Randomized trial of granulocyte transfusions versus intravenous immune globulin therapy for neonatal neutropenia and sepsis.

We prospectively studied newborn infants with sepsis and neutropenia who were randomly selected to receive standard supportive care and either adjuvant granulocyte transfusions or intravenous immune globulin (IVIG) infusions; 21 infants received granulocyte transfusions and 14 received IVIG infusions. Half of the patients were premature (gestational age less than or equal to 32 weeks); the average postnatal age was 5 days (range 3 to 8 days). All infants had neutropenia by the criteria of Manroe et al., and the mean average bone marrow neutrophil storage pool ranged between 35% and 37%. There were no significant differences with respect to serum IgG, IgA, IgM, and total hemolytic complement values between treatment groups or between survivors and nonsurvivors. Clinical severity as defined by hypoxia, acidosis, and hypotension was similar between treatment groups. Group B streptococcus was the most common organism identified and accounted for almost 33% of all bacterial isolates. There was a significantly different survival rate in the group receiving polymorphonuclear leukocyte transfusions (100%, 21/21) compared with the group receiving IVIG infusions (64%, 9/14; p = less than 0.03). There were no significant complications in either treatment group with respect to fluid overload, secondary infection, blood group sensitization, pulmonary complications, or graft-versus-host disease. This pilot study suggests a possible benefit of granulocyte transfusions compared with 'IVIG therapy in the adjuvant treatment of neonatal neutropenia and overwhelming bacterial sepsis.

Role of circulating complement and polymorphonuclear leukocyte transfusion in treatment and outcome in critically ill neonates with sepsis.

We examined the effects of early administration of polymorphonuclear leukocyte (PMN) transfusions in neonates with sepsis by prospectively randomizing 35 consecutive critically ill infants with sepsis, 21 of whom received PMN transfusions in addition to supportive care, one transfusion every 12 hours for a total of five transfusions. Each transfusion consisted of 15 mL/kg containing 0.5 to 1.0 X 10(9) PMN with less than 10% lymphocytes, and was subjected to 1500 rads. PMNs were obtained by continuous-flow centrifugation leukopheresis. Pretreatment values that did not significantly affect survival included weight, gestational age, sex, prematurity, C-reactive protein, initial hematocrit, platelet count and absolute granulocyte count (AGC less than or equal to 1500/mm3), IgM, IgG, IgA, neutrophil supply pool depletion, hypoxia, acidosis, and hypotension. Postnatal age was significantly lower in the nontransfused group than in the transfused group; 2.3 +/- 0.6 vs 6.1 +/- 2.2, (P less than 0.001). Positive blood cultures were obtained in 80% of both groups. Low circulating levels of total hemolytic complement were associated with a poor outcome and higher mortality: 56 +/- 4.0 IU in survivors vs 31 +/- 4.4 IU in nonsurvivors (P less than 0.01). Survival was significantly greater in the PMN transfused group than in the nontransfused group: 20 (95%) of 21 vs nine (64%) of 14 (P less than or equal to 0.05). No untoward effects were attributable to PMN transfusions, either during the study or on subsequent follow-up visits. These preliminary data suggest that early treatment with PMN transfusions improves survival in neonates with overwhelming sepsis. In addition, depleted or low circulating levels of complement may influence prognosis and thus future treatment strategies for neonatal sepsis.

Ligation of the patent ductus arteriosus in newborn respiratory failure.

Patent ductus arteriosus (PDA) is commonly associated with respiratory disease in newborn infants and may require ligation. Surgical ligation of the PDA can be done in small infants with low operative risk and minimal complications. The outcome of patients after ligation depends primarily on the severity of the underlying pulmonary disease. One hundred fifty-one patients have undergone ligation in an eight-year period at this center. A simplified technique performed in the neonatal intensive care unit with the use of local anesthesia and conventional ventilator management is described.

Auditory brainstem response in infant hydrocephalus.

Fifteen infants with hydrocephalus ranging in age from 32 to 43 weeks from conception were studied. The auditory brainstem response (ABR) was measured 48 h prior to the placement of a CSF shunt and within 5 days following shunt insertion. Results of this study showed a general improvement in the ABR following placement of the shunt. No consistent patterns were observed that allowed a clear explanation of the cause and effect of the abnormal ABR. However, the changes seen in the ABR are caused by increased CSF pressure, which may compress the transmission fibers, and generators of the ABR producing a type of neuropraxis. Early shunting appears to have a better outcome on the ABR than later shunting.

Improved survival of newborns receiving leukocyte transfusions for sepsis.

To determine the role of polymorphonuclear (PMN) leukocyte transfusions in neonates with sepsis, 23 consecutive newborns were prospectively randomly selected during an 18-month period in a treatment plan to receive polymorphonuclear leukocyte transfusions with supportive care or supportive care alone. Thirteen neonates received transfusions every 12 hours for a total of five transfusions. Each transfusion consisting of 15 mL/kg of polymorphonuclear leukocytes was subjected to 1,500 rads of radiation. The polymorphonuclear leukocytes were obtained by continuous-flow centrifugation leukapheresis and contained 0.5 to 1.0 X 10(9) granulocytes per 15 mL with less than 10% lymphocytes. Pretreatment demographic, clinical, and laboratory variables that were found to be insignificant in prognosis between newborns who received transfusions and newborns who did not receive transfusions included weight, gestational and postnatal age, hypoxia, acidosis, hypotension, initial absolute granulocyte count (AGC), initial levels of immunoglobulins (IgA, IgG, and IgM), and total hemolytic complement. Positive findings on blood cultures were obtained in 14/23 patients and seven were randomly selected for each treatment group. Absolute granulocyte counts were less than 1,500/microL in 13 patients but tibial bone marrow examinations revealed that the neutrophil supply pool was depleted in only three patients. The survival was significantly greater in the treatment group (13/13, 100%) compared with the group that did not receive transfusions (6/10, 60%, P less than .02).(ABSTRACT TRUNCATED AT 250 WORDS)

Neonatal emergency transport drug box.

The neonatal drug transport box provides a readily available drug supply in appropriate dilutions for newborns. It also supplies a visible neonatal emergency drug dosage list. The use of this box has demonstrated a saving in nursing time, assured an appropriate supply of all necessary drugs, made drugs readily available for emergency use, and provided dosage check.

Short latency mechanically evoked peripheral nerve and somatosensory potentials in newborn infants.

Mechanically evoked short-latency potentials were recorded from ten newborn infants ranging in gestational age from 36 to 42 wk and from a 3-month-old infant during natural sleep. Potentials were recorded from four electrode configurations: (1) over the peripheral nerve at the wrist: distal-proximal; (2) over the peripheral nerve at the axilla-deltoid insertion; (3) over the cervical spinal cord and cerebrum: CII-Fpz; and (4) over the cerebrum: C4-Fpz. All subjects produced clear potentials from configurations 1, 2 and 3. Configuration 4 produced reliable potentials only in one newborn who was large for gestational age (42 wk) and the 3-month-old infant. Average peripheral nerve conduction velocities were 26 m/sec from wrist to axilla and 29 m/sec from axilla to neck. No significant correlation was found between conceptional age and nerve conduction velocity. The application of this technique could allow lesion localization in peripheral as well as central portions of the somatosensory pathway of newborns.

Craniofacial duplication (diprosopus).

No congenital malformation in infants is more profound than anterior craniofacial duplication. The precise term for this rare anomaly is diprosopus, referring to a fetus with a single trunk, normal limbs, and varying degrees of facial duplication. A search of the world literature produced only 16 cases of diprosopus since 1864. Despite the rarity of this anomaly, three such infants were born in the Southern California area during the past year, making this the largest reported series to date. The three infants were born with two distinctly formed faces. Each had four separate eyes, two mouths, two noses, and two ears with a primitive ear or sinus tract at the plane of fusion. In addition, multiple congenital aberrations existed which involved a variety of internal organs. The pathogenesis of diprosopus is not well understood, but environmental stress early in embryologic development has been suggested as a possible factor. The apparent mechanism is a slowing of pregastrulation oxidation with resultant focal developmental arrests.

Technical aspects in the management of the meconium aspiration syndrome with extracorporeal circulation.

Sixteen neonatal patients diagnosed as having the meconium aspiration syndrome were selected for management with extracorporeal circulation with a membrane oxygenator (ECMO) with 8 survivors over 4 yr. All patients weighed greater than 2 kg. Each was placed in the 100% mortality group according to a Neonatal Pulmonary Insufficiency Index (NPII) based on hourly pH and FiO2 determinations. The typical patient course on ECMO was stabilization for the first 12 hr then improvement on high bypass flow rates for 12-24 hr to maintain a pAO2 for 50-60 mm Hg with minimal ventilator settings with an FiO2 of 0.3-0.4. Bypass flow rates were reduced to maintain adequate pAO2 with similar ventilator settings for another 24 hr. Survivors were taken off bypass and decannulated while on similar ventilator settings. Nonsurvivors did stabilize or improve but usually exhibited symptoms of intracranial hemorrhage by 48 hr. Intracranial hemorrhage appeared to be related to the degree of prebypass acidosis. Successful ECMO support reduced the expected mortality from severe meconium aspiration from 100% to 50%. Early institution of ECMO, before acidosis worsens, seems to be indicated to reduce the morbidity of conventional ventilator management and to prevent intracranial hemorrhage from severe prebypass acidosis. Long term followup indicates that these patients have progressed satisfactorily according to developmental testing for as long as 4 yr.

Short latency mechanically evoked somatosensory potentials in humans.

Somatosensory potentials evoked by mechanical stimulation were recorded by surface electrodes over (1) the digital nerves in the index finger, (2) the median nerve at the wrist, (3) the median nerve near the axilla, (4) the brachial plexus, (5) the cervical cord at CII, (6) the scalp overlying the somatosensory cortex. Nerve conduction velocities varied inversely with age and ranged from 43 to 68 m/sec. Mechanically evoked potentials recorded from the electrodes overlying the digital nerves were an artifact of the finger movement. All other electrode configurations recorded potentials comparable to those evoked by electrical stimulation of nerves. These mechanically evoked potentials could prove useful in the assessment of clinical disorders of somatosensory function from receptor to cortex in man.

Mechanically and electrically evoked somatosensory potentials in normal humans.

Somatosensory potentials evoked by mechanical stimulation of the fingernail and electrical stimulation of the nerve in the finger and at the wrist were recorded by surface electrodes over; (1) the digital nerve in the index finger, (2) the median nerve at the wrist, (3) the median nerve at the axilla, (4) the brachial plexus at Erb's point, (5) the cervical cord at C2, and (6) the scalp overlying the somatosensory cortex. Nerve conduction velocities were computed for two portions of the median nerve. Conduction times along the somatosensory pathway between spinal cord and cerebral cortex were also defined. The mechanically evoked potentials had less temporal dispersion, were of lower amplitude, and occasionally consisted of fewer components than the electrically evoked potentials. Electrical stimulation of the nerve trunk at the wrist evoked some additional components not detected by the other stimulation methods. Nerve conduction velocities and conduction times were comparable among the three methods of stimulation.

Prospective application of an index of neonatal necrotizing enterocolitis.

Fifty-five patients were scored 1 to 3 according to the criteria: the character of stools, abdominal findings on palpation, x-ray evidence of pneumatosis intestinalis, the development of pulmonary insufficiency, and the duration of symptoms to positive x-rays. Fifteen patients with scores of less than five were considered to have subclinical NEC with one late death. Twenty-nine of 30 patients with scores of 5-10 responded to medical management with 2 deaths related to recurrent bouts of sepsis without recurrent NEC. Eleven patients required surgery with index scores of 10-14 with 6 deaths occurring uniformly in those patients with scores of 12 or more. Two patients were scored inappropriately low due to the lack of the passage of a stool for analysis. One patient with a score of 4 did not pass a stool but had the other diagnostic criteria for the single false negative of the series. This index correctly determined the severity of NEC of 53 of 55 patients, identified the patients who required surgical intervention and predicted survival.

Management of pulmonary insufficiency in diaphragmatic hernia using extracorporeal circulation with a membrane oxygenator (ECMO).

Persistent fetal circulation (PFC) causes severe pulmonary insufficiency in patients who have demonstrated adequate lung function following diaphragmatic hernia repair. Patent ductus arteriosus (PDA) ligation corrects this condition, but carries the risk of sudden right ventricular failure. Pharmacologic reversal of PFC may be attempted, and if unsuccessful, prolonged venoarterial bypass becomes necessary to provide effective pulmonary support. PDA ligation can then be performed safely and maturation of the pulmonary vasculature allowed to occur. Pulmonary artery pressure monitoring is essential.

Pulmonary artery pressure monitoring in persistent fetal circulation (PFC).

The use of the Swan-Ganz catheter to monitor pulmonary artery pressure in adults with cardiopulmonary failure has become commonplace. Our meager experience was with four neonates diagnosed as having persistent fetal circulation monitored by the use of this PA catheter. Tolazoline was infused directly into the pulmonary circulation via the catheter. Pulmonary artery pressure was temporarily reduced by tolazoline administration, with a marked increase in PaO2. More experience is required to define the role of the Swan-Ganz catheter in neonatal physiologic monitoring.

Development of auditory function in newborn infants revealed by auditory brainstem potentials.

Auditory brainstem potentials were recorded from scalp electrodes in 42 infants ranging in gestational age from 25 to 44 weeks. The latencies of the various potential components decreased with maturation. Wave V, evoked by 65-dB sensation level clicks, changed in latency from 9.9 msec at 26 weeks of gestation of 6.9 msec at 40 weeks of gestation. Central conduction times in the auditory pathway also decreased with maturation from 7.2 msec at 26 weeks to 5.2 msec at 40 weeks. The effects of brainstem and cochlear disorders on auditory brainstem potentials were noted in several abnormal infants. The application of all of these techniques could permit an objective definition of both normal and abnormal sensory processes in newborn infants.

Priapism in preterm infant.

This report of transient priapism in a preterm newborn with respiratory distress syndrome discusses clinical course, therapy, possible etiologic factors, and previously reported cases in newborns. Possible causes include use of arterial catheter, red cell transfusion, hemodynamic changes from a patent ductus arteriosus, and hypoxia.