Neonatal resuscitation in the ward: The role of nurses

Cardiopulmonary resuscitation (CPR) is necessary in about 1-2% of all newly born infants in their first minutes of life. However, CPR may also be needed in newborns beyond the time of birth, particularly in high risk categories of infants admitted in the NICU or in other less specialised units. In all these scenarios, the role of nurses is essential for several aspects, including early recognition of a deteriorating infant, with the aim to prevent cardiac arrest, as well as the starting of immediate basic life support manoeuvres at the bedside, whenever needed. Furthermore, nurses have a special part in family care during cardiopulmonary resuscitation

Transient phrenic nerve paralysis associated with status asthmaticus

Phrenic nerve paralysis is a condition typically occurring after invasive procedures in the chest and neck. Here we describe a case of transient unilateral diaphragmatic paralysis in a child with status asthmaticus complicated by complete right lung atelectasis. Common causes of this disorder and possible implications for our case are discussed

Comment on \u201cA new device for administration of continuous positive airway pressure in preterm infants\u201d by Trevisanuto et al

We read with interest the contribution by Trevisanuto et al. [1] on the effectiveness of a new device for administering continuous positive airway pressure (CPAP) as an alternative to conventional nasal CPAP in ameliorating comfort in preterm infants needing continuous distending pressure. The data which they present are intriguing, but a few points need to be further discussed. First, the use of a \u201ccomfort scale\u201d appears to be a surrogate end-point. To properly assess safety and efficacy of this new technique, even in a pilot study, the authors should have focused on more relevant clinical aspects or potential complications, such as level of respiratory distress, oxygen-dependency, rate of apnea, local damage, air leak, or need for mechanical ventilation. Second, the authors reported a marked reduction in the Neonatal Infant Pain Scale (NIPS) values, i.e., a better comfort status of patients, during treatment with helmet CPAP. Given the lower level of stress imposed by this technique, one might have expected some modifications in the main physiological parameters, such as heart rate, respiratory rate, and arterial blood pressure [2]. On the other hand, none of the investigated parameters differed between the two CPAP treatments, raising doubts about potential bias due to the nonblinded scoring method used in this study. Indeed, NIPS does require a close observation of the infant, making any blinding process quite complex. Such important limitation might be partially circumvented by simultaneous NIPS measurements performed by two independent observers or by video recording. Third, the small number of enrolled patients (powered only for the chosen end-point), the very brief duration of both CPAP treatments, and the relatively healthy status of the population studied preclude any definitive conclusion about this study. Indeed, how would this technique work in sicker infants who may require CPAP continuously for days or weeks? What are the possible effects of long-term application on abdominal distension, or in the prevention of apnea episodes? As regards the latter point, we have had the contrary findings in a single preliminary experience. A premature infant (31weeks of postconceptional age) treated with conventional nasal CPAP (Infant-Flow-Driver, EME) for apnea of prematurity, was shifted to helmet CPAP due to poor tolerance of nasal prongs. However, after 2 h of treatment he had to be returned to nasal CPAP for repeated episodes of apnea and arterial O2 desaturation. Interestingly, as soon as conventional nasal CPAP was applied, the apneic episodes virtually disappeared. Of note, we report some difficulties in maintaining CPAP levels above 3 cmH2O, despite flow rates set as high as 15 lpm and absence of major leaks in the system. We speculate that conventional nasal CPAP, successfully used for apnea of prematurity [3], would be more effective than the new technique in these circumstances. In summary, we congratulate the authors for their original study. Nonetheless, their conclusion that the helmet CPAP \u201cseems to guarantee a better tolerability and at least similar improvement in oxygenation\u201d may be misleading for the reader. We believe that larger randomized controlled studies are needed to better define the role of this new device and to verify its potential superiority over conventional CPAP by means of more appropriate end-points

Early recognition and management of septic shock in children

Septic shock remains a major cause of morbidity and mortality among children, mainly due to acute hemodynamic compromise and multiple organ failures. In the last decade, international guidelines for the management of septic shock, as well as clinical practice parameters for hemodynamic support of pediatric patients, have been published. Early recognition and aggressive therapy of septic shock, by means of abundant fluid resuscitation, use of catecholamines and other adjuvant drugs, are widely considered of pivotal importance to improve the short and long-term outcome of these patients. The aim of this paper is to summarize the modern approach to septic shock in children, particularly in its very initial phase, when pediatric healthcare providers may be required to intervene in the pre-intensive care unit setting or just on admission in the pediatric intensive care unit

Sodium Nitroprusside Toxicity in a Young Infant Following Cardiac Surgery

Adverse effects associated with sodium nitroprusside (SNP) administration are rarely observed in children. Monitoring of metabolic changes appears to be the most sensitive and accurate indicator of early toxicity. We report a case of acute toxicity in a 3-month-old boy treated with high-dose SNP infusion for systemic hypertension after elective coarctectomy, who developed seizures and severe lactic acidosis. We suggest blood lactate levels and base excess levels should be carefully monitored during SNP treatment in children, in order to detect early signs of toxicity, particularly when using high infusion rates

The Importance of Mortality Risk Assessment: Validation of the Pediatric Index of Mortality 3 Score

Objective: To evaluate the performance of the newest version of the Pediatric Index of Mortality 3 score and compare it with the Pediatric Index of Mortality 2 in a multicenter national cohort of children admitted to PICU. Design: Retrospective, prospective cohort study. Setting: Seventeen Italian PICUs. Patients: All children 0 to 15 years old admitted in PICU from January 2010 to October 2014. Interventions: None. Measurement and main results: Eleven thousand one hundred nine children were enrolled in the study. The mean Pediatric Index of Mortality 2 and 3 values of 4.9 and 3.9, respectively, differed significantly (p < 0.05). Overall mortality rate was 3.9%, and the standardized mortality ratio was 0.80 for Pediatric Index of Mortality 2 and 0.98 for Pediatric Index of Mortality 3 (p < 0.05). The area under the curve of the receiver operating characteristic curves was similar for Pediatric Index of Mortality 2 and Pediatric Index of Mortality 3. The Hosmer-Lemeshow test was not significant for Pediatric Index of Mortality 3 (p = 0.21) but was highly significant for Pediatric Index of Mortality 2 (p < 0.001), which overestimated death mainly in high-risk categories. Conclusions: Mortality indices require validation in each country where it is used. The new Pediatric Index of Mortality 3 score performed well in an Italian population. Both calibration and discrimination were appropriate, and the score more accurately predicted the mortality risk than Pediatric Index of Mortality 2

Weaning newborn infants from mechanical ventilation

Invasive mechanical ventilation is a life-saving procedure which is largely used in neonatal intensive care units, particularly in very premature newborn infants. However, this essential treatment may increase mortality and cause substantial morbidity, including lung or airway injuries, unplanned extubations, adverse hemodynamic effects, analgosedative dependency and severe infectious complications, such as ventilator-associated pneumonia. Therefore, limiting the duration of airway intubation and mechanical ventilator support is crucial for the neonatologist, who should aim to a shorter process of discontinuing mechanical ventilation as well as an earlier appreciation of readiness for spontaneous breathing trials. Unfortunately, there is scarce information about the best ways to perform an effective weaning process in infants undergoing mechanical ventilation, thus in most cases the weaning course is still based upon the individual judgment of the attending clinician. Nonetheless, some evidence indicate that volume targeted ventilation modes are more effective in reducing the duration of mechanical ventilation than traditional pressure limited ventilation modes, particularly in very preterm babies. Weaning and extubation directly from high frequency ventilation could be another option, even though its effectiveness, when compared to switching and subsequent weaning and extubating from conventional ventilation, is yet to be adequately investigated. Some data suggest the use of weaning protocols could reduce the weaning time and duration of mechanical ventilation, but better designed prospective studies are still needed to confirm these preliminary observations. Finally, the implementation of short spontaneous breathing tests in preterm infants has been shown to be beneficial in some centres, favoring an earlier extubation at higher ventilatory settings compared with historical controls, without worsening the extubation failure rate. Further research is still required to identify the best practices capable to shorten the duration of mechanical ventilation in term and preterm infants, at the same time keeping to a minimum the risk of extubation failure.   Proceedings of the 9th International Workshop on Neonatology · Cagliari (Italy) · October 23rd-26th, 2013 · Learned lessons, changing practice and cutting-edge researc

Cell Population Data (CPD) for Early Recognition of Sepsis and Septic Shock in Children: A Pilot Study

Objectives: Innovative Cell Population Data (CPD) have been used as early biomarkers for diagnosing sepsis in adults. We assessed the usefulness of CPD in pediatric patients with sepsis/septic shock, in terms of early recognition and outcome prediction. We revised 54 patients (0-15 y) admitted to our Pediatric Intensive Care Unit (PICU) for sepsis/septic shock during a 4-year period. Twenty-eight patients were excluded, 26 septic patients were enrolled (G1). Forty children admitted for elective surgery served as controls (G2). Data on five selected CPD parameters, namely neutrophils fluorescence intensity (NE-SFL), monocytes cells complexity (MO-X), monocytes fluorescence intensity (MO-Y), monocytes complexity and width of dispersion of events measured (MO-WX), and monocytes cells size and width dispersion (MO-WZ), were obtained at time of PICU admission (t0) by a hematological analyzer (Sysmex XN 9000\uae). As the primary outcome we evaluated the relevance of CPD for diagnosing sepsis/septic shock on PICU admission. Furthermore, we investigated if CPD at t0 were correlated with C-reactive protein (CRP), patient survival, or complicated sepsis course. Results: On PICU admission (t0), NE-SFL, MO-WX, and MO-Y were higher in sepsis/septic shock patients compared to controls. NE-SFL values were correlated with CRP values in G1 patients (r = 0.83). None of the five CPD parameters was correlated with survival or complicated sepsis course. Conclusion: We found higher values of NE-SFL, MO-WX, and MO-Y in children with sepsis/septic shock upon PICU admission. These parameters may be a promising adjunct for early sepsis diagnosis in pediatric populations. Larger, prospective studies are needed to confirm our preliminary observations