESULTS: Nine patients with brain injury due to multiple etiologies were identified and demonstrated no spontaneous respirations when formally assessed for apnea. Length of time between brain death and its recognition could not be determined. CONCLUSION: When brain-dead patients who are suitable organ donors are mistakenly identified as having cerebral activity, the diagnosis of brain death is delayed. This delay impacts resource utilization, impedes recovery and function of organs for donation, and adversely affects donor families, potential recipients of organs, and patient donors who may have testing and treatment that cannot be beneficial. Patients with catastrophic brain injury and absent cranial nerve function should undergo immediate formal apnea testing.
Asunto(s)
Muerte Encefálica/diagnóstico , Lesiones Encefálicas/diagnóstico , Lesiones Encefálicas/mortalidad , Respiración Artificial/métodos , Adulto , Anciano , Apnea/diagnóstico , Apnea/mortalidad , Cuidados Críticos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Factores de Tiempo , Donantes de TejidosRESUMEN
BACKGROUND: Identification of the causes of death among low birth weight babies may facilitate interventions required to improve their survival. OBJECTIVE: To determine the epidemiological factors associated with the survival of very low- and extremely low birth weight babies. METHODS: Consecutive low birth weight babies aged <168 h in a Nigerian tertiary hospital were studied between January and December 2008 using bivariate and multivariate methods. RESULTS: Out of 160 babies weighing <2.5 kg admitted, 78 (48.8%) weighed 0.65-1.49 kg. Survival rates were 6.7% for <1 kg, 57.4% for 1-1.49 kg and 84.9% for 1.5-2.49 kg. Overall, survival rate was 84.9% for babies weighing ≥ 1.5 kg (84.9%) compared to 46.4% among babies weighing <1.5 kg (P < 0.0001). Survival among babies who weighed <1.5 kg was associated with EGA ≥ 32 weeks and caesarean delivery while death was associated with the occurrence of asphyxia, apnea and respiratory distress. EGA ≥ 32 weeks (OR = 1.7), absence of respiratory distress (OR = 2.1) and absence of apnea (OR = 5.3) were independent determinants of survival. CONCLUSION: Survival rate of babies weighing <1.5 kg remains high in this population. The poor state of diagnostic and therapeutic facilities in the centre may be contributory.
Asunto(s)
Mortalidad Infantil , Enfermedades del Recién Nacido/mortalidad , Recién Nacido de muy Bajo Peso , Tasa de Supervivencia , Apnea/mortalidad , Asfixia/mortalidad , Femenino , Edad Gestacional , Humanos , Recién Nacido de Bajo Peso , Recién Nacido , Masculino , Nigeria/epidemiología , Síndrome de Dificultad Respiratoria del Recién Nacido/mortalidad , Factores de RiesgoRESUMEN
OBJECTIVE: To review practices of brain death (BD) determination in patients on extracorporeal membrane oxygenation (ECMO). METHODS: A systematic search was applied to PubMed and 6 electronic databases from inception to May 22, 2019. Studies reporting methods of BD assessment in adult patients (>18 years old) while on ECMO were included, after which data regarding BD assessment were extracted. RESULTS: Twenty-two studies (n = 177 patients) met the inclusion criteria. Eighty-eight patients (50%) in 19 studies underwent the apnea test (AT); most commonly through decreasing the ECMO sweep flow in 14 studies (n = 42, 48%), followed by providing CO2 through the ventilator in 2 studies (n = 6, 7%), and providing CO2 through the ECMO oxygenator in 1 study (n = 1, 1%). The details of the AT were not reported in 2 studies (n = 39, 44%). In 19 patients (22%), the AT was nonconfirmatory due to hemodynamic instability, hypoxia, insufficient CO2 rise, or unreliability of the AT. A total of 157 ancillary tests were performed, including electroencephalogram (62%), computed tomography angiography (22%), transcranial Doppler ultrasound (6%), cerebral blood flow nuclear study (5%), cerebral angiography (4%), and other (1%). Forty-seven patients (53% of patients with AT) with confirmatory AT still underwent additional ancillary for BD confirmation. Only 21 patients (12% of all patients) were declared brain-dead using confirmatory ATs alone without ancillary testing. CONCLUSIONS: Performing AT for patients with ECMO was associated with high failure rate and hemodynamic complications. Our study highlights the variability in practice in regard to the AT and supports the use of ancillary tests to determine BD in patients on ECMO.
Asunto(s)
Apnea/diagnóstico , Muerte Encefálica/diagnóstico , Oxigenación por Membrana Extracorpórea/mortalidad , Apnea/mortalidad , Apnea/fisiopatología , Muerte Encefálica/fisiopatología , Oxigenación por Membrana Extracorpórea/efectos adversos , Hemodinámica , Humanos , Valor Predictivo de las Pruebas , Reproducibilidad de los Resultados , RespiraciónRESUMEN
Breathing is an integrated motor behavior that is driven and controlled by a network of brainstem neurons. Zfhx4 is a zinc finger transcription factor and our results showed that it was specifically expressed in several regions of the mouse brainstem. Mice lacking Zfhx4 died shortly after birth from an apparent inability to initiate respiration. We also found that the electrical rhythm of brainstemâspinal cord preparations was significantly depressed in Zfhx4-null mice compared to wild-type mice. Immunofluorescence staining revealed that Zfhx4 was coexpressed with Phox2b and Math1 in the brainstem and that Zfhx4 ablation greatly decreased the expression of these proteins, especially in the retrotrapezoid nucleus. Combined ChIPâseq and mRNA expression microarray analysis identified Phox2b as the direct downstream target gene of Zfhx4, and this finding was validated by ChIPâqPCR. Previous studies have reported that both Phox2b and Math1 play key roles in the development of the respiratory center, and Phox2b and Math1 knockout mice are neonatal lethal due to severe central apnea. On top of this, our study revealed that Zfhx4 is a critical regulator of Phox2b expression and essential for perinatal breathing.
Asunto(s)
Apnea , Proteínas de Homeodominio/genética , Centro Respiratorio , Animales , Apnea/metabolismo , Apnea/mortalidad , Factores de Transcripción con Motivo Hélice-Asa-Hélice Básico/metabolismo , Encéfalo/metabolismo , Tronco Encefálico/metabolismo , Regulación de la Expresión Génica , Proteínas de Homeodominio/metabolismo , Ratones , Ratones Noqueados/genética , Neuronas/metabolismo , Respiración , Centro Respiratorio/embriología , Centro Respiratorio/metabolismo , Factores de Transcripción/genética , Factores de Transcripción/metabolismoRESUMEN
Central serotonin (5-HT) neurons modulate many vital brain functions, including respiratory control. Whether breathing depends critically on 5-HT neurons, or whether their influence is excitatory or inhibitory, remains controversial. Here we show that neonatal Lmx1b(flox/flox;ePet-Cre/+) mice (also called Lmx1b(f/f/p) mice), which selectively lack serotonin neurons, display frequent and severe apnea lasting as long as 55 s. This was associated with a marked decrease in ventilation to less than one-half of normal. These respiratory abnormalities were most severe during the postnatal period, markedly improving by the time the pups were 2-4 weeks old. Despite the severe breathing dysfunction, many of these mice survived, but there was a high perinatal mortality, and those that survived had a decrease in growth rate until the age at which the respiratory defects resolved. Consistent with these in vivo observations, respiratory output was markedly reduced in isolated brainstem-spinal cord preparations from neonatal Lmx1b(f/f/p) mice and completely blocked in perfused brain preparations from neonatal rats treated with selective antagonists of 5-HT(2A) and neurokinin 1 (NK-1) receptors. The ventilatory deficits in neonatal Lmx1b(f/f/p) mice were reversed in vitro and in vivo with agonists of 5-HT(2A) and/or NK-1 receptors. These results demonstrate that ventilatory output in the neonatal period is critically dependent on serotonin neurons, which provide excitatory drive to the respiratory network via 5-HT(2A) and NK-1 receptor activation. These findings provide insight into the mechanisms of sudden infant death syndrome, which has been associated with abnormalities of 5-HT neurons and of cardiorespiratory control.
Asunto(s)
Apnea/metabolismo , Apnea/mortalidad , Neuronas/fisiología , Serotonina/deficiencia , Animales , Animales Recién Nacidos , Apnea/genética , Masculino , Ratones , Ratones Transgénicos , Ratas , Ratas Sprague-Dawley , Mecánica Respiratoria/genética , Serotonina/genéticaRESUMEN
BACKGROUND: Methylxanthine therapy is commonly used for apnea of prematurity but in the absence of adequate data on its efficacy and safety. It is uncertain whether methylxanthines have long-term effects on neurodevelopment and growth. METHODS: We randomly assigned 2006 infants with birth weights of 500 to 1250 g to receive either caffeine or placebo until therapy for apnea of prematurity was no longer needed. The primary outcome was a composite of death, cerebral palsy, cognitive delay (defined as a Mental Development Index score of <85 on the Bayley Scales of Infant Development), deafness, or blindness at a corrected age of 18 to 21 months. RESULTS: Of the 937 infants assigned to caffeine for whom adequate data on the primary outcome were available, 377 (40.2%) died or survived with a neurodevelopmental disability, as compared with 431 of the 932 infants (46.2%) assigned to placebo for whom adequate data on the primary outcome were available (odds ratio adjusted for center, 0.77; 95% confidence interval [CI], 0.64 to 0.93; P=0.008). Treatment with caffeine as compared with placebo reduced the incidence of cerebral palsy (4.4% vs. 7.3%; adjusted odds ratio, 0.58; 95% CI, 0.39 to 0.87; P=0.009) and of cognitive delay (33.8% vs. 38.3%; adjusted odds ratio, 0.81; 95% CI, 0.66 to 0.99; P=0.04). The rates of death, deafness, and blindness and the mean percentiles for height, weight, and head circumference at follow-up did not differ significantly between the two groups. CONCLUSIONS: Caffeine therapy for apnea of prematurity improves the rate of survival without neurodevelopmental disability at 18 to 21 months in infants with very low birth weight. (ClinicalTrials.gov number, NCT00182312 [ClinicalTrials.gov].).
Asunto(s)
Apnea/tratamiento farmacológico , Cafeína/uso terapéutico , Estimulantes del Sistema Nervioso Central/uso terapéutico , Citratos/uso terapéutico , Enfermedades del Prematuro/tratamiento farmacológico , Recién Nacido de muy Bajo Peso , Apnea/mortalidad , Tamaño Corporal/efectos de los fármacos , Parálisis Cerebral/epidemiología , Parálisis Cerebral/prevención & control , Discapacidades del Desarrollo/epidemiología , Discapacidades del Desarrollo/prevención & control , Epilepsia/epidemiología , Epilepsia/prevención & control , Femenino , Estudios de Seguimiento , Humanos , Recién Nacido , Recien Nacido Prematuro/crecimiento & desarrollo , Enfermedades del Prematuro/mortalidad , Recién Nacido de muy Bajo Peso/crecimiento & desarrollo , Modelos Logísticos , Masculino , Oportunidad Relativa , Retinopatía de la Prematuridad/epidemiología , Tasa de SupervivenciaRESUMEN
OBJECTIVE: To compare the risk factors of 153 cases of apparent life-threatening event (ALTE) enrolled in the multicenter Collaborative Home Infant Monitoring Evaluation (CHIME) from 1994 to 1998 with the published risk factors for sudden infant death syndrome (SIDS). STUDY DESIGN: Trained CHIME interviewers gathered histories of infants with ALTE who met the criteria. The following risk factors were analyzed: male predominance, gestational age, low birth weight, very low birth weight, incidence of small for gestational age (SGA), age at the event, multiparity, maternal age, and smoking. Population-based SIDS studies with >100 deaths, focusing on 1 or more pertinent risk factors and carried out during the decade in which CHIME data were collected, were chosen for comparison. RESULTS: One of the 153 infants with ALTE in this study died during follow-up (0.6%). CHIME ALTE differed significantly from SIDS in 4 respects: fewer infants with low birth weight and SGA at birth, fewer teenage pregnancies, and a younger infant age at ALTE. CONCLUSIONS: Although a number of risk factors for ALTE are similar to those for SIDS, the differences warrant a separate focus on ALTE beyond that on SIDS.
Asunto(s)
Apnea/mortalidad , Causas de Muerte , Recién Nacido Pequeño para la Edad Gestacional , Monitoreo Fisiológico/métodos , Muerte Súbita del Lactante/etiología , Apnea/diagnóstico , Estudios de Cohortes , Femenino , Humanos , Lactante , Mortalidad Infantil/tendencias , Recién Nacido , Masculino , Edad Materna , Estudios Multicéntricos como Asunto , Paridad , Embarazo , Estudios Retrospectivos , Factores de Riesgo , Sensibilidad y Especificidad , Factores Sexuales , Muerte Súbita del Lactante/epidemiologíaRESUMEN
BACKGROUND: Respiratory complications can undermine outcome from low cervical spinal cord injury (SCI) (C5-T1). Most devastating of these is catastrophic loss of airway control. This study sought to determine the incidence and effect of catastrophic airway loss (CLA) and to define the need for elective intubation with subsequent tracheostomy to prevent potentially fatal outcomes. METHODS: A database of 54,838 consecutive patients treated in a level I trauma center between January 1988 and December 2004 was queried to identify patients with low cervical SCI, without traumatic brain injury. Patients were then stratified into complete or incomplete SCI groups, based on clinical assessment of their SCI. Mortality, age, injury severity, need for intubation, and tracheostomy were analyzed for each group using Fisher's exact test or Student's t test, as appropriate, accepting p < 0.05 as significant. RESULTS: One hundred eighty-six patients met inclusion criteria. The majority of low cervical spinal cord injuries were complete (58%). Overall, 127 (68%) patients required intubation, 88 (69%) required tracheostomy, and 27 died (15% of study population). Between each group there were significant differences in age and Injury Severity Score, however, within each group there were no significant differences in either. Eleven CSCI patients were not intubated; four of whom were at family request. Six of the remaining seven patients encountered fatal catastrophic airway loss. One patient was discharged to rehabilitation. Patients with incomplete SCI required intubation less frequently (38%); however, 50% of those required tracheostomy for intractable pulmonary failure. CONCLUSIONS: These data indicate that regardless of severity of low cervical SCI, immediate, thorough evaluation for respiratory failure is necessary. Early intubation is mandatory for CSCI patients. For incomplete patients evidence of respiratory failure should prompt immediate airway intervention, half of whom will require tracheostomy.
Asunto(s)
Apnea/terapia , Vértebras Cervicales/lesiones , Intubación Intratraqueal , Insuficiencia Respiratoria/terapia , Resucitación , Traumatismos de la Médula Espinal/terapia , Fracturas de la Columna Vertebral/terapia , Traqueostomía , Adolescente , Adulto , Apnea/etiología , Apnea/mortalidad , Niño , Estudios Transversales , Femenino , Humanos , Incidencia , Puntaje de Gravedad del Traumatismo , Unidades de Cuidados Intensivos , Masculino , Persona de Mediana Edad , Insuficiencia Respiratoria/etiología , Insuficiencia Respiratoria/mortalidad , Estudios Retrospectivos , Traumatismos de la Médula Espinal/complicaciones , Traumatismos de la Médula Espinal/mortalidad , Fracturas de la Columna Vertebral/complicaciones , Fracturas de la Columna Vertebral/mortalidad , Tasa de SupervivenciaRESUMEN
BACKGROUND: Placebo-controlled trials have shown that caffeine is highly effective in treating apnoea of prematurity and reduces the risk of bronchopulmonary dysplasia (BPD) and neurodevelopmental impairment (NDI). OBJECTIVE: To identify, appraise and summarise studies investigating the modulating effect of different caffeine dosages. METHODS: A systematic review identified all randomised controlled trials (RCTs) comparing a high versus a standard caffeine treatment regimen in infants with a gestational age <32 weeks, by searching the main electronic databases and abstracts of the Pediatric Academic Societies. Studies comparing caffeine to placebo or theophylline only were excluded. Primary outcomes were BPD and mortality at 36 weeks postmenstrual age. Secondary key-outcome was neurodevelopmental outcome at 12 and 24 months corrected age. Meta-analysis was performed using RevMan 5.3. RESULTS: Six RCTs including 620 infants were identified. Meta-analysis showed a significant decrease in BPD, the combined outcome BPD or mortality, and failure to extubate in infants allocated to a higher caffeine dose. No differences were found in mortality alone and NDI. The quality of the outcome measures were deemed low to very low according to the Grading of Recommendations Assessment, Development and Evaluation guidelines. CONCLUSIONS: Although this review suggests that administering a higher dose of caffeine might enhance its beneficial effect on death or BPD, firm recommendations on the optimal caffeine dose cannot be given due to the low level of evidence. A large RCT is urgently needed to confirm or refute these findings and determine the optimal dose of caffeine.
Asunto(s)
Apnea/tratamiento farmacológico , Cafeína/administración & dosificación , Estimulantes del Sistema Nervioso Central/administración & dosificación , Apnea/complicaciones , Apnea/mortalidad , Displasia Broncopulmonar/epidemiología , Displasia Broncopulmonar/etiología , Cafeína/efectos adversos , Estimulantes del Sistema Nervioso Central/efectos adversos , Relación Dosis-Respuesta a Droga , Humanos , Lactante , Mortalidad Infantil , Recién Nacido , Recien Nacido Prematuro , Enfermedades del Prematuro/tratamiento farmacológico , Resultado del TratamientoRESUMEN
This study prospectively examined the care of trauma patients in extremis on presentation to a tertiary medical center between January 2000 and August 31, 2002. There were 144 patients who presented without a pulse or spontaneous respiration and required cardiopulmonary resuscitation (mean age, 41.5+/-2.3 years; male-to-female ratio, 105:39). Successfully resuscitated patients, who were either admitted to the surgical intensive care unit (SICU) or who were taken to the operating room for surgical exploration, had significantly shorter duration of cardiopulmonary resuscitation (14.55+/-1.64 minutes vs. 33.32+/-1.23 minutes; P < 0.001) and received less amounts of epinephrine than those who died in the emergency room (P < 0.05). One hundred sixteen patients died in the emergency room. Nineteen admitted patients died within 24 hours of presentation. Nine patients survived beyond 24 hours and all of them were admitted directly to the SICU for the management of brain injury. Six patients were taken to the operating room for surgical exploration to control the bleeding; all of them died in the operating room or shortly thereafter in the SICU. No patient in this study survived to be discharged. The financial cost of successfully resuscitated patients was significantly higher than that of patients who died in the emergency room (P < 0.001). Instead of insisting on aggressive measures to resuscitate trauma patients in extremis on presentation, the authors suggest we should redirect that fervor toward efforts made to promote trauma awareness and injury prevention programs.
Asunto(s)
Apnea/terapia , Reanimación Cardiopulmonar/métodos , Paro Cardíaco/terapia , Heridas y Lesiones/complicaciones , Adolescente , Adulto , Anciano , Apnea/etiología , Apnea/mortalidad , Reanimación Cardiopulmonar/mortalidad , Niño , Preescolar , Femenino , Estudios de Seguimiento , Paro Cardíaco/etiología , Paro Cardíaco/mortalidad , Humanos , Lactante , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Tasa de Supervivencia/tendencias , Taiwán/epidemiología , Índices de Gravedad del Trauma , Resultado del Tratamiento , Heridas y Lesiones/mortalidad , Heridas y Lesiones/terapiaRESUMEN
Five years after the first edition, we have revised and updated the guidelines, re-examining the queries and relative recommendations, expanding the issues addressed with the introduction of a new entity, recently proposed by the American Academy of Pediatrics: BRUE, an acronym for Brief Resolved Unexplained Events. In this manuscript we will use the term BRUE only to refer to mild, idiopathic cases rather than simply replace the acronym ALTE per se.In our guidelines the acronym ALTE is used for severe cases that are unexplainable after the first and second level examinations.Although the term ALTE can be used to describe the common symptoms at the onset, whenever the aetiology is ascertained, the final diagnosis may be better specified as seizures, gastroesophageal reflux, infection, arrhythmia, etc. Lastly, we have addressed the emerging problem of the so-called Sudden Unexpected Postnatal Collapse (SUPC), that might be considered as a severe ALTE occurring in the first week of life.
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Apnea/diagnóstico , Causas de Muerte , Cianosis/diagnóstico , Enfermedades del Recién Nacido/diagnóstico , Guías de Práctica Clínica como Asunto , Muerte Súbita del Lactante/prevención & control , Apnea/mortalidad , Cianosis/mortalidad , Urgencias Médicas , Medicina Basada en la Evidencia , Femenino , Humanos , Lactante , Recién Nacido , Enfermedades del Recién Nacido/mortalidad , Italia , Masculino , Medición de Riesgo , Análisis de SupervivenciaRESUMEN
OBJECTIVE: Early death following cranial trauma is often considered unsurvivable traumatic brain injury (TBI). However, Impact Brain Apnoea (IBA), the phenomenon of apnoea following TBI, may be a significant and preventable contributor to death attributed to primary injury. This paper reviews the history of IBA, cites case examples and reports a survey of emergency responder experience. METHODS: Literature and narrative review and focused survey of pre-hospital physicians. RESULTS: IBA was first reported in the medical literature in 1705 but has been demonstrated in multiple animal studies and is frequently anecdotally witnessed in the pre-hospital arena following human TBI. It is characterised by the cessation of spontaneous breathing following a TBI and is commonly accompanied by a catecholamine surge witnessed as hypertension followed by cardiovascular collapse. This contradicts the belief that isolated traumatic brain injury cannot be the cause of shock, raising the possibility that brain injury may be misinterpreted and therefore mismanaged in patients with isolated brain injury. Current trauma management techniques (e.g. rolling patients supine, compression only cardiopulmonary resuscitation) could theoretically compound hypoxia and worsen the effects of IBA. Anecdotal examples from clinicians attending head injured patients within a few minutes of injury are described. Proposals for the study and intervention for IBA using advances in remote technology are discussed. CONCLUSION: IBA is a potential cause of early death in some head injured patients. The precise mechanisms in humans are poorly understood but it is likely that early, simple interventions to prevent apnoea could improve clinical outcomes.
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Apnea/mortalidad , Lesiones Traumáticas del Encéfalo/mortalidad , Animales , Apnea/etiología , Lesiones Traumáticas del Encéfalo/complicaciones , Lesiones Traumáticas del Encéfalo/diagnóstico por imagen , Reanimación Cardiopulmonar/efectos adversos , Paro Cardíaco/etiología , Paro Cardíaco/mortalidad , Humanos , Imagen por Resonancia Magnética , Factores de Riesgo , Tomografía Computarizada por Rayos XRESUMEN
BACKGROUND: We have studied the relations between physical activity, types of physical activity, and changes in physical activity and all-cause mortality in men with established coronary heart disease (CHD). METHODS AND RESULTS: In 1992, 12 to 14 years after the initial screening (Q1) of 7735 men 40 to 59 years of age from general practices in 24 British towns, 5934 (91% of available survivors, mean age 63 years) provided further information on physical activity (Q92) and were followed up for 5 years; 963 had a physician's diagnosis of CHD (myocardial infarction or angina). After exclusions, there were 772 men with established CHD, 131 of whom died of all causes. The lowest risks for all-cause and cardiovascular mortality were seen in light and moderate activity groups (adjusted relative risk compared with inactive/occasionally active: light, 0.42 (0.25, 0.71); moderate, 0.47 (0.24, 0.92); and moderately vigorous/vigorous, 0.63 (0.39, 1.03). Recreational activity of >/=4 hours per weekend, moderate or heavy gardening, and regular walking (>40 min/d) were all associated with a significant reduction in all-cause mortality. Nonsporting activity was more beneficial than sporting activities. Men sedentary at Q1 who began at least light activity by Q92 showed lower mortality rates on follow-up than those who remained sedentary (relative risk 0.58, 95% CI 0.33 to 1.03; P:=0.06). CONCLUSIONS: Light or moderate activity in men with established CHD is associated with a significantly lower risk of all-cause mortality. Regular walking and moderate or heavy gardening were sufficient to achieve this benefit.
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Causas de Muerte , Enfermedad Coronaria/mortalidad , Ejercicio Físico/fisiología , Adulto , Apnea/mortalidad , Dolor en el Pecho/mortalidad , Enfermedad Coronaria/rehabilitación , Estudios de Seguimiento , Estado de Salud , Humanos , Actividades Recreativas , Locomoción , Masculino , Persona de Mediana Edad , Modelos de Riesgos Proporcionales , Estudios Prospectivos , Factores de Riesgo , Deportes , Caminata/fisiologíaAsunto(s)
Apnea/tratamiento farmacológico , Cafeína/uso terapéutico , Estimulantes del Sistema Nervioso Central/uso terapéutico , Enfermedades del Prematuro/tratamiento farmacológico , Apnea/mortalidad , Discapacidades del Desarrollo/prevención & control , Humanos , Recién Nacido , Recien Nacido Prematuro , Enfermedades del Prematuro/mortalidad , Recién Nacido de muy Bajo Peso/crecimiento & desarrollo , Retinopatía de la Prematuridad/prevención & control , Aumento de Peso/efectos de los fármacosRESUMEN
OBJECTIVES/HYPOTHESIS: Intrathoracic petechiae are a prominent diagnostic finding in sudden infant death syndrome (SIDS) victims. In this study, the laryngeal chemoreflex (LCR) was elicited experimentally to discover whether intrathoracic petechiae would be produced by way of the LCR. The hypothesis was that water stimulation of the larynx in piglets, leading to death by prolonged apnea, would produce postmortem findings similar to those found in SIDS victims. STUDY DESIGN: Using the piglet as an animal model, the LCR was initiated by way of water stimulation of the larynx, resulting in death. Normoxic and hypoxic conditions were established before the stimulation. The piglets were studied postmortem to determine the relationship between the physiologic mechanisms of the LCR and characteristic pathologic findings in SIDS. METHODS: Using protocols approved by animal care, 14 mixed-breed piglets aged 7 to 14 days were sedated with a ketamine/xylazine mixture. Respiratory and pressure-monitoring devices were affixed and light anesthesia maintained with Surital infusion. In 10 of the piglets, a small catheter was placed between the arytenoid cartilages, and 5 mL of tap water was introduced over 1 second. The LCR ensued, producing periods of central apnea bordered by gasping efforts and resulting in hypoxemia and death in all cases. Four piglets underwent this manipulation in normoxic conditions. Six breathed a hypoxic gas mixture for 1 hour to bring their Po2 down to below 50 torr before water was introduced into the larynx. Four control piglets breathed the hypoxic gas mixture for 1 hour (without water stimulation or LCR) before Surital overdose. Within 24 hours of death, all piglets underwent thoracoabdominal autopsy by a blinded evaluator experienced in SIDS pathology. RESULTS: The autopsies revealed nothing remarkable in the abdominal viscera of any of the experimental animals. Thymus, heart, and lungs were graded 0 to 4 to indicate the degree of petechiae on external surfaces. Average cumulative scores (ACS) were applied to each animal. The control (hypoxic) piglets had no petechiae (ACS 0.0). The normoxic experimental piglets had moderate petechiae (ACS 3.5). The hypoxic experimental piglets had more prominent petechiae (ACS 6.3). CONCLUSIONS: Stimulation of the LCR, leading to death by prolonged apnea, produces postmortem findings in piglets similar to those found in SIDS victims. Petechiae were more severe among piglets pretreated with a hypoxic mixture of gases. This study supports the hypothesis that initiation of the LCR may produce pathologic features often prominent in SIDS.