Newborns should be receiving premedication before elective intubation.

BACKGROUND: Intubation is a common neonatal procedure. Premedication is accepted as a standard of care, but its use is not universal and wide variations exist in practice. OBJECTIVE: To evaluate current practices for premedication use prior to elective neonatal intubation in South Africa (SA). METHOD: We invited 481 clinicians to participate in a cross-sectional web-based survey. RESULTS: We received responses from 28.3% of the clinicians surveyed; 54.1% were from the private sector and 45.9% from the state sector. Most respondents worked in medium-sized neonatal units with six to ten beds. Most paediatricians (76.0%) worked in the private sector, and 78.6% of neonatologists in the state sector. Premedication was practised by 71.9% of the respondents, but only 38.5% of neonatal units had a written policy. Sedatives were used for premedication by 63.2% of the respondents. Midazolam (41.5%), morphine (34.0%) and ketamine (20.8%) were most commonly used. Muscle relaxants and atropine were not routinely administered. Suxamethonium was the muscle relaxant of choice. Varied combinations of agents or single agents were used. Midazolam used alone was the preferred option. CONCLUSION: This first survey of premedication for neonatal intubation in SA revealed variations in practice, with a minority of clinicians following a written policy. The findings can be used to benchmark practice and inform the design of local collaborative trials aimed at determining optimal premedication prior to neonatal intubation. The survey demonstrates clinicians' reluctance to participate in surveys, suggesting a need for a national collaborative network to obtain representative data.

Resource implications of adopting a restrictive neonatal blood transfusion policy.

BACKGROUND: Blood transfusions (BTFs) are not without risk and pose a significant financial burden on resource-limited services. In line with current international evidence, the nursery at Groote Schuur Hospital (GSH), Cape Town, South Africa, introduced a restrictive BTF protocol to minimise transfusions and manage costs. OBJECTIVE: To determine whether adopting a restrictive BTF policy results in fewer transfusions. METHODS: Data were retrospectively collected on all infants who received BTFs in the GSH nursery over a 6-month period following adoption of a restrictive BTF policy in 2010. BTF figures for a similar time period before the restrictive policy, during 2008, were obtained for comparison. RESULTS: After introduction of the restrictive BTF policy, 42 of 1 097 infants admitted (3.8%) received a total of 64 BTFs. In comparison, 102 of a total of 940 infants (10.9%) admitted during a period of the same length before introduction of the restrictive BTF policy received a total of 121 transfusions. Comparison between the number of BTFs administered before and after the restrictive policy showed a highly statistically significant difference (p<0.001). The total cost of the blood products used in the two 6-month periods was R91 870 v. R48 640, based on current prices. CONCLUSIONS: By adopting a restrictive policy, we were able to halve the number of BTFs, reduce risks associated with transfusions, and achieve significant cost benefits. Following evidence-based guidelines results in high standards of care, while also making the most effective use of resources.

Enteral Feeding Practices in Preterm Infants in South Africa

Background. Optimal feeding regimens in babies weighing 1 000 g have not been established; and wide variations occur. In South Africa (SA) this situation is complicated by varied resource constraints.Objective. To determine the preterm enteral feeding practices of paediatricians in SA.Methods. We invited 288 paediatricians to participate in a cross-sectional web-based survey. Results. We received responses from 31.2 of the paediatricians; 43.6 were from the state sector and 56.4 from the private sector. Most participants worked in medium-sized neonatal units with 6 - 10 beds. The proportions commencing feeds within the first 24 hours were 24 in infants of 25 weeks' gestational age; 36 in infants 25 - 27 weeks; and 65 in infants 28 - 31 weeks. Feed volumes were routinely advanced daily in 47 of infants 25 weeks; 68 of infants 25 - 27 weeks; and 90 of infants 28 - 31 weeks. Forty-five per cent of infants 25 weeks received continuous intragastric feeds; while 50 of those in the 28 - 31 weeks group were on 3-hourly bolus feeds. The majority of the participants targeted full enteral feeds of 161 - 180 ml/kg/d; 66.7 had access to donor milk; and 77 used breastmilk fortifier.Conclusion. This is the first study to survey feeding practices in SA. The survey did not highlight differences in feeding practices among paediatricians. These data could be valuable in the design of local collaborative trials to determine optimal feeding strategies

A reduction of necrotising enterocolitis at Groote Schuur Hospital nursery.

Necrotising enterocolitis (NEC) is an gastro-intestinal emergency occurring almost solely in preterm, low birth weight infants. Mortality, morbidity and the complication rate are high. An increase in NEC at the Groote Schuur Hospital nursery in 2008 prompted a change of practice, resulting in a significant decrease in the condition.

Evaluating a simple method of neuroprotective hypothermia for newborn infants.

This study describes and evaluates a simple method of neuroprotective hypothermia for infants with hypoxic-ischaemic encephalopathy (HIE). Five term infants with HIE were cooled by applying soft, cold gel bags to the head. A radiant warmer, set to 34 degrees C, servo-controlled the temperature measured at a probe between the infant's back and the mattress. The infants' heads were shielded from the warmer. After 72 h, the infants were re-warmed by 0.2 degrees C per hour, by adjusting the radiant warmer. A rectal temperature of 34 degrees C was attained in a median time of 45 min. Mean rectal temperatures during cooling were 33.9 +/- 0.3 degrees C. There was good correlation between insulated back temperatures and deep rectal temperatures (r = 0.76). There were no major or irreversible adverse events during cooling. This method of cooling achieved rectal temperatures within the target range of 33-34 degrees C and re-warming was effective.

Selective cerebral hypothermia for post-hypoxic neuroprotection in neonates using a solid ice cap.

OBJECTIVE: The main objective of this study was to study the safety and efficacy of a simple, cost-effective method of selective head cooling with mild systemic hypothermia in newborn infants with hypoxic ischaemic encephalopathy. DESIGN: Ethical approval was obtained for a randomized controlled study in which 20 asphyxiated neonates with clinical signs of hypoxic ischaemic encephalopathy would be randomised into cooled and non-cooled groups. However, after cooling the first 4 babies, it was clear that repeated revisions to the cooling technique had to be made which was inappropriate in the context of a randomised controlled trial. The study was therefore stopped and the data for the 4 cooled infants are presented here in the form of a technical report. Hypothermia was achieved by applying an insulated ice cap to the heads of the infants and replacing it at 2-3-hourly intervals, aiming to achieve a target rectal temperature of 35-35.5 degrees C and a target scalp temperature of 10-28 degrees C. SETTING: This study was carried out between July 2000 and September 2001 in the neonatal units of Groote Schuur Hospital and Mowbray Maternity Hospital, Cape Town. SUBJECTS: Term infants with signs of encephalopathy were recruited within the first 8 hours of life if they had required resuscitation at birth and had significant acidosis within the first hour of life. RESULTS: Target rectal temperature was achieved in all infants, but large variations in incubator and scalp temperatures occurred in 3 of the 4 infants. Reducing the target core temperature in a stepwise manner did not prevent excessive temperature variation and resulted in a longer time to reach target temperature. There was least variation in scalp temperature when the ice pack was covered in two layers of mutton cloth before application, but the resulting scalp temperatures were above the target temperature. The maximum scalp temperature variation was reduced from 22 degrees C to 12 degrees C using this method. Nasopharyngeal temperatures varied excessively within less than a minute, suggesting that air cooling via mouth breathing was occurring. The surface site that correlated best with deep rectal temperature was the back, with the infant supine. During cooling, the respiratory rate and heart rate dropped while the mean arterial blood pressure was elevated. There were no irreversible adverse events due to cooling, but infants did become agitated and exhibited shivering which required sedation and analgesia. CONCLUSIONS: Nasopharyngeal temperature monitoring was not reliable as an acute clinical indicator of brain temperature in these spontaneously breathing infants, and the back temperature in supine infants correlated better with deep rectal temperature than did exposed skin temperature. This method of cooling achieved systemic cooling but there were large variations in regional temperatures in 3 of the 4 infants. The variations in temperature were probably due to the excessive cooling effect of the ice cap, coupled with the use of external heating to maintain systemic temperature at 35-35.5 degrees C. Variation in temperature was reduced when additional insulation was provided. However, the additional insulation resulted in the loss of the selective cerebral cooling effect. This cooling technique was therefore not an appropriate method of selective head cooling, but did successfully induce systemic hypothermia. This method of insulating an ice cap could therefore be used to induce whole-body cooling but the use of lower core temperatures of 33-34 degrees C is recommended as this will probably result in fewer regional temperature fluctuations. Ideally a more uniform method of cooling should be used.

Phototherapy and exchange transfusion for neonatal hyperbilirubinaemia: neonatal academic hospitals' consensus guidelines for South African hospitals and primary care facilities.

The purpose of this document is to address the current lack of consensus regarding the management of hyperbilirubinaemia in neonates in South Africa. If left untreated, severe neonatal hyperbilirubinaemia may cause kernicterus and ultimately death and the severity of neonatal jaundice is often underestimated clinically. However, if phototherapy is instituted timely and at the correct intensity an exchange transfusion can usually be avoided. The literature describing intervention thresholds for phototherapy and exchange transfusion in both term and preterm infants is therefore reviewed and specific intervention thresholds that can be used throughout South Africa are proposed and presented graphically. A simplified version for use in a primary care setting is also presented. All academic heads of neonatology departments throughout South Africa were consulted in the process of drawing up this document and consensus was achieved.

Synthesis and antiinflammatory and analgesic activity of 5-aroyl-1,2-dihydro-3H-pyrrolo[1,2-a]pyrrole-1-carboxylic acids. The 6-substituted compounds.

5-Aroyl-6-substituted-1,2-dihydro-3H-pyrrolo[1,2-a]pyrrole-1-carbo xylic acids were synthesized and assayed for analgesic and antiinflammatory activity. Several of these compounds, notably the 5-(4-fluoro- and 4-chlorobenzoyl)-6-methyl derivatives 25 and 26 and the 5-(4-methyl-, 4-fluoro-, 4-chloro-, and 4-methoxybenzoyl)-6-chloro congeners 31-34 were of equal or greater potency than indomethacin as antiinflammatory and analgesic agents both in acute and chronic animal models.

Synthesis and gastric antisecretory properties of allenic 16-phenoxy-omega-tetranor prostaglandin E analogs.

In order to improve the modest oral activity of PGE2 as an inhibitor of gastric acid secretion, analogs were prepared and tested orally in histamine-challenged rats. Insertion of a double bond at C-4, resulting in the 4,5-allene analog of PGE1, gave a small increase in activity. Introduction of the omega-tetranor-16-phenoxy lower sidechain, a modification known to enhance activity in the PGF series, gave an eight-fold increase in activity. The analog having both modifications (enprostil, 2) showed a six hundred-fold increase in oral antisecretory activity over PGE2, which may reflect a potentiation effect. Modification of enprostil at C-1 (various esters) and at C-11 (11-methyl, 11-deoxy) generally resulted in compounds of high activity while modifications at other sites generally resulted in significant reductions in activity.

Absolute configuration of (-)-5-benzoyl-1,2-dihydro-3H-pyrrolo[1,2-alpha]pyrrole-1-carboxylic acid, the active enantiomer of ketorolac.

The (-)-S isomer of 5-benzoyl-1,2-dihydro-3H-pyrrolo[1,2-alpha]pyrrole-1-carboxylic acid is about 60 times more potent than the (+)-R isomer in the carrageenan edema test and ca. 230 times more active than the (+)-R isomer in the mouse phenylquinone writhing assay.

A linked oscillator model of electrical activity of human small intestine.

The electrical slow-wave activity of the human small intestine has been simulated by a chain of 64 coupled electronic relaxation oscillators. The model simulates the frequency gradient of recorded patoentials in the human small intestine and when transected, behaves in a similar way to the transected canine small intestine. The model exhibits a spontaneous effect whereby several adjacent oscillators periodically are in the same state. This effect travels down the model in the time of 20-30 min.