Decision-making for extremely preterm infants with severe hemorrhages on head ultrasound: Science, values, and communication skills.

Severe intracranial hemorrhages are not rare in extremely preterm infants. They occur early, generally when babies require life-sustaining interventions. This may lead to ethical discussions and decision-making about levels of care. Prognosis is variable and depends on the extent, location, and laterality of the lesions, and, importantly also on the subsequent occurrence of other clinical complications or progressive ventricular dilatation. Decision-making should depend on prognosis and parental values. This article will review prognosis and the uncertainty of outcomes for different lesions and provide an outline of ways to conduct an ethically appropriate discussion on the decision of whether to continue life sustaining therapy. It is possible to communicate in a compassionate and honest way with parents and engage in decision-making, focussing on personalized information and decisions, and on function, as opposed to diagnosis.

Continuing utilisation of specialised health services in extremely preterm infants.

OBJECTIVE: To compare healthcare use from neonatal discharge to 18 months corrected age (CA) of two groups of extremely preterm neonates (23-25 vs 26-28 weeks). DESIGN: Cohort study. PATIENTS: Infants born at < or =28 weeks and admitted in three hospital centres in Quebec, Canada (n=254). MAIN OUTCOME MEASURES: Neurodevelopmental outcomes and healthcare use from neonatal discharge to 18 months CA. RESULTS: Re-hospitalisation rates occurred in 57% of children born at 23-25 weeks and in 49% of those born at 26-28 weeks. In these two age groups, by 18 months, 61% vs 59% were followed in physical or occupational therapy, 29% vs 17% were enrolled in a long-term rehabilitation program, 38% vs 28% used prescribed medication, and 59% vs 33% required medical assistive devices, respectively. Risk of re-hospitalisation was related to bronchopulmonary dysplasia (BPD), severe brain injury, use of home oxygen or an apnoea monitor and older age at neonatal discharge. Multiple births, BPD, severe brain injury, older age at neonatal discharge and single parenthood were associated with risk of using out-patient health services above average (>2 services). CONCLUSION: Extremely preterm children are frequently re-hospitalised during infancy and use a substantial amount of healthcare resources. These results highlight the importance of resource allocation to preterm infants for medical and rehabilitation services after discharge from the neonatal intensive care unit.

Hemodynamic correlates of autonomic reflexes in patients with labile and fixed hypertension.

the autonomic sympathetic reflexes to sustained handgrip, upright tilt and the Valsalva maneuver, were tested in 26 patients with labile and 26 with fixed essential hypertension. Sustained handgrip increased systolic (SAP), diastolic (DAP) and mean arterial (MAP) pressure, heart rate (HR), cardiac index (CI), tension time index (TTI) (p less than .01), and had no effect on total peripheral resistance index (TPRI) and left ventricular ejection rate index (LVERI) in both groups of patients. However, the response to upright tilt and the Valsalva maneuver was different in the two groups. Upright tilt in labile hypertensives increased DAP, MAP, HR, and TPRI (p less than .001); decreased CI, stroke index (SI) and LVERI (p less than .01) and had no effect on SAP. In fixed hypertensives, it decreased SAP, MAP, CI, SI and LVERI (p less than .001); increased HR (p less than .01) and had no effect on DAP, and TPRI. The diastolic pressure overshoot of the Valsalva maneuver was attenuated in fixed hypertensives compared to labile (p less then .001). Additionally, when the percent changes from control in DAP, MAP, HR and TPRI to sustained handgrip and upright tilt between the two groups were compared, only differences to upright tilt between the two groups were observed. The results of this investigation suggest that upright tilt and the Valsalva maneuver might serve as better predictors of autonomic reflexes in hypertensive patients than the grip test.

Effects of amiloride on arterial pressure and renal function.

Amiloride was administered to 13 male patients with mild essential hypertension and normal renal function. It effectively reduced supine and standing arterial pressures. The antihypertensive response was associated with a significant decrease in renal inulin clearance and a rise in plasma creatinine concentration, although both values at the end of seven weeks of therapy remained within normal limits. Serum potassium concentrations rose but did not reach hyperkalemic levels. Amiloride did not increase blood levels of glucose, uric acid, lipids, calcium, or urea nitrogen. We conclude that amiloride is an effective antihypertensive and antikaliuretic agents for patients with mild hypertension and normal renal function.

Systemic and renal hemodynamic effects of trimazosin: a new vasodilator.

Trimazosin was administered for 2 days in doses-ranging from 50 to 200 mg to 16 patients with essential hypertension. The patients were randomized on the third day and received either the active drug in a single dose of 300 mg or a placebo. Systemic hemodynamic studies in both the supine and 50 degrees upright tilt position, including the Valsalva maneuver and a 1 min sustained handgrip test at 30% maximal voluntary contraction, were performed during control and 0, 1, 2, and 3 hr after drug administration. Renal function studies including plasma renin activity (PRA) were performed during control period and 3 hr after drug administration. Trimazosin reduced arterial pressure and peripheral vascular and renal vascular resistances, increased heart rate, cardiac output, and renal blood flow, and had no effect on glomerular filtration rate or PRA. Placebo had no effect on any of the above-mentioned parameters. The increase in renal blood flow was independent of cardiac output. We conclude that trimazosin lowers arterial pressure through a direct arteriolar dilation and reduction in peripheral vascular resistance. Its direct renal effects would make it a useful agent in the treatment of hypertension associated with renal function impairment.