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Willgerodt N, Bührer C, Rossi R, Kühn T, Rüdiger M, Avenarius S, Böttger R, Olbertz DM, Proquitte H, Bittrich HJ, Haase R, Fröhlich M, Höhne S, Thome UH. Similar adverse outcome rates with high or low oxygen saturation targets in an area with low background mortality. Front Pediatr 2023; 11:1235877. [PMID: 37941976 PMCID: PMC10628636 DOI: 10.3389/fped.2023.1235877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 09/28/2023] [Indexed: 11/10/2023] Open
Abstract
Background Randomized controlled trials have indicated reduced mortality rates in very preterm infants assigned to high compared to low oxygen saturation (SpO2) target levels, accompanied by higher rates of retinopathy of prematurity and bronchopulmonary dysplasia. However, the benefit-to-harm ratio may depend on the local background mortality risk. We therefore aimed to quantify the risk-benefit ratios of different SpO2 target ranges in 10 tertiary newborn intensive care units (NICUs) in East Germany. Methods In a retrospective multicenter study, 1,399 infants born between 2008 and 2012 at a gestational age between 24 0/7 and 27 6/7 weeks and with a birthweight below 1,250 g were grouped according to the hospital's target SpO2 range [high oxygen saturation group (HOSG) above 90%], low oxygen saturation group (LOSG) below 90%] and the compliance of units with their target SpO2 range. The association between neonatal morbidities, neurodevelopmental outcomes, selected treatment strategies, and target SpO2 ranges was calculated using chi-squared and Mann Whitney U tests. Results Nine of the ten participating NICUs met their SpO2 target ranges. Five units were considered as HOSG, and five units were considered as LOSG. Necrotizing enterocolitis and intraventricular hemorrhage grade ≥ 2 occurred significantly more frequently in the HOSG than in the LOSG (8.4% vs. 5.1%, p = 0.02; and 26.6% vs. 17.7%, p < 0.001). No significant differences in the mortality rate and the rate of retinopathy of prematurity were found. Conclusion In our patient population, a lower SpO2 target range was not associated with increased safety risks in extremely preterm infants. We cannot be sure that our outcome differences are associated with differences in oxygen saturations due to the retrospective study design and the differences in site practices.
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Affiliation(s)
- Nina Willgerodt
- Division of Neonatology, University Hospital for Children, Leipzig, Germany
| | - Christoph Bührer
- Department of Neonatology, Charité—Universitätsmedizin Berlin, Berlin, Germany
| | - Rainer Rossi
- Division of Neonatology, Vivantes Hospital Neukölln, Berlin, Germany
| | - Thomas Kühn
- Division of Neonatology, Vivantes Hospital Neukölln, Berlin, Germany
| | - Mario Rüdiger
- Division of Neonatology and Pediatric Intensive Care Medicine, Klinik für Kinderheilkunde, Medical Faculty, TU Dresden, Dresden, Germany
| | - Stefan Avenarius
- Division of Neonatology, University Hospital for Children, Magdeburg, Germany
| | - Ralf Böttger
- Division of Neonatology, University Hospital for Children, Magdeburg, Germany
| | - Dirk M. Olbertz
- Division of Neonatology, Hospital Südstadt, Rostock, Germany
| | - Hans Proquitte
- Division of Neonatology, University Hospital for Children, Jena, Germany
| | | | - Roland Haase
- Division of Neonatology, University Hospital for Children, Halle (Saale), Germany
- Division of Neonatology, St. Elisabeth and St. Barbara Hospital, Halle (Saale), Germany
| | - Matthias Fröhlich
- Department of Neonatology, Charité—Universitätsmedizin Berlin, Berlin, Germany
| | - Sybille Höhne
- Division of Neonatology, St. Elisabeth and St. Barbara Hospital, Halle (Saale), Germany
| | - Ulrich H. Thome
- Division of Neonatology, University Hospital for Children, Leipzig, Germany
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Franz AR, Engel C, Bassler D, Rüdiger M, Thome UH, Maier RF, Krägeloh-Mann I, Kron M, Essers J, Bührer C, Rellensmann G, Rossi R, Bittrich HJ, Roll C, Höhn T, Ehrhardt H, Avenarius S, Körner HT, Stein A, Buxmann H, Vochem M, Poets CF. Effects of Liberal vs Restrictive Transfusion Thresholds on Survival and Neurocognitive Outcomes in Extremely Low-Birth-Weight Infants: The ETTNO Randomized Clinical Trial. JAMA 2020; 324:560-570. [PMID: 32780138 PMCID: PMC7420159 DOI: 10.1001/jama.2020.10690] [Citation(s) in RCA: 105] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
IMPORTANCE Red blood cell transfusions are commonly administered to infants weighing less than 1000 g at birth. Evidence-based transfusion thresholds have not been established. Previous studies have suggested higher rates of cognitive impairment with restrictive transfusion thresholds. OBJECTIVE To compare the effect of liberal vs restrictive red blood cell transfusion strategies on death or disability. DESIGN, SETTING, AND PARTICIPANTS Randomized clinical trial conducted in 36 level III/IV neonatal intensive care units in Europe among 1013 infants with birth weights of 400 g to 999 g at less than 72 hours after birth; enrollment took place between July 14, 2011, and November 14, 2014, and follow-up was completed by January 15, 2018. INTERVENTIONS Infants were randomly assigned to liberal (n = 492) or restrictive (n = 521) red blood cell transfusion thresholds based on infants' postnatal age and current health state. MAIN OUTCOME AND MEASURES The primary outcome, measured at 24 months of corrected age, was death or disability, defined as any of cognitive deficit, cerebral palsy, or severe visual or hearing impairment. Secondary outcome measures included individual components of the primary outcome, complications of prematurity, and growth. RESULTS Among 1013 patients randomized (median gestational age at birth, 26.3 [interquartile range {IQR}, 24.9-27.6] weeks; 509 [50.2%] females), 928 (91.6%) completed the trial. Among infants in the liberal vs restrictive transfusion thresholds groups, respectively, incidence of any transfusion was 400/492 (81.3%) vs 315/521 (60.5%); median volume transfused was 40 mL (IQR, 16-73 mL) vs 19 mL (IQR, 0-46 mL); and weekly mean hematocrit was 3 percentage points higher with liberal thresholds. Among infants in the liberal vs restrictive thresholds groups, the primary outcome occurred in 200/450 (44.4%) vs 205/478 (42.9%), respectively, for a difference of 1.6% (95% CI, -4.8% to 7.9%; P = .72). Death by 24 months occurred in 38/460 (8.3%) vs 44/491 (9.0%), for a difference of -0.7% (95% CI, -4.3% to 2.9%; P = .70), cognitive deficit was observed in 154/410 (37.6%) vs 148/430 (34.4%), for a difference of 3.2% (95% CI, -3.3% to 9.6%; P = .47), and cerebral palsy occurred in 18/419 (4.3%) vs 25/443 (5.6%), for a difference of -1.3% (95% CI, -4.2% to 1.5%; P = .37), in the liberal vs the restrictive thresholds groups, respectively. In the liberal vs restrictive thresholds groups, necrotizing enterocolitis requiring surgical intervention occurred in 20/492 (4.1%) vs 28/518 (5.4%); bronchopulmonary dysplasia occurred in 130/458 (28.4%) vs 126/485 (26.0%); and treatment for retinopathy of prematurity was required in 41/472 (8.7%) vs 38/492 (7.7%). Growth at follow-up was also not significantly different between groups. CONCLUSIONS AND RELEVANCE Among infants with birth weights of less than 1000 g, a strategy of liberal blood transfusions compared with restrictive transfusions did not reduce the likelihood of death or disability at 24 months of corrected age. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01393496.
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Affiliation(s)
- Axel R. Franz
- Center for Pediatric Clinical Studies, University Children’s Hospital Tübingen, Tübingen, Germany
- Neonatology, University Children’s Hospital Tübingen, Tübingen, Germany
| | - Corinna Engel
- Center for Pediatric Clinical Studies, University Children’s Hospital Tübingen, Tübingen, Germany
| | - Dirk Bassler
- University Hospital Zurich, Department of Neonatology, University of Zurich, Zurich, Switzerland
| | - Mario Rüdiger
- Clinic for Pediatrics, Department for Neonatology and Pediatric Intensive Care Medicine, Medical Faculty, TU Dresden, Dresden, Germany
| | - Ulrich H. Thome
- Children’s Hospital, Division of Neonatology, Department of Women and Children’s Health, University of Leipzig, Leipzig, Germany
| | - Rolf F. Maier
- Children’s Hospital, University Hospital, Philipps University Marburg, Marburg, Germany
| | - Ingeborg Krägeloh-Mann
- Department of Paediatric Neurology and Developmental Medicine, University Children’s Hospital Tübingen, Tübingen, Germany
| | - Martina Kron
- Institute for Epidemiology and Medical Biometry, University of Ulm, Ulm, Germany
| | | | | | | | | | | | - Claudia Roll
- Vestische Kinder-und Jugendklinik Datteln, Universität Witten/Herdecke, Datteln, Germany
| | - Thomas Höhn
- Neonatology and Pediatric Intensive Care, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Harald Ehrhardt
- Department of General Pediatrics and Neonatology, Justus-Liebig-University Giessen, Giessen, Germany
| | | | | | - Anja Stein
- Department of Paediatrics I, University Duisburg-Essen, Essen, Germany
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Zoppelli L, Güttel C, Bittrich HJ, Andrée C, Wirth S, Jenke A. Fecal calprotectin concentrations in premature infants have a lower limit and show postnatal and gestational age dependence. Neonatology 2012; 102:68-74. [PMID: 22613938 DOI: 10.1159/000337841] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2011] [Accepted: 02/26/2012] [Indexed: 11/19/2022]
Abstract
BACKGROUND There is a need for reliable diagnostic biomarkers in necrotizing enterocolitis (NEC). Whereas fecal calprotectin (fCP) has been reported to have insufficient sensitivity and specificity, no previous study has stratified for gestational and postnatal age. OBJECTIVE We aimed to provide developmental specific fCP data in premature infants and to analyze its value in detecting intestinal distress and episodes of NEC. METHODS Between April 2008 and December 2009, 1,899 fecal samples were obtained from 206 very low birth weight infants. RESULTS Mean gestational age (GA) was 28.5 weeks and birth weight 1,057 g. 19 (9.2%) patients developed NEC stage II+, of whom 5 had fulminant NEC with unusually low fCP concentrations in meconium and afterwards. fCP levels showed significant gestational and postnatal age dependent dynamics with particularly low levels in extremely premature infants. In infants with a GA <26 + 1 weeks using GA-adapted reference values, the sensitivity for discriminating moderate NEC from healthy infants and infants with intestinal distress was 0.89 for a cut-off of 180 and 210 µg/g, respectively, at onset of symptoms. Specificity was 0.96 and 0.84. Fulminant NEC was characterized by unusually low fCP concentrations with a cut-off of <24 µg/g having a sensitivity of 0.84 and a specificity of 0.72 for identifying those cases. CONCLUSIONS fCP levels depend on gestational and postnatal age and in contrast to adults, there is a lower limit in premature infants. Taking these observations into account when defining reference values and interpreting fCP data in the clinical context, fCP can be a useful marker in identifying premature infants with gastrointestinal distress and NEC in particular.
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Affiliation(s)
- Luciano Zoppelli
- HELIOS Children's Hospital Wuppertal, Witten/Herdecke University, Wuppertal, Germany
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Meerbach A, Sauerbrei A, Meerbach W, Bittrich HJ, Wutzler P. Fatal outcome of herpes simplex virus type 1-induced necrotic hepatitis in a neonate. Med Microbiol Immunol 2006; 195:101-5. [PMID: 16404606 DOI: 10.1007/s00430-005-0009-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2005] [Indexed: 10/25/2022]
Abstract
In neonates, herpes simplex virus (HSV) infections can lead to severe diseases associated with high mortality. We report a 6-day-old girl who developed clinical signs of fulminant hepatic failure accompanied by infectious-toxic shock and disseminated coagulopathy secondary to HSV type 1 (HSV-1) infection. The diagnosis was performed postmortem by demonstration of HSV-1 DNA in liver tissue as well as by retrospective detection of HSV-specific antibodies.
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MESH Headings
- Antibodies, Viral/blood
- Disseminated Intravascular Coagulation
- Fatal Outcome
- Female
- Hepatitis, Viral, Human/mortality
- Hepatitis, Viral, Human/pathology
- Hepatitis, Viral, Human/virology
- Herpes Simplex/complications
- Herpes Simplex/mortality
- Herpes Simplex/virology
- Herpesvirus 1, Human
- Humans
- Infant, Newborn
- Liver/pathology
- Liver/virology
- Liver Failure, Acute
- Necrosis
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Affiliation(s)
- Astrid Meerbach
- Institute of Virology and Antiviral Therapy, Friedrich-Schiller University of Jena, Hans-Knöll-Street 2, 07745 Jena, Germany.
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