Journal of perinatology : official journal of the California Perinatal Association
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Our purpose was to review the medical records of 122 infants who died in our neonatal intensive care unit (NICU) to characterize decision making for the critically ill neonate near the end of life. The majority of deaths (72%) were related to some complication of prematurity. ⋯ At the time of decision making, prognosis was judged to be poor or hopeless and the burdens of treatment unacceptable for 90% of the infants. This study confirms that health care providers and families together can confront the ethical decision of whether to continue or forego life-sustaining treatment for the critically ill neonate near the end of life and, in the majority of cases, will choose to limit, withdraw, or withhold such support.
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The reliability of pulse oximetry in neonates receiving inotropic drugs because of hypotension and microcirculatory perfusion failure has not been well documented. Signal loss of the pulse oximeter in adult patients receiving dopamine infusions has been reported. To evaluate the relationship between pulse oximeter oxygen saturation (SaO2) and co-oximeter directly measured oxygen saturation, we studied 30 infants in the first 4 days of life (birth weight 620 to 4285 gm, gestational age 26 to 43 weeks) receiving dopamine (30 patients) and dobutamine (10 infants). ⋯ The dosage of dopamine ranged from 4 to 28 micrograms/kg per minute and the dosage of dobutamine varied from 4 to 24 micrograms/kg per minute. Over a wide range of values for mean blood pressure (23 to 66 mm Hg), partial pressure of oxygen at 90% hemoglobin saturation (43.1 to 70.2 mm Hg), and oxygen saturation (SaO2 80% to 100%), linear regression analysis revealed a close correlation between pulse oximeter SaO2 and co-oximeter SaO2 values (r = 0.83, standard error of the estimate 2.2%, p < 0.0001). Our findings indicate that pulse oximetry can be used reliably for continuous oxygen monitoring in normotensive neonates with an SaO2 of 80% to 100% who are receiving dopamine and dobutamine.
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Randomized Controlled Trial Multicenter Study Clinical Trial
Premature infant responses to noise reduction by earmuffs: effects on behavioral and physiologic measures.
The continuous high-intensity noise in the neonatal intensive care unit (NICU) is both stressful and harmful for the premature infant. Although some researchers have found evidence that loud noise can cause hearing loss and alter physiologic and behavioral responses, no study to date has investigated the benefits of noise reduction by the use of earmuffs. In this study earmuffs were placed over the premature infants' ears to reduce noise intensity in the NICU while physiologic and behavioral responses were measured. ⋯ When infants wore the earmuffs, they had significantly higher mean oxygen saturation levels and less fluctuation in oxygen saturation. Furthermore, these infants had less frequent behavioral state changes, spent more time in the quiet sleep state, and had longer bouts in the sleep state. It is imperative that NICUs develop aggressive antinoise policies to substantially and consistently reduce noise.
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Multicenter Study
Perceptions of the limit of viability: neonatologists' attitudes toward extremely preterm infants.
Although recent technologic advances have dramatically improved the survival of preterm infants, little information exists regarding the attitudes of neonatologists toward their smallest patients, infants born at the "limit of viability." In this pilot study we sent a single mailing of a 25-question survey designed to provide information about the medical treatment of extremely preterm infants (< 22 to 27 weeks' gestational age) to 3056 neonatologists practicing in the United States in September 1992. The 1131 (37%) respondents were well distributed geographically and by nature of practice (i.e., academic, academic affiliate, and community hospitals). Most of the respondents counseled parents that all infants < or = 22 weeks' gestational age die and that at least 75% of infants born at 23 weeks' gestation die. ⋯ If an infant who had been previously resuscitated decompensated in spite of maximal medical treatment, most of the neonatologists were not willing to provide full resuscitation for infants born at any gestation less than 27 weeks. However, the number of neonatologists who would actively encourage withdrawal of support in a decompensating infant decreased markedly for infants born at > or equal 25 weeks' gestation. Neonatologists who responded to this survey in 1992 considered 23 to 24 weeks of gestation the limit of viability and had great concerns regarding medical decision making for these infants.
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Case Reports
Nasogastric intubation for nutrition and airway protection in infants with Robin sequence.
Airway obstruction and feeding difficulty associated with Robin sequence may be difficult management problems that require invasive therapeutic measures. We present two cases of infants with airway obstruction who were treated successfully as outpatients by placement of a nasogastric tube for airway maintenance and supplementation of oral feeding. In patients with Robin sequence who have upper airway obstruction and feeding difficulties not resolved by prone positioning, placement of an indwelling nasogastric tube should be considered before an invasive surgical procedure is undertaken.