Summary of recommendations and key points of the consensus of Spanish scientific societies (SEPAR, SEMICYUC, SEMES; SECIP, SENEO, SEDAR, SENP) on the use of non-invasive ventilation and high-flow oxygen therapy with nasal cannulas in adult, pediatric, and neonatal patients with severe acute respiratory failure

Non-invasive respiratory support (NIRS) in adult, pediatric, and neonatal patients with acute respiratory failure (ARF) comprises two treatment modalities, non-invasive mechanical ventilation (NIMV) and high-flow nasal cannula (HFNC) therapy. However, experts from different specialties disagree on the benefit of these techniques in different clinical settings. The objective of this consensus was to develop a series of good clinical practice recommendations for the application of non-invasive support in patients with ARF, endorsed by all scientific societies involved in the management of adult and pediatric/neonatal patients with ARF. To this end, the different societies involved were contacted, and they in turn appointed a group of 26 professionals with sufficient experience in the use of these techniques. Three face-to-face meetings were held to agree on recommendations (up to a total of 71) based on a literature review and the latest evidence associated with 3 categories: indications, monitoring and follow-up of NIRS. Finally, the experts from each scientific society involved voted telematically on each of the recommendations. To classify the degree of agreement, an analogue classification system was chosen that was easy and intuitive to use and that clearly stated whether the each NIRS intervention should be applied, could be applied, or should not be applied.

Summary of recommendations and key points of the consensus of Spanish scientific societies (SEPAR, SEMICYUC, SEMES; SECIP, SENEO, SEDAR, SENP) on the use of non-invasive ventilation and high-flow oxygen therapy with nasal cannulas in adult, pediatric, and neonatal patients with severe acute respiratory failure

Non-invasive respiratory support (NIRS) in adult, pediatric, and neonatal patients with acute respiratory failure (ARF) comprises two treatment modalities, non-invasive mechanical ventilation (NIMV) and high-flow nasal cannula (HFNC) therapy. However, experts from different specialties disagree on the benefit of these techniques in different clinical settings. The objective of this consensus was to develop a series of good clinical practice recommendations for the application of non-invasive support in patients with ARF, endorsed by all scientific societies involved in the management of adult and pediatric/neonatal patients with ARF. To this end, the different societies involved were contacted, and they in turn appointed a group of 26 professionals with sufficient experience in the use of these techniques. Three face-to-face meetings were held to agree on recommendations (up to a total of 71) based on a literature review and the latest evidence associated with 3 categories: indications, monitoring and follow-up of NIRS. Finally, the experts from each scientific society involved voted telematically on each of the recommendations. To classify the degree of agreement, an analogue classification system was chosen that was easy and intuitive to use and that clearly stated whether the each NIRS intervention should be applied, could be applied, or should not be applied.

[Neonatal extracorporeal membrane oxygenation: 9 years of experience]

INTRODUCTION

Extracorporeal membrane oxygenation (ECMO) is a rescue therapy for reversible respiratory or cardiac diseases. Neonatal pathologies requiring this technique are different from the ones found later in life.

OBJECTIVES

To review the main causes requiring ECMO in the neonatal period, to compare the clinical course depending on the initial illness and to identify the sequelae attributable to this technique.

MATERIAL AND METHOD

A retrospective review of clinical records of all neonatal patients that received ECMO support in our centre.

RESULTS

45 neonatal ECMO were performed in our unit between January 2001 and June 2009. Forty techniques were due to respiratory failure, 2 secondary to haemodynamic shock and 3 secondary to sepsis. Veno-venous cannulation was used initially in 24 patients (53.3%). The length of technique varied depending on the underlying disease. Patients with congenital diaphragmatic hernia were in ECMO for longer periods. The overall survival to the technique was 86.3% (38/44 patients), also with differences among diseases. Extracorporeal support was withdrawn in 4 children because of a diagnosis of an irreversible pathology and one because of massive brain haemorrhage. No serious adverse outcomes attributable to the technique were found among survivors.

CONCLUSIONS

Survival among newborns supported with ECMO in our hospital is similar to that recorded by the ELSO in 2004, although we use veno-venous cannulation in more than a half of the patients. The percentage of moderate to severely impaired neurodevelopmental outcome among survivors after this technique was low.

[Cutaneous colonization by Malassezia spp. in neonates]

BACKGROUND

Malassezia spp. is a lipophilic yeast considered to be a normal component of the human skin flora. It has been associated with sepsis in patients receiving intravenous infusion of lipid emulsions through central venous catheters (CVC). Current evidence indicates a high rate of skin colonization in healthy adults, in contrast with the low rate of colonization in prepubertal children. Of note is the high prevalence of colonized infants in the neonatal intensive care unit (NICU).

METHODS

We performed a prospective open observational study of colonization in all infants admitted to the NICU during a nine-month period (October 1997-June 1998). Length of stay in the unit, birthweight and the use of CVC for parenteral fat infusion were evaluated.

RESULTS

Seventy-seven neonates were included in the study. The mean length of stay in the NICU was 24 days. A total of 63.6 % weighed less than 2,500 g at birth and 72 % were given parenteral nutrition supplemented with fat emulsion through a CVC. The overall rate of colonization in the unit was 41.5 and 75 % of the patients became colonized within the first two weeks of admission.

CONCLUSIONS

These data emphasize the need for preventive measures to reduce the transmission of these yeasts in the NICU and to prevent the occurrence of neonatal sepsis due to Malassezia spp. in immunologically immature infants.

[Extracorporeal membrane oxygenation: indications and recommendations on when to refer patients to a specialized unit]

Extracorporeal membrane oxygenation (ECMO) is a highly complex technique of extracorporeal support that has been available in Spain since 1997 and is now provided by three centres. This article aims to detail the guidelines and indications for neonatal and pediatric ECMO in severe cardiorespiratory failure and to provide information on when to contact the referral centres when treating patients who may need this treatment.

[Neonatal endocarditis due to staphylococcus aureus as a complication of neonatal sepsis]

We present the case of a newborn with bacterial endocarditis with mitral valve involvement as a complication of late-onset sepsis due to Staphylococcus aureus with associated pyelonephritis and meningitis. The diagnosis was confirmed by echocardiogram and blood culture with growth of S. aureus. Treatment was medical and surgical. Neonatal bacterial endocarditis is extremely difficult to diagnose. The signs and symptoms are usually nonspecific and cannot be distinguished from those of sepsis or congenital heart disease. Consequently, a high degree of suspicion is needed for the early diagnosis of this condition. Echocardiography should be performed in children who present sepsis and heart murmur and even in those with staphylococcemia (sepsis due to S. aureus) without associated heart murmur. This investigation enables an early diagnosis of endocarditis to be made and appropriate treatment to be given without having to wait for the development of signs and symptoms that frequently go undetected.

[Congenital diaphragmatic hernia: evaluation of two ways of management]

OBJECTIVE

The aim of this study was to analyze the treatment and evolution of congenital diaphragmatic hernia in the last 16 years, distinguishing two ways of management, and to look for parameters that can predict the evolution.

MATERIALS AND METHODS

Between 1978 and 1994, 29 cases of congenital diaphragmatic hernia were treated in our NICU. During the first period (1978-1988) 17 cases (group 1) were treated after birth as a surgical emergency. In the second period (1989-1994), preoperative stabilization was performed before surgery (12 cases, group 2). Two cases of group 2 were excluded because of the association of other malformations that were the cause of death.

RESULTS

Both groups were similar in gestational age, birth weight and Apgar score at 5 minutes. Overall mortality was 48.1% (47.0% in group 1 and 50.0% in group 2). No infants with PaCO2 greater than 40 mmHg and OI greater than 40 or VEI over 1,000 survived.

CONCLUSION

Despite preoperative stabilization, there is no difference in the mortality rate of the two groups. With congenital diaphragmatic hernia, as with other entities of low incidence, collaborative studies are needed to obtain enough cases to analyze the results more precisely.

[Attitude towards parents after the death of their newborn infant in a neonatal unit]

We have analyzed the neonatology team's actions, as well as the parent's reactions, after the death of a newborn baby in the Intensive Care Unit. A questionnaire was drawn-up and sent to 180 parents of decreased newborn babies in order to get to know their opinions about certain aspects related to their experience in the hospital. Only 49 out of the 180 (27.2%) questionnaires were sent back. From their answers, we would like to stress their positive opinion regarding both the medical care (95%) and the information that they received (93%). The suggestion that the hospital should have a trained team of trained professionals available to provide psychological support in such situations was made in 95.9% of the questionnaires. This analysis has justified changes in our team's procedure when confronted with newborn deaths.