Background
There is increased use of early nasal continuous positive airway pressure (NCPAP) to manage respiratory distress in preterm infants but optimal methods and factors associated with ...successful wean are not well defined. A systematic review was performed to define the corrected gestational age (CGA), weight to wean NCPAP and the methods associated with successful weaning of the NCPAP among preterm infants, along with factors affecting it.
Methods
Searches were made of PubMed using the keywords-NCPAP, CPAP, weaning, withdrawal, preterm, and infants from its inception to January 1st, 2014, for studies in all languages but limited to humans. Previous reviews (including cross references) were also searched. We included all randomized and quasi-randomized controlled trials where preterm neonates were randomized to different NCPAP weaning strategies. Details of CGA, weight and methods used for weaning NCPAP were extracted along with factors which affect its withdrawal.
Results
Seven studies met the search criteria. The successful wean was at 32 to 33 weeks CGA and at 1600 g. Three different methods were used for weaning were sudden, gradual pressure wean and gradual graded time off wean. Criteria for readiness, success and failure to wean were defined. Factors affecting successful weaning were intubation, anemia, infection and gastro-esophageal reflux.
Conclusions
The successful wean was at 32 to 33 weeks CGA and 1600 g. Criteria for readiness, success and failure to wean are well defined. Sudden weaning may be associated with a shorter weaning time. Future trials are needed comparing weaning methods using defined criteria for readiness and success of NCPAP wean and stratify the results by gestational age and birth weight.
Background There is paucity of information on the pattern of bacterial colonization of a new neonatal intensive care unit. Objective To study the pattern of bacterial colonization on the ...environmental surfaces in a new neonatal intensive care unit (NICU) and correlate it with infections in the infants. Methods Environmental cultures from the faucets and computer keyboards in the NICU were obtained prospectively every 2 weeks for 1 year. Positive blood, cerebrospinal fluid, and respiratory cultures from the infants in the NICU were also obtained. Results A total of 175 swab cultures was collected, which were sterile for initial 6-week period. Subsequently, 31 cultures grew microbes: 26 (83.8%) from the faucets and 5 (16.2%) from the computers keyboard ( P < .001). Of the 48 positive blood cultures in NICU patients, 6 (12.5%) matched the organism growing from the surveillance sites, but the correlation was not significant ( P = .076). None of the 31 positive respiratory cultures and 1 positive cerebrospinal fluid culture correlated to the organisms grown from the NICU environment. Conclusion The environment was colonized after an initial period of sterile cultures in a new NICU. Once colonized, they can persist, increasing the risk of developing resistance to antibiotics. They did not correlate with the positive cultures from the infants admitted to the NICU during the study period.
Abstract
Introduction
Neonatal thyrotoxicosis is a life-threatening condition with potentially irreversible neurologic sequelae. Most cases are seen in neonates born to mothers with Graves' disease. ...Topical iodine–induced hypothyroidism has been reported in neonates, but iodine–induced neonatal hyperthyroidism has not been described; albeit a familiar entity in adults.
Case Description
Herein we present a unique case of a neonate, born with a giant omphalocele, who was treated with topical povidone-iodine dressings to promote escharification, in preparation for delayed surgical closure. By third day of life (DOL), the baby presented with a suppressed thyroid stimulating hormone of 0.59 µIU/mL, elevated free thyroxine of 5.63 ng/dL, and frank cardiovascular manifestations of thyrotoxicosis. After replacement of the topical iodine dressings with iodine-free silver sulfadiazine, the thyroid status gradually improved with complete resolution of hyperthyroidism by 17th DOL.
Conclusion
This case emphasizes that significant topical iodine exposure can result in both hypothyroidism and hyperthyroidism, and therefore, vigilance in monitoring thyroid function is imperative.
Objective. Identification of the weight and postmenstrual age (PMA) at successful weaning of NCPAP in preterm neonates and the factors influencing the successful wean. Study Design. Retrospective ...review of 454 neonates ≤32 weeks of gestational age (GA) who were placed on NCPAP and successfully weaned to room air was performed. Results. Neonates had a mean birth weight (BW) of 1357±392 grams with a mean GA of 29.3±2.2 weeks. Neonates were weaned off NCPAP at mean weight of 1611±432 grams and mean PMA of 32.9±2.4 weeks. Univariate analysis showed that chorioamnionitis, intubation, surfactant use, PDA, sepsis/NEC, anemia, apnea, GER and IVH were significantly associated with the time to NCPAP wean. On multivariate analysis, among neonates that were intubated, BW was the only significant factor (P<0.001) that was inversely related to time to successful NCPAP wean. Amongst non-intubated neonates, along with BW (P<0.01), chorioamnionitis (P<0.01), anemia (P<0.0001), and GER (P<0.02) played a significant role in weaning from NCPAP. Conclusion. Neonates were weaned off NCPAP at mean weight of 1611±432 grams and mean PMA of 32.9±2.4 weeks. BW significantly affects weaning among intubated and non-intubated neonates, though in neonates who were never intubated chorioamnionitis, anemia and GER also significantly affected the duration on NCPAP.
From Parenteral to Enteral Nutrition Miller, Malki; Vaidya, Ruben; Rastogi, Deepa ...
JPEN. Journal of parenteral and enteral nutrition,
05/2014, Letnik:
38, Številka:
4
Journal Article
Recenzirano
Background: Nutrition practices for preterm infants include phases of parenteral nutrition (PN), full enteral nutrition (EN), and the transitional phase in between. Our aim was to identify the ...nutrition phases during which infants are most likely to exhibit poor growth that would affect risk for growth failure (GF) at discharge and to examine factors associated with GF. Methods: A retrospective chart review was conducted on infants born <32 weeks’ gestation. The neonatal intensive care unit stay was divided into 3 nutrition phases: (1) full PN, (2) transitional PN + EN, and (3) full EN. Weekly growth rates were calculated, and for each growth velocity <10 g/kg/d, the coinciding phase was recorded. GF was defined as a discharge weight below the 10th percentile. The nutrition phases during which growth inadequacy predicted GF at discharge were determined, correcting for other clinical factors associated with GF. Results: In total, 156 eligible infants were identified. Seventy-six infants (49%) were discharged with weights <10%. Incidence of poor growth was highest during the transitional phase (46%) and was predictive of GF when adjusted for gestational age, birth weight, and severity of illness. Although energy intakes during the transitional phase were comparable to baseline parenteral provision, protein intakes progressively decreased (P < .0001), consistently providing <3 g/kg/d as PN was weaned. Serum urea nitrogen also declined and was correlated with protein intake (r = −0.32, P < .001). Conclusion: Growth was compromised during the transitional phase, likely related to decreased protein intake. Optimizing protein provision while PN is weaned is an important strategy to prevent postnatal growth failure.
Background: Growth in preterm infants is compromised during the transition phase of nutrition, when parenteral nutrition (PN) volumes are weaned with advancing enteral nutrition (EN) feeds, likely ...due to suboptimal nutrient intakes during this time. We implemented new PN guidelines designed to maintain optimal nutrient intakes during the transition phase and compared growth outcomes of this cohort with a control group. Materials and Methods: A chart review was conducted on infants born <32 weeks’ gestation, before (control group) and after (study group) a new transition PN protocol was implemented in the neonatal intensive care unit. Weight parameters and nutrient intakes were calculated for the transition phase and compared between the 2 groups. Results: Demographic and clinical characteristics of the 2 groups were comparable except for higher rates of sepsis in control group. Weight-for-age z scores at birth, at 1 week of life, and at the start of the transition phase were similar. At the end of the transition phase, infants in the study group had significantly higher z scores compared with the control group, even when corrected for sepsis, a difference that persisted at 35 weeks’ gestation. During the transition phase, study infants gained 16.1 ± 4.6 g/kg/d compared with 13.2 ± 5.4 g/kg/d in control group (P < .001). Similar results were observed in the subset of expressed breastmilk–only fed infants (15.9 ± 4.6 g/kg/d in the study group compared with 13.2 ± 5.4 g/kg/d in the control group, P < .004). Conclusion: Optimizing nutrition by the use of concentrated PN during the transition phase to maintain appropriate nutrient intakes improves growth rates in preterm infants.
Diffuse cutaneous mastocytosis is a rare variant of mastocytosis in the neonatal period. We describe a case of c-KIT (DV) mutation-positive fatal diffuse cutaneous mastocytosis with systemic ...involvement of the gastrointestinal tract and associated malabsorption and hepatosplenomegaly associated with mast cell mediator release symptoms.
In order to optimize anesthetic management and avoid adverse maternal and fetal outcomes, a clear understanding of the changes in cardiovascular physiology that occur during pregnancy is paramount. ...The effects of normal gestation on the cardiovascular system are particularly significant in a parturient with cardiac valvular pathology. We present a case of a 27-year-old G2P0 at 37 weeks with a past medical history of diabetes, macrosomia, congenital bicuspid aortic valve with severe stenosis (valve area 0.7 cm2) who was scheduled for elective C-section. A multidisciplinary discussion involving cardiologists, cardiac surgeons, obstetric surgeons, neonatal intensivists, perfusion staff, anesthesiologists, and nursing staff was held to formulate a plan for the perioperative management of this parturient. Also, contingency plans were formulated and discussed with the care providers, in the event of acute decompensation of the mother and baby and possible need for emergency aortic valvuloplasty and/or aortic valve replacement.
Incidence and Risk Factors of Early Onset Neonatal AKI Charlton, Jennifer R; Boohaker, Louis; Askenazi, David ...
Clinical journal of the American Society of Nephrology,
02/2019, Letnik:
14, Številka:
2
Journal Article
Recenzirano
Odprti dostop
Neonatal AKI is associated with poor short- and long-term outcomes. The objective of this study was to describe the risk factors and outcomes of neonatal AKI in the first postnatal week.
The ...international retrospective observational cohort study, Assessment of Worldwide AKI Epidemiology in Neonates (AWAKEN), included neonates admitted to a neonatal intensive care unit who received at least 48 hours of intravenous fluids. Early AKI was defined by an increase in serum creatinine >0.3 mg/dl or urine output <1 ml/kg per hour on postnatal days 2-7, the neonatal modification of Kidney Disease: Improving Global Outcomes criteria. We assessed risk factors for AKI and associations of AKI with death and duration of hospitalization.
Twenty-one percent (449 of 2110) experienced early AKI. Early AKI was associated with higher risk of death (adjusted odds ratio, 2.8; 95% confidence interval, 1.7 to 4.7) and longer duration of hospitalization (parameter estimate: 7.3 days 95% confidence interval, 4.7 to 10.0), adjusting for neonatal and maternal factors along with medication exposures. Factors associated with a higher risk of AKI included: outborn delivery; resuscitation with epinephrine; admission diagnosis of hyperbilirubinemia, inborn errors of metabolism, or surgical need; frequent kidney function surveillance; and admission to a children's hospital. Those factors that were associated with a lower risk included multiple gestations, cesarean section, and exposures to antimicrobials, methylxanthines, diuretics, and vasopressors. Risk factors varied by gestational age strata.
AKI in the first postnatal week is common and associated with death and longer duration of hospitalization. The AWAKEN study demonstrates a number of specific risk factors that should serve as "red flags" for clinicians at the initiation of the neonatal intensive care unit course.
Findings from single-centre studies suggest that neonatal acute kidney injury (AKI) is associated with poor outcomes. However, because of the small sample size of those studies, few inferences can ...been made regarding the independent associations between AKI, mortality, and hospital length of stay. We aimed to establish whether neonatal AKI is independently associated with increased mortality and length of hospital stay.
We did this multicentre, multinational, retrospective cohort study of critically ill neonates admitted to 24 participating neonatal intensive care units (NICUs) in four countries (Australia, Canada, India, USA) between Jan 1 and March 31, 2014. We included infants born or admitted to a level 2 or 3 NICU and those who received intravenous fluids for at least 48 h. Exclusion criteria were admission at age 14 days or older, congenital heart disease requiring surgical repair within 7 days of life, lethal chromosomal anomaly, death within 48 h of admission, inability to determine AKI status, or severe congenital kidney abnormalities. We defined AKI as an increase in serum creatinine of 0·3 mg/dL or more (≥26·5 μmol/L) or 50% or more from the previous lowest value, or a urinary output of less than 1 mL/kg per h on postnatal days 2–7. We used logistic regression to calculate crude odds ratios (ORs) and associated 95% CIs for the association between AKI and likelihood of death. We used linear regression to calculate the crude parameter estimates and associated 95% CIs for the association between AKI and length of hospital stay. Multivariable logistic and linear regression models were run to account for potential confounding variables. We additionally created regression models stratified by gestational age groups (22 weeks to <29 weeks, 29 weeks to <36 weeks, and ≥36 weeks). This study is registered with ClinicalTrials.gov, number NCT02443389.
We enrolled 2162 infants, of whom 2022 (94%) had data to ascertain AKI status. 605 (30%) infants had AKI. Incidence of AKI varied by gestational age group, occurring in 131 (48%) of 273 of patients born at 22 weeks to less than 29 weeks, 168 (18%) of 916 patients born at 29 weeks to less than 36 weeks, and 306 (37%) of 833 patients born at 36 weeks or older. Infants with AKI had higher mortality than those without AKI (59 10% of 605 vs 20 1% of 1417 infants; p<0·0001), and longer length of hospital stay (median 23 days IQR 10–61 vs 19 days 9–36; p<0·0001). These findings were confirmed in both crude analysis of mortality (OR 7·5, 95% CI 4·5–12·7; p<0·0001 for AKI vs no AKI) and length of stay (parameter estimate 14·9 days, 95% CI 11·6–18·1; p<0·0001) and analysis adjusted for multiple confounding factors (adjusted OR 4·6, 95% CI 2·5–8·3; p<0·0001 and adjusted parameter estimate 8·8 days, 95% CI 6·1–11·5; p<0·0001, respectively).
Neonatal AKI is a common and independent risk factor for mortality and increased length of hospital stay. These data suggest that AKI might have a similar effect in neonates as in paediatric and adult patients. Strategies designed to prevent AKI and treatments to reduce the burden of AKI, including renal support devices designed for neonates, are greatly needed to improve the outcomes of these vulnerable infants.
US National Institutes of Health, University of Alabama at Birmingham, Cincinnati Children's Hospital, University of New Mexico, Canberra Hospital Private Practice fund, and 100 Women Who Care.
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