Effect of decreasing target oxygen saturation on retinopathy of prematurity.

INTRODUCTION: The authors of previous studies suggest that the oxygenation status of premature infants contributes to the development of retinopathy of prematurity (ROP). In this study we compared the incidence and severity of ROP before and after institution of a new neonatal intensive care unit oxygen protocol. METHODS: A retrospective chart review was performed of all eligible inborn patients screened for ROP during the 2 years immediately before (Group 1) to and the 2 years after (Group 2) the initiation of a new oxygen protocol. In the new protocol, target oxygen saturation was adjusted from 90%-99% to 85%-93%. Treatment criteria adhered to Early Treatment for Retinopathy of Prematurity guidelines for the study's duration. RESULTS: There were 387 infants in Group 1 and 386 infants in Group 2 (descriptive statistics adjusted for correlation due to multiple births). Mean birth weights (BWs) and gestational ages were 1,194 g and 29.2 weeks (ranges, 525-2,085 g; 23 2/7-39 6/7 weeks) for Group 1 and 1,139 g and 28.9 weeks (ranges, 520-2,500 g; 22 6/7-35 3/7 weeks) for Group 2 (p = 0.02/0.10). ROP developed in 32.7% of infants in Group 1 and 27.8% in Group 2 (p = 0.17). The incidence of ROP requiring treatment was 19.9% in Group 1 and 20.5% in Group 2 (p = 0.91). Subanalysis of infants with BW ≤ 1,000g (Group 1, n = 119; Group 2, n = 141) revealed ROP incidence of 75.1% versus 57.1%, respectively (p < 0.01); treatable disease occurred in 37.5% and 21.9% of affected infants (p = 0.19). CONCLUSIONS: Lowering target oxygen saturation for inborn premature infants was associated with decreased incidence of ROP only in infants with BW ≤ 1,000 g. Severity of disease, including need for treatment, was similar in both groups.

Clinical considerations for the pharmacologic management of patent ductus arteriosus with cyclooxygenase inhibitors in premature infants.

When medical management is warranted for closure of a persistent patent ductus arteriosus (PDA) in premature infants, treatment with a cyclooxygenase (COX) inhibitor is indicated. Indomethacin, available since 1976, has been the conventional pharmacologic treatment for PDA, but its use is associated with vasoconstrictive effects that impair renal, mesenteric and cerebral blood flow. Intravenous (IV) ibuprofen lysine, approved in the United States in 2006, has less severe vasoconstrictive effects on these vital organs than IV indomethacin. Clinical trials have shown both of these COX inhibitors to be equally effective in closing the PDA in approximately 70%-80% of treated infants, with less vasoconstrictive and adverse renal effects occurring with IV ibuprofen lysine.1,2 Several clinical considerations are important in the process of medical decision-making when faced with the need for PDA treatment with one of these pharmacologic agents in the premature infant. This paper focuses on these clinical considerations, including cerebral, renal and mesenteric blood flow, renal function, pulmonary effects, protein-binding capacity as it relates to hyperbilirubinemia, and platelet aggregation. No differences in chronic lung disease, pulmonary hypertension, hyperbilirubinemia and coagulopathy were observed in clinical trials when comparing these 2 COX inhibitors; however, significant differences have been observed in arterial blood flow to the cerebral, renal and mesenteric organs, suggesting that IV ibuprofen lysine may be the more favorable agent.

Retinopathy of prematurity in infants with birth weight>or=1250 grams-incidence, severity, and screening guideline cost-analysis.

PURPOSE: To determine the incidence and severity of retinopathy of prematurity (ROP) in infants with birth weight (BW) 1250 to 1800 g, to examine the influence of systemic conditions on the development of ROP in this population, and to evaluate the cost-effectiveness of various screening guidelines. METHODS: We reviewed records from 259 consecutive infants with BW 1250 to 1800 g who were screened for ROP over a 3-year period. Extracted data included presence and severity of ROP, and the following potential risk factors (RF) for ROP development: sepsis, meningitis, necrotizing enterocolitis, intraventricular hemorrhage greater than stage I, pneumothorax, direct bilirubin>2 mg/dl, central line placement, antibiotic treatment>14 days, greater than seven red blood cell (RBC) transfusions, and mechanical ventilation>96 hours. RESULTS: The overall incidence of ROP in this population was 4.2%. Two infants had stage 3 ROP, one with plus disease. Infants with stage 3 ROP had significantly lower BW (1299 versus 1484 g, P=0.013) and gestational age (GA) (28 versus 31 weeks, P=0.002) than those with no ROP. No infant with BW>1500 g developed treatable ROP. Conditions that best predicted ROP development in the 1501 to 1800 g BW group were sepsis, ventilation >96 hours, antibiotic use >14 days, RBC transfusions greater than seven units, and central line placement (P=0.001, P=0.001, P=0.012, P=0.014 and P=0.035, respectively). All infants with BW>1500 g who developed ROP had greater than or equal to two of these RF. CONCLUSIONS: All cases of high-risk ROP would have been identified by current screening guidelines. Modified screening criteria of infants with (1) BW

Practical considerations in the selection and use of pulmonary surfactant therapy for neonatal respiratory distress syndrome in the intensive care setting.

Pulmonary surfactant is the treatment of choice for neonatal respiratory distress syndrome, as it significantly reduces infant morbidity and mortality. Extensive clinical trials compare the surfactant products and their optimal usage, but often the practical administration issues are less frequently discussed. Herein, a panel of respiratory therapists and neonatal nurse practitioners share their experience regarding surfactant usage. According to the panelists, the primary criteria for surfactant selection are the ability to rapidly decrease ventilatory requirements toward extubation, a low incidence of adverse effects, cost-effectiveness, and ease of use. In most cases, surfactant is most efficacious when given as early as possible where indicated. The surfactant products differ in their storage, handling, preparation, and administration traits, and this may affect rapid dosing of the surfactant during acute treatment. During and after administration, optimal response to therapy depends on efficient management of ventilator settings, which requires vigilant monitoring of the infant. Common adverse effects include endotracheal tube reflux, bradycardia, and desaturation. Using a surfactant which requires a small dosing volume may decrease the incidence of these adverse effects. An emerging trend in clinical practice is the quick extubation of the infant to nasal continuous positive airway pressure after surfactant administration. This practice can reduce the need for ventilation and reduce the risk of ventilator-related lung damage. Nebulization of surfactant may be a future avenue of delivery, but further research is required to determine its precise role. The practical considerations summarized in this discussion may be useful for other clinicians in their own practice.

Room air resuscitation versus oxygen resuscitation in the delivery room.

The use of 100% oxygen for delivery room resuscitation is currently the recommended standard of the American Academy of Pediatrics and the Neonatal Resuscitation Program. However, there is mounting evidence from animal and human studies suggesting that resuscitation with room air (RA, 21% oxygen), including positive pressure ventilation with bag and face mask, may be as effective as that with 100% oxygen, and that the use of 100% oxygen may pose a risk of adverse physiologic sequelae. Resuscitation with RA has been demonstrated to result in faster recovery and improved neonatal mortality in comparison to 100% oxygen resuscitation. In addition, studies of normal oxygen saturation immediately after birth suggest delivery room personnel may be rushing to high saturation unnecessarily. The question for perinatal medical and nursing personnel involved in newborn resuscitation in the delivery room is whether the use of RA reduces the possible adverse effects of 100% oxygen, including delay in short-term stabilization, death, neurological disability, and possible secondary oxygen free radical injury. A systematic synopsis of both animal studies and human studies involving the advantages, disadvantages, possible risks, and short- and long-term effects of these 2 methods of resuscitation is presented.