Clinical predictability of intraventricular hemorrhage in preterm infants.

Ninety-eight infants of less than 35 weeks' gestation, consecutively admitted to a regional neonatal intensive care unit, were followed prior to computerized tomography (CT) scan for clinical signs of subependymal and/or intraventricular hemorrhage. The presence or absence of intracerebral hemorrhage was confirmed by CT scan in all patients, and the severity of hemorrhage was quantitated as mild, moderate, or marked. Thirty-seven out of 98 infants (38%) demonstrated intracerebral hemorrhage on CT scan; 20 of 37 (54%) were predicted clinically. Clinical predictability was related to severity of hemorrhage as quantitated by CT scan. Clinical signs that were found helpful in predicting subependymal and/or intraventricular hemorrhage were fall in hematocrit, failure of rise in hematocrit with transfusion of packed red blood cells, tight fontanel, decrease in spontaneous activity, decreased tone, abnormal eye signs, and seizures.

Comparison of lumbar puncture with computed tomography scan as an indicator of intracerebral hemorrhage in the preterm infant.

Computed tomography (CT) scan is the most accurate method for diagnosing intracerebral hemorrhage in the high-risk preterm infant. The present study was undertaken to evaluate lumbar puncture (LP) as a reliable means of diagnosing such hemorrhages. Forty eight infants less than 35 weeks gestation, requiring intensive care, were evaluated by CT scan at 48 to 96 hours of life, and serial LPs were performed. The initial LP preceded the CT scan by one to four hours and repeat LPs were done three and five days later if the initial CT scan revealed intracerebral hemorrhage. The initial LP was successfully performed in 28 of 48 infants. Of these 48 infants, 15 had hemorrhage by CT scan. The initial LP was consistent with the diagnosis on scan in eight of these 15. In the other seven infants, initial LP was normal in three, traumatic in one, and unsuccessful in three. The second LP was consistent with hemorrhage in four of the latter seven. Thus, in only eight of 15 infants, in whom CT scans revealed intracerebral hemorrhage, was the initial LP useful in confirming the diagnosis. Furthermore, LPs showed bloody cerebrospinal fluid in 10 of 18 infants whose CT scans were normal. At the present time LP cannot be considered a reliable means of identifying infants with subependymal-intraventricular hemorrhage.

Reliability of ultrasound in diagnosis of intracerebral hemorrhage and posthemorrhagic hydrocephalus: comparison with computed tomography.

Subependymal and intraventricular hemorrhage are frequent complications of the high risk preterm infant. It has been stated recently that ultrasound may be used to diagnose intraventricular hemorrhage. A comparative prospective study of ultrasound scan (US) with a commercially available B-mode real time linear array US machine and the computed tomography (CT) scan was undertaken to determine the accuracy of US in diagnosing the presence and quantity of subependymal and intraventricular hemorrhage and in following infants with hemorrhage for the development of progressive hydrocephalus. There were 101 patients followed with serial US examination for evidence of subependymal and/or intraventricular hemorrhage. CT correlation was obtained on each patient. The US examination correlated with the CT scan in 77 of these 101 patients. The demonstration of hydrocephalus by US in eight infants with postthemorrhagic hydrocephalus was reliable, and the correlation with CT scan was excellent.

Intraventricular hemorrhage: a prospective evaluation of etiopathogenesis.

In a study population of 151 newborn infants less than 35 weeks gestation, who required intensive care for more than 24 hours, clinical and biochemical factors associated with the presence of intraventricular hemorrhage (IVH) were prospectively evaluated. The diagnosis of IVH was confirmed by computed tomography, ventricular tap, or autopsy. Alveolar rupture was highly correlated with the presence of IVH. Other factors associated with IVH were: hypoxemia, hypercarbia, mechanical ventilation, peak inflation presser > 25 cm H2O, inspiratory to expiratory ratio > 1:1, patent ductus arteriosus, bicarbonate administration after the first day of life, volume expansion in the first day of life, hypotension, stages III and IV hyaline membrane disease, and intrauterine growth retardation. Early bicarbonate administration (first day), sodium administration > 8 mEq/kg/day, acidosis and birth weight less than or equal to 1,200 gm were associated with IVH only in the infants who died with IVH. Factors not associated with IVH were Apgar less than or equal to 5 at one and five minutes, birth weight, gestational age, male sex, osmolality greater than or equal to 300, serum sodium greater than or equal to 150, hypothermia, continuous distending pressure > 6 cm H2O, positive end-expiratory pressure > 5 cm H2O, outborn birth, obstetric trauma, or coagulopathy. Certain therapeutic interventions may lead to an increase incidence of intracerebral hemorrhage in the high-risk preterm infant.

Relationship between pressure passivity and subependymal/intraventricular hemorrhage as assessed by pulsed Doppler ultrasound.

A prospective study was undertaken using a range-gated, pulsed Doppler velocimeter to study flowpressure relationships in the anterior cerebral artery. Serial velocity and pressure studies were performed with each infant serving as his or her own control. The hypothesis tested was that ill preterm infants sustaining subependymal/intraventricular hemorrhage would have absent autoregulation. The hypothesis has been tested in 88 studies on 32 infants. Of 32 infants studied, 15 were judged to be pressure passive; nine of these children bled. The other 17 infants were not pressure passive; eight of these children bled (P greater than .05). From these studies, it may be concluded that the pressure passive state is not the final common link in the genesis of subependymal/intravertricular hemorrhage. Pulsed Doppler ultrasound may provide an extremely useful noninvasive technique for studying both the arterial and venous sides of the cerebral circulation.

Resuscitation of the newborn.

Effective resuscitation of the newborn requires knowledge of the cause of depression. Four major causes are trauma, asphyxia, medication, and malformation. More than one of these may contribute to depression in a single infant. The first principles of resuscitation are to avoid cooling the infant and to establish an airway. Infants with an Apgar score of 3 to 4 at one minute usually need bag-and-mask ventilation, while those with scores of 0 to 2 require immediate ventilation, preferably by means of endotracheal intubation. Severely depressed infants may also require chemical resuscitation and closed cardiac massage. Fetal depression caused by narcotic analgesics given to the mother can be reversed with the use of naloxone hydrochloride (Narcan). Infants asphyxiated on the basis of malformations may benefit from expeditious diagnostic and therapeutic procedures performed in the delivery room.

Behavioral and neurological characteristics of a hydranencephalic infant.

A modified Prechtl neurological examination and the Brazelton Neonatal Assessment Scale were serially administered to a hydranencephalic infant over the first eight weeks of life. Clinical, roentgenographic, neurological and behavioral findings are reported. In contrast to earlier reports, visual tracking of a moving field and auditory and visual habituation were observed. Further, in addition to previously reported reflex automatisms, the infant also possessed what are termed "socially relevant behavioral automatisms". The implications of these findings are discussed.

Amniotic band syndrome.

Amniotic band syndrome is an uncommon, congenital fetal abnormality with multiple disfiguring and disabling manifestations. A wide spectrum of clinical deformities are encountered and range from simple ring constrictions to major craniofacial and visceral defects. Lower extremity limb malformations are extremely common and consist of asymmetric digital ring constrictions, distal atrophy, congenital intrauterine amputations, acrosyndactyly, lymphedema and clubfoot. Although debated, early amnion rupture with subsequent entanglement of fetal parts (mostly limbs and appendages) by amniotic strands is the primary theory of pathogenesis. The sporadic nature of this congenital anomaly is discussed, as well as a case study involving the surgical correction of an associated rigid clubfoot deformity.

Intraventricular hemorrhage in the high-risk preterm infant: incidence and outcome.

To determine the incidence of subependymal (SEH) or intraventricular hemorrhage (IVH) and its short-term outcome, infants of less than 35 weeks' gestation who required intensive care were evaluated and computerized tomographic scans obtained. If the scans showed blood, serial scans were followed until the hemorrhage had resolved and ventricle size was stable. Hemorrhage was quantitated; Seventy-seven of 191 (40.3%) infants were shown to have SEH, IVH, or both; 22 of them (28%) died, and hemorrhage was thought to be the primary cause of death in 17. Fifty-five survivors (71%) with SEH, IVH, or a combination of the two had serial follow-up scans. Six had SEH alone; 49 had IVH. Severe progressive hydrocephalus developed in 12 (22%) infants. Thirty-seven (75.5%) die not show progressive hydrocephalus. The degree of hemorrhage in these 37 was mild in 14, moderate in 13, and marked in 10. Of those with progressive hydrocephalus, hemorrhage was marked in 8 and moderate in 4. Hydrocephalus resolved spontaneously in 4 of the 12. Medical treatment (repeated lumbar punctures) was successful in 3, but failed in 4. Hydrocephalus was managed by shunt surgery in 5. This study revealed that the quantity of blood is prognostically important with regard to both survival (p less than 0.001) and development of progressive hydrocephalus (p less than 0.05). Furthermore, hydrocephalus, even if progressive, may not necessitate surgical management;

ESWL: Comparing two analgesic techniques. Our experience.

OBJECTIVE: We compared the effects of intramuscular analgesia versus intramuscular analgesia associated with topical application of Luan (gel containing lidocaine 1%) on the efficacy of extracorporeal shockwave lithotripsy (ESWL). MATERIAL AND METHODS: From January 2001 to November 2002, 300 patients (mean age 46) were treated for kidney or upper ureteral radiopaque stones with ESWL, using a Dornier Compact Delta magneto lithotripter. The patients were divided into two groups: group A, 180 patients, received intramuscular analgesia with Ketorolac 30 mg, Tramadolo 100 mg and, during treatment, intravenous betametasone 4 mg. Group B, 120 patients, received the same pharmacological treatment associated with topical application of Luan. RESULTS: At 3 months, the stone-free rate in group A was 61% compared with 79% in group B. The energy of treatment was less than 13 kV in group A and less than 15 kV in group B. CONCLUSIONS: For ESWL treatment of kidney stones of 20 mm or less and ureteral stones of 15 mm or less, we suggest local analgesia with topical Luan and intramuscular analgesia. This approach increases the success rate of ESWL and reduces the discomfort associated with treatment.

Pulmonary effects of furosemide in preterm infants with lung disease.

Twenty preterm infants recovering from respiratory distress syndrome at 1 week of age were randomized in this study either to a control or a treatment group. Those treated received a single daily dose of furosemide (1 mg/kg) intravenously. Pulmonary compliance was observed to improve significantly at two hours in the treated group, as compared with that in the controls. The calculated alveolar-arterial oxygen gradient was noted to decrease two hours after furosemide and to remain decreased over the four-day period in the treated group. This improvement in lung function was not secondary to diuresis in the infants treated with furosemide. We conclude that furosemide may have a direct pulmonary effect and improve lung function acutely as well as with chronic administration.

[Current views on the subject of vertical transmission and prevention of hepatitis B]. / Attualità in tema di trasmissione verticale e di profilassi dell'epatite B.

After stressing the different incidence of hepatitis B in the various geographic areas, with notable differences even from one region to another in Italy, and after paying particular attention to the problem of the vertical transmission of the virus from mother to child, stress is laid on the importance of active and passive immunoprophylaxis in newborns of HBsAg positive mothers for the purpose of both preventing possible severe complications in these subjects at risk and of eliminating an important link in the chain of HBV diffusion. Finally a vaccination protocol using a low number of doses compared to that generally recommended without protection being compromised, as evidenced by the personal series of 75 newborns of HBsAg positive mothers and 67 children living with HBsAg positive subjects is outlined. Of the 75 newborns, 21 were vaccinated with four doses of 5 mcg of Hevac Pasteur vaccine and 54 with three doses only; of the latter, only 42 completed the vaccination cycle, with an amply protective antibody response as in the previous group of 21 newborns. The same low protocol of three doses of vaccine was applied to the 67 children living with HBsAg positive subjects and fo the 49 children who completed the cycle only 3 did not present seroconversion.

Range-gated pulsed Doppler ultrasonographic evaluation of carotid arterial blood flow in small preterm infants with patent ductus arteriosus.

Range-gated pulsed Doppler (RGPD) ultrasonography was utilized to study the effect of a patent ductus arteriosus (PDA) on carotid arterial blood flow in small preterm infants. Carotid arterial flow velocity studies were performed on 23 preterm infants, sampling right and left carotid arteries. Studies on seven infants after PDA ligation and on seven who developed no evidence of PDA were used as controls. A strong relationship was demonstrated between diastolic reversal in the carotid arteries and PDA. The results of this study indicate that the RGPD flow velocity curve from the carotid artery is more sensitive than M-mode echocardiography or clinical examination in detecting PDA, and that PDA in small preterm infants is associated with a distinct abnormality in the carotid arterial flow pattern.