Non‐Pulmonary Management of Newborns with Respiratory Distress

Due to the developmental immaturity of the lungs and other organs, the premature newborns are more prone to develop respiratory distress syndrome (RDS) and other problems of prematurity. The prevention of heat and water loses improves survival. Intolerance to excessive fluids and electrolytes in the transitional period may affect urine and sodium excretion together with maladaptation of cardiovascular system, the development of heart failure, and deterioration of RDS due to patent ductus arteriosus (PDA) and further development of bronchopulmonary dysplasia (BPD). Closure of PDA is frequently needed. The “trophic feeding” and intensive nutrition as soon as possible prevent weight loss and further growth restriction. Greater sensitivity to pain, short‐ and long‐term effects of inappropriately treated pain, use of opioids and sedatives are of concern in the short‐ and long‐term outcomes. Cardiovascular stability and adequate perfusion of the brain both affect the neurological outcome. Delayed cord clamping and erythropoietin help maintaining adequate levels of circulating hemoglobin which might affect later cognitive outcomes. In the following sections, detailed descriptions of non‐pulmonary management will be presented. We conducted electronic searches of articles on supportive (non‐pulmonary) management of newborns with RDS. Consensus guidelines on newborns with respiratory distress have been reviewed

Respiratory Care of the Neonate

The respiratory distress is a very common condition both in term and in preterm neonates and the most frequent reason for admission to the neonatal intensive care unit (NICU). The aetiology greatly depends on the maturation of neonate’s organs and perinatal events. The clinical picture is sometimes scarce and very nonspecific for the etiologic determination. Treatment of neonatal RD begins first with the application of a mixture of oxygen and air, then with different modes of non-invasive respiratory support methods. Non-invasive respiratory support can be sustained with nasal continuous positive airway pressure, bi-level positive airway pressure and high-flow nasal cannula ventilation. Non-invasive ventilation with high-frequency oscillations through nasal cannula or masks is also possible with some respiratory devices. Non-invasive ventilation is usually combined with the application of natural surfactant and other therapeutic means, like methylxanthine therapy, prevention and closure of patent ductus arteriosus, and control of infection. In the case of non-invasive ventilation failure, different kinds of invasive ventilation methods are available and being practiced in NICUs. The invasive respiratory support can be maintained by controlled or intermittent mandatory ventilation combined with different supportive synchronous positive inspiratory ventilation, offered by modern respirators

Hemodynamic Monitoring in Neonates

Sick neonates are often hemodynamically unstable, hence their organs are inadequately supplied with oxygen. In order to maintain blood flow to vital organs, a number of compensatory mechanisms divert the blood flow away from the non‐vital organs. If hemodynamic changes are detected early, the cardiovascular compromise can be recognized in compensated phase and thereby the escalation to decompensated phase of low cardiac output syndrome might be prevented. In the treatment of hemodynamically unstable neonate venous filling, contractility of the heart muscle, blood pressure in the aorta, systemic blood flow, and regional distribution of blood flow should be evaluated. There are many evaluation and measurement methods based on different physical basis, each of them having their advantages and disadvantages. For most of them, it has not been demonstrated that they improve outcomes of sick neonates. Using these methods, useful hemodynamic data for the treatment of sick neonates can be obtained. Using new techniques will clarify the pathophysiology of cardiovascular failure in sick neonates, assess the effects of drugs on blood pressure and perfusion of the heart and other organs

Produžena hospitalizacija je rizični čimbenik za nastanak delirija: jednodnevna studija učestalosti u slovenskim intezivnim jedinicama

Delirium is a clinical syndrome often underestimated in the intensive care units (ICU). The aim of this study was to determine the prevalence and factors that influence the onset of delirium. A questionnaire was sent to intensivists in Slovenian ICUs, who estimated the prevalence of delirious patients. The questionnaire consisted of demographic data, type of ICU, diagnosis, reason for admission to the ICU, type of anesthesia and surgery, clinical condition, type of supportive therapy, presence of delirium, data on discharge, transfers between departments or patient outcome on day 30. Patient consciousness was assessed by the Richmond Agitation-Sedation Scale (RASS) and the presence of delirium by the validated delirium-screening Confusion Assessment Method for the ICU (CAM-ICU). Replies received from intensivists included data on 103 patients. According to RASS ≥-3, the prevalence of delirium was 9.5% (7 out of 74 patients). There was no difference in the prevalence of delirium between surgical and medical ICU patients (p=0.388). Delirious patients had longer hospital stay (p=0.002) and ICU stay (p=0.032) compared to patients without delirium. All delirious patients survived until day 30, whereas 19 patients without delirium died (p=0.092). Logistic regression analysis dismissed any association of delirium with patient mortality (p=0.998). Age, gender, anesthesia, mechanical ventilation, and type of surgical procedure could not be evaluated as risk factors for delirium. In Slovenian ICUs, a lower proportion of delirium was observed, as reported from similar studies. Risk factors such as gender, age, mechanical ventilation, sedation, anesthesia, or department could not predict delirium. However, prolonged hospitalization of ICU patients could predict the onset of delirium, but the presence of delirium did not increase patient mortality.Delirij je klinički sindrom koji se često podcjenjuje u jedinicama intenzivnog liječenja (JIL ). Cilj ovog istraživanja bio je utvrditi učestalost i čimbenike koji utječu na pojavu delirija. Upitnik je poslan intenzivistima u slovenskim jedinicama za intenzivno liječenje, koji su procijenili učestalost bolesnika s delirijem. Upitnik se sastojao od demografskih podataka, vrste intenzivnog liječenja, dijagnoze, razloga za prijam u JIL , vrste anestezije i operacije, kliničkog stanja, vrste potporne terapije, prisutnosti delirija, podataka o iscjedku, prijenosa između odjela ili ishoda bolesnika 30. dana. Svijest bolesnika je procijenjena pomoću Richmondove ljestvice za agitaciju-sedaciju (RASS), a prisutnost delirija pomoću validirane metode za procjenu konfuzije za primjenu u JIL (CAM-ICU). Odgovori dobiveni od intenzivista uključivali su podatke za 103 bolesnika. Prema RASS ≥-3, učestalost delirija bila je 9,5% (7 od 74 bolesnika). Nije bilo razlike u učestalosti delirija između kirurških i medicinskih bolesnika u intenzivnim odjelima (p=0,388). Bolesnici s delirijem imali su duži boravak u bolnici (p=0,002) i boravak u JIL (p=0,032) u usporedbi s bolesnicima bez delirija. Svi bolesnici s delirijem preživjeli su do 30. dana, dok je 19 bolesnika bez delirija umrlo (p=0,092). Logistička regresijska analiza odbacila je bilo kakvu povezanost delirija sa smrtnošću bolesnika (p=0,998). Dob, spol, anestezija, mehanička ventilacija i vrsta kirurškog zahvata nisu se mogli procijeniti kao čimbenici rizika za delirij. U slovenskim JIL zabilježen je manji udio delirija u usporedbi sa sličnim studijama. Čimbenici rizika kao što su spol, dob, mehanička ventilacija, sedacija, anestezija ili odjel ne mogu predvidjeti delirij. Međutim, dugotrajna hospitalizacija bolesnika u JIL mogla je predvidjeti početak delirija, ali prisutnost delirija nije povećala smrtnost bolesnika

External validation of population pharmacokinetic models of gentamicin in paediatric population from preterm newborns to adolescents

The aim of this study was to externally validate the predictive performance of published population pharmacokinetic models of gentamicin in all paediatric age groups, from preterm newborns to adolescents. We first selected published population pharmacokinetic models of gentamicin developed in the paediatric population with a wide age range. The parameters of the literature models were then re-estimated using the PRIOR subroutine in NONMEM®. The predictive ability of the literature and the tweaked models was evaluated. Retrospectively collected data from a routine clinical practice (512 concentrations from 308 patients) were used for validation. The models with covariates characterising developmental changes in clearance and volume of distribution had better predictive performance, which improved further after re-estimation. The tweaked model by Wang 2019 performed best, with suitable accuracy and precision across the complete paediatric population. For patients treated in the intensive care unit, a lower proportion of patients would be expected to reach the target trough concentration at standard dosing. The selected model could be used for model-informed precision dosing in clinical settings where the entire paediatric population is treated. However, for use in clinical practice, the next step should include additional analysis of the impact of intensive care treatment on gentamicin pharmacokinetics, followed by prospective validation

Probable association of neonatal death with the use of tramadol to treat labour pain

Tramadol is often used in obstetrics for the relief of labour pain. It has a dual mechanism of action, a monoaminergic effect of tramadol itself and an opioid effect, primarily mediated by its metabolite O-desmethyl tramadol, formed by genetically polymorphic cytochrome P450 2D6. In newborns, elimination of O-desmethyl tramadol is prolonged due to immature renal function. We report on a case of neonatal death following rectal administration of tramadol to treat labour pain to a birth-giving mother. An objective causality assessment using the Naranjo probability scale revealed that the likelihood of tramadol causing respiratory depression was probable. We hypothesize that neonatal death was associated with an increased exposure to O-desmethyl tramadol due to ultrarapid metabolizer cytochrome P450 2D6 genotype of the mother. More evidence is needed to support this association. Nevertheless, in obstetric analgesia, tramadol should be used with more caution until more safety data are available

Diagnosticiranje kongenitalnega sifilisa pri novorojenčku: pregled literature in prikaz primera

Sifilis je kronična sistemska okužba, ki jo povzroča spiroheta T. pallidum. Metoda izbire za postavitev diagnoze so serološki testi, in sicer testi za treponemska in testi za netreponemska protitelesa. Nezdravljena okužba v času nosečnosti lahko povzroči bolezen tudi pri otroku z možnimi dolgotrajnimi posledicami zanj. V Sloveniji je presejalno testiranje nosečnic na sifilis ob prvem pregledu v nosečnosti obvezno. S pravočasno postavitvijo diagnoze in z zdravljenjem nosečnice lahko v veliki večini primerov preprečimo prenos okužbe na plod. Diagnozo kongenitalni sifilis postavimo s primerjavo seroloških preiskav pri materi in otroku. Zdravljenje je odvisno od tveganja za prisotnost kongenitalnega sifilisa pri otroku. Predstavljamo klinični primer obravnave nosečnice s pozitivnim presejalnim testom v nosečnosti ter obravnavo novorojenčka s sumom na kongenitalni sifilis

Navigating the shadows: medical professionals’ values and perspectives on end-of-life care within pediatric intensive care units in Croatia

Background and aimThis study explores healthcare professionals’ perspectives on end-of-life care in pediatric intensive care units (ICUs) in Croatia, aiming to illuminate their experiences with such practices, underlying attitudes, and major decision-making considerations. Amid the high variability, complexity, and emotional intensity of pediatric end-of-life decisions and practices, understanding these perspectives is crucial for improving care and policies.MethodsThe study utilized a cross-sectional survey intended for physicians and nurses across all pediatric ICUs in Croatia. It included healthcare professionals from six neonatal and four pediatric ICUs in total. As the data from neonatal and pediatric ICUs were examined jointly, the term pediatric ICU was used to denominate both types of ICUs. A statistical analysis was performed using Python and JASP, focusing on professional roles, professional experience, and regional differences.ResultsThe study included a total of 103 participants (with an overall response rate—in relation to the whole target population—of 48% for physicians and 29% for nurses). The survey revealed diverse attitudes toward and experiences with various aspects of end-of-life care, with a significant portion of healthcare professionals indicating infrequent involvement in life-sustaining treatment (LST) limitation discussions and decisions, as well as somewhat ambiguous attitudes regarding such practices. Notably, discrepancies emerged between different professional roles and, in particular, regions, underscoring the high variability of LST limitation-related procedures.ConclusionsThe findings highlight a pressing need for more straightforward guidelines, legal frameworks, support mechanisms, and communication strategies to navigate the complex terrain of rather burdensome end-of-life pediatric care, which is intrinsically loaded with profound ethical quandaries

Newborn Readmissions to Slovenian Children's Hospitals in One Summer Month and One Autumn Month: A Retrospective Study

With the shortening length of stay of newborns in hospitals after birth, concerns have been raised about the possible rise in readmission rates. In Slovenia, where the normal length of stay is 3 days, no data on readmissions were available. We sought to determine the frequency and causes for readmissions. Methods: We conducted a retrospective study on all newborns readmitted to Slovenian children's hospitals and wards in June 2012 and November 2012. We obtained basic demographic data for newborns and mothers, analyzed the frequency of diagnoses, and compared the duration of treatment between summer months and autumn months. Results: The proportion of readmissions in June 2012 and November 2012 was 6% and 5.9%, respectively. Around 10% more boys were readmitted in June 2012 and November 2012. In June 2012, the mean age was 12.2 days, and the mean birth weight was 3444 g. In November, the mean age was 10.5 days, and the mean birth weight was 3271 g. Around 50% of mothers were primiparous, and their mean age was around 31 years. Most received > 10 prenatal check-ups and participated in a prenatal class. The most common diagnosis in June 2012 and November 2012 was jaundice. The duration of treatment did not statistically significantly differ between summer months and autumn months, but it was associated with the admission diagnosis and infants' characteristics. Conclusion: Our study showed that the readmission rate in Slovenia was much higher than in some other developed countries. Prospective studies are needed to further confirm the findings and highlight the possible causes for this observation