Neonatology
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Hemodynamic problems are common in neonatal intensive care. They occur in the context of incomplete myocardial and vascular development and in cardiovascular responses to interventions which are, as a result, limited and often uncertain and unpredictable. In this review, I outline the hemodynamic features of 4 neonatal conditions which often require intervention: (1) persistent pulmonary hypertension of the newborn, (2) cardiogenic shock (most commonly in the context of hypoxic ischemic injury), (3) sepsis and (4) low blood pressure in the transitional period of the extremely preterm infant. I also look at the evidence which exists for effective interventions and the most important research questions for the future.
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Excessive ambient noise levels have been identified as a potential risk factor for adverse outcome in very preterm infants. Noise level measurements for continuous positive airway pressure (CPAP) devices demonstrated that these constantly exceed current recommendations. The use of high-flow nasal cannula (HFNC) as an alternative non-invasive ventilation modality has become more popular in recent years in neonatal care. ⋯ Both HFNC devices generated higher noise levels than the CPAP device. All noise levels were far above current recommendations of the American Academy of Pediatrics. In light of the long duration of non-invasive respiratory support of very preterm infants, less noisy devices are required to prevent the potentially adverse effects of continuing excessive noise exposure in the neonatal intensive care unit.
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Mechanical ventilation (MV) is associated with changes in autonomic nervous system activity in preterm infants, which can be assessed by measurements of heart rate variability (HRV). Decreased HRV has been described in adults undergoing disconnection from MV; such information is not available in preterm infants. ⋯ Infants considered 'ready to be extubated' but who subsequently failed their first extubation attempt had decreased HRV prior to extubation. Though promising, the value of HRV as a predictor of extubation readiness requires further evaluation.
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Clinical Trial
Introduction of hypothermia for neonates with perinatal asphyxia in the Netherlands and Flanders.
Therapeutic hypothermia was introduced in the Netherlands and Flanders, Belgium, in 2008. Since then, an increasing number of patients has been treated - up to 166 in 2010. Complications and outcome were registered in an online database. ⋯ The introduction of therapeutic hypothermia for neonates with perinatal asphyxia in the Netherlands and Flanders has been rapid and successful, with results similar to findings in the randomised controlled trials.
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Initiation of empiric antibiotic treatment for possible early-onset sepsis is recommended for late preterm and term neonates with respiratory distress. There is no evidence base to this approach. ⋯ This study suggests that empiric postnatal antibiotic treatment may not be warranted for late preterm and term infants with TTN in the absence of specific infectious risk factors.