Clinics in perinatology
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Clinics in perinatology · Sep 2002
Meta AnalysisThe effectiveness of premedication for endotracheal intubation in mechanically ventilated neonates. A systematic review.
Extrapolating information from the adult and pediatric literature suggests that awake intubation is probably inappropriate in most neonates. Because premedication attenuates the physiologic responses to intubation, its use is recommended. Adequately skilled staff who have a full understanding of the potential benefits and harms of the interventions used should perform intubation and the administration of premedication in neonates. ⋯ There is a need for well-designed and well-executed randomized controlled trials assessing the effectiveness and potential adverse effects of premedicated intubation in neonates. A valid pain assessment measure or approach should be used. Both short-term and long-term physiologic and clinical outcomes should be incorporated into the trial design.
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Clinics in perinatology · Sep 2002
Clinical utility and clinical significance in the assessment and management of pain in vulnerable infants.
Pain in vulnerable populations unable to provide verbal report is challenging in terms of measurement and treatment. Clinicians strive to provide the best possible pain management for infants in the NICU, yet they are often hindered due to paucity of measures that are not only reliable and valid but also clinically useful. Clinical utility of measures is difficult to establish due to a lack of consistent definition of the construct, varied methods of determination, and the secondary importance afforded to this issue in relation to the establishment of reliability and utility. ⋯ The issue of defining the extent of change in pain scores that is clinically significant or important remains unclear. Clarity will involve assigning meaning to particular changes in pain scores for vulnerable infants across a broad array of situations and severities of pain. Although research on this topic in children and adults provides some guidance to this dilemma, only through innovative and creative methods will we be able to address these issues.
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Extracorporeal membrane oxygenation was established as a standard of care by demonstrating its ability to save lives in moribund infants. The designs of early studies provided no living cohorts of similarly ill patients by which to measure accurately other (and perhaps to many more important) outcomes of interest: long-term neurodevelopmental outcomes or cost. Prospective cohort studies of neurodevelopmental outcomes post-ECMO demonstrate: (1) because ECMO, as used, saves lives, there will be an increase in the absolute number of handicapped children surviving; (2) there is little evidence that ECMO creates a relative increase in the percent of handicapped children surviving severe respiratory failure. ⋯ When such costs are compared with similar therapies in other fields (in such terms as cost per survivor), the cost of ECMO does not seem to be an outlier. Trials of newer therapies, such as iNO, show the capacity to decrease the use of ECMO but have failed to demonstrate either cost-effectiveness or better long-term outcomes. It has not been shown that either society or individual patients have benefited from the decreased need for ECMO.
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Proportional assist ventilation and respiratory mechanical unloading is a new mode of respiratory assistance that produces similar gas exchange with lower airway pressures than conventional ventilation in infants. This is achieved by tailoring the ventilator pressure contour to the specific derangements in lung mechanics and by a near perfect synchronization with the infant's own inspiratory effort. In contrast to conventional ventilation, PAV only amplifies the effect on ventilation of the spontaneous respiratory effort and relies on the subject's respiratory control. Whether PAV will reduce the incidence of acute complications and chronic pulmonary sequelae in infants needs to be evaluated in randomized controlled trials.
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Lung injury can be initiated at birth with the delivery room resuscitation. Adequate tidal volume must be achieved gradually and adjusted with each subsequent breath to achieve adequate, but not excessive, tidal volume delivery. Time constants vary greatly within the lung because some alveoli are collapsed, and some are inflated. ⋯ The best volume of inflation is achieved at the lowest pressure cost. Maintaining alveolar recruitment with the use of exogenous surfactant and positive end-expiratory pressure avoids alveolar collapse and injury with succeeding distending breaths. Although there have been significant advances in neonatal respiratory care, further improvement in outcomes may be expected by successfully avoiding ventilator-induced lung injury.