A randomized controlled evaluation of absorption of silver with the use of silver alginate (Algidex) patches in very low birth weight (VLBW) infants with central lines.

OBJECTIVE: To measure systemic silver absorption when using silver-impregnated alginate central catheter dressings in very low birth weight (VLBW) neonates and to monitor blood stream infection. STUDY DESIGN: Fifty infants were enrolled in a prospective, randomized controlled trial lasting 28 days. Each patient was assigned to standard dressing or silver alginate (Algidex) group. Serum silver concentrations were obtained on day 1, 7, and 28. RESULT: Significant differences in mean serum silver concentrations for the treatment versus standard dressing group were observed using student's t-test analysis. The silver alginate group had a 45.8% reduction in infection/1000 line days, although too few patients were enrolled to draw meaningful efficacy conclusions about prevention of blood stream infection. CONCLUSION: Mean serum silver concentrations in the treatment group were significantly higher than controls although below levels anticipated to result in toxicity. A large study evaluating reduced blood stream infections in VLBW infants is warranted.

Early high-frequency oscillatory ventilation versus synchronized intermittent mandatory ventilation in very low birth weight infants: a pilot study of two ventilation protocols.

OBJECTIVE: To evaluate the feasibility of conducting a prospective, randomized trial comparing early high-frequency oscillatory ventilation (HFOV) to synchronized intermittent mandatory ventilation (SIMV) in very low birth weight (VLBW) premature infants. This pilot study evaluated two ventilator management protocols to determine how well they could be implemented in a multicenter clinical trial. Although this pilot study was not powered to detect differences in outcome, we also collected outcome data. DESIGN: Prospective, multicenter, randomized pilot study. SETTING: Seven tertiary-level intensive care nurseries with previous experience with both HFOV and flow-triggered SIMV. PATIENTS: Fifty infants weighing 501 to 1200 g, less than 4 hours of age, who had received one dose of surfactant and required ventilation with mean airway pressure > or =6 cm H2O and F(I)O2 > or =0.25, and had an anticipated duration of ventilation greater than 24 hours. INTERVENTIONS: Patients were stratified by birth weight and prenatal steroid status, then randomized to either HFOV or SIMV with tidal volume monitoring. Ventilator management for patients in both study arms was strictly governed by protocols that included optimizing lung inflation and blood gases, weaning strategies, and extubation criteria. MEASUREMENTS: Data were collected using the tools planned for the larger collaborative study. Protocol compliance was closely monitored, with successive changes in the protocol made as necessary to improve clarity and increase compliance. The incidence of major neonatal adverse outcomes was recorded. MAIN RESULTS: Data are presented for 24 HFOV and 24 SIMV infants (two infants, twins, were withdrawn from the study at parent's request). Nineteen of the 24 HFOV infants and 20 of the 24 SIMV infants survived to 36 weeks corrected age. Age at final extubation for survivors was 16+/-16 (mean+/-SD) days for HFOV infants and 24+/-24 days for SIMV infants. At 36 weeks corrected age, 14 of the 19 HFOV survivors were extubated and in room air, whereas 5 required supplemental oxygen. In comparison, 6 of the 20 SIMV survivors were extubated and in room air, whereas 14 required supplemental oxygen. Grade III/IV IVH and/or periventricular leukomalacia occurred in 2 HFOV and 2 SIMV patients. Overall compliance with the ventilator protocols was 82% for the SIMV protocol, and 88% for the HFOV protocol. CONCLUSIONS: The preliminary outcome data supports conducting the large randomized trial, which began in July of 1998. The protocols for the ventilator management of VLBW infants, both with HFOV and with SIMV were easily implemented and consistently followed, and are presented here.

Giant epignathus. A case report.

We report the successful treatment of a 2.8 kg female infant born with a giant epignathus, and we present our current prenatal and neonatal recommendations for managing this problem. We recommend that the delivery be done by cesarean section, that an adjacent operating room be ready for the baby, and that a neonatologist, anesthesiologist, and pediatric surgeon be standing by. The term epignathus now commonly applies to a teratoma protruding from a newborn's mouth. The survival of these otherwise normal children has been very low. We discuss the perinatal, neonatal, and operative care necessary to improve survival, as evidenced by the case presented.

Temporary banding of the gastroesophageal juncture in a very small neonate with esophageal atresia and tracheoesophageal fistula.

A 700 gm, small-for-gestational-age infant with severe respiratory distress, esophageal atresia, and Type C tracheoesophageal fistula was treated with initial banding of the gastroesophageal juncture followed by a gastrostomy. Primary repair was completed later, when the infant had stabilized and grown. Continuous air pressure had distended the fistula, thus dilating the distal esophagus and facilitating repair. In very small, high-risk infants with Type C esophageal atresia and tracheoesophageal fistula, banding of the distal esophagus enables enteral feeding and time for growth while protecting the lungs from repetitive aspiration and pneumonia and facilitates subsequent repair. The patient described here is one of the smallest infants reported to survive this problem. It is also the first time the enlargement of the distal pouch and removal of the band from above have been described.

Changes in the auditory brainstem response associated with intravenous infusion of unconjugated bilirubin into infant rhesus monkeys.

The auditory brainstem response (ABR) was monitored in nine infant rhesus monkeys during the intravenous infusion of 50-168 mg/kg of unconjugated bilirubin. Sulfisoxazole (200 mg/kg) was sometimes given near the end of or just before the bilirubin infusion if no obvious ABR change had yet occurred. Five of the animals were term gestation, four were preterm, and they ranged from 1 to 40 days of age at the time of study. The three oldest term animals, studied at 20, 35 and 40 days of age, respectively, showed variable changes in the ABR waves during bilirubin infusion and these changes were not altered further by sulfisoxazole administration. The other two term infants, studied at 1 and 6 days of age, respectively, showed sulfisoxazole enhanced ABR wave latency increase and amplitude reduction followed by loss of the ABR. Both of these animals became apneic following ABR loss and eventually died. The ABR reappeared in one animal prior to death. Minimal gross and microscopic changes were present in the brain of the 6-day-old animal at autopsy. The four preterm animals all had a progressive wave amplitude decrease followed by loss of the ABR with bilirubin alone. These preterm animals were sacrificed shortly after the ABR loss with only one showing yellow staining of the basal ganglia at autopsy. The infant rhesus monkey may be a useful paradigm for bilirubin-induced ototoxicity as manifested by potentially reversible ABR changes. The changes are dependent on gestational and chronological age of the animal and appear to occur in the peripheral eighth nerve or cochlea as well as in brainstem pathways.

Elevated ratios of type I/III collagen in the lungs of chronically ventilated neonates with respiratory distress.

Increased synthesis of type I collagen, leading to increased ratios of type I to type III collagen in the lungs, has been observed in the lungs of animals with experimental pulmonary fibrosis. Similar changes in collagen type ratios have been observed in lungs of humans dying of idiopathic pulmonary fibrosis and of adult respiratory distress syndrome. In this study, lung collagen type ratios were examined in infants with acute and chronic lung disease. Tissue from the right lower lobes of neonates was obtained post mortem. Specific collagen types were quantitated by solubilization of lung collagen with CNBr and fractionation of the resulting mixture of peptides by column chromatography and polyacrylamide gel electrophoresis. Ratios of type I/III collagen were calculated for each lung sample using two independent pairs of marker peptides for these determinations. In some cases the ratio of type V to type III collagen in these same lung samples was also quantitated. We observed a significant increase in the ratio of type I/III collagen in infants with a premortem diagnosis of chronic lung disease, usually preceded by respiratory distress syndrome. We also observed two infants with large changes in collagen type ratios who might have had pulmonary fibroplasia secondary to intrauterine lung disease. These data suggest that there may be several subsets of infants with respiratory distress syndrome, each having a different prognosis.

Sodium nitroprusside for control of severe hypertensive disease of pregnancy: a case report and discussion of potential toxicity.

Sodium nitroprusside has been used to alter blood pressure in severe hypertensive disease of pregnancy; however, concern exists in regard to potential lethal complications from cyanide toxicity in both mother and fetus. We recently evaluated levels of cyanide in the liver of an infant stillborn to a woman in whom sodium nitroprusside was used to control gestational hypertension secondary to mitral valve disease. The fetal liver demonstrated levels of cyanide below toxic ranges. Biologic activity, potential toxicity, and treatment of toxic symptoms of nitroprusside are discussed.