Cytokine elaboration in critically ill infants with bacterial sepsis, necrotizing entercolitis, or sepsis syndrome: correlation with clinical parameters of inflammation and mortality.

OBJECTIVE: To test the hypothesis that cytokines might distinguish critically ill infants with bacterial sepsis or necrotizing enterocolitis (NEC) from those with sepsis syndrome and that these elevations would be correlated with clinical variables of inflammation and mortality. STUDY DESIGN: We measured plasma and tracheal aspirate (TA) levels of interleukin-8 (IL-8), epithelial neutrophil activating peptide (ENA-78), IL-10, and IL-18 in 84 neonates with suspected sepsis or NEC. Thirty-one infants had bacterial sepsis, 19 had NEC, and 34 infants with negative results on cultures had sepsis syndrome. RESULTS: Plasma IL-8 and IL-10 levels were significantly increased in infants with bacterial sepsis compared with those in infants with sepsis syndrome. Plasma IL-8, ENA-78, and IL-10 levels were elevated in infants with NEC compared with those in infants with sepsis syndrome. TA IL-8 and IL-10 levels were also increased in infants with bacterial sepsis; TA ENA-78, and IL-18 were not elevated in infants with sepsis or NEC when compared with infants with sepsis syndrome. Plasma and TA cytokine levels correlated with hematologic parameters. Plasma cytokine levels were higher in infants who did not survive than in infants who did survive. CONCLUSIONS: Plasma and TA cytokine levels are elevated in critically ill infants with bacterial sepsis or NEC compared with those in infants with sepsis syndrome. Our results suggest distinct patterns of cytokine elaboration in different disease states.

Fear of litigation may increase resuscitation of infants born near the limits of viability.

OBJECTIVES: To explore how fear of litigation influences neonatal treatment decisions. STUDY DESIGN: In a mailed survey, we presented a hypothetical vignette of a premature infant to 1000 neonatologists. We asked them to estimate prognosis, indicate appropriate intervention, and respond to parental treatment requests. Subjects were randomly assigned to receive one of two questionnaires, "litigious" or "nonlitigious," which differed only in the description of the infant's parents. RESULTS: The response rate was 63.0%. The vast majority of respondents deferred to parental requests rather than adhering to their best judgment. They deferred whether or not parents requested treatment and whether or not parents were described as litigious (P <.0001). Among those respondents who shifted their resuscitation opinion after parental introduction, respondents to the nonlitigious version were more likely to shift their opinion from "treat" to "do not treat" after parental requests to "use your best judgment" (P <.042). The influence of parental litigiousness was primarily seen among neonatologists who thought that the infant's prognosis was dismal (P <.044). CONCLUSIONS: There is a strong disposition among neonatologists toward respecting parental wishes. This disposition is stronger when neonatologists are given additional reason to be concerned about litigation.