Early complications in the treatment of newborns with congenital diaphragmatic hernia

Prirođena dijafragmalna kila (PDK) je razvojni defekt dijafragme koji omogućuje prolaps abdominalnih organa u prsište. Unatoč napretku intenzivne skrbi novorođenčadi rezultati liječenja i u najboljim centrima dosežu stopu preživljenja od svega 50%. Ovakav nezadovoljavajući rezultat pripisuje se upravo komplikacijama same bolesti u ranom novorođenačkom periodu. Najteži rezultat hernijacije abdominalnih organa jest razvitak plućne hipoplazije, zbog čega novorođenče ima povećani rizik razvitka perzistirajuće plućne hipertenzije (PPHN). Ova se komplikacija prezentira se u prva 24h znakovima respiratornog distres sindroma. Kod sumnje na PPHN provodi se probir pulsnom oksimetrijom, a definitivna dijagnoza postavlja se pomoću ultrazvuka srca. Liječenje perzistirajuće plućne hipertenzije novorođenčeta uključuje osnovnu potpornu terapiju kardiorespiratornog sustava volumenom, inotropnim lijekovima i kisikom te korekciju acidoze, a u liječenje se po potrebi uključuju i dodatne mjere kao što su vazodilatacijski lijekovi i potpora izvantjelesnom membranskom oksigenacijom (ECMO). Novi protokol liječenja PDK temelji se na preoperativnoj stabilizaciji plućne hipertenzije te poštednoj mehaničkoj ventilaciji malim volumenima, visokom frekvencijom i reduciranim vršnim tlakom radi sprečavanja barotraume pluća. Unatoč velikim očekivanjima od ECMO potpore, novije studije pokazuju da se prednosti korištenja ECMO očituju tek u teškim slučajevima PDK kada su konvencionalne terapijske mogućnosti iscrpljene.Najteža poslijeoperacijska komplikacija jest povratak plućne hipertenzije. Od drugih postoperativnih komplikacija češće se susreće hilotoraks, a temeljni pristup u liječenju jest smanjiti produkciju limfe, drenirati i obliterirati pleuralni prostor, nadoknađivati tekućinu i nutritivne tvari i zbrinjavati disanje.Congenital diaphragmatic hernia (CDH) is a developmental defect of the diaphragm that allows abdominal viscera to herniate into thoracic cavity. Despite of the improvements in the intensive neonatal care results of the treatment of this condition remain rather poor with an overall survival rate estimated at 50%. These unsatisfactory results stem from the complications which appear in the early neonatal period. The most difficult outcome of herniation is development of the pulmonary hypoplasia and an increased risk of persistent pulmonary hypertension of newborn (PPHN). This is seen already in the first day of life as newborn shows signs of respiratory distress syndrome. Should CDH be suspected, a screening with pulse oximetry should be conducted and final diagnosis based on findings of echocardiography. Current treatment of the persistent pulmonary hypertension of newborn includes general supportive therapy of cardiorespiratory system with volume, inotropic agents and oxygen as well as treatment of the underlying acidosis. When needed, treatment can also involve supplemental therapy such as vasodilator agents and extracorporeal membrane oxygenation (ECMO). New treatment protocol focuses on preoperative stabilization of pulmonary hypertension and lung protective mechanical ventilation using small volumes, high frequency and low peak inspiratory pressure. Despite high expectations of ECMO support, it has recently been showed that ECMO is of critical importance only in severe cases for which conventional measures remain insufficient. An operation of diaphragmatic defect follows after clinical stabilization. Recurrence of the pulmonary hypertension presents the most difficult postoperative complication. Other postoperative complications include chylothorax, which is best treated with reduction of lymph production, drainage and obliteration of pleural space. In addition, the patient should be supported with fluid, electrolytes and nutrients and respiratory stabilized

Chironomid larvae (Chironomidae, Diptera) in epiphytic communities of shallow freshwater ecosystem

Mali Sakadaš je specifičan slatkovodni ekosustav s obzirom da se može po površini klasificirati kao bara za vrijeme niskog vodostaja (~ 0.25 ha) ili kao (plitko) jezero tijekom razdoblja plavljenja i visoke vode. S obzirom na to da svjetlost prodire do dna, omogućen je razvoj makrofitske vegetacije. Veliki biodiverzitet vrsta čine ga vrlo složenim sustavom. Istraživanje je provedeno u listopadu 2016. godine pri čemu je utvrđeno sedam rodova makrofitske vegetacije. Pojedine makrofitske vrste su odvojene te posebno isprane da bi se utvrdio sastav epifitske zajednice na svakoj vrsti posebno. Taksonomske skupine beskralježnjaka su prebrojane i razdvojene, dok su ličinke trzalaca (Chironomidae, Diptera) determinirane do najniže taksonomske kategorije i svrstane u funkcionalne hranidbene skupine. Utvrđena je dominantnost ličinki trzalaca na svim lokalitetima te je najveća raznolikost i brojnost ličinki trzalaca zabilježena na dominantnoj submerznoj vrsti Ceratophyllum demersum. Makrofitska vrsta C demersum se pokazala kao povoljan tip substrata za ličinke trzalaca osiguravajući dovoljnu količinu hrane. U istraživanju su potpunosti prevladavale Chironominae u brojnosti i raznolikosti, dok su sljedeće najbrojnije bile skupine Ephemeroptera i Zygoptera. Pronađene svojte ličinki trzalaca su karakteristične za eutrofna vodena tijela.Mali Sakadas is a specific freshwater ecosystem since it can be classified as a pond during low water levels (~ 0.25 ha) or as a (shallow) lake during times of flooding and high water levels. Since light penetrates to the bottom, it is possible to develop submerged macrophyte vegetation. A large amount of nutrients and high biodiversity make it a very complex system. This research was conducted in October 2016, when seven species of macrophyte vegetation were identified. Macrophyte species are separated and especially washed to determine the composition of the epiphytic community on each species separately. Taxonomic groups of invertebrates were counted and separated, while chironomid lavaes (Chironomidae, Diptera) were identified to the lowest taxonomic category and classified into functional feeding groups. The dominance of chironomid larvae on all sites was determined and the largest variety and number of chironomid larvae were recorded on the dominant submerged species Ceratophyllum demersum. Macrophytic species of C. demersum proved to be a preferred type of substrate for chironomid larvae providing sufficient amounts of food. According to the research, Chironomidae were prevalent in number and diversity ahead of Ephemeroptera and Zygoptera, respectively. The found chironomid taxa are characteristic for eutrophic water bodie

Early complications in the treatment of newborns with congenital diaphragmatic hernia

Prirođena dijafragmalna kila (PDK) je razvojni defekt dijafragme koji omogućuje prolaps abdominalnih organa u prsište. Unatoč napretku intenzivne skrbi novorođenčadi rezultati liječenja i u najboljim centrima dosežu stopu preživljenja od svega 50%. Ovakav nezadovoljavajući rezultat pripisuje se upravo komplikacijama same bolesti u ranom novorođenačkom periodu. Najteži rezultat hernijacije abdominalnih organa jest razvitak plućne hipoplazije, zbog čega novorođenče ima povećani rizik razvitka perzistirajuće plućne hipertenzije (PPHN). Ova se komplikacija prezentira se u prva 24h znakovima respiratornog distres sindroma. Kod sumnje na PPHN provodi se probir pulsnom oksimetrijom, a definitivna dijagnoza postavlja se pomoću ultrazvuka srca. Liječenje perzistirajuće plućne hipertenzije novorođenčeta uključuje osnovnu potpornu terapiju kardiorespiratornog sustava volumenom, inotropnim lijekovima i kisikom te korekciju acidoze, a u liječenje se po potrebi uključuju i dodatne mjere kao što su vazodilatacijski lijekovi i potpora izvantjelesnom membranskom oksigenacijom (ECMO). Novi protokol liječenja PDK temelji se na preoperativnoj stabilizaciji plućne hipertenzije te poštednoj mehaničkoj ventilaciji malim volumenima, visokom frekvencijom i reduciranim vršnim tlakom radi sprečavanja barotraume pluća. Unatoč velikim očekivanjima od ECMO potpore, novije studije pokazuju da se prednosti korištenja ECMO očituju tek u teškim slučajevima PDK kada su konvencionalne terapijske mogućnosti iscrpljene.Najteža poslijeoperacijska komplikacija jest povratak plućne hipertenzije. Od drugih postoperativnih komplikacija češće se susreće hilotoraks, a temeljni pristup u liječenju jest smanjiti produkciju limfe, drenirati i obliterirati pleuralni prostor, nadoknađivati tekućinu i nutritivne tvari i zbrinjavati disanje.Congenital diaphragmatic hernia (CDH) is a developmental defect of the diaphragm that allows abdominal viscera to herniate into thoracic cavity. Despite of the improvements in the intensive neonatal care results of the treatment of this condition remain rather poor with an overall survival rate estimated at 50%. These unsatisfactory results stem from the complications which appear in the early neonatal period. The most difficult outcome of herniation is development of the pulmonary hypoplasia and an increased risk of persistent pulmonary hypertension of newborn (PPHN). This is seen already in the first day of life as newborn shows signs of respiratory distress syndrome. Should CDH be suspected, a screening with pulse oximetry should be conducted and final diagnosis based on findings of echocardiography. Current treatment of the persistent pulmonary hypertension of newborn includes general supportive therapy of cardiorespiratory system with volume, inotropic agents and oxygen as well as treatment of the underlying acidosis. When needed, treatment can also involve supplemental therapy such as vasodilator agents and extracorporeal membrane oxygenation (ECMO). New treatment protocol focuses on preoperative stabilization of pulmonary hypertension and lung protective mechanical ventilation using small volumes, high frequency and low peak inspiratory pressure. Despite high expectations of ECMO support, it has recently been showed that ECMO is of critical importance only in severe cases for which conventional measures remain insufficient. An operation of diaphragmatic defect follows after clinical stabilization. Recurrence of the pulmonary hypertension presents the most difficult postoperative complication. Other postoperative complications include chylothorax, which is best treated with reduction of lymph production, drainage and obliteration of pleural space. In addition, the patient should be supported with fluid, electrolytes and nutrients and respiratory stabilized

Chironomid larvae (Chironomidae, Diptera) in epiphytic communities of shallow freshwater ecosystem

Mali Sakadaš je specifičan slatkovodni ekosustav s obzirom da se može po površini klasificirati kao bara za vrijeme niskog vodostaja (~ 0.25 ha) ili kao (plitko) jezero tijekom razdoblja plavljenja i visoke vode. S obzirom na to da svjetlost prodire do dna, omogućen je razvoj makrofitske vegetacije. Veliki biodiverzitet vrsta čine ga vrlo složenim sustavom. Istraživanje je provedeno u listopadu 2016. godine pri čemu je utvrđeno sedam rodova makrofitske vegetacije. Pojedine makrofitske vrste su odvojene te posebno isprane da bi se utvrdio sastav epifitske zajednice na svakoj vrsti posebno. Taksonomske skupine beskralježnjaka su prebrojane i razdvojene, dok su ličinke trzalaca (Chironomidae, Diptera) determinirane do najniže taksonomske kategorije i svrstane u funkcionalne hranidbene skupine. Utvrđena je dominantnost ličinki trzalaca na svim lokalitetima te je najveća raznolikost i brojnost ličinki trzalaca zabilježena na dominantnoj submerznoj vrsti Ceratophyllum demersum. Makrofitska vrsta C demersum se pokazala kao povoljan tip substrata za ličinke trzalaca osiguravajući dovoljnu količinu hrane. U istraživanju su potpunosti prevladavale Chironominae u brojnosti i raznolikosti, dok su sljedeće najbrojnije bile skupine Ephemeroptera i Zygoptera. Pronađene svojte ličinki trzalaca su karakteristične za eutrofna vodena tijela.Mali Sakadas is a specific freshwater ecosystem since it can be classified as a pond during low water levels (~ 0.25 ha) or as a (shallow) lake during times of flooding and high water levels. Since light penetrates to the bottom, it is possible to develop submerged macrophyte vegetation. A large amount of nutrients and high biodiversity make it a very complex system. This research was conducted in October 2016, when seven species of macrophyte vegetation were identified. Macrophyte species are separated and especially washed to determine the composition of the epiphytic community on each species separately. Taxonomic groups of invertebrates were counted and separated, while chironomid lavaes (Chironomidae, Diptera) were identified to the lowest taxonomic category and classified into functional feeding groups. The dominance of chironomid larvae on all sites was determined and the largest variety and number of chironomid larvae were recorded on the dominant submerged species Ceratophyllum demersum. Macrophytic species of C. demersum proved to be a preferred type of substrate for chironomid larvae providing sufficient amounts of food. According to the research, Chironomidae were prevalent in number and diversity ahead of Ephemeroptera and Zygoptera, respectively. The found chironomid taxa are characteristic for eutrophic water bodie

Survival prediction of high-risk outborn neonates with congenital diaphragmatic hernia from capillary blood gases

BACKGROUND: The extent of lung hypoplasia in neonates with congenital diaphragmatic hernia (CDH) can be assessed from gas exchange. We examined the role of preductal capillary blood gases in prognosticating outcome in patients with CDH. ----- METHODS: We retrospectively reviewed demographic data, disease characteristics, and preductal capillary blood gases on admission and within 24 h following admission for 44 high-risk outborn neonates. All neonates were intubated after delivery due to acute respiratory distress, and were emergently transferred via ground ambulance to our unit between 1/2000 and 12/2014. The main outcome measure was survival to hospital discharge and explanatory variables of interest were preductal capillary blood gases obtained on admission and during the first 24 h following admission. ----- RESULTS: Higher ratio of preductal partial pressure of oxygen to fraction of inspired oxygen (PcO2/FIO2) on admission predicted survival (AUC = 0.69, P = 0.04). However, some neonates substantially improve PcO2/FIO2 following initiation of treatment. Among neonates who survived at least 24 h, the highest preductal PcO2/FIO2 achieved in the initial 24 h was the strongest predictor of survival (AUC = 0.87, P = 0.002). Nonsurvivors had a mean admission preductal PcCO2 higher than survivors (91 ± 31 vs. 70 ± 25 mmHg, P = 0.02), and their PcCO2 remained high during the first 24 h of treatment. ----- CONCLUSION: The inability to achieve adequate gas exchange within 24 h of initiation of intensive care treatment is an ominous sign in high-risk outborn neonates with CDH. We suggest that improvement of oxygenation during the first 24 h, along with other relevant clinical signs, should be used when making decisions regarding treatment options in these critically ill neonates

Survival of outborns with congenital diaphragmatic hernia: the role of protective ventilation, early presentation and transport distance: a retrospective cohort study

BACKGROUND: Congenital diaphragmatic hernia (CDH) is a congenital malformation associated with life-threatening pulmonary dysfunction and high neonatal mortality. Outcomes are improved with protective ventilation, less severe pulmonary pathology, and the proximity of the treating center to the site of delivery. The major CDH treatment center in Croatia lacks a maternity ward, thus all CDH patients are transferred from local Zagreb hospitals or remote areas (outborns). In 2000 this center adopted protective ventilation for CDH management. In the present study we assess the roles of protective ventilation, transport distance, and severity of pulmonary pathology on survival of neonates with CDH. ----- METHODS: The study was divided into Epoch I, (1990-1999, traditional ventilation to achieve normocapnia), and Epoch II, (2000-2014, protective ventilation with permissive hypercapnia). Patients were categorized by transfer distance (local hospital or remote locations) and by acuity of respiratory distress after delivery (early presentation-occurring at birth, or late presentation, ≥ 6 h after delivery). Survival between epochs, types of transfers, and acuity of presentation were assessed. An additional analysis was assessed for the potential association between survival and end-capillary blood CO2 (PcCO2), an indirect measure of pulmonary pathology. ----- RESULTS: There were 83 neonates, 26 in Epoch I, and 57 in Epoch II. In Epoch I 11 patients (42%) survived, and in Epoch II 38 (67%) (P = 0.039). Survival with early presentation (N = 63) was 48 % and with late presentation 95% (P <0.001). Among early presentation, survival was higher in Epoch II vs. Epoch I (57% vs. 26%, P = 0.031). From multiple logistic regression analysis restricted to neonates with early presentation and adjusting for severity of disease, survival was improved in Epoch II (OR 4.8, 95%CI 1.3-18.0, P = 0.019). Survival was unrelated to distance of transfer but improved with lower partial pressure of PcCO2 on admission (OR 1.16, 95%CI 1.01-1.33 per 5 mmHg decrease, P = 0.031). ----- CONCLUSIONS: The introduction of protective ventilation was associated with improved survival in neonates with early presentation. Survival did not differ between local and remote transfers, but primarily depended on severity of pulmonary pathology as inferred from admission capillary PcCO2

Early complications in the treatment of newborns with congenital diaphragmatic hernia

Prirođena dijafragmalna kila (PDK) je razvojni defekt dijafragme koji omogućuje prolaps abdominalnih organa u prsište. Unatoč napretku intenzivne skrbi novorođenčadi rezultati liječenja i u najboljim centrima dosežu stopu preživljenja od svega 50%. Ovakav nezadovoljavajući rezultat pripisuje se upravo komplikacijama same bolesti u ranom novorođenačkom periodu. Najteži rezultat hernijacije abdominalnih organa jest razvitak plućne hipoplazije, zbog čega novorođenče ima povećani rizik razvitka perzistirajuće plućne hipertenzije (PPHN). Ova se komplikacija prezentira se u prva 24h znakovima respiratornog distres sindroma. Kod sumnje na PPHN provodi se probir pulsnom oksimetrijom, a definitivna dijagnoza postavlja se pomoću ultrazvuka srca. Liječenje perzistirajuće plućne hipertenzije novorođenčeta uključuje osnovnu potpornu terapiju kardiorespiratornog sustava volumenom, inotropnim lijekovima i kisikom te korekciju acidoze, a u liječenje se po potrebi uključuju i dodatne mjere kao što su vazodilatacijski lijekovi i potpora izvantjelesnom membranskom oksigenacijom (ECMO). Novi protokol liječenja PDK temelji se na preoperativnoj stabilizaciji plućne hipertenzije te poštednoj mehaničkoj ventilaciji malim volumenima, visokom frekvencijom i reduciranim vršnim tlakom radi sprečavanja barotraume pluća. Unatoč velikim očekivanjima od ECMO potpore, novije studije pokazuju da se prednosti korištenja ECMO očituju tek u teškim slučajevima PDK kada su konvencionalne terapijske mogućnosti iscrpljene.Najteža poslijeoperacijska komplikacija jest povratak plućne hipertenzije. Od drugih postoperativnih komplikacija češće se susreće hilotoraks, a temeljni pristup u liječenju jest smanjiti produkciju limfe, drenirati i obliterirati pleuralni prostor, nadoknađivati tekućinu i nutritivne tvari i zbrinjavati disanje.Congenital diaphragmatic hernia (CDH) is a developmental defect of the diaphragm that allows abdominal viscera to herniate into thoracic cavity. Despite of the improvements in the intensive neonatal care results of the treatment of this condition remain rather poor with an overall survival rate estimated at 50%. These unsatisfactory results stem from the complications which appear in the early neonatal period. The most difficult outcome of herniation is development of the pulmonary hypoplasia and an increased risk of persistent pulmonary hypertension of newborn (PPHN). This is seen already in the first day of life as newborn shows signs of respiratory distress syndrome. Should CDH be suspected, a screening with pulse oximetry should be conducted and final diagnosis based on findings of echocardiography. Current treatment of the persistent pulmonary hypertension of newborn includes general supportive therapy of cardiorespiratory system with volume, inotropic agents and oxygen as well as treatment of the underlying acidosis. When needed, treatment can also involve supplemental therapy such as vasodilator agents and extracorporeal membrane oxygenation (ECMO). New treatment protocol focuses on preoperative stabilization of pulmonary hypertension and lung protective mechanical ventilation using small volumes, high frequency and low peak inspiratory pressure. Despite high expectations of ECMO support, it has recently been showed that ECMO is of critical importance only in severe cases for which conventional measures remain insufficient. An operation of diaphragmatic defect follows after clinical stabilization. Recurrence of the pulmonary hypertension presents the most difficult postoperative complication. Other postoperative complications include chylothorax, which is best treated with reduction of lymph production, drainage and obliteration of pleural space. In addition, the patient should be supported with fluid, electrolytes and nutrients and respiratory stabilized