[Pneumothorax during mechanical ventilation--therapeutic options in term and preterm neonates]. / Pneumothorax unter Beatmung--ein Vergleich möglicher Therapieoptionen bei Reif- und Frühgeborenen.

A pneumothorax (PTX) is a potentially life threatening event during mechanical ventilation. Aim of this study was to analyse 3 different ways of management: expectant treatment, once-only pleural puncture and thoracic drainage.Retrospective data analysis in term and preterm neonates admitted to the NICU of the Medical University of Graz (between 2000-2010) and Innsbruck (2002-2010) who suffered from a PTX during continuous positive airway pressure (CPAP) or conventional mechanical ventilation (CMV).104 neonates, 33 term and 71 preterm neonates with PTX were included. 33 term neonates: 52% were treated expectantly, 36% with thoracic drainage and 12% with once-only pleural puncture (100% thoracic drainage after pleural puncture). 71 preterm neonates: 25% were treated expectantly, 52% with thoracic drainage and 23% with pleural puncture (63% thoracic drainage after pleural puncture). In CPAP-subgroup (n=64), term neonates were treated in 60% expectantly and in 40% with thoracic drain-age, preterm neonates in 33% expectantly, in 47% with thoracic drainage and in 20% with pleural puncture (50% thoracic drainage after pleural puncture). In CMV-subgroup (n=40), term neonates were treated in 44% expectantly, in 33% with thoracic drainage and in 22% with pleural puncture (100% thoracic drainage after pleural puncture), preterm neonates in 9% expectantly, in 64% with thoracic drainage and in 27% with pleural puncture (83% thoracic drain-age after pleural puncture).Present data show that expectant treatment is feasible. If invasive intervention is needed, once-only pleural puncture was not successful, as often thoracic drainage was necessary in addition.

Smoking in pregnancy: a risk factor for adverse neurodevelopmental outcome in preterm infants?

AIM: To assess whether smoking in pregnancy influences neurodevelopmental outcome at 2-years of age in preterm infants with a gestational age <32 weeks. METHODS: Between January 2003 and December 2005 we prospectively enrolled 181 infants born alive between 23 and 32 weeks of gestation; 142 infants (78.5%) completed the follow-up visit. The association between candidate risk factors and delayed motor or mental development (Bayley Scales of Infant Development II; psychomotor or mental developmental index <85) was analysed by means of logistic regression analysis. RESULTS: Low maternal age, smoking in pregnancy, low gestational age, low birth weight, small for gestational age, chronic lung disease, intracerebral haemorrhage, periventricular leucomalacia, and retinopathy of prematurity (stages 3 and 4) all were associated with an increased risk for delayed development (p < 0.05, each). Smoking in pregnancy, small for gestational age and chronic lung disease maintained significance in a multivariable analysis. CONCLUSION: Smoking in pregnancy emerged as a risk predictor for adverse neurodevelopmental outcome in our study. Strategies to reduce smoking in pregnancy should be further endorsed.

Neurodevelopmental outcome following congenital cytomegalovirus infection in preterm infants with twin-to-twin transfusion syndrome: a case report.

Twin-to-twin transfusion syndrome and conital cytomegalovirus infection bear the risk of brain damage. In the 27th week of gestation of a twin pregnancy a Caesarean section was performed because of pathological cardiotocogram and Doppler ultrasonography of the second twin (recipient). Both infants presented with severe, persistent thrombocytopenia, elevated liver enzymes and direct hyperbilirubinemia. Primary congenital CMV infection was diagnosed. Both twins showed severe neuropathological symptoms, pathological aEEG with seizure activity and severe neurodevelopmental delay at corrected age of 12 months. The severity of brain pathology, the complex etiology, its consequence for neurotion with extreme prematurity make this case of special interest.

Adverse neurodevelopmental outcome in preterm infants: risk factor profiles for different gestational ages.

AIM: Assessment of risk predictors for adverse neurodevelopmental outcome at 1 year of age in preterm infants with a gestational age <30 weeks (Group I) and 30-32 weeks (Group II). METHODS: Between January 2003 and December 2006, we prospectively enrolled 310 live-born infants between 23 and 32 weeks of gestation. The association between candidate risk factors and delayed motor or mental development (Bayley Scales of infant development II; psychomotor or mental developmental index <85) was analysed by means of logistic regression analysis. RESULTS: Two hundred and fifty infants were eligible for follow-up, and 205 (82.0%) completed the follow-up visit. Intracerebral haemorrhage, small for gestational age and late-onset sepsis were associated with an increased risk for delayed development in Group I (p < 0.05, each). Premature rupture of membranes was a risk condition relevant to Group II. Antenatal steroids were associated with a decreased risk of neurodevelopmental delay in both groups. CONCLUSION: This study identified distinct risk factors for adverse outcome in preterm infants of lower (<30 weeks) and higher (30-32 weeks) gestational age. In the lower gestational age group, neonatal risk predictors are most important. Antenatal steroids appear to decrease the risk for adverse outcome in both age groups.

Conjoined epigastric heteropagus twins: excision of a parasitic twin from the anterior abdominal wall of her sibling.

Epigastric heteropagus twins (EHT) are an exceedingly rare form of asymmetric conjoined twins in whom the dependent twin (parasite) is attached to the right or left upper abdomen of the dominant part (autosite). Such a case observed at our institution with 34 month follow-up is presented here and the surgical technique described. A magnetic resonance imaging (MRI)-supported surgical separation of the parasite with successful closure of the abdominal wall defect of the autosite was performed. Follow-up studies showed an autosite which was alive and in optimal health. A comprehensive review including data from English and non-English literature is presented.

Intratracheal pulmonary ventilation and continuous positive airway pressure in a sheep model of severe acute respiratory failure.

STUDY OBJECTIVES: Previously we have shown that optimal pulmonary gas exchange can be sustained at normal airway pressures in a model of severe acute respiratory failure (ARF), using intratracheal pulmonary ventilation (ITPV), with weaning to room air. In an identical model of ARF, we have now explored whether ITPV, combined with continuous positive airway pressure (CPAP), can sustain adequate ventilation, with weaning to room air. DESIGN: Randomized study in sheep. SETTING: Animal research laboratory at the National Institutes of Health. INTERVENTIONS: ARF was induced in 12 sheep, using mechanical ventilation at peak inspiratory pressure of 50 cm H2O, but excluding 5 to 8% of lungs. Sheep were then randomized into two groups: the CPAP-ITPV group (n=6), in which ITPV was combined with a novel CPAP system; and a control group (n=6) in which the same CPAP circuit was used, but without ITPV. MEASUREMENTS AND RESULTS: All sheep in the CPAP-ITPV group were weaned to room air in 38.7+/-14 h. PaO2/fraction of inspired oxygen (FIO2) progressively increased from 108.8+/-43 to 355.7+/-93.1; PaCO2 remained within normal range; respiratory rate (RR) ranged from 18 to 120 breaths/min, and tidal volume (VT) was as low as 1.1 mL/kg. All sheep in the control group (CPAP alone) developed severe respiratory acidosis and hypoxemia after 4.8+/-4 h. PaO2/FIO2 decreased from 126.6+/-58.2 to 107.2+/-52.5 mm Hg, with a final PaCO2 of 166.8+/-73.3 mm Hg. CONCLUSIONS: All sheep treated with CPAP-ITPV maintained good gas exchange without hypercapnia at high RR and at low VT, with weaning to room air. All control animals treated with CPAP alone developed severe hypercapnia, respiratory acidosis, and severe hypoxemia, and were killed.

Changes in left ventricular function in shocked newborns.

OBJECTIVE: To assess whether the change in cardiac output after volume replacement is due to elevation of stroke volume or heart rate and to determine the effect of mechanical ventilation on the hemodynamic situation. DESIGN: Prospective study. SETTING: A ten-bed neonatal intensive care unit (level III) at a university hospital. PATIENTS: 15 consecutive newborns with blood pressure below the 10th percentile related to age and weight. INTERVENTIONS: Volume replacement with Ringer's lactate 20 ml/kg body weight. MEASUREMENTS AND RESULTS: Before and after volume replacement, arterial pressure recordings, blood gas analysis, and an echocardiographic study were carried out. Left ventricular and aortic diameters were measured by the two-dimensional M-mode technique and velocity time integral of aortic flow by the pulsed color Doppler technique. From these data, stroke volume and cardiac output were calculated. Cardiac output (703 +/- 204 vs 826 +/- 166 ml/ min, p < 0.005) and cardiac index (267 +/- 69 vs 302 +/- 55 ml/min per kg body weight, p < 0.01) changed significantly due to an appreciable elevation in stroke volume (5.2 +/- 1.7 vs 5.8 +/- 1.7 ml, p < 0.05), whereas heart rate was unaltered (140 +/- 12 vs 142 +/- 20 beats/min; NS). The change in blood pressure (32 +/- 5 vs 38 +/- 8 mm Hg, p < 0.01) was also significant. Cardiac index before and after volume replacement showed a significant inverse correlation with the severity of respiratory disease expressed as alveolar-arterial oxygen difference (A-aDO2) (A-aDO2 vs cardiac index before volume replacement: r = -0.77, p < 0.001; after volume replacement: r = -0.73, p < 0.005) or oxygenation index (oxygenation index vs cardiac index before volume replacement: r = -0.73, p < 0.005; after volume replacement: r = -0.73, p < 0.005). Changes in left ventricular diastolic diameter, left ventricular systolic diameter, and fractional shortening were not significant. CONCLUSIONS: These results indicate that the major regulator of left ventricular output in newborns with hypovolemic or cardiogenic shock is stroke volume and not heart rate and that cardiac output depends on the severity of the respiratory disease.

Comparison of different modes of high-frequency ventilation in surfactant-deficient rabbits.

Various modes of high-frequency ventilation (HFV) have been developed to avoid the disadvantages of conventional mechanical ventilation. In the present study, we examined the hypothesis that high-frequency oscillation (HFO) is superior to high-frequency positive pressure ventilation (HPPV) and combined high-frequency ventilation (CHFV) in surfactant-deficient rabbits. The aim of the ventilator strategy was to adjust the mean airway pressure to 2 cm above critical opening pressure of the inflation limb of the respiratory system pressure volume (P/V) curve, achieve a normal tidal volume (VT) (5 ml/kg body weight) and apply repeated sustained inflations. We studied the effect of these HFV modes on oxygenation, lung mechanics and lung histology in 15 New Zealand White rabbits during a 6-hour experiment. Statistically, the HFO group demonstrated significantly better oxygenation (P < 0.05), lung mechanics (lung stability index: P < 0.05), and better lung tissue histology compared to the HPPV and CHFV groups. In contrast to the HPPV and CHFV groups, the P/V curves of the HFO group showed significant recovery over the 6-hour period after lavage. The lungs of the HFO-treated group had a more uniform distribution of alveoli and less overdistention than the HPPV group (P < 0.002), and less atelectasis than the CHFV group (P < 0.05). The HFO group had less lung injury than the CHFV groups (P < 0.01) and its lungs contained significantly less water than both other groups (P < 0.05). We conclude that the relationship between mean and end-expiratory pressures impacts strongly on both oxygenation and the progression of injury during HFV at the same mean airway pressures. The HFO group showed less acute lung injury than the other ventilatory groups.

Intraosseous lines in preterm and full term neonates.

AIM: To evaluate the use of intraosseous lines for rapid vascular access in primary resuscitation of preterm and full term neonates. METHODS: Thirty intraosseous lines were placed in 27 newborns, in whom conventional venous access had failed. RESULTS: All the neonates survived the resuscitation procedure, with no long term side effects. CONCLUSION: Intraosseous infusion is quick, safe, and effective in compromised neonates.

[Thrombolysis with recombinant tissue-type plasminogen activator (rt-PA) in 13 children: a case series]. / Thrombolyse mit rekombinantem Gewebe-Plasminogenaktivator (rt-PA) bei 13 Kindern: Eine Fallserie.

Since thromboembolic events (TE) are rare among children there is only limited information on the optimal choice of antithrombotic agents, dose and duration of antithrombotic therapy. Recombinant tissue plasminogen activator (rt-PA) is increasingly used for thrombolytic therapy of organ- and limb threatening thrombosis in children. We investigated retrospectively the efficacy and safety of rt-PA in 13 children treated consecutively between 1996-1999, following the same protocol. The median age was 3.9 years (3 days to 16 years). All children suffered from underlying diseases. In addition, 7 children had cardiac catheters and central venous catheters and two children suffered from Factor V Leiden mutation. Seven children presented with a TE in the arterial system, 6 with one in the venous system. All children were treated with continuous infusion of rt-PA (median dose 0.05; 0.0125-0.2 mg/kg/h) together with low-dose standard heparin (median dose 8; 5-15 IU/kg/h). Thrombolysis was performed for a median time period of 102 hours (6 hours to 16 days). Treatment effects on the thrombus were regularly confirmed by ultrasound. Plasma levels of fibrinogen and haemoglobin decreased moderately during treatment. No cumulative effect or increased dose requirement of rt-PA was detected during extended treatment. Patency of obstructed vessels was achieved in all children. One child developed severe gastrointestinal bleeding. Six children (46%) developed minor bleeding at the site of catheter puncture. One child developed rethrombosis at the site of the previous thrombus 2 weeks after completion of rt-PA treatment. Under rigorous laboratory and ultrasound control, our protocol using low dose rt-PA over a prolonged period of time was effective and safe.

An unusual case of intrauterine symptomatic neonatal liver failure.

UNLABELLED: We present an unusual case of neonatal liver failure. Isolated ascites was diagnosed in a female fetus at week 34 gestational age upon routine ultrasound. In the 35th week of gestation a cesarean section was carried out after puncture of fetal ascites. After birth the patient showed symptoms and complications of acute liver failure with portal hypertension. High serum ferritin concentrations, MRI findings compatible with tissue iron overload and no evidence for infectious disease or inborn errors of metabolism suggested possible neonatal hemochromatosis (NH). HFE gene mutation analysis studies of the child and parents were negative. An anti-oxidative and iron chelating therapy was introduced, followed by clinical stabilisation of the newborn and normalisation of liver function. The liver biopsy at 4 month of age showed mild fibrosis with a few iron-loaded hepatocytes and macrophages. At 2 years of age the child was virtually healthy. CONCLUSION: The clinical course of our patient indicates that the pathological changes in the liver being associated with presumptive NH may be reversible when NH is diagnosed early and antioxidative and chelating therapy is immediately initiated.

Dependence on a respiratory ventilator due to an atrial septal defect.

An atrial septal defect is commonly thought of as a benign cardiac lesion especially in infancy. The haemodynamic consequences for the lungs, nonetheless, can be comparable to that produced by patency of the arterial duct. In a preterm boy, this lesion led to the development of broncho-pulmonary dysplasia, and dependence on a respiratory ventilator. He could be extubated shortly after surgical closure of the septal defect.

A standardized method of oleic acid infusion in experimental acute respiratory failure.

UNLABELLED: Commonly, acute respiratory failure (ARF) in laboratory animals is induced through the intravenous infusion of oleic acid (OA). The methods by which OA is infused, and the methods by which droplets are generated, differ greatly among investigators. The resulting ARF, and the distribution of the underlying pulmonary pathology, are not highly reproducible. A method was developed that generated a reproducible, known spectrum of OA microdroplets. This method was applied to infuse a known volume of OA into the vena cava superior (VCS) in sheep, to induce ARF. In vitro studies were conducted in an observation chamber filled with saline or plasma. The distal end was cut off a 7F Swan Ganz catheter. The catheter was immersed in an observation chamber. Through one of the channels OA was infused at a low flow rate while saline was infused at variable high flow rates through a second channel. The size and the distribution spectrum of the so generated OA droplets were determined from flash photographic studies. The distribution and the size of the microdroplets depended on the media in the observation chamber, and on the saline infusion rate. In vivo studies were conducted in six anesthetized and ventilated sheep. We chose in our in vivo studies a saline flow rate of 126 mL/min and at an OA flow rate of 3 mL/min, that generated OA microdroplets 125 +/- 32 microm SD in size. OA microdroplets were generated in situ in the VCS and where then embolized into small pulmonary vessels. A total dose of 0.06 mL/kg of OA was administered in three separate doses of 0.02 mL/kg, each 10 min apart. The evolving ARF was manifested by a progressive deterioration in arterial blood gases, and a uniform opacification of all lung fields on chest X-ray films. At autopsy the lungs were diffusely consolidated. CONCLUSION: A method was developed to standardize the infusion of OA in laboratory animals that resulted in diffuse involvement of the all lungs, with a predictable and reproducible severe acute respiratory failure.

Tracheal mucus velocity remains normal in healthy sheep intubated with a new endotracheal tube with a novel laryngeal seal.

BACKGROUND: Tracheal mucus velocity (TMV), an index of mucociliary clearance, is reduced markedly in patients intubated with standard endotracheal tubes (ETTs) with high-compliance low-pressure (hi-lo) cuffs. The authors developed a new ultra-thin walled ETT in which the inflatable cuff is replaced with a no-pressure seal, positioned at the level of the larynx. The seal consists of 12 to 20 toroidal layers of thin polyurethane film ("gills") at the level of the vocal cords and prevents both air leak and fluid aspiration. The authors hypothesized that ETTs with the new laryngeal seal may impair TMV less than ETTs with inflated hi-lo cuffs do. METHODS: The TMV was measured in seven healthy female sheep by radiographically tracking the motion of small discs of tantalum inserted into the trachea through a bronchoscope. The TMV was measured in spontaneously breathing sheep before intubation (baseline) and after intubation with either a hi-lo ETT (control group) or after intubation with a new ETT with gills (study group). Four to six weeks later, the studies were repeated, but the sheep that were previously in the control group served as the study group, and those in the study group served as controls. RESULTS: Baseline TMV did not differ in the two groups. In the control group, TMV decreased significantly (by 67%) from baseline. In the study group, TMV did not differ significantly from baseline and remained steady during 3 h of intubation. CONCLUSIONS: The TMV does not change in sheep intubated with new ETTs with gills. The new ETT's may help promote a normal mucociliary clearance in patients who require ventilation.

Spontaneous pneumocephalus in a newborn infant with myelomeningocele and hydromyelia.

The authors report a preterm boy, born at 35 weeks gestation with hydrocephalus and an open sacral myelomeningocele. Cranial ultrasound showed ventricular dilatation with posture-dependent intraventricular bright echoes, representing air. Ultrasound of the cervical spine and the craniocervical junction revealed marked hydromyelia of the whole spinal cord, as well as a Chiari II malformation. Air penetrating the enlarged central canal through the neural tube defect and subsequently ascending to the cranial cavity was demonstrated by fluoroscopy. After a review of the literature, the authors conclude that the association of spontaneous pneumocephalus with myelomeningocele could indicate severe hydromyelia. These malformations are readily demonstrated by ultrasound in newborn infants.