The large, international, randomized controlled NeoPInS trial showed that procalcitonin (PCT)-guided decision making was superior to standard care in reducing the duration of antibiotic therapy and ...hospitalization in neonates suspected of early-onset sepsis (EOS), without increased adverse events. This study aimed to perform a cost-minimization study of the NeoPInS trial, comparing health care costs of standard care and PCT-guided decision making based on the NeoPInS algorithm, and to analyze subgroups based on country, risk category and gestational age.
Data from the NeoPInS trial in neonates born after 34 weeks of gestational age with suspected EOS in the first 72 h of life requiring antibiotic therapy were used. We performed a cost-minimization study of health care costs, comparing standard care to PCT-guided decision making.
In total, 1489 neonates were included in the study, of which 754 were treated according to PCT-guided decision making and 735 received standard care. Mean health care costs of PCT-guided decision making were not significantly different from costs of standard care (€3649 vs. €3616). Considering subgroups, we found a significant reduction in health care costs of PCT-guided decision making for risk category 'infection unlikely' and for gestational age ≥ 37 weeks in the Netherlands, Switzerland and the Czech Republic, and for gestational age < 37 weeks in the Czech Republic.
Health care costs of PCT-guided decision making of term and late-preterm neonates with suspected EOS are not significantly different from costs of standard care. Significant cost reduction was found for risk category 'infection unlikely,' and is affected by both the price of PCT-testing and (prolonged) hospitalization due to SAEs.
Cardiovascular abnormalities and small vascular size may preclude transvenous pacing and necessitate epicardial lead implantation. This study evaluates the performance of steroid-eluting, bipolar ...epicardial pacing leads.
We prospectively enrolled 114 children with 239 atrial and ventricular bipolar epicardial leads (Medtronic CapSure 10366 or 4968, Minneapolis, MN), followed up to 12.2 years (median, 3.2). Lead data were obtained at implant and at semi-annual visits. Analysis was done for left or right atrial and ventricular leads.
Median atrial and ventricular pacing thresholds remained below 1.2 V at 0.5 ms. Thresholds did not differ between pacing sites: left atrial, 0.82 V at 0.5 ms; right atrial, 0.74 V at 0.5 ms (p = 0.85); and left ventricular, 0.96 V at 0.5 ms; right ventricular, 0.94 V at 0.5 ms (p = 0.65). Sensing demonstrated no difference for atrial leads, at left atrial, 3.4 mV; and right atrial, 2.9 mV (p = 0.12), but there was superiority of left over right ventricular leads (11.2 vs 7.7 mV, p = 0.002). During follow-up, the 239 atrial and ventricular leads experienced 19 (8%) lead failures. Lead survival at 2 and 5 years was 99% and 94% for atrial leads and 96% and 85% for ventricular leads, respectively.
Bipolar steroid-eluting epicardial leads demonstrate excellent sensing characteristics and persistent low median pacing thresholds below 1.2 V at 0.5 ms in children during up to 12 years follow-up. Considering growing and active patients with most having congenital heart disease, the lead survival of 85% to 94% at 5 years is favorable. Subanalysis shows superior sensing for left ventricular leads. Bipolar steroid-eluting leads provide an alternative approach for permanent pacing and may also be considered for left atrial and ventricular pacing, resynchronization, or defibrillator therapy.
Summary
Background : Undiagnosed tracheobronchial foreign body aspiration (FBA) or delayed extraction can lead to serious morbidity. The aim of this study was to evaluate anesthetic and ...periinterventional morbidity of a straightforward regime using rigid bronchoscopy to rule out or remove a tracheobronchial foreign body in children with suspicion of FBA.
Methods : We retrospectively analyzed rigid bronchoscopy charts of children with suspicion of acute (≤24 h) and subacute (>24 h–2 weeks) tracheobronchial FBA (1990–2003). Patient characteristics, duration of fasting, technique/course of anesthesia induction, and duration/course of rigid bronchoscopy were taken. Anesthetic, periinterventional complications and length of hospital stay were noted. Data are given in median (range interquartile range).
Results : A total of 287 children were included in this study. Median age was 1.7 years (0.2–14.2 1.2–2.5); in 72.1% a tracheobronchial foreign body was found and removed. Fasting time before induction of anesthesia was 5 h (1–14 4.0–7.0). Anesthesia adverse events were seen in 0.7%, whereas periinterventional complication from rigid bronchoscopy was observed in 7.6%. Hospital discharge within 4 h after bronchoscopy was possible in 65.2%. Complications of delayed diagnosis (>24 h) were prolonged duration of rigid bronchoscopy because of severe mucosal changes or difficulties in foreign body extraction.
Conclusions : General anesthesia for rigid bronchoscopy to rule out a tracheobronchial foreign body in children carries low morbidity. Most of the complications originated from the foreign body itself especially in patients with late diagnosis. The risk for serious complications caused by retained foreign bodies outweighs the low morbidity of explorative rigid bronchoscopy in children with suspected FBA or children with prolonged cough or pulmonary infection unresponsive to medical treatment.
Residual shunts may be detected by intraoperative or postoperative echocardiography after surgical closure of a ventricular septal defect (VSD). The hemodynamic relevance and rate of late closure are ...unknown.
Between 1994 and 2005, 198 consecutive patients underwent surgical correction of an isolated VSD (n = 100), tetralogy of Fallot (n = 52) or atrioventricular septal defect (n = 46). Intraoperative transesophageal echocardiography (TEE) was routine, and postoperative transthoracic echocardiography was performed in the intensive care unit, at hospital discharge, and during follow-up. Residual defects were graded as absent, between 1 and 2 mm, or greater than 2 mm.
Shunt-related discrepancy was observed between intraoperative TEE and intensive care unit transthoracic echocardiographic findings; significantly so after Fallot repair (p < 0.0001). After discharge, 83% of all residual defects less than 2 mm closed. Of nine residual defects greater than 2 mm, only three closed after a median follow-up of 3.1 years. In patients with residual shunts, they were hemodynamically insignificant, required no medication, and no endocarditis was noted. At last follow-up, there was no significant difference between the percentage of residual shunts among the three groups (p = 0.135).
Postsurgical residual VSDs less than 2 mm closed spontaneously in the majority within a year. Defects greater than 2 mm are unlikely to close spontaneously. Residual shunts after atrioventricular septal defect repair almost always close, whereas one third will remain open after Fallot or isolated VSD repair. At midterm follow-up, residual shunts remained hemodynamically and clinically irrelevant. Revision of a residual defect greater than 2 mm on cardiopulmonary bypass at initial repair, guided by TEE, may spare late redo surgery and lifelong antibiotic prophylaxis.
The cardiac sympathetic nervous system is one putative key factor involved in the intrauterine programming of adult cardiovascular disease. We therefore analyzed cardiac autonomic system activity in ...small for gestational age (SGA) neonates. Heart rate variability (HRV) from 24-h ECG recordings were analyzed for time-domain and frequency-domain parameters in 27 SGA neonates median 261 (240-283) days of gestation compared with 27 appropriate for gestational age (AGA) neonates median 270 (239-293) days of gestation. In addition, salivary alpha-amylase levels were analyzed during resting conditions and in response to a pain-induced stress event in 18 SGA median 266 (240-292) days of gestation and 34 AGA median 271 (240-294) days of gestation neonates. Overall HRV was not significantly different in SGA neonates compared with AGA neonates (SD of all valid NN intervals: P = 0.14; triangular index: P = 0.29), and the sympathovagal balance low frequency (LF)/high frequency (HF) was similar (P = 0.62). Parameters mostly influenced by sympathetic activity did not reveal significant differences: (SD of the average of valid NN intervals: P = 0.27; average of the hourly means of SDs of all NN intervals: P = 0.66, LF: P = 0.83) as well as vagal tone-influenced parameters were unaltered (average of the hourly square root of the mean of the sum of the squares of differences between adjacent NN intervals: P = 0.59; proportion of pairs of adjacent NN intervals differing by >50 ms: P = 0.93; HF: P = 0.82). Median resting levels for alpha-amylase were not significantly different in SGA neonates (P = 0.13), and a neonatal stress stimulus revealed similar stress response patterns (P = 0.29). HRV and salivary alpha-amylase levels as indicators of cardiac autonomic activity were not altered in SGA neonates compared with AGA neonates. Thus, it appears that the intrauterine activation of the sympathetic system in SGA fetuses does not directly persist into postnatal life, and neonatal sympathovagal balance appears to be preserved.
Implantable cardioverter defibrillators in children have proven to be an effective therapy for life-threatening ventricular arrhythmias. The optimal electrode and device placement for implantable ...cardioverter defibrillator therapy in children is still controversial. We describe our initial experience after epicardial and pleural electrode insertion with abdominal or intrathoracic device placement in 8 children.
Chronic right ventricular (RV) pacing can induce structural and functional cardiac deterioration. Because animal studies showed a benefit of left ventricular (LV) over RV pacing, this study compared ...the effects of chronic RV and LV pacing in children. Retrospectively, echocardiographic data were evaluated from 18 healthy children (control subjects) and from children undergoing chronic epicardial RV pacing (7 RVP) or LV pacing (7 LVP). Assessment included LV end-diastolic wall thickness (LVEDWT) and end-systolic wall thickness (LVESWT) as well as LV end-diastolic diameter (LVEDD) and end-systolic diameter (LVESD). The shortening fraction and eccentricity index (LV diameter/2 × LV wall thickness) were calculated as measures of LV function and eccentricity, respectively. Duration of QRS and septal posterior wall motion delay (SPWMD) were used as measures of electrical and mechanical dyssynchrony, respectively. A
p
value less than 0.05 determined significance. As the findings showed, LVEDD, LVESD, LVEDWT, and LVESWT were not significantly different between the groups. The shortening fraction was significantly lower in the RVP (21.7% ± 6.0%) than in the LVP (32.2% ± 5.2%) or control (29.3% ± 4.3%) children. The systolic LV eccentricity index was significantly larger in the RVP (1.8 ± 0.2) than in the LVP (1.4 ± 0.1) or control (1.4 ± 0.2) children. The SPWMD was significantly larger in the RVP (338 ± 20 ms) than in the LVP (−16 ± 14 ms) or control (−5 ± 35 ms) group, whereas QRS duration was similarly longer in the RVP (157 ± 10 ms) and LVP (158 ± 22 ms) groups compared than in the control group (69 ± 7 ms). The authors conclude that LV function in children is preserved by chronic pacing at the LV lateral wall.
Healthcare-associated infections (HAI) in preterm infants are a challenge to the care of these fragile patients. HAI-incidence rates range from 6 to 27 infections per 1000 patient-days. Most ...nosocomial infections are bloodstream infections and of these, the majority is associated with the use of central venous catheters. Many studies identified parenteral nutrition as an independent risk factor for HAI, catheter-associated bloodstream infection, and clinical sepsis. This fact and various published outbreaks due to contaminated parenteral nutrition preparations highlight the importance of appropriate standards in the preparation and handling of intravenous solutions and parenteral nutrition. Ready-to-use parenteral nutrition formulations may provide additional safety in this context. However, there is concern that such formulations may result in overfeeding and necrotizing enterocolitis. Given the risk for catheter-associated infection, handling with parenteral nutrition should be minimized and the duration shortened. Further research is required about this topic.
Abstract
Background
Neonatal early-onset sepsis (EOS) is one of the main causes of global neonatal mortality and morbidity, and initiation of early antibiotic treatment is key. However, antibiotics ...may be harmful.
Methods
We performed a secondary analysis of results from the Neonatal Procalcitonin Intervention Study, a prospective, multicenter, randomized, controlled intervention study. The primary outcome was the diagnostic accuracy of serial measurements of C-reactive protein (CRP), procalcitonin (PCT), and white blood count (WBC) within different time windows to rule out culture-positive EOS (proven sepsis).
Results
We analyzed 1678 neonates with 10 899 biomarker measurements (4654 CRP, 2047 PCT, and 4198 WBC) obtained within the first 48 hours after the start of antibiotic therapy due to suspected EOS. The areas under the curve (AUC) comparing no sepsis vs proven sepsis for maximum values of CRP, PCT, and WBC within 36 hours were 0.986, 0.921, and 0.360, respectively. The AUCs for CRP and PCT increased with extended time frames up to 36 hours, but there was no further difference between start to 36 hours vs start to 48 hours. Cutoff values at 16 mg/L for CRP and 2.8 ng/L for PCT provided a sensitivity of 100% for discriminating no sepsis vs proven sepsis.
Conclusions
Normal serial CRP and PCT measurements within 36 hours after the start of empiric antibiotic therapy can exclude the presence of neonatal EOS with a high probability. The negative predictive values of CRP and PCT do not increase after 36 hours.
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