Early lumbar puncture and risk of intraventricular hemorrhage in very low birth weight infants

Recent Review of Germinal Matrix Hemorrhage-Intraventricular Hemorrhage in Preterm Infants

Germinal matrix hemorrhage-intraventricular hemorrhage (GMH-IVH) is a particular type of intracranial hemorrhage that affects the preterm population. GMH-IVH originates from bleeding within the highly vascular area near the center of the brain known as the germinal matrix. The pathogenesis of GMH-IVH is unclear; it is likely related to hemodynamic changes and fluctuations in cerebral blood flow within a fragile developing brain. Cranial ultrasound is the primary diagnostic test and reveals the degree of GMH-IVH based on a grading system. Management includes prevention of preterm delivery with meticulous antenatal and postnatal preventative strategies. This article discusses current evidence specific to the pathogenesis, risk factors, diagnosis, grading scales, and management approaches with GMH-IVH in preterm infants.

Impact of a “Brain Protection Bundle” in Reducing Severe Intraventricular Hemorrhage in Preterm Infants <30 Weeks GA: A Retrospective Single Centre Study

Background: despite advances in perinatal care, periventricular/intraventricular hemorrhage (IVH) continues to remain high in neonatal intensive care units (NICUs) worldwide. Studies have demonstrated the benefits of implementing interventions during the antenatal period, stabilization after birth (golden hour management) and postnatally in the first 72 h to reduce the incidence of IVH. Objective: to compare the incidence of severe intraventricular hemorrhage (IVH ≥ Grade III) before and after implementation of a “brain protection bundle” in preterm infants <30 weeks GA. Study design: a pre- and post-implementation retrospective cohort study to compare the incidence of severe IVH following execution of a “brain protection bundle for the first 72 h from 2015 to 2018. Demographics, management practices at birth and in the NICU, cranial ultrasound results and short-term morbidities were compared. Results: a total of 189 and 215 infants were included in the pre- and post-implementation phase, respectively. No difference in the incidence of severe IVH (6.9% vs. 9.8%, p = 0.37) was observed on the first cranial scan performed after 72 h of age. Conclusion: the implementation of a “brain protection bundle” was not effective in reducing the incidence of severe IVH within the first 72 h of life in our centre.

Impact of bundle implementation on the incidence of peri/intraventricular hemorrhage among preterm infants: a pre-post interventional study

BACKGROUND

Peri/intraventricular hemorrhage (PIVH) is a frequent cause of death and morbidity among preterm infants. Few studies have addressed the use of bundles for preventing PIVH.

OBJECTIVE

To evaluate the efficacy of a bundle of interventions designed to decrease the incidence of intraventricular hemorrhage at hospital discharge among preterm infants.

DESIGN AND SETTING

Pre-post interventional study with retrospective and prospective data collection performed before and after bundle implementation in the neonatal intensive care unit of a university hospital.

METHODS

Infants with gestational age < 32 weeks without malformations, who survived > 6 days were included. The bundle consisted of the following actions during the first 72 hours of life: maintenance of head in neutral position with the body in supine position, minimal handling, including delay of lumbar puncture until after 72 hours and absence of respiratory therapy maneuvers. Cranial ultrasound was performed on days 3, 7 and 28, or later if needed. The effect of the bundle was analyzed through logistic regression and results were adjusted for confounding variables.

RESULTS

167 infants met the inclusion criteria; 146 (87%) were analyzed. Bundle implementation was associated with decreased chances of PIVH at hospital discharge (odds ratio 0.29; 95% confidence interval 0.13-0.65). Cerebrospinal fluid collection within the first 72 hours increased the odds of PIVH of any grade during the hospital stay fourfold, after adjustment for all variables included in the model.

CONCLUSION

Implementation of a bundle of interventions to avoid intraventricular hemorrhage was effective for decreasing the incidence of all grades of PIVH in preterm infants.

What clinical practice strategies have been shown to decrease incidence rates of intraventricular haemorrhage in preterm infants?

AIM

To answer the clinical question 'In infants about to be delivered and admitted to neonatal units, what clinical practice strategies, compared to standard care, have been shown to decrease incidence rates of intraventricular haemorrhage (IVH)?'

METHODS

MEDLINE via Ovid (1943 to 5 January 2018), Embase via Ovid (1974 to 5 January 2018) and the Cochrane Library (5 January 2018) were searched for relevant articles.

RESULTS

A total of 478 articles, after the removal of duplicates, were found and screened by title and abstract. Forty full-text articles were subsequently reviewed, and 19 were included as relevant to the structured clinical question. An additional article was included based on expert advice.

CONCLUSION

There are various levels of research evidence for clinical practice strategies to decrease the incidence rates of IVH. Higher-quality evidence suggests that antenatal corticosteroids decrease the rates of IVH, and multiple evidence-based intervention bundles implemented in the neonatal unit are associated with decreased rates of IVH.

Physiologically-Based Pharmacokinetic Modeling of Fluconazole Using Plasma and Cerebrospinal Fluid Samples From Preterm and Term Infants

Fluconazole is used to treat hematogenous Candida meningoencephalitis in preterm and term infants. To characterize plasma and central nervous system exposure, an adult fluconazole physiologically‐based pharmacokinetic (PBPK) model was scaled to infants, accounting for age dependencies in glomerular filtration and metabolism. The model was optimized using 760 plasma samples from 166 infants (median postmenstrual age (range) 28 weeks (24–50)) and 27 cerebrospinal fluid (CSF) samples from 22 infants (postmenstrual age 28 weeks (24–33)). Simulations evaluated achievement of the surrogate efficacy target of area under the unbound concentration‐time curve ≥ 400 mg • hour/L over the dosing interval in plasma and CSF using dosing guidelines. Average fold error of predicted concentrations was 0.73 and 1.14 for plasma and CSF, respectively. Target attainment in plasma and CSF was reached faster after incorporating a loading dose of 25 mg/kg. PBPK modeling can be useful in exploring CNS kinetics of drugs in children.