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Mukerji A, Read B, Yang J, Baczynski M, Ng E, Dunn M, Ethier G, Abou Mehrem A, Beltempo M, Drolet C, da Silva O, Louis D, Lemyre B, Afifi J, Singh B, Sherlock R, Stavel M, Masse E, Kanungo J, Wong J, Bodani J, Khurshid F, Lee KS, Augustine S, de Oliveira CB, Makary H, Newman A, Ojah C, Shah PS. CPAP Versus NIPPV Postextubation in Preterm Neonates: A Comparative-Effectiveness Study. Pediatrics 2024; 153:e2023064045. [PMID: 38511227 DOI: 10.1542/peds.2023-064045] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/05/2024] [Indexed: 03/22/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Nasal intermittent positive pressure ventilation (NIPPV) has been shown to be superior to nasal continuous positive airway pressure (CPAP) postextubation in preterm neonates. However, studies have not permitted high CPAP pressures or rescue with other modes. We hypothesized that if CPAP pressures >8 cmH2O and rescue with other modes were permitted, CPAP would be noninferior to NIPPV. METHODS We conducted a pragmatic, comparative-effectiveness, noninferiority study utilizing network-based real-world data from 22 Canadian NICUs. Centers self-selected CPAP or NIPPV as their standard postextubation mode for preterm neonates <29 weeks' gestation. The primary outcome was failure of the initial mode ≤72 hours. Secondary outcomes included failure ≤7 days, and reintubation ≤72 hours and ≤7 days. Groups were compared using a noninferiority adjusted risk-difference (aRD) margin of 0.05, and margin of no difference. RESULTS A total of 843 infants extubated to CPAP and 974 extubated to NIPPV were included. CPAP was not noninferior (and inferior) to NIPPV for failure of the initial mode ≤72 hours (33.0% vs 26.3%; aRD 0.07 [0.03 to 0.12], Pnoninferiority(NI) = .86), and ≤7 days (40.7% vs 35.8%; aRD 0.09 [0.05 to 0.13], PNI = 0.97). However, CPAP was noninferior (and equivalent) to NIPPV for reintubation ≤72 hours (13.2% vs 16.1%; aRD 0.01 [-0.05 to 0.02], PNI < .01), and noninferior (and superior) for reintubation ≤7 days (16.4% vs 22.8%; aRD -0.04 [-0.07 to -0.001], PNI < .01). CONCLUSIONS CPAP was not noninferior to NIPPV for failure ≤72 hours postextubation; however, it was noninferior to NIPPV for reintubation ≤72 hours and ≤7 days. This suggests CPAP may be a reasonable initial postextubation mode if alternate rescue strategies are available.
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Affiliation(s)
- Amit Mukerji
- McMaster Children's Hospital, Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
| | - Brooke Read
- London Health Sciences Centre, London, Ontario, Canada
| | - Junmin Yang
- Mount Sinai Hospital, Department of Pediatrics
| | | | - Eugene Ng
- Sunnybrook Health Sciences Centre, Department of Pediatrics
| | - Michael Dunn
- Sunnybrook Health Sciences Centre, Department of Pediatrics
| | - Guillaume Ethier
- CHU Sainte-Justine, Department of Pediatrics, University of Montreal, Montreal, Quebec, Canada
| | - Ayman Abou Mehrem
- Foothills Medical Centre, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Marc Beltempo
- Montreal Children's Hospital, McGill University, Montreal, Quebec, Canada
| | - Christine Drolet
- CHU de Quebec, Department of Pediatrics, Laval University, Quebec, Quebec City, Canada
| | - Orlando da Silva
- London Health Sciences Centre, Department of Pediatrics, Western University, London, Ontario, Canada
| | - Deepak Louis
- Health Sciences Centre and St. Boniface Hospital, Department of Pediatrics, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Brigitte Lemyre
- The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | | | | | | | | | - Edith Masse
- CIUSSSE-CHUS, Department of Pediatrics, University of Sherbrooke, Quebec, Canada
| | - Jaideep Kanungo
- Royal Victoria Hospital, University of Victoria, Victoria, British Columbia, Canada
| | - Jonathan Wong
- BC Women's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jaya Bodani
- Regina General Hospital, Department of Pediatrics, University of Regina, Regina, Saskatchewan, Canada
| | - Faiza Khurshid
- Kingston General Hospital, Queen's University, Kingston, Ontario, Canada
| | - Kyong-Soon Lee
- Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | | | | | | | - Alana Newman
- Saint John Regional Hospital, Saint John, New Brunswick, Department of Pediatrics, Dalhousie University, Halifax, Novia Scotia, Canada
| | - Cecil Ojah
- Saint John Regional Hospital, Saint John, New Brunswick, Department of Pediatrics, Dalhousie University, Halifax, Novia Scotia, Canada
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Zhu F, Ibarra Rios D, Joye S, Baczynski M, Rios D, Giesinger RE, McNamara PJ, Jain A. Cardiopulmonary physiological effects of diuretic therapy in preterm infants with chronic pulmonary hypertension. J Perinatol 2023; 43:1288-1294. [PMID: 37550529 DOI: 10.1038/s41372-023-01742-0] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 07/10/2023] [Accepted: 07/27/2023] [Indexed: 08/09/2023]
Abstract
OBJECTIVE Using targeted neonatal echocardiography (TNE) to examine cardiopulmonary physiological impact of diuretics in preterm infants with chronic pulmonary hypertension (cPH). STUDY DESIGN Retrospective study comparing TNE indices pre- and ≤2 weeks (post) of initiating diuretic therapy in infants born <32 weeks gestational age with cPH. RESULTS Twenty-seven neonates with mean gestational age, birthweight and interval between pre-post diuretic TNE of 27.0 ± 2.8 weeks, 859 ± 294 grams, and 7.8 ± 3.0 days respectively were studied. Diuretics was associated with improvement in pulmonary vascular resistance [pulmonary artery acceleration time (PAAT); 34.27(9.76) vs. 40.24(11.10)ms, p = 0.01), right ventricular (RV) ejection time:PAAT ratio [5.92(1.66) vs. 4.83(1.14), p < 0.01)], RV fractional area change [41.6(9.8) vs. 46.4(6.5%), p = 0.03)] and left ventricular myocardial performance index [0.55(0.09) vs. 0.41(0.23), p < 0.01)]. Post-treatment, frequency of bidirectional/right-to-left inter-atrial shunts decreased significantly (24% vs. 4%, p = 0.05). CONCLUSION Primary diuretic treatment in neonates with cPH may result in improvement in PVR, RV and LV function and compliance.
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Affiliation(s)
- Faith Zhu
- Department of Paediatrics, Mount Sinai Hospital, Toronto, ON, Canada
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada
| | - Daniel Ibarra Rios
- Neonatology Department, Hospital Infantil de México Federico Gómez, Mexico City, Mexico
| | | | | | - Danielle Rios
- Department of Pediatrics, University of Iowa, Iowa City, IA, USA
| | | | | | - Amish Jain
- Department of Paediatrics, Mount Sinai Hospital, Toronto, ON, Canada.
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada.
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Kharrat A, Zhu F, Baczynski M, Ye XY, Weisz D, Jain A. Organ dysfunction and mortality in preterm neonates with late-onset bloodstream infection. Pediatr Res 2023; 94:1044-1050. [PMID: 36906720 DOI: 10.1038/s41390-023-02541-1] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 02/06/2023] [Accepted: 02/08/2023] [Indexed: 03/13/2023]
Abstract
BACKGROUND Organ dysfunction (ODF) in late-onset bloodstream infection (LBSI) is associated with increased risk of adverse outcomes. However, no established definition of ODF exists among preterm neonates. Our objective was to describe an outcome-based ODF definition for preterm infants, and assess factors associated with mortality. METHODS This is a six-year retrospective study of neonates <35 weeks gestational age, >72 h of age, with non-CONS bacterial/fungal LBSI. Discriminatory ability of each parameter for mortality was evaluated: base deficit ≤-8 mmol/L (BD8), renal dysfunction (urine output <1 cc/kg/h or creatinine ≥100 μmol/L), hypoxic respiratory failure (HRF, ventilated, FiO2 = 1.0), or vasopressor/inotrope use (V/I). Multivariable logistic regression analysis was performed to derive a mortality score. RESULTS One hundred and forty-eight infants had LBSI. BD8 had the highest individual predictive ability for mortality (AUROC = 0.78). The combination BD8 + HRF + V/I was used to define ODF (AUROC = 0.84). Fifty-seven (39%) infants developed ODF, among which 28 (49%) died. Mortality increased inversely relative to GA at LBSI-onset (aOR 0.81 [0.67, 0.98]) and directly relative to ODF occurrence (12.15 [4.48, 33.92]). Compared to no-ODF, ODF infants had lower GA and age at illness, and higher frequency of Gram-negative pathogen. CONCLUSIONS Among preterm neonates with LBSI, significant metabolic acidosis, HRF, and vasopressor/inotrope use may identify infants high risk for mortality. These criteria could help identify patients for future studies of adjunctive therapies. IMPACT Sepsis-related organ dysfunction is associated with increased risk of adverse outcomes. Among preterm neonates, significant metabolic acidosis, use of vasopressors/inotropes, and hypoxic respiratory failure may identify high-risk infants. This can be used to target research and quality improvement efforts toward the most vulnerable infants.
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Affiliation(s)
- Ashraf Kharrat
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada.
- Department of Paediatrics, Mount Sinai Hospital, Toronto, ON, Canada.
| | - Faith Zhu
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada
- Department of Paediatrics, Mount Sinai Hospital, Toronto, ON, Canada
| | | | - Xiang Y Ye
- MiCare Research Centre, Mount Sinai Hospital, Toronto, ON, Canada
| | - Dany Weisz
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada
- Newborn and Developmental Paediatrics, Sunnybrook Health Sciences, Toronto, ON, Canada
| | - Amish Jain
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada
- Department of Paediatrics, Mount Sinai Hospital, Toronto, ON, Canada
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, ON, Canada
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Baczynski M, Jasani B, De Castro C, Dani C, Subhedar NV, Chandrasekharan P, Lakshminrusimha S, McNamara PJ, Bischoff AR, Jain A. Association between immediate oxygenation response and survival in preterm infants receiving rescue inhaled nitric oxide therapy for hypoxemia from pulmonary hypertension: A systematic review and meta-analysis. Early Hum Dev 2023; 184:105841. [PMID: 37542786 DOI: 10.1016/j.earlhumdev.2023.105841] [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: 06/14/2023] [Revised: 07/22/2023] [Accepted: 08/01/2023] [Indexed: 08/07/2023]
Abstract
PURPOSE To investigate whether immediate response to inhaled nitric oxide (iNO) therapy is associated with reduced mortality in preterm infants with hypoxemic respiratory failure (HRF) and pulmonary hypertension (PH). METHODS A systematic review and meta-analysis of observational studies was conducted to examine the association between immediate response (improved oxygenation ≤6 h) compared to non-response, and all-cause mortality among preterm infants <34 weeks gestational age without congenital anomalies or genetic disorders who received iNO treatment. Adjusted and unadjusted odds ratio, were pooled using a random effects meta-analysis Hartung-Knapp-Sidik-Jonkman approach. Subgroup analyses were planned for infants with preterm premature rupture of membranes (PPROM) and those treated within 72 h after birth. RESULTS The primary analysis included 5 eligible studies, a total of 400 infants (196 responders; 204 non-responders). The studies were rated as low to moderate risk of bias based on the Quality in Prognostic Studies tool. Immediate iNO responsiveness was associated with reduced odds of mortality [odds ratio (OR) 0.22, 95 % confidence interval (95 % CI) (0.10-0.49)]. Although there was insufficient data for a subgroup analysis of infants with PPROM, infants treated with iNO within 72 h demonstrated consistent findings of reduced mortality [OR 0.21 95 % CI (0.13-0.36)]. Based on the GRADE approach, considering the risk of bias of included studies, the overall strength of evidence was rated as moderate. CONCLUSION There is evidence to suggest that immediate improvement in oxygenation following iNO therapy is associated with reduced odds of mortality before discharge in preterm infants with HRF and clinically suspected or confirmed PH.
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Affiliation(s)
- Michelle Baczynski
- Department of Pediatrics, Mount Sinai Hospital, Toronto, Ontario, Canada.
| | - Bonny Jasani
- Department of Neonatology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Charmaine De Castro
- Sidney Liswood Health Sciences Library, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Carlo Dani
- Division of Neonatology, Careggi University Hospital of Florence, Florence, Italy; Department of Neurosciences, Psychology, Drug Research, and Child Health, University of Florence, Florence, Italy
| | - Nimish V Subhedar
- Department of Neonatal Medicine, Liverpool Women's Hospital, Liverpool, UK
| | | | | | - Patrick J McNamara
- Division of Neonatology, Department of Pediatrics, University of Iowa, USA
| | | | - Amish Jain
- Department of Pediatrics, Mount Sinai Hospital, Toronto, Ontario, Canada
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Baczynski M, Deekonda V, Hamilton L, Lindsay B, Ye XY, Jain A. Clinical impact of less invasive surfactant administration using video laryngoscopy in extremely preterm infants. Pediatr Res 2023; 93:990-995. [PMID: 35854087 DOI: 10.1038/s41390-022-02197-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 05/05/2022] [Revised: 06/13/2022] [Accepted: 06/28/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Examine the real-world clinical impact of adopting less invasive surfactant administration (LISA) as the primary surfactant administration method in extremely preterm infants. METHODS Single-center pre-post cohort study conducted over a 4-year period comparing outcomes of spontaneously breathing inborn infants 24+0-28+6 weeks gestational age (GA) receiving surfactant via endotracheal tube (pre-cohort, n = 154) or LISA via thin catheter (post-cohort, n = 70). Primary outcome was need for invasive mechanical ventilation (IMV, ≥2 h) ≤72 h of age. Secondary outcomes were a composite of mortality, bronchopulmonary dysplasia, intraventricular hemorrhage ≥grade 3 or necrotizing enterocolitis, and its individual components. Groups were compared using propensity score methods, including covariates: GA, birth weight, sex, small for GA, SNAP II ≥20, premature rupture of membranes, maternal hypertension/diabetes, and C-section. RESULTS GA and birth weight were 27.1 (26, 28.1) weeks and 914 (230) g, and 27.1 (26.1, 28.1) weeks and 920 (236) g for pre- and post-cohorts, respectively. Pre-cohort had higher C-section rates, (67% vs. 51%, p = 0.03). After adjustment for covariates, LISA was associated with reduced IMV exposure [AOR (95% CI) 0.07 (0.04, 0.11)], lower odds of the composite clinical outcome [0.49 (0.33, 0.73)], and most of its individual components. CONCLUSION Real-world experience favors LISA as the primary method in extremely preterm infants with established spontaneous respiration. IMPACT Less invasive surfactant administration (LISA) is associated with a reduction in respiratory morbidity, but real-world data of routine use among extremely preterm infants are limited. LISA is associated with reduced frequency of exposure to and duration of IMV in both ≤72 h after birth and during hospital stay. LISA is associated with a reduction in mortality, and most other major morbidities including bronchopulmonary dysplasia, and interventricular hemorrhage. Data from a large North American center providing real-world clinical outcomes following LISA as the primary method of surfactant administration.
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Affiliation(s)
- Michelle Baczynski
- Department of Respiratory Therapy, Mount Sinai Hospital, Toronto, ON, Canada.
| | - Veena Deekonda
- Department of Respiratory Therapy, Mount Sinai Hospital, Toronto, ON, Canada
| | - Lisa Hamilton
- Department of Respiratory Therapy, Mount Sinai Hospital, Toronto, ON, Canada
| | - Brittany Lindsay
- Department of Respiratory Therapy, Mount Sinai Hospital, Toronto, ON, Canada
| | - Xiang Y Ye
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, ON, Canada
| | - Amish Jain
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, ON, Canada
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada
- Department of Paediatrics, Mount Sinai Hospital, Toronto, ON, Canada
- Department of Physiology, University of Toronto, Toronto, ON, Canada
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Nissimov S, Joye S, Kharrat A, Zhu F, Ripstein G, Baczynski M, Choudhury J, Jasani B, Deshpande P, Ye XY, Weisz DE, Jain A. Dopamine or norepinephrine for sepsis-related hypotension in preterm infants: a retrospective cohort study. Eur J Pediatr 2023; 182:1029-1038. [PMID: 36544000 DOI: 10.1007/s00431-022-04758-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [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: 09/24/2022] [Revised: 12/03/2022] [Accepted: 12/07/2022] [Indexed: 12/24/2022]
Abstract
The purpose of this study is to compare the clinical effectiveness of dopamine (DA) versus norepinephrine (NE) as first-line therapy for sepsis-related hypotension in preterm infants. This is a retrospective cohort study over 10 years at two tertiary neonatal units. Preterm infants born < 35 weeks post-menstrual age (PMA), who received DA or NE as primary therapy for hypotension during sepsis, defined as culture-positive or culture-negative infections or necrotizing enterocolitis (NEC), were included. Episode-related mortality (< 7 days from treatment), pre-discharge mortality, and major morbidities among survivors were compared between two groups. Analyses were adjusted using the inverse probability of treatment weighting estimated by propensity score (PS). A total of 156 infants were included, 113 received DA and 43 NE. The mean ± SD PMA at birth and at treatment for the DA and NE groups were 25.8 ± 2.3 vs. 25.2 ± 2.0 weeks and 27.7 ± 3.0 vs. 27.1 ± 2.6 weeks, respectively (p > 0.05). Pre-treatment, the NE group had higher mean airway pressure (14 ± 4 vs. 12 ± 4 cmH2O), heart rate (185 ± 17 vs. 175 ± 17 beats per minute), and median (IQR) fraction of inspired oxygen [0.67 (0.42, 1.0) vs. 0.52 (0.32, 0.82)] (p < 0.05 for all). After PS adjustment, NE was associated with lower episode-related mortality [adjusted odds ratio (95% CI) 0.55 (0.33, 0.92)], pre-discharge mortality [0.60 (0.37, 0.97)], post-illness new diagnosis of significant neurologic injury [0.32 (0.13, 0.82)], and subsequent occurrence of NEC/sepsis among the survivors [0.34, (0.18, 0.65)]. CONCLUSION NE may be more effective than DA for management of sepsis-related hypotension among preterm infants. These data provide a rationale for prospective evaluation of these commonly used agents. WHAT IS KNOWN •Dopamine is the commonest vasoactive agent used to support blood pressure among preterm infants. •For adult patients, norepinephrine is recommended as the preferred therapy over dopamine for septic shock. WHAT IS NEW •This is the first study examining the relative clinical effectiveness of dopamine and norepinephrine as first-line pharmacotherapy for sepsis-related hypotension among preterm infants. •Norepinephrine use may be associated with lower mortality and morbidity than dopamine in preterm infants with sepsis.
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Affiliation(s)
- Sagee Nissimov
- Department of Paediatrics, Mount Sinai Hospital, ON, Toronto, Canada
| | - Sébastien Joye
- Clinic of Neonatology, Lausanne University Hospital, Lausanne, Switzerland
| | - Ashraf Kharrat
- Department of Paediatrics, Mount Sinai Hospital, ON, Toronto, Canada
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada
| | - Faith Zhu
- Department of Paediatrics, Mount Sinai Hospital, ON, Toronto, Canada
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada
| | | | - Michelle Baczynski
- Department of Respiratory Therapy, Mount Sinai Hospital, Toronto, ON, Canada
| | - Julie Choudhury
- Department of Pharmacy, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Bonny Jasani
- Division of Neonatology, Department of Pediatrics, Hospital for Sick Children, Toronto, ON, Canada
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada
| | - Poorva Deshpande
- Department of Paediatrics, Mount Sinai Hospital, ON, Toronto, Canada
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada
| | - Xiang Y Ye
- Lunnenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, ON, Canada
| | - Dany E Weisz
- Newborn and Developmental Paediatrics, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada
| | - Amish Jain
- Department of Paediatrics, Mount Sinai Hospital, ON, Toronto, Canada.
- Lunnenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, ON, Canada.
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada.
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Mohsen N, Nasef N, Ghanem M, Yeung T, Deekonda V, Ma C, Kajal D, Baczynski M, Jain A, Mohamed A. Accuracy of lung and diaphragm ultrasound in predicting successful extubation in extremely preterm infants: A prospective observational study. Pediatr Pulmonol 2023; 58:530-539. [PMID: 36324211 DOI: 10.1002/ppul.26223] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [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: 08/10/2022] [Revised: 09/28/2022] [Accepted: 11/01/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Chest ultrasound has emerged as a promising tool in predicting extubation readiness in adults and children, yet its utility in preterm infants is lacking. Our aim was to assess the utility of lung ultrasound severity score (LUSS) and diaphragmatic function in predicting extubation readiness in extremely preterm infants. STUDY DESIGN In this prospective cohort study, preterm infants < 28 weeks gestational age (GA) who received invasive mechanical ventilation for ≥12 h were enrolled. Chest ultrasound was performed before extubation. The primary outcome was lung ultrasound accuracy for predicting successful extubation at 3 days. Descriptive statistics and logistic regression were done using SPSS version 22. RESULTS We enrolled 45 infants, of whom 36 (80%) were successfully extubated. GA and postmenstrual age (PMA) at extubation were significantly higher in the successful group. The LUSS was significantly lower in the successful group compared to failed group (11.9 ± 3.2 vs. 19.1 ± 3.1 p < 0.001). The two groups had no statistically significant difference in diaphragmatic excursion or diaphragmatic thickness fraction. Logistic regression analysis controlling for GA and PMA at extubation showed LUSS was an independent predictor for successful extubation (odd ratio 0.46, 95% confidence interval [0.23-0.9], p = 0.02). The area under the receiver operating characteristic curve was 0.95 (p ˂ 0.001) for LUSS, and a cut-off value of ≥15 had 95% sensitivity and 85% specificity in detecting extubation failure. CONCLUSION In extremely preterm infants, lung ultrasound has good accuracy for predicting successful extubation. However, diaphragmatic measurements were not reliable predictors.
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Affiliation(s)
- Nada Mohsen
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada.,Mount Sinai Hospital, Toronto, Ontario, Canada.,Department of Pediatrics, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Nehad Nasef
- Department of Pediatrics, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Mohab Ghanem
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada.,Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Telford Yeung
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada.,Mount Sinai Hospital, Toronto, Ontario, Canada.,Department of Pediatrics, Windsor Regional Hospital Metropolitan campus, Windsor, Ontario, Canada
| | | | - Carmen Ma
- Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Dilkash Kajal
- Mount Sinai Hospital, Toronto, Ontario, Canada.,Joint Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
| | | | - Amish Jain
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada.,Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Adel Mohamed
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada.,Mount Sinai Hospital, Toronto, Ontario, Canada
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Kharrat A, Ripstein G, Baczynski M, Zhu F, Ye XY, Joye S, Jain A. Validity of the vasoactive-inotropic score in preterm neonates receiving cardioactive therapies. Early Hum Dev 2022; 173:105657. [PMID: 36087459 DOI: 10.1016/j.earlhumdev.2022.105657] [Citation(s) in RCA: 3] [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: 06/07/2022] [Revised: 08/12/2022] [Accepted: 08/15/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Vasoactive-Inotropic Score (VIS) is a weighted sum of various vasopressors and inotropes; its utility among preterm neonates is understudied. OBJECTIVE To investigate the association between maximum VIS (VISmax) during the first 12, 24 and 48 h of treatment among preterm neonates who received vasopressors/inotropes, and the composite outcome of death/severe neuroinjury (sNI). METHODS Retrospective cohort study, over 6-years, including neonates <35 weeks gestational age (GA). Infants who met the primary composite outcome of death or sNI (defined as new intraventricular hemorrhage ≥grade 3 or periventricular leukomalacia) were compared to those who survived without sNI. Maximum VIS was categorized as <10, 10-19 or ≥ 20 for comparison. RESULTS 192 infants (mean GA and birth weight 26.8 ± 3.3 weeks and 952 ± 528 g, respectively) were included. The most common primary diagnosis was sepsis/necrotizing enterocolitis (69 %). Median VIS for the entire cohort was 10. Death/sNI was associated with lower GA at birth and treatment, as well as higher frequency of VISmax of 10-19 or ≥20, compared to <10, during each time period (all p < 0.01). Multivariable regression revealed GA at treatment and VISmax ≥ 20 [not 10-19, referenced to <10] were associated death/sNI; adjusted odds ratio (95 % CI) for VISmax ≥ 20 within 12, 24, and 48 h were 4.2 (1.6-11.0), 4.9 (1.9-12.3), and 6.7 (2.7-16.7), respectively. CONCLUSIONS Vasoactive-Inotropic Score may be a valid measure to quantify cardiovascular support in preterm infants needing hemodynamic support. Maximum VIS ≥20 within 48 h of treatment initiation may identify patients at high risk of adverse outcomes.
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Affiliation(s)
- Ashraf Kharrat
- Department of Paediatrics, Mount Sinai Hospital, Toronto, ON, Canada; Department of Paediatrics, University of Toronto, Toronto, ON, Canada.
| | | | - Michelle Baczynski
- Department of Respiratory Therapy, Mount Sinai Hospital, Toronto, ON, Canada
| | - Faith Zhu
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada
| | - Xiang Y Ye
- Maternal-Infant Care Research Centre, Mount Sinai Hospital, Toronto, ON, Canada
| | - Sebastien Joye
- Clinic of Neonatology, Lausanne University Hospital, Lausanne, Switzerland
| | - Amish Jain
- Department of Paediatrics, Mount Sinai Hospital, Toronto, ON, Canada; Department of Paediatrics, University of Toronto, Toronto, ON, Canada; Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, ON, Canada
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Baczynski M, Kharrat A, Zhu F, Ye XY, Shah PS, Weisz DE, Jain A. Factors associated with antibiotic administration delay among preterm infants with late-onset bloodstream infection. J Hosp Infect 2021; 120:31-35. [PMID: 34800611 DOI: 10.1016/j.jhin.2021.09.026] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 09/08/2021] [Accepted: 09/08/2021] [Indexed: 11/25/2022]
Abstract
Early antibiotic administration is an important modifiable factor in reducing mortality from late-onset bloodstream infections in preterm infants. In a cohort study including 142 infants with non-coagulase negative staphylococcus bloodstream infection at two tertiary neonatal intensive care units, we identified typical practice-related factors that may be targeted to prevent delays in antibiotic administration. Collection of cerebrospinal fluid or urine sample before administering antibiotics, a longer time taken to site a peripheral intravenous catheter among those without pre-existing access, and a longer time taken to administer fluid boluses were associated with a longer than median time to antibiotic administration.
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Affiliation(s)
- M Baczynski
- Department of Respiratory Therapy, Mount Sinai Hospital, Toronto, ON, Canada
| | - A Kharrat
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada; Department of Paediatrics, Mount Sinai Hospital, Toronto, ON, Canada
| | - F Zhu
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada
| | - X Y Ye
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, ON, Canada
| | - P S Shah
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada; Department of Paediatrics, Mount Sinai Hospital, Toronto, ON, Canada; Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, ON, Canada
| | - D E Weisz
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada; Department of Newborn and Developmental Paediatrics, Sunnybrook Health Science Center, Toronto, ON, Canada
| | - A Jain
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada; Department of Paediatrics, Mount Sinai Hospital, Toronto, ON, Canada; Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, ON, Canada; Department of Physiology, University of Toronto, Toronto, ON, Canada.
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10
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Baczynski M, Kharrat A, Zhu F, Ye XY, Shah PS, Weisz DE, Jain A. Bloodstream Infections in Preterm Neonates and Mortality-Associated Risk Factors. J Pediatr 2021; 237:206-212.e1. [PMID: 34166670 DOI: 10.1016/j.jpeds.2021.06.031] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [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: 02/27/2021] [Revised: 06/11/2021] [Accepted: 06/15/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To investigate the association of early (±4 hours after onset of bloodstream infection) clinical and laboratory variables with episode-related mortality (<7 days). STUDY DESIGN This 2-site retrospective study included 142 neonates born at <35 weeks of gestational age with positive blood/cerebrospinal fluid (CSF) culture at >72 hours of age from organisms other than coagulase-negative Staphylococcus. Early variables were compared between those with bloodstream infection-related mortality and survivors. Multivariable analysis was conducted for the primary outcome, and the area under the curve (AUC) was estimated for relevant variables. RESULTS The neonates who died were of lower gestational age at disease onset. After adjusting for relevant variables, lowest mean blood pressure (MBP) (aOR, 0.10; 95% CI, 1.02-1.19) and highest base deficit (aOR, 1.18; 95% CI, 1.06-1.32) were independently associated with mortality. The AUC was 0.87 (95% CI, 0.78-0.96) for base deficit, increasing to 0.91 (95% CI, 0.83-0.99) with the addition of MBP. CONCLUSION Low MBP and high base deficit within ±4 hours of bloodstream infection onset identify preterm neonates at risk of mortality.
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Affiliation(s)
- Michelle Baczynski
- Department of Respiratory Therapy, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Ashraf Kharrat
- Department of pediatrics, University of Toronto, Toronto, Ontario, Canada; Department of pediatrics, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Faith Zhu
- Department of pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Xiang Y Ye
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Prakesh S Shah
- Department of pediatrics, University of Toronto, Toronto, Ontario, Canada; Department of pediatrics, Mount Sinai Hospital, Toronto, Ontario, Canada; Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Dany E Weisz
- Department of pediatrics, University of Toronto, Toronto, Ontario, Canada; Department of Newborn and Developmental pediatrics, Sunnybrook Health Science Center, Toronto, Ontario, Canada
| | - Amish Jain
- Department of pediatrics, University of Toronto, Toronto, Ontario, Canada; Department of pediatrics, Mount Sinai Hospital, Toronto, Ontario, Canada; Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada; Department of Physiology, University of Toronto, Toronto, Ontario, Canada.
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11
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Baczynski M, Kelly E, McNamara PJ, Shah PS, Jain A. Short and long-term outcomes of chronic pulmonary hypertension in preterm infants managed using a standardized algorithm. Pediatr Pulmonol 2021; 56:1155-1164. [PMID: 33270376 DOI: 10.1002/ppul.25200] [Citation(s) in RCA: 1] [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] [Received: 11/05/2020] [Revised: 11/25/2020] [Accepted: 11/27/2020] [Indexed: 01/22/2023]
Abstract
BACKGROUND There is limited data on management strategies for chronic pulmonary hypertension (cPH) in chronic lung disease (CLD) of prematurity. Our objective was to evaluate clinical outcomes following a standardized policy, wherein only cPH with right-ventricular (RV) dilatation was treated and diuretics were employed as first-line therapy; cPH without RV-dilatation was managed expectantly. METHOD In this retrospective cohort study, all infants with CLD were categorized as "CLD-only" or "CLD-cPH," using echocardiography at ≥36 weeks postmenstrual age. Intergroup comparison was performed. Regression analysis examined the association between cPH and primary outcome of death or disability at 18-24 months. RESULTS Of 128 CLD infants, 48 (38%) had cPH, of which 29 (60%) received diuretics. Symptomatic improvement within 1-week was recorded in 90%. Although CLD-cPH had worse in-hospital respiratory course than CLD-only, all post-discharge respiratory and neurodevelopmental outcomes were similar. cPH was not associated with death or disability (adjusted odds ratio, 1.02; 95% confidence interval, 0.32-3.27). Disease progression treated with sildenafil occurred in 2 (4%) cases. There was no death from respiratory or RV failure. CONCLUSION Primary treatment of CLD-cPH with diuretics using RV-dilatation as therapeutic threshold, may result in symptomatic improvement, disease stabilization and post-discharge outcomes comparable to infants without cPH.
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Affiliation(s)
- Michelle Baczynski
- Department of Respiratory Therapy, Mount Sinai Hospital, Toronto, Canada
| | - Edmond Kelly
- Department of Pediatrics, Mount Sinai Hospital, Toronto, Canada
| | - Patrick J McNamara
- Division of Neonatology, University of Iowa Stead Family Children's Hospital, Iowa, USA
| | - Prakesh S Shah
- Department of Pediatrics, Mount Sinai Hospital, Toronto, Canada.,Lunnenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Canada.,Department of Pediatrics, University of Toronto, Toronto, Canada
| | - Amish Jain
- Department of Pediatrics, Mount Sinai Hospital, Toronto, Canada.,Lunnenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Canada.,Department of Pediatrics, University of Toronto, Toronto, Canada.,Department of Physiology, University of Toronto, Toronto, Canada
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12
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Thomas L, Baczynski M, Deshpande P, Kharrat A, Joye S, Zhu F, Ibarra-Rios D, Shah PS, Mertens L, Jankov RP, Ye XY, Neary E, Ting J, Castaldo M, Levy P, Smith A, El-Khuffash AF, Giesinger RE, McNamara PJ, Weisz DE, Jain A. Multicentre prospective observational study exploring the predictive value of functional echocardiographic indices for early identification of preterm neonates at risk of developing chronic pulmonary hypertension secondary to chronic neonatal lung disease. BMJ Open 2021; 11:e044924. [PMID: 33789855 PMCID: PMC8016080 DOI: 10.1136/bmjopen-2020-044924] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
INTRODUCTION Although chronic pulmonary hypertension (cPH) secondary to chronic neonatal lung disease is associated with increased mortality and respiratory and neurodevelopmental morbidities, late diagnosis (typically ≥36 weeks postmenstrual age, PMA) and the use of qualitative echocardiographic diagnostic criterion (flat interventricular septum in systole) remain significant limitations in clinical care. Our objective in this study is to evaluate the utility of relevant quantitative echocardiographic indices to identify cPH in preterm neonates, early in postnatal course and to develop a diagnostic test based on the best combination of markers. METHODS AND ANALYSIS In this ongoing international prospective multicentre observational diagnostic accuracy study, we aim to recruit 350 neonates born <27 weeks PMA and/or birth weight <1000 g and perform echocardiograms in the third week of age and at 32 weeks PMA (early diagnostic assessments, EDA) in addition to the standard diagnostic assessment (SDA) for cPH at 36 weeks PMA. Predefined echocardiographic markers under investigation will be measured at each EDA and examined to create a scoring system to identify neonates who subsequently meet the primary outcome of cPH/death at SDA. Diagnostic test characteristics will be defined for each EDA. Pulmonary artery acceleration time and tricuspid annular plane systolic excursion are the primary markers of interest. ETHICS AND DISSEMINATION Ethics approval has been received by the Mount Sinai Hospital Research Ethics Board (REB) (#16-0111-E), Sunnybrook Health Sciences Centre REB (#228-2016), NHS Health Research Authority (IRAS 266498), University of Iowa Human Subjects Office/Institutional Review Board (201903736), Rotunda Hospital Research and Ethics Committee (REC-2019-008), and UBC Children's and Women's REB (H19-02738), and is under review at Boston Children's Hospital Institutional Review Board. Study results will be disseminated to participating families in lay format, presented to the scientific community at paediatric and critical care conferences and published in relevant peer-reviewed journals. TRAIL REGISTRATION NUMBER NCT04402645.
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Affiliation(s)
- Laura Thomas
- Paediatrics, Sinai Health System, Toronto, Ontario, Canada
- Newborn and Developmental Paediatrics, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | | | - Poorva Deshpande
- Paediatrics, Sinai Health System, Toronto, Ontario, Canada
- Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Ashraf Kharrat
- Paediatrics, Sinai Health System, Toronto, Ontario, Canada
- Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Sébastien Joye
- Clinic of Neonatology, Lausanne University Hospital, Lausanne, Switzerland
| | - Faith Zhu
- Paediatrics, Sinai Health System, Toronto, Ontario, Canada
| | - Daniel Ibarra-Rios
- Neonatology, Hospital Infantil de Mexico Federico Gomez, Mexico City, Mexico
| | - Prakesh S Shah
- Paediatrics, Sinai Health System, Toronto, Ontario, Canada
- Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Luc Mertens
- Division of Cardiology, Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Robert P Jankov
- Division of Neonatology, Department of Paediatrics, University of Ottawa, Ottawa, Ontario, Canada
| | - Xiang Y Ye
- MiCare Research Centre, Sinai Health System, Toronto, Ontario, Canada
| | - Elaine Neary
- Neonatology, Liverpool Women's Hospital NHS Foundation Trust, Liverpool, UK
| | - Joseph Ting
- Neonatology, The University of British Columbia, Vancouver, Ontario, Canada
| | - Michael Castaldo
- Neonatology, The University of British Columbia, Vancouver, Ontario, Canada
| | - Philip Levy
- Boston Children's Hospital Department of Pediatrics, Boston, Massachusetts, USA
- Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | | | | | - Regan E Giesinger
- Pediatrics, The University of Iowa Stead Family Children's Hospital, Iowa City, Iowa, USA
| | - Patrick J McNamara
- Pediatrics, The University of Iowa Stead Family Children's Hospital, Iowa City, Iowa, USA
| | - Dany E Weisz
- Newborn and Developmental Paediatrics, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Amish Jain
- Paediatrics, Sinai Health System, Toronto, Ontario, Canada
- Paediatrics, University of Toronto, Toronto, Ontario, Canada
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13
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Baczynski M, Bell EF, Finan E, McNamara PJ, Jain A. Survey of practices in relation to chronic pulmonary hypertension in neonates in the Canadian Neonatal Network and the National Institute of Child Health and Human Development Neonatal Research Network. Pulm Circ 2020; 10:2045894020937126. [PMID: 32728420 PMCID: PMC7366415 DOI: 10.1177/2045894020937126] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 06/03/2020] [Indexed: 11/17/2022] Open
Abstract
Current knowledge gaps pertaining to diagnosis and management of neonatal chronic
pulmonary hypertension (cPH) may result in significant variability in clinical practice.
The objective of the study is to understand cPH management practices in neonatal intensive
care units affiliated with the Canadian Neonatal Network (CNN) and National Institute of
Child Health and Human Development Neonatal Research Network (NRN). A 32-question survey
seeking practice details for cPH evaluation, diagnostic criteria, conservative measures,
pharmacotherapeutics, and follow-up was e-mailed to a designated physician at each center.
Responses were described as frequency (percentage) and compared between CNN and NRN, where
appropriate. Overall response rate was 67% (CNN 20/28 (71%), NRN 9/15 (60%)). While 8
(28%) centers had standardized management protocols, 17 (59%) routinely evaluate high-risk
patients; moderate-severe chronic lung disease being the commonest indication. While
interventricular septal flattening on echocardiography was the commonest listed diagnostic
criterion, several adjunctive indices were also identified. Asymptomatic neonates with cPH
were managed expectantly (routine care) in 50% of sites, and using various conservative
measures in others. Pulmonary vasodilators were prescribed for symptomatic cases, with 60%
of sites using them early (86% reporting any use). Seventy-five percent of sites use
inhaled nitric oxide and sildenafil citrate as first- and second-line agents,
respectively. Use of standard protocols, cardiac catheterization, and conservative
measures for asymptomatic cases was more common in NRN units
(p < 0.05). While there is relative homogeneity in patient
identification and diagnostic criteria used for neonatal cPH, significant interunit
inconsistencies still exists in routine evaluation, use of additional investigations,
management of asymptomatic cases, frequency and type of conservative measures, and choice
of pulmonary vasodilators.
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Affiliation(s)
| | - Edward F Bell
- Division of Neonatology, University of Iowa Stead Family Children's Hospital, Iowa City, IA, USA
| | - Emer Finan
- Department of Pediatrics, Mount Sinai Hospital, Toronto, Canada.,Lunnenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Canada.,Department of Paediatrics, University of Toronto, Toronto, Canada
| | - Patrick J McNamara
- Division of Neonatology, University of Iowa Stead Family Children's Hospital, Iowa City, IA, USA.,Physiology, University of Toronto, Toronto, Canada
| | - Amish Jain
- Department of Pediatrics, Mount Sinai Hospital, Toronto, Canada.,Lunnenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Canada.,Department of Paediatrics, University of Toronto, Toronto, Canada
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14
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Deshpande P, Jain A, Ibarra Ríos D, Bhattacharya S, Dirks J, Baczynski M, McNamara KP, Hahn C, McNamara PJ, Shah P, Guerguerian AM. Combined Multimodal Cerebral Monitoring and Focused Hemodynamic Assessment in the First 72 h in Extremely Low Gestational Age Infants. Neonatology 2020; 117:504-512. [PMID: 32814317 DOI: 10.1159/000508961] [Citation(s) in RCA: 5] [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: 01/28/2020] [Accepted: 05/24/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Characteristic changes in cerebral saturation (CrSO2), amplitude-integrated electroencephalography (aEEG), and echocardiography (ECHO) may be associated with intraventricular hemorrhage (IVH); however, the feasibility of their combined application is not known. OBJECTIVE The aim of this work was to investigate the feasibility and safety of combined multimodal cerebral and hemodynamic monitoring in extremely low gestational age (ELGA) infants in the first 72 h after birth. METHODS In this prospective -observational study of 50 infants born between 23 + 0 and 27 + 6 weeks gestation, we measured CrSO2 and aEEG, starting <8 h until 72 h of age. Sequential echocardiography and head ultrasound were performed at 4-8, 12-18, 24-30, and 48-60 h of age. The primary outcome was feasibility of multimodal monitoring, defined as >75% of the subjects satisfying at least 3/4 criteria: (a) CrSO2 and (b) aEEG monitoring each for >75% of the time, and (c) at least 2 out of 4 ECHO and (d) head ultrasounds (at least one by age 24 h). Adverse reactions to sensors, desaturation, and bradycardia during ultrasound studies were recorded. RESULTS Fifty infants were enrolled over 14 months. Multimodal monitoring was feasible in 49 (98%) infants. Forty-one (82%) infants fulfilled all 4 criteria. Mild erythema below CrSO2 sensors lasting 3-8 h without skin breakdown was noted in 8/50 subjects (16%). Desaturation was noted during 17/197 (8.6%) of the ultrasound studies. In total, 26/50 (52%) infants developed IVH (grade I/II, n = 22; grade III/IV, n = 4). CONCLUSION Multimodal monitoring is feasible, safe, and well tolerated in ELGA infants in the first 72 h after birth.
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Affiliation(s)
- Poorva Deshpande
- Mount Sinai Hospital, Toronto, Ontario, Canada, .,Division of Neonatology, University of Toronto, Toronto, Ontario, Canada,
| | - Amish Jain
- Mount Sinai Hospital, Toronto, Ontario, Canada.,Division of Neonatology, University of Toronto, Toronto, Ontario, Canada
| | | | | | - Julia Dirks
- Neurosciences and Mental Health Program, Toronto, Ontario, Canada
| | | | | | - Cecil Hahn
- Hospital for Sick Children, Toronto, Ontario, Canada.,Neurosciences and Mental Health Program, Toronto, Ontario, Canada
| | - Patrick J McNamara
- Hospital for Sick Children, Toronto, Ontario, Canada.,Division of Neonatology, University of Toronto, Toronto, Ontario, Canada
| | - Prakesh Shah
- Mount Sinai Hospital, Toronto, Ontario, Canada.,Division of Neonatology, University of Toronto, Toronto, Ontario, Canada
| | - Anne-Marie Guerguerian
- Hospital for Sick Children, Toronto, Ontario, Canada.,Neurosciences and Mental Health Program, Toronto, Ontario, Canada
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15
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Ahmed MS, Giesinger RE, Ibrahim M, Baczynski M, Louis D, McNamara KP, Jain A, Weisz DE, McNamara PJ. Clinical and echocardiography predictors of response to inhaled nitric oxide in hypoxic preterm neonates. J Paediatr Child Health 2019; 55:753-761. [PMID: 30537276 DOI: 10.1111/jpc.14286] [Citation(s) in RCA: 7] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Revised: 09/12/2018] [Accepted: 10/04/2018] [Indexed: 11/30/2022]
Abstract
AIM To evaluate the clinical and echocardiography modulators of treatment response in hypoxemic preterm infants exposed to inhaled nitric oxide (iNO). METHODS In this multicentre retrospective study, clinical parameters, including oxygenation, ventilation and haemodynamics, were collected for preterm infants <36 weeks gestation before and 2 h after initiation of iNO for acute hypoxemia. Comprehensive echocardiography, performed near the time iNO initiation, was analysed by experts blind to the clinical course. Multiple logistic regression analysis was used to identify factors associated with iNO response as defined by a reduction in the fraction of inspired oxygen by >0.20. RESULTS A total of 213 infants met eligibility criteria, of which 73 had echocardiography data available and formed the study cohort. Response to iNO was demonstrated in 56% of patients. Younger post-natal age (odds ratio (OR) 0.94; 95% confidence interval (CI) 0.89, 0.99) and the presence of pulmonary hypertension (PH) (OR 4.47; 95% CI 1.23-11.9) were independently predictive of iNO response regardless of gestational age. Among neonates <72 h old with documented PH, iNO response was seen in 82%. The onset of a new diagnosis of severe (grade III/IV) intraventricular haemorrhage (IVH) after iNO treatment was seen in 6 of 40 patients <28 weeks' gestational age, with a greater frequency in responders (32 vs. 0%, P = 0.02). CONCLUSIONS Positive response to iNO is greatest in the first 3 days of life and in patients with echo-confirmed PH, independent of gestational age. The association between critical illness, iNO administration and IVH in extremely premature infants may merit prospective delineation.
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Affiliation(s)
- Mohamed Shalabi Ahmed
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada.,Department of Pediatrics, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Regan E Giesinger
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada.,Division of Neonatology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Mohamed Ibrahim
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada.,Department of Pediatrics, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Michelle Baczynski
- Department of Pediatrics, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Deepak Louis
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada.,Department of Pediatrics, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Karl P McNamara
- Department of Physiology, University of Toronto, Toronto, Ontario, Canada
| | - Amish Jain
- Department of Pediatrics, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Dany E Weisz
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada.,Department of Pediatrics, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Patrick J McNamara
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada.,Division of Neonatology, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Physiology, University of Toronto, Toronto, Ontario, Canada
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16
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Baczynski M, Ginty S, Weisz DE, McNamara PJ, Kelly E, Shah P, Jain A. Short-term and long-term outcomes of preterm neonates with acute severe pulmonary hypertension following rescue treatment with inhaled nitric oxide. Arch Dis Child Fetal Neonatal Ed 2017; 102:F508-F514. [PMID: 28483819 DOI: 10.1136/archdischild-2016-312409] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [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: 11/24/2016] [Revised: 03/13/2017] [Accepted: 03/17/2017] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To describe short-term and long-term outcomes of preterm neonates with severe acute pulmonary hypertension (aPHT) in relation to response to rescue inhaled nitric oxide (iNO) therapy. DESIGN Retrospective cohort studyover a 6 year period. SETTING Tertiary neonatal intensive care unit. PATIENTS 89 neonates <35 weeks gestational age (GA) who received rescue iNO for aPHT, including 62 treated at ≤3 days of age (early aPHT). INTERVENTIONS iNO ≥ 1 hour. MAIN OUTCOME MEASURES Positive responders (reduction in fraction of inspired oxygen (FiO2) ≥0.20 within 1 hour of iNO) were compared with non-responders. Primary outcome was survival without moderate-to-severe disability at 18 months of age. RESULTS Mean (SD) GA and birth weight was 27.7 (3.0) weeks and 1077 (473) gm, respectively. Median (IQR) pre-iNO FiO2 was 1.0 (1.0, 1.0). Positive response rate to iNO was 46%. Responders showed improved survival without disability (51% vs 15%; p<0.01), lower mortality (34% vs 71%; p<0.01) and disability among survivors (17% vs 50%; p=0.06). Higher GA (adjusted OR: 1.44 (95% CI 1.10 to 1.89)), aPHT in context of preterm prolonged rupture of membranes (6.26 (95% CI 1.44 to 27.20)) and positive response to rescue iNO (5.81 (95% CI 1.29 to, 26.18)) were independently associated with the primary outcome. Compared with late cases (>3 days of age), early aPHT had a higher response rate to iNO (61% vs 11%; p<0.01) and lower mortality (43% vs 78%; p<0.01). CONCLUSION A positive response to rescue iNO in preterm infants with aPHT is associated with survival benefit, which is not offset by long-term disability.
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Affiliation(s)
- Michelle Baczynski
- Department of Respiratory Therapy, Mount Sinai Hospital, Toronto, Canada
| | - Shannon Ginty
- Department of Respiratory Therapy, Mount Sinai Hospital, Toronto, Canada
| | - Dany E Weisz
- Department of Newborn and Developmental Paediatrics, Sunnybrook Health Science Center, Toronto, Canada.,Department of Paediatrics, University of Toronto, Toronto, Canada
| | - Patrick J McNamara
- Department of Paediatrics, University of Toronto, Toronto, Canada.,Division of Neonatology, Hospital for Sick Children, Toronto, Canada.,Physiology, University of Toronto, Toronto, Canada
| | - Edmond Kelly
- Department of Paediatrics, University of Toronto, Toronto, Canada.,Department of Paediatrics, Mount Sinai Hospital, Toronto, Canada
| | - Prakeshkumar Shah
- Department of Paediatrics, University of Toronto, Toronto, Canada.,Department of Paediatrics, Mount Sinai Hospital, Toronto, Canada.,Lunnenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Canada
| | - Amish Jain
- Department of Paediatrics, University of Toronto, Toronto, Canada.,Physiology, University of Toronto, Toronto, Canada.,Department of Paediatrics, Mount Sinai Hospital, Toronto, Canada.,Lunnenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Canada
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17
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Abstract
In this study we report on the clinical, radiological and pathologic data of 42 intraosseous ganglia which had been verified histologically. Of the patients, 26 were male and 16 female. Their mean age was 41.8 years (range 20-71 years). Exclusively solitary ganglia were included in this study; mainly they were located within the lower extremity. In most cases (n = 12), the malleolus medialis was involved. In 40 patients, treatment consisted of curettage, in 39 cases in combination with autologous or homologous bone grafting. In 2 cases, a resection was performed. No local recurrence was observed. Etiology and pathogenesis are discussed.
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Affiliation(s)
- U Helwig
- Department of Orthopedics, University of Vienna, Austria
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