El Servicio de Neonatología en el Hospital Universitario y Politécnico La Fe en el año 2013 / The Neonatology Department in the University and Polytechnic Hospital La Fe in the year 2013

El presente documento representa un resumen del a organización actual del Servicio de Neonatología (SN). En primer lugar se describe la misión, visión y los valores del mismo, se sigue de una reseña estructural y de la cartera de Servicios. A Continuación se describe la actividad asistencial del paciente ingresado en planta de hospitalización obstétrica y neonatal y su seguimiento ambulatorio en el área de consultas externas. Seguidamente, se expondrá la actividad docente de grado, la formación especializada en Pediatría y la formación continuada. Se comentan las inquietudes en proyectos de investigación y las estrategias de mejora de la calidad del servicio fomentando el plan de humanización del SN centrándose en los cuidados centrados en el desarrollo y la familia. Para finalizar cabe resaltar los objetivos asistenciales, docentes y de investigación actuales de mayor relevancia (AU)

This document represents a summary of the current Neonatology Service (NS) of the University Hospital La Fe de Valencia. In the first place, the mission, vision and values will e described followed by a structural review and all the services that the Hospital provides. Moreover, it will be explained the medical attendance towards patients in obstetric and neonatal hospitalization and its subsequent follow-up out patient clinic. Subsequently, teaching degree, specialized formation in Pediatric and continuing education training will be exposed. Concerns in research projects and strategies to improve the quality of the service in promoting the humanization of NS and focusing on Centered Care and Family Development are described. Finally it is worth emphasizing the attendance, teaching and research objectives (AU)

[Review of standards and recommendations for the design of a neonatology unit]. / Revisión de los estándares y recomendaciones para el diseño de una unidad de neonatología.

Standards for the design of a neonatology unit are reviewed. The process should begin with a planning team to outline the desired objectives to be achieved, followed by the intervention of a team of architects. Medical considerations, standards and recommendations, as well as architectural considerations (adequate privacy and intimacy, need for social support and communication, flexibility and accessibility) should be taken into account. From the architectural point of view, the greatest problem is the space available; furthermore, if the aim is to personalize the unit for the newborn and family, the need for space will be even greater. The following aspects should be analyzed and integrated into the design of the unit: standards and recommendations regarding space, the site of the unit, area of direct neonatal care, electrical installation, equipment, lighting and noise levels, nursing staff, communication systems, maintenance and refurbishment.

Revisión de los estándares y recomendaciones para el diseño de una unidad de neonatología / Review of standards and recommendations for the design of a neonatology unit

Se revisan los estándares para el diseño de una unidad de neonatología. El proceso debe iniciarse con un equipo de planificación que debe indicar los objetivos que se desean conseguir, para que posteriormente intervenga el equipo de arquitectos. Se deben tener en cuenta las aportaciones médicas, los estándares y recomendaciones, y las aportaciones arquitectónicas (adecuada privacidad e intimidad, necesidad de apoyo social y comunicación, flexibilidad y accesibilidad). Desde el punto de vista arquitectónico, el mayor problema es el del espacio disponible, y debemos tener en cuenta que si queremos personalizar el entorno del cuidado para el recién nacido y su familia e introducir los cuidados centrados en la familia, las necesidades de espacio serán aún mayores. Se analizan los estándares y recomendaciones relativos al espacio, ubicación de la unidad, área de atención directa al neonato, instalación eléctrica, iluminación y nivel de ruido, equipamiento, personal de enfermería, sistemas de comunicaciones, mantenimiento y renovación

Standards for the design of a neonatology unit are reviewed. The process should begin with a planning team to outline the desired objectives to be achieved, followed by the intervention of a team of architects. Medical considerations, standards and recommendations, as well as architectural considerations (adequate privacy and intimacy, need for social support and communication, flexibility and accessibility) should be taken into account. From the architectural point of view, the greatest problem is the space available; furthermore, if the aim is to personalize the unit for the newborn and family, the need for space will be even greater. The following aspects should be analyzed and integrated into the design of the unit: standards and recommendations regarding space, the site of the unit, area of direct neonatal care, electrical installation, equipment, lighting and noise levels, nursing staff, communication systems, maintenance and refurbishment

[Ibuprofen versus indomethacin in the preterm persistent patent ductus arteriosus therapy: review and meta-analysis]. / Ibuprofeno frente a indometacina para el tratamiento de la persistencia del conducto arterioso del prematuro: revisión sistemática y metaanálisis.

INTRODUCTION: Persistent patent ductus arteriosus (PDA) is a common pathology in the preterm whose traditional treatment has been indomethacin. Recently, ibuprofen has shown its effectiveness in closing the PDA with less hemodynamic effects. The objective of this paper is to review the current literature in order to determine if there is any benefit of ibuprofen versus indomethacin in the PDA therapy. MATERIAL AND METHODS: Eleven trials comparing intravenous ibuprofen versus indomethacin in the treatment of PDA confirmed by echocardiography in < 35 weeks preterm or < 1,500 g birth weight were included. A meta-analysis of the trials data was performed. RESULTS: No trial show statistically significant differences in the failure of closing PDA, neither the meta-analysis (RR 0.96 [CI 95 %: 0.74-1.26], with a power of 0.995). No differences were found in the rate of reopening and surgical ligation. Complications were similar, except for a significant lower incidence of oliguria in the ibuprofen group (RR 0.23 [CI 95 %: 0.10-0.51]). There were no differences in the respiratory outcomes (RR of bronchopulmonary dysplasia (BPD) at 28 days 1.32 [CI 95 %: 0.99-1.76]). CONCLUSIONS: In our revision ibuprofen was as effective as indomethacin in closing PDA. No significant differences were found in the incidence of complications except for less renal impairment with ibuprofen. A higher risk of BPD in the ibuprofen group is not confirmed, although more studies are needed.

Quilotórax neonatal congénito y posquirúrgico: revisión y algoritmo diagnóstico-terapéutico / Congenital and postoperative chylothorax in newborns: review and diagnostic and therapeutic algorithm

El quilotórax se define como la acumulación de linfa en el espacio pleural. Realizamos un estudio retrospectivo durante un periodo de 14 años, en el que encontramos 15 casos de quilotórax neonatal: 6 congénitos y 9 posquirúrgicos. En los casos congénitos hubo dos casos de hydrops y uno se asoció a feblectasia congénita. Los posquirúrgicos fueron 4 tras cirugía cardiovascular y 5 tras cirugía de reparación de hernias diafragmáticas. La evolución fue buena en los 15 pacientes, con resolución del quilotórax. Todos los casos congénitos fueron diagnosticados prenatalmente mediante ecografía fetal, precisando todos reanimación profunda y/o ventifación mecánica tras el nacimiento. El diagnóstico fue confirmado mediante análisis del líquido pleural. El tratamiento inicial fue conservador en todos los casos, con drenaje del líquido pleural y soporte respiratorio, cardiovascular, hemodinámico y nutricional. Este tratamiento fue efectivo en el 80% de los casos, precisando cirugía sólo 3 quilotórax posquirúrgicos. No hemos encontrado diferencias significativas respecto a los volúmenes drenadas, los días de ventilación mecánica, los días de nutrición parenteral total, la duración del quilotórax y el porcentaje de complicaciones entre los casos congénitos y los posquirúrgicos. En el caso de los congénitos, es importante el diagnóstico prenatal para planificar una reanimación neonatal adecuada. Tras la revisión actual, proponemos un algoritmo de manejo de esta compleja patología

Chylothoraxis defined as an effusion of lymphin to the pleural cavity. In a retrospective study covering a 14-year period, we found 15 cases of chylothorax occurring during the neonatal period: 6 congenital and 9 postoperative. Congenital chylothorax was associated with hydrops in two cases and with congenital phlebectasia in one case. Postoperative chylothorax occurred after cardiovascula surgery in tour cases and after surgical repair of diaphragmatic hernia in five. The clinical outcome was good in all the patients. Congenital chylothorax was diagnosed by prenatal ultrasound, and mechanical ventilation was required after birth in every case. The diagnosis was confírmed by the analysis of the pleural fluid. Initial treatment was conservative, with continuous or intermittent drainage of chyle and respiratory, cardiovascular, hemodynamic and nutritional support, which was effective in 80% of the cases. Three patients with postoperative chylothorax required surgery for resolution. We have observed no significant differences between the two groups in terms of volume of Lymph drained, days on mechanical ventilation, days with total parenteral nutrition, duration of chylothorax or complications. Prenatal diagnosis is important for planning neonatal resuscitation. We propase an algorithm for the diagnosis and treatment of this complex entity

[Ibuprofen versus indomethacin in the treatment of patent ductus arteriosus in preterm infants]. / Ibuprofeno frente a indometacina en el tratamiento del conducto arterioso persistente del prematuro.

INTRODUCTION: Persistent patent ductus arteriosus (PDA) is a common entity in preterm infants. The most commonly used pharmacological treatment to close the ductus is indomethacin but it can affect cerebral, renal and mesenteric blood flow. Ibuprofen has recently been shown to be effective in closing PDA with fewer hemodynamic effects. In this study we compared the safety and efficacy of ibuprofen and indomethacin in the treatment of PDA in preterm infants. MATERIAL AND METHODS: A randomized trial was performed. Premature infants with symptomatic PDA confirmed by echocardiography in the first week of life and who required respiratory support were included. The patients were randomly assigned to receive either intravenous indomethacin or ibuprofen. The rate of ductal closure, need for additional treatment, complications, and clinical course were evaluated. RESULTS: Twenty-four patients were treated with indomethacin and 23 with ibuprofen. The clinical characteristics before treatment were similar in both groups. Both treatments were effective in closing PDA (87.5% in the indomethacin group and 82.6% in the ibuprofen group). The two cohorts did not differ in the rate of reopening, need for a second pharmacologic treatment, or surgical ductal ligation. No patient in the ibuprofen group developed gastrointestinal adverse effects, but two infants in the indomethacin group had isolated bowel perforation and one had necrotizing enterocolitis. Transient renal dysfunction developed in seven patients (29%) in the indomethacin group versus two (9%) in the ibuprofen group. Transient renal insufficiency was found in one patient in the indomethacin group and in none in the ibuprofen group. The rate of other complications was similar in both groups. CONCLUSIONS: In our trial ibuprofen was as effective as indomethacin in closing PDA. No significant differences were found in the incidence of complications but fewer renal complications and no gastrointestinal complications were found in the ibuprofen group.

Ibuprofeno frente a indometacina en el tratamiento del conducto arterioso persistente del premature / Ibuprofen versus indomethacin in the treatment of patient ductus arteriosus in preterm infants

Introducción. El conducto (ductus) arterioso persistente (DAP) es una enfermedad frecuente en el prematuro. La indometacina es el tratamiento más utilizado en su cierre, pero puede alterar el flujo cerebral, renal y mesentérico. Recientemente el ibuprofeno ha mostrado ser eficaz en el cierre del DAP con menores efectos hemodinámicos. Este estudio se realizó para comparar la eficacia y seguridad del ibuprofeno frente a la indometacina en el cierre del DAP en el prematuro. Material y métodos. Estudio aleatorizado que incluyó prematuros con DAP sintomáticos, diagnosticados mediante ecografía en la primera semana de vida, que precisaron soporte ventilatorio. Los pacientes fueron asignados aleatoriamente a indometacina o ibuprofeno por vía intravenosa. Se evaluó la tasa de cierre ductal, la necesidad de tratamiento adicional, las complicaciones y la evolución clínica. Resultados. Se trataron 24 pacientes con indometacina y 23 con ibuprofeno. Sus características clínicas previas al diagnóstico fueron similares. Ambos tratamientos se mostraron eficaces en el cierre, 87,5 % para la indometacina y 82,6 % para el ibuprofeno. Las dos cohortes no se diferenciaron en la frecuencia de reaperturas, necesidad de dos tandas de fármaco, ni proporción de ligaduras quirúrgicas. Ningún paciente tratado con ibuprofeno presentó enfermedad abdominal que sí apareció en el grupo de indometacina (dos perforaciones intestinales y una enterocolitis necrosante). Siete pacientes (29 %) del grupo de indometacina desarrollaron disfunción renal transitoria frente a 2 casos (9 %) en el de ibuprofeno. En el grupo de indometacina un paciente experimentó insuficiencia renal transitoria y ninguno en el de ibuprofeno. El resto de complicaciones fue similar en ambos grupos. Conclusiones. En nuestra serie el ibuprofeno se mostró igual de eficaz que la indometacina en el cierre del DAP. No hubo diferencias significativas en la incidencia de complicaciones entre ambos grupos, aunque los tratados con ibuprofeno tuvieron menos complicaciones renales y ninguna intestinal

Introduction. Persistent patent ductus arteriosus (PDA) is a common entity in preterm infants. The most commonly used pharmacological treatment to close the ductus is indomethacin but it can affect cerebral, renal and mesenteric blood flow. Ibuprofen has recently been shown to be effective in closing PDA with fewer hemodynamic effects. In this study we compared the safety and efficacy of ibuprofen and indomethacin in the treatment of PDA in preterm infants. Material and methods. A randomized trial was performed. Premature infants with symptomatic PDA confirmed by echocardiography in the first week of life and who required respiratory support were included. The patients were randomly assigned to receive either intravenous indomethacin or ibuprofen. The rate of ductal closure, need for additional treatment, complications, and clinical course were evaluated. Results. Twenty-four patients were treated with indomethacin and 23 with ibuprofen. The clinical characteristics before treatment were similar in both groups. Both treatments were effective in closing PDA (87.5 % in the indomethacin group and 82.6 % in the ibuprofen group). The two cohorts did not differ in the rate of reopening, need for a second pharmacologic treatment, or surgical ductal ligation. No patient in the ibuprofen group developed gastrointestinal adverse effects, but two infants in the indomethacin group had isolated bowel perforation and one had necrotizing enterocolitis. Transient renal dysfunction developed in seven patients (29 %) in the indomethacin group versus two (9 %) in the ibuprofen group. Transient renal insufficiency was found in one patient in the indomethacin group and in none in the ibuprofen group. The rate of other complications was similar in both groups. Conclusions. In our trial ibuprofen was as effective as indomethacin in closing PDA. No significant differences were found in the incidence of complications but fewer renal complications and no gastrointestinal complications were found in the ibuprofen group

[Nasal continuous positive airway pressure in preterm infants: comparison of two low-resistance models]. / Presión positiva continua en la vía aérea por vía nasal en el recién nacido prematuro: estudio comparativo de dos modelos de baja resistencia.

OBJECTIVE: To compare the safety and efficacy of two low expiratory resistance models of nasal continuous positive airway pressure (n-CPAP) in preterm infants. MATERIAL AND METHODS: A 1-year prospective trial was performed in the Neonatal Intensive Care Unit of La Fe Hospital to compare the Infant Flow (IF) and Medijet (MJ) devices. All preterm infants requiring n-CPAP for respiratory distress at birth (group I), infants weighting less than 1500 g requiring postextubation (group II) and those with apnea-bradycardia syndrome (ABS) (group III) were included. The patients were randomly assigned to IF or MJ. RESULTS: A total of 125 patients received 226 treatments (IF: n 5 126: MJ: n 5 110). The mean gestational age was 29.4 weeks and the mean birth weight was 1340 g.Efficacy. In group I (n 5 73) no difference were found between systems and 6 hours' after initiation of n-CPAP decreases in FiO2, CO2 and respiratory effort were similar. The need for intubation was also similar (IF: 34.6 %; MJ: 24.1 %). In group II (n 5 73) the need for reintubation at 48 hours was similar with both treatments (IF:19 %; MJ: 8 %). In group III (n 5 80) resolution of ABS was similar after 24 hours of n-CPAP (IF: 46 %; MJ: 58 %). The need for intubation was also similar (IF: 26 %; MJ: 10 %).Complications. Air leaks occurred in six preterm infants (IF: 4; MJ: 2). Severe abdominal distension occurred in 5 % with both systems. Five infants had significant nasal lesions (IF: 1; MJ: 4). CONCLUSIONS: The efficacy and safety of both systems was similar in the variables studied and no significant differences were found.

Presión positiva continua en la vía aérea por vía nasal en el recién nacido prematuro: estudio comparativo de dos modelos de baja resistencia / Nasal continuous positive airway pressure in preterm infants: comparison of two low-resistance models

Objetivo: Comparar la eficacia y seguridad de dos modelos diferentes de presión positiva continua en la vía aérea por vía nasal (CPAP-n) de baja resistencia, en recién nacidos pretérminos. Material y métodos: Estudio prospectivo realizado en cuidados intensivos neonatales del Hospital La Fe durante un año, comparando los sistemas Infant Flow (IF) y Medijet (MJ). Se incluyeron todos los pretérminos que precisaron CPAP-n por distrés respiratorio al ingreso (grupo I), postextubación en menores de 1.500 g al nacimiento (grupo II) y síndrome apneico-bradicárdico (grupo III); asignación aleatoria a uno u otro sistema. Resultados: Estudiamos 125 pacientes, que recibieron 226 tratamientos; 126 con IF y 110 con MJ. Media edad gestacional, 29,4 semanas, y peso al nacimiento, 1.340 g. Eficacia. Grupo I (n 73): no hubo diferencias entre los 2 modelos consiguiéndose a las 6 h del inicio de CPAP-n descensos de la fracción inspiratoria de oxígeno (FiO2), presión parcial de dióxido de carbono (pCO2) y esfuerzo respiratorio; necesidad similar de intubación y ventilación (34,6 por ciento IF y 24,1 por ciento MJ). Grupo II (n 73): porcentaje de reintubación semejante a 48 h (19 por ciento IF y 8 por ciento MJ). Grupo III (n 80): tras 24 h de CPAP-n desaparecieron las apneas en proporción similar (46 por ciento IF y 58 por ciento MJ); precisaron intubación y ventilación 24 por ciento del IF y 10 por ciento del MJ. Complicaciones. Escapes aéreos: 6 pacientes (4 IF y 2 MJ). Distensión abdominal grave: similar con ambos sistemas (5 por ciento). Lesión nasal significativa: 5 pacientes (1 IF y 4 MJ).Conclusiones Los dos sistemas de CPAP-n han sido efectivos y seguros en los supuestos estudiados, sin diferencias significativas en los resultados (AU)

[The value of capnography and exhaled CO2 in neonatal intensive care units]. / Valor de la capnografía y del CO2 exhalado en las unidades de cuidados intensivos neonatales.

OBJECTIVE: The objective of this study was to investigate the reliability of end-tidal CO2 (PetCO2) as a non-invasive guide of PaCO2 in the newborn and to analyze the influence of the relationship between ventilation-perfusion in the correlation between both determinations. PATIENTS AND METHODS: End-tidal CO2 (PetCO2) was monitored by capnography in 9 ventilated newborns: 146 arterial blood gas samples were drawn and the results were compared with the PetCO2 values obtained. The gradient or difference between PaCO2 and PetCO2 was calculated to determine the correlation. The ratio a/AO2 was used as an indirect indicator of the ventilation/perfusion relationship (V/Q ratio). RESULTS: The mean gestational age was 30.9 +/- 2.8 weeks and birth weight 1,648 +/- 596 g. The age at the beginning of the study was 2 +/- 1.5 days. The diagnoses corresponded to 5 cases of RDS (56%), 2 cases of wet lung syndrome (22%), 1 case of pneumonia (11%) and 1 pneumothorax (11%). The results of this monitoring were classified in function of the a/AO2 ratio obtained: Group A, a/AO2 < 0.2 and PaCO2-PetCO2 gradient = 13.3 +/- 5; Group B, a/AO2 = 0.2-0.29 and PaCO2-PetCO2 gradient = 8 +/- 2.7; and Group C, a/AO2 > 0.29 and PaCO2-PetCO2 gradient = 2 +/- 1.7. The results show a very good correlation from a a/AO2 ratio > or = 0.3 onwards. The a/AO2 ratio is the major determinant of PaCO2-PetCO2 differences and respiratory frequency has less influence. CONCLUSIONS: 1) Monitoring of end-tidal CO2 does not maintain a good correlation with PaCO2 in serious lung illness. 2) End-tidal CO2 measurement is an effective and accurate technique for the monitoring of newborns when the a/AO2 ratio > or = 0.3 and it can be useful for weaning of mechanical ventilation. 3) PaCO2-PetCO2 differences accurately show the changes in the ventilation-perfusion relationship.

Hypertrophic cardiomyopathy in preterm infants treated with dexamethasone.

UNLABELLED: Steroid therapy has been widely used in neonates for its beneficial effects. Adverse side-effects have been described, also affecting the cardiovascular system. We report two cases of hypertrophic cardiomyopathy in two preterm newborns secondary to dexamethasone treatment. Full recovery occurred after discontinuing steroids. Risk/benefit ratios must be carefully considered before using steroids in the neonatal period. CONCLUSION: Serial echocardiographic evaluations should be performed to evaluate prevalence and clinical relevance of hypertrophic cardiomyopathy in preterm infants treated with dexamethasone.

[High frequency oscillatory ventilation in the newborn infant]. / Ventilación oscilatoria de alta frecuencia en el recién nacido.

OBJECTIVE: The objective of this study was to determine the effectivity, results and complications after application of HFOV in a group of newborns with serious respiratory distress. PATIENTS AND METHODS: Between February and October 1995, HFOV was required by 18 newborns in the NICU of the Hospital "La Fe" of Valencia, as ventilatory rescue therapy because of the failure of conventional ventilation in 10 cases (group A) and serious air leaks in 8 cases (group B). We used pure HFOV without superimposed cycles of conventional IMV following a high volume-high pressure strategy. Among the lung pathology, RDS was most frequent (11/18). RESULTS: Twenty-four hours after beginning HFOV, a decrease of the FiO2 was obtained in group A from 0.89 to 0.4 and in group B from 0.7 to 0.4. Oxygenation, ventilation, OI and a/AO2 ration also improved. In the group with conventional ventilation failure, this improvement was significant for all parameters in the first two hours after the start of HFOV (p < 0.01). In the group with air leaks, all parameters improved at two hours, but this change was significant only for oxygenation (p < 0.01). Four newborns died (22%) in the first month. CONCLUSIONS: HFOV is an effective and secure ventilatory method when conventional ventilation fails or serious air leaks occur. Important improvement in oxygenation and ventilation is obtained during the first two hours and it is possible to decrease the oxygen requirements at 24 hours after the start of HFOV.