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Fraga MV, Dysart KC, Stoller JZ, Huber M, Fedec A, Mercer-Rosa L, Kirpalani H. Echocardiographic Assessment of Pulmonary Arterial Hypertension Following Inhaled Nitric Oxide in Infants with Severe Bronchopulmonary Dysplasia. Neonatology 2023; 120:633-641. [PMID: 37573771 DOI: 10.1159/000531586] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 06/08/2023] [Indexed: 08/15/2023]
Abstract
OBJECTIVES Inhaled nitric oxide (iNO) is an effective pulmonary vasodilator. However, the efficacy of iNO in former premature infants with established bronchopulmonary dysplasia (BPD) has not been studied. This study aimed to determine the efficacy of iNO in reducing pulmonary artery pressure in infants with severe BPD as measured by echocardiography. STUDY DESIGN Prospective, observational study enrolling infants born at less than 32 weeks gestation and in whom (1) iNO therapy was initiated after admission to our institution, or (2) at the outside institution less than 48 h before transfer and received an echocardiogram prior to iNO initiation, and (3) had severe BPD. Data were collected at three time-points: (1) before iNO; (2) 12-48 h after initiation of iNO; and (3) 48-168 h after initiation of iNO. The primary outcome was the effect of iNO on pulmonary artery pressure measured by echocardiography in patients with severe BPD between 48 and 168 h after initiating iNO therapy. RESULTS Of 37 enrolled, 81% had echocardiographic evidence of pulmonary arterial hypertension (PAH) before iNO and 56% after 48 h of iNO (p = 0.04). FiO2 requirements were significantly different between time-points (1) and (3) (p = 0.05). There were no significant differences between Tricuspid Annular Plane Systolic Excursion (TAPSE) Z-Scores, time to peak velocity: right ventricular ejection time (TPV:RVET), and ventilator changes. CONCLUSIONS Although we found a statistically significant reduction of PAH between time-point (1) and (3), future trials are needed to further guide clinical care.
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Affiliation(s)
- María V Fraga
- Division of Neonatology, Department of Pediatrics, The Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Kevin C Dysart
- Division of Neonatology, Department of Pediatrics, Nemours Children's Health, duPont Hospital for Children, Wilmington, Delaware, USA
| | - Jason Z Stoller
- Division of Neonatology, Department of Pediatrics, The Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Matthew Huber
- Division of Neonatology, Department of Pediatrics, The Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Anysia Fedec
- Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Laura Mercer-Rosa
- Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Haresh Kirpalani
- Emeritus Professor of Pediatrics, Division of Neonatology, Department of Pediatrics, The Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Emeritus Professor of Pediatrics, Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
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Jensen EA, Wiener LE, Rysavy MA, Dysart KC, Gantz MG, Eichenwald EC, Greenberg RG, Harmon HM, Laughon MM, Watterberg KL, Walsh MC, Yoder BA, Lorch SA, DeMauro SB. Assessment of Corticosteroid Therapy and Death or Disability According to Pretreatment Risk of Death or Bronchopulmonary Dysplasia in Extremely Preterm Infants. JAMA Netw Open 2023; 6:e2312277. [PMID: 37155165 PMCID: PMC10167571 DOI: 10.1001/jamanetworkopen.2023.12277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 03/24/2023] [Indexed: 05/10/2023] Open
Abstract
Importance Meta-analyses suggest that corticosteroids may be associated with increased survival without cerebral palsy in infants at high risk of bronchopulmonary dysplasia (BPD) but are associated with adverse neurologic outcomes in low-risk infants. Whether this association exists in contemporary practice is uncertain because most randomized clinical trials administered corticosteroids earlier and at higher doses than currently recommended. Objective To evaluate whether the pretreatment risk of death or grade 2 or 3 BPD at 36 weeks' postmenstrual age modified the association between postnatal corticosteroid therapy and death or disability at 2 years' corrected age in extremely preterm infants. Design, Setting, and Participants This cohort study analyzed data on 482 matched pairs of infants from 45 participating US hospitals in the National Institute of Child Health and Human Development Neonatal Research Network Generic Database (GDB). Infants were included in the cohort if they were born at less than 27 weeks' gestation between April 1, 2011, and March 31, 2017; survived the first 7 postnatal days; and had 2-year death or developmental follow-up data collected between January 2013 and December 2019. Corticosteroid-treated infants were propensity score matched with untreated controls. Data were analyzed from September 1, 2019, to November 30, 2022. Exposure Systemic corticosteroid therapy to prevent BPD that was initiated between day 8 and day 42 after birth. Main Outcomes and Measures The primary outcome was death or moderate to severe neurodevelopmental impairment at 2 years' corrected age. The secondary outcome was death or moderate to severe cerebral palsy at 2 years' corrected age. Results A total of 482 matched pairs of infants (mean [SD] gestational age, 24.1 [1.1] weeks]; 270 males [56.0%]) were included from 656 corticosteroid-treated infants and 2796 potential controls. Most treated infants (363 [75.3%]) received dexamethasone. The risk of death or disability associated with corticosteroid therapy was inversely associated with the estimated pretreatment probability of death or grade 2 or 3 BPD. The risk difference for death or neurodevelopmental impairment associated with corticosteroids decreased by 2.7% (95% CI, 1.9%-3.5%) for each 10% increase in the pretreatment risk of death or grade 2 or 3 BPD. This risk transitioned from estimated net harm to benefit when the pretreatment risk of death or grade 2 or 3 BPD exceeded 53% (95% CI, 44%-61%). For death or cerebral palsy, the risk difference decreased by 3.6% (95% CI, 2.9%-4.4%) for each 10% increase in the risk of death or grade 2 or 3 BPD and transitioned from estimated net harm to benefit at a pretreatment risk of 40% (95% CI, 33%-46%). Conclusions and Relevance Results of this study suggested that corticosteroids were associated with a reduced risk of death or disability in infants at moderate to high pretreatment risk of death or grade 2 or 3 BPD but with possible harm in infants at lower risk.
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Affiliation(s)
- Erik A. Jensen
- Division of Neonatology and Department of Pediatrics, Children’s Hospital of Philadelphia and University of Pennsylvania, Philadelphia
| | - Laura Elizabeth Wiener
- Biostatistics and Epidemiology Division, RTI International, Research Triangle Park, North Carolina
| | - Matthew A. Rysavy
- Department of Pediatrics, University of Texas McGovern Medical School, Houston
| | - Kevin C. Dysart
- Neonatal/Perinatal Medicine, Nemours Children’s Hospital, Wilmington, Delaware
| | - Marie G. Gantz
- Biostatistics and Epidemiology Division, RTI International, Research Triangle Park, North Carolina
| | - Eric C. Eichenwald
- Division of Neonatology and Department of Pediatrics, Children’s Hospital of Philadelphia and University of Pennsylvania, Philadelphia
| | - Rachel G. Greenberg
- Department of Pediatrics and Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Heidi M. Harmon
- Stead Family Department of Pediatrics, University of Iowa, Iowa City
| | - Matthew M. Laughon
- Department of Pediatrics, The University of North Carolina at Chapel Hill, Chapel Hill
| | | | - Michele C. Walsh
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
| | | | - Scott A. Lorch
- Division of Neonatology and Department of Pediatrics, Children’s Hospital of Philadelphia and University of Pennsylvania, Philadelphia
| | - Sara B. DeMauro
- Division of Neonatology and Department of Pediatrics, Children’s Hospital of Philadelphia and University of Pennsylvania, Philadelphia
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Chalak LF, Pappas A, Tan S, Das A, Sánchez PJ, Laptook AR, Van Meurs KP, Shankaran S, Bell EF, Davis AS, Heyne RJ, Pedroza C, Poindexter BB, Schibler K, Tyson JE, Ball MB, Bara R, Grisby C, Sokol GM, D’Angio CT, Hamrick SEG, Dysart KC, Cotten CM, Truog WE, Watterberg KL, Timan CJ, Garg M, Carlo WA, Higgins RD. Association Between Increased Seizures During Rewarming After Hypothermia for Neonatal Hypoxic Ischemic Encephalopathy and Abnormal Neurodevelopmental Outcomes at 2-Year Follow-up: A Nested Multisite Cohort Study. JAMA Neurol 2021; 78:1484-1493. [PMID: 34882200 PMCID: PMC8524352 DOI: 10.1001/jamaneurol.2021.3723] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 08/17/2021] [Indexed: 01/19/2023]
Abstract
Importance Compared with normothermia, hypothermia has been shown to reduce death or disability in neonatal hypoxic ischemic encephalopathy but data on seizures during rewarming and associated outcomes are scarce. Objective To determine whether electrographic seizures are more likely to occur during rewarming compared with the preceding period and whether they are associated with abnormal outcomes in asphyxiated neonates receiving hypothermia therapy. Design, Setting, and Participants This prespecified nested cohort study of infants enrolled in the Optimizing Cooling (OC) multicenter Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) Neonatal Research Network trial from December 2011 to December 2013 with 2 years' follow-up randomized infants to either 72 hours of cooling (group A) or 120 hours (group B). The main trial included 364 infants. Of these, 194 were screened, 10 declined consent, and 120 met all predefined inclusion criteria. A total of 112 (90%) had complete data for death or disability. Data were analyzed from January 2018 to January 2020. Interventions Serial amplitude electroencephalography recordings were compared in the 12 hours prior and 12 hours during rewarming for evidence of electrographic seizure activity by 2 central amplitude-integrated electroencephalography readers blinded to treatment arm and rewarming epoch. Odds ratios and 95% CIs were evaluated following adjustment for center, prior seizures, depth of cooling, and encephalopathy severity. Main Outcomes and Measures The primary outcome was the occurrence of electrographic seizures during rewarming initiated at 72 or 120 hours compared with the preceding 12-hour epoch. Secondary outcomes included death or moderate or severe disability at age 18 to 22 months. The hypothesis was that seizures during rewarming were associated with higher odds of abnormal neurodevelopmental outcomes. Results A total of 120 newborns (70 male [58%]) were enrolled (66 in group A and 54 in group B). The mean (SD) gestational age was 39 (1) weeks. There was excellent interrater agreement (κ, 0.99) in detection of seizures. More infants had electrographic seizures during the rewarming epoch compared with the preceding epoch (group A, 27% vs 14%; P = .001; group B, 21% vs 10%; P = .03). Adjusted odd ratios (95% CIs) for seizure frequency during rewarming were 2.7 (1.0-7.5) for group A and 3.2 (0.9-11.6) for group B. The composite death or moderate to severe disability outcome at 2 years was significantly higher in infants with electrographic seizures during rewarming (relative risk [95% CI], 1.7 [1.25-2.37]) after adjusting for baseline clinical encephalopathy and seizures as well as center. Conclusions and Relevance Findings that higher odds of electrographic seizures during rewarming are associated with death or disability at 2 years highlight the necessity of electroencephalography monitoring during rewarming in infants at risk. Trial Registration ClinicalTrials.gov Identifier: NCT01192776.
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Affiliation(s)
- Lina F. Chalak
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas
| | - Athina Pappas
- Department of Pediatrics, Wayne State University, Detroit, Michigan
| | - Sylvia Tan
- Social, Statistical and Environmental Sciences Unit, RTI International, Research Triangle Park, North Carolina
| | - Abhik Das
- Social, Statistical and Environmental Sciences Unit, RTI International, Rockville, Maryland
| | - Pablo J. Sánchez
- Department of Pediatrics, Nationwide Children’s Hospital, Ohio State University College of Medicine, Columbus
| | - Abbot R. Laptook
- Department of Pediatrics, Women & Infants Hospital, Brown University, Providence, Rhode Island
| | - Krisa P. Van Meurs
- Department of Pediatrics, Division of Neonatal and Developmental Medicine, Stanford University School of Medicine and Lucile Packard Children’s Hospital, Palo Alto, California
| | - Seetha Shankaran
- Department of Pediatrics, Wayne State University, Detroit, Michigan
| | | | - Alexis S. Davis
- Department of Pediatrics, Division of Neonatal and Developmental Medicine, Stanford University School of Medicine and Lucile Packard Children’s Hospital, Palo Alto, California
| | - Roy J. Heyne
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas
| | - Claudia Pedroza
- Department of Pediatrics, University of Texas Medical School at Houston, Houston
| | - Brenda B. Poindexter
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis
- Emory University Hospital Midtown, Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Kurt Schibler
- Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Jon E. Tyson
- Department of Pediatrics, University of Texas Medical School at Houston, Houston
| | - M. Bethany Ball
- Department of Pediatrics, Division of Neonatal and Developmental Medicine, Stanford University School of Medicine and Lucile Packard Children’s Hospital, Palo Alto, California
| | - Rebecca Bara
- Department of Pediatrics, Wayne State University, Detroit, Michigan
| | - Cathy Grisby
- Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Gregory M. Sokol
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis
| | - Carl T. D’Angio
- University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Shannon E. G. Hamrick
- Emory University Hospital Midtown, Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Kevin C. Dysart
- Department of Pediatrics, University of Pennsylvania, Philadelphia
| | | | - William E. Truog
- Department of Pediatrics, Children’s Mercy Hospital, Kansas City, Missouri
| | | | - Christopher J. Timan
- Department of Pediatrics, Nationwide Children’s Hospital, Ohio State University College of Medicine, Columbus
| | - Meena Garg
- Department of Pediatrics, University of California, Los Angeles
| | - Waldemar A. Carlo
- Division of Neonatology, University of Alabama at Birmingham, Birmingham
| | - Rosemary D. Higgins
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
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Napolitano N, Jalal K, McDonough JM, Monk HM, Zhang H, Jensen E, Dysart KC, Kirpalani HM, Panitch HB. Identifying and treating intrinsic PEEP in infants with severe bronchopulmonary dysplasia. Pediatr Pulmonol 2019; 54:1045-1051. [PMID: 30950245 DOI: 10.1002/ppul.24328] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 03/01/2019] [Accepted: 03/18/2019] [Indexed: 11/11/2022]
Abstract
RATIONALE Infants with severe bronchopulmonary dysplasia (sBPD) and airway obstruction may develop dynamic hyperinflation and intrinsic positive end-expiratory pressure (PEEPi ), which impairs patient/ventilator synchrony. OBJECTIVES To determine if PEEPi is present in infants with sBPD during spontaneous breathing and if adjusting ventilator PEEP improves patient/ventilator synchrony and comfort. METHODS Interventional study in infants with sBPD. PEEPi measured by esophageal pressure (Pes) and pneumotachometer, during pressure-supported breaths. PEEP i defined as the difference between Pes at start of the inspiratory effort minus Pes at onset of inspiratory flow. The set PEEP was adjusted to minimize PEEP i . "Best PEEP" was the setting with minimal wasted efforts (WE), an inspiratory effort seen on the Pes waveform without a corresponding ventilator breath. FiO 2 and SpO 2 measured pre- and post-PEEP adjustment. Sedation requirements evaluated 72 hours preprocedure and postprocedure. RESULTS Twelve infants were assessed (gestational age, 24.9 ± 1.4 weeks; study age, 48.8 ± 1.5 weeks, postmenstrual age). Mean baseline ventilator PEEP was 16.4 cm H2 O (14-20 cm H 2 O). Eight infants required an increase, one, a reduction, and three, no change in the set PEEP. For the eight infants requiring an increase in set PEEP, there was an 18.9% reduction in WE and a reduction in FiO 2 (0.084 ± 0.058) requirements in the subsequent 24 hours. Conditional sedation was reduced in five infants postprocedure. No adverse events occurred during testing. CONCLUSION PEEPi is measurable in infants with sBPD with concurrent esophageal manometry and flow-time tracings without the need for pharmacological paralysis. In those with PEEP i , increasing ventilator PEEP to offset PEEP i improves synchrony.
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Affiliation(s)
- Natalie Napolitano
- Department of Respiratory Therapy, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Khair Jalal
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Joseph M McDonough
- Department of Respiratory Therapy, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Division of Pulmonary Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Heather M Monk
- Department of Pharmacy Services, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Huayan Zhang
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Erik Jensen
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Kevin C Dysart
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Haresh M Kirpalani
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Howard B Panitch
- Division of Pulmonary Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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Jensen EA, Foglia EE, Dysart KC, Simmons RA, Aghai ZH, DO AC, Greenspan JS, DeMauro SB. Adverse effects of small for gestational age differ by gestational week among very preterm infants. Arch Dis Child Fetal Neonatal Ed 2019; 104:F192-F198. [PMID: 29730594 PMCID: PMC6335180 DOI: 10.1136/archdischild-2017-314171] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Revised: 04/09/2018] [Accepted: 04/16/2018] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To characterise the excess risk for death, grade 3-4 intraventricular haemorrhage (IVH), bronchopulmonary dysplasia (BPD) and stage 3-5 retinopathy of prematurity independently associated with birth small for gestational age (SGA) among very preterm infants, stratified by completed weeks of gestation. METHODS Retrospective cohort study using the Optum Neonatal Database. Study infants were born <32 weeks gestation without severe congenital anomalies. SGA was defined as a birth weight <10th percentile. The excess outcome risk independently associated with SGA birth among SGA babies was assessed using adjusted risk differences (aRDs). RESULTS Of 6708 infants sampled from 717 US hospitals, 743 (11.1%) were SGA. SGA compared with non-SGA infants experienced higher unadjusted rates of each study outcome except grade 3-4 IVH among survivors. The excess risk independently associated with SGA birth varied by outcome and gestational age. The highest aRD for death (0.27; 95% CI 0.13 to 0.40) occurred among infants born at 24 weeks gestation and declined as gestational age increased. In contrast, the peak aRDs for BPD among survivors (0.32; 95% CI 0.20 to 0.44) and the composites of death or BPD (0.35; 95% CI 0.24 to 0.46) and death or major morbidity (0.35; 95% CI 0.24 to 0.45) occurred at 27 weeks gestation. The risk-adjusted probability of dying or developing one or more of the evaluated morbidities among SGA infants was similar to that of non-SGA infants born approximately 2-3 weeks less mature. CONCLUSION The excess risk for neonatal morbidity and mortality associated with being born SGA varies by adverse outcome and gestational age.
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Affiliation(s)
- Erik A Jensen
- Department of Pediatrics, Division of Neonatology, The Children’s Hospital of Philadelphia and The University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Elizabeth E Foglia
- Department of Pediatrics, Division of Neonatology, The Children’s Hospital of Philadelphia and The University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Kevin C Dysart
- Department of Pediatrics, Division of Neonatology, The Children’s Hospital of Philadelphia and The University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Rebecca A Simmons
- Department of Pediatrics, Division of Neonatology, The Children’s Hospital of Philadelphia and The University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Zubair H Aghai
- Division of Neonatology, Nemours/Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
| | | | - Jay S Greenspan
- Division of Neonatology, Nemours/Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Sara B DeMauro
- Department of Pediatrics, Division of Neonatology, The Children’s Hospital of Philadelphia and The University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
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Fraga MV, Dysart KC, Rintoul N, Chaudhary AS, Ratcliffe SJ, Fedec A, Kren S, Cohen MS, Kirpalani H. Cardiac Output Measurement Using the Ultrasonic Cardiac Output Monitor: A Validation Study in Newborn Infants. Neonatology 2019; 116:260-268. [PMID: 31326967 DOI: 10.1159/000501005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2019] [Accepted: 05/06/2019] [Indexed: 11/19/2022]
Abstract
OBJECTIVES We aimed to determine the accuracy and validity of the Ultrasonic Cardiac Output Monitor (USCOM) measurements of cardiac output (CO) compared to echocardiography in newborn infants, and the inter-rater agreement of USCOM measurements. METHODS In a single-center study we prospectively evaluated neonates undergoing an echocardiographic evaluation. USCOM measurements of CO were obtained at the pulmonary and aortic valve by 2 physicians blinded to the echocardiographic results. All echocardiographic measurements were performed blinded to USCOM measurements. We first enrolled an ascertainment cohort which was subsequently validated in an independent new cohort. Agreement between echocardiography and USCOM methods was assessed by Bland-Altman analysis. Intra-class correlation coefficients (ICC) assessed the agreement between the 2 operators. The ascertainment cohort correction factors were applied in a second validation cohort and agreement of the calibrated measures evaluated with repeat Bland-Altman comparisons. RESULTS A total of 50 infants were enrolled in the initial cohort and 15 in the validation cohort. There was a high degree of correlation between the USCOM operators (ICC = 0.975). USCOM measurements of CO were significantly higher compared to echocardiography (left ventricular output bias 95 ± 52 mL/kg/min and right ventricular output bias 64 ± 30 mL/kg/min). There was no difference in the subgroup of infants with and without a ductus arteriosus. After the correction was applied to the validation cohort, there was no longer a significant difference between the measures. CONCLUSIONS CO measured by USCOM consistently overestimated the results obtained from echocardiography. USCOM is not adequate to provide absolute estimates of CO. However, it may allow longitudinal hemodynamic assessment of sick neonates.
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Affiliation(s)
- María V Fraga
- Division of Neonatology, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA,
| | - Kevin C Dysart
- Division of Neonatology, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Natalie Rintoul
- Division of Neonatology, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Aasma S Chaudhary
- Division of Neonatology, Hospital of University of Pennsylvania, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Sarah J Ratcliffe
- Department of Biostatistics and Epidemiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Anysia Fedec
- Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Stephanie Kren
- Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Meryl S Cohen
- Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Haresh Kirpalani
- Division of Neonatology, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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Partridge EA, Davey MG, Hornick M, Dysart KC, Olive A, Caskey R, Connelly JT, Hedrick HL, Peranteau WH, Flake AW. Pumpless arteriovenous extracorporeal membrane oxygenation: A novel mode of respiratory support in a lamb model of congenital diaphragmatic hernia. J Pediatr Surg 2018; 53:1453-1460. [PMID: 29605270 DOI: 10.1016/j.jpedsurg.2018.02.061] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Revised: 02/26/2018] [Accepted: 02/27/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) is commonly required in neonates with congenital diaphragmatic hernia (CDH) complicated by pulmonary hypertension (PH). ECMO carries significant risk, and is contraindicated in the setting of extreme prematurity or intracranial hemorrhage. Pumpless arteriovenous ECMO (P-ECMO) may represent an alternative for respiratory support. The present study summarizes our initial experience with P-ECMO in a lamb model of CDH. STUDY DESIGN Surgical creation of CDH was performed at 65-75days' gestation. At term (135-145days), lambs were delivered into the P-ECMO circuit. Three animals were maintained on a low-heparin infusion protocol (target ACT 160-180) and three animals were maintained with no systemic heparinization. RESULTS Animals were supported by the circuit for 380.7 +/- 145.6h (range, 102-504h). Circuit flow rates ranged from 97 to 208ml/kg/min, with adequacy of organ perfusion demonstrated by stable serum lactate levels (3.0 +/- 1.7) and pH (7.4 +/- 0.3). Necropsy demonstrated no evidence of thrombogenic complications. CONCLUSION Pumpless extracorporeal membrane oxygenation achieved support of CDH model lambs for up to three weeks. This therapy has the potential to bridge neonates with decompensated respiratory failure to CDH repair with no requirement for systemic anticoagulation, and may be applicable to patients currently precluded from conventional ECMO support.
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Affiliation(s)
- Emily A Partridge
- Center for Fetal Research, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104
| | - Marcus G Davey
- Center for Fetal Research, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104
| | - Matthew Hornick
- Center for Fetal Research, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104
| | - Kevin C Dysart
- Center for Fetal Research, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104
| | - Aliza Olive
- Center for Fetal Research, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104
| | - Robert Caskey
- Center for Fetal Research, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104
| | - James T Connelly
- Center for Fetal Research, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104
| | - Holly L Hedrick
- Center for Fetal Research, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104
| | - William H Peranteau
- Center for Fetal Research, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104
| | - Alan W Flake
- Center for Fetal Research, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104.
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Hornick MA, Davey MG, Partridge EA, Mejaddam AY, McGovern PE, Olive AM, Hwang G, Kim J, Castillo O, Young K, Han J, Zhao S, Connelly JT, Dysart KC, Rychik J, Peranteau WH, Flake AW. Umbilical cannulation optimizes circuit flows in premature lambs supported by the EXTra-uterine Environment for Neonatal Development (EXTEND). J Physiol 2018; 596:1575-1585. [PMID: 29392729 PMCID: PMC5924826 DOI: 10.1113/jp275367] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Accepted: 01/22/2018] [Indexed: 11/08/2022] Open
Abstract
KEY POINTS Bronchopulmonary dysplasia is a disease of extreme prematurity that occurs when the immature lung is exposed to gas ventilation. We designed a novel 'artificial womb' system for supporting extreme premature lambs (called EXTEND) that obviates gas ventilation by providing oxygen via a pumpless arteriovenous circuit with the lamb submerged in sterile artificial amniotic fluid. In the present study, we compare different arteriovenous cannulation strategies on EXTEND, including carotid artery/jugular vein (CA/JV), carotid artery/umbilical vein (CA/UV) and umbilical artery/umbilical vein (UA/UV). Compared to CA/JV and CA/UV cannulation, UA/UV cannulation provided significantly higher, physiological blood flows to the oxygenator, minimized flow interruptions and supported significantly longer circuit runs (up to 4 weeks). Physiological circuit blood flow in UA/UV lambs made possible normal levels of oxygen delivery, which is a critical step toward the clinical application of artificial womb technology. ABSTRACT EXTEND (EXTra-uterine Environment for Neonatal Development) is a novel system that promotes physiological development by maintaining the premature lamb in a sterile fluid environment and providing gas exchange via a pumpless arteriovenous oxygenator circuit. During the development of EXTEND, different cannulation strategies evolved with the aim of improving circuit flow. The present study examines how different cannulation strategies affect EXTEND circuit haemodynamics in extreme premature lambs. Seventeen premature lambs were cannulated at gestational ages 105-117 days (term 145-150 days) and supported on EXTEND for up to 4 weeks. Experimental groups were distinguished by cannulation strategy: carotid artery outflow and jugular vein inflow (CA/JV; n = 4), carotid artery outflow and umbilical vein inflow (CA/UV; n = 5) and double umbilical artery outflow and umbilical vein inflow (UA/UV; n = 8). Circuit flows and pressures were measured continuously. As we transitioned from CA/JV to CA/UV to UA/UV cannulation, mean duration of circuit run and weight-adjusted circuit flows increased (P < 0.001) and the frequency of flow interruptions declined (P < 0.05). Umbilical vessels generally accommodated larger-bore cannulas, and cannula calibre was directly correlated with circuit pressures and indirectly correlated with flow:pressure ratio (a measure of post-membrane resistance). We conclude that UA/UV cannulation in fetal lambs on EXTEND optimizes circuit flow dynamics and flow stability and also supports circuit flows that closely approximate normal placental flow.
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Affiliation(s)
| | | | | | | | | | | | - Grace Hwang
- Center for Fetal ResearchDepartment of Surgery
| | - Jenny Kim
- Center for Fetal ResearchDepartment of Surgery
| | | | | | | | - Sheng Zhao
- Center for Fetal ResearchDepartment of Surgery
| | | | | | - Jack Rychik
- Division of Cardiology, Department of PediatricsChildren's Hospital of PhiladelphiaPhiladelphiaPAUSA
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9
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Jensen EA, Foglia EE, Dysart KC, Aghai ZH, Cook A, Greenspan JS, DeMauro SB. Car Seat Tolerance Screening in the Neonatal Intensive Care Unit: Failure Rates, Risk Factors, and Adverse Outcomes. J Pediatr 2018; 194:60-66.e1. [PMID: 29269198 PMCID: PMC5826836 DOI: 10.1016/j.jpeds.2017.11.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Revised: 10/11/2017] [Accepted: 11/01/2017] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To characterize the epidemiology of Car Seat Tolerance Screening (CSTS) failure and the association between test failure and all-cause 30-day postdischarge mortality or hospital readmission in a large, multicenter cohort of preterm infants receiving neonatal intensive care. STUDY DESIGN This retrospective cohort study used the prospectively collected Optum Neonatal Database. Study infants were born at <37 weeks of gestation between 2010 and 2016. We identified independent predictors of CSTS failure and calculated the risk-adjusted odds of all-cause 30-day mortality or hospital readmission associated with test failure. RESULTS Of 7899 infants cared for in 788 hospitals, 334 (4.2%) failed initial CSTS. Greater postmenstrual age at testing and African American race were independently associated with decreased failure risk. Any treatment with an antacid medication, concurrent use of caffeine or supplemental oxygen, and a history of failing a trial off respiratory support were associated with increased failure risk. The mean adjusted post-CSTS duration of hospitalization was 3.1 days longer (95% CI, 2.7-3.6) among the infants who failed the initial screening. Rates of 30-day all-cause mortality or readmission were higher among infants who failed the CSTS (2.4% vs 1.0%; P = .03); however, the difference was not significant after confounder adjustment (OR, 0.38; 95% CI, 0.11-1.31). CONCLUSION CSTS failure was associated with longer post-test hospitalization but no difference in the risk-adjusted odds for 30-day mortality or hospital readmission. Whether CSTS failure unnecessarily prolongs hospitalization or results in appropriate care that prevents adverse postdischarge outcomes is unknown. Further research is needed to address this knowledge gap.
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Affiliation(s)
- Erik A. Jensen
- Department of Pediatrics, Division of Neonatology, The Children’s Hospital of Philadelphia and The University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Elizabeth E. Foglia
- Department of Pediatrics, Division of Neonatology, The Children’s Hospital of Philadelphia and The University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Kevin C. Dysart
- Department of Pediatrics, Division of Neonatology, The Children’s Hospital of Philadelphia and The University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Zubair H. Aghai
- Division of Neonatology, Nemours/Sidney Kimmel Medical College at Thomas, Jefferson University, Philadelphia, Pennsylvania
| | | | - Jay S. Greenspan
- Division of Neonatology, Nemours/Sidney Kimmel Medical College at Thomas, Jefferson University, Philadelphia, Pennsylvania
| | - Sara B. DeMauro
- Department of Pediatrics, Division of Neonatology, The Children’s Hospital of Philadelphia and The University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
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10
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Tkach EK, White AM, Dysart KC, Waber B, Nawab US, Zhang H, Jensen EA. Comparison of Intact Parathyroid Hormone, Alkaline Phosphatase, Phosphate Levels for Diagnosing Severe Metabolic Bone Disease in Infants with Severe Bronchopulmonary Dysplasia. Am J Perinatol 2017; 34:1199-1204. [PMID: 28431438 DOI: 10.1055/s-0037-1602419] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [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] [Indexed: 10/19/2022]
Abstract
Objective We compared the accuracy of serum intact parathyroid hormone (iPTH), alkaline phosphatase (ALP), and phosphate (phos) levels for diagnosing severe metabolic bone disease (MBD) in very low-birth-weight (VLBW) infants with severe bronchopulmonary dysplasia (BPD).
Study Design Retrospective analysis of VLBW infants with severe BPD admitted between 2010 and 2012 and with ≥ 1 iPTH, ALP, and phos level collected within a similar 72-hour period. MBD severity was classified by serial radiography.
Results Laboratory values were available for 65 infants, of whom 24 (36.9%) developed severe MBD. A maximum ALP > 660 IU/L was the most accurate for diagnosing severe MBD (area under the curve: 88.4%; 95% confidence interval [CI]: 77.2–94.5%). Maximum iPTH was the least accurate (optimal cut point > 130 pg/mL; area under the curve: 70.5%; 95% CI: 58.2–81.4).
Conclusion Maximum ALP was more accurate than iPTH or phos for diagnosing severe MBD among preterm infants with severe BPD.
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Affiliation(s)
- Erin K Tkach
- Division of Neonatology, Department of Pediatrics, University of Pennsylvania, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Ammie M White
- Division of Radiology, Department of Pediatrics, University of Pennsylvania, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Kevin C Dysart
- Division of Neonatology, Department of Pediatrics, University of Pennsylvania, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Brenda Waber
- Division of Neonatology, Department of Pediatrics, University of Pennsylvania, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Ursula S Nawab
- Division of Neonatology, Department of Pediatrics, University of Pennsylvania, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Huayan Zhang
- Division of Neonatology, Department of Pediatrics, University of Pennsylvania, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Erik A Jensen
- Division of Neonatology, Department of Pediatrics, University of Pennsylvania, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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11
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Partridge EA, Davey MG, Hornick MA, McGovern PE, Mejaddam AY, Vrecenak JD, Mesas-Burgos C, Olive A, Caskey RC, Weiland TR, Han J, Schupper AJ, Connelly JT, Dysart KC, Rychik J, Hedrick HL, Peranteau WH, Flake AW. An extra-uterine system to physiologically support the extreme premature lamb. Nat Commun 2017; 8:15112. [PMID: 28440792 PMCID: PMC5414058 DOI: 10.1038/ncomms15112] [Citation(s) in RCA: 143] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Accepted: 03/02/2017] [Indexed: 12/18/2022] Open
Abstract
In the developed world, extreme prematurity is the leading cause of neonatal mortality and morbidity due to a combination of organ immaturity and iatrogenic injury. Until now, efforts to extend gestation using extracorporeal systems have achieved limited success. Here we report the development of a system that incorporates a pumpless oxygenator circuit connected to the fetus of a lamb via an umbilical cord interface that is maintained within a closed 'amniotic fluid' circuit that closely reproduces the environment of the womb. We show that fetal lambs that are developmentally equivalent to the extreme premature human infant can be physiologically supported in this extra-uterine device for up to 4 weeks. Lambs on support maintain stable haemodynamics, have normal blood gas and oxygenation parameters and maintain patency of the fetal circulation. With appropriate nutritional support, lambs on the system demonstrate normal somatic growth, lung maturation and brain growth and myelination.
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Affiliation(s)
- Emily A Partridge
- Center for Fetal Research, Department of Surgery, The Children's Hospital of Philadelphia Research Institute, Room 1116B, 3615 Civic Center Boulevard, Philadelphia, Pennsylvania 19104, USA
| | - Marcus G Davey
- Center for Fetal Research, Department of Surgery, The Children's Hospital of Philadelphia Research Institute, Room 1116B, 3615 Civic Center Boulevard, Philadelphia, Pennsylvania 19104, USA
| | - Matthew A Hornick
- Center for Fetal Research, Department of Surgery, The Children's Hospital of Philadelphia Research Institute, Room 1116B, 3615 Civic Center Boulevard, Philadelphia, Pennsylvania 19104, USA
| | - Patrick E McGovern
- Center for Fetal Research, Department of Surgery, The Children's Hospital of Philadelphia Research Institute, Room 1116B, 3615 Civic Center Boulevard, Philadelphia, Pennsylvania 19104, USA
| | - Ali Y Mejaddam
- Center for Fetal Research, Department of Surgery, The Children's Hospital of Philadelphia Research Institute, Room 1116B, 3615 Civic Center Boulevard, Philadelphia, Pennsylvania 19104, USA
| | - Jesse D Vrecenak
- Center for Fetal Research, Department of Surgery, The Children's Hospital of Philadelphia Research Institute, Room 1116B, 3615 Civic Center Boulevard, Philadelphia, Pennsylvania 19104, USA
| | - Carmen Mesas-Burgos
- Center for Fetal Research, Department of Surgery, The Children's Hospital of Philadelphia Research Institute, Room 1116B, 3615 Civic Center Boulevard, Philadelphia, Pennsylvania 19104, USA
| | - Aliza Olive
- Center for Fetal Research, Department of Surgery, The Children's Hospital of Philadelphia Research Institute, Room 1116B, 3615 Civic Center Boulevard, Philadelphia, Pennsylvania 19104, USA
| | - Robert C Caskey
- Center for Fetal Research, Department of Surgery, The Children's Hospital of Philadelphia Research Institute, Room 1116B, 3615 Civic Center Boulevard, Philadelphia, Pennsylvania 19104, USA
| | - Theodore R Weiland
- Center for Fetal Research, Department of Surgery, The Children's Hospital of Philadelphia Research Institute, Room 1116B, 3615 Civic Center Boulevard, Philadelphia, Pennsylvania 19104, USA
| | - Jiancheng Han
- Center for Fetal Research, Department of Surgery, The Children's Hospital of Philadelphia Research Institute, Room 1116B, 3615 Civic Center Boulevard, Philadelphia, Pennsylvania 19104, USA
| | - Alexander J Schupper
- Center for Fetal Research, Department of Surgery, The Children's Hospital of Philadelphia Research Institute, Room 1116B, 3615 Civic Center Boulevard, Philadelphia, Pennsylvania 19104, USA
| | - James T Connelly
- Center for Fetal Research, Department of Surgery, The Children's Hospital of Philadelphia Research Institute, Room 1116B, 3615 Civic Center Boulevard, Philadelphia, Pennsylvania 19104, USA
| | - Kevin C Dysart
- Division of Neonatology, Department of Pediatrics, The Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, Pennsylvania 19104, USA
| | - Jack Rychik
- Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, Pennsylvania 19104, USA
| | - Holly L Hedrick
- Center for Fetal Research, Department of Surgery, The Children's Hospital of Philadelphia Research Institute, Room 1116B, 3615 Civic Center Boulevard, Philadelphia, Pennsylvania 19104, USA
| | - William H Peranteau
- Center for Fetal Research, Department of Surgery, The Children's Hospital of Philadelphia Research Institute, Room 1116B, 3615 Civic Center Boulevard, Philadelphia, Pennsylvania 19104, USA
| | - Alan W Flake
- Center for Fetal Research, Department of Surgery, The Children's Hospital of Philadelphia Research Institute, Room 1116B, 3615 Civic Center Boulevard, Philadelphia, Pennsylvania 19104, USA
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12
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Tramper J, Zhang H, Foglia EE, Dysart KC, Padula MA, Sullivan KV, Jensen EA. The Association between Positive Tracheal Aspirate Cultures and Adverse Pulmonary Outcomes in Preterm Infants with Severe Bronchopulmonary Dysplasia. Am J Perinatol 2017; 34:96-104. [PMID: 27285471 DOI: 10.1055/s-0036-1584541] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [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] [Indexed: 10/21/2022]
Abstract
Objective Bacterial colonization of the airway may contribute to the development of bronchopulmonary dysplasia. Whether airway colonization increases risk for later adverse respiratory outcomes is less clear. We described tracheal aspirate culture results obtained from preterm infants receiving mechanical ventilation at 36 weeks postmenstrual age (PMA) and evaluated the association between bacteria type and the risk for prolonged supplemental oxygen use. Study Design We conducted a retrospective, single-center cohort study comparing infants (1) with and without a tracheal aspirate culture that grew a Gram-negative rod (GNR) and (2) with and without a culture that grew a Gram-positive cocci (GPC). Results Among 121 infants, 65 (53.7%) and 51 (42.2%) had a tracheal aspirate culture that grew a potentially pathogenic GNR and GPC prior to 36 weeks PMA, respectively. GNR were associated with increased risk for death or use of supplemental oxygen at discharge (adjusted odds ratio [aOR], 6.2; 95% confidence interval [CI], 1.8-21.1), and use of supplemental oxygen at discharge among survivors (aOR, 5.5; 95% CI, 1.6-19.0). GPC did not affect the risk for any study outcomes. Conclusion GNR but not GPC in the airways of preterm infants receiving mechanical ventilation at 36 weeks PMA is associated with increased risk for prolonged supplemental oxygen use.
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Affiliation(s)
- Jacobus Tramper
- Division of Neonatology, Department of Pediatrics, The Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Huayan Zhang
- Division of Neonatology, Department of Pediatrics, The Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Elizabeth E Foglia
- Division of Neonatology, Department of Pediatrics, The Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Kevin C Dysart
- Division of Neonatology, Department of Pediatrics, The Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Michael A Padula
- Division of Neonatology, Department of Pediatrics, The Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Kaede V Sullivan
- Department of Pathology and Laboratory Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Erik A Jensen
- Division of Neonatology, Department of Pediatrics, The Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
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13
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Dysart KC. Physiologic Basis for Nasal Continuous Positive Airway Pressure, Heated and Humidified High-Flow Nasal Cannula, and Nasal Ventilation. Clin Perinatol 2016; 43:621-631. [PMID: 27837748 DOI: 10.1016/j.clp.2016.07.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Noninvasive support modalities have become ever more present in the care of newborns with a wide variety of disease processes. As clinicians have continued to avoid intubation and mechanical ventilation in preterm and term infants, the technologies available to support these groups have grown. Despite this rapid growth they can be broken down into 3 large categories of support, all attempting to deliver both flow and pressure to the nasopharynx supporting both phases of spontaneous breathing. The goal of all of the therapies is to stabilize a heterogeneous group of disorders with some common pathologies and avoid invasive support modalities.
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Affiliation(s)
- Kevin C Dysart
- Children's Hospital of Philadelphia, 34th and Civic Center Boulevard, Philadelphia, PA 19104, USA.
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14
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Jensen EA, DeMauro SB, Kornhauser M, Aghai ZH, Greenspan JS, Dysart KC. Effects of Multiple Ventilation Courses and Duration of Mechanical Ventilation on Respiratory Outcomes in Extremely Low-Birth-Weight Infants. JAMA Pediatr 2015; 169:1011-7. [PMID: 26414549 PMCID: PMC6445387 DOI: 10.1001/jamapediatrics.2015.2401] [Citation(s) in RCA: 122] [Impact Index Per Article: 13.6] [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] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Extubation failure is common in extremely preterm infants. The current paucity of data on the adverse long-term respiratory outcomes associated with reinitiation of mechanical ventilation prevents assessment of the risks and benefits of a trial of extubation in this population. OBJECTIVE To evaluate whether exposure to multiple courses of mechanical ventilation increases the risk of adverse respiratory outcomes before and after adjustment for the cumulative duration of mechanical ventilation. DESIGN, SETTING, AND PARTICIPANTS We performed a retrospective cohort study of extremely low-birth-weight (ELBW; birth weight <1000 g) infants born from January 1, 2006, through December 31, 2012, who were receiving mechanical ventilation. Analysis was conducted between November 2014 and February 2015. Data were obtained from the Alere Neonatal Database. EXPOSURES The primary study exposures were the cumulative duration of mechanical ventilation and the number of ventilation courses. MAIN OUTCOMES AND MEASURES The primary outcome was bronchopulmonary dysplasia (BPD) among survivors. Secondary outcomes were death, use of supplemental oxygen at discharge, and tracheostomy. RESULTS We identified 3343 ELBW infants, of whom 2867 (85.8%) survived to discharge. Among the survivors, 1695 (59.1%) were diagnosed as having BPD, 856 (29.9%) received supplemental oxygen at discharge, and 31 (1.1%) underwent tracheostomy. Exposure to a greater number of mechanical ventilation courses was associated with a progressive increase in the risk of BPD and use of supplemental oxygen at discharge. Compared with a single ventilation course, the adjusted odds ratios for BPD ranged from 1.88 (95% CI, 1.54-2.31) among infants with 2 ventilation courses to 3.81 (95% CI, 2.88-5.04) among those with 4 or more courses. After adjustment for the cumulative duration of mechanical ventilation, the odds of BPD were only increased among infants exposed to 4 or more ventilation courses (adjusted odds ratio, 1.44; 95% CI, 1.04-2.01). The number of ventilation courses was not associated with increased risk of supplemental oxygen use at discharge after adjustment for the length of ventilation. A greater number of ventilation courses did not increase the risk of tracheostomy. CONCLUSIONS AND RELEVANCE Among ELBW infants, a longer cumulative duration of mechanical ventilation largely accounts for the increased risk of chronic respiratory morbidity associated with reinitiation of mechanical ventilation. These results support attempts of extubation in ELBW infants receiving mechanical ventilation on low ventilator settings, even when success is not guaranteed.
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Affiliation(s)
- Erik A. Jensen
- Division of Neonatology, Department of Pediatrics, The Children’s Hospital of Philadelphia and The University of Pennsylvania School of Medicine, Philadelphia
| | - Sara B. DeMauro
- Division of Neonatology, Department of Pediatrics, The Children’s Hospital of Philadelphia and The University of Pennsylvania School of Medicine, Philadelphia
| | | | - Zubair H. Aghai
- Division of Neonatology, Nemours/Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Jay S. Greenspan
- Division of Neonatology, Nemours/Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Kevin C. Dysart
- Division of Neonatology, Department of Pediatrics, The Children’s Hospital of Philadelphia and The University of Pennsylvania School of Medicine, Philadelphia
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15
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Shankaran S, Laptook AR, Pappas A, McDonald SA, Das A, Tyson JE, Poindexter BB, Schibler K, Bell EF, Heyne RJ, Pedroza C, Bara R, Van Meurs KP, Grisby C, Huitema CMP, Garg M, Ehrenkranz RA, Shepherd EG, Chalak LF, Hamrick SEG, Khan AM, Reynolds AM, Laughon MM, Truog WE, Dysart KC, Carlo WA, Walsh MC, Watterberg KL, Higgins RD. Effect of depth and duration of cooling on deaths in the NICU among neonates with hypoxic ischemic encephalopathy: a randomized clinical trial. JAMA 2014; 312:2629-39. [PMID: 25536254 PMCID: PMC4335311 DOI: 10.1001/jama.2014.16058] [Citation(s) in RCA: 181] [Impact Index Per Article: 18.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Hypothermia at 33.5°C for 72 hours for neonatal hypoxic ischemic encephalopathy reduces death or disability to 44% to 55%; longer cooling and deeper cooling are neuroprotective in animal models. OBJECTIVE To determine if longer duration cooling (120 hours), deeper cooling (32.0°C), or both are superior to cooling at 33.5°C for 72 hours in neonates who are full-term with moderate or severe hypoxic ischemic encephalopathy. DESIGN, SETTING, AND PARTICIPANTS A randomized, 2 × 2 factorial design clinical trial performed in 18 US centers in the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) Neonatal Research Network between October 2010 and November 2013. INTERVENTIONS Neonates were assigned to 4 hypothermia groups; 33.5°C for 72 hours, 32.0°C for 72 hours, 33.5°C for 120 hours, and 32.0°C for 120 hours. MAIN OUTCOMES AND MEASURES The primary outcome of death or disability at 18 to 22 months is ongoing. The independent data and safety monitoring committee paused the trial to evaluate safety (cardiac arrhythmia, persistent acidosis, major vessel thrombosis and bleeding, and death in the neonatal intensive care unit [NICU]) after the first 50 neonates were enrolled, then after every subsequent 25 neonates. The trial was closed for emerging safety profile and futility analysis after the eighth review with 364 neonates enrolled (of 726 planned). This report focuses on safety and NICU deaths by marginal comparisons of 72 hours' vs 120 hours' duration and 33.5°C depth vs 32.0°C depth (predefined secondary outcomes). RESULTS The NICU death rates were 7 of 95 neonates (7%) for the 33.5°C for 72 hours group, 13 of 90 neonates (14%) for the 32.0°C for 72 hours group, 15 of 96 neonates (16%) for the 33.5°C for 120 hours group, and 14 of 83 neonates (17%) for the 32.0°C for 120 hours group. The adjusted risk ratio (RR) for NICU deaths for the 120 hours group vs 72 hours group was 1.37 (95% CI, 0.92-2.04) and for the 32.0°C group vs 33.5°C group was 1.24 (95% CI, 0.69-2.25). Safety outcomes were similar between the 120 hours group vs 72 hours group and the 32.0°C group vs 33.5°C group, except major bleeding occurred among 1% in the 120 hours group vs 3% in the 72 hours group (RR, 0.25 [95% CI, 0.07-0.91]). Futility analysis determined that the probability of detecting a statistically significant benefit for longer cooling, deeper cooling, or both for NICU death was less than 2%. CONCLUSIONS AND RELEVANCE Among neonates who were full-term with moderate or severe hypoxic ischemic encephalopathy, longer cooling, deeper cooling, or both compared with hypothermia at 33.5°C for 72 hours did not reduce NICU death. These results have implications for patient care and design of future trials. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01192776.
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Affiliation(s)
- Seetha Shankaran
- Department of Pediatrics, Wayne State University, Detroit, Michigan
| | - Abbot R Laptook
- Department of Pediatrics, Women and Infants Hospital, Brown University, Providence, Rhode Island
| | - Athina Pappas
- Department of Pediatrics, Wayne State University, Detroit, Michigan
| | - Scott A McDonald
- Social, Statistical, and Environmental Sciences Unit, RTI International, Research Triangle Park, North Carolina
| | - Abhik Das
- Social, Statistical, and Environmental Sciences Unit, RTI International, Rockville, Maryland
| | - Jon E Tyson
- Department of Pediatrics, University of Texas Medical School at Houston
| | - Brenda B Poindexter
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis
| | - Kurt Schibler
- Perinatal Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Edward F Bell
- Department of Pediatrics, University of Iowa, Iowa City
| | - Roy J Heyne
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas
| | - Claudia Pedroza
- Perinatal Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Rebecca Bara
- Department of Pediatrics, Wayne State University, Detroit, Michigan
| | - Krisa P Van Meurs
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California
| | - Cathy Grisby
- Perinatal Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | - Meena Garg
- Department of Pediatrics, University of California, Los Angeles
| | - Richard A Ehrenkranz
- Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut
| | - Edward G Shepherd
- Department of Pediatrics, Nationwide Children's Hospital, Ohio State University, Columbus
| | - Lina F Chalak
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas
| | - Shannon E G Hamrick
- Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Amir M Khan
- Department of Pediatrics, University of Texas Medical School at Houston
| | | | - Matthew M Laughon
- Division of Neonatal/Perinatal Medicine, Department of Pediatrics, University of North Carolina, Chapel Hill
| | - William E Truog
- Department of Pediatrics, Children's Mercy Hospital, Kansas City School of Medicine, University of Missouri
| | - Kevin C Dysart
- Department of Pediatrics, Perelman School of Medicine, Children's Hospital of Philadelphia, University of Pennsylvania
| | | | - Michele C Walsh
- Department of Pediatrics, Rainbow Babies and Children's Hospital, Case Western Reserve University, Cleveland, Ohio
| | | | - Rosemary D Higgins
- Pregnancy and Perinatology Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
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16
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Partridge EA, Davey MG, Dysart KC, Caskey R, Connelly JT, Misfeldt A, Hedrick HL, Peranteau WH, Flake AW. Pumpless Arterio-Venous Extracorporeal Membrane Oxygenation in the Management of Congenital Diaphragmatic Hernia. J Am Coll Surg 2014. [DOI: 10.1016/j.jamcollsurg.2014.07.178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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17
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Taha D, Kirkby S, Nawab U, Dysart KC, Genen L, Greenspan JS, Aghai ZH. Early caffeine therapy for prevention of bronchopulmonary dysplasia in preterm infants. J Matern Fetal Neonatal Med 2014; 27:1698-702. [PMID: 24479608 DOI: 10.3109/14767058.2014.885941] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To determine if an early commencement of caffeine is associated with improved survival without bronchopulmonary dysplasia (BPD) in preterm infants. METHODS Retrospective data analysis from the Alere Neonatal Database for infants weighing ≤1250 g, and treated with caffeine within the first 10 days of life. The neonatal outcomes were compared between the infants who received early caffeine (0-2 days) with the infants who received delayed caffeine (3-10 days). RESULTS A total of 2951 infants met the inclusion criteria (early caffeine 1986, late caffeine 965). The early use of caffeine was associated with reduction in BPD (OR 0.69, 95% CI 0.58-0.82, p < 0.001) and BPD or death (OR 0.77, 95% CI 0.63-0.94, p = 0.01). Other respiratory outcomes also improved with the early commencement of caffeine. The frequency of severe intraventricular hemorrhage and patent ductus arteriosus was lower and the length of hospitalization was shorter in infants receiving early caffeine therapy. However, early use of caffeine was associated with an increase in the risk of nectrotizing enterocolits (NEC) (OR 1.41, 95% CI 1.04-1.91, p = 0.027). CONCLUSION Early commencement of caffeine was associated with improvement in survival without BPD in preterm infants. The risk of NEC with early caffeine use requires further investigation.
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Affiliation(s)
- Dalal Taha
- Division of Pediatrics/Neonatology, Thomas Jefferson University/Nemours , Philadelphia, PA , USA
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Anagnostis EA, Sadaka RE, Sailor LA, Moody DE, Dysart KC, Kraft WK. Formulation of buprenorphine for sublingual use in neonates. J Pediatr Pharmacol Ther 2012; 16:281-4. [PMID: 22768012 DOI: 10.5863/1551-6776-16.4.281] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES The only medication used sublingually in the neonate is buprenorphine for the treatment of neonatal abstinence syndrome (NAS). Compared with morphine, buprenorphine reduces the length of treatment and length of hospitalization in neonates treated for NAS. The objective of this study was to characterize the stability of ethanolic buprenorphine for sublingual administration. METHODS Buprenorphine solution was prepared and stored in amber glass source bottles at either 68°F to 77°F (20°C-25°C) or 36°F to 46°F (2.2°C-7.8°C). Samples were collected from each of these batches on days 0, 3, 7, 14, and 30. Additional samples were withdrawn at baseline from each batch and placed in oral dispensing syringes for 3 and 7 days. Buprenorphine concentration was assessed by liquid chromatography-electrospray ionization-tandem mass spectrometry. RESULTS Neither storage temperature (p=0.65) nor storage time (p=0.24) significantly affected buprenorphine concentrations. All of the mean concentrations, regardless of storage temperature, were above 95% of the labeled concentration, and the potency was maintained for samples stored either in the original amber glass source bottles or in oral syringes. CONCLUSIONS An ethanolic buprenorphine solution is stable at room temperature for 30 days.
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Seligman NS, Almario CV, Hayes EJ, Dysart KC, Berghella V, Baxter JK. Relationship between maternal methadone dose at delivery and neonatal abstinence syndrome. J Pediatr 2010; 157:428-33, 433.e1. [PMID: 20472252 DOI: 10.1016/j.jpeds.2010.03.033] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [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: 08/13/2009] [Revised: 02/08/2010] [Accepted: 03/26/2010] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To estimate the relationship between maternal methadone dose and the incidence of neonatal abstinence syndrome (NAS). STUDY DESIGN We performed a retrospective cohort study of pregnant women treated with methadone for opiate addiction who delivered live-born neonates between 1996 and 2006. Four dose groups, on the basis of total daily methadone dose, were compared (<or=80 mg/d, 81-120 mg/d, 121-160 mg/d, and >160 mg/d). The primary outcome was treatment for NAS. Symptoms of NAS were objectively measured with the Finnegan scoring system, and treatment was initiated for a score>24 during the prior 24 hours. RESULTS A total of 330 women treated with methadone and their 388 offspring were included. Average methadone dose at delivery was 117+/-50 mg/d (range, 20-340 mg/d). Overall, 68% of infants were treated for NAS. Of infants exposed to methadone doses<or=80 mg/d, 81-120 mg/d, 121-160 mg/d, and >160 mg/d, treatment for NAS was initiated for 68%, 63%, 70%, and 73% of neonates, respectively (P=.48). The rate of maternal illicit opiate abuse at delivery was 26%, 28%, 19%, and 11%, respectively (P=.04). CONCLUSION No correlation was found between maternal methadone dose and rate of NAS. However, higher doses of methadone were associated with decreased illicit opiate abuse at delivery.
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Affiliation(s)
- Neil S Seligman
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Jefferson Medical College of Thomas Jefferson University, Philadelphia, PA 19107, USA.
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Kumar MA, Jain A, Dechant VE, Saito T, Rafael T, Aizawa H, Dysart KC, Katayama T, Ito Y, Araki N, Abe T, Balice-Gordon R, Dalmau J. Anti-N-methyl-D-aspartate receptor encephalitis during pregnancy. Arch Neurol 2010; 67:884-887. [PMID: 20625099 DOI: 10.1001/archneurol.2010.133] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
OBJECTIVE To report 3 patients who developed anti-N-methyl-d-aspartate receptor encephalitis during pregnancy. DESIGN Case reports. SETTING University hospitals. Patients Three young women developed at 14, 8, and 17 weeks of gestation acute change of behavior, prominent psychiatric symptoms, progressive decrease of consciousness, seizures, dyskinesias, and autonomic dysfunction. MAIN OUTCOME MEASURES Clinical, radiological, and immunological findings. RESULTS The 3 patients had cerebrospinal fluid pleocytosis, normal magnetic resonance imaging, and electroencephalogram showing slow activity. All had higher antibody titers in cerebrospinal fluid than in serum and 2 had ovarian teratomas that were removed. The pregnancy was terminated in 1 patient with recurrent bilateral teratomas. All patients had substantial neurological recoveries, and the 2 newborns were normal. Results of extensive antibody testing in 1 of the babies were negative. CONCLUSION The current study shows that anti-NMDAR encephalitis during pregnancy can have a good outcome for the mother and newborn.
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Affiliation(s)
- Monisha A Kumar
- Department of Neurology, University of Pennsylvania, Philadelphia, 19104, USA
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Chong E, Dysart KC, Chidekel A, Locke R, Shaffer TH, Miller TL. Heat shock protein 70 secretion by neonatal tracheal tissue during mechanical ventilation: association with indices of tissue function and modeling. Pediatr Res 2009; 65:387-91. [PMID: 19127221 PMCID: PMC2676716 DOI: 10.1203/pdr.0b013e31819913f5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Mechanical ventilation (MV) of the neonatal airway alters mechanical properties and activates tissue-modeling pathways. Heat shock protein (HSP70) is a marker of tissue injury and modulates inflammation, which may influence subsequent pulmonary tissue modeling by matrix metalloproteinases (MMPs). HSP70 secretion is up-regulated in MV airway tissues and associated with changes in airway elasticity and secretion of MMPs. Proximal tracheal segments were isolated in 13 newborn lambs and were either MV for 4 h or SHAM. At baseline and hourly, tracheal segments were flushed and tracheal elasticity was determined. Tracheal wash fluid was assayed for HSP70 by ELISA and for MMPs by substrate zymography. HSP70 secretion increased from baseline to a peak at 1 h in both groups (p < 0.01), greater in the MV group (p < 0.05), and returned to baseline values by 2 h. This response was in contrast to the progressive decrease in tracheal elasticity (p < 0.05). The HSP70 elevation pattern was noted in MMP-2, but beyond 1 h, MMP-2 returned to baseline values in MV group but remained elevated in SHAM (p < 0.05). HSP70 secretion is associated with the degree of biophysical tracheal injury as well as the time course of MMP-2 secretion by tracheal tissues.
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Affiliation(s)
- Euming Chong
- Department of Pediatrics, Jefferson Medical College, Philadelphia, Pennsylvania 19107, USA.
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Seligman NS, Salva N, Hayes EJ, Dysart KC, Pequignot EC, Baxter JK. Predicting length of treatment for neonatal abstinence syndrome in methadone-exposed neonates. Am J Obstet Gynecol 2008; 199:396.e1-7. [PMID: 18928986 DOI: 10.1016/j.ajog.2008.06.088] [Citation(s) in RCA: 89] [Impact Index Per Article: 5.6] [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: 03/01/2008] [Revised: 05/01/2008] [Accepted: 06/25/2008] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The objective of the study was to identify maternal variables predicting length of treatment for neonatal abstinence syndrome (NAS). STUDY DESIGN This was a retrospective cohort study of infants treated for NAS during 2000-2006 whose mothers were on methadone maintenance at delivery. Mixed-effects linear regression was used to examine the interaction of maternal and neonatal variables with length of treatment. RESULTS Of 204 neonates born to methadone exposed mothers, the average dose at delivery was 127 mg daily (25-340 mg) with median length of treatment 32 days (1-122 days). Trimester of initial exposure (P = .33), methadone dose at delivery (P = .198), body mass index (P = .31), antidepressant use (P = .40), cigarette use (P = .76), race (P = .78), and maternal age (P = .84) did not predict length of treatment. In the multivariate analysis, gestational age at delivery and benzodiazepine use were significant predictors of length of treatment. CONCLUSION Later gestational age and concomitant benzodiazepine use were associated with longer treatment.
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Affiliation(s)
- Neil S Seligman
- Department of Obstetrics and Gynecology, Thomas Jefferson University, Philadelphia, PA 19107, USA.
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Nankervis CA, Preston TJ, Dysart KC, Wilkinson WD, Chicoine LG, Welty SE, Nelin LD. Assessing Heparin Dosing in Neonates on Venoarterial Extracorporeal Membrane Oxygenation. ASAIO J 2007; 53:111-4. [PMID: 17237658 DOI: 10.1097/01.mat.0000247777.65764.b3] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
We studied 12 consecutive neonates placed on venoarterial extracorporeal membrane oxygenation (ECMO) in 2004-2005. Activated clotting times (ACT) and anti-factor Xa levels were measured, and the corresponding heparin drip rate was noted. The mean heparin drip rate was 42.2 +/- 10.9 (SD) U/kg/hour (range 20.0-69.5 U/kg/hour). There were 55 simultaneous ACT and anti-factor Xa samples drawn. The mean ACT was 167 +/- 20 seconds (range 128-227 seconds). There was no correlation between ACT levels and heparin dose (r = 0.21; p = 0.12). The mean anti-factor Xa activities were 0.73 +/- 0.19 U/ml (range 0.1-1.0 U/ml). There was a correlation (r = 0.75; p < 0.0001) between anti-factor Xa and heparin dose. We also examined the effect of day on ECMO on heparin drip rate, ACT, and anti-factor Xa. There was no correlation between day on ECMO and either heparin drip rate (r = 0.21, p = 0.12) or ACT (r = 0.002, p = 0.99). However, there was a positive correlation (r = 0.46, p < 0.0005) between day on ECMO and anti-factor Xa activities. In these neonatal patients on venoarterial ECMO, ACT was not a reliable indicator of heparin effect. Furthermore, the increase in anti-factor Xa levels with time on ECMO suggests that heparin accumulates and/or that anti-thrombin III levels decrease with time on ECMO.
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Affiliation(s)
- Craig A Nankervis
- Neonatal ECMO Program, Columbus Children's Hospital, Columbus, Ohio, USA
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