Care practices and outcomes of extremely preterm neonates born at 22–24 weeks –A single centre experience

BACKGROUND: Wide variation in the care practices and survival rates of neonates born at peri-viable gestational ages of 22 +0 –24 +6 weeks exists. This study elucidates the postnatal risk factors for morbidity/mortality, contrasts the care practices and short-term outcomes of this vulnerable group of preterm neonates from a single center with others. METHODS: Retrospective study of neonates born at 22 +0 –24 +6 weeks in a level 3 neonatal intensive care unit in UK, over a period of 4 years (2016–2019). RESULTS: 94 neonates given active care studied. Survival until discharge was 51.1%(22–23 wks –44%, 24 wks –59.1%) and survival with no major brain injury (MBI) [grade III/IV IVH, cystic periventricular leukomalacia] was 38.3%(22–23 wks –32%, 24 wks –45.4%). Of those who survived until discharge, 75%had no MBI (22–23 wks –72.7%, 24 wks –76.9%). Neonates requiring significant respiratory support within first 72 hours as well as needing rescue high frequency ventilation had significantly high risk of mortality or MBI [aOR –7.17 (2.24–25.79), p = 0.00; 4.76 (1.43–20.00), p = 0.01]. CONCLUSIONS: Survival rate differed from other centres. MBI was low amongst survivors. Severe respiratory disease in the initial days was associated with a higher risk of death or MBI.

Safety application of muscle relaxants and the traditional low-frequency ventilation during the flexible or rigid bronchoscopy in patients with central airway obstruction: a retrospective observational study

Background Bronchoscopy treatments of central airway obstruction (CAO) under general anesthesia are high-risky procedures, and posing a giant challenge to the anesthesiologists. We summarized and analyzed our clinical experience in patients with CAO undergoing flexible or rigid bronchoscopy, to estimate the safety of skeletal muscle relaxants application and the traditional Low-frequency ventilation. Methods Clinical data of 375 patients with CAO who underwent urgent endoscopic treatments in general anesthesia from January 2016 to October 2019 were retrospectively reviewed. The use ratio of skeletal muscle relaxants, dose of skeletal muscle relaxants used, the incidence of perioperative adverse events, adequacy of ventilation and gas exchange, post-operative recovery between rigid bronchoscopy and flexible bronchoscopy therapy, and risk factors for postoperative ICU admission were evaluated. Results Of the 375 patients with CAO, 204 patients were treated with flexible bronchoscopy and 171 patients were treated with rigid bronchoscopy. Muscle relaxants were used in 362 of 375 patients (including 313 cisatracurium, 45 rocuronium, 4 atracurium, and 13 unrecorded). The usage rate of muscle relaxants (96.5% in total) was very high in patients with CAO who underwent either flexible bronchoscopy (96.6%) or rigid bronchoscopy (96.5%) therapy. The dosage of skeletal muscle relaxants (Cisatracium) used was higher in rigid bronchoscopy compared with flexible bronchoscopy therapy (10.8 ± 3.8 VS 11.6 ± 3.6 mg, respectively, p < 0.05). No patient suffered the failure of ventilation, bronchospasm and intraoperative cough either in flexible or rigid bronchoscopy therapy. Hypoxemia was occurred in 13 patients (8 in flexible, 5 in rigid bronchoscopy) during the procedure, and reintubation after extubation happened in 2 patients with flexible bronchoscopy. Sufficient ventilation was successfully established using the traditional Low-frequency ventilation with no significant carbon dioxide accumulation and hypoxemia occurred both in flexible and rigid bronchoscopy group (p > 0.05). Three patients (1 in flexible and 2 in rigid) died, during the post-operative recovery, and the higher grade of American Society of Anesthesiologists (ASA) and obvious dyspnea or orthopnea were the independent risk factors for postoperative ICU admission. Conclusion The muscle relaxants and low-frequency traditional ventilation can be safely used both in flexible and rigid bronchoscopy treatments in patients with CAO. These results may provide strong clinical evidence for optimizing the anesthesia management of bronchoscopy for these patients.

Management of Pulmonary Hypertension in Term Infants—A Review

Pulmonary hypertension (PH) in the term newborn is associated with roughly one-fifth higher mortality and morbidity. The diagnosis of PH is confirmed by echocardiogram based on established criteria, including assessment of cardiac function, size of the shunts, and presence of hypovolemia. The elementary steps in the management of PH are supportive measures followed by oxygenation, ventilation including possibly high frequency ventilation; lung recruitment and surfactant therapy. Ventilation strategies are based on the etiology of persistent pulmonary hypertension of the newborn (PPHN)-like lung parenchymal disease, or hypoplasia. Oxygenation index (OI) or oxygen saturation index (OSI) are the parameters used for monitoring the disease progression and treatment. Surfactant is given if OI >5 in PPHN due to underlying lung disease, and pulmonary vasodilators such as sildenafil are contemplated if OI <15 and inhaled nitric oxide (iNO) if OI >15. If iNO and sildenafil fail, the options available are milrinone, bosentan, adenosine, and prostaglandins. Extra corporeal membrane oxygenation is the final option available with OI >40. A structured algorithmic approach for the management of PH in term infants is discussed in this review. Novel therapies targeting specific pathways in the pulmonary vasculature are under investigation.

Lessons from a suicide attempt by intra-abdominal ricin injection

A 19-year-old woman was admitted to the emergency department 7 hours after a suicide attempt with an intra-abdominal injection of self-prepared ricin solution. In the following 6 days, she has developed multiorgan-failure, and despite all intensive care interventions—including plasma exchange, high-frequency ventilation, and continuous renal replacement therapy—she passed away. We describe in detail the chain of events and discuss shortly the known literature about this rare poisoning.

A retrospective observational study of anesthesia management during the flexible or rigid bronchoscopy in patients with central airway obstruction: Safety application of muscle relaxants and the traditional Low-frequency ventilation

Background: Bronchoscopy treatments of central airway obstruction (CAO) under general anesthesia are high-risky procedures, and posing a giant challenge to the anesthesiologists. We summarized and analyzed our clinical experience in anesthesia management in patients with CAO undergoing flexible or rigid bronchoscopy, including the use of muscle relaxants , the traditional Low-frequency ventilation.Methods: Clinical data of 375 patients with CAO who underwent urgent endoscopic treatments in general anesthesia from January 2016 to October 2019 were retrospectively reviewed. The use ratio of skeletal muscle relaxants, dose of skeletal muscle relaxants used, the incidence of perioperative adverse events, adequacy of ventilation and gas exchange, post-operative recovery between rigid bronchoscopy and flexible bronchoscopy therapy, and risk factors for postoperative ICU admission were evaluated.Results: There was a high usage rate (96.5%) of skeletal muscle relaxants in patients with CAO who underwent either flexible bronchoscopy or rigid bronchoscopy therapy and a higher dosage of skeletal muscle relaxants used in rigid bronchoscopy compared with flexible bronchoscopy therapy. This procedure had a low incidence of perioperative adverse events, with no significant difference between flexible and rigid bronchoscopy therapy. Sufficient ventilation was successfully established using the traditional Low-frequency ventilation both in flexible and rigid bronchoscopy group. There was a low mortality (0.8%) during the post-operative recovery, and the higher grade of American Society of Anesthesiologists (ASA) and obvious dyspnea or orthopnea were the independent risk factors for postoperative ICU admission.Conclusion: The muscle relaxants and low-frequency traditional ventilation can be safely used both in flexible and rigid bronchoscopy treatments in patients with CAO These results may provide strong clinical evidence for optimizing the anesthesia management of bronchoscopy for such patients.