Prenatal growth characteristics and pre/postnatal management of bronchopulmonary sequestrations

PURPOSE

The prenatal natural history of intralobar and extralobar bronchopulmonary sequestrations (BPSs), including lesion growth patterns and need for prenatal intervention, have not been fully characterized. We review our series of BPSs to determine their natural history and outcomes in the context of the need for prenatal intervention.

METHODS

A retrospective review of the pre/postnatal course of 103 fetuses with an intralobar (n=44) or extralobar BPS (n=59) managed at a single institution between 2008 and 2015 was performed. Outcomes included prenatal lesion growth trajectory, presence of hydrops, need for prenatal intervention, survival, and postnatal surgical management.

RESULTS

Most extralobar (71%) and intralobar BPSs (94%) decreased in size or became isoechoic from initial to final evaluation. Peak lesion size occurred at 26-28weeks gestation. Eight fetuses developed hydrothorax, four of which (all extralobar BPSs) also developed hydrops. All four hydropic fetuses received maternal betamethasone, and three hydropic fetuses underwent thoracentesis and/or thoracoamniotic shunt placement with subsequent hydrops resolution. All fetuses survived. Forty-one intralobar (93%) and 35 extralobar BPSs (59%) were resected after birth.

CONCLUSIONS

BPSs tend to decrease in size after 26-28weeks gestation and rarely require fetal intervention. Lesions resulting in hydrothorax ± hydrops can be effectively managed with maternal steroids and/or drainage of the hydrothorax.

LEVEL OF EVIDENCE

IV.

Fetal Myelomeningocele Repair: The Post-MOMS Experience at the Children's Hospital of Philadelphia

Background: Fetal myelomeningocele (fMMC) repair has become accepted as a standard of care option in selected circumstances. We reviewed our outcomes for fMMC repair from referral and evaluation through surgery, delivery and neonatal discharge. Material and Methods: All patients referred for potential fMMC repair were reviewed from January 1, 2011 through March 7, 2014. Maternal and neonatal data were collected on the 100 patients who underwent surgery. Results: 29% of those evaluated met the criteria and underwent fMMC repair (100 cases). The average gestational age was 21.9 weeks at evaluation and 23.4 weeks at fMMC repair. Complications included membrane separation (22.9%), preterm premature rupture of membranes (32.3%) and preterm labor (37.5%). Average gestational age at delivery was 34.3 weeks and 54.2% delivered at ≥35 weeks. The perinatal loss rate was 6.1% (2 intrauterine fetal demises and 4 neonatal demises); 90.8% of women delivered at the Children's Hospital of Philadelphia and 3.4% received transfusions. With regard to the neonates, 2 received ventriculoperitoneal shunts prior to discharge; 71.1% of neonates had no evidence of hindbrain herniation on MRI. Of the 80 neonates evaluated, 55% were assigned a functional level of one or more better than the prenatal anatomic level. Conclusion: In an experienced program, maternal and neonatal outcomes for patients undergoing fMMC repair are comparable to results of the MOMS trial.

Earlier discharge of infants from neonatal intensive care units: a pilot program of specialized case management and home care. Delaware Valley Child Health Alliance

A multidisciplinary approach using a neonatology independent physicians association, affiliated hospitals, a pediatric home care company, and a health maintenance organization was designed to promote earlier safe discharge of infants from intensive care. This pilot project involved 43 infants who received case management and early discharge home with home oxygen, monitoring, intravenous antibiotics, gavage feedings, phototherapy, or nutritional management for poor weight gain. A staff neonatologist remained the primary physician until the patient would have been discharged according to standard criteria. Two patients had unscheduled readmissions and all infants survived. This approach resulted in an estimated savings of 456 hospital days and $329,982; 89% of parents rated the care as good to excellent, and 83% were satisfied with the program and outcome. This study suggests that a prospectively designed program can be designed to promote safe earlier discharge of infants in intensive care.

Skin-to-skin parental contact with fragile preterm infants

Skin-to-skin contact has been implemented recently to facilitate maternal-infant bonding of preterm infants. The technique allows the removal of fragile preterm infants from an incubator to the bare chest of a parent or caretaker. When specific guidelines are followed, thermal stability can be maintained, parent-infant bonding can be facilitated, and parental satisfaction can be enhanced. We illustrate a case in which a preterm infant has skin-to-skin contact while being monitored for physiologic parameters, including heart and respiratory rate, oxyhemoglobin saturation, and nasal airflow. Improvements in breathing patterns in this infant during skin-to-skin care and maintenance of a normal temperature suggest that this technique may not only be safe and psychologically beneficial, but it may also promote physiologic improvement.

Partial liquid ventilation in critically ill infants receiving extracorporeal life support. Philadelphia Liquid Ventilation Consortium

OBJECTIVES

To demonstrate that a period of partial liquid ventilation (PLV) with perflubron improves pulmonary function, without adverse events, in a select group of critically ill infants receiving extracorporeal life support (ECLS) with a high likelihood of mortality.

METHODS

This was an open-label, noncontrolled, phase I and II trial of PLV in two infants with congenital diaphragmatic hernia and four infants with acute respiratory distress syndrome (ARDS) who were failing to improve while receiving ECLS. PLV was performed by instilling and maintaining a functional residual capacity of sterile perflubron for 4 to 96 hours.

RESULTS

Four infants were successfully weaned off ECLS for at least 3 days, and two infants (both with ARDS) are long-term survivors after PLV. All infants demonstrated lung recruitment and improved lung compliance, and there were no adverse events related to PLV.

CONCLUSIONS

The study suggests that perflubron PLV is safe, improves lung function, and recruits lung volume in critically ill infants receiving ECLS. PLV therapy for infants with ARDS seems to have a great deal of promise. Based on this and other phase I and II trials, studies of PLV on selected full-term infants before ECLS have been initiated.

Leech therapy: new procedures for an old treatment

Experiences of pediatric ICU nurses as they cared for a child requiring leech therapy are described in this article along with the clinical conditions and therapy of the case. The nurses' ambivalence about participating in what seemed to be an archaic therapy and how they had to put such feelings aside to support the family are explained.