Neonates Flashcards
‘Oxygen Saturation and Outcomes in Preterm Infants’ The BOOST II United Kingdom, Australia, and New Zealand Collaborative Groups. NEJM 2013.
Background The clinically appropriate range for oxygen saturation in preterm infants is unknown. Previous studies have shown that infants had reduced rates of retinopathy of prematurity when lower targets of oxygen saturation were used. Methods In three international randomized, controlled trials, we evaluated the effects of targeting an oxygen saturation of 85 to 89%, as compared with a range of 91 to 95%, on disability-free survival at 2 years in infants born before 28 weeks’ gestation. Halfway through the trials, the oximeter-calibration algorithm was revised. Recruitment was stopped early when an interim analysis showed an increased rate of death at 36 weeks in the group with a lower oxygen saturation. We analyzed pooled data from patients and now report hospital-discharge outcomes. Results A total of 2448 infants were recruited. Among the 1187 infants whose treatment used the revised oximeter-calibration algorithm, the rate of death was significantly higher in the lower-target group than in the higher-target group (23.1% vs. 15.9%; relative risk in the lower-target group, 1.45; 95% confidence interval [CI], 1.15 to 1.84; P = 0.002). There was heterogeneity for mortality between the original algorithm and the revised algorithm (P = 0.006) but not for other outcomes. In all 2448 infants, those in the lower-target group for oxygen saturation had a reduced rate of retinopathy of prematurity (10.6% vs. 13.5%; relative risk, 0.79; 95% CI, 0.63 to 1.00; P = 0.045) and an increased rate of necrotizing enterocolitis (10.4% vs. 8.0%; relative risk, 1.31; 95% CI, 1.02 to 1.68; P = 0.04). There were no significant between group differences in rates of other outcomes or adverse events. Conclusions Targeting an oxygen saturation below 90% with the use of current oximeters in extremely preterm infants was associated with an increased risk of death.
Cochrane Review, 2011, Jardine et al. Strategies for the withdrawal of nasal continuous positive airway pressure (NCPAP) in preterm infants
A B S T R A C T Background While indications for the use of nasal continuous positive airway pressure (NCPAP) and its associated risks and benefits are extensively investigated, the best strategy for the withdrawal of NCPAP remains unknown. In a survey of Australian and New Zealand Neonatologists, 56% stated that their approach to NCPAP weaning was “ad hoc” (Jardine 2008). At what point an infant is considered stable enough to attempt to start withdrawing their NCPAP is not clearly established. The criteria for a failed attempt at NCPAP withdrawal is also not clear. Objectives To determine the risks and benefits of different strategies used for the withdrawal of NCPAP in preterm infants. Search methods Searches were made of the Cochrane Neonatal Review Group Specialised Register, MEDLINE from 1966 to June 2010, CINAHL from 1982 to June 2010, and the Cochrane Central Register of Controlled Trials (CENTRAL, The Previous reviews (including cross references) were also searched. Selection criteria We included all randomised and quasi-randomised controlled trials in which either individual newborn infants or clusters of infants (such as separate neonatal units) were randomised to different NCPAP withdrawal strategies (from the first time they come off NCPAP and any subsequent weaning and/or withdrawal attempt). Data collection and analysis We used standard methods of The Cochrane Collaboration and its Neonatal Review Group. Main results We identified four potentially eligible studies. Three studies are included in this review. One study showed a significant decrease in the duration of oxygen therapy and a significantly decreased length of stay for babies randomised to a weaning strategy where NCPAP is simply stopped when infants met predefined stability criteria. Authors’ conclusions Infants who have their NCPAP pressure weaned to a predefined level and then stop NCPAP completely have less total time on NCPAP and shorter durations of oxygen therapy and hospital stay compared with those that have NCPAP removed for a predetermined number of hours each day. Future trials of withdrawing NCPAP should compare proposed strategies with weaning NCPAP pressure to a predefined level and then stopping NCPAP completely. Clear criteria need to be established for the definition of stability prior to attempting to withdraw NCPAP. P L A I N L A N G U A G E S U M M A R Y Strategies used for the withdrawal of nasal continuous positive airway pressure (NCPAP) in preterm infants. Nasal continuous positive airway pressure (NCPAP) is a formof respiratory support commonly used in the treatment of preterm infants. Potential risks of NCPAP include damage to the nose and leaking of air from the lungs. Infants on NCPAP require more nursing care and the use of extra equipment. However, potential complications of removing NCPAP from babies too early include increasing episodes of forgetting to breathe, increased oxygen needs, increased effort of breathing, the need to restart NCPAP and the need for a breathing tube with mechanical ventilation. Any of these complications can be seen as a “failure” and are potentially distressing to staff and family. The best way to withdraw NCPAP once it has been started is unknown. Options include simply stopping, weaning the pressure, increasing the time off NCPAP each day or combinations of both. A recent study has suggested that stopping the NCPAP all together once compared to having periods of time off NCPAP decreases the incidence of chronic neonatal lung disease and the length of hospital stay. We aimed to determine the benefits and risks of different strategies used for the withdrawal of NCPAP in preterm infants who are stable and may be ready to have NCPAP withdrawn. This review identified three studies but, due to differences in the studies and the limited data available, the results could not be combined. Infants who have their NCPAP pressure weaned to a predefined level and then stop NCPAP completely have less total time on NCPAP and shorter durations of oxygen therapy and hospital stay compared with those that have NCPAP removed for a predetermined number of hours each day. Clear criteria need to be established for the definition of stability prior to attempting to withdraw NCPAP and for the definition of failure to withdraw.
Cochrane 2002. Continuous distending pressure for respiratory distress in preterm infants. Ho et al.
A B S T R A C T Background Respiratory distress syndrome (RDS) is the single most important cause of morbidity and mortality in preterm infants (Greenough 1998, Bancalari 1992). Intermittent positive pressure ventilation (IPPV) with surfactant is the standard treatment for the condition. The major difficulty with IPPV is that it is invasive, resulting in airway and lung injury and contributing to the development of chronic lung disease. Objectives To determine the effect of continuous distending pressure (CDP) on the need for IPPV and associated morbidity in spontaneously breathing preterm infants with respiratory distress. Search methods The standard search strategy of the Neonatal Review Group was used. This included searches of the Oxford Database of Perinatal Trials, Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 2, 2008), MEDLINE (1966 - February, 2008), and EMBASE (1980 - February 2008), previous reviews including cross references, abstracts, conference and symposia proceedings, expert informants, journal hand searching mainly in the English language. Selection criteria All trials using random or quasi-random allocation of preterm infants with respiratory distress were eligible. Interventions were continuous distending pressure including continuous positive airway pressure (CPAP) by mask, nasal prong, nasopharyngeal tube, or endotracheal tube, or continuous negative pressure (CNP) via a chamber enclosing the thorax and lower body, compared with standard care. Data collection and analysis Standard methods of the Cochrane Collaboration and its Neonatal Review Group were used, including independent assessment of trial quality and extraction of data by each author. Main results CDP is associated with a lower rate of failed treatment (death or use of assisted ventilation) [summary RR 0.65 (95% CI 0.52, 0.81), RD -0.20 (95% CI -0.29, -0.10), NNT 5 (95% CI 4, 10)], overall mortality [summary RR 0.52 (95% CI 0.32, 0.87), RD -0.15 (95% CI -0.26, -0.04), NNT 7 (95% CI 4, 25)], and mortality in infants with birth weights above 1500 g [summary RR 0.24 (95% CI 0.07, 0.84), RD -0.28 (95% CI -0.48, -0.08), NNT 4 (95% CI 2, 13)]. The use of CDP is associated with an increased rate of pneumothorax [summary RR 2.64 (95% CI 1.39, 5.04), RD 0.10 (95% CI 0.04, 0.17), NNH 17 (95% CI 17, 25)]. Authors’ conclusions In preterminfants with respiratory distress the application of CDP either as CPAP or CNP is associated with reduced respiratory failure and reduced mortality. CDP is associated with an increased rate of pneumothorax. Four out of six of these trials were done in the 1970’s. Therefore, the applicability of these results to current practice is difficult to assess. Where resources are limited, such as in developing countries, CPAP for RDS may have a clinical role. Further research is required to determine the best mode of administration and the role of CDP in modern intensive care settings. P L A I N L A N G U A G E S U M M A R Y Continuous distending pressure for respiratory distress in preterm infants Some benefits found in using continuous distending pressure (CDP) for respiratory distress syndrome in preterm babies. Respiratory distress syndrome (RDS) is the most common cause of disease and death in babies born before 34 weeks gestation. Intermittent positive pressure ventilation (IPPV) is the standard way of helping these babies breathe. A simpler method of assisting breathing is to provide a continuous lung distending pressure - either no continuous positive pressure to the airway or continuous negative pressure (partial vacuum). The review of trials found that continuous distending pressure (CDP) reduces the rate of death or the need for assisted ventilation and reduced the need for IPPV. The small and mostly dated trials also found that CDP can increase the rate of pneumothorax (air outside the lung in the chest cavity).
Cochrane 2014. Nasal intermittent positive pressure ventilation (NIPPV) versus nasal continuous positive airway pressure (NCPAP) for preterm neonates after extubation. Lemyre et al.
P L A I N L A N G U A G E S U M M A R Y Background There is some evidence that nasal intermittent positive pressure ventilation (NIPPV) increases the effectiveness of nasal continuous positive airway pressure (NCPAP) in preterm babies who no longer need an endotracheal tube (tube in the windpipe). Preterm babies with breathing problems often require help from a machine (ventilator) that provides regular breaths through a tube in the windpipe. The process of extubation or removal of this tube does not always go smoothly and the tube may need to go back in if the baby cannot manage by him/herself. NCPAP and NIPPV are ways of supporting babies’ breathing in a less invasive way - the tubes are shorter and go only to the back of the nose and, therefore, cause less damage to the lungs. NCPAP and NIPPV may be used after extubation to reduce the number of babies that need to have the endotracheal tube reinstated. NCPAP provides steady pressure to the back of the nose that is transmitted to the lungs, helping the baby breathe more comfortably. NIPPV provides the same support, but also adds some breaths from the ventilator. Study characteristics We search scientific databases for studies comparing NCPAP with NIPPV in preterm infants (born before 37 completed weeks of pregnancy) who no longer needed an endotracheal tube. We looked at breathing problems, the need for the endotracheal tube to be reinstated and side effects. The evidence is current to August 2013. Key results We found eight trials comparing NCPAP with NIPPV. Five out of eight studies that compared NCPAP and NIPPV showed that NIPPV reduced the need for the endotracheal tube to be replaced. Further studies are needed to determine how best to deliver NIPPV to infants. Quality of the evidence The quality of the studies included in this review was overall good. A B S T R A C T Background Previous randomised trials and meta-analyses have shown nasal continuous positive airway pressure (NCPAP) to be a useful method of respiratory support after extubation. However, infants managed in this way sometimes ’fail’ and require endotracheal reintubation with its attendant risks and expense. Nasal intermittent positive pressure ventilation (NIPPV) is a method of augmenting NCPAP by delivering ventilator breaths via nasal prongs. Older children and adults with chronic respiratory failure benefit from NIPPV and the technique has been applied to neonates. However, serious side effects including gastric perforation have been reported with older techniques to provide NIPPV. Objectives To determine the effect of management with NIPPV compared with NCPAP on the need for additional ventilatory support in preterm infants having their endotracheal tube removed following a period of intermittent positive pressure ventilation. To compare the rates of gastric distension, gastrointestinal perforation, necrotising enterocolitis, chronic lung disease, duration of hospitalisation, rates of apnoea, air leaks and mortality between NIPPV and NCPAP. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 7, 2013), MEDLINE (1966 to 4 September 2013), EMBASE (1980 to 4 September 2013), CINAHL (1982 week 3 to August 2013) and PubMed (4 September 2013). We searched previous reviews including cross-references, and conference and symposia proceedings. We contacted experts in the field. We also searched Clinicaltrials.gov for any ongoing trials. Selection criteria We included randomised and quasi-randomised trials comparing the use of NIPPV with NCPAP in preterm infants being extubated. NIPPV included non-invasive support delivered by a mechanical ventilator or a bilevel device in a synchronised or non-synchronised way. Participants included ventilated preterm infants who were ready to be extubated to non-invasive respiratory support. Interventions compared were NIPPV, either by short nasal prongs or nasopharyngeal tube, and NCPAP, delivered by the same methods. Types of outcomes measures included: failure of therapy (respiratory failure, rates of endotracheal reintubations); gastrointestinal complications (i.e. abdominal distension requiring cessation of feeds, gastrointestinal perforation or necrotising enterocolitis); pulmonary air leaks; chronic lung disease (oxygen requirement at 36 weeks’ postmenstrual age) and mortality. Data collection and analysis Three review authors independently extracted data regarding clinical outcomes including extubation failure, endotracheal reintubation, rates of apnoea, gastrointestinal perforation, feeding intolerance, necrotising enterocolitis, chronic lung disease, air leaks and duration of hospital stay.We analysed the trials using risk ratio (RR), risk difference (RD) and number needed to treat for an additional beneficial outcome (NNTB) or additional harmful outcome (NNTH) for dichotomous outcomes and mean difference (MD) for continuous outcomes. Main results The search identified eight trials enrolling 1316 infants in total and comparing extubation of infants to NIPPV or NCPAP. Five trials used the synchronised form of NIPPV, two trials used the non-synchronised form and one trial used both methods. Six studies used NIPPV delivered by a ventilator, one study used a bilevel device and one study used both methods. When all studies were included, the meta-analysis demonstrated a statistically and clinically significant reduction in the risk of meeting extubation failure criteria (typical RR 0.71, 95% CI 0.61 to 0.82; typical RD -0.12, 95% CI -0.17 to -0.07; NNTB 8, 95% CI 6 to 14; 8 trials, 1301 infants) and needing reintubation (typical RR 0.76, 95% CI 0.65 to 0.88; typical RD -0.10, 95% CI -0.15 to -0.05; NNTB 10, 95% CI 7 to 20; 8 trials, 1301 infants). While the method of synchronisation varied (Graseby capsule or pneumotachograph/flow-trigger), the five trials that synchronised NIPPV showed a statistically significant benefit for infants extubated to NIPPV in terms of prevention of extubation failure up to one week after extubation. NIPPV provided via a ventilator appeared more beneficial than bilevel devices in reducing extubation failure in the first week. There was no significant reduction in the rates of chronic lung disease (typical RR 0.97, 95% CI 0.83 to 1.14; typical RD -0.01, 95% CI -0.07 to 0.05), death or difference in the incidence of necrotising enterocolitis between interventions. There was a reduction in air leaks in infants randomised to NIPPV (typical RR 0.50, 95% CI 0.28 to 0.89; typical RD -0.03; 95% CI -0.05 to -0.01; NNTB 33, 95% CI 20 to 100). Authors’ conclusions Implications for practice: NIPPV reduces the incidence of symptoms of extubation failure and need for reintubation within 48 hours to one week more effectively than NCPAP; however, it has no effect on chronic lung disease or mortality. Synchronisation may be important in delivering effective NIPPV. The device used to deliver NIPPV may also be important; however, there are insufficient data to support strong conclusions. NIPPV does not appear to be associated with increased gastrointestinal side effects. Implications for research: the impact of synchronisation of NIPPV on the technique’s safety and efficacy should be established in large trials. The efficacy of bilevel devices should be compared with NIPPV provided by a ventilator in trials. The best combination of settings for NIPPV needs to be established in future trials.
Cochrane 2009. Nasal continuous positive airways pressure immediately after extubation for preventing morbidity in preterm infants. Davis et al.
P L A I N L A N G U A G E S U M M A R Y Continuous positive airway pressure (CPAP) provides extra gas flow through the nose and thereby helps keep the lung properly inflated. This helps reduce breathing problems in preterm babies after the tube used to assist breathing is removed from their windpipe. Preterm babies (babies born before 37 weeks) may need help to breathe properly. Sometimes this is given via a tube placed into the windpipe, through the mouth or nose, to give oxygen from a machine (mechanical ventilation). This method helps restore breathing but when the tube is removed (this process of removal is called extubation), breathing problems can occur. Nasal continuous positive airways pressure (NCPAP) provides extra gas flow through the nose and thereby helps keep the lung properly inflated. The review of trials found NCPAP is effective in preventing failure of extubation after a period of mechanical ventilation. A B S T R A C T Background Preterm infants being extubated following a period of intermittent positive pressure ventilation via an endotracheal tube are at risk of developing respiratory failure as a result of apnea, respiratory acidosis and hypoxia. Nasal continuous positive airway pressure appears to stabilise the upper airway, improve lung function and reduce apnea and may therefore have a role in facilitating extubation in this population. Objectives To evaluate the effect of management with nasal continuous positive airways pressure (NCPAP) compared to extubation directly to headbox oxygen on the need for additional ventilatory support in preterm infants having their endotracheal tube removed following a period of intermittent positive pressure ventilation (IPPV), Search methods Searchesweremade of theOxfordDatabase of Perinatal Trials, PubMed up toNovember 2007, Cochrane Central Regsiter of Controlled Trials (The Cochrane Library, Issue 4, 2007), previous reviews including cross references, abstracts of conferences and symposia proceedings, expert informants and journal handsearching mainly in the English language. Selection criteria All trials utilising random or quasi-random patient allocation, in whichNCPAP (delivered by any method) was compared with headbox oxygen for post-extubation care were included. Methodological quality was assessed independently by the two review authors. Data collection and analysis Data were extracted independently by the two review authors. Data were analysed using relative risk (RR), risk difference (RD) and number needed to treat (NNT). Prespecified subgroup analysis to determine the impact of different levels of NCPAP, differences in duration of IPPV and use of aminophylline were also performed. Main results When applied to preterm infants being extubated following IPPV, nasal CPAP reduces the incidence of respiratory failure (apnea, respiratory acidosis and increased oxygen requirements) indicating the need for additional ventilatory support [typical RR 0.62 (95% CI 0.51, 0.76), typical RD -0.17 (95% CI -0.23, -0.10), NNT 6 (4,10)]. Authors’ conclusions Implications for practice: nasal CPAP is effective in preventing failure of extubation in preterminfants following a period of endotracheal intubation and IPPV. Implication for research: further definition of the gestational age and weight groups in whom these results apply is warranted. Optimal levels of NCPAP as well as methods of administration remain to be determined.
Hypovolaemic Shock. You attend an EmCS done due to placental abruption and baby is shocked at birth. What would you transfuse, how much, and over how much time? Before giving the O negative blood what information would you like to collect?
While blood sample should be sent for cross-match and blood should be ordered this infant needs blood immediately and that can usually be non-crossmatched O negative blood. As an example, 10 ml/kg blood can be given over 5-15 minutes followed by the infusion of another 10 ml/kg over a longer period. In case this is not available fluid resuscitation should be given using 10-20 ml/kg normal saline or, if there are concerns regarding consumption coagulopathy, fresh frozen plasma (FFP). Increasing the volume of the dextrose infusion is not appropriate as this has no electrolyte in it; the osmotic value of the dextrose is low and transient as it is quickly metabolised.
The baby has got severe acidosis that is primarily metabolic. The capillary pCO2 is only borderline increased and the diagnostic value of a capillary pCO2 is questionable in case of poor tissue perfusion. The metabolic acidosis is most probably due to the inadequate tissue perfusion. The respiratory distress is also related to the shock and metabolic acidosis and does not necessary imply lung pathology. Therefore, intubation of this baby is not absolutely necessary. On the other hand it can be argued that circulatory collapse of this degree by itself warrants elective intubation in order to take away the work of breathing and allowing more control over blood gases.
Before giving O neg blood, you should know of any history of a) intrauterine transfusion or b) isoimmunisation during pregnancy
The cause of the anaemia in this case is most probably blood loss due to abruption although isoimmunization need to be excluded. In case of isoimmunisation the baby may not be hypovolaemic; impaired tissue oxygen delivery and metabolic acidosis could still be present due to the anaemia. In that case the baby would require an urgent exchange transfusion. Some of these babies do require an emergency top-up transfusion while the exchange transfusion is being arranged. If the anaemia is caused by anti-D isoimmunisation and urgent top-up is needed, O negative blood needs to be given but it needs to be irradiated if intrauterine transfusion was given to avoid graft versus host disease. If the isoimmunisation has been caused by an irregular antibody (e.g. anti-c or anti-e) the emergency O-negative blood may not be compatible.
