RESUMO
OBJECTIVES AND STUDY DESIGN: To evaluate the morbidity and mortality of preterm infants with congenital heart disease (CHD), a chart review was performed for infants with CHD, excluding isolated patent ductus arteriosus, who were <37 weeks' gestation, weighed <2500 g, and were admitted to our neonatal intensive care unit from 1976 to 1999 (N = 201). RESULTS: Patients in the study represented 1.9% of the total neonatal intensive care unit population <37 weeks' gestation and <2500 g. The median gestational age was 33 weeks, and the mean birth weight was 1852 g. CHD diagnosis frequencies were similar to those reported in other large incidence studies, except for a higher percentage of conotruncal defects. The risk of necrotizing enterocolitis was 1.7 times higher and the overall mortality twice as high in our patients compared with patients in the neonatal intensive care unit who did not have CHD. Cardiac surgery (n = 133) was performed on 108 patients. During the recent period of 1985 to 1999, compared with our institution's overall results for CHD surgery, the operative mortality rate was 10.4% versus 5.4% for closed procedures and 25.4% versus 10.5% for open procedures. The actuarial survival rate is 51% at 10 years; survival improved as the study period progressed. CONCLUSIONS: Infants with both CHD and prematurity did significantly worse than either group alone. Such outcome data are required for proper allocation of resources to care for this high-risk pediatric population.
Assuntos
Cardiopatias Congênitas/mortalidade , Cardiopatias Congênitas/cirurgia , Doenças do Prematuro/mortalidade , Doenças do Prematuro/cirurgia , Procedimentos Cirúrgicos Cardíacos , Humanos , Recém-Nascido , Recém-Nascido Prematuro , Terapia Intensiva Neonatal , Morbidade , Estudos Retrospectivos , Taxa de SobrevidaRESUMO
To determine the effect of analgesia and paralysis on lung volume and oxygenation in premature infants supported by mechanical ventilation because of hyaline membrane disease, functional residual capacity (FRC), and arterial/alveolar oxygen tension ratio were measured in nine premature infants with hyaline membrane disease before and after the administration of morphine sulfate and pancuronium bromide. Without a change of positive end-expiratory pressure, ventilator rate and peak inspiratory pressure were increased before the first set of measurements to minimize the contribution of the infants' own respiratory effort to total ventilation. These ventilator settings were then held constant (except fraction of inspired oxygen) before and after the administration of the drugs. The FRC was measured with a multiple-breath N2 washout technique by means of whole-body plethysmography to measure airway flow. The FRC and the ratio of arterial to alveolar oxygen tension decreased in seven of nine patients after treatment with morphine and pancuronium. The decrease in FRC for all patients was significant (2.4 +/- 2.9 ml/kg; p < 0.05), and a significant correlation was demonstrated between the change in the arterial/alveolar oxygen tension ratio and the change in FRC (r = 0.82; p < 0.01). Gestational age, birth weight, postnatal age, severity of lung disease, and time after the administration of morphine and pancuronium were not significantly correlated with the change in FRC. We believe that a decrease in oxygenation caused by alveolar derecruitment occurred even though the ventilator settings had been increased before the first set of measurements. The decrease in FRC in these infants, who are thought to have alveolar instability because of surfactant deficiency, may have resulted from the loss of expiratory braking mechanisms. We conclude that analgesia and paralysis should be used with caution under these circumstances.
Assuntos
Capacidade Residual Funcional/efeitos dos fármacos , Doença da Membrana Hialina/fisiopatologia , Recém-Nascido Prematuro/fisiologia , Morfina/farmacologia , Oxigênio/sangue , Pancurônio/farmacologia , Humanos , Doença da Membrana Hialina/terapia , Recém-Nascido , Recém-Nascido Prematuro/sangue , Respiração ArtificialRESUMO
The effect of indomethacin on systolic and diastolic cardiac function was assessed in 15 premature infants. Seven infants (group 1) received indomethacin to treat a clinically significant patent ductus arteriosus (PDA), and eight infants (group 2) received indomethacin prophylactically at 24 hours of age because of their high risk for PDA. Diastolic cardiac function was assessed using instantaneous rates of change of left ventricular (LV) cavity dimension, derived from M-mode echocardiography. The maximum velocity of lengthening of the LV cavity dimension, an index of early diastolic function, fell from 63 +/- 19 mm/sec before indomethacin to 48 +/- 16 mm/sec 1 hour after indomethacin in group 1 (P less than 0.01), with the ductus still patent and the LV chamber still dilated, and also decreased in group 2, from 52 +/- 7 mm/sec to 38 +/- 6 mm/sec (P less than 0.01). This index, when normalized for loading conditions, was decreased 1 hour after indomethacin at 12 +/- 2 sec-1 and 12 +/- 1 sec-1 for groups 1 and 2, respectively, compared with values before indomethacin of 15 +/- 3 sec-1 and 15 +/- 2 sec-1. There was no effect of indomethacin on the indices of systolic function. We conclude that indomethacin decreases early diastolic function in premature infants.
Assuntos
Diástole/efeitos dos fármacos , Permeabilidade do Canal Arterial/tratamento farmacológico , Indometacina/uso terapêutico , Contração Miocárdica/efeitos dos fármacos , Permeabilidade do Canal Arterial/prevenção & controle , Ecocardiografia , Humanos , Recém-Nascido , Recém-Nascido Prematuro , Sístole/efeitos dos fármacosRESUMO
Urinary excretion of prostacyclin and thromboxane metabolites (2,3-dinor-6-ketoprostaglandin F1 alpha, thromboxane B2, and 2,3-dinor-thromboxane B2) as indices of systemic biosynthesis was prospectively determined in nine premature infants during the first 10 days of life, by gas chromatography-mass spectrometry. The patients ranged in gestational age from 27 to 29 weeks and in birth weight from 720 to 980 gm. Four infants developed symptomatic patent ductus arteriosus (PDA). Excretion of all metabolites exceeded adult values on the basis of body surface area at birth, reached a maximum on the fourth day of life, was related to urine output, and did not distinguish patients with and without symptomatic PDA. We conclude that neither circulating prostacyclin nor thromboxane A2 contribute significantly to the pathophysiology of symptomatic PDA in very low birth weight infants.
Assuntos
Permeabilidade do Canal Arterial/metabolismo , Epoprostenol/biossíntese , Recém-Nascido de Baixo Peso , Doenças do Prematuro/metabolismo , 6-Cetoprostaglandina F1 alfa/análogos & derivados , 6-Cetoprostaglandina F1 alfa/urina , Cromatografia Gasosa-Espectrometria de Massas , Idade Gestacional , Humanos , Recém-Nascido , Estudos Prospectivos , Tromboxano B2/análogos & derivados , Tromboxano B2/urinaRESUMO
The administration of a single intravenous injection of indomethacin was followed by a major constrictive effect on the ductus in 36 of 42 very-low-birth-weight (less than or equal to 1000 gm) infants with symptomatic patent ductus arteriosus (PDA). In 26 of the 36 responders, the effect was sustained; symptomatic PDA recurred in the remaining 10. Infants who experienced a recurrence of symptomatic PDA had lower birth weights and had received indomethacin at an earlier postnatal age than did infants with a sustained effect. These results may be explained by differences in the production and clearance of prostaglandins or in the sensitivity of the ductus to prostaglandin effects between infants with a recurrence and infants with sustained constriction of PDA.
Assuntos
Permeabilidade do Canal Arterial/tratamento farmacológico , Indometacina/efeitos adversos , Recém-Nascido de Baixo Peso , Doenças do Prematuro/tratamento farmacológico , Permeabilidade do Canal Arterial/mortalidade , Ecocardiografia , Feminino , Humanos , Indometacina/uso terapêutico , Recém-Nascido , Doenças do Prematuro/mortalidade , Injeções Intravenosas , Masculino , Pico do Fluxo Expiratório , Prostaglandinas/farmacologia , RecidivaAssuntos
Doença da Membrana Hialina/complicações , Hiponatremia/complicações , Recém-Nascido de Baixo Peso , Doenças do Prematuro/complicações , Enfisema Mediastínico/etiologia , Pneumotórax/etiologia , Água Corporal , Humanos , Doença da Membrana Hialina/diagnóstico por imagem , Doença da Membrana Hialina/fisiopatologia , Recém-Nascido , Doenças do Prematuro/diagnóstico por imagem , Pulmão/fisiopatologia , Enfisema Mediastínico/diagnóstico por imagem , Pneumotórax/diagnóstico por imagem , Radiografia , Respiração ArtificialRESUMO
A modified impedence cardiographic technique was developed using a tetrapolar apnea monitor and minicomputer system. Evaluation of this technique in premature infants with and without symptomatic patent ductus arteriosus indicates that the magnitude of the cardiac-related deflection in the impedance signal is useful in the assessment of ductus shunting. Since the infant under study is involved only by the attachment of two double electrodes to the thorax, continuous assessment of ductur shunting is possible without disturbing routine care.
Assuntos
Cardiografia de Impedância/métodos , Permeabilidade do Canal Arterial/diagnóstico , Pletismografia de Impedância/métodos , Humanos , Recém-Nascido , MinicomputadoresRESUMO
As a result of randomized assignment, 15 preterm infants weighing 1,500 gm or less at birth and who had a symptomatic PDA were treated according to a medical management protocol, and ten according to an early surgical closure protocol. All infants required mechanical ventilation at the time of study entry, which was one week after birth. Birth weight, gestational age, age at onset of congestive failure, age at study entry, and the initial morbidity of members of the two groups were similar. The nine surviving infants managed according to the surgical closure protocol were weaned from mechanical ventilation sooner, had a decreased need for digoxin and furosemide, achieved gastrointestinal function sooner, and had a smaller hospital bill than the 12 survivors of the medical management group. These results indicate that infants with a symptomatic PDA still requiring mechanical ventilation at one week after birth will benefit from surgical closure of the ductus at that time.
Assuntos
Permeabilidade do Canal Arterial/terapia , Digoxina/uso terapêutico , Permeabilidade do Canal Arterial/tratamento farmacológico , Permeabilidade do Canal Arterial/cirurgia , Economia Médica , Furosemida/uso terapêutico , Humanos , Recém-Nascido , Recém-Nascido Pequeno para a Idade Gestacional , Tempo de InternaçãoRESUMO
During 1975, 38 of 44 infants with a birth weight of less than or equal to 1,500 gm who developed pulmonary edema and congestive heart failure due to a patent ductus arteriosus were managed medically until the ductus closed spontaneously days or weeks later. Overall survival was 71%, and there were no deaths among 11 infants weighing more than 1,250 gm. Pulmonary complications were prevalent and were attributed to the extensive use of mechanical ventilation required to control pulmonary edema. The results of this study document the results to be expected when small preterm infants with a symptomatic patent ductus arteriosus are managed without surgical or pharmacologic intervention and provide a basis for the rational design of clinical trials evaluating other management approaches.