Impact of bundle implementation on the incidence of peri/intraventricular hemorrhage among preterm infants: a pre-post interventional study

ABSTRACT BACKGROUND: Peri/intraventricular hemorrhage (PIVH) is a frequent cause of death and morbidity among preterm infants. Few studies have addressed the use of bundles for preventing PIVH. OBJECTIVE: To evaluate the efficacy of a bundle of interventions designed to decrease the incidence of intraventricular hemorrhage at hospital discharge among preterm infants. DESIGN AND SETTING: Pre-post interventional study with retrospective and prospective data collection performed before and after bundle implementation in the neonatal intensive care unit of a university hospital. METHODS: Infants with gestational age < 32 weeks without malformations, who survived > 6 days were included. The bundle consisted of the following actions during the first 72 hours of life: maintenance of head in neutral position with the body in supine position, minimal handling, including delay of lumbar puncture until after 72 hours and absence of respiratory therapy maneuvers. Cranial ultrasound was performed on days 3, 7 and 28, or later if needed. The effect of the bundle was analyzed through logistic regression and results were adjusted for confounding variables. RESULTS: 167 infants met the inclusion criteria; 146 (87%) were analyzed. Bundle implementation was associated with decreased chances of PIVH at hospital discharge (odds ratio 0.29; 95% confidence interval 0.13-0.65). Cerebrospinal fluid collection within the first 72 hours increased the odds of PIVH of any grade during the hospital stay fourfold, after adjustment for all variables included in the model. CONCLUSION: Implementation of a bundle of interventions to avoid intraventricular hemorrhage was effective for decreasing the incidence of all grades of PIVH in preterm infants.

Trombolisis intravenosa en accidente cerebro vascular isquémico agudo en un hospital público de Chile: análisis prospectivo de 54 casos / Intravenous thrombolysis for ischemic stroke: experience in 54 patients

Background: Intravenous thrombolysis with recombinant tissue plasminogen activator (rt-PA) reduces disability in patients with ischemic stroke. However, its implementation in Chilean public general hospitals has been slow and faces some difficulties. Aim: To analyze the results of an intravenous thrombolysis protocol implementation in a public general hospital. Material and Methods: During a lapse of 28 months a standardized protocol for intravenous thrombolysis implemented in the emergency room of a public hospital, was prospectively evaluated. Fifty four patients with ischemic stroke were treated and assessed three months later as outpatients. Results: At three months of follow-up, 66.4% of patients subjected to thrombolysis had a favorable evolution, defined as having 0 to 1 points in the modified Rankin scale. Intracerebral hemorrhage rate was 11.1%, including 5.5% of symptomatic intracerebral hemorrhage. Four percent of patients had systemic bleeding complications after thrombolysis. The mortality rate was 14.8%. Conclusions: The success rates, mortality, and complications rate were comparable to the results obtained in international studies, despite of the absence of a stroke unit to manage stroke and its complications.

Presión positiva continua en la vía aérea comparada con la respiración mecánica asistida en prematuros de 28 a 32 semanas de gestación con administración precoz de surfactante pulmonar / Nasal CPAP versus mechanical ventilation in 28 to 32-week preterm infants with early surfactant administration

Introducción. La presión positiva continua en la vía aérea ( Continuous Positive Airway Pressure , CPAP) es útil en prematuros de 28 a 32 semanas de gestación con síndrome de dificultad respiratoria, pero no se ha precisado si es mejor que la respiración mecánica asistida después de la administración precoz de surfactante pulmonar. Objetivo. Comparar la incidencia de eventos adversos en prematuros de 28 a 32 semanas de gestación con síndrome de dificultad respiratoria atendidos con surfactante y respiración mecánica asistida o CPAP de burbuja. Materiales y métodos. Se atendieron 147 neonatos con respiración mecánica asistida y 176 con CPAP, ninguno de los cuales presentaba asfixia perinatal o apnea. Resultados. La incidencia de fracaso de la CPAP fue de 6,5 % (IC 95% 11,3-22,8 %). Fallecieron 29 pacientes, 7 de los cuales habían recibido CPAP (4,0 %) y, 22, respiración mecánica asistida (15,0 %; p<0,001). El riesgo relativo (RR) de morir de quienes recibieron CPAP, comparado con el de quienes recibieron respiración mecánica asistida, fue de 0,27 (IC 95% 0,12-0,61), pero, al ajustar por los factores de confusión, el uso de CPAP no implicó mayor riesgo de morir (RR=0,60; IC 95% 0,29-1,24). La letalidad con respiración mecánica asistida fue de 5,70 (IC 95% 3,75-8,66) muertes por 1.000 días-paciente, mientras que con CPAP fue de 1,37 (IC 95% 0,65-2,88; p<0,001). La incidencia de neumopatía crónica fue menor con CPAP (RR=0,71, IC 95% 0,54-0,96), al igual que la de hemorragia cerebral (RR=0,28; IC 95% 0,09-0,84) y la de sepsis (RR=0,67; IC 95% 0,52-0,86), pero fue similar en cuanto a escapes de aire (RR=2,51; IC 95% 0,83-7,61) y enterocolitis necrosante (RR=1,68; IC 95% 0,59-4,81). Conclusión. La incidencia de neumopatía crónica, hemorragia ventricular y sepsis es menor con el uso de CPAP.

Introduction: Continuous positive airway pressure (CPAP) is useful in low birth weight infants with respiratory distress, but it is not known if it is a better alternative to mechanical ventilation after early pulmonary surfactant administration. Objective: To compare the incidence of adverse events in 28 to 32-week newborns with respiratory distress managed with mechanical ventilation or CPAP after early surfactant administration. Materials and methods: In total, 176 newborns were treated with CPAP and 147 with mechanical ventilation, all with Apgar scores >3 at five minutes and without apnea. Results: The incidence of CPAP failure was 6.5% (95% CI: 11.3-22.8%); 29 patients died: 7 with CPAP (4.0%) and 22 with mechanical ventilation (15.0%, p<0.001). The relative risk of dying with CPAP versus mechanical ventilation was 0.27 (95% CI: 0.12-0.61), but after adjusting for confounding factors, CPAP use did not imply a higher risk of dying (RR=0.60; 95% CI: 0.29-1.24). Mechanical ventilation fatality rate was 5.70 (95% CI: 3.75-8.66) deaths/1,000 days-patient, while with CPAP it was 1.37 (95% CI: 0.65-2.88, p<0.001). Chronic lung disease incidence was lower with CPAP than with mechanical ventilation (RR=0.71; 95% CI: 0.54-0.96), as were intracranial hemorrhage (RR=0.28, 95% CI: 0.09-0.84) and sepsis (RR=0.67; 95%CI: 0.52-0.86), and it was similar for air leaks (RR=2.51; 95% CI: 0.83-7.61) and necrotizing enterocolitis (RR=1.68, 95% CI: 0.59-4.81). Conclusion: CPAP exposure of premature infants with respiratory distress syndrome is protective against chronic lung disease, intraventricular hemorrhage and sepsis compared to mechanical ventilation. No differences were observed regarding air leak syndrome or death.

Estudio prospectivo y randomizado de suplementación de hierro temprana versus tardía en niños con peso al nacer menor de 1.301 g / Prospective randomized study of early versus late enteral iron supplementation in children who weighed < 1, 301 grams at birth

Objetivo: Determinar si la suplementación temprana de hierro disminuye la necesidad, el número y volúmen de glóbulos rojos transfundidos, en relación a la suplementación tardía de hierro en niños con peso de nacimiento menor a 1.301 g. Pacientes y Método: Recién nacidos de muy bajo peso (RNMPN) fueron randomi-zados a recibir suplementación temprana de hierro de 3 mg/kg/día, tan pronto estaban tolerando alimentación enteral de 100 ml/kg/día, o a los 61 días de vida como suplementación tardía. Se midió niveles de hemoglobina al inicio de la suplementación temprana de hierro y a los 2 meses de vida. La transfusión de glóbulos rojos fue restringida de acuerdo a las guías de transfusión y no se administró eritropoyetina. Resultados: No hay diferencias en el número de transfusiones de glóbulos rojos entre los grupos y en relación a las morbilidades asociadas con la prematuridad no habría diferencias significativas. Conclusiones: La suplementación temprana de hierro cuando el niño este tolerando 100 ml/kg/día de leche, no disminuiría la incidencia de las transfusiones de glóbulos rojos en relación al inicio tardío de hierro a los 61 días de vida y probablemente sea segura en los niños menores de 1.301 g.

Objective: Determine whether early iron supplementation would decrease the need, the number and volume of transfused red blood cells in relation to late iron supplementation in children with birth weight less than 1,301 g. Patients and Methods: Very low birth weight (VLBW) infants were randomly assigned to receive early iron supplementation of 3 mg/kg/day as soon as they could tolerate enteral feeding of 100 ml/kg/day, or at 61 days of life as late supplementation. Hemoglobin levels were measured at the beginning of early iron supplementation and at 2 months of age. The red blood cell transfusion was performed according to transfusion guidelines and erythropoietin was not administered. Results: No differences were observed regarding the number of red cell transfusions between the groups. Morbidities associated with prematurity presented no significant differences. Conclusions: Early iron supplementation to a child that is tolerating 100 mL/kg/day of milk, does not decrease the incidence of red blood cell transfusions compared to late start iron at 61 days of life, and it is probably safe in infants with birth weight < 1,301 g.

Uso antenatal do corticosteroide e hemorragia peri-intraventricular: [revisão] / Antenatal corticosteroids and intraventricular hemorrhage: [review]

OBJETIVO: Realizar uma revisão bibliográfica sobre o uso antenatal do corticosteroide na prevenção da hemorragia peri-intraventricular. FONTES DE DADOS: Levantamento bibliográfico por meio do Pubmed e SciELO abrangendo os últimos 20 anos. Foram utilizadas as palavras chaves no idioma inglês: "cerebral hemorrhage", "steroids" e "newborn, infant". SÍNTESES DE DADOS: A hemorragia peri-intraventricular é uma importante patologia nos prematuros, sobretudo nos menores de 34 semanas, devido a suas graves sequelas neurológicas. Uma vez ocorrido o sangramento, não há tratamento específico. Desta forma, a prevenção torna-se o maior objetivo das pesquisas. O resultado da meta-análise de estudos randomizados demonstrou que o corticosteroide antenatal reduz a mortalidade e a incidência da doença de membrana hialina e da hemorragia peri-intraventricular. O efeito protetor na redução do risco da hemorragia peri-intraventricular não está completamente esclarecido. Além de acelerar a maturidade pulmonar, o corticosteroide antenatal estimula a maturação da microvasculatura da matriz germinativa, promove o espessamento da membrana basal, acelera a formação proteica nas junções firmes e estabiliza o fluxo sanguíneo cerebral. Também melhora as condições de nascimento dos fetos pré-termo. CONCLUSÕES: O uso antenatal do corticosteroide associado à implementação de melhores práticas de atendimento ao prematuro tem sido responsável pela evidente redução dos índices dessa doença. Apesar de comprovada eficácia e segurança, não é amplamente utilizado. Medidas devem ser tomadas para estimular seu uso como prática rotineira no atendimento de gestantes com risco de parto prematuro.

OBJECTIVE: To conduct a literature review on the use of antenatal corticosteroids for the prevention of peri-intraventricular hemorrhage. DATA SOURCE: Bibliography search in Pubmed and SciELO databases covering the past 20 years using the following key-words: "cerebral hemorrhage", "steroids" and "newborn infant". DATA SYNTHESIS: The peri-intraventricular hemorrhage is an important disease of preterm infants, especially those with less than 34 weeks, due to its serious neurological sequelae. Once the bleeding occurs, there is no specific treatment. Thus, prevention becomes the main goal of the research. Meta-analysis of randomized studies showed that antenatal corticosteroids reduce mortality and the incidence of hyaline membrane disease and peri-intraventricular hemorrhage. The physiologic basis for this protective effect in reducing the risk of peri-intraventricular hemorrhage is not completely clear. Besides accelerating lung maturity, antenatal steroids stimulate the maturation of the microvasculature of the germinal matrix, promote the thickening of the basement membrane, accelerate the formation of protein in tight functions and stabilize the cerebral blood flow. They also improve the birth conditions of preterm babies. CONCLUSIONS: The use of antenatal corticosteroids associated with implementing best practices to assist preterm infants reduces the frequency of peri-intraventricular hemorrhage. Despite its proven efficacy and safety, it is not widely used. Measures should be taken to encourage its use as a routine practice in the care of pregnant women at risk of premature birth.

Arteriovenous malformation, complications, and perioperative anesthetic management

Arteriovenous malformations [AVMs] are the most common intracranial vascular malformation, with an estimated occurrence of 1:5000-1:2000 persons. The repair requires careful embolization, often followed by stereotactic radiosurgery and can also include open craniotomy. Preoperatively, patients may be healthy or dramatically unstable, as 30-50% of these cases present with acute cerebral hemorrhage. One of the most important considerations for the anesthesiologist should be attempting to achieve hemodynamic stability in the face of potential increased intracranial pressure and subsequent vulnerability of the tissues to ischemic insult. Knowledge of the risks and hazards of the procedure and collaboration with specialists, including neuroradiologists, critical care physicians, and potentially neurosurgeons, ultimately form the basis for appropriate management. AVM's can lead to potentially fatal ischemic or hemorrhagic complications that may occur in up to 8% of cases. The protection of the airway, adequate monitoring, and maintaining cardiovascular and neurological stability, are critical. Further, in the setting of a radiological suite, peripheral location considerations involving equipment, monitors, and appropriate drugs and sustaining the patient's immobility during the radiological procedures, while managing potential perioperative complications are all essential

use of indomethacin for the prevention of intraventricular brain hemorrhage in high-risk neonates

The objective of this study was to determine the effect of indomethacin on reducing the incidence of intraventricular hemorrhage in premature infants treated in our units at King Faisal Specialist Hospital and Research Centre. This historical cohort study included 45 infants born with birth weights of 1250g or less and received indomethacin in the first 12 hours of life for intraventricular hemorrhage prevention. The treated infants were compared to 33 other infants with birth weights of 1250g or less who did not receive indomethacin for intraventricular hemorrhage prevention. Data collected included demographic, complications of prematurity, renal function and maternal data. Mean birth weight [grams] and gestational age [week] were 928.6+34, 1066.2+38.9, 27.2+0.37 and 29+0.42 for the treated and the control infants. Overall incidence of intraventricular hemorrhage decreased significantly in the treated infants in comparison to the controls [P=0.0169]. There was no infant with Grade 3-4 intraventricular hemorrhage found in the treated group while 2 developed grade 3-4 intraventricular in the control group which was insignificant. There were no statistically significant differences between the groups in terms of the complications of prematurity, Apgar scores at 5 minutes, airleak syndrome and the use of umbilical catheters. The total fluid intake in the first 4 days after starting the treatment was comparable between the groups. There were no significant differences between the groups in urine output in day 1, 3 and 4. However the urine output decreased significantly in day 2 in the treated group [P = 0.0349]. There were no statistically significant differences in serum urea and creatinine between the groups Low dose indomethacin given in the first 12 hours of life was shown to be associated with a decrease in intraventricular hemorrhage in premature infants and it was not associated with significant adverse effect

Role of ethamsylate in preventing periventricular-intraventricular hemorrhage in premature infants below 34 weeks of gestation.

OBJECTIVE: To determine the role of ethamsylate in prevention of PVH-IVH in premature infants <34 weeks gestational age. DESIGN: Prospective, randomized, controlled study. METHODS: Infants less than 34 weeks gestational age were included in the trial. Neonates with congenital malformations, family history of bleeding disorders and with Apgar scores <5 at 5 minutes were excluded. Subjects were randomized into two groups--Group A infants received intravenous ethamsylate (12.5 mg/kg) six hourly for four days and Group B infants served as a control group. Regular cranial ultrasounds to detect the presence of PVH-IVH were done between days 3-5, 10-14 and 28-30 of post natal age, and before hospital discharge in all infants and weekly in infants detected to have PVH-IVH on earlier scans. Various antenatal and postnatal factors known to affect the incidence of PVH-IVH were recorded. RESULTS: A total of 192 infants underwent the trial, 93 in Group A and 99 in Group B. Antenatal corticosteroids (1 or 2 doses) were administered to 32 ( 34.4%) and 36 (36.3%) women in Group A and Group B, respectively. None of the mothers received phenobarbitone, vitamin K or indomethacin antenatally and none of the infants received phenobarbitone, vitamin E or indomethacin postnatally during the study period. PVH-IVH was seen in 26 infants in Group A, of which Grade I IVH occurred in 9, Grade II in 14, Grade III in 2 and Grade IV in one infant. Twenty-nine infants had PVH-IVH in Group B of which 11 had Grade I, 15 Grade II and 3 Grade III. None of the differences were statistically significant. CONCLUSION: Postnatal administration of ethamsylate did not decrease the incidence of PVH-IVH in the study infants.

Use of prenatal phenobarbital in the prevention of subependymal/intraventricular hemorrhage in premature infants

Background. Subependymal/intraventricular hemorrhage (SE/IVH) is a frequent cause of disability and mortality. Methods. This is a prospective, randomized, double-blind study which included 100 pergnant Mexican women who need to interrupt their pregnancy within 28-32 weeks of gestation. One group was given a single dose of intravenous (IV) phenobarbital 10 µg/kg (phenobarbital group, n=50), and the other was provided with diluted distilled water (control group). Measurements of phenobarbital serum concentrations were taken by both mother and newborn, and head sonograms were applied during the first 24 hours, at the 3rd and 7 th days of life. Results. The sample was made up of 42 newborns in the phenobarbital group, and 46 in the control group; the newborns had phenobarbital levels of 11.5 5.7 g/µl at birth, and of 9.5 ñ 5.9 g/µl 24 hours later. SE/IVH was found in 12 patients from the phenobarbital group and in 29 from the control group (p<0.005), the first group were 11 mild SE/IVH (2 grade I, and 9 grade II), and 26 in the control group (4 grade I, and 22 grade II), p <0.005. Severe hemorrhages were similar between groups. A larger frequency of SE/IVH was found in the newborns group which received mechanical ventilation (p=0.0008). Conclusions. Prenatal phenobarbital can reduce the SE/IVH frequency in premature infants younger than 32 weeks at birth. Its main effect could be shown in patients with mechanical ventilation

Frecuencia de hemorragia intracraneana en niños hemofílicos / Intracranial hemmorrhage frequency in patients hemophilic

La hemorragia intracraneana es la principal causa de muerte entre los pacientes hemofílicos. Por esta razón se revisaron 75 expedientes clínicos de pacientes menores de 16 años con el diagnóstico de hemofilia. Se encontraron seis niños con hemorragia intracraneana (HIC). El tiempo de inicio de la sintomatología fue de 12 h hasta cuatro días con una media de 39 h. Los signos y síntomas encontrados fueron: cefalea, vómito, crisis convulsiva, hematoma en el sitio del traumatismo, hemiperesia corporal izquierda, nistagmus, náusea. Se dio tratamiento substitutivo en todos los niños. Cuatro presentaron secuelas neurológicas. La frecuencia de HIC se estimó en 8 por ciento de los hemofílicos. Se concluye que para prevenir la muerte y minimizar las secuelas, una terapia de reemplazo adecuada, ésta debe ser instituida tan pronto como se sospecha el sangrado o inmediatamente después del traumatismo craneoencefálico

Effect of prenatal T4 treatment in neonatal morbidity: preliminary findings

We report our experience with the use of intra-amniotic thyroxine to accelerate fetal maturation in preterm delivered infants. One hundred and fourteen infants who had received 500 micrograms of thyroxine weekly prenatally until an L/S ratio greater or equal to 2.0 was achieved, were compared to 113 premature infants who had not been given thyroxine or steroids prenatally. After stratification by weight, the relative incidence of respiratory distress syndrome (RDS), patent ductus arteriosus (PDA), necrotizing enterocolitis (NEC) and intraventricular hemorrhage (IVH) were compared. A decrease in the incidence of RDS was observed in the infants with birth weight between 1000 and 1500 g who had received more than one dose of intra-amniotic thyroxine. No difference in the incidence of RDS was observed in infants with birth weight of less than 1000 g or over 1500 g. One dose of thyroxine had no effect in decreasing the incidence of RDS, PDA, NEC, and IVH in any of the groups. We conclude intra-amniotic thyroxine seems to decreases the incidence of RDS in very low birth weight infants

Estudio comparativo de dosis baja de indometacina profiláctica para hemorragia subependimaria/intraventricular en neonatos pretérmino con ventilación mecánica / Low doses indomethacin for prevention of intraventricular hemorrhage in the preterm newborn baby with mechanical ventilation: final report of a randomized

Se reportan los resultados finales de un estudio prospectivo doble ciego, aplicado para evaluar la utilidad de indometacina endovenosa profiláctica versus placebo (solución fisiológica) en la prevención de la hemorragia subependimaria/intraventricular (HSE/IV) realizado en neonatos pretérmino, de 28 a 36 semanas de gestación, que requirieron ventilación mecánica convencional y que a su ingreso a la Unidad de Cuidados Intensivos Neonatales no presentaban HSE/IV evaluada por ultrasonido. De un total de 12,028 recién nacidos, se estudiaron 80 casos, 40 para el grupo control y 40 para el grupo problema. Ambos grupos fueron homogéneos para: peso, sexo, edad gestacional, vía de nacimiento, apgar y tiempo de ruptura de membranas. En morbilidad y mortalidad neonatal se presentó con mayor frecuencia el síndrome de dificultad respiratoria, sepsis e hiperbilirrubinemia multifactorial. El grupo placebo tuvo mayor presentación de persistencia de conducto arterioso (PCA) (P<0.01) y mayor mortalidad (P<0.01). No se observaron diferencias en las variables ventilatorias, hemodinámicas ni de gases arteriales. El grupo con indometacina presentó diferencias en las cifras de glucosa, plaquetas y densidad urinaria; sin embargo, los resultados nunca excedieron las variantes normales. No se encontró diferencia en la frecuencia de la HSE/IV pero se observó mayor grado de severidad para el grupo placebo (P<0.01). Se concluye que la administración de indometacina en las primeras 12 horas de vida y con las dosis empleadas no proviene la HSE/IV, pero disminuye la severidad de la misma. Por otro lado, también se asoció menor mortalidad y menor frecuencia de PCA

Revisión retrospectiva de 278 casos de accidentes cerebrovasculares en mujeres internadas en el Hospital General Nacional Arzobispo Loayza / A retrospective review of 278 cases of strokes in internal women in the Hospital General Nacional Arzobispo Loayza (Lima-Perú)

El presente estudio es una revisión retrospectiva de 278 casos de accidentes cerebrovasculares en mujeres internas en el Hospital General Nacional Arzobispo Loayza entre los años 1983-1988. Tiene como objetivo el incentivar el interés de los médicos en general, y no sólo de los neurólogos, en el conocimiento de los accidentes cerebrovasculares, patología de manejo frecuente en nuestro ambiente hospitalario. En nuestro trabajo hemos hallado una incidencia hospitalaria de accidentes cerebrovasculares de 6/1000 casos en población femenina. El 79.5 por ciento de los diagnósticados fue clínico. El 64.4 por ciento de las pacientes presentó complicaciones médicas durante su hospitalización. las más frecuentes fueron las infecciones del tracto urinario (37.1 por ciento), las neumonías aspirativas (29.1 por ciento) y las sepsis (13.3 por ciento). La letalidad general hospitalaria fue de 34.9 por ciento. El 59.6 por ciento de los cuáles falleció durante la primera semana de hospitalización. Clínicamente el enclavamiento por hipertensión endocraneana (40.2 por ciento) y la sepsis (34.0 por ciento) fueron las 2 causas de muerte más frecuentes. El 44.2 por ciento de los pacientes que sobrevivieron fue dado de alta con algún déficit neurológico. Los más frecuentes fueron los motores puros (19.9 por ciento) y los combinados con disartria (13.8 por ciento)

Hemisferectomia: modificaçäo técnica / Hemisferectomy: a techinical modification

Os autores relatam uma modificaçäo técnica nas hemisferectomias totais, com intuito de prevenir os sangramentos tardios e distorçöes cerebrais