Journal of perinatology : official journal of the California Perinatal Association
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Review Comparative Study
To tube or not to tube babies with respiratory distress syndrome.
The use of mechanical ventilation in premature infants with respiratory distress syndrome (RDS) and respiratory failure often results in barotrauma, volutrauma and chronic lung disease (CLD). Research indicates that early surfactant therapy and initiation of nasal continuous positive airway pressure (CPAP) for these infants significantly reduces the need for mechanical ventilation and the incidence of CLD. ⋯ Clinical trials indicate that optimal management of neonatal RDS could be improved by early surfactant treatment followed immediately by extubation and stabilization on CPAP. Evidence suggests a synergistic effect between early surfactant administration (within 2 h of birth) and rapid extubation to nasal CPAP with a significant reduction in the need for mechanical ventilation and its associated morbidities.
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The complexity of postnatal cardiovascular transition has only recently been better appreciated in the very low birth weight neonate. As blood pressure in itself poorly represents systemic blood flow, especially when the fetal channels are open and the developmentally regulated vital organ assignment may not have been completed, efforts to measure systemic blood flow have resulted in a novel, yet incomplete, understanding of the principles and clinical relevance of cardiovascular adaptation during postnatal transition in this patient population. ⋯ Only after gaining an insight into these complex relationships and processes will we be able to design clinical trials of selected treatment modalities targeting relevant patient sub-populations for the management of neonatal cardiovascular compromise. Only clinical trials based on a solid understanding of developmental cardiovascular physiology tailored to the appropriate patient sub-population hold the promise of being effective and practical, and can lead to improvements in both hemodynamic parameters and clinically relevant outcome measures.
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Cortisol release in the face of illness or stress is vital for survival. Relative adrenal insufficiency occurs when a patient's cortisol response is inadequate for the degree of illness or stress. ⋯ There is increasing evidence that relative adrenal insufficiency may be an etiology for hemodynamic instability and hypotension in the critically ill newborn, but compared with the adult population, there is still a paucity of data in this population. Randomized controlled trials are needed to evaluate the efficacy and safety of glucocorticoids for the treatment of cardiovascular insufficiency due to relative adrenal insufficiency in ill preterm and term newborn infants.
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Surfactant treatment in preterm infants and term newborns with (acute respiratory distress syndrome) ARDS-like severe respiratory failure has become part of an individualized treatment strategy in many intensive care units around the world. These babies constitute heterogeneous groups of gestational ages, lung maturity, as well as of the underlying disease processes and postnatal interventions. The pathophysiology of respiratory failure in preterm infants is characterized by a combination of primary surfactant deficiency and surfactant inactivation as a result of plasma proteins leaking into the airways from areas of epithelial disruption and injury. ⋯ Although for the majority of suggested indications no data from randomized controlled trials exist, a surfactant replacement that counterbalances surfactant inactivation seems to improve oxygenation and lung function in many babies with ARDS without any apparent negative side effects. Newborns with MAS will definitely benefit from a reduced need for extracorporeal membrane oxygenation (ECMO). Clinical experience seems to justify surfactant treatment in neonates with ARDS.
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Comparative Study
Neonatal cerebral oximetry monitoring during ECMO cannulation.
Neonates were monitored with a cerebral oximeter before, during, and after cannulation for ECMO to determine the direct effects of ligation of the right internal jugular vein and right carotid artery on cerebral oxygenation. ⋯ Neonates are vulnerable to SctO(2) during the pre-ECMO surgical period.