Utilidad de la ecografía pulmonar y diafragmática en la insuficiencia respiratoria del recién nacido muy prematuro

[spa] INTRODUCCIÓN: A pesar de la mejora de los cuidados perinatales, el síndrome de distrés respiratorio (SDR) neonatal sigue siendo una de las principales causas de morbilidad y mortalidad en los recién nacidos muy prematuros (RNMP), evolucionando muchos de los menores de 28 semanas a displasia broncopulmonar (DBP). El origen de la DBP es multifactorial, siendo característica la detención del crecimiento de la vía aérea distal y de la vascularización del pulmón. A pesar de que su definición ha evolucionado en los últimos años, las formas más graves se siguen asociando a un peor neurodesarrollo y a una mayor morbilidad respiratoria durante la infancia y vida adulta. El tratamiento precoz con surfactante, administrado antes de las dos horas de vida, y los corticoides postnatales entre otros, han demostrado su eficacia a la hora de prevenir la DBP en el RNMP. No obstante, se desconoce en qué subgrupo de pacientes y en qué momento de la evolución, su administración podría resultar más beneficiosa. La ecografía pulmonar (EP) es una técnica segura, exenta de radiación, con una curva de aprendizaje corta y que permite valorar la aireación pulmonar en tiempo real. En los últimos años, la EP ha demostrado ser útil para el diagnóstico y el seguimiento de la patología respiratoria neonatal. La ecografía diafragmática (ED), utilizada habitualmente en el paciente crítico adulto, también podría ser útil en la valoración de la disfunción diafragmática y la fatiga muscular en el RNMP con insuficiencia respiratoria. HIPÓTESIS Y OBJETIVOS: Nuestro objetivo es demostrar que la EP y la ED son útiles en el manejo respiratorio del RNMP, tanto al ingreso como en su evolución, de una forma fiable y reproducible, mediante un protocolo de estudio adaptado al prematuro extremo. Al ingreso, van a permitir identificar de forma precoz y con mayor exactitud que la radiografía de tórax (RxT), aquellos RNMP afectos de SDR que precisarán administración de surfactante. A partir de la semana de vida, van a permitir identificar a los RNMP con mayor riesgo de evolución respiratoria adversa, definida como la necesidad de soporte respiratorio a las 36 semanas de EPM. La integración de marcadores ecográficos y variables clínicas nos permitirá construir modelos predictivos, fácilmente trasladables a la práctica clínica, y útiles en la toma de decisiones de cara a optimizar el manejo respiratorio del RNMP. MÉTODOS: Estudio prospectivo de cohortes realizado durante el periodo comprendido entre enero 2018 y abril 2020 en el Hospital Clínic de Barcelona, que incluyó a prematuros nacidos entre las 23,0 y las 31,6 semanas de edad gestacional (EG), y que precisaron intubación o soporte respiratorio al nacer. Se excluyeron los pacientes con malformaciones mayores o admitidos para cuidados paliativos. El estudio fue aprobado por el comité de ética local y se obtuvo el consentimiento informado de los padres. Se recogieron variables perinatales, del parto y de la evolución respiratoria durante el ingreso (necesidad de surfactante y horas de vida en el momento de su administración, días de ventilación mecánica (VM), días de oxígeno, etc.) así como el cociente entre la saturación de oxígeno y la FiO2 (SaFi). Se utilizó un protocolo estandarizado de EP y de ED adaptado al RNMP. Se realizó RxT y se calculó la puntuación radiológica (Pt-RxT). La EP se realizó entre los 60 y 120 minutos de vida, a los 7 y a los 28 días. Se estudiaron tres regiones torácicas (anterior, lateral y posterior) y se calculó la puntuación ecográfica (Pt-EP). Junto con la EP al ingreso se evaluó la función diafragmática midiendo la fracción de acortamiento diafragmática (FAD). La indicación para la administración de surfactante fue: dificultad respiratoria, RxT sugestiva de SDR y necesidad de una FiO2 >0,3. El diagnóstico de DBP se hizo en base a las dos definiciones más utilizadas actualmente (NICHD 2001 y Jensen 2019). Se evaluó el acuerdo interobservador entre la Pt-EP y la Pt-RxT mediante el coeficiente kappa ponderado de Cohen. Se identificaron los mejores predictores clínicos y ecográficos y se utilizó un análisis multivariante mediante regresión logística por pasos hacia atrás, para seleccionar el mejor modelo para predecir la administración de surfactante por un lado, y la evolución a DBP por otro, en función del modelo de regresión final y la dirección del efecto. La bondad de ajuste de los modelos se evaluó mediante el coeficiente de determinación R2 de Nagelkerke y la prueba de Hosmer-Lemeshow. La precisión diagnóstica (área bajo la curva de la característica operativa del receptor o AUC), la sensibilidad (Se), la especificidad (Sp), el valor predictivopositivo (VPP), el valor predictivo negativo (VPN), los índices de verosimilitud positivo (LR+) y negativo (LR-) se calcularon en todos los predictores y modelos. RESULTADOS: Se estudiaron 144 RNMP con una EG media de 28 semanas. Los mejores predictores del tratamiento con surfactante fueron la Pt-EP con un punto de corte >8 (AUC=0,95), la SaFi con un punto de corte 3 (AUC=0,81). Tanto el sistema de puntuación de la RxT como el de la EP presentaron un buen acuerdo interobservador. Ni la EG ni la FAD mostraron ser buenos predictores de la necesidad de surfactante. Un modelo incluyendo sólo dos parámetros (SaFi y Pt-EP), evaluados entre los 60 y 120 minutos de vida, mostró una capacidad predictiva excelente para la necesidad de administración de surfactante, con un AUC>0,95. Las alteraciones en la línea pleural, el patrón de líneas B y las consolidaciones subpleurales fueron hallazgos característicos a los 7 y a los 28 días, de los RNMP que evolucionaron a DBP, independientemente de la definición de DBP utilizada. La Pt-EP a los 7 días demostró ser un predictor independiente de DBP, con un punto de corte ¿8 para la definición del NICHD 2001 y ¿9 para la definición de Jensen 2019. Un modelo de regresión incluyendo tres parámetros a partir de la semana de vida (Pt-EP a los 7 días de vida, necesidad de VM >5 días y oxigenoterapia >7 días) predijo de forma adecuada la necesidad de soporte respiratorio a las 36 semanas de EPM, con un AUC de 0,90. CONCLUSIONES: La EP permite identificar, entre los 60 y 120 minutos de vida, a aquellos RNMP que van a precisar administración de surfactante y a los 7 días de vida a aquellos que evolucionarán a DBP, independientemente de la definición utilizada. La combinación de la EP con variables clínicas incrementa la precisión diagnóstica, con una AUC >0,90, para predecir tanto la administración de surfactante como la evolución a DBP. La integración de la EP en el manejo respiratorio del RNMP durante la primera semana de vida permite identificar aquellos pacientes que presentarán mayor morbilidad respiratoria. Con los modelos de predicción obtenidos se ha diseñado una calculadora web de libre acceso que puede ayudar a los clínicos en la toma de decisiones

L'ecografia pulmonar guanya protagonisme a les unitats neonatals

Immediatesa en l'exploració, precisió en el diagnòstic, encert en la predicció i innocuïtat per als nadons. Són els sòlids arguments, després de fer un estudi amb cent nounats, amb què els autors d'aquest article, doctors i investigadors dels hospitals Parc Taulí (UAB) i Sant Joan de Déu (UB), defensen la necessitat de fer servir l'ecografia pulmonar com una eina bàsica per a la cura i el tractament dels bebés que ingressen a l'hospital en les primeres hores de vida amb dificultat respiratòria.Inmediatez en la exploración, precisión en el diagnóstico, acierto en la predicción e inocuidad para los bebés. Son los sólidos argumentos, después de hacer un estudio con cien neonatos, con los que los autores de este artículo, doctores e investigadores de los hospitales Parc Taulí (UAB) y Sant Joan de Déu (UB), defienden la necesidad de usar la ecografía pulmonar como una herramienta básica para la cura y el tratamiento de los bebés que en las primeras horas de vida ingresan en el hospital con dificultad respiratoria.Quick exploration, accuracy in diagnosis, correct prediction and no harm to newborns. After conducting a research with one hundred babies, these are the strong arguments given by doctors and researchers from the hospitals Parc Taulí (UAB) and Sant Joan de Déu (UB) on the need to use lung ultrasounds as a basic tool for the care and treatment of newborns being admitted with respiratory distress to hospital in their first hours of life

The Effects of Vegetarian and Vegan Diet during Pregnancy on the Health of Mothers and Offspring

Vegetarian and vegan diets have increased worldwide in the last decades, according to the knowledge that they might prevent coronary heart disease, cancer, and type 2 diabetes. Althought plant-based diets are at risk of nutritional deficiencies such as proteins, iron, vitamin D, calcium, iodine, omega-3, and vitamin B12, the available evidence shows that well planned vegetarian and vegan diets may be considered safe during pregnancy and lactation, but they require a strong awareness for a balanced intake of key nutrients. A review of the scientific literature in this field was performed, focusing specifically on observational studies in humans, in order to investigate protective effects elicited by maternal diets enriched in plant-derived foods and possible unfavorable outcomes related to micronutrients deficiencies and their impact on fetal development. A design of pregestational nutrition intervention is required in order to avoid maternal undernutrition and consequent impaired fetal growth

Eating disorders during gestation: Implications for mother's health, fetal outcomes, and epigenetic changes

Introduction: Eating disorders (EDs) have increased globally in women of childbearing age, related to the concern for body shape promoted in industrialized countries. Pregnancy may exacerbate a previous ED or conversely may be a chance for improving eating patterns due to the mother's concern for the unborn baby. EDs may impact pregnancy evolution and increase the risk of adverse outcomes such as miscarriage, preterm delivery, poor fetal growth, or malformations, but the knowledge on this topic is limited. Methods: We performed a systematic review of studies on humans in order to clarify the mechanisms underpinning the adverse pregnancy outcomes in patients with EDs. Results: Although unfavorable fetal development could be multifactorial, maternal malnutrition, altered hormonal pathways, low pre-pregnancy body mass index, and poor gestational weight gain, combined with maternal psychopathology and stress, may impair the evolution of pregnancy. Environmental factors such as malnutrition or substance of abuse may also induce epigenetic changes in the fetal epigenome, which mark lifelong health concerns in offspring. Conclusions: The precocious detection of dysfunctional eating behaviors in the pre-pregnancy period and an early multidisciplinary approach comprised of nutritional support, psychotherapeutic techniques, and the use of psychotropics if necessary, would prevent lifelong morbidity for both mother and fetus. Further prospective studies with large sample sizes are needed in order to design a structured intervention during every stage of pregnancy and in the postpartum period

Development and validation of a multivariable prediction model of spontaneous preterm delivery and microbial invasion of the amniotic cavity in women with preterm labor

BACKGROUND: Early spontaneous preterm delivery is often associ- ated with microbial invasion of the amniotic cavity and/or intraamniotic inflammation. OBJECTIVE: The objective of the study was to develop and validate clinically feasible multivariable prediction models of spontaneous delivery within 7 days and microbial invasion of the amniotic cavity in women admitted with diagnose of preterm labor and intact membranes below 34 weeks. STUDY DESIGN: We used data from a cohort of women admitted from 2012 to 2018 with diagnosis of preterm labor below 34 weeks who had undergone amniocentesis to rule out microbial invasion of the amniotic cavity. The main outcome was spontaneous delivery within 7 days from admission. The secondary outcome was microbial invasion of the amniotic cavity, defined by a positive culture and/or 16S ribosomal RNA gene in the amniotic fluid. The sample (n 1⁄4 358) was divided into derivation (2012e2016) and validation cohorts (2017e2018). Logistic regression models using a stepwise selection of variables were developed for the outcomes evaluated. We explored as predictive variables ultrasound cervical length measurement at admission, maternal C-reactive protein, gestational age, amniotic fluid glucose, and interleukin-6 (expressed as log units). Models were developed in the derivation cohort and applied to the validation cohort and diagnostic performance was calculated. RESULTS: The derivation cohort included 263 women and the valida- tion cohort 95 women. One hundred five of the women (39%, 105 of 268) spontaneously delivered in the following 7 days and 68 (19%, 68 of 358) had microbial invasion of the amniotic cavity. For spontaneous delivery within 7 days after admission, 4 predictors were identified: cervical length at admission, gestational age, amniotic fluid glucose, and interleukin-6. The diagnostic performance of the model was assessed in the validation cohort using the receiver operating characteristic curve and showed an area under curve of 0.86 (95% confidence interval, 0.77e0.95) with a detection rate of spontaneous delivery within 7 days of 87%, a false- positive rate of 33%, a negative predictive value of 80%, and a negative likelihood ratio of 0.1908. For microbial invasion of the amniotic cavity, 2 independent predictors of the amniotic cavity were identified: amniotic fluid glucose and maternal C-reactive protein. The receiver operating characteristic curve and an area under curve in the validation cohort was 0.83 (95% confidence interval, 0.70e0.96) with a detection rate of 76%, a false-positive rate of 8%, a negative predictive value of 93%, and a negative likelihood ratio of 0.2591. CONCLUSION: In women with preterm labor, we propose 2 clinically feasible prediction models to classify as low vs high risk of spontaneous delivery within 7 days and of microbial invasion of the amniotic cavity. The models showed a high diagnostic performance and could be of value to optimize clinical management

Analysis of exposure to electromagnetic fields in a healthcare environment: simulation and experimental study

Recent advances in wireless technologies have produced an increase in wireless instrumentation present in healthcare centers. This paper analyzes the signals of the different wireless communications systems in the Canary University Hospital Consortium (CUHC), in order to evaluate the electromagnetic (EM) conditions. The results of the assessment are represented through 2D contour maps. The electromagnetic conditions detected with the experimental measures have been estimated with the software “EFC-400 Telecommunication”, commercialized by Narda Safety Test Solutions. This tool allows the simulation of real healthcare environment conditions considered in this study. The proposed graph and simulation surveys aim to provide a methodology of studying the electromagnetic environments that could help in the design of healthcare centers, in the installation of new radiofrequency systems based on wireless technology, or in the evaluation of the safety conditions of workers, patients, and people in general.This work was supported by the project “Electromagnetic Safety and Protection of Patients”,DGPY 1445/08 (PI08/90185), belonging to the NationalPlan of Research Developmentand Innovation 2008-2011, and funding from Sub-Directorate-General for Research Assessment and Promotion (Health Institute Carlos III).S

Clinical outcomes after more conservative management of patent ductus arteriosus in preterm infants

Management of patent ductus arteriosus is still controversial. This study aimed to describe the impact of a more conservative approach on treatment rates and on main outcomes of prematurity, especially in preterm infants with <26 weeks of gestation. Clinical charts review of infants ≤30 weeks with patent ductus arteriosus between 2009 and 2016 at two centers. In 2011, the authors changed patent ductus arteriosus management: in first period (2009-2011), patients who failed medical treatment underwent surgical closure; in second period (2012-2016), only those with cardiopulmonary compromise underwent surgical ligation. Medical treatment, surgical closure, mortality, and survival-without-morbidity were compared. This study included 188 patients (27 ± 2 weeks, 973 ± 272 grams); 63 in P1 and 125 in P2. In P2, significantly lower rates of medical treatment (85.7% P1 versus 56% P2, p < 0.001) and surgical closure (34.5% P1 versus 16.1% P2, p < 0.001) were observed. No differences were found in chronic lung disease (28.8% versus 13.9%, p = 0.056), severe retinopathy of prematurity (7.5% versus 11.8%, p = 0.403), necrotizing enterocolitis (15.5% versus 6.9%, p = 0.071), severe intraventricular hemorrhage (25.4% versus 18.4%, p = 0.264), mortality (17.5% versus 15.2%, p = 0.690) or survival-without-morbidity adjusted OR = 1.10 (95% CI: 0.55-2.22); p = 0.783. In P2, 24.5% patients were discharged with patent ductus arteriosus. The subgroup born between 23 and 26 weeks (n = 82) showed significant differences: lower incidence of chronic lung disease (50% versus 19.6%, p = 0.019) and more survival-without-morbidity (20% versus 45.6%, p = 0.028) were found. A conservative approach in preterm infants with patent ductus arteriosus can avoid medical and surgical treatments, without a significant impact in survival-without-morbidity. However, two-thirds of preterm infants under 26 weeks are still treated

Assessing the impact of the COVID-19 pandemic on parental satisfaction in two European neonatal intensive care units

Background Neonatal units across the world have altered their policies to prevent the spread of infection during the COVID-19 pandemic. Our aim was to report parental experience in two European neonatal units during the pandemic.Methods Parents of infants admitted to each neonatal unit were asked to complete a questionnaire regarding their experience during the COVID-19 pandemic. At King’s College Hospital, UK (KCH), data were collected prospectively between June 2020 and August 2020 (first wave). At the Hospital Clínic Barcelona (HCM), data were collected retrospectively from parents whose infants were admitted between September 2020 and February 2021 (second and third wave).Results A total of 74 questionnaires were completed (38 from KCH and 36 from HCM). The parents reported that they were fully involved or involved in the care of their infants in 34 (89.4%) responses in KCH and 33 (91.6%) responses in HCM. Quality time spent with infants during the pandemic was more negatively affected at KCH compared with HCM (n=24 (63.2%) vs n=12 (33.3%)). Parents felt either satisfied or very satisfied with the updates from the clinical care team in 30 (79.0%) responses at KCH and 30 (83.4%) responses in HCM. The parents felt that the restrictions negatively affected breast feeding in six (15.8%) responses at KCH and two (5.6%) responses in HCM. Travelling to the hospital was reported overall to be sometimes difficult (39.2%); this did not differ between the two units (14 (36.8%) respondents at KCH and 15 (41.6%) from HCM). Furthermore, the self-reported amount of time spent giving kangaroo care also did not differ between the two countries.Conclusion Restrictive policies implemented due to the COVID-19 pandemic had a negative impact on the perception of quality of time spent by parents with their newborns admitted to neonatal units

Ultrasound-guided vascular access in the neonatal intensive care unit: a nationwide survey.

Ultrasound-guided vascular access (USG-VA) is recommended by international practice guidelines but information regarding its use in the neonatal intensive care unit (NICU) is lacking. Our objective was to assess neonatologist's perceptions and current implementation of USG-VA in Spain. This was a nationwide online survey. The survey was composed of 37 questions divided in 4 domains: (1) neonatologist's background, (2) NICU characteristics, (3) personal perspectives about USG-VA, and (4) clinical experience in USG-VA. One-hundred and eighty survey responses from 59 NICUs (62% of Spanish NICUs) were analyzed. Most neonatologists (81%) perceive that competence in USG-VA is indispensable or very useful in clinical practice. However, 64 (35.5%) have never used USG-VA in real patients. Among neonatologists with some experience in USG-VA most perform less than 5 procedures per year (59% in venous access and 80% in arterial access) and a 38% and 60% have never used USG for venous and arterial access, respectively, in very low birth weight infants (VLBWI). More than a half of neonatologists (55.5%) use US to check catheter tip location but a 46.6% always perform a radiography for confirmation. Spanish neonatologists report that resident/fellow training in USG-VA is absent (52.2%) or unstructured (32%) in their units. The lack of adequate training is identified by a 60% of neonatologists as the most important barrier for implementation of USG-VA and 87% would recommend that future neonatologists receive formal training. Spanish neonatologists perceive that USG-VA is important in clinical practice but currently, these techniques are largely underused. Our results indicate that specific training in USG-VA should be implemented in the NICU. • Ultrasound-guided vascular access is recommended as the preferred method for central venous access and arterial line placement in children and adults. • The degree of current implementation of ultrasound for vascular access in the NICU and the perceptions of neonatologist about its use are largely unknown. • Most neonatologists consider that competence in ultrasound-guided vascular access is an indispensable aid for clinical practice. • However, most neonatologists are not adequately trained in ultrasound-guided vascular access and the technique is largely underused