Different Effects of Two Protocols for Pre-Procedural Analgosedation on Vital Signs in Neonates during and after Endotracheal Intubation.

BACKGROUND: Analgosedation is often used for endotracheal intubation in neonates, but no consensus exists on the optimal pre-procedural medication. AIMS: To compare the time to intubation and vital signs during and after intubation in 2 NICUs using different premedication protocols. METHODS: Prospective observational study in 2 tertiary NICUs, comparing fentanyl and optional vecuronium for elective neonatal endotracheal intubation (NICU-1) with atropine, morphine, midazolam and optional pancuronium (NICU-2). Primary endpoints were: time to intubate and number of intubation attempts; secondary endpoints were: deviations of heart rate, oxygen saturation and blood pressure from baseline until 20 min post intubation. RESULTS: 45 and 30 intubations were analyzed in NICU-1 and NICU-2. Time to intubation was longer in NICU-1 (7 min) than in NICU-2 (4 min; p=0.029), but the mean number of intubation attempts did not differ significantly. Bradycardias (34 vs. 1, p<0.001) and hypoxemias (136 vs. 48, p<0.001) were more frequent in NICU-1, and tachycardias (59 vs. 72, p<0.001) more frequent in NICU-2. Mean arterial blood pressure (MAP) increased in NICU-1 (+6.18 mmHg) and decreased in NICU-2 (-5.83 mmHg), whereas mean heart rates (HR) decreased in NICU-1 (-19.29 bpm) and increased in NICU-2 (+15.93 bpm). MAP and HR returned to baseline 6-10 min after intubation in NICU-1 and after 11-15 min and 16-20 min in NICU-2, respectively. CONCLUSIONS: The two protocols yielded significant differences in the time to intubation and in the extent and duration of physiologic changes during and post-intubation. Short acting drugs should be preferred and vital signs should be closely monitored at least 20 min post intubation. More studies are required to identify analgosedation protocols that minimize potentially harmful events during endotracheal intubation.

Primary laparotomy is effective and safe in the treatment of necrotizing enterocolitis.

INTRODUCTION: There is ongoing controversy regarding the surgical treatment of necrotizing enterocolitis (NEC) in infants with extremely low birth weight (ELBW). We hypothesize that primary laparotomy is a safe and effective treatment for all infants with surgical NEC. METHODS: We retrospectively compared a group of ELBW infants (<1,000 g, group A, n = 39) with preterm infants (≥1,000 g, group B, n = 18) with surgical NEC during a 4-year period (10/2008-09/2012). Indications for emergency operation were Bell stages IIIa or IIIb. The main outcome measure was survival. Data were analyzed using Chi squared test and Spearman's rank correlation coefficient. RESULTS: Fifty-seven patients were included with a gestational age from 24 to 30 weeks in group A and 27-38 weeks in group B. There were no significant differences in Bell stage (IIIa; IIIb) and NEC type (focal; segmental; pannecrosis). The operative techniques were not significantly different between the groups and included resection and stoma formation in 44 of 57 (77 %) patients; resection and anastomosis in 6 of 57 (11 %); and inspection only, followed by withdrawal of care, in 7 of 57 (12 %). Overall mortality was 10 of 57 (17 %) with no significant difference between the groups. The only significant correlation was observed between the length of necrotic bowel and mortality. In total, 7 of 57 infants required repeated surgery after initial treatment. We observed stoma complications in 36 % of the patients in group A and 21 % in group B without the need of stoma revision. All stomas were successfully closed at the time of the study. One of 44 patients with stoma closure required a relaparotomy due to bowel obstruction. CONCLUSIONS: Early primary laparotomy is safe and effective for the management of surgical NEC in ELBW infants. Outcome of affected infants is not influenced by age or weight at surgery but by the length of necrotic bowel.

Purpura fulminans after therapeutic hypothermia in an asphyxiated neonate with streptococcemia.

OBJECTIVE: Therapeutic hypothermia is an established therapeutic regimen in severely asphyxiated term neonates. The amount of cerebral injury is reduced resulting in an improved neurologic outcome. Therapeutic hypothermia-induced side effects mostly affect the circulatory system, kidney, and liver. However, asphyxia and hypothermia in itself reduce the hemostatic capacity of each individual organism. STUDY DESIGN: A case of a neonate with severe asphyxia and purpura fulminans after hypothermia is described. RESULTS AND CONCLUSION: Although purpura fulminans cannot be attributed to hypothermia solely, the influence of hypothermia on hemostasis may have promoted severe coagulopathy with a fatal outcome. Further studies are necessary to reveal therapeutic hypothermia as a trigger for severe coagulopathies in asphyxiated neonates, especially in those with sepsis and overt coagulopathy prior to therapeutic hypothermia.

Feeding of very low birth weight infants born to HCMV-seropositive mothers in Germany, Austria and Switzerland.

AIM: To evaluate the enteral feeding practice of preterm infants <32 weeks (W) gestational age (GA) or <1500 g birth weight (BW) from human cytomegalovirus (HCMV)-seropositive mothers in Germany, Austria and Switzerland. METHODS: This prospective cross-sectional study included all neonatal units (NU) admitting preterm infants <32W or <1500g BW in Germany, Austria and Switzerland. In June and July 2009, an anonymized questionnaire was sent via e-mail, asking whether mothers of the above patients were screened for HCMV, and about the enteral feeding protocol for preterm infants <32W GA or <1500g BW from HCMV-seropositive mothers. RESULTS: During the study period, 58.6% of the questionnaires (123/210) from Germany, 50% (13/26) from Austria and 50% (6/12) from Switzerland were returned, yielding a total of 6232 preterm infants for analysis. Formula was given to the mentioned preterm infants in 28.5% (35/123) of the German NUs but not in Austria or Switzerland. Untreated breast milk was given in 66.6% (4/6) of the Swiss, 14.6% (18/123) of the German and no Austrian NU. Long-term pasteurized breast milk was given in 32.5% (40/123) of the German and 38.5% (5/13) of the Austrian NUs, but not in Switzerland. Short-term pasteurized breast milk was given only in 5.7% (7/123) of German NUs. Freeze-thawed breast milk was given in Germany (4.9%; 6/123), Austria (61.5%; 8/13) and Switzerland (16.7%; 1/6). CONCLUSION: Preterm infants <32W GA or <1500g BW born to HCMV-seropositive mothers are fed according to different regimes in German-speaking countries. About 28.5% of the German VLBW-infants receive formula, which is not recommended.

Intracerebral mass bleeding in a term neonate: manifestation of hereditary protein S deficiency with a new mutation in the PROS1 gene.

BACKGROUND: Vitamin K deficiency is the major cause of coagulopathy-induced intracranial bleeding in term neonates and is considered first in any term neonate with severe hemorrhage. The most common manifestation of hereditary prothrombotic disorders during the neonatal period is thrombosis of the A. cerebri media or sinus thrombosis. CASE REPORT: A 4-day-old newborn was admitted with seizures and hemorrhagic shock. Ultrasound revealed a left-sided intraparenchymatous bleeding. MRI findings supported a subarachnoidal and intracerebral mass bleeding. Vitamin K deficiency-related bleeding or hemophiliac diseases were excluded; however, homozygous protein S deficiency with a new mutation in the protein S (PROS1) gene (c.701A>G, p.Tyr234Cys) was found. The patient experienced an additional thrombosis of the A. abdominalis and expired. CONCLUSION: Congenital prothrombotic disorders have to be considered in the differential diagnosis of neonatal intracranial hemorrhage. This newly described mutation in the PROS1 gene (c.701A>G, p.Tyr234Cys) appears to be of clinical relevance.

Incidence and clinical outcome of cytomegalovirus transmission via breast milk in preterm infants

AIM: To evaluate incidence, timing and clinical relevance of acquired human cytomegalovirus (HCMV) infection in preterm infants. METHODS: The prospective longitudinal study included preterm infants

Linezolid treatment of glycopeptide-resistant Enterococcus faecium in very low birth weight premature neonates.

Glycopeptide-resistant Enterococcus faecium has emerged as an important nosocomial pathogen with limited therapeutic options. Here we report the successful treatment of glycopeptide-resistant E. faecium infection in two very low birth weight premature infants with the new oxazolidinone linezolid. Treatment with linezolid at a dosage of 10 mg/kg every 8 h intravenously for a duration of 16 days and 14 days, respectively, was well tolerated and led to complete clinical recovery and clearance of the organism from all body sites. The two cases support the clinical efficacy and safety of linezolid in very low birth weight premature neonates with glycopeptide-resistant E. faecium infections.

Fatal transplacental infection with non-typhoidal Salmonella.

We report a case of transplacentally acquired neonatal sepsis with non-typhoid Salmonella. The infant's mother, a 36-y-old woman, presented with fever and malaise in the 25th week of gestation. Because of a pathological cardiotocogram, Caesarean section was performed a few h following admission. The premature infant had clinical signs of sepsis with multiorgan failure and died 4 d later despite intensive medical care. Maternal blood cultures and swab cultures taken from within the uterine cavity and from cutaneous and mucosal surfaces of the infant grew Salmonella virchow. This case and the few sporadic reports in the literature indicate that septicaemia due to non-typhoidal Salmonella spp. during pregnancy is highly lethal to the foetus or newborn, whereas prognosis for the mother apparently is excellent.