Barriers in Referring Neonatal Patients to Perinatal Palliative Care: A French Multicenter Survey

International audienceBackground When an incurable fetal condition is detected, some women (or couples) would rather choose to continue with the pregnancy than opt for termination of pregnancy for medical reasons, which, in France, can be performed until full term. Such situations are frequently occurring and sometimes leading to the implementation of neonatal palliative care. The objectives of this study were to evaluate the practices of perinatal care french professionals in this context; to identify the potential obstacles that might interfere with the provision of an appropiate neonatal palliative care; and, from an opposite perspective, to determine the criteria that led, in some cases, to offer this type of care for prenatally diagnosed lethal abnormality. Methods We used an email survey sent to 434 maternal-fetal medicine specialists (MFMs) and fetal care pediatric specialists (FCPs) at 48 multidisciplinary centers for prenatal diagnosis (MCPD). Results Forty-two multidisciplinary centers for prenatal diagnosis (87.5%) took part. In total, 102 MFMs and 112 FCPs completed the survey, yielding response rate of 49.3%. One quarter of professionals (26.2%) estimated that over 20% of fetal pathologies presenting in MCPD could correspond to a diagnosis categorized as lethal (FCPs versus MFMs: 24% vs 17.2%, p = 0.04). The mean proportion of fetal abnormalities eligible for palliative care at birth was estimated at 19.30% (+/- 2.4) (FCPs versus MFMs: 23.4% vs 15.2%, p = 0.029). The degree of diagnostic certainty appears to be the most influencing factor (98.1%, n = 207) in the information provided to the pregnant woman with regard to potential neonatal palliative care. The vast majority of professionals, 92.5%, supported considering the practice of palliative care as a regular option to propose antenatally. Conclusions Our study reveals the clear need for training perinatal professionals in perinatal palliative care and for the standardization of practices in this field

Caesarean section at term: the relationship between neonatal respiratory morbidity and microviscosity in amniotic fluid.

None of the authors report any conflicts of interest.International audienceOBJECTIVES: The incidence of neonatal respiratory morbidity following an elective caesarean section is 2-3 times higher than after a vaginal delivery. The microviscosity of surfactant phospholipids, as measured with fluorescence polarisation, is linked with the functional characteristics of fetal surfactant and thus fetal lung maturity, but so far this point has received little attention in new-borns at term. The aim of the study is to evaluate the correlation between neonatal respiratory morbidity and amniotic microviscosity (Fluorescence Polarisation Index) in women undergoing caesarean section after 37 weeks' gestation. STUDY DESIGN: The files of 136 women who had undergone amniotic microviscosity studies during elective caesarean deliveries at term were anonymised. Amniotic fluid immaturity (AFI) was defined as a Fluorescence Polarisation Index higher than 0.335. RESULTS: Respiratory morbidity was observed in 10 babies (7.3%) and was independently associated with AFI (OR: 6.11 [95% CI, 1.20-31.1] with p=0.029) and maternal body mass index (OR: 1.12 [95% CI, 1.02-1.22] with p=0.019). Gestational age at the time of caesarean delivery was inversely associated with AFI (odds ratio, 0.46 [95% confidence interval, 0.29-0.71], p<0.001), especially before 39 weeks, and female gender was associated with an increased risk (odds ratio, 3.29 [95% confidence interval, 1.48-7.31], p=0.004). CONCLUSIONS: AFI assessed by amniotic microviscosity was significantly associated with respiratory morbidity and independently correlated with shorter gestational age especially before 39 weeks. This finding provides a physiological rationale for recommending delaying elective caesarean section delivery until 39 weeks of gestation to decrease the risk for respiratory morbidity

Respiratory support by neurally adjusted ventilatory assist (NAVA) in severe RSV-related bronchiolitis: a case series report

<p>Abstract</p> <p>Background</p> <p>Neurally adjusted ventilatory assist (NAVA) is a new mode of mechanical ventilation controlled by diaphragmatic electrical signals. The electrical signals allow synchronization of ventilation to spontaneous breathing efforts of a child, as well as permitting pressure assistance proportional to the electrical signal. NAVA provides equally fine synchronization of respiratory support and pressure assistance varying with the needs of the child. NAVA has mainly been studied in children who underwent cardiac surgery during the period of weaning from a respirator.</p> <p>Case presentation</p> <p>We report here a series of 3 children (1 month, 3 years, and 28 days old) with severe respiratory distress due to RSV-related bronchiolitis requiring invasive mechanical ventilation with a high level of oxygen (FiO₂≥50%) for whom NAVA facilitated respiratory support. One of these children had diagnosis criteria for acute lung injury, another for acute respiratory distress syndrome.</p> <p>Establishment of NAVA provided synchronization of mechanical ventilatory support with the breathing efforts of the children. Respiratory rate and inspiratory pressure became extremely variable, varying at each cycle, while children were breathing easily and smoothly. All three children demonstrated less oxygen requirements after introducing NAVA (57 ± 6% to 42 ± 18%). This improvement was observed while peak airway pressure decreased (28 ± 3 to 15 ± 5 cm H₂O). In one child, NAVA facilitated the management of acute respiratory distress syndrome with extensive subcutaneous emphysema.</p> <p>Conclusions</p> <p>Our findings highlight the feasibility and benefit of NAVA in children with severe RSV-related bronchiolitis. NAVA provides a less aggressive ventilation requiring lower inspiratory pressures with good results for oxygenation and more comfort for the children.</p

Answering for human vulnerability : the responsibility towards the human other, the concern about the other

Après un examen de figures de la vulnérabilité humaine relevées dans des domaines de l’agir humain (juridique, socio-politique, biomédical), a été traité le thème central de cette étude : répondre de la vulnérabilité humaine, à savoir s’engager en faveur de la vulnérabilité et l’assumer par le souci de l’autre, le plus vulnérable, par une responsabilité illimitée à son égard, responsabilité d’otage. À partir d’une approche méthodologique fondée sur les notions d’emphase chez Lévinas, de situation limite chez Jaspers et des causes de la souffrance repérées par Freud, ont été retenus et étudiés quatre thèmes représentatifs de la vulnérabilité : le handicap (confronté à la menace de l’eugénisme libéral), la souffrance humaine, la vulnérabilité propre au sujet humain et celle causée par la socialité. C’est par l’étude de la responsabilité et du souci de l’autre, chez Ricœur, Jonas, Lévinas et Kant, qu’ont été abordés ces deux thèmes : une responsabilité pour autrui, précédant toute liberté, et le souci de l’autre, nous incitant à protéger le plus vulnérable : l’amour que nous portons au nouveau né, le combat désespéré contre la souffrance injustifiable d’un enfant, la protection de la personne handicapée ou dépendante. Par les menaces qui pèsent sur elles, par la mise en cause de leur droit à l’existence et par leur mise à l’écart de la société, les personnes handicapées représentent de façon hyperbolique la vulnérabilité humaine. Nous soutenons comme modèle de l’hospitalité à offrir à toute vulnérabilité humaine, celui du pacte parental, principe originaire de la sociabilité humaine et d’une humanité répondant de l’existence et de la vie de la personne vulnérable.The first stage of this study looks at figures of human vulnerability in legal, socio-political, biomedical areas. Afterwards we have dealt with the issue of this thesis : answering for human vulnerability, namely, commiting oneself to the vulnerability and being assigned to the concern for the other, as the most vulnerable, by an unlimited hostage-like responsibility. Thru a methodological approach relying upon the concepts of emphasis in Levinas, of ultimate situation in Jaspers, as well as upon causes of suffering for Freud, four representative themes of vulnerability were studied : the disability (disabled people faced with the threat of liberal eugenics), the suffering of man, the vulnerability related to the human subject and the vulnerability stemming from society. From the study of responsability in Ricoeur, Jonas, Levinas and Kant, those both themes have been addressed : the responsibility ahead of any freedom, and the concern for the other as such, that both entail the protection of the most vulnerable : the love towards our just new born, the struggle with an unjustifiable suffering of a child, the protection of a disabled or dependent person. Questioning their right to exist, keeping them away from society, are actual threats for disabled people, hence they represent, in a hyperbolic way, extreme human vulnerability. At the end of this study, we will go along with a model of the hospitality towards the pervasive human vulnerability, as the model of a parental covenant, native principle of human sociability and mankind answering for the existence and the life of the vulnerable person

[Palliative care in delivery room for preterm infants less than 24weeks of gestation. Analysis of two different behaviors.]

International audienceAIMS OF THE STUDY: To describe the management of extremely preterm newborns at the threshold of viability before 24weeks of gestation in the delivery room when the decision has been made not to provide intensive care; to assess the role of palliative care (PC); to report the problems encountered. METHOD: A prospective qualitative study was conducted using semi-structured interviews from November 2009 to June 2010 in two level III French maternity hospitals (A and B). In each center, four midwives, two obstetricians, two pediatricians, two anesthetists, and one chief midwife were interviewed. RESULTS: In maternity hospital A, a protocol was in place that proposed PC derived from developmental care (noise limitation, drying, warming) provided by parents or staff. The problems reported were related to former euthanasia practices rather than new procedures. In maternity hospital B, no palliative care protocol had been set up. Euthanasia was practiced and accepted fatalistically because the only currently existing alternative (letting the infant die) was considered inhumane. Few problems were reported. The reluctance to carry out PC is conceptual and organizational (the ratio of births per midwife in maternity hospital B was twice that of maternity hospital A). Lexical analysis showed preferential use of the words "fetus" and "expulsion" versus "child" and "delivery" in maternity hospital B (p<0.05) when speaking of the delivery of the extremely preterm infant. Our explanatory hypothesis is that the concept of "fetus ex utero" legitimates euthanasia by assimilating it to feticide. CONCLUSION: At the time of this study, two very different approaches to the death of extremely preterm, non-resuscitated newborns in the delivery room coexisted in France. Palliative care is obviously possible, after group reflection, if a true motivation to change, a better understanding of the law, and a clear identification of the respective status of the fetus and the newborn exist in the maternity hospital

[Neonatal resuscitation and unreasonable obstinacy: a hospital ordered to pay damages].

International audienc

Uncorrelated Randomness of the Heart Rate Is Associated with Sepsis in Sick Premature Infants.

International audienceBackground: Late-onset sepsis in the premature infant is frequently revealed by severe, unusual and recurrent bradycardias. In view of the high morbidity and mortality associated with infection, reliable markers are needed. Objectives: It was the aim of this study to determine if heart rate (HR) behavior may help the diagnosis of infection in premature infants with such cardiac decelerations. Methods: Electrocardiogram recordings were collected in 51 premature infants with a postmenstrual age <33 weeks with frequent bradycardias. Newborns in the sepsis group (C-reactive protein increase and positive blood culture) were compared with a no-sepsis group (C-reactive protein <5 mg/l before and 24 h after recording and negative blood cultures) for their HR characteristics, i.e. RR series distribution (mean, median, skewness, kurtosis, sample asymmetry), magnitude of variability in time and frequency domain, fractal exponents (alpha(1), alpha(2)) and complexity measurements (approximate and sample entropy). Results are presented as the median (25%, 75%). Results: Gestational, chronological and postmenstrual age and gender were similar in the sepsis (n = 10) and no-sepsis group (n = 38). Three infants had an increase in C-reactive protein but negative cultures. Low entropy measurements [approximate entropy 0.4 (0.3, 0.5) vs. 0.8 (0.6, 1); p < 0.001] and long-range fractal exponent [alpha(2) 0.78 (0.71, 0.83) vs. 0.92 (0.8, 1.1); p < 0.05] were significantly associated with sepsis. No other HR characteristic was associated with sepsis. The decrease in 0.1 units of approximate entropy was associated with an over 2-fold increase in the odds of sepsis. Conclusion: Late-onset sepsis is associated with uncorrelated randomness of the HR. This abnormal HR behavior may help to monitor premature infants presenting with frequent and severe bradycardias

Therapeutic guidelines for prescribing antibiotics in neonates should be evidence-based: a French national survey

International audienceOBJECTIVE: This survey aims to describe and analyse the dosage regimens of antibiotics in French neonatal intensive care units (NICUs). METHODS: Senior doctors from 56 French NICUs were contacted by telephone and/or email to provide their local guidelines for antibiotic therapy. RESULTS: 44 (79%) NICUs agreed to participate in this survey. In total, 444 dosage regimens were identified in French NICUs for 41 antibiotics. The number of different dosage regimens varied from 1 to 32 per drug (mean 9, SD 7.8). 37% of intravenous dosage regimens used a unique mg/kg dose from preterm to full-term neonates. Doses and/or dosing intervals varied significantly for 12 antibiotics (amikacin, gentamicin, netilmicin, tobramycin, vancomycin administered as continuous infusion, ceftazidime, cloxacillin, oxacillin, penicillin G, imipenem/cilastatin, clindamycin and metronidazole). Among these antibiotics, 6 were used in more than 70% of local guidelines and had significant variations in (1) maintenance daily doses for amikacin, imipenem/cilastatin, ceftazidime and metronidazole; (2) loading doses for continuous infusion of vancomycin; and (3) dosing intervals for gentamicin and amikacin. CONCLUSIONS: A considerable inter-centre variability of dosage regimens of antibiotics exists in French NICUs. Developmental pharmacokinetic-pharmacodynamic studies are essential for the evaluation of antibiotics in order to establish evidence-based dosage regimens for effective and safe administration in neonates

Multiple Brain Abscesses Caused by Pseudomonas luteola.

Published in "Pediatric Infectious Disease Journal" vol.28 n°12Letter to the Edito