Do Not Resuscitate orders and ethical decisions in a neonatal intensive care unit in a Muslim community.

AIMS: To evaluate the need for Do Not Resuscitate (DNR) orders in a tertiary referral centre for neonatal intensive care, the criteria used in making these decisions, and the applicability of the Muslim ethical stance among parents in an Islamic community. METHODS: A prospective evaluation of all DNR decisions in the neonatal intensive care unit at the Royal Hospital in Oman, over a one year period between November 1999 and October 2000. This included decision criteria, and parental responses and expectations. RESULTS: Of 659 admissions to the neonatal intensive care unit during this period, DNR orders were written in 39 (6%) instances. Most related to congenital malformations (24/39, 62%). In those in whom ventilation was commenced (19/39, 49%) withdrawal was not culturally acceptable and expressly permitted in only 11%. For those in whom ventilation was not commenced (20/39, 51%), 70% agreed not to put their child on the ventilator if they did require it. Presence of extended family support (grandparents) and clergy was extremely useful. CONCLUSIONS: Asking parents alone to be explicitly involved or take full responsibility for decisions involving life and death is not culturally or socially acceptable in this community. Presence of extended family, and indirectly sounding out and taking into account their wishes, is more appropriate after assessing the resources and support services available.

Steroids in full term infants with respiratory failure and pulmonary hypertension due to meconium aspiration syndrome.

Persistent pulmonary hypertension of the newborn (PPHN) due to meconium aspiration syndrome (MAS), has a high morbidity and mortality especially in centres with limited access to extra-corporeal membrane oxygenation or nitric oxide therapy. In such a setting, we conducted a pilot study to evaluate the effect of dexamethasone on severe respiratory failure with PPHN due to MAS with a view to exploring possible justification for randomised controlled trials in similar patients. We prospectively managed a consecutive case series of 14 infants over a 3-year period with the above mentioned diagnosis, who were ventilated and with an oxygenation index >25. Dexamethasone was commenced in a dose of 0.5 mg/kg per day and given for up to a maximum of 9 days in a reducing schedule. Differences between time points were analysed using analysis of variance for repeated measures. The mean age of commencing dexamethasone was 79.9 h. There was a rapid, significant improvement (P < 0.05) in the respiratory status in 13 of these infants after commencing dexamethasone, allowing weaning from the ventilator and eventual extubation at a mean age of 8.7 days. One infant died. Two infants had infective episodes. Conclusion. Dexamethasone, if started early in infants with respiratory failure and persistent pulmonary hypertension of the newborn due to meconium aspiration syndrome may be effective in improving gas exchange, and possibly avoiding extra-corporeal membrane oxygenation. A randomised controlled trial of using dexamethasone early in similar patients and setting is warranted.

Effects of antenatal steroids on the complications of prematurity in an era of surfactant replacement therapy in Oman.

The aim of this study was to assess the effects of a complete course of antenatal steroids (dexamethasone 12 mg every 12 h x 2) on the complications of prematurity, in an era of surfactant replacement therapy in an Asian population. Between January 1995 and December 1998 we analysed all preterm births (-32 weeks) from women who had received antenatal care and delivered at our institution. Group A comprised those who did not receive, or received only an incomplete course of antenatal dexamethasone. Group B were those who received a complete course, i.e. delivered at least 24 h after commencing dexamethasone. There were 256 infants in Group A, and 168 in Group B. Mortality was significantly reduced (21.8 per cent in Group A vs. 10.7 per cent in Group B; p = 0.003), and the incidence of necrotising enterocolitis (NEC) was increased (2.7 per cent in Group A vs. 10.1 per cent in Group B;p = 0.001) in those whose mothers received dexamethasone. There was no difference in the incidence of respiratory distress syndrome (RDS), patent ductus arteriosus (PDA), chronic lung disease, major intraventricular hemorrhage (IVH) or PVL. There was, however, a trend towards an increased number of septic episodes in infants of Group B. It was concluded that antenatal steroids reduced mortality, but had no effect on the incidence of RDS, PDA, CLD, major IVH or PVL in an Asian population who were given surfactant for respiratory distress syndrome. There was a trend towards greater neonatal infections. These results need to be confirmed in similar population groups.

Comparative trial of artificial and natural surfactants in the treatment of respiratory distress syndrome of prematurity: experiences in a developing country.

We conducted a randomized clinical trial to compare the effects of a synthetic (Exosurf) and natural (Survanta) surfactant in infants with neonatal respiratory distress syndrome. Eighty-nine patients were randomly allocated to receive one of the two surfactants. Primary outcome variables were the acute and long-term effects of the surfactant preparations, i.e., ventilatory requirements at 24 h of age as judged by the oxygenation index (OI), and the combined incidence of chronic lung disease or death at 28 days. The OIs in the Exosurf and Survanta groups at 24 h were the same (10.1 and 7, respectively; P > 0.05). The magnitude and rapidity of response, however, were greater for Survanta than for Exosurf. When arterial/alveolar oxygen tension ratios (a/A) were compared, the Exosurf group had a significantly worse a/A ratio at 24 h than the Survanta group (0.21 Exosurf vs. 0.37 Survanta; P < 0.05). The long-term outcome as judged by the combined incidence of death or chronic lung disease was not different in the two groups (18.6% Exosurf vs. 15.2% Survanta; P > 0.05). When the complications of prematurity were compared, there were no statistically significant differences between the two groups. We conclude that both preparations are reasonable choices for the treatment of respiratory distress syndrome of prematurity.

PIP: This study compares the effects of synthetic (Exosurf) and natural (Survanta) surfactants on infants with neonatal respiratory distress syndrome in Oman. Subjects included 89 patients, randomly allocated to receive one of the two surfactants. Results suggest that 43 and 46 of the total infants enrolled in the study were randomized to the Exosurf and Survanta groups, respectively. The oxygenation index in the Exosurf and Survanta groups at 24 hours were the same (10.1 and 7, respectively; P 0.05). The magnitude and rapidity of response, however, were greater for Survanta than for Exosurf. Moreover, when arterial/alveolar oxygen tension ratios (a/A) were compared, the Exosurf group had a significantly worse a/A ratio at 24 hours than the Survanta group. There were no statistically significant differences between the two groups when the complications of prematurity were compared. In conclusion, both preparations offer reasonable choices in the treatment of the respiratory distress syndrome. However, this should be weighed against the minor theoretical risks of transmission of infectious agents in a natural preparation, and the easier storage and transport of the synthetic surfactant.