Outcomes of preterm infants treated with hypothermia for hypoxic-ischemic encephalopathy.

BACKGROUND: Therapeutic hypothermia reduces the risk of death, or moderate to severe neurodevelopmental impairment (NDI) in term infants with hypoxic-ischemic encephalopathy (HIE). Reports of its safety and efficacy in preterm infants are scarce. OBJECTIVE: Report short and long-term outcomes of preterm infants with HIE who received therapeutic hypothermia. METHODS: A retrospective cohort analysis of all preterm infants <36 weeks' gestation with HIE who received whole body hypothermia in a single center from January 2007 to April 2015. The primary outcome was death or moderate to severe NDI defined by moderate or severe cerebral palsy, severe hearing or visual impairment, or cognitive score < 85 on the Bayley Scales of Infant Development III (BSID III) at 18-24 months' adjusted age. RESULTS: 30 infants with a median gestational age and birthweight of 35 weeks' (range; 33-35) and 2575 g (1850-4840) and a median first postnatal blood pH of 6.81 (6.58-7.14). Complications included coagulopathy (50%), early clinical seizures (43.3%), arterial hypotension (40%), persistent metabolic acidosis (37%) and thrombocytopenia (20%). Four infants died before or soon after discharge (18.2%). Eighteen surviving infants (69.2%) had follow up data; 7 of them had moderate to severe NDI (38.9%). Cognitive, motor and language mean composite BSID III scores were 84 (54-110), 83 (46-118), and 78 (46-112). Death or moderate to severe NDI occurred in 11/22 (50%) infants with known outcomes. CONCLUSION: Large randomized trials on efficacy and safety are needed in this highly vulnerable population as the incidence of complications and the combined outcome of death and NDI is concerning.

Outcomes of Preterm Infants following Discussions about Withdrawal or Withholding of Life Support.

OBJECTIVES: To describe the frequency of postnatal discussions about withdrawal or withholding of life-sustaining therapy (WWLST), ensuing WWLST, and outcomes of infants surviving such discussions. We hypothesized that such survivors have poor outcomes. STUDY DESIGN: This retrospective review included registry data from 18 centers of the National Institute of Child Health and Human Development Neonatal Research Network. Infants born at 22-28 weeks of gestation who survived >12 hours during 2011-2013 were included. Regression analysis identified maternal and infant factors associated with WWLST discussions and factors predicting ensuing WWLST. In-hospital and 18- to 26-month outcomes were evaluated. RESULTS: WWLST discussions occurred in 529 (15.4%) of 3434 infants. These were more frequent at 22-24 weeks (27.0%) compared with 27-28 weeks of gestation (5.6%). Factors associated with WWLST discussion were male sex, gestational age (GA) of ≤24 weeks, birth weight small for GA, congenital malformations or syndromes, early onset sepsis, severe brain injury, and necrotizing enterocolitis. Rates of WWLST discussion varied by center (6.4%-29.9%) as did WWLST (5.2%-20.7%). Ensuing WWLST occurred in 406 patients; of these, 5 survived to discharge. Of the 123 infants for whom intensive care was continued, 58 (47%) survived to discharge. Survival after WWLST discussion was associated with higher rates of neonatal morbidities and neurodevelopmental impairment compared with babies for whom WWLST discussions did not occur. Significant predictors of ensuing WWLST were maternal age >25 years, necrotizing enterocolitis, and days on a ventilator. CONCLUSIONS: Wide center variations in WWLST discussions occur, especially at ≤24 weeks GA. Outcomes of infants surviving after WWLST discussions are poor. TRIAL REGISTRATION: ClinicalTrials.gov: NCT00063063.

Gabapentin Use in the Neonatal Intensive Care Unit.

Gabapentin was used for the treatment of term and preterm infants with suspected visceral hyperalgesia caused by a variety of neurologic and gastrointestinal morbidities. Improved feeding tolerance and decreased irritability were seen, as well as decreased usage of opioids and benzodiazepines. Adverse events occurred with abrupt discontinuation of this medication.

Sedatives and Analgesics Given to Infants in Neonatal Intensive Care Units at the End of Life.

OBJECTIVE: To describe the administration of sedatives and analgesics at the end of life in a large cohort of infants in North American neonatal intensive care units. STUDY DESIGN: Data on mortality and sedative and analgesic administration were from infants who died from 1997-2012 in 348 neonatal intensive care units managed by the Pediatrix Medical Group. Sedatives and analgesics of interest included opioids (fentanyl, methadone, morphine), benzodiazepines (clonazepam, diazepam, lorazepam, midazolam), central alpha-2 agonists (clonidine, dexmedetomidine), ketamine, and pentobarbital. We used multivariable logistic regression to evaluate the association between administration of these drugs on the day of death and infant demographics and illness severity. RESULTS: We identified 19 726 infants who died. Of these, 6188 (31%) received a sedative or analgesic on the day of death; opioids were most frequently administered, 5366/19 726 (27%). Administration of opioids and benzodiazepines increased during the study period, from 16/283 (6%) for both in 1997 to 523/1465 (36%) and 295/1465 (20%) in 2012, respectively. Increasing gestational age, increasing postnatal age, invasive procedure within 2 days of death, more recent year of death, mechanical ventilation, inotropic support, and antibiotics on the day of death were associated with exposure to sedatives or analgesics. CONCLUSIONS: Administration of sedatives and analgesics increased over time. Infants of older gestational age and those more critically ill were more likely to receive these drugs on the day of death. These findings suggest that drug administration may be driven by severity of illness.

Neuroprotección mediante hipotermia moderada en recién nacidos con encefalopatía hipóxico-isquémica / Neuroprotection by mild hypothermia in newborn with hypoxic-ischemic encephalopathy

En la mayoría de los países desarrollados el tratamiento con la hipotermia se ha convertido en un pilar fundamental para la neuroprotección del recién nacido con encefalopatía hipóxico-isquémica (EHI). En la unidad de cuidados intensivos neonatales de la universidad de Duke, la hipotermia moderada se aplica desde el 2005. El tratamiento con hipotermia es muy limitado en otros países porque en adición a un equipamiento especializado, requiere de manejo detallado de las disfunciones multiorgánicas, documentación meticulosa de la información clínica con cuidados y control del paciente en forma protocolizada. Como punto de partida, y para facilitar la introducción de la hipotermia en las unidades de cuidados intensivos neonatales en Uruguay, se presenta la evolución de cinco pacientes internados en la unidad de cuidados intensivos del centro hospitalario de Duke (Carolina del Norte, EE.UU.), evaluando la respuesta al tratamiento con hipotermia moderada y su evolución clínica

Neuroprotección mediante hipotermia moderada en recién nacidos con encefalopatía hipóxico-isquémica / Neuroprotection by mild hypothermia in newborn with hypoxic-ischemic encephalopathy

En la mayoría de los países desarrollados el tratamiento con la hipotermia se ha convertido en un pilar fundamental para la neuroprotección del recién nacido con encefalopatía hipóxico-isquémica (EHI). En la unidad de cuidados intensivos neonatales de la universidad de Duke, la hipotermia moderada se aplica desde el 2005. El tratamiento con hipotermia es muy limitado en otros países porque en adición a un equipamiento especializado, requiere de manejo detallado de las disfunciones multiorgánicas, documentación meticulosa de la información clínica con cuidados y control del paciente en forma protocolizada. Como punto de partida, y para facilitar la introducción de la hipotermia en las unidades de cuidados intensivos neonatales en Uruguay, se presenta la evolución de cinco pacientes internados en la unidad de cuidados intensivos del centro hospitalario de Duke (Carolina del Norte, EE.UU.), evaluando la respuesta al tratamiento con hipotermia moderada y su evolución clínica

Vasopressin for refractory hypotension in extremely low birth weight infants.

Intravenous vasopressin at 0.01 to 0.04 units/kg/h increased median mean blood pressure from 26 mm Hg (range 18-44) to 41 mm Hg (range 17-90) by 12 hours of infusion (P=.002) and allowed weaning of catecholamines in a group of extremely low birth weight infants with refractory hypotension.