Minerva pediatrica
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Therapeutic hypothermia (whole body or selective head cooling) is becoming standard of care for brain injury in infants with perinatal hypoxic ischemic encephalopathy (HIE). Brain cooling reduces the rate of apoptosis and early necrosis, reduces cerebral metabolic rate and the release of nitric oxide and free radicals. Animal models of perinatal brain injury show histological and functional improvement due to of early hypothermia. ⋯ Recent meta-analyses and systematic reviews in human neonates show reduction in mortality and long-term neurodevelopmental disability at 12-24 months of age, with more favourable effects in the less severe forms of HIE. The authors describe their experience in 53 term newborns with moderate-severe HIE treated with whole body cooling between 2001 and 2009, and studied with magnetic resonance imaging (MRI) and general movements (GMs) assessment. The creation of a network connecting the Neonatal Intensive Care Unit with the level I-II hospitals of the reference area, as part of regional network, is of paramount importance to enroll potential candidates and to start therapeutic hypothermia within optimal time window.
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Endotracheal intubation is frequently performed in neonatal intensive care. This procedure is extremely distressing and painful, and it has the potential for causing laryngospasm, hemodynamic changes, a rise in intracranial pressure and a risk of hemorrhage and airway injury. These adverse changes can be attenuated by using premedication with analgesic, sedative and muscle-relaxant drugs. ⋯ In Italy, a recent survey (in press) showed that the majority of NICU (Neonatal Intensive Care Units) use the sa me association of drugs for analgesia and sedation before tracheal intubation, but "not always" in more than half of these units. There is clearly a persistent concern about using such drugs in preterm and newborn infants, despite recent evidence showing that premedication for elective neonatal intubation is safer and more effective than when the infant is awake. Here we review the effects of using analgesic and sedative drugs on intubation conditions (good jaw relaxation, open and immobile vocal cord, suppression of pharyngeal and laryngeal reflex), on the time it takes to complete the procedure successfully, on pain control and the potentially adverse effects of using combinations of drugs for sedation.
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In the neonatal population, pleural effusion and particularly tension pneumothorax can be a deadly situation. Pneumothorax occurs more often in the neonatal period that any other time of life. Tension pneumothorax can result in very high pressures within the pleural space, collapsing the lung on the involved side and resulting in immediate hypoxia, hypercapnia and subsequent circulatory collapse. ⋯ If a tension pneumothorax is suspected, emergency needle decompression in the second intercostal space in the midclavicular line is required. In this article, we describe the management of tube thoracostomy using trocar tubes or pigtail catheters. Besides, we pay attention to the use of pain control for neonates undergoing painful procedures such as chest tube insertion.
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Mortality in pediatric cardiovascular failure is markedly improved with the advent of neonatal and pediatric intensive care and with the implementation of treatment guidelines. In 2002 the American College of Critical Care Medicine Clinical Practice Parameters for Hemodynamic Support of Pediatric and Neonatal Shock reported mortality rates of 0%-5% in previously healthy and 10% in chronically ill children with septic shock associated with implementation of "best clinical practices". Early recognition of shock is the key to successful resuscitation in critically ill children. ⋯ Isotonic fluids form the cornerstone of treatment and the amount required for resuscitation is based on etiologies and therapeutic response. After resuscitation has been initiated, targeted history and clinical evaluation must be performed to ascertain the cause of shock and management of co-morbidities should be implemented simultaneously. While the management of shock can be protocol based, the treatment needs to be individualized depending on the suspected etiology and therapeutic response particularly for children who suffer from congenital heart disease.