Neonatology
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Higher patient-to-nurse ratios and nursing workload are associated with increased mortality in the adult intensive care unit (ICU). Most neonatal ICUs (NICUs) in the United Kingdom do not meet national staffing recommendations. The impact of staffing on outcomes in the NICU is unknown. ⋯ Nurse-to-patient ratios appear to affect outcomes of neonatal intensive care, but limitations of the existing literature prevent clear conclusions about optimal staffing strategies. Evidence-based standards for staffing could impact public policy and lead to improvements in patient safety and decreased rates of adverse outcomes. More research on this subject, including a standard and valid measure of nursing workload, is urgently needed.
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Review Comparative Study
Elective high-frequency oscillatory ventilation versus conventional ventilation for acute pulmonary dysfunction in preterm infants.
Respiratory failure due to lung immaturity is a major cause of mortality in preterm infants. Although the use of intermittent positive pressure ventilation in neonates with respiratory failure saves lives, its use is associated with lung injury and chronic lung disease (CLD). A newer form of ventilation called high-frequency oscillatory ventilation (HFOV) has been shown to result in less lung injury in experimental studies. ⋯ Seventeen eligible studies of 3,652 infants were included. Meta-analysis comparing HFOV with CV revealed no evidence of effect on mortality at 28-30 days of age or at approximately term equivalent age. These results were consistent across studies and in subgroup analyses. The effect of HFOV on CLD in survivors at term equivalent gestational age was inconsistent across studies and the reduction was of borderline significance overall. The effect was similar in trials with a high lung volume strategy for HFOV targeting at very low FiO(2) and trials with a high lung volume strategy with somewhat higher or unspecified target FiO(2). Subgroups of trials showed a significant reduction in CLD with HFOV when no surfactant was used, when piston oscillators were used for HFOV, when lung protective strategies for CV were not used, when randomization occurred at two to six hours of age, and when inspiratory:expiratory ratio of 1:2 was used for HFOV. In the meta-analysis of all trials, pulmonary air leaks occurred more frequently in the HFOV group. In some studies, short-term neurological morbidity with HFOV was found, but this effect was not statistically significant overall. The subgroup of two trials not using a high-volume strategy with HFOV found increased rates of grade 3 or 4 intraventricular hemorrhage and of periventricular leukomalacia. An adverse effect of HFOV on long-term neurodevelopment was found in one large trial but not in the five other trials that reported this outcome. The rate of retinopathy of prematurity is reduced overall in the HFOV group.
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Retinopathy of prematurity (ROP) was first observed soon after the widespread introduction of oxygen therapy into neonatal care. Early trials suggested that restricting oxygen supplementation could reduce ROP without other consequences, but when oxygen restriction became widespread, increased mortality was observed. ⋯ These results illustrate the importance of randomized trials because, prior to these recent studies, trends in practice based on observational data were favouring lower SpO2. Follow-up data may yet further inform clinical practice.
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Review Historical Article
The journey towards lung protective respiratory support in preterm neonates.
The aim of this conceptual review is to provide the reader with a broad perspective on progress made in respiratory support of preterm infants over the past five decades. Landmark discoveries are described in their historical context and underlying theories of lung protection are discussed. The review finishes by integrating different approaches and perspectives into a state-of-the-art concept for lung-protective ventilation in this fragile patient population. ⋯ Given the fact that progress made in the last decade has only resulted in minor improvements in mortality and morbidity rates of neonates with respiratory failure, it seems unlikely that further refinements of current technologies will produce giant leaps forward in high-resource countries. It appears that entirely new approaches would be required. In contrast, knowledge and technology transfer of basic respiratory support strategies (e.g. use of oxygen, simple systems to provide continuous positive airway pressure), could have an enormous impact on the prognosis of neonates with respiratory failure in low-resource countries.
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Hemodynamic problems are common in neonatal intensive care. They occur in the context of incomplete myocardial and vascular development and in cardiovascular responses to interventions which are, as a result, limited and often uncertain and unpredictable. In this review, I outline the hemodynamic features of 4 neonatal conditions which often require intervention: (1) persistent pulmonary hypertension of the newborn, (2) cardiogenic shock (most commonly in the context of hypoxic ischemic injury), (3) sepsis and (4) low blood pressure in the transitional period of the extremely preterm infant. I also look at the evidence which exists for effective interventions and the most important research questions for the future.