Incidence and risk factors of bacterial sepsis and invasive fungal infection in neonates and infants requiring major surgery: an Italian multicentre prospective study.

BACKGROUND: Limited data are currently available on the incidence rates and risk factors for bacterial sepsis and invasive fungal infections (IFIs) among neonates and infants undergoing major surgery. AIM: To assess the incidence of bacterial sepsis and IFI, fungal colonization, risk factors for sepsis, and mortality in neonates and infants aged <3 months undergoing major surgery. METHODS: A multicentre prospective study was conducted involving 13 level-3 neonatal intensive care units in Italy, enrolling all infants aged ≤3 months undergoing major surgery. FINDINGS: From 2018 to 2021, 541 patients were enrolled. During hospitalization, 248 patients had a bacterial infection, and 23 patients had a fungal infection. Eighty-four patients were colonized by fungal strains. Overall, in-hospital mortality was 2.8%, but this was higher in infected than in uninfected infants (P = 0.034). In multivariate analysis, antibiotic exposure before surgery, ultrasound-guided or surgical placement of vascular catheters, vascular catheterization duration, and gestational age ≤28 weeks were all associated with bacterial sepsis. The risk of IFI was markedly higher in colonized infants (odds ratio (OR): 8.20; P < 0.001) and was linearly associated with the duration of vascular catheterization. Fungal colonization in infants with abdominal surgery increased the probability of IFI 11-fold (OR: 11.1; P < 0.001). CONCLUSION: Preventive strategies such as early removal of vascular catheters and the fluconazole prophylaxis should be considered to prevent bacterial and fungal sepsis in infants undergoing abdominal surgery, and even more so in those with fungal colonization.

Efficacy of lung volume optimization maneuver monitored by optoelectronic pletismography in the management of congenital diaphragmatic hernia.

Newborns affected by congenital diaphragmatic hernia (CDH) need cardio-respiratory stabilization before undergoing surgical repair. Open lung strategy is a well-established approach to optimize lung volume in preterm infants with Respiratory Distress Syndrome (RDS), using both High Frequency Oscillatory Ventilation (HFOV) and Conventional Mechanical Ventilation (CMV). We report a case of left CDH with severe lung hypoplasia, managed applying open lung strategy in HFOV (pre-surgery period) and in Assist-Control with Volume Guarantee (post-surgery period), guided by SpO2 changes, TcPO2 and TcPCO2 monitoring. Opto-electronic plethysmography was used to measure end-expiratory chest wall volume changes (ΔEEcw) related to lung volume variations occurring during pressure changes. OEP confirmed the efficacy of using SpO2 and transcutaneous gas monitoring during this recruitment maneuver.

Sustained inflation: Prophylactic or rescue maneuver?

Application of nasal continuous positive airway pressure (nCPAP) in the delivery room is a valid alternative to mechanical ventilation in the management of respiratory failure of preterm infants, with reduced occurrence of bronchopulmonary dysplasia and death. nCPAP at birth is still burdened by a high failure rate. Sustained inflation appears to be an intriguing approach to allow the respiratory transition at birth by clearing the lung fluid, thus obtaining an adequate functional residual capacity. This may enhance nCPAP success. Sustained inflation reduces the need for mechanical ventilation in the first 72 h of life, with no changes in the incidence of bronchopulmonary dysplasia and death. The efficacy of sustained inflation seems to be related to the presence of open glottis with active breathing of the infant. Further studies are needed to recommend the application of sustained inflation during delivery room management of preterm infants at risk of respiratory distress or with clinical signs of respiratory failure.

Cesarean section plus delayed cord clamping approach in the perinatal management of congenital high airway obstruction syndrome (CHAOS): a case report.

In this case, we describe a newborn with prenatal diagnosis of congenital high airway obstruction syndrome (CHAOS), successfully managed with a cesarean section with delayed cord clamping 180 seconds. In case of prenatal diagnosis of CHAOS, prompt airway intervention at delivery allows survival of this otherwise fatal condition. Ex utero intrapartum treatment (EXIT) is considered the elective procedure to secure the fetal airway before the baby is completely separated from the maternal circulation. In cases where the EXIT procedure is not possible for maternal reasons (Ballantyne's syndrome), delayed cord clamping may serve as an alternative method to manage CHAOS.

The precision and accuracy of Nellcor and Masimo oximeters at low oxygen saturations (70%) in newborn lambs.

BACKGROUND: Administration of oxygen in the delivery room is informed by oxygen saturation (SpO2). An oxygen saturation range of 60%-70% is the threshold for administering oxygen in the first minutes after birth. The accuracy of newer generation oximeters to measure SpO2 has not been compared against the 'gold standard', direct arterial blood oxygen saturation (SaO2) when SaO2 is low. The aim of this study was to determine the accuracy and precision of Nellcor and Masimo oximeters to measure SpO2 when SaO2 <70%. METHOD: Prospective observational study in ventilated anaesthetised newborn lambs with an indwelling carotid artery catheter. Ventilation was adjusted to achieve hypoxaemia. Nellcor (Oxi-Max 600 with Max-N sensor) and Masimo (Rad 4 with low noise optical probe (LNOP) sensor) sensors were applied to the right forelimb (preductal). An arterial blood sample was collected at 1-5 min intervals when the animal was hypoxic. The displayed SpO2 was recorded. We used Bland-Altman analysis to determine precision and accuracy of each oximeter when SaO2 <70%. RESULTS: 17 lambs were studied, 165 measurements were obtained, 123 were SaO2 <70%. The mean difference (±1.96 SD) Nellcor SpO2-SaO2 when SaO2 <70% was 17% (-12% to 46%). The mean difference (±1.96 SD) Masimo SpO2-SaO2 when SaO2 <70% was 13% (-19% to 45%). CONCLUSIONS: At SaO2<70%, both monitors overestimated oxygen saturation (SpO2) compared with the gold standard. Both oximeters were equally inaccurate when SaO2 was low.

ELBW infants: to intubate or not to intubate in the delivery room?

Few years ago, elective tracheal intubation in the delivery room was considered as the routine approach in managing respiratory failure in extremely-low-birth-weight infants (ELBW), at least in terms of surfactant administration. Over recent years, the indications and principles of neonatal resuscitation of ELBW infants have been partially reviewed: many randomized clinical trials (RCT) have demonstrated that these infants do not die quickly without intubation in the delivery room, and many infants only need a little help in completing foetal-neonatal transition through the use of lung recruitment manoeuvres in the delivery room (e.g. sustained lung inflation, CPAP) and then only non-invasive ventilation support. Tracheal intubation and mechanical ventilation can be reserved solely for depressed or ELBW, although further RCTs are needed to provide additional information and to provide a conclusive response to the eternal debate as to whether intubation at birth can influence outcome for ELBW infants.

Alveolar recruitment in the delivery room.

Most preterm babies with a gestational age less than 23-27 weeks need a respiratory support in the delivery room (DR); the aim of ventilation is to create and maintain a functional residual capacity (FRC); to facilitate gas exchange and to minimize acute lung injury. The application of a continuous positive airway pressure (CPAP) from the first breaths helps in obtaining a lung volume stabilization. Efficacy and safety of the application of a sustained lung inflation (SLI) at birth is still under careful evaluation. The prompt increase of the hearth rate and oxygen saturation in the preliminary studies at the moment available in the literature are signs of the good efficacy of the manoeuvre but the effects of the SLI on oxygenation and hemodynamics are undetermined. When preterm infants need respiratory assistance in the DR, respiratory function monitoring is desirable to apply adequate and gentle resuscitation manoeuvres. Clinical large trials taking place in the DR are needed but they are also extremely difficult to be designed and performed.

Volume guarantee versus high-frequency ventilation: lung inflammation in preterm infants.

BACKGROUND: Appropriate ventilation together with improvement of clinical care of premature babies can contribute to reducing lung inflammation, known to represent the "primum movens" of bronchopulmonary dysplasia (BPD). High-frequency oscillatory ventilation (HFOV) and volume-guarantee (VG) ventilation are effective in the treatment of neonatal respiratory distress syndrome (RDS). OBJECTIVE: To assess the potential of HFOV and VG to prevent BPD in the acute phase of RDS, by a randomised clinical study evaluating lung inflammation in premature infants. STUDY DESIGN: Forty infants (gestational age 25-32 weeks) with RDS were assigned to assist-control ventilation plus VG (Vt = 5 ml/kg) or HFOV (both with a Dräger Babylog 8000 plus ventilator). Levels of interleukin (IL) 6, IL8 and tumour necrosis factor were determined in tracheal aspirate on days 1, 3 and 7 of life. RESULTS: In the HFOV group IL6 levels were significantly higher on day 3 (0.5 (0.2) vs assisted-control ventilation plus VG group 0.1 (0.2) ng/ml) and oxygen dependency was significantly longer (36 (23) vs assisted-control ventilation plus VG group 19 (11) days). CONCLUSION: VG ventilation is an effective lung-protective strategy to be used in acute RDS, inducing a lower expression of early inflammation markers than HFOV. Whether the use of this initial ventilatory strategy contributes to the prevention of BPD requires further studies.