Editor,
We read with great interest the article published by Filippi et al. (1)
regarding the usefulness of dopamine in the treatment of hypotension in
preterm, very low birth weight (VLBW) infants.
Recently Dempsey and Barrington (2) reported how there are marked
variations between neonatologists in interventions and treatments for
neonatal hypotension. In medical literature is well reported how dopamine
should be cons...
Editor,
We read with great interest the article published by Filippi et al. (1)
regarding the usefulness of dopamine in the treatment of hypotension in
preterm, very low birth weight (VLBW) infants.
Recently Dempsey and Barrington (2) reported how there are marked
variations between neonatologists in interventions and treatments for
neonatal hypotension. In medical literature is well reported how dopamine
should be considered the first choice to support neonates, even if the
labelling information regarding the use of inotropes in this population is
inadequate (3).
It came to our attention the case of a VLBW infant hospitalized in our III
level neonatal intensive care unit.
After an uneventful bicorial and biamniotic pregnancy, the baby, first of
two twins, was born by caesarean section at 32 weeks of gestation.
Two hours after birth he developed hypotension (blood pressure 39/20 mm
Hg; mean pressure 27 mm Hg) and we decided to give him a saline bolus of
10 cc/Kg in 20 minutes to maintain adequate tissue perfusion. Because of
persistent hypotension, dopamine was added at 5 mcg/Kg/min via umbilical
venous catheter. After three hours no ameliorations in his systolic
pressure were noticed, although dopamine was increased at 8 mcg/Kg/min.
Suddenly, he presented a cyanotic skin rash characterized by acromial
ischemia. We decided to stop therapies, worried about an allergic reaction
and hydrocortisone was given (1mg/Kg) in order to promote resolution. The
rash and the acromial ischemia of right arm and left foot took few hours
to resolve. Dopamine was not given again. Ischemia in our patient did not
involve other organs, systolic pressure improved after this episode and no
other inotrope had to be used. To our records, this is the first
experience we had about dopamine sudden side effects, and surprisingly,
even if this is mentioned in the drug label, we could not find any report
in medical literature.
References
1. Filippi L, Pezzati M, Poggi C, Rossi S, Cecchi A, Santoro C. Dopamine
versus dobutamine in very low birthweight infants: Endocrine effects. Arch
Dis Child Fetal Neonatal Ed 2007; 92 (5): F367-F371.
2. Dempsey EM, Barrington KJ. Treating hypotension in the preterm infant:
when and with what: a critical and systematic review. J Perinatol 2007; 27
(8): 469-78.
3. Evans JR, Short BL, Van Meurs K and Sachs HC. Cardiovascular support in
preterm infants. Clin Ther 2006; 28 (9): 1366-1384.
The recent paper advocating “a new dosage schedule” for giving
vancomycin in early infancy [1] confirms what others have long said is
usually the most appropriate total daily dose for babies of less than 34
weeks gestation who are more than a week old, and focuses on the time-
dependent rather than concentration-dependent mode of vancomycin killing.
Continuous infusion may prevent the risks of high peaks and low troughs...
The recent paper advocating “a new dosage schedule” for giving
vancomycin in early infancy [1] confirms what others have long said is
usually the most appropriate total daily dose for babies of less than 34
weeks gestation who are more than a week old, and focuses on the time-
dependent rather than concentration-dependent mode of vancomycin killing.
Continuous infusion may prevent the risks of high peaks and low troughs
seen with intermittent dosage. However, we disagree with the suggestion
that a first loading dose is not necessary. The earlier paper that
recommended this same strategy ten years ago [2] correctly said
“Vancomycin half-life is usually between 3 and 10 hr in neonates.
The time to reach steady state, which is 4 to 5 times the half-life, might
thus be expected to be around 48 hours in this specific population. Such
a time to reach early bactericidal efficacy appeared too long in cases of
septicaemia. For this reason, we decided to inject a 7 mg.kg -1 loading
dose.”
The one trial to look at the relative merits of intermittent and
continuous infusion, which found no evidence that continuous infusions
were better than intermittent infusions in adults [3] also used a loading
dose. The reference used to justify the assertion that a loading dose is
not necessary was data presented by poster stating that therapeutic levels
were reached within 12 hours in much older children, [4] but this
overlooks the fact that the half life is much shorter in 5-10 year old
children than it is in the first few weeks of life and, indeed, also
rather shorter than it is adult life.
Failure to give a loading dose where there is clear evidence of
septicaemia will leave any young baby dangerously under-treated for many
hours. There are reasons for thinking that a continuous infusion may be a
useful option when treating meningitis, as the discussion of these issues
in the Neonatal Formulary web site argues [5], but a loading dose is
required.
Dr Nicholas D Embleton (n.d.embleton@ncl.ac.uk),
Dr Janet Berrington
Newcastle Neonatal Service,
Royal Victoria Infirmary,
Newcastle Hospitals NHS Trust,
Newcastle upon Tyne NE1 4LP
References
1. Plan O, Cambonie G, Barbotte E, et al. Continuous-infusion vancomycin
therapy for preterm neonates with suspected or documented Gram-positive
infections: a new dosage schedule. Arch Dis Child 2008;93:F418–21.
2. Pawlotsky F, Thomas A, Kergueris MF, et al. Constant rate
infusion of vancomycin in premature neonates: a new dosage schedule. Br J
Clin Pharmacol 1998;46:163–7.
3. Wysocki M, Delatour F, Faurisson F, et al. Continuous versus
intermittent infusion of vancomycin in severe staphylococcal infections:
prospective multicenter randomised trial. Antimicrob Agents Chemother
2001;45:2460–7.
4. Le Normand Y, Avetloiseau H, Kergueris F, et al. Ceftazidime and
vancomycin constant-rate infusion in neutropenic children: pharmacokinetic
parameters and clinical implications. [Abstract] Antimicrob Agents
Chemother 1993;37;A939
Support transition by keeping the placental circulation intact – even in newborns apparently requiring resuscitation.
Detecting ‘fetal distress’ in labour allows timely delivery, followed by effective resuscitation, if required, to restore or maintain adequate circulation with oxygenated blood to the baby. This should prevent or minimise brain damage from hypoxaemia or hypovolaemia. Nielso...
Support transition by keeping the placental circulation intact – even in newborns apparently requiring resuscitation.
Detecting ‘fetal distress’ in labour allows timely delivery, followed by effective resuscitation, if required, to restore or maintain adequate circulation with oxygenated blood to the baby. This should prevent or minimise brain damage from hypoxaemia or hypovolaemia. Nielson et al (1) find the prevalence of cerebral palsy unchanged despite major changes in clinical care. This apparent failure of obstetric intervention and neonatal resuscitation should perhaps prompt a “back-to-basics” review of present paradigms. Morley’s excellent review (2) noted that “Newborn infants who do not breathe sufficiently need gentle assistance to make the transition from placental to pulmonary gas exchange” and “Current research is challenging widely held views about neonatal ’resuscitation’ and that a less aggressive, more gentle, approach may actually be more beneficial” but omitted the most aggressive intervention, of routine cord clamping.
Although a minute is recommended before initiating aggressive resuscitation - to assess the condition, count the heart rate and dry the newborn baby (3) - in practice decisions are made within seconds based on the CTG and first impressions. When the neonate is floppy, pale and does not establish breathing quickly, it seems obvious that the baby’s lungs should be ventilated with air. Nevertheless, this strategy does not seem to have delivered improvements. What if the journey to the resuscitaire to get air into the lungs, deprives the neonate of circulating blood to deliver oxygen to the brain? Sick neonates may be adversely affected by the abrupt interruption of the placental circulation and placental gas exchange. Back in 1981 it was advised that “There is … good reason in cases of resuscitation to keep the placental circulation intact.”(4) There is no logic in cutting off the functional, failing placental circulation before the pulmonary circulation is established. The pulmonary circulation could gently take over respiratory function as the placental circulation closes down. This happens gradually in nature with physiological management of the third stage. It could be replicated in medical practice, but somehow it is not convenient to combine the continuation of post-birth placental circulation with assessment of the neonatal condition, basic resuscitation and assisted ventilation.
The link between nuchal cord and two-fold increased risk for spastic cerebral palsy should give neonatologists food for thought (1). Iffy (5) also reported untoward sequelae when the nuchal cord was clamped before delayed delivery of the shoulders, considered to be due to the total loss of the placental circulation. However, as a result of cord compression, the return of oxygenated blood through the cord after delivery of the head but before delivery of the body is likely to be trivial. As cord compression leads to placental engorgement, and in consequence, fetal hypovolaemia, (6) clamping a nuchal cord may have little effect on the circulation before delivery is completed, but as soon as the baby is born the hypovolaemia then becomes critical as there is no opportunity for the blood backed up in the placenta to return. This is the “good reason” described to keep the placental circulation intact.(4)
Although early cord clamping clearly interrupts the physiological process of fetal adaptation to neonatal life, NICE recommends that the current practice is continued until there is conclusive evidence from RCTs that it is harmful.(7) A recent RCOG opinion paper also concluded that more evidence for effects (harm or benefit) on the neonate were required but that the timing of cord clamping had no impact on active third stage management.(8) All trials of cord clamping only address the issue in the baby not requiring resuscitation. Healthy babies usually cope with the sudden closure of the placental circulation, (9) so much so that it is generally considered part of normal transition. The impression that clamping a functioning placental circulation is normal is even promoted by physiology (10), paediatric (11) and cardiology (12) text books. In contrast, the first publication of its invention (13) instructed that the clamp should be applied “when pulsation in the cord has ceased”.
Clamping the cord before the placental circulation has been closed down naturally by the neonate has many significant and potentially adverse effects: there is a sudden increase in the afterload on the heart (9); the volume of blood required to fill the new pulmonary vascular bed must be “stolen” from the rest of the neonatal circulation (14), as the placental transfusion has been interrupted; this results in hypovolaemia which may be severe and unrecognised and could theoretically lead to the release of cytokines responsible for brain damage(15); it has been postulated that the acidaemia from accumulated lactic acid of labour may be exacerbated by early cord clamping (16); and lastly, a proportion of the baby’s stem cells, thought to be capable of repairing both brain and heart damage, will be lost within the clamped cord and placenta. (17) The opportunity to prevent asphyxia-related conditions, such as nuchal cord and occult cord compression, is lost: Firstly, division of a nuchal cord is rarely necessary (18); and secondly, there may indeed be other unidentified conditions (e.g. shoulder dystocia) where immediate cord clamping leads to greater disturbance in the neonatal vascular system and post-birth depression than is presently realised.
The concept of maintaining placental circulation during resuscitation is gaining some recognition (19) though the practicalities of bringing the resuscitation to the baby, rather than the baby to the resuscitaire, are still to be realised. At normal delivery it is relatively simple to move to the bedside. (Mercer J, personal communication) (20) Ironically, resuscitation with an adequately long intact cord at caesarean section is also straightforward. (21) Vaginal instrumental delivery may present the greater challenge and require some innovative design and thinking. The strategy may be even more important in preterm babies. (22)
There is no physiological sense in clamping the umbilical cord before resuscitation, which can only exacerbate the risks of hypoxia and ischaemia, thought to be causes of cerebral palsy.
References
1. Nielson LF, Schenedel D, Grove J, Hvidtjorn D, Jacobsson B, Josiassen T, Vestergaard M, Uldall P, Thorsen P. Asphyxia related risk factors and their timing in spastic cerebral palsy. BJOG 2008;115:1518-1528
2. Morley CJ, Davis PG. Advances in neonatal resuscitation: supporting transition Arch Dis Child Fetal Neonatal Ed 2008;93:F334–F336
3. Richmond S. Newborn Life Support. London; Resuscitation Council (UK):2005
4. Peltonen T. Placental transfusion - advantage and disadvantage. Eur J Pediatr 1981;137:141-146
5. Iffy L, Varadi V. Cerebral palsy following cutting of the nuchal cord before delivery. Med Law 1994;13:323–30
6. Dunn PM. Tight nuchal cord and neonatal hypovolaemic shock. Arch Dis Child 1988;63:570–1
7. NICE intrapartum care guideline http://www.nice.org.uk/nicemedia/pdf/CG55FullGuideline.pdf
accessed 2/11/07
8. RCOG opinion paper http://www.rcog.org.uk/resources/public/doc/draftearlylatecordclamping.doc
accessed 2/11/07
9. Gardiner HM. Response of the fetal heart to changes in load: from hyperplasia to heart failure. Heart 2005;91:871–873
10. Keel CA & Neil E (Eds.) Sampson Wright’s Applied Physiology 12th Edition. London, Oxford University Press 1971:551
11. Campbell AGM & McIntosh N. Forfar and Arneil’s Textbook of Pediatrics 5th Edition Churchill Livingstone New York, Edinburgh. 1998:106-107
12. Braunwald E, Zipes DP, Libby P. Heart Disease. In: A Textbook of Cardiovascular Medicine 6th edition Saunders Philadelphia 2001:1512
13. Magennis E. Analytical records – new inventions. A midwifery surgical clamp. Lancet 1899;May 20th:1373
14. Linderkamp O. Placental transfusion: determinants and effects. Clin Perinatol 1982;9:559–92
15. Rajnik, M., et al. Salkowski, CA. Thomas, KE. ; Li, Y; Rollwagen, F M. Vogel, SN., Induction of early inflammatory gene expression in a murine model of nonresuscitated, fixed-volume hemorrhage. Shock, 2002;17(4):322-8
16. Hutchon DJR. Immediate cord clamping may increase neonatal acidaemia. BJOG 2008;115(9):1190-1
17. Cord Blood for Neonatal Hypoxic-Ischemic Encephalopathy NCT00593242 http://clinicaltrials.gov/ct2/show/NCT00593242
Accessed 16/11/2008
18. Mercer JS, Skovgaard RL, Peareara-Eaves J, Bowman TA. Nuchal cord management and nurse-midwifery practice. J Midwifery Womens Health 2005;50:373–9
19. Wyllie J & Niermeyer S. The role of resuscitation drugs and placental transfusion in the delivery room management of newborn infants. Seminars in Fetal and Neonatal Medicine 2008;13:416-23
20. Mercer J. Potential effects of immediate cord clamping at birth. Seminar “Hypovolaemia and resuscitation – is the timing of cord clamping relevant?” Royal Hospital for Sick Children, Glasgow 5th June 2008
21. Hutchon DJR. How to resuscitate the neonate with the cord intact at caesarean section. British International Congress of Obstetrics and Gynaecology, 6 July 2007, London
22. Bell EF. When to transfuse preterm babies. Arch Dis Child Fetal Neonatal Ed 2008;93:F469–F473
David J R Hutchon
Consultant Obstetrician
Susan Bewley,
Consultant Obstetrician, Guy’s & St Thomas’ NHS Foundation Trust,
10th floor North Wing
St Thomas’ Hospital
Westminster Bridge Road
London SE1 7EH
Richard Nichol,
Consultant Neonatologist,
Northwick Park Hospital,
North West Hospitals NHS Trust,
Harrow HA1 3UJ
The interesting article written by Gunlemez and Isken relates a
complication case of nasal CPAP in a low resource country. Unaware, the
expiratory tubing was submerged besides the wished, causing an excessive
pressure and propitiating a pneumothorax 1.
Bublle CPAP is simple, cheap and as efficient as the other systems, but it
requires trained professionals in the device installation, as any CPAP
System2. There is no evide...
The interesting article written by Gunlemez and Isken relates a
complication case of nasal CPAP in a low resource country. Unaware, the
expiratory tubing was submerged besides the wished, causing an excessive
pressure and propitiating a pneumothorax 1.
Bublle CPAP is simple, cheap and as efficient as the other systems, but it
requires trained professionals in the device installation, as any CPAP
System2. There is no evidence that it has more pneumothorax risk that the
devices that use other kind of resistors.
With much property, the authors emphasize that new devices of nasal CPAP
need to evolve, in the attempt of annul any risk to the patient.
It was recently manufactured in Brazil a newborn bubble CPAP device,
Babypap® Fanem. It is a simple model that relies on a blender and a
flowmeter, the afferent tubing carries the mixture of gases in direction
to nasal prong, and the expiratory tubing is submerged in water to
generate pressure in the system.
The difference is precisely in bubble CPAP resistor. In the device
of Fisher & Paykel (Fig 1), cited in Gunlemez and Isken's report, the
level of water column is fixed, and expiratory tubing should be submerged
until the level of wished pressure. In the Babypap Fanem (Fig 2), the
distal extremity of the expiratory tubing is fixed and the flask is filled
of water until the level of the wished pressure. Thus, it gets more
difficult to happen accidental variations of the offered pressure.
References:
1. Gunlemez A, Isken T. Bubble CPAP must be used with care to avoid
harm. Arch. Dis. Child. Fetal Neonatal Ed. 2008;93;170-171
2. Koyamaibole L, Kado J, Qovu JD, et al. An evaluation of bubble-
CPAP in a neonatal unit in a developing country: effective respiratory
support that can be
applied. J Trop Pediatr 2006;52:249–53.
Jamalpuri et al reported on the problems drawing up surfactant
following recommendations from the National Patient Safety Agency (NPSA)
to replace nasogastric tubes (1). They suggest using the old method of
syringe and needle to draw up surfactant and transferring the content into
a Penta syringe (Pentaferte, Campli, Italy) that can then be attached to
the nasogastric tube. In response to this CM Kissack and Y Freer (2)...
Jamalpuri et al reported on the problems drawing up surfactant
following recommendations from the National Patient Safety Agency (NPSA)
to replace nasogastric tubes (1). They suggest using the old method of
syringe and needle to draw up surfactant and transferring the content into
a Penta syringe (Pentaferte, Campli, Italy) that can then be attached to
the nasogastric tube. In response to this CM Kissack and Y Freer (2)
suggest the continued use of intravenous syringes with nasogastric tubes
to avoid loss of surfactant and delay in administration. The problem here
is that intravenous syringes do not fit the new style nasogastric tubes
with female luer lock.
Following the NPSA recommendations (3) our unit faced similar
problems. We introduced enteral Penta syringes and new nasogastric tubes
(Medicina, Bolton, UK) in 2005 to minimise the risk of wrong route errors
(4). To administer surfactant we used the method as described by Jamalpuri
et al. Recently however, we have started using a needleless vial access
cap that attaches to a surfactant vial and enables drawing up of
surfactant with an appropriate enteral syringe. This method was suggested
in the same letter by CM Kissack and Y Freer (2). Pentaforte currently do
not appear to be manufacturing a vial access cap that fits the current
Penta syringes in use. We have therefore started using Vygon Nutrisafe 2
enteral syringes and vial access caps (Vygon, Ecouen, France). These are
prepacked together with a Vygon nasogastric tube, labelled ‘Surfactant
administration pack’ and kept next to the surfactant vials. This is to
avoid confusion with the Penta syringes used for enteral feeds.
We feel this is a quick and safe solution for drawing up and
administering surfactant that can be practiced elsewhere until
manufacturing companies have all of the appropriate products to comply
with the NPSA guidance.
References
1. V Jamalpuri, P Smith, J Lilley. The new nasogastric tubes:
implications for neonatal practice, Arch Dis Child 2008;93:F394
2. CM Kissack, Y Freer. A response to "The new nasogastric tubes:
implications for neonatal practice", Arch Dis Child Fetal Neonatal Ed.
Online, 20 Oct 2008
3. National Patient Safety Agency. Promoting safer measurement and
administration of liquid medicines via oral and other enteral routes.
Patient safety alert. London: NPSA, 2007.
4. L Bridge. Reducing the risk of wrong route errors, Paed Nurs 2007
Jul;19(6):33-5
Sir, the paper of Wilkinson and colleagues describes an approach to
resuscitation of extremely preterm newborn we believe excessively
schematic, based only on gestational age and parental expectations. In the
same document intensive therapies are suggested only for newborns of 23-24
weeks who show capability of survival, therefore the burden of proof for
obtaining intensive care is put on children who have to demonstrate...
Sir, the paper of Wilkinson and colleagues describes an approach to
resuscitation of extremely preterm newborn we believe excessively
schematic, based only on gestational age and parental expectations. In the
same document intensive therapies are suggested only for newborns of 23-24
weeks who show capability of survival, therefore the burden of proof for
obtaining intensive care is put on children who have to demonstrate
favourable clinical criteria.
Although an increased risk of major negative neurological outcomes is well
known in infants born at very small gestational age, selective
resuscitation leads to smaller percentage of infants survived without
disabilities.(1) It has been demonstrated that a proactive approach may
increase survival rates without any increased risk of major disability.(2)
In a relative perspective it is hardly comprehensible why these little
patients should be differently treated with respect to older children and
adults who have just a quarter of probability of survival after a cardiac
arrest, without violating the principle of justice.(3,4) In an absolute
perspective the probability of success for resuscitation of 23-24 weeks
newborns is well above the threshold of medical futility.(5)
Children are not a property, parents have a duty to protect interests of
their children and eventual disabilities can never be considered worst
than death, unless modern society wants to reintroduce the concept of
“lives not worth living”.(6)
In the EPICure 2 study survival of very preterm babies remains extremely
rare, but authors conclude that “These national population-based data show
increased survival at all gestational ages less than 26 weeks but no clear
evidence of change of major morbidity; the increased numbers of babies
treated for retinopathy of prematurity may be attributable to improved
screening and lowered threshold for treatment”.(7) At present, a selective
resuscitation has been approved neither by any Italian scientific society,
as far as we know, nor by the Italian Superior Council of Health, which is
the technical advisory council of the Minister of Health.(8) Similarly,
overall perspective of the Florentine document has not been approved by
the National Bioethics Committee.(9)
Arosio P. ASL 3 Monza,Bellieni C TIN Siena, Biasini A UO TIN Cesena,
Cocchi G UO-Neonatologia AOSP Bologna, Doni D. TIN Monza, Guerrini L UO
Neonatologia Pisa , Isimbaldi C UO Pediatria Merate, Locatelli C.
Neonatologia Bologna,Paterlini G TIN Monza, Puccetti R.. Promed Galileo
IMS - Bioethic Area Pisa, Rinaldi M.R. Neonatologia Catania, Squicciarini
E TIN Acquaviva delle Fonti, Villani G TIN Foggia , Villani P
Neonatologia e TIN Brescia
References:
1.Lorenz JM, Paneth N, Jetton JR, Ouden L, Tyson JE. Comparison of
management strategies for extreme prematurity in New Jersey and the
Netherlands: outcomes and resource expenditure. Pediatrics. 2001;108:
1269–1274
2.Hakansson S, Farooqi A, Holmgrem PA, Serenius F, Hogberg
U:Proactive Management Promotes Outcome in Extremely Preterm Infants: A
population-based Comparison of two Perinatal Management Strategies.
Pediatrics Vol. 2004, 114:58-64.
Dear Editor,
I have read with great interest the article by Wilkinson et al (1)
discussing one of the most challenging aspects of perinatal medicine.
These authors most appropriately point out that treatment of ELBW newborns
needs to be customized and that any intervention should be performed in
the patient’s best interest. The authors also emphasise the important
role parents have in deciding whether to start and/or co...
Dear Editor,
I have read with great interest the article by Wilkinson et al (1)
discussing one of the most challenging aspects of perinatal medicine.
These authors most appropriately point out that treatment of ELBW newborns
needs to be customized and that any intervention should be performed in
the patient’s best interest. The authors also emphasise the important
role parents have in deciding whether to start and/or continue
resuscitation. Nowadays the approach of neonatologists to the medical
care of extremely premature newborn differs from country to country, as it
is influenced by different medical, social ethical and legal
considerations. For instance, in Italy parental rights are meant as a
role rather than as a subjective privilege, since parental authority is
basically centred on the sole interest of the child. Moreover, any
decision made by the parents should be based on the actual understanding
of correct information. When dealing with an extremely preterm delivery,
a physician is faced with the need to make rapid decisions, but he or she
is often unable to foresee the prognosis and therefore to provide the
parents with all the necessary information that would allow them to
participate in the decision process with full awareness. Hence, in the
case of urgent interventions, the physician cannot share the
responsibility of the choices made to try to achieve the best perspectives
of life and health for the newborn. In Italy, even in case of extreme
prematurity, every newborn attains the legal status of person, and as
such is fully entitled by the Constitution (Art. 3) to get all the
medical care he or she requires. This, therefore, makes unacceptable the
fact that some premature children get all the necessary health care
because their physician and parents have so decided that they should,
whereas others are abandoned because their parents and physicians have
taken the opposite decision. Equally arbitrary is perhaps the a priori
decision by a physician and/or parent to provide or not provide health
care to a newborn on the mere basis of statistical criteria that estimate
survival only by gestational age. It should be borne in mind that
gestational age is often unknown and that it cannot necessarily be defined
in ELBW infants on the basis of their clinical signs at birth. Perhaps
the severity of the disease rather than gestational age is the element
that should be most accounted for in providing medical care to an ELBW
child. Experience tells us that a child born at 26 weeks’ gestation may
be in worse conditions than one born at 24 weeks. Of course, in case of
extreme prematurity, if the neonatologist realizes that any therapeutic
effort is useless, intensive therapies that could translate into pursuit
of futile treatment should of course be curtailed.
Mario De Curtis
Department of Gynaecological Sciences, Perinatology and Puericulture
La Sapienza University, Rome, Italy
Reference
1 )Wilkinson AR, Ahluwalia J, Cole A, Crawford D, Fyle J, Gordon A,
Moorcraft J, Pollard T, Roberts T. The Management of Babies born Extremely
Preterm at less than 26 weeks of gestation. A Framework for Clinical
Practice at the time of Birth. Arch Dis Child Fetal Neonatal Ed. 2008 Oct
6
We write in response to the letter from Jamalpuri et al (1)
concerning the potential implications of the introduction of new
nasogastric tubes in response to the National Patient Safety Agency Alert
(2). This alert referred to the oral/enteral and intravenous routes but
not to the tracheal route. It is likely that the NPSA were completely
unaware of the impact of the alert on the administration of surfactant by
this rou...
We write in response to the letter from Jamalpuri et al (1)
concerning the potential implications of the introduction of new
nasogastric tubes in response to the National Patient Safety Agency Alert
(2). This alert referred to the oral/enteral and intravenous routes but
not to the tracheal route. It is likely that the NPSA were completely
unaware of the impact of the alert on the administration of surfactant by
this route, a process that commonly employs a combination of equipment
designed for both intravenous and enteral routes.
Although we support the NPSA’s response to the safety incidents
discussed in the alert, inadvertent intravenous administration of
surfactant is extremely unlikely. A literature search revealed only one
incident 14 years ago, a case in which Exosurf was administered via the
umbilical venous line rather than an endotracheal tube side-port (3). In
the UK today Curosurf, the surfactant with the leading market share, is
usually administered as a tracheal bolus. If the individual administering
the surfactant draws up the medicine into a syringe and attaches the
nasogastric tube at the cotside before approaching the endotracheal tube,
it is difficult to see how this could lead to inadvertent intravenous
administration.
Jamalpuri et al suggest, having drawn the surfactant up into an
intravenous syringe, decanting it into an enteral syringe (1). This could
risk the loss of surfactant and delay administration. There are perhaps
other solutions. Pages 4 and 5 of the patient safety alert which deal with
the matter of when intravenous syringes have to be used to prepare oral
medicine doses and when medical devices (such as nasogastric tubes) are
used for purposes other than their original intent. In such a situation
the health professionals involved should carry out a full risk assessment.
It may be that, when all the alternatives are considered, the continued
use of intravenous syringes and the associated nasogastric tubes for the
administration of surfactant carries the lowest risk.
We have contacted representatives of Trinity-Chiesi, the manufacturer
of Curosurf, and Vygon, who supply nasogastric tubes, and have learned
that Vygon plan to produce a surfactant administration pack, which would
include a vial access cap for drawing up the surfactant without the use of
a needle, an intravenous syringe and a depth-marked catheter for
administration. The introduction of such a pack would improve the
procedures for administering surfactant, and would resolve the issues
raised by the NPSA patient safety alert by avoiding the use of enteral
equipment.
References
1. Jamalpuri V, Smith P, Lilley J. The new nasogastric tubes:
implications for neonatal practice. Arch Dis Child Fetal Neonatal Ed
2008;93:F394
2. National Patient Safety Agency. Promoting safer measurement and
administration of liquid medicines via oral and other enteral routes.
Patient safety alert, 28 March 2007.
http://www.npsa.nhs.uk/EasySiteWeb/GatewayLink.aspx?alId=5317
3. Frey B, Keller E, Losa M. Seizures after inadvertent umbilical
venous infusion of synthetic surfactant (Exosurf): cause or coincidence?
Eur J Pediatr 1999;158(7):610
Opiate drugs can affect the function of the gastrointestinal tract of
premature babies, as confirmed by Menon et al. A new development in
palliative care medicine may someday help us with this problem.
Methylnaltrexone is an opiate antagonist that does not cross the
blood-brain barrier. In theory, giving methylnaltrexone along with
opiates would allow the opiates to give the desired analgesia while
maintaining...
Opiate drugs can affect the function of the gastrointestinal tract of
premature babies, as confirmed by Menon et al. A new development in
palliative care medicine may someday help us with this problem.
Methylnaltrexone is an opiate antagonist that does not cross the
blood-brain barrier. In theory, giving methylnaltrexone along with
opiates would allow the opiates to give the desired analgesia while
maintaining normal gastrointestinal motility. Research done in adults is
encouraging thus far, (NEJM 358:2332-2343, 2008).
Methylnaltrexone may also be be useful in the treatment of premature
babies, but much more research is clearly needed.
We enjoyed reading the paper of Hoellering et al. on the impact of
closed versus open endotracheal suctioning on lung volume and
cardiorespiratory changes in ventilated newborns.1 We fully agree that the
respiratory and cardiovascular response during and following different
suctioning techniques should be evaluated. However, in addition to these
variables and similar to the observations on the difference b...
We enjoyed reading the paper of Hoellering et al. on the impact of
closed versus open endotracheal suctioning on lung volume and
cardiorespiratory changes in ventilated newborns.1 We fully agree that the
respiratory and cardiovascular response during and following different
suctioning techniques should be evaluated. However, in addition to these
variables and similar to the observations on the difference between heel
lancing and venous puncture for blood sampling, we would like to suggest
to the caregivers consider also the potential relevance of adaptations in
procedural techniques to blunt the stress and pain response in neonates.
Many procedural interventions during neonatal stay remain a burden as they
cause pain or discomfort. Endotracheal suctioning might be one of these
techniques to be evaluated 2,3
In a prospective study in ventilated infants in the first 72 h of life, we
evaluated the stress response associated with an closed endotracheal
suctioning technique and these newly collected data were compared with an
earlier reported cohort in whom an open suctioning technique was
performed.4
The standardized endotracheal suctioning procedure currently used in the
unit can be described as follows: 0.2 ml normal saline (0.9% sodium
chloride) is injected into the tracheal tube by the side hole of the Trach
Care Mac®. This is a closed suction system. The suction catheter is
introduced into the endotracheal tube hereby ensuring that the tip of the
suction catheter will be just at the tip of the endotracheal tube. This is
feasible since distance is clearly indicated on the suction catheter and
measurement of the length of the endotracheal tube and the connection to
the ventilator can be done before the procedure. Finally, the suction
catheter is progressively retracted under continuous negative pressure (50
-100 mmHg). Stress and pain expression were evaluated before, during and
after endotracheal aspiration by clinical and endocrine profiles. All
infants were videotaped for 2 min before (-5 min), during and after the
procedure (5, 10, 20, 30, 40, 60 and 80 min). Videotapes were scored
afterwards with a validated pain assessment instrument for this age group,
the Neonatal Infant Pain Scale (NIPS). The NIPS scale consists of 6
behavioural (facial expression, breathing patterns, arms, legs and state
of arousal, each grade 0 or 1 point and crying, graded 0, 1 or 2 points,
resulting in a score between 0 and 7) items. Clinical characteristics and
the administration of continuous background opioids were registered. Vital
signs (heart rate, mean arterial pressure, MAP) were recorded before (-60,
-10, -5), during and after (5, 10, 20, 40, 60, 80 min) the intervention.
Endocrine response was evaluated by sequential measurement of serum
(nor)adrenaline levels. Blood samples (heparin microcontainer, 0.4 ml)
were collected before (-5 min) and after (5, 10, 20, 40 min) initiation of
endotracheal suctioning. All blood samples were stored on ice until
centrifugation. Serum samples were stored at –80°C until analysis.
Concentrations of (nor)adrenaline were measured by HPLC using fluorimetric
detection. Only infants who had an arterial line in place for clinical
indications were included to enable blood sampling (maximal 1 ml/kg)
without further stress or pain. Infants on continuous (nor)adrenaline
infusions were excluded to enable evaluation of the endocrine stress
response while infants on muscular relaxants were excluded to enable
clinical evaluation. Paired Wilcoxon was used to compare vital signs,
adrenaline and noradrenaline levels before, during or after endotracheal
suctioning.3
Ten procedures in 10 infants were recorded. Median gestational age was 34
weeks (range 27-39), median postnatal age was 29 h (range 12-68). Six
infants were on continuous opioids (fentanyl, 1-3 ìg/kg/h or tramadol, 3-8
mg/kg/day) infusion. Median duration of the suctioning procedure was 72
(range 35-110) seconds. Median heart rate (HR) before suctioning was 137
(range 129 – 147) beats per min (bpm) and median MAP was 44 (range 40 –
52) mmHg. After five min, median HR was 143 (range 136 – 163) bpm and
median MAP was 45 (39 – 55) mmHg. There was a significant increase in HR 5
min after initiation of the procedure when compared to pre-procedural
findings (p<0.05) which did not remain significant after 10 min. No
episodes of bradycardia (<80 bpm) were documented during or after
endotracheal suctioning. There was no significant increase in MAP at any
time after initiation of the procedure. Median noradrenaline before
endotracheal suctioning was 1.0 (range 0.5- 2.4 nmol/l) and median
adrenaline before endotracheal suctioning was 0.08 (range 0.05 – 0.33
nmol/l). Median nor- and adrenaline 5 min after initiation of endotracheal
suctioning were 1.5 nmol/l (range 0.6 – 2.4) (p<0.05) and 0.11 nmol/l
(0.06 – 0.42) (NS). Median procedural increase in nor- and adrenaline was
30% and 15% respectively. Videotapes were scored afterwards by 2
caregivers using the NIPS. Both caregivers had experience with the NIPS
score. Median NIPS was 0 (range 0 – 1) before suctioning. During
suctioning, median NIPS was 1 (range 0 –7). After 5 and 20 min, median
NIPS was 0 (range 0 – 4).
We can compare trends in vital signs in this cohort (n=10) with an earlier
cohort (n=13) from the same NICU using a disconnection technique.4 In this
earlier cohort, changes in heart rate and MAP were more pronounced since
mean change in heart rate was 23 (SD 17) and median change in heart rate
was 10 bpm (SD 14, range -1 to + 37 bpm). In a bench test evaluation of a
closed tracheal suction system, it was concluded that continuity of
ventilation volume or pressure delivery during suction are not preserved
and therefore can not explain the reported reduction in suction-related
hypoxia.5 It is not unlikely that the blunted stress response in part
explains this reduction.
In addition to cardiovascular or respiratory characteristics of a
suctioning technique, such techniques should also be evaluated on the
associated stress response in neonates.
References
1.Hoellering AB, Copnell B, Dargaville PA, Mills JF, Morley CJ,
Tingay DG. Lung volume and Cardiorespiratory changes during open and
closed endotracheal suction in ventilated newborn infants. Fetal Neonatal
Ed doi:10.1136/adc.2007.132076
2.Simons SH, van Dijk M, Anand KS, Roofthooft D, van Lingen RA, Tibboel D.
Do we still hurt newborn babies ? A prospective study of procedural pain
and analgesia in neonates. Arch Pediatr Adolesc Med 2003;157:1058-64.
3.Allegaert K, Tibboel D. Shouldn’t we reconsider procedural techniques to
prevent neonatal pain ? Eur J Pain 2007;11:910-2.
4.Bernert G, von Siebenthal K, Seidl R, Vanhole C, Devlieger H, Casaer P.
The effect of behavioural states on cerebral oxygenation during
endotracheal suctioning of preterm infants. Neuropediatrics 1997;28:111-5.
5.Cordero L, Sananes M, Ayers LW. Comparison of a closed (Trach Care MAC)
with an open endotracheal suction system in small premature infants. J
Perinatol 2000;20:151-6.
Editor, We read with great interest the article published by Filippi et al. (1) regarding the usefulness of dopamine in the treatment of hypotension in preterm, very low birth weight (VLBW) infants. Recently Dempsey and Barrington (2) reported how there are marked variations between neonatologists in interventions and treatments for neonatal hypotension. In medical literature is well reported how dopamine should be cons...
The recent paper advocating “a new dosage schedule” for giving vancomycin in early infancy [1] confirms what others have long said is usually the most appropriate total daily dose for babies of less than 34 weeks gestation who are more than a week old, and focuses on the time- dependent rather than concentration-dependent mode of vancomycin killing. Continuous infusion may prevent the risks of high peaks and low troughs...
Support transition by keeping the placental circulation intact – even in newborns apparently requiring resuscitation.
Detecting ‘fetal distress’ in labour allows timely delivery, followed by effective resuscitation, if required, to restore or maintain adequate circulation with oxygenated blood to the baby. This should prevent or minimise brain damage from hypoxaemia or hypovolaemia. Nielso...
The interesting article written by Gunlemez and Isken relates a complication case of nasal CPAP in a low resource country. Unaware, the expiratory tubing was submerged besides the wished, causing an excessive pressure and propitiating a pneumothorax 1. Bublle CPAP is simple, cheap and as efficient as the other systems, but it requires trained professionals in the device installation, as any CPAP System2. There is no evide...
Jamalpuri et al reported on the problems drawing up surfactant following recommendations from the National Patient Safety Agency (NPSA) to replace nasogastric tubes (1). They suggest using the old method of syringe and needle to draw up surfactant and transferring the content into a Penta syringe (Pentaferte, Campli, Italy) that can then be attached to the nasogastric tube. In response to this CM Kissack and Y Freer (2)...
Sir, the paper of Wilkinson and colleagues describes an approach to resuscitation of extremely preterm newborn we believe excessively schematic, based only on gestational age and parental expectations. In the same document intensive therapies are suggested only for newborns of 23-24 weeks who show capability of survival, therefore the burden of proof for obtaining intensive care is put on children who have to demonstrate...
Dear Editor, I have read with great interest the article by Wilkinson et al (1) discussing one of the most challenging aspects of perinatal medicine. These authors most appropriately point out that treatment of ELBW newborns needs to be customized and that any intervention should be performed in the patient’s best interest. The authors also emphasise the important role parents have in deciding whether to start and/or co...
We write in response to the letter from Jamalpuri et al (1) concerning the potential implications of the introduction of new nasogastric tubes in response to the National Patient Safety Agency Alert (2). This alert referred to the oral/enteral and intravenous routes but not to the tracheal route. It is likely that the NPSA were completely unaware of the impact of the alert on the administration of surfactant by this rou...
Opiate drugs can affect the function of the gastrointestinal tract of premature babies, as confirmed by Menon et al. A new development in palliative care medicine may someday help us with this problem.
Methylnaltrexone is an opiate antagonist that does not cross the blood-brain barrier. In theory, giving methylnaltrexone along with opiates would allow the opiates to give the desired analgesia while maintaining...
Sir,
We enjoyed reading the paper of Hoellering et al. on the impact of closed versus open endotracheal suctioning on lung volume and cardiorespiratory changes in ventilated newborns.1 We fully agree that the respiratory and cardiovascular response during and following different suctioning techniques should be evaluated. However, in addition to these variables and similar to the observations on the difference b...
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