Association between early echocardiography screening of low systemic blood flow and intraventricular hemorrhage in preterm infants: a multicenter cohort study.

OBJECTIVE: To determine whether early echocardiography screening of low systemic blood flow reduces intraventricular hemorrhage in preterm infants. STUDY DESIGN: Prospective multicenter study in preterm infants below 33 weeks of gestational age at nine neonatal units. Five units performed early echocardiography screening for low systemic blood flow and guided clinical management (exposure group) and 4 units did not (control group). Our main outcome was ≥grade II intraventricular hemorrhage or death within the first 7 days of life. The main analysis used the inverse probability of treatment weighting. RESULTS: Three hundred and thirty-two preterm infants (131 in the exposure group and 201 in the control group) were included. Exposure to early echocardiography screening was associated with a significant reduction in ≥grade II intraventricular hemorrhage or early death [odds ratio 0.285 (95% CI: 0.133-0.611); p = 0.001]. CONCLUSIONS: Early echocardiography screening for low systemic blood flow may reduce the incidence of intraventricular hemorrhage in preterm infants.

Bedside Ultrasound for Early Diagnosis of Necrotizing Enterocolitis: A Pilot Study.

OBJECTIVE: This study aimed to assess whether bedside ultrasound (BUS) as the first imaging modality allows an earlier diagnosis of necrotizing enterocolitis (NEC) compared with abdominal radiography. STUDY DESIGN: A before-after controlled study in preterm infants with suspected NEC. The intervention group (October 2019-October 2021) received BUS as the first imaging modality and was managed accordingly to BUS findings. The control group (October 2015-September 2019) received radiography as the first imaging modality. The main outcome was NEC confirmation at the time of initial imaging. Secondary outcomes included time to diagnosis, laboratory data, and treatment requirements. RESULTS: Thirty-five episodes of suspected NEC with 14 (40%) confirmed NEC cases and 49 episodes of suspected NEC with 22 (44.9%) confirmed NEC cases were included in the intervention and control groups, respectively. In the intervention group, 11 of 14 (78.6%) NEC cases were confirmed at initial evaluation compared with 5 of 22 (22.7%) in the control group (p = 0.001). Infants in the intervention group developed thrombocytopenia and coagulopathy less frequently, were exposed to less radiation, and required less days of parenteral nutrition compared with the control group (p < 0.05). CONCLUSION: The use of BUS as the first imaging modality allowed an earlier diagnosis and timely treatment of NEC compared with abdominal radiography.Key Points · This is the first study that has assessed the role of BUS as the first imaging modality in NEC.. · BUS improves early diagnosis of NEC compared with abdominal radiography.. · BUS shortens time to NEC confirmation and treatment initiation which may reduce clinical severity of the NEC episode..

Respiratory Variation in Aortic Blood Flow Velocity in Hemodynamically Unstable, Ventilated Neonates: A Pilot Study of Fluid Responsiveness.

OBJECTIVES: To assess whether respiratory variation in aortic blood flow peak velocity can predict preload responsiveness in mechanically ventilated and hemodynamically unstable neonates. DESIGN: Prospective observational diagnostic accuracy study. SETTING: Third-level neonatal ICU. PATIENTS: Hemodynamically unstable neonates under mechanical ventilation. INTERVENTIONS: Fluid challenge with 10 mL/kg of normal saline over 20 minutes. MEASUREMENTS AND MAIN RESULTS: Respiratory variation in aortic blood flow peak velocity and superior vena cava flow were measured at baseline (T0), immediately upon completion of the fluid infusion (T1), and at 1 hour after fluid administration (T2). Our main outcome was preload responsiveness which was defined as an increase in superior vena cava flow of at least 10% from T0 to T1. Forty-six infants with a median (interquartile range) gestational age of 30.5 weeks (28-36 wk) were included. Twenty-nine infants (63%) were fluid responders, and 17 (37%) were nonresponders Fluid responders had a higher baseline (T0) respiratory variation in aortic blood flow peak velocity than nonresponders (9% [8.2-10.8] vs 5.5% [3.7-6.6]; p < 0.001). Baseline respiratory variation in aortic blood flow peak velocity was correlated with the increase in superior vena cava flow from T0 to T1 (rho = 0.841; p < 0.001). The area under the receiver operating characteristic curve of respiratory variation in aortic blood flow peak velocity to predict preload responsiveness was 0.912 (95% CI, 0.82-1). A respiratory variation in aortic blood flow peak velocity cut-off point of 7.8% provided a 90% sensitivity (95% CI, 71-97), 88% specificity (95% CI, 62-98), 7.6 positive likelihood ratio (95% CI, 2-28), and 0.11 negative likelihood ratio (95% CI, 0.03-0.34) to predict preload responsiveness. CONCLUSIONS: Respiratory variation in aortic blood flow velocity may be useful to predict the immediate response to a fluid challenge in hemodynamically unstable neonates under mechanical ventilation. If our results are confirmed, this measurement could be used to guide safe and individualized fluid resuscitation in critically ill neonates.

Early assessment of lung aeration using an ultrasound score as a biomarker of developing bronchopulmonary dysplasia: a prospective observational study.

The objective of this study was to assess the predictive value of a lung ultrasound (LUS) score in the development of moderate-severe bronchopulmonary dysplasia (sBPD). This was a prospective  observational diagnostic accuracy study in a third-level neonatal intensive care unit. Preterm infants with a gestational age below 32 weeks were included. A LUS score (range 0-24 points) was calculated by assessing aeration semiquantitatively (0-3 points) in eight lung zones on the 7th day of life (DOL) and repeated on the 28th DOL. ROC curves and logistic regression were used for analysis. Forty-two preterm infants were included. The LUS on the 7th DOL had an area under the receiver operating characteristic curve (AUROC) of 0.94 (95% CI: 0.87-1) for the prediction of sBPD (optimal cutoff of ≥8 points: sensitivity 93%, specificity 91%). The LUS score was independently associated with sBPD [OR 2.1 (95% CI: 1.1-3.9), p = 0.022, for each additional point in the score]. Conclusions: Lung aeration as assessed by LUS on the 7th DOL may predict the development of sBPD.

Ecografía a pie de cama en el diagnóstico precoz de la enterocolitis necrosante: una estrategia para mejorar el pronóstico / Bedside ultrasound in the early diagnosis of necrotising enterocolitis: A strategy to improve the prognosis

No disponible

Ultrasound-guided supraclavicular cannulation of the brachiocephalic vein may reduce central line-associated bloodstream infection in preterm infants.

The objective of this study was to assess the risk of central line-associated bloodstream infection (CLABSI) of ultrasound (US)-guided cannulation of the brachiocephalic vein (BCV) compared to standard epicutaneous cava catheters (ECCs) in preterm infants. This was a retrospective cohort study in preterm infants with a birth weight of less than 1500 g. Each BCV catheter was matched 1:3 with ECCs according to sex, birth weight, and year of insertion. The main outcome was the CLABSI density rate per 1000 days. Secondary outcomes included CLABSI episodes, CLABSI episodes per infant, and CLABSI/death. A multivariate Cox regression analysis was performed to assess whether the type of catheter (ECC vs. BCV) was associated with CLABSI risk. Ninety-six catheters (21 BCVs and 75 ECCs) in 79 infants were included (993 catheter days). BCV catheters were associated with a reduced CLABSI density rate compared to ECCs (3.05/1000 days vs 21.1/1000 days; p < 0.001). ECCs were associated with increased CLABSI risk compared to BCV catheters in multivariate analysis (hazard ratio 36; (95% CI, 2.5-511); p = 0.008).Conclusion: US-guided supraclavicular cannulation of the BCV was associated with a reduced risk of CLABSI compared to ECCs. This finding deserves further multicenter research. What is Known: • An epicutaneous-cava catheter (ECC) is commonly used in preterm infants for routine care (eg. delivery of nutrition and antibiotics) but this device may not suffice in infants who need high-intensity care (multiple drugs, hemodynamic monitoring, fluid resuscitation etc.). • Ultrasound-guided brachiocephalic vein (BCV) catheterization has shown a high success rate and few immediate complications in neonates and small infants but it has never been compared to standard ECCs. What is New: • When the operator in properly trained, US guided cannulation of the BCV in preterm infants is feasible, safe and may reduce the risk of CLABSI compared to standard ECCs. • This fact may expand the use of BCV catheters in selected high-risk preterm infants who need a large bore venous access.

A case report of arterial and venous thromboembolism in a patient with severe COVID-19 pneumonia.

BACKGROUND: Coronavirus disease 2019 (COVID-19) has spread rapidly worldwide since the outbreak originated in Wuhan, China in December 2019. Cardiovascular complications in patients with severe COVID-19 have been reported and are associated with a worse outcome. Coagulopathy is one of the most common life-threatening complication increasing mortality; however, little evidence is available regarding prevention strategies or its treatment in COVID-19 patients. CASE SUMMARY: We report a case of a 70-year-old woman admitted to hospital with severe COVID-19 bilateral pneumonia who developed severe coagulopathy with multiple both, venous and arterial, embolisms in major vessels such as bilateral pulmonary embolism, acute thrombus in abdominal aorta, and acute thrombotic occlusion of the right iliac common artery. The patient underwent emergent surgical thrombectomy of the right lower limb; in spite of anticoagulant treatment at therapeutic doses, patient presented poor clinical evolution and an infracondylar amputation of right lower limb was made finally. Subsequently, the patient received low molecular weight heparin (LMWH), antibiotics and antiviral therapy improving her renal function and her pneumonia, so she could be discharged safely. DISCUSSION: Prothrombotic coagulopathy due to enhanced acute inflammatory response and diffuse intravascular coagulation has been described in severe critical COVID-19 patients. This state of hypercoagulability is associated with organ dysfunction and mortality and may predispose to both, venous and arterial, thromboembolism. Little data are available regarding the best therapeutic and prevention strategies in this scenario, although thrombosis prophylaxis with LMWH has been associated with a better outcome.

Foramen oval restrictivo intraútero: causa de hipertensión pulmonar neonatal / Intrauterine restrictive foramen ovale: cause of neonatal pulmonary hypertension

El cierre prematuro del foramen oval o foramen oval restrictivo intraútero es una entidad rara de etiología desconocida. Dicha patología se asocia a un riesgo elevado de hipertensión pulmonar y puede ocasionar insuficiencia cardíaca congestiva con hidrops y muerte fetal. También, se puede asociar con disfunción diastólica en el período neonatal. Se presenta a un recién nacido en el que, en una ecografía prenatal, se visualizó un aumento de las cavidades derechas. En el ecocardiograma posnatal, se confirmó la dilatación de las cavidades derechas con hipertensión pulmonar en rango sistémico y septo interauricular inmóvil con foramen oval cerrado. A los 9 días, ante la persistencia de dificultad respiratoria, se realizó un ecocardiograma, con mejoría de la hipertensión pulmonar, pero con disfunción sistólica biventricular leve y diastólica del ventrículo izquierdo con edema pulmonar. Se indicó el tratamiento diurético, con normalización de la función ventricular.

Premature closure of the foramen ovale (FO) or intrauterine restrictive FO is a rare entity of unknown etiology. This pathology is associated with an elevated risk of pulmonary hypertension, which can cause congestive heart failure with hydrops and fetal death. Patients with restrictive intrauterine FO may develop left ventricle diastolic dysfunction and pulmonary edema. A newborn with increased right cavities in the prenatal ultrasound is presented. In postnatal echocardiogram, dilatation of right cavities was confirmed with pulmonary hypertension in the systemic range and immobile interatrial septum with closed FO. After 9 days of persistent respiratory distress, an echocardiogram was performed with improvement of pulmonary hypertension but with mild biventricular and diastolic and systolic dysfunction of the left ventricle with pulmonary edema. Diuretic treatment was decided, with normalization of ventricular function.

[Intrauterine restrictive foramen ovale: cause of neonatal pulmonary hypertension]. / Foramen oval restrictivo intraútero: causa de hipertensión pulmonar neonatal.

Premature closure of the foramen ovale (FO) or intrauterine restrictive FO is a rare entity of unknown etiology. This pathology is associated with an elevated risk of pulmonary hypertension, which can cause congestive heart failure with hydrops and fetal death. Patients with restrictive intrauterine FO may develop left ventricle diastolic dysfunction and pulmonary edema. A newborn with increased right cavities in the prenatal ultrasound is presented. In postnatal echocardiogram, dilatation of right cavities was confirmed with pulmonary hypertension in the systemic range and immobile interatrial septum with closed FO. After 9 days of persistent respiratory distress, an echocardiogram was performed with improvement of pulmonary hypertension but with mild biventricular and diastolic and systolic dysfunction of the left ventricle with pulmonary edema. Diuretic treatment was decided, with normalization of ventricular function.

El cierre prematuro del foramen oval o foramen oval restrictivo intraútero es una entidad rara de etiología desconocida. Dicha patología se asocia a un riesgo elevado de hipertensión pulmonar y puede ocasionar insuficiencia cardíaca congestiva con hidrops y muerte fetal. También, se puede asociar con disfunción diastólica en el período neonatal. Se presenta a un recién nacido en el que, en una ecografía prenatal, se visualizó un aumento de las cavidades derechas. En el ecocardiograma posnatal, se confirmó la dilatación de las cavidades derechas con hipertensión pulmonar en rango sistémico y septo interauricular inmóvil con foramen oval cerrado. A los 9 días, ante la persistencia de dificultad respiratoria, se realizó un ecocardiograma, con mejoría de la hipertensión pulmonar, pero con disfunción sistólica biventricular leve y diastólica del ventrículo izquierdo con edema pulmonar. Se indicó el tratamiento diurético, con normalización de la función ventricular.

Impacto del cribado y tratamiento del bajo flujo sistémico en la prevención de hemorragia intraventricular grave y/o muerte en el prematuro / Impact of screening and treatment of low systemic blood flow in the prevention of severe intraventricular haemorrhage and/or death in pre-term infants

OBJETIVO: Evaluar el efecto de un protocolo de cribado y tratamiento del bajo flujo sistémico (BFS) durante el periodo transicional en la aparición de hemorragia intraventricular (HIV) grave y/o muerte en prematuros. MÉTODOS: Estudio cuasi-experimental con controles retrospectivos. En la fase de intervención se incluyeron los prematuros de menos de 30semanas de edad gestacional (enero 2016-julio 2017). Los controles (enero de 2013-diciembre de 2015) fueron pareados por edad gestacional, peso al nacimiento y sexo con una relación 1:2. Los casos diagnosticados de BFS por ecocardiografía funcional durante el protocolo recibieron tratamiento con dobutamina (DB) entre 5-10 mig/kg/min durante 48 h. RESULTADOS: Se incluyeron 29 casos en la fase de intervención (aplicación del protocolo) y 54 controles (fase preintervención). Diez de 29 (34,5%) casos durante el protocolo recibieron DB por BFS con 3/29 (10,3%) casos de HIV grave y/o muerte comparado con 17/54 (31,5%) en la fase pre-protocolo (p = 0,032). El protocolo se asoció de forma independiente a una reducción en la HIV grave y/o muerte tanto en la regresión logística (OR: 0,11 (IC95%: 0,01-0,65), p = 0,015) como en el análisis de ponderación por la probabilidad inversa de tratamiento (OR: 0,23 (IC95%: 0,09-0,56); p = 0,001). CONCLUSIONES: En un estudio con controles retrospectivos, la aplicación de un protocolo de cribado y tratamiento del BFS en prematuros se asoció a una reducción en la HIV grave y/o muerte. Son necesarios ensayos clínicos de suficiente potencia para determinar si las intervenciones posnatales sobre el BFS pueden mejorar el pronóstico neurológico

OBJECTIVE: To assess the effect of a protocolised intervention for low systemic blood flow (SBF) in the occurrence of severe intraventricular haemorrhage (IVH) or death in pre-term infants. METHODS: A study with a quasi-experimental design with retrospective controls was conducted on pre-term infants of less than 30 weeks of gestational age, born between January 2016 and July 2017, who were consecutively included in the intervention period. The control cohort included pre-term infants (born between January 2013 and December 2015) matched by gestational age, birth weight, and gender (two controls for each case). The cases of low SBF diagnosed according to functional echocardiography during the study period received dobutamine (5-10 mig/kg/min) for 48 hours. RESULTS: The study included 29 cases (intervention period) and 54 controls (pre-intervention period). Ten out of 29 (34.5%) infants received dobutamine for low SBF during the intervention period, with 3/29 (10.3%) cases of severe IVH and/or death compared to 17/54 (31.5%) in the control cohort (p = .032). There was an independent association between the intervention and a decreased occurrence of severe IVH/death after adjusting for confounding factors both in the logistic regression model (OR 0.11 (95% CI: 0.01-0.65), p = .015), as well as in the sensitivity analysis using inverse probability of treatment weighting (OR 0.23 (95% CI: 0.09-0.56); p = .001). CONCLUSIONS: In this study with retrospective controls, a protocolised screening, and treatment for low SBF was associated with a decreased occurrence of severe IVH or death in preterm infants. Large, adequately powered trials, are needed in order to determine whether postnatal interventions directed at low SBF can improve neurological outcomes

N-terminal-probrain natriuretic peptide as a biomarker of moderate to severe bronchopulmonary dysplasia in preterm infants: A prospective observational study.

OBJECTIVE: N-terminal-probrain natriuretic peptide (NT-proBNP) is a marker of hemodynamically significant patent ductus arteriosus (HsPDA) in preterm infants. In this study, we assessed whether NT-proBNP levels could predict the risk of moderate to severe bronchopulmonary dysplasia (BPD) and/or death. METHODS: This was an observational prospective study of preterm infants with GA ≤32 weeks. Infants who died within the first 48 h or who had major congenital malformations or incomplete information were excluded. NT-proBNP was determined at 48-96 h of life and at 5-10 days of life. The predictive capacity of NT-proBNP for the combined outcome of BPD and/or death was evaluated using receiver operator characteristic (ROC) curves and multivariate regression. RESULTS: Of the 125 eligible patients, 110 completed the analysis. Twenty-eight developed BPD (n = 15) and/or died (n = 13). Infants who developed BPD and/or died had higher NT-proBNP levels ​​at 48-96 h (26,848 ng/L, interquartile range [IQR] 7818-60,684 vs 3008 ng/L, IQR 1425-9876) and at 5-10 days (8849 ng/L, IQR 3796-19,526 vs 1427 ng/L, IQR 907-2889). The NT-proBNP levels at 5-10 days, but not at 48-96 h, were independently associated with BPD and/or death after adjustments for HsPDA and other confounders (OR = 3.36; 95%CI: 1.52-7.4, P = 0.006). For the prediction of this result, a cutoff of 3348 ng/L had a sensitivity and specificity of 82% and 83%, respectively (area under the curve [AUC] = 0.87; 95%CI: 0.79-0.95). CONCLUSION: The NT-proBNP levels at 5-10 days of life may identify preterm infants with an HsPDA who are at high risk of BPD or death and may be useful for individualized preventive and therapeutic strategies.

[Impact of screening and treatment of low systemic blood flow in the prevention of severe intraventricular haemorrhage and/or death in pre-term infants]. / Impacto del cribado y tratamiento del bajo flujo sistémico en la prevención de hemorragia intraventricular grave y/o muerte en el prematuro.

OBJECTIVE: To assess the effect of a protocolised intervention for low systemic blood flow (SBF) in the occurrence of severe intraventricular haemorrhage (IVH) or death in pre-term infants. METHODS: A study with a quasi-experimental design with retrospective controls was conducted on pre-term infants of less than 30weeks of gestational age, born between January 2016 and July 2017, who were consecutively included in the intervention period. The control cohort included pre-term infants (born between January 2013 and December 2015) matched by gestational age, birth weight, and gender (two controls for each case). The cases of low SBF diagnosed according to functional echocardiography during the study period received dobutamine (5-10µg/kg/min) for 48hours. RESULTS: The study included 29 cases (intervention period) and 54 controls (pre-intervention period). Ten out of 29 (34.5%) infants received dobutamine for low SBF during the intervention period, with 3/29 (10.3%) cases of severe IVH and/or death compared to 17/54 (31.5%) in the control cohort (p=.032). There was an independent association between the intervention and a decreased occurrence of severe IVH/death after adjusting for confounding factors both in the logistic regression model [OR 0.11 (95%CI: 0.01-0.65), p=.015], as well as in the sensitivity analysis using inverse probability of treatment weighting [OR 0.23 (95%CI: 0.09-0.56); p=.001]. CONCLUSIONS: In this study with retrospective controls, a protocolised screening, and treatment for low SBF was associated with a decreased occurrence of severe IVH or death in preterm infants. Large, adequately powered trials, are needed in order to determine whether postnatal interventions directed at low SBF can improve neurological outcomes.

Ultrasound-Guided Cannulation of the Brachiocephalic Vein in Neonates and Preterm Infants: A Prospective Observational Study.

INTRODUCTION: Percutaneous central venous catheter (CVC) insertion is a challenging procedure in neonates, especially in preterm infants. OBJECTIVE: This study aims to describe the technical success and safety profile of ultrasound (US)-guided brachiocephalic vein (BCV) cannulation in neonates. METHODS: Prospective observational study. Neonates admitted to the neonatal intensive care unit (NICU) in whom US-guided cannulation of the BCV was attempted were eligible. Outcomes included first attempt success rate, the overall success rate, the number of attempts, the cannulation time, immediate mechanical complications, catheter indwelling days, and late complications. RESULTS: A total of 40 procedures in 37 patients were included. Median weight and age at the time of cannulation were 1.85 kg (0.76-4.8) and 13 days (3-31), respectively. First attempt and overall success rates were 29 (72.5%) and 38 (95%), respectively. No major complications were observed. Catheter-associated infection rate was 2.4/1,000 catheter days. There were no difference in outcomes between low weight preterm infants (<1.5 kg) and the rest of the cohort. There was no linear relationship between weight at time of insertion and the number of puncture attempts (r = 0.250; p = 0.154) or cannulation time (r = 0.257; p = 0.142). CONCLUSION: US-guided cannulation of the BCV may be considered in acutely ill neonates, including small preterm infants, who need a large bore CVC.