Pre-Medications for Non-Emergency Tracheal Intubation in the United States Neonatal Intensive Care Units.

BACKGROUND: Premedication in neonates undergoing elective intubation effectively minimizes the negative physiological events of bradycardia, systemic hypertension, intracranial hypertension, and hypoxia. Premedication decreases procedure-related pain and discomfort. This study aimed to evaluate the current practice of pre-intubation medications for non-emergent intubations in preterm and term neonates in the United States. STUDY DESIGN: A cross-sectional survey (Appendix) was sent via e-mail to all level 3 and 4 Neonatal Intensive Care Units (NICUs) of the Organization of Neonatal Perinatal Medicine Training Program Directors (ONTPD), NICU directors with pediatric residency only, and Baylor Scott and White Health, Mednax, and Envision health services systems. RESULTS: Of 170 responses, 41% (69/168) routinely premedicate, 38% (64/168) premedicate under specific circumstances, and 21% (35/168) do not administer any routine pre-intubation medications. Only 46% (77/168) of units had a written policy. The most frequently used drugs were fentanyl (68%, 116/170), atropine (39%, 66/170), midazolam (38%, 64/170), and morphine (26%, 45/170). 21% (36/170) used a two-drug combination, and 38% (64/170) used a three-drug combination. The most commonly used two-drug combination was atropine and fentanyl, and the most common three-drug combination was atropine, fentanyl, and a paralytic agent. CONCLUSION:  Despite the well-documented benefits of premedication for NICU intubations, as aligned with AAP recommendations, the US lags behind other nations, with stagnant rates since 2006. This disparity persists despite a rise in written policies, which exhibit significant content variations. The authors advocate for the adoption of standardized, AAP-aligned policies across all NICUs in the US. Continued research is vital to monitor the progress of this crucial practice and address any underlying barriers to implementation.

Maternal preeclampsia as a risk factor for developing bronchopulmonary dysplasia in neonates.

OBJECTIVE: To determine the effect of preeclampsia on the development of bronchopulmonary dysplasia (BPD) in preterm infants. METHODS: Retrospective cohort study of infants' ≤32 weeks' gestation admitted to a level-IV single center neonatal intensive care unit from 2014 to 2016. Infants with major congenital anomalies, death or transfer before 28 days were excluded. Infants were stratified by maternal preeclampsia status. Demographic, clinical, and laboratory data were reviewed. Logistic regression was used to examine predictors for BPD. MAIN OUTCOME MEASURE: The primary outcome was BPD incidence. RESULTS: 432 infants met inclusion criteria; 22% developed BPD, of which, 16% had severe BPD. Thirty-eight percent of infants were born to preeclamptic mothers, with 23% of those infants developing BPD. Infants born to preeclamptic mothers were delivered by cesarean section (88% vs. 60%; p<0.0001) more often and had lower birthweight (Median=1265g, IQR 910-1555 vs. Median=1388g, IQR 959-1752; p=0.008) compared to infants born to non-preeclamptic mothers. Higher incidence of intrauterine growth restriction was noted in pre-eclampsia group,24% vs 8%, p=0.0001). Gestational age, length of stay and days on ventilator were all associated with the development of BPD. In multivariable logistic regression, preeclampsia was not a risk factor for development of BPD (OR 1.12 [0.68, 1.83]). CONCLUSIONS: Preeclampsia was not a significant risk factor for development of BPD nor the severity of BPD in infants' ≤32 weeks' gestation. IUGR infants with or without preeclampsia mothers were at higher risk for BPD.

Newborn with Lethargy, Jaundice, and Coagulopathy.

Laboratory results include the following: white blood cell count, 21,600/µL (21.6 × 109/L; reference range, 9,000-30,000/µL [9-30 × 109/L]); hemoglobin, 18.2 g/dL (182 g/L; reference range, 14.0-24.0 g/dL [140-240 g/L]); platelet count, 111 × 103/µL (111 × 109/L; reference range, 150-450 × 103/µL [150-450 × 109/L]); blood type, B+; direct antiglobulin test, negative; and reticulocyte count, 4% (reference range, 3%-7%). Comprehensive metabolic panel is significant for hyponatremia, with a sodium level of 132 mEq/L (132 mmol/L; reference range, 135-145 mEq/L [135-145 mmol/L]). Liver enzyme levels are normal (alanine aminotransferase, 41 U/L [0.68 µkat/L]; aspartate aminotransferase, 86 U/L [1.44 µkat/L]), as are total protein (5.4 g/dL [54 g/L]) and albumin (3.0 g/dL [30 g/L]) levels. Repeated bilirubin level is 12.4 mg/dL (212 µmol/L) at 14 hours after birth, with an elevated direct bilirubin level of 2.9 mg/dL (49.6 µmol/L). Direct or conjugated hyperbilirubinemia is defined as a direct bilirubin level greater than 2 mg/dL (34.2 mmol/L) or more than 20% of total bilirubin. γ-Glutamyl transferase level is normal. Coagulation studies show an elevated prothrombin time of 23.4 seconds (reference range, 11-17 seconds), with an international normalized ratio of 2.1 (reference range, 0.9-1.3); activated partial thromboplastin level is 49.5 seconds (reference range, 30-60 seconds). Fibrinogen level is decreased at 70 mg/dL (0.70 g/L) (reference range, 230-450 mg/dL [230-450 g/L]). Lactate level is 24.3 mg/dL (2.7 mmol/L; reference range, 2.0-26.9 mg/dL [0.22-2.98 mmol/L]). Ammonia level is 96.6 µg/dL (69 µmol/L; reference range, 89.6-149.9 µg/dL [64-107 µmol/L]). Cerebrospinal fluid studies are unremarkable. Magnetic resonance imaging (MRI) of the brain and echocardiography are normal. Ultrasonography of the abdomen shows diffuse hepatic echogenicity. Blood and cerebrospinal fluid cultures are negative. Further testing reveals the diagnosis.

Early and Mid-Term Outcomes of Patients Undergoing Coronary Artery Bypass Grafting in Ischemic Cardiomyopathy.

Background Many observational studies and trials have shown that coronary artery bypass grafting improves the survival in patients with ischemic cardiomyopathy. However, these results are based on data generated from developed countries. Poor socioeconomic statuses, lack of uniformity in healthcare delivery, differences in risk profile, and affordability to access optimal health care are some factors that make the conclusions from these studies irrelevant to patients from India. Methods and Results One-hundred and sixty-two patients with severe left ventricular dysfunction (ejection fraction ≤35%) who underwent coronary artery bypass grafting from 2009 to 2017 were enrolled for this study. Mean age of the study population was 58.67±9.70 years. Operative mortality was 11.62%. Thirty day/in-house composite outcome of stroke and perioperative myocardial infarction were 5.8%. The percentage of survival for 1 year was 86.6%, and 5-year survival was 79.9%. Five-year event-free survival was 49.3%. The mean ejection fraction improved from 30.7±4.08% (range 18-35) to 39.9±8.3% (range 24-60). Lack of improvement of left ventricular function was a strong predictor of late mortality (hazard ratio, 21.41; CI 4.33-105.95). Even though there was a trend towards better early outcome in off-pump CABG , the 5-year survival rates were similar in off-pump and on-pump group (73.4% and 78.9%, respectively; P value 0.356). Conclusions We showed that coronary artery bypass grafting in ischemic cardiomyopathy was associated with high early composite outcomes. However, the 5-year survival rates were good. Lack of improvement of left ventricular function was a strong predictor of late mortality.