Dispositifs de ventilation pour la réanimation à la naissance: revue systématique et méta-analyse

peer reviewed("[en] UNLABELLED: Initial management of inadequate adaptation to extrauterine life relies on non-invasive respiratory support. Two types of devices are available: fixed pressure devices (FPD; T-pieces or ventilators) and hand driven pressure devices (HDPD; self- or flow-inflating bags). This systematic review and meta-analysis aims to compare clinical outcomes after neonatal resuscitation according to device type. METHODS: Four databases were searched from inception to 2022, January. Search strategies included Mesh/Emtree terms as well as free language without any restriction. Randomized, quasi-randomized studies and prospective cohorts comparing the use of the two types of devices in neonatal resuscitation were included. RESULTS: Nine studies recruiting 3621 newborns were included: 5 RCTs, 2 RCTs with interventions bundles and 2 prospective cohorts. Meta-analysis of the 5 RCTs demonstrated significant reductions in bronchopulmonary dysplasia (RR0,68[0,48-0,96]-NNT 31) and other respiratory outcomes: intubation in the delivery room (RR0,72[0,58-0,88]-NNT 13,4), mechanical ventilation requirements (RR0,81[0,67-0,96]-NNT 17) and duration (MD-1,54 days[-3,03- -0,05]), need for surfactant (RR0,79[0,64-0,96]-NNT 7,3). The overall analysis found a lower mortality in the FPD group (OR0,57[0,47-0,69]-NNT 12,7) and confirmed decreases in intubation, surfactant requirement and mechanical ventilation rates (OR 0,56[0,40-0,79]- NNT7,5; OR 0,67[0,55-0,82]-NNT10,7 and OR0,58[0,42-0,80]- NNT 7,4 respectively). The risk of cystic periventricular leukomalacia (cPVL) decreased significantly with FPD (OR0.59[0.41-0.85]-NNT 27). Pneumothorax rates were similar (OR0.82[0.44-1.52]). CONCLUSION AND RELEVANCE: Resuscitation at birth with FPD improves respiratory transition and decreases BPD with a very low to moderate certainty of evidence. There is suggestion of decreases in mortality and cPVL. Further studies are still needed to confirm those results.","[en] ",""

Analgosedation before Less-Invasive Surfactant Administration: A Systematic Review

Background: Surfactant therapy is the cornerstone of respiratory distress syndrome management. “Less-invasive surfactant administration (LISA)” is now recommended for spontaneously breathing preterm infants. Analgosedation remains controversial as 52% of European neonatologists do not use any. This systematic review aims to describe the efficacy and safety of different drugs for analgosedation during LISA. Methods: MEDLINE via Ovid, Embase, Scopus, and Cochrane Library of Trials were searched independently by 2 reviewers for studies on sedation or analgesia for LISA, without filters or limits. Results: Eight studies (1 randomized controlled trial) recruiting 945 infants were included. Infant pain was significantly reduced, with more infants evaluated as comfortable. Failure, defined as need for intubation or for a second dose of surfactant, was not different between sedated and unsedated groups. Analgosedation was associated with a higher occurrence of desaturation and need for positive pressure ventilation during procedure, but the need for mechanical ventilation within 24 or 72 h of life was not significantly different. There does not seem to be any difference in clinical tolerance and complications (e.g., hypotension, mortality, air leaks, etc.). Procedural conditions were evaluated as good or excellent in 83% after sedation. Discussion and Conclusion: Analgesia or sedative drugs increase infant comfort and allow good procedural conditions, with a limited impact on the clinical evolution. Questions remain about the best choice of drugs and dosages, with the constraint to maintain spontaneous breathing and have a rapid offset. Further good quality studies are needed to provide additional evidence to supplement those limited existing data

Syndrome d'Activation Macrophagique secondaire à un infection à CMV chez un nouveau-né

Macrophage activation syndrome is a rare and potentially fatal systemic immunologic disorder. It generally occurs in patients who encounters specific pathogens in the context of preexisting congenital or acquired immune deficiencies. It is associated with a reported 20-30% mortality rates with a much better prognosis in secondary disease. The earlier recognition of its clinical features and treatment are critical. In our patient, immunological workup showed no indication of a familial HLH. Genetic analysis for homozygocy showed that all known genes for FHLH or secondary HLH to metabolic diseases were heterozygous. X-linked forms were excluded. We concluded that CMV was probably the causative agent of secondary macrophage activation syndrome. Further follow-up comforts this idea

Thyroid-related bone lesions: clinical case

peer reviewe

Dispositifs à pression fixes (pièces en T) ou dispositifs à pression variables manuelless (BAGS) pour la réanimation à la naissance : revue systématique et méta-analyse

Background: Initial management of inadequate adaptation to extrauterine life relies on non-invasive respiratory support. Two types of devices are commonly available: fixed pressure devices (FP; T-pieces or ventilators) and hand driven pressure devices (HDP; eg self-inflating bags). There is no consensus about benefices that each option offers. However, some studies reported a higher incidence of pneumothorax since T-piece utilisation. Methods: A systematic review and meta-analysis was carried out. Medline, Embase, Scopus and Cochrane Library of Trials were searched. Randomised, quasi-randomised studies and prospective cohorts comparing the use of the two types of devices in neonatal resuscitation were included. Results: Eight (8) studies recruiting 3571 newborns were included: 4 RCTs, 2 qRCTs and 2 prospective cohorts. Mortality was decreased in FP group (OR 0.57 95% CI (0.47–0.69)−NNT 12.5). Several respiratory outcomes were also improved: intubation in the delivery room (OR 0.55 (0.39–0.79)−NNT 7), mechanical ventilation (OR 0.58 (0.42–0.80)−NNT 7) and its duration (SMD −0.16 (−0.29 to −0.03)), surfactant administration in premature infants (OR 0.67 (0.55–0.82)−NNT 30) and combined risk of mortality or bronchopulmonary dysplasia (RR 0.60 (0.50–0.71)−NNT 9). Decreases in mortality, intubation and mechanical ventilation rates remained when focusing on randomized studies (RR 0.62 (0.41–0.94), RR 0.61 (0.38–0.99) and RR 0.72 (0.53–0.98)) respectively). Common morbidities of premature birth as patent ductus requiring treatment, intraventricular haemorrhage, retinopathy of premature and necrotizing enterocolitis were similar in the two groups. The risk of cystic periventricular leukomalacia decreased significantly with FP (OR 0.59 (0.41–0.85)−NNT 27). Finally, there wasn’t any significant difference in pneumothorax rates between the two groups (OR 0.82 (0.44–1.52)). Conclusion: Resuscitation at birth with fixed pressure devices increases its effectiveness, without increasing morbidity. Longer term benefits may include decreased mortality, mortality or bronchopulmonary dysplasia, and cystic periventricular leukomalacia. Devices providing fixed pressures should therefore prevail for resuscitation at birth. Registration: PROSPERO 2020 CRD4202019168

Sédation intranasale en soins intensifs néonatals: une revue systématique

[en] AIM: Pain management is important for newborns' immediate and long-term well-being. While intranasal analgesia and sedation have been well studied in children, their use could be extended to term and preterm infants. This systematic review aims to assess the use of intranasal medications for procedural analgesia or sedation in the neonatal intensive care unit. METHODS: MEDLINE via Ovid, Scopus, Embase, and Cochrane Library were searched independently by two reviewers for clinical studies on sedation or analgesia given intranasally. RESULTS: Seven studies, with 401 patients, were included. The studies described various molecules (midazolam, fentanyl, ketamine, or dexmedetomidine) for different procedures such as intubation in the delivery room, screening for retinopathy, or magnetic resonance imaging. All studies reported significant reduction in pain and sedation markers (based on clinical scales, skin conductance, and clinical variables such as heart rate and crying time). Adverse effects were uncommon and mostly consisted in desaturation, apnoea, hypotension, or paradoxical reactions. DISCUSSION AND CONCLUSION: The intranasal route seems a potential alternative for procedural pain management and sedation in neonates, especially when intravenous access is not available. However, data about safety remain limited. Reported sides effects could be attributed to molecules used rather than the intranasal route. Optimal drugs and doses still need to be characterized. Further studies are needed to ensure safety before promoting a widespread use of intranasal medications in neonatology.OBJECTIF : La gestion de la douleur est importante pour le bien-être immédiat et à long terme des nouveau-nés. Si l'analgésie et la sédation intranasales ont été bien étudiées chez les enfants, leur utilisation pourrait être étendue aux nouveau-nés à terme et prématurés. Cette revue systématique vise à évaluer l'utilisation de médicaments intranasaux pour l'analgésie ou la sédation procédurale en soins intensifs néonatals. MÉTHODES : MEDLINE via Ovid, Scopus, Embase et la Cochrane Library ont été recherchés indépendamment par deux examinateurs pour les études cliniques sur la sédation ou l'analgésie administrée par voie intranasale. RÉSULTATS : Sept études, portant sur 401 patients, ont été incluses. Les études décrivaient diverses molécules (midazolam, fentanyl, kétamine ou dexmedetomidine) pour différentes procédures telles que l'intubation en salle d'accouchement, le dépistage de la rétinopathie ou l'imagerie par résonance magnétique. Toutes les études ont rapporté une réduction significative des marqueurs de la douleur et une amélioration de la sédation (sur la base d'échelles cliniques, de la conductance cutanée et de variables cliniques telles que la fréquence cardiaque et le temps de pleurs). Les effets indésirables étaient peu fréquents et consistaient principalement en une désaturation, une apnée, une hypotension ou des réactions paradoxales. DISCUSSION ET CONCLUSION : La voie intranasale semble être une alternative potentielle pour le traitement de la douleur et la sédation chez les nouveau-nés, en particulier lorsque l'accès intraveineux n'est pas disponible. Cependant, les données sur la sécurité restent limitées. Les effets secondaires rapportés pourraient être attribués aux molécules utilisées plutôt qu'à la voie intranasale. Les médicaments et les doses optimales doivent encore être caractérisés. D'autres études sont nécessaires pour garantir la sécurité avant de promouvoir une utilisation généralisée des médicaments intranasaux en néonatologie

Prémédication avant administration moins invasive de surfactant: revue systématique

Background: Surfactant therapy is the cornerstone of the management of respiratory distress syndrome. Alternatives to endotracheal intubation for surfactant administration currently include “less invasive surfactant administration”. Its effectiveness was demonstrated by meta-analyses and guidelines now recommend it as the optimal method of surfactant administration in spontaneously breathing babies. While it still requires a direct laryngoscopy, the issue of sedation and analgesia during the procedure remains controversial as 52% of European neonatologists do not use any. Methods: Medline via Ovid, Embase, Scopus and Cochrane Library of Trials were searched for studies of LISA after sedation without any filters or limits independently by two reviewers. Risk of bias (RoB) and quality assessment were evaluated using the RoB2 for RCT or the Newcastle Ottawa Scales (NOS) for cohort studies. Results: We included eight studies: one RCT, two prospective, three retrospective and two RCT comparing INSURE and LISA after sedation (LISA arms assessed as prospective cohorts), for a total of 908 newborns. Failure, defined as need for intubation or for a second dose of surfactant was no different between sedated and unsedated groups. Infant pain was significantly reduced, with more infants evaluated as comfortable. LISA with sedations led to higher occurrences of intraprocedural desaturation and need for positive pressure ventilation, but need for mechanical ventilation within 24 or 72 h of life was not significantly different. Clinical tolerance and complications (hypotension, mortality, air leaks, BPD…) were similar. Procedural conditions were evaluated as good or excellent in 83% after sedation. Discussion and conclusion: This systematic review highlighted that analgesia or sedative drugs increase infant comfort and allow good procedural conditions, with a limited impact on the clinical evolution. Many questions remain about the optimal drug and dosage, given the need to maintain spontaneous breathing and to act only for the shortest duration. Despite limited data, we found no reason to avoid sedative drugs for LISA, given how deleterious awake laryngoscopy can be. Large RCT’s should be initiated in units currently not sedating infants prior to LISA. Other Prospero registration: CRD42020205365.Contexte : Le traitement par surfactant est la pierre angulaire de la prise en charge du syndrome de détresse respiratoire. Parmi les alternatives à l'intubation endotrachéale pour l'administration de surfactant, on trouve actuellement "l'administration moins invasive de surfactant". Son efficacité a été démontrée par des méta-analyses et les directives la recommandent désormais comme la méthode optimale d'administration de surfactant chez les bébés à respiration spontanée. Bien qu'elle nécessite toujours une laryngoscopie directe, la question de la sédation et de l'analgésie pendant la procédure reste controversée puisque 52% des néonatologistes européens n'en utilisent aucune. Méthodes : Medline via Ovid, Embase, Scopus et Cochrane Library of Trials ont été recherchés pour les études de LISA après sédation sans aucun filtre ou limite, indépendamment par deux examinateurs. Le risque de biais (RoB) et l'évaluation de la qualité ont été évalués à l'aide du RoB2 pour les ECR ou des Newcastle Ottawa Scales (NOS) pour les études de cohorte. Résultats : Nous avons inclus huit études : un ECR, deux études prospectives, trois rétrospectives et deux ECR comparant INSURE et LISA après sédation (bras LISA évalués comme cohortes prospectives), pour un total de 908 nouveau-nés. L'échec, défini comme la nécessité d'une intubation ou d'une deuxième dose de surfactant, n'était pas différent entre les groupes sous sédation et sans sédation. La douleur du nourrisson a été réduite de manière significative, et un plus grand nombre de nourrissons ont été jugés confortables. La LISA avec sédation a entraîné une fréquence plus élevée de désaturation intraprocédurale et de besoin de ventilation à pression positive, mais le besoin de ventilation mécanique dans les 24 ou 72 heures de vie n'était pas significativement différent. La tolérance clinique et les complications (hypotension, mortalité, fuites d'air, DBP...) étaient similaires. Les conditions procédurales ont été évaluées comme bonnes ou excellentes dans 83% après sédation. Discussion et conclusion : Cette revue systématique a mis en évidence que les médicaments analgésiques ou sédatifs augmentent le confort du nourrisson et permettent de bonnes conditions procédurales, avec un impact limité sur l'évolution clinique. De nombreuses questions subsistent quant au médicament et au dosage optimal, étant donné la nécessité de maintenir la respiration spontanée et de n'agir que pendant la plus courte durée possible. Malgré des données limitées, nous n'avons trouvé aucune raison d'éviter les médicaments sédatifs pour la LISA, étant donné le caractère délétère de la laryngoscopie éveillée. Des ECR de grande envergure devraient être lancés dans les unités qui ne sédatent pas actuellement les nourrissons avant la LISA