American journal of perinatology
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It is standard practice for physicians to use blood gas (BG) evaluations when evaluating neonates with respiratory distress. In this study we addressed two questions: (1) What is the distribution of BG values in a population of infants receiving BG evaluation in the first 4 hours of life; and (2) How does the behavior of physicians correlate with BG values in these infants? We discuss the implications of our findings for claims about "standards" of medical care for newborn infants with respiratory distress. We reviewed medical records for 226 infants with birthweight > 2000 grams who were not intubated at the time of first BG determination. ⋯ Recognizing that anecdotal recall of experience, even by "experts," may be inaccurate and is often systematically biased (the "Monday morning quarterback" phenomenon), we propose that the testimony of expert witnesses ought to conform, whenever possible, to a data-based description of medical care that actually is "ordinary used in similar circumstances". Our current observations suggest that (1) expert opinions of the "standard" to evaluate neonatal respiratory distress with a BG sample should reflect that the time scale is 1 to 2 hours, not 10 to 20 minutes; and (2) expert opinions that "abnormal" BG values either "require" or "preclude" intubation for most newborn infants with respiratory distress find little support in data. Clinical observation, not BG values, appears to be the most powerful "standard" by which physicians determine whether to initiate mechanical ventilation for newborn infants with respiratory distress.
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Results of a national survey of the current use of steroids in newborns in 1993 showed that 95% of the neonatologists in the United States have used dexamethasone for neonates at risk for chronic lung disease. Dexamethasone therapy for a period of a week or longer is associated with suppression of the hypothalamic-pituitary-adrenal axis (HPAA) in a substantial number of premature infants. A review of our current understanding of the biochemical tests evaluating HPAA function in premature infants and suggested guidelines for HPAA evaluation and management following dexamethasone therapy are presented.