CPAP Scholars

[cpapscholars]

Uses & Misuses of Albumin in the NICU

PubMed ID: 28739260

Year: 2017

Journal: Seminars in Fetal & Neonatal Medicine

-Reviews the use of albumin in the NICU and when we should/shouldn't use it - most often we shouldn’t 

-Pathophysiology review:

Albumin is the most abundant protein in plasma

Made in the liver as pre-proalbumin, once synthesized it is rapidly transferred to the plasma where it will cross the capillary wall to the ECS and be re-ciruclated intravascularly by the lymphatic system

Normal concentrations depend on GA - lots of variety. At birth it can range from 2-3 at term and increases by 15% in the first 3 weeks of life regardless of GA

Full term infants turn it over in 2-3 weeks, preterm infants in 5-7 days

-Current uses:

Hypotension - poor evidence for its use, probably because usually the neonatal hypotension is not due to hypovolemia. There were also no differences in long term outcomes looking at LOS, days on MV, PDA, or IVH

Delivery Room Resuscitation - not recommended 

Metabolic acidosis - not recommended

Pro-inflammatory states (AKA sepsis) - All the data is extrapolated from adult data - no use for albumin in neonates for sepsis or post-operative states

Hypoalbuminemia replacement - Low albumin might be physiological not pathological. Neonates may tolerate the lower levels as being normal - NOT recommended

Malnutrition - nope.

Hyperbilirubinemia - it might make exchange transfusions work better, but not routinely recommended

Chylothorax - the ONLY indication that you might get away with using albumin but more recent reviews have shown that it is more important to ensure adequate nutrition and hydration

-Bottom line: there is no place (maybe one indication...) for the use of albumin of any kind in the NICU

[cpapscholars]

The Use of NSAIDS for PDAs

PubMed ID: 28724506 Year: 2017 Journal: Seminars in Fetal & Neonatal Medicine

-Very well written, brief and concise article regarding the use of NSAIDs to close PDAs in preterm infants, specifically looking at long term outcomes 

-Between 1980 and 2016, 51 RCTs have looked at this question - enrolling 4937 infants - none of which show support in using NSAIDs to close ducts to improve long term outcomes, summarized below:

Most of these trials used indomethacin (41), 9 used ibuprofen and 1 used acetaminophen 

Treatment was prophylaxis in 29 studies, for asymptomatic infants in 6 and symptomatic in 16

All showed consistency with closing the duct, also showed a significant decreased rate of Gr2 or higher IVH, and an increased rate of ROP grade 3 and higher

These studies used three different drugs by different routes for at least 3 different indications - casts doubt on external validity of results

-Authors concluded that early routine NSAID use should NOT be done

-We don’t know what criteria should exist for using NSAIDs past 1-2 weeks of life postnatally

-Use your clinical judgement when making the decision to treat or not

[cpapscholars]

Assessing the potential impact of extending antenatal steroids to the late preterm period.

PubMed ID: 28455087 Year: 2017 Journal: American Journal of Obstetrics and Gynecology

-retrospective multi-center review, looking at late preterms (34+0 to 36+6) who were eligible for ANCS -36 weekers: no difference in respiratory outcomes -34-35 weekers accounted for the majority of babies who had resp symptoms, but this is 171 babies out of 2942 late preterms. -mothers ineligible for steroids (pre-pregnancy DM, chorio) —> babies even more likely to have resp issues -in conclusion: the babies that need it the most have moms who are probably ineligible, however, 34-35 weekers may still benefit. 36 weekers unlikely to benefit.

[cpapscholars]

Norepinephrine to Improve Hemodynamics During Neonatal Septic Shock

Pubmed ID: 28992392 Year: 2017 Journal: Acta Paediatrica

-Retrospective review of infants receiving NE infusions for septic shock between 2009-2011

-Data collected included: HR, BP, UoP every 15 minutes 8 hours before NE infusion, 8 hours after the start of infusion and 8 hours after the end of the infusion

-Primary outcomes were not well defined but assumed to be mean blood pressure, heart rate, FiO2 requirement, and urine output.

-Secondary outcomes include IVH, mortality, and long term follow up findings

-30 infants looked at, mean GA of 26.5 weeks - all of whom had significant increases in their MBP, UoP and decreased FiO2. They also found a significant decrease in other inotrope usage after discontinuing the NE.

-Authors feel that NE may improve systemic perfusion despite its increased SVR effects as seen by evidence of better UoP and improved pH

-NE carries a risk of PPHN - not seen in this population (lower FiO2)

-Weaknesses included only 18% of patients having confirmed sepsis by BCx, many babies received hydrocortisone if volume/inotropes didn't work

[cpapscholars]

The Impact of Routine Evaluation of Gastric Residual Volumes on the Time to Achieve Full Enteral Feeding in Preterm Infants.

PubMed ID:  28625498 Year: 2017 Journal: The Journal of Pediatrics

-retrospective study to eval new standard of care of not checking residuals unless symptoms arose, compared to 2011 when it was typical to check all babies -primary outcome: time to full enteral feeds -secondary outcomes: incidence of NEC, # of NPO and PN days, age at full PO, LOS, weight at discharge - “Selective Gastric Residual Evaluation Group” (aka only checking if there were other concerning symptoms) started feeds sooner, reached full OG feeds sooner, but no difference in time to full PO or LOS. No difference in NEC rates.  -Linear regression showed: GA most significant predictor of when full feeds would be achieved, but, routine gastric residual evals did delay them too 

[cpapscholars]

Starting enteral nutrition with preterm single donor milk instead of formula affects time to full enteral feeding in very low birthweight infants.

PubMed ID:  28498519 Year: 2017 Journal: Acta Paediatrica

-observational, prospective study -studying time to enteral feeds in preterm donor milk vs preterm formula -babies 1500g, 32 weeks -preterm formula group was retrospective, preterm donor group was prospective. both groups adv 20ml/kg/day, unless feeding intolerance -donor milk group achieved full feeds 4 days earlier than formula group -donor milk group had lower incidence of ROP, sepsis, and had lower length of stay. Formula group had faster passage of last meconium. -formula patients weighed more at discharge -my opinion: they define feeding intolerance in the methods, but no comment on it in the results to help explain why formula fed babies took longer to get to full feeds.

[cpapscholars]

Exposure to acetaminophen and all its metabolites upon 10, 15, and 20 mg/kg intravenous acetaminophen in very-preterm infants.

PubMed ID: 28553988  Year: 2017 Journal: Pediatric Research -randomized trial, investigators blinded -acetaminophen metabolism: 55% glucuronidation, 30% sulfation, 5-10% CYP2E1, 2-5% excreted unchanged.  -APAP via CYP2E1 --> NAPQI, which needs to be inactivated by glutathione, otherwise can lead to mitochondrial dysfunction -Babies randomly allocated to 10mg/kg, 15mg/kg, or 20mg/kg IV APAP. Groups stratified by GA (24-28wk or 28-32wk) -APAP levels and metabolites significantly higher in babies who got higher doses -gestational age affected type of metabolism, thought to be due to maturation of liver metabolic pathways (especially glucuronidation) -this article does not offer info on NAPQI accumulation 

[cpapscholars]

Residual brain injury after early discontinuation of cooling therapy in mild neonatal encephalopathy.

PubMed ID:  28935718 Year: 2017 Journal: Arch Dis Child Fetal Neonatal Ed

-prospective cohort of 10 babies who had cooling stopped early (median 9 hours) due to rapid clinical recovery -chosen babies were all resuscitated with at least PPV, all initially met criteria for aEEG. All had normal aEEG at start of cooling and throughout, as well as normal neuro exam at time of rewarming -MRI (median age of imaging 6 days) results: 5/10 babies had normal MRI, the other five babies had assorted abnormalities -Zero out of ten babies had cerebral palsy at age 2 -2 out of ten babies had some level of delay -my opinion: too small a cohort to make any changes in practice. 

[cpapscholars]

Maternal magnesium therapy, neonatal serum magnesium concentration and immediate neonatal outcomes

PubMed ID: 28981078 Journal: Journal of Perinatology Year: 2017

Summary: -retrospective review -compared neonates with mag levels of 2.5, 2.5-4.5, and >4.5 -babies with mag >4.5 more likely to have apgar 5, need resusc, have IVH and PVL, longer stays in NICU, longer time to full feeds -IVH independently assoc with highest and lowest Mag groups, even after adjusting for birthweight; suggests mid-range therapeutic window -cumulative dose given to mom correlated with Mag levels in babies -Lower BW assoc with higher Mag, but GA had no effect.

[cpapscholars]

Urinary NT-proBNP levels and echocardiographic parameters for patent ductus arteriosus.

PubMed ID: 28906496 Journal: Journal of Perinatology Year: 2017

-prospective study -babies divided into 3 groups: med/large PDA, small PDA, no PDA -urine collected daily in first 7 days and on f/u echo days. cardiologist reading echo was masked to urinary pro-BNP levels -med/large PDA babies had significantly higher urinary pro-BNP than small PDA babies, who had significantly higher values than no PDA babies -treated PDA babies had decreases in urinary pro-BNP if their duct got smaller or closed. if no change in duct size, no change in pro-BNP.