Patent ductus arteriosus management in very-low-birth-weight prematurity: a place for an early operation?

OBJECTIVES: The goal was to evaluate neonatal outcomes based on treatment strategies and time points for haemodynamically significant patent ductus arteriosus (hsPDA) in very-low-birth-weight preterm infants, with a particular focus on surgical closure. METHODS: This retrospective study included very-low-birth-weight infants born between 2014 and 2021 who received active treatment for hsPDA. Neonatal outcomes were compared between (i) primary surgical closure versus primary ibuprofen; (ii) early (<14th post-natal day) versus late primary surgical closure (≥14th post-natal day); and (iii) primary versus secondary surgical closure after ibuprofen failure. Further analysis using 1:1 propensity score matching was performed. Logistic regression was conducted to analyse the risk factors for post-ligation cardiac syndrome (PLCS) and/or acute kidney injury (AKI). RESULTS: A total of 145 infants with hsPDA underwent active treatment for closure. The in-hospital death rate and the incidence of severe bronchopulmonary dysplasia (BPD) were similar between the primary surgical closure group and the primary ibuprofen group in a 1:1 matched analysis. Severe BPD was significantly higher in the late surgical closure group than in the early primary surgical closure group with 1:1 propensity score matching (72.7% vs 40.9%, P=0.033). The secondary surgical closure group showed the mildest clinical condition; however, the probability of PLCS/AKI was highest (38.6%) compared to the early (15.2%) or the late primary surgical group (28.1%, P<0.001), especially in extremely premature infants (gestational age < 28 weeks). CONCLUSIONS: Surgical patent ductus arteriosus closure is not inferior to pharmacologic treatment. Considering the harmful effect of a prolonged patent ductus arteriosus shunt exposure, a timely decision and timely efforts should be made to minimize the risk of severe BPD and PLCS/AKI after surgical closure.

Impact of increased paternal age on neonatal outcomes in very-low-birth-weight infants.

OBJECTIVE: Despite the trend of increasing paternal age, its impact on neonatal outcomes, particularly in preterm infants, has not been thoroughly investigated. We aimed to evaluate the perinatal characteristics and neonatal outcomes associated with paternal age. METHODS: Electronic medical records of very low-birthweight infants admitted to our unit from July 2013 to March 2022 were reviewed. Infants grouped according to paternal age (<35 years, 35-39 years, and ≥40 years) were analyzed for differences in perinatal findings and neonatal outcomes. RESULTS: A total of 637 infants were included (194, 294, and 149 in the <35, 35-39, and ≥40 years groups, respectively). The increase in paternal age paralleled the increase in maternal age. The Z-score of head circumference at birth was significantly different between the groups, showing the lowest median value in the ≥40 years group. Small-for-gestational age (Odds ratio 71.074, p < .001, 95% confidence interval 19.337 - 261.236) and male sex (Odds ratio 3.309, p < .034, 95% confidence interval 1.089 - 8.425), but not paternal or maternal age groups were significant factors associated with head circumference Z-scores less than -2 standard deviation based on the multivariable logistic regression analysis. Infants affected by chromosomal or genetic anomaly were more frequently identified (3.4 vs 0.0 vs 0.5%) in the ≥40 years group than in the other two groups. When infants with anomalies or critical illnesses were excluded, overall neonatal outcomes did not statistically differ according to paternal age. CONCLUSION: Although increased paternal age ≥40 years may be associated with relatively smaller head circumferences, the impact on fetal head growth does not imply a definite risk for microcephaly. Nonetheless, based on the possible negative impact on chromosomal/genetic anomaly, increased paternal age warrants attention, even though neonatal outcomes concerning prematurity were not significantly affected. A large-scale longitudinal study is needed to further elucidate the impact of advanced paternal age in preterm infants and provide guidelines for appropriate antenatal counseling and surveillance.

Mimicking Hypoxic-Ischemic Encephalopathy in a Newborn with 21q Deletion Originating from Ring Chromosome 21.

Partial deletion of the long arm (q) in chromosome 21 is an extremely rare condition with various phenotypes, including microcephaly, neurodevelopmental delay, dysmorphic features, and epileptic seizures. Neonatal hypoxic-ischemic encephalopathy (HIE) is an encephalopathy associated with a hypoxic-ischemic event in the brain where seizures usually occur in the earliest days of life. Neonatal encephalopathy is a distinct entity resulting from metabolic disorders, congenital infections or genetic abnormalities that could often mimic HIE features, leading to a misdiagnosis of HIE. Here, we present a case of a newborn who was initially misdiagnosed with HIE due to HIE-like features, and eventually was diagnosed to have a de novo ring chromosome 21 with 21q microdeletion. Clinical findings, including severe hypotonia with respiratory/feeding difficulties and intractable seizures, and radiologic findings of ischemic encephalopathy were discovered. Subsequent atypical findings of the clinical presentation ultimately led to her undergoing genetic testing confirming that she had a neonatal encephalopathy with a genetic abnormality. Our case highlights the importance of identifying non-HI neonatal encephalopathy by careful and structured evaluation for current history with a clinical course and a multidisciplinary approach including genetic testing, to provide an accurate diagnosis, treat curable inherited disorders, and develop future genetic counseling.

Using adenosine triphosphate bioluminescence level monitoring to identify bacterial reservoirs during two consecutive Enterococcus faecium and Staphylococcus capitis nosocomial infection outbreaks at a neonatal intensive care unit.

INTRODUCTION: This study aimed to assess the role of adenosine triphosphate (ATP) bioluminescence level monitoring for identifying reservoirs of the outbreak pathogen during two consecutive outbreaks caused by Enterococcus faecium and Staphylococcus capitis at a neonatal intensive care unit (NICU). The secondary aim was to evaluate the long-term sustainability of the infection control measures employed one year after the final intervention measures. METHODS: Two outbreaks occurred during a 53-day period in two disconnected subunits, A and B, that share the same attending physicians. ATP bioluminescence level monitoring, environmental cultures, and hand cultures from healthcare workers (HCW) in the NICU were performed. Pulsed-field gel electrophoresis (PFGE) typing was carried out to investigate the phylogenetic relatedness of the isolated strains. RESULTS: Four cases of E. faecium sepsis (patients A-8, A-7, A-9, B-8) and three cases of S. capitis sepsis (patients A-16, A-2, B-8) were diagnosed in six preterm infants over a span of 53 days. ATP levels remained high on keyboard 1 of the main station (2076 relative light unit [RLU]/100 cm2) and the keyboard of bed A-9 (4886 RLU/100 cm2). By guidance with the ATP results, environmental cultures showed that E. faecium isolated from the patients and from the main station's keyboard 1 were genotypically indistinguishable. Two different S. capitis strains caused sepsis in three patients. A total 77.8% (n = 7/9) of S. capitis cultured from HCW's hands were genotypically indistinguishable to the strains isolated from A-2 and A-16. The remaining 22.2% (n = 2/9) were genotypically indistinguishable to patient B-8. Three interventions to decrease the risk of bacterial transmission were applied, with the final intervention including a switch of all keyboards and mice in NICU-A and B to disinfectable ones. Post-intervention prospective monitoring up to one year showed a decrease in blood culture positivity (P = 0.0019) and catheter-related blood stream infection rate (P = 0.016) before and after intervention. CONCLUSION: ATP monitoring is an effective tool in identifying difficult to disinfect areas in NICUs. Non-medical devices may serve as reservoirs of pathogens causing nosocomial outbreaks, and HCWs' hands contribute to bacterial transmission in NICUs.

Echocardiographic assessment of brain sparing in small-for-gestational age infants and association with neonatal outcomes.

Brain sparing is an adaptive phenomenon (redistribution of blood flow to the brain) observed in fetuses exposed to chronic hypoxia, who are at risk of intrauterine growth restriction. Here, we assessed the blood flow distribution during the early neonatal period (< 7 days of life) using echocardiography, and evaluated the impact of brain-sparing on postnatal course and neurodevelopmental outcomes. This retrospective study included 42 small-for-gestational age (SGA) infants [further classified into asymmetric SGA (a-SGA, n = 21) and symmetric SGA (s-SGA, n = 21) groups according to their birth head circumference percentiles], and 1: 2 matched appropriate-for-gestational age (AGA) infants (n = 84) admitted to the neonatal intensive care unit. Left ventricular (LV) stroke volume, LV cardiac output (LVCO), upper body blood flow (UBBF), and UBBF/LVCO ratio (%) were significantly higher in both a-SGA and s-SGA infants than in AGA infants. Both a-SGA and s-SGA groups consisted predominantly of infants with higher UBBF/LVCO (%). A UBBF/LVCO ≥ 58.2% (3rd interquartile range) was associated with a later need for rehabilitative therapy after discharge. In summary, brain-sparing effect may continue during the early postnatal life in SGA infants, and may be a promising marker to detect future adverse neurodevelopmental outcomes.

Impact of preterm premature rupture of membranes and oligohydramnios on in-hospital outcomes of very-low-birthweight infants.

OBJECTIVE: To analyze neonatal outcomes in very-low-birthweight (VLBW) infants depending on the presence of preterm premature rupture of membranes (PPROM), oligohydramnios, or both. METHODS: The electronic medical records of VLBW infants admitted during the study period, January 2013 to September 2018, were reviewed. Neonatal outcomes (primary outcome: neonatal death; secondary outcome: neonatal morbidity) were compared depending on whether the infant was affected by PPROM or oligohydramnios. Logistic regression analysis was performed to assess the association of PPROM and oligohydramnios with neonatal outcomes. RESULTS: Three hundred and nineteen VLBW infants were included: (1) 141 infants in the PPROM group vs. 178 infants in the non-PPROM group, and (2) 54 infants in the oligohydramnios group vs. 265 infants in the non-oligohydramnios group. The infants affected by PPROM were at significantly younger gestational ages at birth with lower 5-min Apgar scores than those not affected by PPROM. Histologic chorioamnionitis was significantly more frequent in the PPROM group than in the non-PPROM group. The proportions of small-for-gestational-age infants and infants affected by multiple births were significantly higher in the non-PPROM group. The median (interquartile range) PPROM latency and onset were 50.5 (9.0 - 103.0) h and 26.6 (24.1 - 28.5) weeks, respectively. Based on the logistic regression analysis assessing the association of PPROM and oligohydramnios with the significant neonatal outcome, oligohydramnios was significantly associated with neonatal death (odds ratio [OR] = 2.831, 95% confidence interval [CI] 1.447 - 5.539), air leak syndrome (OR = 2.692, 95% CI 1.224 - 5.921), and persistent pulmonary hypertension (PPH) (OR = 2.380, 95% CI 1.244 - 4.555). PPROM per se was not associated with any neonatal outcome. However, early onset PPROM and prolonged PPROM latency were associated with neonatal morbidity and mortality. When PPROM was accompanied by oligohydramnios, it was associated with increased odds for PPH (OR = 2.840, 95% CI 1.335 - 6.044), retinopathy of prematurity (OR = 3.308, 95% CI 1.325 - 8.259), and neonatal death (OR = 2.282, 95% CI 1.021 - 5.103). CONCLUSION: PPROM and oligohydramnios affect neonatal outcomes differently. Oligohydramnios, but not PPROM, is a significant risk factor for adverse neonatal outcomes, which is presumably related to pulmonary hypoplasia. Prenatal inflammation appears to complicate neonatal outcomes in infants affected by early PPROM and prolonged PPROM latency.

Role of birthweight discordance in preterm twins' outcomes in the Korean neonatal network.

BACKGROUND: Twin pregnancies can be complicated by birthweight (BW) discordance. We analyzed the impact of BW discordance on clinical outcomes of very-low-birthweight (VLBW) twins. METHODS: The study population was preterm infants in the Korean Neonatal Network registry. Multivariate logistic regression analyses were used to determine the contribution of BW discordance on respiratory morbidities and mortality of VLBW infants. Also, we assessed the effect of small for gestational age (SGA) on morbidity and mortality in discordant twins (DTs) and compared separately the clinical outcomes of smaller and larger DTs with different singletons matched for perinatal factors including BW percentile. RESULTS: A total of 935 twin pairs [1548 concordant twins (CTs) and 322 DTs] were included. BW discordance was associated with increased odds of moderate bronchopulmonary dysplasia, mortality, and composite outcomes. Compared with the CTs, the smaller, but not larger, DTs had greater odds of morbidities and mortality. DTs had higher odds of adverse neonatal outcome when combined with SGA. Meanwhile, DTs had morbidities and mortality similar to singletons matched for BW percentile. CONCLUSION: BW discordance in VLBW twins adversely affects neonatal mortality or respiratory morbidity which is predominant in smaller DTs. The impact of BW discordance could be increased through SGA.

Non-reassuring fetal status and anesthetic impact on cesarean section-delivered very-low-birthweight infants.

BACKGROUND: There is limited evidence concerning the impact on neonatal outcomes of different types of anesthesia used for cesarean delivery due to non-reassuring fetal status (NRFS). We aimed to assess the impact of NRFS and general anesthesia (GA) on neonatal outcomes in very-low-birthweight (VLBW) infants delivered by cesarean section. METHODS: Data were collected relating to VLBW infants admitted to our institution. Infants were grouped into no-NRFS and NRFS groups and further subcategorized into GA and regional anesthesia (RA) subgroups. Neonatal outcomes were evaluated based on the presence of NRFS and the type of anesthesia. RESULTS: A total of 356 infants were included. The GA subgroup in the no-NRFS group had higher requirements for respiratory support. However, GA was not associated with adverse neonatal outcomes based on the multivariable logistic regression analysis except for 5 min Apgar score <5. On the other hand, NRFS was associated with an increased risk of 5 min Apgar score <5 [adjusted odds ratio (aOR) 2.062, 95% confidence interval (CI) 1.064-3.997], use of high-frequency ventilation (aOR: 2.891, 95% CI: 1.477-5.658), and pulmonary hypertension (aOR: 2.890, 95% CI: 1.436-5.819). CONCLUSIONS: In our cohort of VLBW infants, NRFS was a significant risk factor for a low 5 min Apgar score, increased respiratory support requirement, and pulmonary hypertension. Accurate assessment of fetal well-being, timely delivery, and presence of a resuscitation team fully aware of perinatal conditions and anesthetic impact is important.

Short-term outcomes of very-low-birth-weight infants born to mothers of advanced and very advanced maternal age.

OBJECTIVE: To evaluate whether advanced maternal age (35-39 years, AMA)/very advanced maternal age (≥40 years, VAMA) impacts neonatal outcomes of very-low-birth-weight (VLBW) infants. METHODS: Data of VLBW infants admitted to our unit were reviewed. Demographic findings and neonatal outcomes were compared among maternal age [(<35 years, not advanced maternal age, n = 329), AMA (n = 209), and VAMA (n = 43)] groups. Univariate and multivariate analyses were performed to identify the associated risk factors for neonatal outcomes. RESULT: Mortality and overall morbidities showed no significant intergroup differences, except for massive pulmonary hemorrhage (MPH). Multivariate analysis revealed that AMA/VAMA was not significantly associated with MPH development, while ≥ two doses of surfactant administration was. Higher gestational age and antenatal corticosteroid administration were protective. CONCLUSION: AMA/VAMA is not associated with neonatal mortality and morbidities. Since the proportion of AMA/VAMA mothers is expected to increase, perinatal medicine practitioners should focus on approaches before and immediately after birth of such infants.

Risk factors associated with prolonged mechanical ventilation after surgical patent ductus arteriosus ligation in preterm infants.

BACKGROUND: One of the main pathophysiologies of a hemodynamically significant patent ductus arteriosus (hsPDA) involves pulmonary over-circulation. However, PDA treatment does not present with uniform effects on pulmonary outcomes. We aimed to evaluate the clinical characteristics - in particular, respiratory parameters - associated with prolonged mechanical ventilation after PDA ligation. METHODS: Preterm infants ≤32 weeks gestation were included in the study. Infants who underwent PDA ligation were grouped depending on whether the infant successfully was extubated ≤14 d after ligation or required prolonged invasive mechanical ventilation >14 d after ligation. The clinical characteristics, including the parameters concerning the respiratory illness severity and hemodynamical significance of PDA shunt, were compared between the two groups. RESULTS: Among 172 preterm infants, 36 (20.9%) infants underwent surgical PDA ligation. Fifteen (41.6%) infants were successfully extubated at ≤14 d after ligation, and 21 (58.3%) infants required prolonged invasive mechanical ventilation for >14 d after ligation. In the univariable analysis, the infants who required prolonged mechanical ventilation was significantly smaller in terms of gestational age (GA) and birth weight and tended to present a greater respiratory illness severity [represented by the use of high-frequency oscillatory ventilation (HFOV) and greater RSS (respiratory severity score)/kg] with a larger PDA size prior to PDA ligation. In the multivariable logistic regression analysis, peak preoperative RSS/kg (p = 0.012, OR = 0.207, 95% CI = 0.060-0.706) was the only significant factor associated with prolonged mechanical ventilation after PDA ligation. CONCLUSION: Preterm infants with the compromised respiratory condition may be prone to prolonged mechanical ventilation after PDA ligation. The respiratory status during the early phase of life should be considered when evaluating the effect of PDA treatment. With an extended view, distinguishing infants with such risk factors may lead to more polished treatment strategies toward hsPDA.

Dose completion of antenatal corticosteroids and neonatal outcomes in non-small-for-gestational age or small-for-gestational age very-low-birthweight infants: A Korean population-based cohort study.

BACKGROUND: The protective effect of antenatal corticosteroids (ACS) in preterm infants has been well established but it remains unclear in growth-restricted fetuses. Furthermore, a substantial number of pregnant women receive only incomplete ACS treatment because of late presentation or imminent delivery at arrival to the delivery site. How this affects neonatal outcomes in small for gestational age (SGA) infants is not rigorously described. We evaluated the influence of ACS completion on in-hospital neonatal outcomes in very low birthweight (VLBW) infants, depending on appropriately or inappropriately grown singletons. METHODS: Electronic data were retrieved from the Korean Neonatal Network database between 2013 and 2017. We assessed perinatal and neonatal characteristics and neonatal mortality and morbidities. Multivariable logistic regression analyses were performed to evaluate neonatal outcome variables influenced by an incomplete as compared to a complete course of ACS in non-SGA and SGA infants. RESULTS: In total, 4441 VLBW infants were included in the study. Complete ACS treatment significantly reduced the risk for death before 28 days of life [odds ratio (OR) = 0.525, 95% confidence interval (CI) = 0.414-0.666], death before neonatal intensive care unit discharge (OR = 0.606, 95% CI = 0.489-0.750), respiratory distress syndrome (OR = 0.634, 95% CI = 0.507-0.793), severe intraventricular hemorrhage (OR = 0.539, 95% CI = 0.424-0.684)], and necrotizing enterocolitis (OR = 0.720, 95% CI = 0.561-0.924) in non-SGA infants. ACS completion did not change the risk for neonatal outcomes in SGA infants. CONCLUSIONS: This study suggests that a complete course of ACS has a favorable effect on several neonatal outcomes in non-SGA VLBW infants. There were no significant differences between the complete exposure and incomplete exposure group in SGA infants.

Clinical characteristics predicting abnormal brain magnetic resonance image findings in hypoxic-ischemic encephalopathy infants.

BACKGROUND: The aim of this study was to elucidate the specific clinical characteristics associated with abnormal brain magnetic resonance image (MRI) findings in hypoxic ischemic encephalopathy (HIE) infants in order to discern how to predict poorer outcomes more accurately. METHODS: A retrospective data analysis of HIE infants admitted to the neonatal intensive care unit of a tertiary hospital was performed. Baseline perinatal information and physical and neurological findings were compared in HIE infants according to the presence of abnormal brain MRI findings. RESULTS: A total of 69 infants were enrolled in the study. Of these, 48(69.6%) infants received therapeutic hypothermia, and 60(87.0%) infants presented abnormal findings on brain MRI. Decreased muscle tone and lower Apgar scores were more often observed in infants with abnormal MRI results(P<0.05). The presence of hypotonia and 1- and 5-minute Apgar scores equal to or less than the yielded cut-off values (5.5 and 7.5, respectively)were associated with a 7.23-, 9.14-, 9.78-fold increased risk of having abnormal brain MRI results. CONCLUSIONS: As muscle tone and Apgar scores were associated with abnormal brain MRI findings in HIE infants, these clinical characteristics may serve as early indicators of poor neurodevelopmental outcomes and signal the need for special attention and in-depth follow-up by MRI.

Respiratory Severity Score with Regard to Birthweight during the Early Days of Life for Predicting Pulmonary Hypertension in Preterm Infants.

OBJECTIVE: The respiratory severity score (RSS) has been demonstrated to be associated with the oxygenation index in intubated newborn infants. We aimed to evaluate the usefulness of RSS with regard to birthweight (BW) in preterm infants for predicting an association with future pulmonary hypertension (PH). METHODS: Preterm infants with <30 weeks' gestation and <1250 g BW were reviewed and grouped into two (PH vs. no PH). Basic perinatal characteristics, comorbidities and parameters reflecting lung condition, including duration of invasive mechanical ventilator care, were compared. Respiratory support parameters (FiO2, RSS and RSS/kg) during the first 5 days of birth (0-120 h) were compared between the groups, and receiver operating characteristics curves were produced to evaluate the association with PH. RESULTS: RSS/kg, of the three respiratory support parameters, demonstrated significantly higher values in the PH group in the early days of life. Particularly, RSS/kg at day 2 of life had the greatest area under the curve [0.762, 95% confidence interval (CI) 0.655-0.869, p < 0.001] and maintained statistical significance [odds ratio (OR) 1.352, 95% CI 1.055-1.732, p = 0.017] in the multivariable analysis for a potential association with PH, along with gestational age (OR 0.996, 95% CI 0.993-0.999, p = 0.015) and preterm premature rupture of membrane >18 h (OR 4.907, 95% CI 1.436-16.765, p = 0.011). CONCLUSION: RSS/kg is a potential marker associated with the development of PH. Future studies could verify its usefulness as a reliable surrogate for predicting respiratory morbidity in clinical settings.

Enlarged subarachnoid space on cranial ultrasound in preterm infants: Neurodevelopmental implication.

The role of enlarged subarachnoid space (ESS) in preterm infants has not been described in concrete. We aimed to evaluate whether ESS should be considered a risk factor potentially associated with adverse neurodevelopmental outcomes in prematurity. Electronic medical records of 197 preterm infants (median 32.1 weeks' gestation) including cranial ultrasound (cUS) images, head circumferences, and Korean Developmental Screening Tests for Infants and Children (K-DST) results at 18-24 months corrected age were reviewed. The clinical characteristics and K-DST results were compared in infants with and without ESS (sinocortical width > 3.5 mm). A multivariable logistic regression analysis was performed to identify potential risk factors associated with positive K-DST results. At a median corrected age of 39.0 weeks, 81/197 (41.1%) infants presented ESS. A significantly greater percent of infants in the ESS group screened positive on the K-DST than in the no ESS group (27.2% vs 12.1%, p = 0.007). Within the ESS group, micro-/macrocephaly at term-equivalent age was not different with regard to the K-DST results. From the multivariable logistic regression analysis, gestational age (p = 0.016, OR = 0.855, 95% CI = 0.753-0.971) and ESS (p = 0.019, OR = 1.310, 95% CI = 1.046-1.641) were two significant risk factors associated with positive K-DST results. ESS identified on cUS at term-equivalent age in preterm infants is associated with possible developmental delays. Macrocephaly at term-equivalent age does not guarantee a benign prognosis. Future studies are required to verify ESS as a potential marker for neurodevelopmental delay in preterm infants.

Patent ductus arteriosus ligation on neurodevelopmental outcomes at corrected 2 years.

BACKGROUND: Our aim in this study was to evaluate whether very low birth weight infants (VLBWI) ligated for patent ductus arteriosus (PDA) were associated with worse neurodevelopmental outcomes at corrected 2 years. The ligated group was subdivided into ≤2 weeks of life (early) and ligated > 2 weeks of life (late) groups and compared the in-hospital morbidities and long term outcomes. METHODS: Between Dec 2013 and Dec 2015, VLBWI diagnosed with hs PDA were evaluated. RESULTS: Of the 191 VLBW infants with hs PDA, 28 (14.7%) infants had surgical ligation for PDA; 11 (39%) infants had EL and 17 (61%) infants had LL. Surgical ligation of hs PDA group had higher morbidities and mortality. Among the142 (83.0%) infants of 171 VLBWI with PDA survived, infants who were ligated had significantly lower scores of Bayley Scales of Infant and Toddler Development III at corrected age of 18 months. However, among the ligated group, there was little evidence of differences between the EL and LL groups. In a multivariable logistic regression analysis, only longer exposure of hs PDA and mechanical ventilation were consistently associated with worse neurodevelopmental outcomes. CONCLUSION: Our results suggest that surgical ligation for hs PDA may not increase risk for poor neurodevelopmental outcomes at corrected 2 years of age. The early surgical ligation may not be a risk factor.

Preoperative metabolic acidosis and acute kidney injury after open laparotomy in the neonatal intensive care unit.

BACKGROUND: This study evaluated potential risk factors associated with acute kidney injury (AKI) in infants undergoing bedside open laparotomy in the neonatal intensive care unit (NICU), and analyzed the association between postoperative AKI and outcomes. METHODS: Retrospective data, including neonatal characteristics, perioperative findings (i.e. vital signs and fluid status), postoperative AKI incidence, and postoperative mortality rate of infants who underwent bedside open laparotomy in the NICU between May 2013 and May 2018 were collected and analyzed. RESULTS: A total of 53 cases (26 in AKI group vs 27 in non-AKI group) were analyzed. On univariable analysis, transfusion, pre- and postoperative blood gas analysis and number of inotropic agents, cumulative postoperative percentage fluid overload (48 h), and preoperative hourly urine output were associated with the development of postoperative AKI. On multivariable logistic regression analysis, preoperative acidosis (pH <7.15 or base deficit >10; P = 0.002; OR, 11.067; 95%CI: 2.499-49.017) and preoperative urine output (P = 0.035; OR, 0.548; 95%CI: 0.314-0.959) were significant factors associated with postoperative AKI. Postoperative mortality rate 30 days after surgery was higher in the AKI group, but the difference was not significant. CONCLUSIONS: Preoperative metabolic acidosis and urine output are important factors potentially associated with the development of postoperative AKI in neonates undergoing bedside open laparotomy. Strategies such as alkali therapy, which protect the kidney from further injury, should be validated in future studies. A decreasing urine output may suggest deteriorating kidney function prior to surgery, potentially amplifying the risk of postoperative AKI.

Perinatal prediction model for severe intraventricular hemorrhage and the effect of early postnatal acidosis.

PURPOSE: Severe acidosis is one of the strongest predictors of neurologic outcomes in full-term infants with suspected hypoxic-ischemic encephalopathy. However, the relative importance of acidosis as a predictor of outcomes in preterm infants is much less clear. The goals of the present study were to examine the association between postnatal acidosis and severe intraventricular hemorrhage (IVH) and to establish a new score model including acid-base status after birth for predicting the risk of this morbidity. METHODS: The study sample was very low birth weight (VLBW) infants in the Korean Neonatal Network (KNN) cohort registry, collected prospectively from January 2013 to December 2014. Infants with blood pH and base deficit (BD) values collected within the first hour after birth, and documentation of severe IVH, were included. Multivariate stepwise logistic regression analysis was used to determine the contribution of postnatal acidosis to predicting severe IVH in VLBW infants. In addition, a prediction model was developed. RESULTS: Data from 2518 VLBW infants were analyzed. Infants with postnatal acidosis had a higher incidence of severe IVH. The clinical model plus blood BD values improved predictive performance, compared with models using only perinatal data or blood pH. CONCLUSIONS: A prediction model for severe IVH was developed using the KNN registry of VLBW infants. Immediate postnatal acidosis, defined based on blood BD, was associated with a higher-risk-adjusted incidence of severe IVH.

Impact of histologic chorioamnionitis on pulmonary hypertension and respiratory outcomes in preterm infants.

We aimed to evaluate the association between the presence of histologic chorioamnionitis (HC) and development of pulmonary hypertension (PH) during neonatal intensive care unit (NICU) stay. Data of preterm infants born at 32 weeks of gestation or less were reviewed. The development of PH and other respiratory outcomes were compared according to the presence of HC. Potential risk factors associated with the development of PH during NICU stay were used for multivariable logistic regression analysis. A total of 188 infants were enrolled: 72 in the HC group and 116 in the no HC group. The HC group infants were born at a significantly shorter gestational age and lower birthweight, with a greater proportion presenting preterm premature rupture of membrane (pPROM) > 18 h before delivery. More infants in the HC group developed pneumothorax ( P = 0.008), and moderate and severe bronchopulmonary dysplasia (BPD; P = 0.001 and P = 0.006, respectively). PH in the HC group was significantly more frequent compared to the no HC group (25.0% versus 8.6%, P = 0.002). Based on a multivariable logistic regression analysis, birthweight ( P = 0.009, odds ratio [OR] = 0.997, 95% confidence interval [CI] = 0.995-0.999), the presence of HC ( P = 0.047, OR = 2.799, 95% CI = 1.014-7.731), and duration of invasive mechanical ventilation (MV) > 14 days ( P = 0.015, OR = 8.036, 95% CI = 1.051-43.030) were significant factors. The presence of HC and prolonged invasive MV in infants with lower birthweight possibly synergistically act against preterm pulmonary outcomes and leads to the development of PH. Verification of this result and further investigation to establish effective strategies to prevent or ameliorate these adverse outcomes are needed.

Echocardiographic assessment of patent ductus arteriosus in very low birthweight infants over time: prospective observational study.

BACKGROUND: We aimed to determine the echocardiographic parameters that can predict the presence of patent ductus arteriosus (PDA) and haemodynamically significant ductus arteriosus (HSDA) at different time points. METHODS: Echocardiogram was performed on postnatal days 3 and 7(D3-Echo and D7-Echo, respectively) in 71 very low birthweight infants with a median gestational age of 28.0 weeks. We first assessed the correlation between D3-Echo findings among infants with ductal patency and persistent ductal patency on D7-Echo. We subsequently assessed the correlation between D7-Echo findings and ultimate need for PDA treatment. RESULTS: Forty-nine (69.0%) infants had ductal patency on D3-Echo, and 32(65.3%) of these had persistent PDA on D7-Echo. Twenty of the latter (62.5%) underwent PDA treatment at a median chronological age of 19 days. PDA treatment was significantly correlated with DA size and DA peak-systolic-to-end-diastolic velocity(S/D) ratio on D3- and D7-Echo. Receiver operating characteristic curve analysis revealed that DA size ≥2.040 mm and S/D ratio ≥2.016 had fair sensitivity, specificity, and predictive values for PDA treatment. CONCLUSION: The significance of different echocardiographic parameters associated with future ductal patency or HSDA depends on the time of assessment. DA size and S/D ratio on day 7 are two reliable indicators of the need for future PDA treatment.

Impacts of therapeutic hypothermia on cardiovascular hemodynamics in newborns with hypoxic-ischemic encephalopathy: a case control study using echocardiography.

PURPOSE: The effects of therapeutic hypothermia (TH) on hemodynamics in newborns with hypoxic-ischemic encephalopathy (HIE) were evaluated. MATERIALS AND METHODS: Thirty-two neonates (gestational age, 39.4 ± 1.3 weeks) who had TH for HIE and echocardiographic hemodynamic assessments during TH and post-TH period were studied. Gestational-age-matched 34 healthy neonates were enrolled for comparison. RESULTS: During TH, patients had significantly decreased left ventricular cardiac output (LVCO), descending aorta blood flow (DABF), and DABF/LVCO ratio, and increased resistive index of DA compared to controls. Upper body blood flow (UBBF) remained unchanged but UBBF/LVCO ratio significantly increased during TH. Urine output decreased significantly during TH and increased after rewarming, and showed significant positive correlation with DABF/LVCO ratio. Sixteen patients (50%) showed hypoxic-ischemic (HI) lesions on brain magnetic resonance imaging (MRI) and had significantly increased UBBF/LVCO ratio during TH compared to patients without HI lesions. Patients with UBBF/LVCO ratio >55% had significantly higher risk of having HI lesions on brain MRI (odds ratio 13.0; 95% CI, 2.4-70.2). CONCLUSIONS: Decrease in cardiac output and descending aorta blood flow, and preferential cerebral redistribution of cardiac output along with an increase in systemic peripheral vascular resistance may affect systemic organ perfusion and cerebral metabolism.