超早产儿出生时间与复苏结局的关系

目的 探讨非工作时间(工作日夜间6 pm～8 am、周末和国家法定节假日)出生的与正常工作时间出生的超早产儿复苏过程和早期结局有无差异.方法 回顾性收集2010年1月1日至2020年12月31日于北京大学第三医院出生并转入新生儿重症监护病房的超早产儿病例.根据出生时间的不同分为工作时间出生组(n=77)和非工作时间出生...     

Description of an adenovirus type 8 outbreak in hospitalized neonates born prematurely.

An adenovirus (Ad) type 8 outbreak was prospectively studied in a neonatal intensive care unit. Nasopharyngeal secretions were cultured weekly for viruses and clinical information was obtained daily in each infant. Eleven of 112 neonates were infected with Ad; 8 of 9 available isolates represented one variant of Ad 8. The median age at infection was 54 days and the median duration of virus shedding was 2 days. Seven of 11 infants had onset of new symptoms and/or required acute respiratory support; only 2 infants had eye disease. Maternal characteristics, race, gender, age at entry into study and respiratory distress syndrome at birth were similar for both groups. Ad-infected infants tended to have earlier gestations and lower birth weights. Ad-infected neonates stayed longer in the neonatal intensive care unit, required more days of respiratory support and were more likely to develop bronchopulmonary dysplasia. Thus an association was established between lung disease in premature neonates and Ad infection.     

The ethics of neonatal resuscitation at the margins of viability: informed consent and outcomes

OBJECTIVES: To determine the adequacy of records of parental counseling in mothers with threatened preterm delivery before 27 weeks gestation, whether interventions performed at birth were consistent with recorded antenatal decisions and whether extent of resuscitation affected the occurrence of serious short-term morbidity. STUDY DESIGN: Antenatal consultation records and records of resuscitation and short-term outcomes were analyzed of 65 mothers with threatened delivery at 21 weeks to 26 weeks and 6 days gestation, and their 61 infants who delivered before 27 weeks. RESULTS: Discussions about survival rates and the frequency of handicap were more likely to be recorded before 25 weeks gestation than after; the adequacy of the records varied among individuals. A decision not to resuscitate was present in 6 of the 13 consultations performed before 23 weeks gestation, and in none of the 52 at 23 weeks or above. A decision to resuscitate only if the infant's condition at birth was good was found in 7 consultations, 6 of which were at less than 24 weeks gestation. All infants born at 23 weeks and above were resuscitated, including the infants with conditional resuscitation decisions. Three of the 6 infants receiving heart massage were discharged alive without major short-term morbidity (severe intracranial hemorrhage, periventricular leukomalacia, or threshold retinopathy). All 8 infants of less than 25 weeks gestation with a heart rate at 3 minutes that was still less than 100 beats/min, in spite of active resuscitation, either died or had major short-term morbidity. CONCLUSIONS: Records of antenatal consultations were often lacking important information. Variations in physician documentation practices are substantial and affect the care offered to infants at the threshold of viability. Even extensive resuscitation can be followed by intact survival if the resuscitation required is brief.     

Comparative outcome study between triplet and singleton preterm newborns

AIM: To evaluate the outcome of triplet versus singleton preterm newborns. METHODS: The study population included 64 sets of preterm triplet (gestational age 25-34 wk) and 64 singleton controls. Data on prenatal and perinatal findings, neonatal complications, duration of hospitalization, and neonatal mortality were collected by chart review. RESULTS: Mothers of triplets were more likely to receive prenatal tocolytic treatment and more antenatal steroids for foetal lung maturation, and to be delivered by caesarean section. No differences were found between the groups in perinatal parameters (cord pH, Apgar score, respiratory support after birth), respiratory parameters (severity of acute and chronic lung disease, use and duration of oxygen treatment and assisted ventilation), or neonatal complications (patent ductus arteriosus, intraventricular haemorrhage, periventricular leukomalacia, necrotizing enterocolitis, retinopathy of prematurity, meningitis, sepsis and jaundice). This was also true for duration of hospitalization and neonatal mortality. No differences were recorded by birth order among the triplets for any of these parameters. CONCLUSION: The study indicates that good prenatal care can lead to a good outcome for preterm triplets, close to that of preterm singleton infants. Families and physicians should consider this information when foetal reduction is offered.     

Pleuro-amniotic shunting for fetal chylothorax

The immediate neonatal course of two babies with gross hydrops fetalis, associated with chylothorax, is compared. One fetus managed by antenatal insertion of a pleuro-amniotic shunt had no evidence of pleural effusion at birth and required less resuscitation.     

Home oxygen therapy following neonatal intensive care

In a 12-month period 28 of 164 consecutive very low birthweight (VLBW) infants receiving intensive care within 48 h of birth at King's College Hospital developed chronic lung disease, (oxygen dependence beyond 28 days of age). Fifteen of the 28 infants were eligible for home oxygen therapy, but this was only practical, because of home circumstances, in 8 infants (4.9%). These 8 infants received home oxygen therapy. One further infant, born at term and suffering from pulmonary hypoplasia was also discharged home on oxygen therapy. Two infants subsequently required readmission due to a deterioration in their respiratory status and died. Three others required re-admissions (total duration 32 days) for respiratory problems. The median duration of home oxygen therapy was 17 weeks (range 4-486 days). We conclude that home oxygen therapy is needed by only a very small number of preterm infants and is appropriate for only a proportion of them. Parents need to be counselled carefully regarding the possibility that the need for oxygen might be protracted.     

Longitudinal assessment of infant lung function following pregnancies complicated by prolonged and preterm rupture of the membranes

Serial measurements of functional residual capacity (FRC) were made in 22 infants (median gestational age at delivery 32 weeks, range 25–40) during the first 2 years of life. All infants had been delivered from pregnancies complicated by prolonged and preterm rupture of the membranes (PPROM) of at least 1 week in duration. The onset of membrane rupture was at a median of 26 weeks (range 15–32) with a median duration of 5.5 weeks (range 1–21). The mean FRC at all postnatal ages studied: 25 ml/kg at 6 and 12 months and 24ml/kg at 18 and 24 months did not differ significantly from the control population (mean 24ml/kg). There was, however, a wider scatter of results in the study population: four infants born very preterm consistently had FRC results above the 95% confidence limits of the controls but only two infants had FRCs consistently below this range. These results suggest PPROM may not be an invariable association of abnormal antenatal lung growth.     

Randomised controlled trial of effect of terbutaline before elective caesarean section on postnatal respiration and glucose homeostasis.

AIM: To determine if terbutaline given to mothers before elective caesarean section facilitates neonatal respiration and metabolism. METHODS: A randomised controlled trial of 25 full term infants delivered by elective caesarean section was conducted. The mothers received a continuous infusion of terbutaline or saline 120-0 minutes before birth. Umbilical artery blood was collected at birth and analysed for blood gases and catecholamines. The lung function of each infant was assessed two hours after birth, and blood pressure, heart rate, blood glucose and body temperature were monitored until 24 hours of age. RESULTS: The infants of the treated mothers (n = 13) had significantly higher dynamic lung compliance (p < 0.001), lower airway resistance (p < 0.001), and respiratory frequency than control infants (n = 12). Blood glucose and adrenaline concentrations were significantly higher in the treated group (p = 0.0014 and p < 0.01). None of these infants had any clinical respiratory difficulties; there were two cases of transient tachypnoea in the control group. No negative side effects due to the terbutaline treatment were seen among the infants. The mothers felt no discomfort caused by the terbutaline infusion, although they bled more during surgery (p = 0.03). CONCLUSION: Stimulation of the beta adrenoceptors in utero with terbutaline infusion to the mothers promotes neonatal respiratory and metabolic adaptation after elective caesarean section.     

Mucocutaneous and invasive candidiasis among very low birth weight (less than 1,500 grams) infants in intensive care nurseries: a prospective study

To determine whether mucocutaneous candidiasis presages the development of invasive candidiasis and to assess factors influencing the development of mucocutaneous candidiasis and invasive candidiasis among infants requiring neonatal intensive care, all infants admitted to our neonatal intensive care unit during a 47-month period were prospectively examined twice weekly for mucocutaneous candidiasis. Because 16 of 18 (89%) infants in whom invasive candidiasis (defined by positive cultures of blood, CSF, deep tissue or greater than or equal to 2 supra-pubic urine aspirates) developed had birth weights less than 1,500 g, further analysis was focused toward the very low birth weight group. Of 358 very low birth weight infants hospitalized for less than three days and serially studied until discharge from the neonatal intensive care unit, mucocutaneous candidiasis developed in 28 (7.8%), invasive candidiasis developed in 16 (4.5%), and in 323 there was no evidence of mucocutaneous candidiasis or invasive candidiasis. Although many risk factors were shown by univariate analysis to be significantly more common among those with invasive candidiasis and mucocutaneous candidiasis, adjustment for the covariant effects of duration of hospitalization and gestational age revealed that only prolonged duration of antibiotic therapy and duration of endotracheal intubation were significantly associated with invasive candidiasis. Invasive candidiasis developed later in nine of 28 (32%) infants with mucocutaneous candidiasis despite nystatin therapy of mucocutaneous candidiasis in all nine (median duration of therapy before invasive candidiasis, nine days). Very low birth weight infants in whom mucocutaneous candidiasis develops are at significantly greater risk of invasive candidiasis developing later than those in whom mucocutaneous candidiasis did not develop (9/28 v 7/330, P less than .001).     

Improving survival of vulnerable infants increases neonatal intensive care unit nosocomial infection rate

OBJECTIVE: To determine the factors associated with an increasing rate of nosocomial infections in infants with very low birth weights. METHODS: Retrospective review of clinical and nosocomial infection databases for all infants with birth weights of 1500 g or less admitted to an academic neonatal intensive care unit between January 1, 1991, and December 31, 1997 (N = 1184). Two study periods were compared: 1991-1995 and 1996-1997. RESULTS: Among the 1085 infants who survived beyond 48 hours, the proportion who developed nosocomial infections increased from 22% to 31% (P =.001) and the infection rate increased from 0.5 to 0.8 per 100 patient-days (P<.001) during the period from 1996 to 1997. In that same period, the median duration of indwelling vascular access increased from 10 to 16 days (P<.001), and the median duration of mechanical ventilation increased from 7 to 12 days (P<.001). Although the device-specific rate of bloodstream or respiratory infections did not change, the increase in infections was directly attributable to the increasing proportion of infants who required these devices. In both study periods, the peak incidence of initial infection occurred between 10 and 20 days of age. For the entire sample, proportional hazard models identified birth weight, duration of vascular access, and postnatal corticosteroid exposure as significant contributors to the risk of infection. CONCLUSIONS: The increasing number of technology-dependent infants was the primary determinant in the increase of nosocomial infections. Because these infections occur in a small proportion of infants, understanding the host factors that contribute to this vulnerability is necessary to decrease nosocomial infections in neonatal intensive care units.     

Abnormal velocity waveforms of the umbilical artery in growth retarded fetuses: relationship to antepartum late heart rate decelerations and outcome

In 70 intrauterine growth-retarded (IUGR) fetuses with antepartum late heart rate decelerations recordings of velocity waveforms of the umbilical artery were made with Doppler ultrasound and calculated as pulsatility indexes (PI). In 29 of these fetuses longitudinal recordings were made. Abnormal PIs preceded the occurrence of late heart rate decelerations in 27 (93%) of the 29 fetuses. The median duration of the interval between the first abnormal PI and the first appearance of antenatal heart rate decelerations was 17 days (range 0-60 days). This wide range can mainly be attributed to the gestational age at which the first abnormal velocity wave-form was recorded; during early gestation the interval was much longer than later in pregnancy. Absent end-diastolic velocity (AEDV) was found in 17 of the 29 fetuses (59%) and preceded the occurrence of decelerations with a median interval of 12 days. In the total group, 4 of the 70 IUGR fetuses with antepartum decelerations had a normal velocity waveform of the umbilical artery. Fetuses with AEDV (n = 45) were more severely growth retarded and were delivered at an earlier gestational age than those with end-diastolic velocity (n = 25). Also perinatal mortality and morbidity were higher in the group with AEDV. Yet, when fetuses were matched for gestational age and birth weight no differences in perinatal outcome were found in the groups with and without end-diastolic velocity.     

Duration of ductal shunting in healthy preterm infants: an echocardiographic color flow Doppler study

The purpose of this investigation was to assess the duration of ductal shunting after birth in healthy preterm infants (30 to 37 weeks gestational age) without evidence of respiratory distress. Thirty-six infants were evaluated in the first 12 hours of life by means of two-dimensional echocardiography and color flow Doppler techniques, and then once daily until no ductal flow was detected (defined as functional closure). Preterm infants were subdivided into two groups by gestational age: group 1 = 30 to 33 weeks (n = 12); group 2 = 34 to 37 weeks (n = 24). Sixteen full-term infants (38 to 41 weeks) were similarly evaluated as control subjects (Group 3). One infant from each group had a closed ductus at the time of the first study (performed at a mean of 7.7 +/- 3.2 hours). Subsequent studies for the entire group were performed at a mean of 31.3 +/- 5.4 hours (day 2), 55.0 +/- 4.5 hours (day 3), and 80.3 +/- 6.1 hours (day 4). For the three groups, the rates of ductal closure ranged from 50.0% to 58.3% on day 2 and 81.3% to 87.5% on day 3. For the entire group, all but one infant had demonstrated closure of the ductus arteriosus by day 4. Within the range of gestational ages studied, we conclude that prematurity, in the absence of respiratory distress syndrome, does not prolong the initial duration of physiologic ductal shunting.     

EARLY CLOSURE OF PATENT DUCTUS ARTERIOSUS WITH INDOMETHACIN IN PRETERM INFANTS WITH IDIOPATHIC RESPIRATORY DISTRESS SYNDROME

ABSTRACT. Thirty-seven preterm infants with idiopathic respiratory distress syndrome were prospectively studied for the effect of the early closure of patent ductus arteriosus with indomethacin on the course of idiopathic respiratory distress syndrome. Serial retrograde aortograms were performed in all infants in order to visualize the ductus arteriosus, apart from three patients, who died early and were evaluated aortographically only once. The ductus was initially open in 27 infants and closed in 10 infants. The infants with open ductus arteriosus were randomly divided into two groups. The first group consisted of 13 infants, in whom the ductus was closed with indomethacin at a median age of 18 hours. The other 14 infants served as controls. Total time on assisted ventilation and duration of exposure to additional oxygen were significantly shorter in medicated infants than in controls. Oxygenation of infants with an initially closed ductus was better from birth and duration of their ventilatory assistance and oxygen exposure were shorter than in infants with initial ductal shunting. The data suggest that the early closure of the patent ductus arteriosus with indomethacin in distressed preterm infants has a favourable effect on the course of idiopathic respiratory distress syndrome.     

Bradycardia and desaturation during skin-to-skin care: no relationship to hyperthermia

OBJECTIVE: We recently found increased temperature and increased bradycardia and desaturation during skin-to-skin care (SSC). We wanted to determine if these effects were related. STUDY DESIGN: Twenty-two infants (median gestational age at birth 28.5 weeks [range 24-31], median age at study 25.5 days [range 10-60 days], median birth weight 1025 g [range 550-1525 g], median weight at study 1320 g [range 900-2460 g]) underwent three 2-hour recordings of breathing movements, nasal airflow, heart rate, and pulse oximeter saturation (SpO 2 ): at thermoneutrality (TN) during incubator care, at TN during SSC, and at elevated temperature (ET) during incubator care. Core temperature was measured via a rectal probe. Recordings were analyzed for the summed rate of bradycardia and desaturation (heart rate <2/3 of baseline; SpO 2 相似文献   

Effects of theophylline on the pattern of spontaneous breathing in preterm infants less than 1000 g of birth weight

Proportional assist ventilation (PAV) amplifies the ventilatory effect of the spontaneous respiratory effort and therefore allows analysis of drug-induced changes in the spontaneous breathing pattern of subjects who depend on mechanical ventilatory assistance. We hypothesized that theophylline will reduce the number and duration of respiratory pauses and apneic events in infants less than 1000 g of birth weight on PAV. Twelve infants were studied: median birth weight was 773 g; gestational age 26.0 weeks and postnatal age 9 days. Measurements were obtained over a 2-h period before and after 5 mg/kg of intravenous theophylline. A respiratory pause was defined as cessation of breathing for at least the duration of three preceeding breaths. The total number of respiratory pauses and the number of apneas followed by either cardiac slowing (decrease in heart rate more than 10%) or bradycardia decreased significantly. Minute ventilation increased due to a rise in tidal volume from 5.6+/-1.3 to 6.1+/-1.2 ml/kg (p=0.004). The duration of respiratory pauses, the respiratory rate, and the number of apneas followed by desaturation did not change significantly. We conclude that theophylline stimulates spontaneous breathing in infants less than 1000 g, reduces the number of apneas, and increases minute volume by increasing the tidal volumes.     

Exposure to repeat doses of antenatal glucocorticoids is associated with altered cardiovascular status after birth

OBJECTIVE: To determine if exposure to more than one course of antenatal glucocorticoids is associated with changes in infant blood pressure and myocardial wall thickness in the first month after birth. DESIGN: Prospective cohort study. SETTING: Tertiary neonatal intensive care unit. PARTICIPANTS: Mothers who were eligible for but declined to enter a randomised trial of repeated doses of antenatal glucocorticoids (ACTORDS)-that is, who had a singleton, twin, or triplet pregnancy at <32 weeks gestation, had received an initial course of glucocorticoids seven or more days previously, and were considered to be at continued risk of preterm birth. MAIN OUTCOME MEASURES: Blood pressure daily for the first week then weekly until 4 weeks of age. End diastolic interventricular septal and left ventricular posterior wall (EDIVS and EDLVPW) thickness at 48-72 hours after birth. RESULTS: Thirty seven women were enrolled and delivered 50 infants. Thirty mothers (39 infants) were exposed to one course of glucocorticoids, and seven mothers (11 infants) to more than one course. Blood pressures were higher in the first week after birth in infants exposed to multiple courses of glucocorticoids, and in infants with a latency between last exposure and delivery of less than seven days. Systolic blood pressure on day 1 was >2SD above published normal ranges in 67% of babies exposed to multiple courses and 24% of babies exposed to a single course of glucocorticoids (p = 0.04). There was no difference between groups in thickness of the EDIVS or EDLVPW. However, 44/50 (88%) babies had EDIVS and 49/50 (98%) babies had EDLVPW thickness >2 SD above the expected mean for birth weight and gestation. EDIVS but not EDLVPW thickness increased with increasing latency (mean 0.02 mm/day, p = 0.03). CONCLUSION: Future randomised trials should assess the long term effects of exposure to antenatal glucocorticoids, particularly multiple courses, on the cardiovascular status of the infant.     

Perinatal outcome following conservative management of mid-trimester pre-labour rupture of the membranes

To assess perinatal outcome and the effect of antenatal steroid use following conservative management of 86 consecutive singleton pregnancies complicated by pre-labour rupture of membranes (ROM) in the mid-trimester (13–26 weeks; mean 22.8 weeks).

Methodology:

Review of obstetric and neonatal case notes between 1 January 1990 and 31 December 1993.

Results:

The duration of ruptured membranes (latent period) ranged from 1.25 to 105 days (mean 23.8 days; median 14 days) and was inversely related to gestational age at ROM. There was clinical evidence of chorioamnionitis in 39.5% with placental histological changes consistent with chorioamnionitis in 76.6%. All infants were delivered before 33 weeks gestation (mean 26 weeks). Overall, the mortality rate was 43.0% but 62.5% in infants with ROM before 24 completed weeks gestation. Adverse outcome (defined as death, severe intraventricular haemorrhage (IVH) or periventricular leucomalacia (PVL)) occurred in 46.5% and was significantly related to both gestation at delivery and gestation at ROM. In the group ( n = 40) with ROM before 24 weeks gestation, adverse outcome occurred in 65% and was inversely related to gestation at ROM independent of gestation at delivery. Antenatal steroid administration resulted in less adverse outcome independent of gestation at delivery (OR 0.31; 95% CI (0.09–0.98; P = 0.046)).

Conclusion:

From the neonatal perspective conservative management is justified for pregnancies with ROM at or after 24 weeks gestation; in this group the use of antenatal steroids prior to delivery may improve perinatal outcome. A poor outcome is associated with ROM that occurs before 24 weeks gestation.     

Perinatal factors and the development of chronic lung disease in preterm infants: A case control study

A case control study of neonates was performed to determine those factors contributing to the development of chronic lung disease (CLD). During the 5 years 1981 -84 there were 487 neonatal survivors at gestations of 25–32 weeks; 391 of these developed respiratory failure (oxygen therapy required for more than 6 h). Fifty-six of the latter developed CLD (oxygen therapy required for more than 28 days and a coarse reticular pattern on chest X-ray). These neonates were predominantly of the shortest gestational ages, regardless of the initial chest X-ray diagnosis. Forty-three of these infants with CLD were matched for gestation and initial chest X-ray appearance (respiratory distress syndrome, n = 20; normal, n = 15; non-specific, n = 8) with 42 control infants.
The mean duration of oxygen therapy ( P < 0.001), maximum FiO₂ ( P < 0.001), incidence ( P < 0.01) and duration of intermittent positive pressure respiration (IPPR; P < 0.05) and peak IPPR ( P < 0.05) were significantly greater in the CLD group. Mean birthweight ( P < 0.001), arterial cord pH ( P < 0.05) and base excess ( P < 0.05) were significantly lower in the CLD group. Factors that were not statistically significant in the development of CLD included antenatal fetal heart rate abnormality, hypertensive disease of pregnancy, acute intrauterine infection (chorioamnionitis or umbilical vasculitis). administration of antenatal steroids, sex, patent ductus arteriosus and pneumothorax.     

Review of treatment of bronchiolitis related apnoea in two centres.

AIMS: To determine whether the use of negative pressure ventilation (NPV) was associated with a lower rate of endotracheal intubation in infants with recurrent apnoea secondary to acute bronchiolitis. METHODS: Retrospective review of two paediatric intensive care units (PICU) databases and case notes; one PICU offered NPV. RESULTS: Fifty two infants with bronchiolitis related apnoea were admitted to the two PICUs (31 to the NPV centre). There were no significant differences between infants in the two centres in age and weight on admission, gestational age at birth, birth weight, history of apnoea of prematurity or chronic lung disease, days ill before referral, respiratory syncytial virus status, oxygen requirement before support, and numbers retrieved from secondary care centres. Respiratory support was provided to all 31 infants in the NPV centre (23 NPV, 8 PPV), and 19/21 in the non-NPV centre (18 PPV, 1 CPAP); the NPV centre had lower rates of endotracheal intubation rates (8/31 v 18/21), shorter durations of stay (median 2 v 7 days), and less use of sedation (16/31 v 18/21). In the two years after the NPV centre discontinued use of NPV, 14/17 (82%) referred cases were intubated, with a median PICU stay of 7.5 days. CONCLUSIONS: The use of NPV was associated with a reduced rate of endotracheal intubation, and shorter PICU stay. A prospective randomised controlled trial of the use of NPV in the treatment of bronchiolitis related apnoea is warranted.     

Congenital chylothorax: lymphopenia and high risk of neonatal infections

AIM: To describe the clinical course of patients with congenital chylothorax focusing on infectious complications. Congenital chylothorax is a common manifestation of non-immune hydrops fetalis (NIHF). The drainage of chyle leads to loss of cellular and plasmatic factors that influence the patient's immune response and increase the risk of infections. METHODS: In a retrospective analysis of 24 preterm infants with NIHF treated between 1998 and 2002, congenital chylothorax was diagnosed in 7 patients. RESULTS: All 7 patients were treated conservatively with pleural drainage over a median period of 22 d (range 10-36 d). Lymphopenia was found in all patients (median of minimal lymphocyte counts 285/microl, range 80-770). The nadir was on day 5 (2-6 d). Lymphopenia lasted for 12 d median (range 4-39 d) and was significantly correlated with the duration of lymph drainage (p = 0.001). Cell-surface analysis of peripheral blood lymphocytes was performed in two patients. Both patients had a decreased number of total T cells. Four out of seven (57%) patients developed nosocomial infections. This incidence of nosocomial infections in patients with congenital chylothorax is about three times higher than that in other neonatal patients. None of the children suffered from fungal or viral infection. Although there was a very high incidence of infections, no correlation between lymphopenia and the occurrence of infections could be shown. CONCLUSION: Drainage of congenital chylothorax results in the loss of lymphocytes and bears a high risk of infections.