Neonatal Updates #38

Simons SHP, van der Lee R, Reiss IKM, van Weissenbruch MM: Clinical evaluation of propofol as sedative for endotracheal intubation in neonates. Acta Paediatrica 2013, 102(11):e487-e492 Many readers will know that I was the author of the recent CPS position statement on premedication for endotracheal intubation in the newborn. We did not say much about propofol, because there was so little data. This publication doesn’t change that very much, it is a report of the use of propofol as routine sedation prior to intubation, showing that you need high doses, and then you get a lot of hypotension. The authors say that we should study this properly, I think these data suggest that we should not!

Morelli A, Ertmer C, Westphal M, et al.: Effect of heart rate control with esmolol on hemodynamic and clinical outcomes in patients with septic shock: A randomized clinical trial. JAMA 2013:-I would never even have thought of doing this. This is a trial in critically ill patients with septic shock, who often are tachycardic. I always just assumed that this was normal. In a very abnormal situation. That is, if you are in septic shock tachycardia is part of the physiologic adjustments, and you mess with those adjustments at your peril. Most of our efforts to improve outcomes in septic shock have been either unsuccessful or worse. This RCT included 154 critically ill adults who were on high dose norepinephrine to keep their mean blood pressure up, and gave the intervention group a continuous infusion of the short acting beta-1 blocker esmolol. The authors were able to reduce the heart rate, which was the primary outcome, and  they seemed to have less mortality (50% vs 80% at 28 days, 67% vs 90% died before going home, this is a bad disease). This may turn out to be a good thing to do.

Barrett JFR, Hannah ME, Hutton EK, Willan AR, Allen AC, Armson BA, et al. A Randomized Trial of Planned Cesarean or Vaginal Delivery for Twin Pregnancy. Prestigious New England Journal of Medicine. 2013;369(14):1295-305. This very large multicenter trial randomized 2800 women who were pregnant with twins at between 32 and 38 weeks gestation. The two groups were a plan for cesarean, or a plan for vaginal delivery, in both groups this was supposed to be between 37 weeks 5 days and 38 weeks 6 days, unless the mother went into preterm labour. The primary outcome was fetal or neonatal death or serious morbidity, which was expected in 4% of the vaginal delivery babies. There was no apparent difference in this outcome, which actually occurred in about 2% in each group. 40% of the vaginal delivery group actually had a cesarean, and about 5% had the first twin vaginally then had a cesarean for the second. There was also no real difference in maternal morbidities either. The babies and mothers were followed up to 28 days, and there is planned further follow up, including infants developmental testing. But for now it seems that planned vaginal delivery if the first twin is in cephalic presentation is just as safe as cesarean.

Rocha G, Flor-de-Lima F, Proenca E, Carvalho C, Quintas C, Martins T, et al. Failure of early nasal continuous positive airway pressure in preterm infants of 26 to 30 weeks gestation. J Perinatol. 2013 04//print;33(4):297-301.1. This is a nice multicenter prospective cohort study, looking at reasons for CPAP failure in very preterm babies. If the infant needed to be resuscitated in the delivery room with more than 30% oxygen, if they developed RDS needing oxygen and if they were a boy, they were more likely to fail CPAP. Why do boys get the worst of everything in the NICU?

About Keith Barrington

I am a neonatologist and clinical researcher at Sainte Justine University Health Center in Montréal
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