T-piece versus self-inflating bag ventilation in preterm neonates at birth.

OBJECTIVE: To verify whether the use of the T-piece resuscitator compared with the self-inflating bag in preterm infants ventilated at birth modifies survival to hospital discharge without major morbidities. DESIGN: Pragmatic prospective cohort study. SETTING: 20 Brazilian university hospitals of Brazilian Network on Neonatal Research. Patients were 1962 inborn infants in 2014-2015 ventilated at birth with 23-33' weeks gestation and birth weight 400-1499 g without malformations. Patients transferred until the 27th day after birth were excluded. INTERVENTIONS: Positive pressure ventilation at birth with T-piece resuscitator or self-inflating bag without positive end expiratory pressure valve. Intervention with ventilation followed the Brazilian Society of Pediatrics guidelines. The choice of the equipment was at the neonatologist's discretion in each delivery. The main outcome measures were survival to hospital discharge without bronchopulmonary dysplasia, severe peri-intraventricular haemorrhage and periventricular leucomalacia. Logistic regression adjusted for confounding variables was applied for main outcome. RESULTS: 1456 (74%) were only ventilated with T-piece resuscitator and 506 (26%) with the self-inflating bag. The characteristics of those ventilated with T-Piece resuscitator versus self-inflating bag were birth weight 969 ± 277 vs 941 ± 279 g, gestational age 28.2±2.5 vs 27.8±2.7 weeks and survival to hospital discharge without major morbidities 47% vs 35%. Logistic regression adjusted for maternal characteristics, obstetric and neonatal morbidities showed that the T-piece resuscitator increased the chance of survival to hospital discharge without major morbidities (OR=1.38; 95% CI 1.06 to 1.80; Hosmer-Lemeshow goodness of fit: 0.695). CONCLUSION: This study is the first that highlights the effectiveness of T-piece resuscitator ventilation in improving relevant outcomes in preterm neonates.

[Cerebral blood flow assessment of preterm infants during respiratory therapy with the expiratory flow increase technique]. / Avaliação do fluxo sanguíneo cerebral de recém-nascidos prematuros durante a fisioterapia respiratória com a técnica do aumento do fluxo expiratório.

OBJECTIVE: To assess the impact of respiratory therapy with the expiratory flow increase technique on cerebral hemodynamics of premature newborns. METHODS: This is an intervention study, which included 40 preterm infants (≤34 weeks) aged 8-15 days of life, clinically stable in ambient air or oxygen catheter use. Children with heart defects, diagnosis of brain lesion and/or those using vasoactive drugs were excluded. Ultrasonographic assessments with transcranial Doppler flowmetry were performed before, during and after the increase in expiratory flow session, which lasted 5minutes. Cerebral blood flow velocity and resistance and pulsatility indices in the pericallosal artery were assessed. RESULTS: Respiratory physical therapy did not significantly alter flow velocity at the systolic peak (p=0.50), the end diastolic flow velocity (p=0.17), the mean flow velocity (p=0.07), the resistance index (p=0.41) and the pulsatility index (p=0.67) over time. CONCLUSIONS: The expiratory flow increase technique did not affect cerebral blood flow in clinically-stable preterm infants.

Cerebral blood flow assessment of preterm infants during respiratory therapy with the expiratory flow increase technique / Avaliação do fluxo sanguíneo cerebral de recém-nascidos prematuros durante a fisioterapia respiratória com a técnica do aumento do fluxo expiratório

Objective: To assess the impact of respiratory therapy with the expiratory flow increase technique on cerebral hemodynamics of premature newborns. Methods: This is an intervention study, which included 40 preterm infants (≤34 weeks) aged 8-15 days of life, clinically stable in ambient air or oxygen catheter use. Children with heart defects, diagnosis of brain lesion and/or those using vasoactive drugs were excluded. Ultrasonographic assessments with transcranial Doppler flowmetry were performed before, during and after the increase in expiratory flow session, which lasted 5min. Cerebral blood flow velocity and resistance and pulsatility indices in the pericallosal artery were assessed. Results: Respiratory physical therapy did not significantly alter flow velocity at the systolic peak (p=0.50), the end diastolic flow velocity (p=0.17), the mean flow velocity (p=0.07), the resistance index (p=0.41) and the pulsatility index (p=0.67) over time. Conclusions: The expiratory flow increase technique did not affect cerebral blood flow in clinically-stable preterm infants.

Objetivo: Avaliar a repercussão da fisioterapia respiratória com a técnica de aumento do fluxo expiratório sobre a hemodinâmica cerebral de recém-nascidos prematuros. Métodos: Estudo de intervenção no qual foram incluídos 40 neonatos prematuros (≤34 semanas) com 8-15 dias de vida, clinicamente estáveis em ar ambiente ou em uso de cateter de oxigênio. Foram excluídas crianças com malformações cardíacas, diagnóstico de lesão cerebral e/ou em uso de drogas vasoativas. Exames de ultrassonografia com avaliação por dopplerfluxometria cerebral foram feitos antes, durante e depois da sessão de aumento do fluxo expiratório, que durou cinco minutos. Foram avaliadas as velocidades de fluxo sanguíneo cerebral e os índices de resistência e pulsatilidade na artéria pericalosa. Resultados: A fisioterapia respiratória não alterou significativamente a velocidade de fluxo no pico sistólico (p=0,50), a velocidade de fluxo diastólico final (p=0,17), a velocidade média de fluxo (p=0,07), o índice de resistência (p=0,41) e o índice de pulsatilidade (p=0,67) ao longo do tempo. Conclusões: A manobra de aumento do fluxo expiratório não afetou o fluxo sanguíneo cerebral em recém-nascidos prematuros clinicamente estáveis.

Epileptic manifestations induced by midazolam in the neonatal period

Antiepileptic drugs may cause worsening of epilepsy by aggravating pre-existing seizures or by triggering new seizure types. There are several reports of adverse effects related to midazolam, but only a few authors reported epileptic manifestations. We report four newborns seen at the Neonatal Intensive Care Unit of our University Hospital, who developed seizures a few seconds after the administration of midazolam. It is difficult to identify the patients at risk, but it is important to be aware and recognize this situation