Is There a Role for Cerebral Ultrasonography in Near-Term/Term Neonates Following Assisted Vaginal Delivery? A Prospective, Single-Center Study.

AIM: To evaluate the role of cerebral ultrasonography studies (CUSS) in detecting intracerebral and cranial pathologies (hemorrhages, ischemia, skull fractures) in near-term and term neonates following assisted vaginal delivery. PATIENTS AND METHODS: Prospective single-center study (11/2017-11/2018) at the University Children's Hospital of Saarland, Homburg, Germany including newborns with a gestational age ≥ 36 weeks born by assisted vaginal delivery. In all newborns, a standardized CUSS was performed within the first three days of life prior to discharge. RESULTS: 200 neonates (43.0 % female, 57.0 % male; gestational age 39.6 ±â€Š1.3 weeks) were included in this study (birth weight 3345.6 ±â€Š450.6 g, body length 51.7 ±â€Š2.5 cm, head circumference 35.0 ±â€Š1.5 cm). 67 (33.5 %) neonates had minor external injuries of the scalp. 5 children showed clinical neurologic abnormalities: 4 (2.0 %) seizures and 1 facial palsy (0.5 %). In 34 (17.0 %) patients, minor incidental intracranial abnormalities unrelated to mode of delivery were detected on CUSS. No intracerebral, cranial pathologies or skull fractures were seen on routine CUSS. CONCLUSION: Routine CUSS in newborns after assisted vaginal delivery did not yield clinically relevant results in our cohort. Clinical observation and selective CUSS in symptomatic newborns might be more efficient than routine CUSS.

Iatrogenic severe hyperglycemia due to parenteral administration of glucose in children - a case series.

BACKGROUND: Iatrogenic severe hyperglycemia (ISH) caused by glucose-containing i.v. solution is a potentially fatal treatment error. The objective of this study was to investigate the causes, circumstances, course of disease, and complications of ISH > 300 mg/dl (16.7 mmol/l) in neonates and children. METHODS: We emailed a survey to 105 neonatal and pediatric intensive care units in Germany, Austria, and Switzerland, asking to retrospectively report cases of ISH. RESULTS: We received 11 reports about premature infants to children. Four patients (36%) had poor outcome: 2 died and 2 suffered persistent sequelae. The highest observed blood glucose was at median 983 mg/dl (54.6 mmol/l) (range 594-2240 mg/dl; 33.0-124.3 mmol/l) and median time to normoglycemia was 7 h (range 2-23). Blood glucose was higher and time to normoglycemia longer in patients with poor outcome. Invasive therapy was required in 73% (mechanical ventilation) and 50% (vasopressor therapy) of patients, respectively. Administration of insulin did not differ between outcome groups. Patients with poor outcome showed coma (100% vs. 40%) and seizures (75% vs. 29%) more frequently than those with good outcome. CONCLUSIONS: ISH is a severe condition with high morbidity and mortality. Further research to amplify the understanding of this condition is needed, but focus should largely be held on its prevention.

Effects of small for gestational age status on mortality and major morbidities in ≤750 g neonates.

BACKGROUND: Controversy exists regarding the impact of small for gestational age (SGA = birth weight < 10th percentile) status on mortality and major morbidities. AIM: To assess the effects of SGA on mortality and major morbidities in ≤750 gram (g) neonates. STUDY DESIGN: Retrospective (01/2005-12/2017), single center study at a tertiary NICU. SUBJECTS: SGA neonates ≤ 750 g. OUTCOME: Effect of SGA status on mortality and major morbidities. RESULTS: 183 infants were enrolled. 103 (56.3%) were non-SGA (mean gestational age 25 + 1 weeks ±â€¯9.9 days, mean birth weight 662.6 ±â€¯75.2 g), and 80 (43.7%) SGA (mean gestational age 26 + 6 weeks ±â€¯14.0 days, mean birth weight 543.9 ±â€¯114.7 g). Mortality was 24.1% (non-SGA: 30/103 (29.1%), SGA: 14/80 (17.5%); p = 0.08). Univariable logistic regression analysis revealed a significant protective effect of SGA status on pneumothoraces (OR 0.28, 95%-CI [0.11-0.69]), IVH (≥3) (OR 0.38; 95%-CI [0.15-0.67]), and seizures (OR 0.09, 95%-CI [0.01-0.76]), but NEC (≥2a) occurred more frequently in SGA neonates (p = 0.024). Multiple logistic regression analysis found SGA status to negatively influence ROP (≥3) (OR 2.87, 95%-CI [1.14-7.23]) and need for home monitoring (OR 2.38, 95%-CI [1.05-5.41]). Other major morbidities (IVH, PVL, RDS, BPD, NEC, FIP, sepsis, hearing impairment) and mortality rates were not significantly affected, but distinct organ-specific patterns were seen. CONCLUSION: SGA had negative effects on the rate of severe ROP and the need for home monitoring, but other major morbidities as well as mortality rates were not significantly affected. In the future, it will be important to delineate underlying pathophysiological mechanisms that contribute to this pattern.

Mechanisms of disease/hypothesis: neurogenic left ventricular dysfunction and neurogenic pulmonary oedema.

BACKGROUND: Acute onset of cardiovascular dysfunction may be the result of insults to the central nervous and autonomic system. Several cerebral regions (insular cortex, lateral, hypothalamus, and brain stem) have been identified as part of the "central autonomic network". The brain stem plays an integral role in controlling and mediating autonomic tone. PATIENT AND METHODS: Case reports. RESULTS: These two case reports demonstrate the intimate connectivity between the cardiovascular/pulmonary system and the central nervous system in a 13-year-old girl with occipital angiomatosis, but no history of heart disease who developed profound left ventricular dysfunction and pulmonary oedema following pontine haemorrhage, and in a 5-year-old girl who developed severe pulmonary oedema after suffering from status epilepticus. CONCLUSIONS: The two case reports suggest that cardiovascular dysfunction secondary to central nervous insults and neurogenic pulmonary oedema are not two separate clinical entities, but may very well encompass two different presentations of central autonomic disturbances.

Iatrogenic ventricular tachycardia.

Cardiac arrhythmias may complicate the clinical course in infants and children following cardiac surgery. Here, we report on a 6-week-old neonate who developed life-threatening ventricular tachycardia with cardio-circulatory compromise after the removal of a substernal catheter that surrounded the heart. The treating physician should be prepared for device-related ventricular tachycardia when temporary devices are removed, and adequate treatment must be initiated immediately.

Vasopressin in catecholamine-resistant septic and cardiogenic shock in very-low-birthweight infants.

AIM: To evaluate vasopressin as a rescue therapy in catecholamine-refractory septic and cardiogenic shock in very-low-birthweight (VLBW) infants. METHODS: Prospective assessment of vasopressin therapy in three VLBW infants with catecholamine-refractory septic shock (24 + 6 wk, 600 g) and cardiogenic shock (26 + 1 wk, 890 g; 26 + 1 wk, 880 g) at a university hospital. RESULTS: Adequate systemic arterial blood pressure could only be restored after vasopressin administration as a continuous infusion over a 36-h period in the preterm suffering from septic shock; in the two neonates with cardiogenic shock, only a transient stabilization in mean arterial pressure was observed, which did not impact on the poor prognosis. CONCLUSION: Although vasopressin appears to be a suitable rescue therapy in catecholamine-resistant septic shock in VLBW infants, further evaluation in controlled clinical trials is warranted.