Encuesta española de reanimación neonatal 5 años después. ¿Vamos mejorando? / Five years after the Spanish neonatal resuscitation survey. Are we improving?

INTRODUCCIÓN: Se analizan prácticas de reanimación neonatal en salas de partos (SP) de centros hospitalarios españoles. MÉTODOS: Se envió un cuestionario por centro a neonatólogos responsables de la atención del RN en SP de hospitales españoles. RESULTADOS: De 180 cuestionarios enviados, se cumplimentaron 155 (86%); 71 centros fueron de nivel I-II(46%) y 84 de nivel III (54%). La familia y el equipo médico participaron en decisiones de no reanimar o interrumpir la reanimación en el 74,2% de los centros. La disponibilidad de 2 o más reanimadores fue del 80% (94,0% en nivel II I y 63,9% en nivel I-II, p < 0,001). En un 90,3% de centros se realizan cursos de Reanimación. En centros de nivel III fueron más frecuentes los mezcladores de gases, pulsioxímetros, ventiladores manuales y envoltorios de plástico. El uso de envoltorios de polietileno fue del 63,9%. En RN a término se inició la reanimación con aire en el 89,7% de los centros. El dispositivo más usado para aplicar VPP fue el «ventilador manual» (78,6% en nivel III y 42,3% en nivel I-II, p < 0,001). En el 91,7% de los centros de nivel III se utilizó CPAP precoz en prematuros. En los últimos 5 años han mejorado prácticas como son la formación de profesionales, el uso de pulsioxímetros y de CPAP precoz. CONCLUSIONES: Existe una mejora progresiva en algunas prácticas de reanimación neonatal. Se encuentran diferencias en aspectos generales, equipamientos y protocolos de actuación durante la reanimación y transporte entre unidades de diferentes niveles

INTRODUCTION: An analysis is presented of delivery room (DR) neonatal resuscitation practices in Spanish hospitals. METHODS: A questionnaire was sent by e-mail to all hospitals attending deliveries in Spain. RESULTS: A total of 180 questionnaires were sent, of which 155 were fully completed (86%). Less than half (71, 46%) were level I or II hospitals, while 84 were level III hospital (54%). In almost three-quarters (74.2%) of the centres, parents and medical staff were involved in the decision on whether to start resuscitation or withdraw it. A qualified resuscitation team (at least two members) was available in 80% of the participant centres (63.9% level I-II, and 94.0% level III,P<.001). Neonatal resuscitation courses were held in 90.3% of the centres. The availability of gas blenders, pulse oximeters, manual ventilators, and plastic wraps was higher in level IIIhospitals. Plastic wraps for pre-term hypothermia prevention were used in 63.9% of the centres (40.8% level I-IIand 83.3% level III, P<.001). Term newborn resuscitation was started on room air in 89.7% of the centres. A manual ventilator (T-piece) was the device used in most cases when ventilation was required (42.3% level I-IIand 78.6% level III, P<.001). Early CPAP in preterm infants was applied in 91.7% of the tertiary hospitals. In last 5 years some practices have improved, such neonatal resuscitation training, pulse oximeter use, or early CPAP support. CONCLUSIONS: There is an improvement in some practices of neonatal resuscitation. Significant differences have been found as regards the equipment or practices in the DR, when comparing hospitals of different levels of care

[Five years after the Spanish neonatal resuscitation survey. Are we improving?]. / Encuesta española de reanimación neonatal 5 años después. ¿Vamos mejorando?

INTRODUCTION: An analysis is presented of delivery room (DR) neonatal resuscitation practices in Spanish hospitals. METHODS: A questionnaire was sent by e-mail to all hospitals attending deliveries in Spain. RESULTS: A total of 180 questionnaires were sent, of which 155 were fully completed (86%). Less than half (71, 46%) were level i or ii hospitals, while 84 were level iii hospital (54%). In almost three-quarters (74.2%) of the centres, parents and medical staff were involved in the decision on whether to start resuscitation or withdraw it. A qualified resuscitation team (at least two members) was available in 80% of the participant centres (63.9% level i-ii, and 94.0% level iii, P<.001). Neonatal resuscitation courses were held in 90.3% of the centres. The availability of gas blenders, pulse oximeters, manual ventilators, and plastic wraps was higher in level iii hospitals. Plastic wraps for pre-term hypothermia prevention were used in 63.9% of the centres (40.8% level i-iiand 83.3% level iii, P<.001). Term newborn resuscitation was started on room air in 89.7% of the centres. A manual ventilator (T-piece) was the device used in most cases when ventilation was required (42.3% level i-iiand 78.6% level iii, P<.001). Early CPAP in preterm infants was applied in 91.7% of the tertiary hospitals. In last 5 years some practices have improved, such neonatal resuscitation training, pulse oximeter use, or early CPAP support. CONCLUSIONS: There is an improvement in some practices of neonatal resuscitation. Significant differences have been found as regards the equipment or practices in the DR, when comparing hospitals of different levels of care.

Cribado universal de infección por citomegalovirus en prematuros de menos de 1.500 g / Universal cytomegalovirus infection screening in premature newborns less than 1500 g

INTRODUCCIÓN: La infección por citomegalovirus es una infección endémica y los niños que acuden a guardería constituyen el foco de infección más importante para las gestantes. OBJETIVO: Establecer una recomendación para el diagnóstico basada en la evidencia médica sobre la infección de trasmisión vertical por citomegalovirus en prematuros menores de 1.500g al nacer. ANTECEDENTES: La infección en la gestante puede ser primaria o secundaria. Aunque exista infección fetal, el 85% de los recién nacidos serán asintomáticos. Los síntomas de infección son: bajo peso al nacer, hepatoesplenomegalia, trombocitopenia, microcefalia y trastornos neurológicos. El pronóstico de los niños sintomáticos suele ser grave, con elevada mortalidad y secuelas neurológicas. El virus se puede reactivar durante la lactancia y es posible la infección precoz a través de la leche materna, probablemente con poca repercusión en niños a término, aunque en prematuros puede afectar al neurodesarrollo a largo plazo. El método diagnóstico de elección es la identificación del citomegalovirus en orina; la determinación en las 2 primeras semanas de vida indica infección congénita. Un diagnóstico posterior sugiere que puede haber sido adquirida en el parto o a través de la leche materna o transfusión de sangre contaminada. Conclusión y recomendación: Determinar el ADN viral por reacción en cadena de la polimerasa a las 4-6 semanas de vida. En caso positivo, investigar en muestras obtenidas los primeros días de vida y en leche materna. Ello debe permitir clasificar al recién nacido en 3 estados: «no infectado», «infección congénita» e «infección adquirida»

INTRODUCTION: Cytomegalovirus (CMV) infection is endemic, and children who attend day care are the most important source of infection. OBJECTIVE: To establish recommendations based on the medical evidence on the vertical transmission of cytomegalovirus in preterm infants weighing less than 1500g at birth. BACKGROUND: Infection in pregnant women may be primary or secondary. Although there is fetal infection, 85% of newborn infants are asymptomatic. Symptoms of infection include low birth weight, hepatosplenomegaly, thrombocytopenia, microcephaly and neurological disorders. The prognosis of symptomatic children is very poor, with high mortality and neurological disorders. The virus can be reactivated during breast feeding, and early infection is possible through breast milk, probably with little impact in term infants, although the long-term neurological outcome worsens in preterm infants. The diagnostic method of choice is the identification of CMV in urine; the determination in the first two weeks of life suggests congenital infection; later it can be acquired at birth or through breast milk or contaminated blood transfusion. Conclusion and recommendation: Determine viral DNA at 4-6 weeks of life by protease chain reaction. If it is positive, monitoring of samples from the first days of life and breast milk are mandatory. This should allow the newborn to be classified into three states: «Without CMV infection», «Congenital CMV infection», «Acquired CMV infection»

[Universal cytomegalovirus infection screening in premature newborns less than 1500 g]. / Cribado universal de infección por citomegalovirus en prematuros de menos de 1.500 g.

INTRODUCTION: Cytomegalovirus (CMV) infection is endemic, and children who attend day care are the most important source of infection. OBJECTIVE: To establish recommendations based on the medical evidence on the vertical transmission of cytomegalovirus in preterm infants weighing less than 1500g at birth. BACKGROUND: Infection in pregnant women may be primary or secondary. Although there is fetal infection, 85% of newborn infants are asymptomatic. Symptoms of infection include low birth weight, hepatosplenomegaly, thrombocytopenia, microcephaly and neurological disorders. The prognosis of symptomatic children is very poor, with high mortality and neurological disorders. The virus can be reactivated during breast feeding, and early infection is possible through breast milk, probably with little impact in term infants, although the long-term neurological outcome worsens in preterm infants. The diagnostic method of choice is the identification of CMV in urine; the determination in the first two weeks of life suggests congenital infection; later it can be acquired at birth or through breast milk or contaminated blood transfusion. CONCLUSION AND RECOMMENDATION: Determine viral DNA at 4-6 weeks of life by protease chain reaction. If it is positive, monitoring of samples from the first days of life and breast milk are mandatory. This should allow the newborn to be classified into three states: "Without CMV infection", "Congenital CMV infection", "Acquired CMV infection".

Antitumour activity on extrinsic apoptotic targets of the triterpenoid maslinic acid in p53-deficient Caco-2 adenocarcinoma cells.

We report that a novel triterpenoid, (2a,3b)-2,3-dihydroxyolean-12-en-28-oic acid (maslinic acid), isolated from olive pomace from Olea europaea, triggers primarily the extrinsic and later the intrinsic apoptotic pathways in Caco-2 human colon-cancer cells. Apoptosis induced by maslinic acid was confirmed by FACS analysis using annexine-V FICT staining. This induction of apoptosis was correlated with the early activation of caspase-8 and caspase-3, the activation of caspase-8 was also correlated with higher levels of Bid cleavage and decreased Bcl-2, but with no change in Bax expression. Maslinic acid also induced a sustained activation of c-Jun N-terminal kinase (JNK). Incubation with maslinic acid also resulted in the later activation of caspase-9, which, together with the lack of any Bax activation, suggests that the mitochondrial pathway is not required for apoptosis induced by maslinic acid in this cell line. In this study we found that the mechanism of apoptotic activation in p53-deficient Caco-2 cells differs significantly from that found in HT-29 cells. Natural agents able to activate both the extrinsic and intrinsic apoptotic pathways by avoiding the mitochondrial resistance mechanisms may be useful for treatment against colon cancer regardless of its aetiology.

Recomendaciones para la informatización de los servicios de neonatología / Recommendations for the computerisation of neonatology services

El objetivo es proporcionar el marco para la recopilación de datos en el área de la salud de los recién nacidos que permitan la armonización de la asistencia sea cual sea su lugar de nacimiento. Para ello es necesario conocer la población atendida y la mayor dificultad es la ausencia de un sistema de recopilación de datos y de unos estándares asistenciales para todas las condiciones del recién nacido. Es imprescindible disponer de un registro único en el que se recojan los principales datos perinatales y neonatales de todos los recién nacidos. La Sociedad Española de Neonatología (SEN) debe ser el depositario y responsable de la base de datos, que debe cumplir todas las exigencias legales de privacidad y confidencialidad. A nivel de cada centro es posible conocer el peso relativo de la afección atendida por grupos de diagnósticos relacionados (DRG) y los resultados desde el aspecto de calidad asistencial. Mediante análisis comparativos (estudios de benchmarking,...) es posible establecer las pautas de diagnóstico y tratamiento.Es necesario conocer la población de recién nacidos atendida y definir criterios de diagnóstico y tratamiento para mejorar la calidad asistencial. La SEN desea dirigirse a los responsables asistenciales de los centros hospitalarios para pedirles su apoyo y colaboración en la puesta en marcha de estas recomendaciones (AU)

The aim is to provide a framework for data collection in the health area of newborn infants allowing harmonization of their care. This requires knowing the population served, and the greatest difficulty is the absence of a data collection system and standards of care for all conditions of the newborn infant. It is essential to have a single record with the main perinatal and neonatal data of all newborn infants. The Spanish Society of Neonatology (SEN) should be responsible for the database, which must meet all legal requirements of privacy and confidentiality. It is possible to determine the relative weight of the pathology treated using Diagnostic Related Groups (DRG) and the results from a quality care perspective. Guidelines for diagnosis and treatment may be established by comparative analysis (benchmarking studies…).Conclusion and Recommendation. It is necessary to know the newborn population served, and define criteria for diagnosis and treatment to improve quality of care. The SEN wishes to address those responsible for the care in hospitals, and to ask for their support and cooperation in the implementation of these recommendations(AU)

[Recommendations for the computerisation of neonatology services]. / Recomendaciones para la informatización de los servicios de neonatología.

The aim is to provide a framework for data collection in the health area of newborn infants allowing harmonization of their care. This requires knowing the population served, and the greatest difficulty is the absence of a data collection system and standards of care for all conditions of the newborn infant. It is essential to have a single record with the main perinatal and neonatal data of all newborn infants. The Spanish Society of Neonatology (SEN) should be responsible for the database, which must meet all legal requirements of privacy and confidentiality. It is possible to determine the relative weight of the pathology treated using Diagnostic Related Groups (DRG) and the results from a quality care perspective. Guidelines for diagnosis and treatment may be established by comparative analysis (benchmarking studies…). Conclusion and Recommendation. It is necessary to know the newborn population served, and define criteria for diagnosis and treatment to improve quality of care. The SEN wishes to address those responsible for the care in hospitals, and to ask for their support and cooperation in the implementation of these recommendations.

Adaptación de las recomendaciones internacionales sobre reanimación neonatal 2010: comentarios / Changes in the international recommendations on neonatal resuscitation, 2010: comments

Desde la publicación de las últimas recomendaciones ILCOR del 2005, los cambios más significativos que se han implementado en las del 2010 son los siguientes: valoración del recién nacido mediante 2 características vitales (frecuencia cardiaca y respiración) para decidir inicialmente el siguiente paso en la reanimación; evaluación de la oxigenación mediante monitorización por pulsioximetría (el color no es fiable); inicio de la reanimación con aire en el recién nacido a término en lugar de oxígeno al 100%; uso de mezcladores de oxígeno y aire para administrar oxígeno suplementario en caso de necesidad; controversia en la aspiración endotraqueal en recién nacidos deprimidos con aguas meconiales; la proporción de ventilación compresión sigue siendo de 3/1, excepto en la parada cardiorrespiratoria de origen cardiaco, en que se debería considerar una proporción más alta; indicación de hipotermia terapéutica en recién nacidos a término o casi término diagnosticados de encefalopatía hipóxico-isquémica moderada o grave con protocolos y seguimiento coordinados por el sistema regional perinatal (cuidados posreanimación); retraso de al menos 1 min en la ligadura del cordón umbilical de recién nacidos que no requieren reanimación (no existe suficiente evidencia para recomendar un tiempo de ligadura de cordón en aquellos que requieren reanimación), y si no se detecta latido cardiaco después de 10 min de una correcta reanimación, se acepta desde un punto de vista ético, la posibilidad de interrumpir la reanimación, aunque muchos factores contribuyen a la decisión de seguir más allá de 10 min. En determinadas situaciones, no iniciar la reanimación se puede plantear teniendo en cuenta las recomendaciones generales, los resultados propios y la opinión de los padres (AU)

Since previous publication in 2005, the most significant changes that have been addressed in the 2010 International Liaison Committee on Resuscitation (ILCOR) recommendations are as follows: (I) use of 2 vital characteristics (heart rate and breathing) to initially evaluate progression to the following step in resuscitation; (II) oximetry monitoring for the evaluation of oxygenation (assessment of color is unreliable); (III) for babies born at term it is better to start resuscitation with air rather than 100% oxygen; (IV) administration of supplementary oxygen should be regulated by blending oxygen and air; (V) controversy about endotraqueal suctioning of depressed infants born through meconium-stained amniotic fluid; (VI) chest compression-ventilation ratio should remain at 3/1 for neonates unless the arrest is known to be of cardiac etiology, in which case a higher ratio should be considered; (VII)use of therapeutic hypothermia for infants born at term or near term evolving to moderate or severe hypoxic-ischemic encephalopathy, with protocol and follow-up coordinated through a regional perinatal system (post-resuscitation management); (VIII) cord clamping delay for at least 1 minute in babies who do not require resuscitation (there is insufficient evidence to recommend a time for clamping in those who require resuscitation) and, (IX) it is appropriate to consider discontinuing resuscitation if there has been no detectable heart rate for 10 minutes, although many factors contribute to the decision to continue beyond 10 minutes. Under certain circumstances, non-initiation of resuscitation could be proposed taking into consideration general recommendations, own results and parents’ opinion (AU)

[Changes in the international recommendations on neonatal resuscitation, 2010: comments]. / Adaptación de las recomendaciones internacionales sobre reanimación neonatal 2010: comentarios.

Since previous publication in 2005, the most significant changes that have been addressed in the 2010 International Liaison Committee on Resuscitation (ILCOR) recommendations are as follows: (i) use of 2 vital characteristics (heart rate and breathing) to initially evaluate progression to the following step in resuscitation; (ii) oximetry monitoring for the evaluation of oxygenation (assessment of color is unreliable); (iii) for babies born at term it is better to start resuscitation with air rather than 100% oxygen; (iv) administration of supplementary oxygen should be regulated by blending oxygen and air; (v) controversy about endotraqueal suctioning of depressed infants born through meconium-stained amniotic fluid; (vi) chest compression-ventilation ratio should remain at 3/1 for neonates unless the arrest is known to be of cardiac etiology, in which case a higher ratio should be considered; (vii) use of therapeutic hypothermia for infants born at term or near term evolving to moderate or severe hypoxic-ischemic encephalopathy, with protocol and follow-up coordinated through a regional perinatal system (post-resuscitation management); (viii) cord clamping delay for at least 1 minute in babies who do not require resuscitation (there is insufficient evidence to recommend a time for clamping in those who require resuscitation) and, (ix) it is appropriate to consider discontinuing resuscitation if there has been no detectable heart rate for 10 minutes, although many factors contribute to the decision to continue beyond 10 minutes. Under certain circumstances, non-initiation of resuscitation could be proposed taking into consideration general recommendations, own results and parents' opinion.

A survey of neonatal resuscitation in Spain: gaps between guidelines and practice.

OBJECTIVES: To audit the knowledge and application of internationally recommended newborn resuscitation (NR) guidelines among delivery room (DR) caregivers of Spanish hospitals. METHODS: A questionnaire-type survey on NR equipment and practices was performed in hospitals of the Spanish National Health System classified according to level of care provided. RESULTS: 88% of the questionnaires were complimented. Limit of viability was set in 23-24 weeks in 78% of the centres. Availability of board-certified and instructors in NR was significantly higher in level III versus level I-II centres (94 vs. 70% and 78 vs. 51%, respectively). No differences in equipment or knowledge of guidelines of resuscitation were found between centres. Substantial differences were observed in supplementation and monitorization of oxygen, and positive pressure ventilation during resuscitation and transportation. CONCLUSION: Equipment availability and knowledge of guidelines of NR does not differ between hospitals independent of their level of care. However, performance during resuscitation and transportation in level III hospitals is in significantly greater acquaintance with internationally recommended NR guidelines.

Controversias en el manejo terapéutico de la hernia diafragmática congénita: actualización a través de la medicina basada en pruebas / Controversies in the therapeutical management of congenital diaphragmatic hernia: update by means of evidence-based medicine

Introducción. La hernia diafragmática congénita (HDC) es una enfermedad de alto riesgo en cirugía neonatal. El objetivo de este artículo es realizar una actualización sobre las controversias terapéuticas (momento de la cirugía y estabilización médica) de la HDC, por medio de una revisión sistemática y crítica de las mejores pruebas científicas de la literatura. Métodos. Revisión sistemática y estructurada de los artículos relacionados con el manejo terapéutico de la HDC (cirugía, ventilación mecánica, óxido nítrico inhalado, oxigenación por membrana extracorpórea, surfactante, etc.) publicados en fuentes de información secundaria (TRIPdatabase, revisiones sistemáticas de la Colaboración Cochrane, guías de práctica clínica, informes de evaluación de tecnología sanitaria, etc.) y primaria (bases de datos, revistas biomédicas, libros de texto, etc.) y valoración crítica por medio de la metodología del Evidence- Based Medicine Working Group. Seleccionamos las publicacionescon la mejor evidencia científica en artículos sobre tratamiento (ensayo clínico, revisión sistemática, metaanálisis y guías de práctica clínica). Resultados. La principal información secundaria se detecta en The Cochrane Library: 3 revisiones sistemáticas en Neonatal Group (una en relación con el momento de la cirugía, y dos relacionadas con el uso de óxido nítrico y oxigenación por membrana extracorpórea en el fracaso respiratorio grave del recién nacido). Pero la mayoría de los artículos relevantes se detectan en la base de datos Pubmed, principalmente publicados en Journal Pediatric Surgery y con determinados grupos de investigación (Congenital Diaphragmatic Hernia Study Group en la Universidad de Texas y Buffalo Institute of Fetal Therapy en la Universidad de New York). Conclusiones. A partir del análisis de la medicina basada en pruebas, los resultados sobre el manejo de la HDC no fueron claros entre la cirugía precoz y tardía, pero la cirugía diferida (con estabilización preoperatoria) se ha convertido en el manejo preferido en la mayoría de los centros, así como que la cirugía fetal in utero no ofrece ventajas sobre la cirugía neonatal. La opinión respecto al tiempo adecuado de la cirugía ha cambiado gradualmente desde la intervención precoz a la estabilización inicial con posterior cirugía. Debido a la hipertensión pulmonar persistente y/o hipoplasia pulmonar en la HDC, el tratamiento médico se ha focalizado hacia la optimización de la oxigenación evitando el barotrauma, utilizando ventilación «suave» e hipercapnia permisiva. La ventilación de alta frecuencia oscilatoria, óxido nítrico inhalado y oxigenación con membrana extracorpórea, se utilizarán en casos graves, pero estos tratamientos no mejoran claramente el pronóstico en recién nacidos con HDC. La utilidad de surfactante y ventilación líquida parcial se fundamentan en estudios de experimentación animal, debido a que los ensayos clínicos en neonatos son escasos y no concluyentes. Los cambios de futuro en esta área de estudio incluyen la necesidad de mayores y mejores ensayos clínicos, que incluyan efectos a largo plazo entre los niños supervivientes (AU)

Introduction. Congenital diaphragmatic hernia (CDH) is one of the high-risk diseases in neonatal surgery. The aim of this article is to make an update of the controversies about the therapeutic management (time of surgery and modalities of medical stabilization) of CDH, by means of a systematic and critical review of the best scientific evidence in bibliography. Methods. Systematic and structured review of the articles about therapeutic management of CDH (surgery, mechanical ventilation, inhaled nitric oxide, extracorporeal membrane oxygenation, surfactant, etc) published in secondary (TRIPdatabase, systematic review in Cochrane Collaboration, clinical practice guidelines, health technology assessment database, etc) and primary (bibliographic databases, biomedical journals, books, etc) publications and critical appraisal by means of methodology of the Evidence-Based Medicine Working Group. We selected the publications with the main scientific evidence in therapeutical articles (clinical trial, systematic review, meta-analysis and clinical practice guideline). Results. The main secondary information is found in The Cochrane Library: 3 systematic review in the Neonatal Group (one specific about the time of surgery, and two related to the use of nitric oxide and extracorporeal membrane oxygenation in neonatal severe respiratory failu-re). But we found the main relevant articles in Pubmed database, mainly published in Journal Pediatric Surgery and with some clusters of investigation (Congenital Diaphragmatic Hernia Study Group in Texas University and Buffalo Institute of Fetal Therapy in New York University). Conclusions. From the evidence-based analysis, the results of CDH management between immediate versus delayed surgery were unclear, but delayed surgical (with pre-operative stabilization) has become preferred approach in many centers, and foetal surgery is not better than neonatal one. Opinion regarding the time of surgery has gradually shifted from early repair to a policy of stabilization and delayed repair. Because of associated persistent pulmonary hypertension and/or pulmonary hypoplasia in CDH, medical therapy is focused toward optimizing oxygenation while avoiding barotrauma, using gentle ventilation and permissive hypercarbia. High frequency oscillatory ventilation, inhaled nitric oxide and extracorporeal membrane oxygenation are used in severe cases, but these treatments do not clearly improve the outcome in neonates with CDH. The usefulness of surfactant and partial liquid ventilation are based in animal model experimentation, because the clinical trials in newborns are little and non-conclusive. Challenges for the future in this thematic area include the need for bigger and better trials of therapy in this field, with long-term outcomes among surviving children (AU)

[Controversies in the therapeutical management of congenital diaphragmatic hernia: update by means of evidence-based medicine]. / Controversias en el manejo terapéutico de la hernia diafragmática congenita: actualización a través de la medicina basada en pruebas.

INTRODUCTION: Congenital diaphragmatic hernia (CDH) is one of the high-risk diseases in neonatal surgery. The aim of this article is to make an update of the controversies about the therapeutic management (time of surgery and modalities of medical stabilization) of CDH, by means of a systematic and critical review of the best scientific evidence in bibliography. METHODS: Systematic and structured review of the articles about therapeutic management of CDH (surgery, mechanical ventilation, inhaled nitric oxide, extracorporeal membrane oxygenation, surfactant, etc) published in secondary (TRIPdatabase, systematic review in Cochrane Collaboration, clinical practice guidelines, health technology assessment database, etc) and primary (bibliographic databases, biomedical journals, books, etc) publications and critical appraisal by means of methodology of the Evidence-Based Medicine Working Group. We selected the publications with the main scientific evidence in therapeutical articles (clinical trial, systematic review, meta-analysis and clinical practice guideline). RESULTS: The main secondary information is found in The Cochrane Library: 3 systematic review in the Neonatal Group (one specific about the time of surgery, and two related to the use of nitric oxide and extracorporeal membrane oxygenation in neonatal severe respiratory failure). But we found the main relevant articles in Pubmed database, mainly published in Journal Pediatric Surgery and with some clusters of investigation (Congenital Diaphragmatic Hernia Study Group in Texas University and Buffalo Institute of Fetal Therapy in New York University). CONCLUSIONS: From the evidence-based analysis, the results of CDH management between immediate versus delayed surgery were unclear, but delayed surgical (with pre-operative stabilization) has become preferred approach in many centers, and foetal surgery is not better than neonatal one. Opinion regarding the time of surgery has gradually shifted from early repair to a policy of stabilization and delayed repair. Because of associated persistent pulmonary hypertension and/or pulmonary hypoplasia in CDH, medical therapy is focused toward optimizing oxygenation while avoiding barotrauma, using gentle ventilation and permissive hypercarbia. High frequency oscillatory ventilation, inhaled nitric oxide and extracorporeal membrane oxygenation are used in severe cases, but these treatments do not clearly improve the outcome in neonates with CDH. The usefulness of surfactant and partial liquid ventilation are based in animal model experimentation, because the clinical trials in newborns are little and non-conclusive. Challenges for the future in this thematic area include the need for bigger and better trials of therapy in this field, with long-term outcomes among surviving children.

Absceso de partes blandas por Rhodococcus Equi en una paciente en hemodiálisis / No disponible

No disponible