RESUMEN
OBJECTIVES: To examine the variation in intraventricular hemorrhage (IVH) incidence among neonatal intensive care units and identify potentially modifiable risk factors. STUDY DESIGN: Multiple logistic regression analysis was used to examine variations in > or =grade 3 IVH, adjusting for baseline population risk factors, admission illness severity, and therapeutic risk factors. Subjects were born at <33 weeks' gestational age, admitted within 4 days of life to 1 of 17 participating Canadian NICU network sites in 1996-97, and had neuroimaging in the first 2 weeks of life. RESULTS: Of 5126 subjects <33 weeks' gestational age, 3806 had neuroimaging reports. Five of 17 sites had significantly (P <.05) different crude incidence rates of grade 3-4 IVH (odds ratios [OR] 0.2, 3.2, 2.6, 2.1, 1.9) than the hospital with median incidence. With adjustment for baseline population risk factors, perinatal risks, and admission illness severity, IVH incidence rates remained significantly (P <.05) higher at 3 sites (OR 2.9, 2.3 and 2.1). Inclusion of therapy-related variables (treatment of acidosis and vasopressor use on the day of admission) in the model eliminated all site differences. CONCLUSIONS: IVH incidence rates vary significantly. Patient characteristics explain some of the variance. Early treatment of hypotension and acidosis and mode of delivery are potentially modifiable factors and warrant further study in IVH prevention.
Asunto(s)
Hemorragia Cerebral/epidemiología , Enfermedades del Prematuro/epidemiología , Unidades de Cuidado Intensivo Neonatal , Canadá/epidemiología , Femenino , Edad Gestacional , Humanos , Recién Nacido , Recien Nacido Prematuro , Modelos Logísticos , Masculino , Factores de Riesgo , Gestión de RiesgosRESUMEN
Sensorineural hearing loss (SNHL) is a significant neurologic morbidity in survivors of neonatal congenital diaphragmatic hernia (CDH), with a reported incidence of up to 60%. In a historical cohort study of 37 neonates with CDH, we investigated the use of pancuronium bromide (PB) and common ototoxic drugs during the neonatal period and their relationship to SNHL in childhood survivors. Survivors with SNHL (n = 23) had significantly higher cumulative dose of PB administered during the neonatal illness than survivors without SNHL (n = 14). The cumulative dose and duration of PB use significantly correlated (r = 0.66-0.81) and independently predicted (adjusted r (2) = 0.42-0.64) the greatest intensity (in decibels) and the widest band (lowest frequency in hertz) loss of SNHL. No differences were identified between survivors with and without SNHL regarding demographic and neonatal characteristics (including oxygenation and ventilation variables and the cumulative dose and duration of therapy with aminoglycosides, vancomycin, and furosemide), although survivors with SNHL had received a modestly higher cumulative dose of ethacrynic acid than survivors without SNHL. Although we show that prolonged administration of PB during the neonatal period is associated with SNHL in childhood survivors of CDH, further multicenter studies are required to investigate the possible etiologies of SNHL in this high-risk population.
Asunto(s)
Pérdida Auditiva Sensorineural/inducido químicamente , Hernia Diafragmática/tratamiento farmacológico , Hernias Diafragmáticas Congénitas , Fármacos Neuromusculares no Despolarizantes/efectos adversos , Pancuronio/efectos adversos , Alberta/epidemiología , Análisis de Varianza , Relación Dosis-Respuesta a Droga , Oxigenación por Membrana Extracorpórea/efectos adversos , Estudios de Seguimiento , Pérdida Auditiva Sensorineural/epidemiología , Humanos , Recién Nacido , Factores de RiesgoRESUMEN
Although inhaled nitric oxide (INO) improves oxygenation in critically ill neonates, the neurodevelopmental outcome of premature neonates with severe hypoxemic respiratory failure treated with INO has not been reported. Mortality and prospective neurodevelopmental assessment in early childhood were studied in a cohort of 24 very low birth weight neonates (
Asunto(s)
Recién Nacido de muy Bajo Peso , Óxido Nítrico/uso terapéutico , Síndrome de Dificultad Respiratoria del Recién Nacido/tratamiento farmacológico , Vasodilatadores/uso terapéutico , Administración por Inhalación , Encéfalo/crecimiento & desarrollo , Desarrollo Infantil , Humanos , Hipoxia/etiología , Recién Nacido , Óxido Nítrico/administración & dosificación , Desempeño Psicomotor , Síndrome de Dificultad Respiratoria del Recién Nacido/complicaciones , Resultado del Tratamiento , Vasodilatadores/administración & dosificaciónRESUMEN
In a multicenter, double-masked, placebo-controlled rescue trial conducted at 12 Canadian hospitals, two 5 ml/kg doses of a synthetic surfactant or air placebo were administered to 224 infants with birth weights of 500 to 749 gm who had established respiratory distress syndrome and an arterial/alveolar oxygen tension ratio of less than 0.22. The first dose was given between 2 and 24 hours of age; the second dose was given 12 hours later to the infants continuing to receive mechanical ventilation. Infants were stratified at study entry by birth weight and gender. Infants receiving synthetic surfactant showed significant improvements in alveolar-arterial oxygen tension gradient, arterial/alveolar oxygen tension ratio, and oxygen and ventilator requirements through day 7. In the group randomized to synthetic surfactant, significant improvements were seen in oxygen requirements at the first time point measured (2 hours; p = 0.02), in the alveolar-arterial oxygen tension gradient by the second time point measured (6 hours; p = 0.03), and in mean airway pressure after 6 hours. Overall mortality at 28 days was not significantly different in the two groups (50% vs 46%, air placebo group vs synthetic surfactant group; p = 0.586). Similarly, neither the incidence of bronchopulmonary dysplasia (37% vs 30%, air placebo group vs synthetic surfactant group; p = 0.089) nor the incidence of survival without BPD through 28 days (17% vs 26%, respectively; p = 0.070) was significantly different in the two groups. No significant differences in the incidence of safety-related outcomes or in adverse effects such as apnea or pulmonary hemorrhage were noted. These findings indicate that rescue therapy with synthetic surfactant results in physiologic improvements in very tiny premature infants, but improvements in overall mortality or other complications of respiratory distress syndrome were not documented in the sample evaluated.
Asunto(s)
Alcoholes Grasos/administración & dosificación , Recién Nacido de Bajo Peso , Fosforilcolina , Polietilenglicoles/administración & dosificación , Surfactantes Pulmonares/administración & dosificación , Síndrome de Dificultad Respiratoria del Recién Nacido/tratamiento farmacológico , Aire , Método Doble Ciego , Combinación de Medicamentos , Alcoholes Grasos/efectos adversos , Femenino , Humanos , Recién Nacido , Masculino , Polietilenglicoles/efectos adversos , Estudios Prospectivos , Surfactantes Pulmonares/efectos adversos , Síndrome de Dificultad Respiratoria del Recién Nacido/complicaciones , Síndrome de Dificultad Respiratoria del Recién Nacido/mortalidad , Tasa de SupervivenciaRESUMEN
We evaluated the use of inhaled nitric oxide in eight premature infants (520 to 1440 gm, 24 to 31 weeks of gestation) who failed to respond to conventional management and who had prolonged rupture of the membranes and oligohydramnios. All infants had a significant improvement in oxygenation and a fall in mean airway pressure with inhaled nitric oxide. Further studies are required to determine the safety and efficacy of this form of therapy.
Asunto(s)
Hipoxia/terapia , Recien Nacido Prematuro , Óxido Nítrico/uso terapéutico , Administración por Inhalación , Estudios de Evaluación como Asunto , Femenino , Rotura Prematura de Membranas Fetales/complicaciones , Humanos , Recién Nacido , Oligohidramnios/complicaciones , Terapia por Inhalación de Oxígeno , Embarazo , Resultado del TratamientoRESUMEN
To determine the role of inhaled nitric oxide (NO) in a population of critically ill hypoxic near-term infants and to determine the dose response to inhaled NO, we examined a consecutive group of 23 infants referred for neonatal extracorporeal membrane oxygenation (ECMO) who had an oxygen index of 20 or greater after treatment with bovine surfactant. Inhaled NO was administered in concentrations from 5 to 80 ppm in random order to 23 infants. Overall, 13 infants had a significant response (an improvement in arterial oxygen pressure > 10 mm Hg or arterial oxygen saturation > 10%) to the first administration of inhaled NO, and one infant had a late response. There was no significant difference in the response to inhaled NO as measured by changes in arterial oxygen pressure or in the alveolar-arterial difference in partial pressure of oxygen, for any of the doses from 5 to 80 ppm. Thirteen infants had echocardiographic evidence of persisted pulmonary hypertension; 11 of these infants responded, compared with 3 responders among the 10 infants without persistent pulmonary hypertension of the newborn (p < 0.01). Overall, 11 infants required ECMO; there were two deaths in this group. Seven infants had congenital diaphragmatic hernia; five of those had a response to NO inhalation and four required ECMO. Our study demonstrates that there is no significant difference in response between low and high doses of inhaled NO and that this treatment may prevent the need for ECMO in some infants referred for this therapy, especially in infants with pulmonary hypertension. Prospective, controlled, randomized, and blinded trials of low doses of inhaled NO are needed to determine the clinical role of this potentially useful therapy.
Asunto(s)
Óxido Nítrico/uso terapéutico , Síndrome de Circulación Fetal Persistente/tratamiento farmacológico , Insuficiencia Respiratoria/tratamiento farmacológico , Administración por Inhalación , Relación Dosis-Respuesta a Droga , Oxigenación por Membrana Extracorpórea , Hernia Diafragmática/complicaciones , Hernia Diafragmática/terapia , Hernias Diafragmáticas Congénitas , Humanos , Recién Nacido , Oxígeno/sangre , Síndrome de Circulación Fetal Persistente/complicaciones , Síndrome de Circulación Fetal Persistente/terapia , Síndrome de Dificultad Respiratoria del Recién Nacido/tratamiento farmacológico , Síndrome de Dificultad Respiratoria del Recién Nacido/terapia , Insuficiencia Respiratoria/etiología , Insuficiencia Respiratoria/terapiaRESUMEN
In an across study analysis of five multicenter, placebo-controlled trials of the synthetic surfactant, Exosurf Neonatal in infants weighing at least 700 gm, the incidence of clinical pulmonary hemorrhage was 1.9% in treated infants and 1.0% in control infants. To investigate whether a similar increase was also present histologically at postmortem examination, a blinded retrospective review of all autopsy reports from infants dying during these five trials was conducted. Pulmonary hemorrhage was present in 55% of 159 infants undergoing autopsy; the incidence was not different in infants treated with surfactant or air placebo. Birth weight was inversely related to the incidence of pulmonary hemorrhage in both groups. Pulmonary pathologic findings significantly associated with pulmonary hemorrhage included pulmonary interstitial emphysema and necrotizing laryngotracheitis in both groups. In the surfactant group, patent ductus arteriosus, intraventricular hemorrhage, and pneumothorax were significantly more frequent among those who developed pulmonary hemorrhage. In contrast to clinical diagnosis, pathologic diagnosis of pulmonary hemorrhage at autopsy was not more common in infants treated with Exosurf Neonatal.
Asunto(s)
Alcoholes Grasos/uso terapéutico , Hemorragia/epidemiología , Enfermedades del Prematuro/epidemiología , Enfermedades Pulmonares/epidemiología , Fosforilcolina , Polietilenglicoles/uso terapéutico , Surfactantes Pulmonares/uso terapéutico , Autopsia , Método Doble Ciego , Combinación de Medicamentos , Alcoholes Grasos/efectos adversos , Hemorragia/etiología , Hemorragia/patología , Humanos , Incidencia , Recién Nacido , Recien Nacido Prematuro , Enfermedades del Prematuro/etiología , Enfermedades del Prematuro/patología , Enfermedades Pulmonares/etiología , Enfermedades Pulmonares/patología , Polietilenglicoles/efectos adversos , Surfactantes Pulmonares/efectos adversos , Síndrome de Dificultad Respiratoria del Recién Nacido/prevención & controlAsunto(s)
Displasia Broncopulmonar/mortalidad , Fosforilcolina , Displasia Broncopulmonar/tratamiento farmacológico , Combinación de Medicamentos , Alcoholes Grasos/uso terapéutico , Hospitales , Humanos , Recién Nacido de Bajo Peso , Recién Nacido , Estudios Multicéntricos como Asunto , Polietilenglicoles/uso terapéutico , Surfactantes Pulmonares/uso terapéutico , Estados UnidosRESUMEN
A blinded, randomized, placebo-controlled trial was conducted to evaluate the effectiveness of theophylline and doxapram therapy in 31 infants with significant apnea of prematurity. Of 10 infants, two had a short-term response to placebo, 8 of 10 infants to theophylline, and 7 of 11 infants to doxapram (placebo vs treatment with theophylline or doxapram: p = 0.01). The two infants who initially responded to placebo remained responsive for the duration of the study. Of the eight infants in whom treatment with placebo failed, five were randomly assigned to receive theophylline, for a total of 15 infants treated with theophylline, and two of the eight were randomly assigned to receive doxapram, for a total of 13 infants treated with doxapram; the remaining infant required tracheal intubation. Of the 15 infants randomly assigned to receive theophylline, seven responded for the duration of the study; of the eight infants who did not respond to treatment with theophylline, five responded to doxapram, one responded to a combination of theophylline and doxapram, and two remained resistant to treatment. Of the 13 infants randomly assigned to receive doxapram four responded for the duration of the study; of the nine who did not respond to doxapram, seven responded to theophylline, one responded to a combination of theophylline and doxapram, and one remained resistant to treatment. This study demonstrates that although therapy with theophylline or doxapram is associated with a significant short-term reduction in the incidence of apnea compared with that in placebo-treated infants, the long-term response to treatment is frequently incomplete and is not sustained more than 1 week.
Asunto(s)
Apnea/tratamiento farmacológico , Doxapram/uso terapéutico , Recien Nacido Prematuro , Teofilina/uso terapéutico , Apnea/prevención & control , Doxapram/administración & dosificación , Doxapram/sangre , Combinación de Medicamentos , Femenino , Humanos , Recién Nacido , Infusiones Intravenosas , Masculino , Placebos , Ensayos Clínicos Controlados Aleatorios como Asunto , Método Simple Ciego , Teofilina/administración & dosificación , Teofilina/sangreAsunto(s)
Enfermedad de los Legionarios/complicaciones , Convulsiones/etiología , Estado Epiléptico/etiología , Adolescente , Anticuerpos Antivirales/análisis , Anticonvulsivantes/uso terapéutico , Humanos , Legionella/inmunología , Enfermedad de los Legionarios/inmunología , Masculino , Convulsiones/tratamiento farmacológicoRESUMEN
Fifteen enterally fed preterm infants not receiving additional trace element supplements and 22 preterm infants receiving total or partial parenteral nutrition supplemented with zinc at 350 micrograms/kg/day and copper at 20 micrograms/kg/day were examined 1, 7, 14, 21, and 28 days after birth. Mean serum Zn concentrations in the parenteral group remained relatively constant and were significantly higher (P less than 0.01) at day 21 than the value for the enteral group. In contrast, a significant decline in mean serum Zn concentrations occurred between days 1 and 21 in the enteral group. The mean serum Cu concentrations in the parenteral group rose during the first week, and were significantly higher at days 14 and 21 than corresponding values in the enteral group. This trend did not result from copper supplementation alone but was also attributed to the presence of ceruloplasmin in blood transfusions. Mean serum Se concentrations did not change significantly, either between or within the two groups, except during the first week, at which time levels rose in the parenteral group. The addition of Zn, Cu, and probably of Se to parenteral infusates, allows the maintenance of appropriate serum values.