Outcome for the extremely premature neonate: how far do we push the edge? Paediatr Anaesth
ABSTRACT Significant advances in perinatal and neonatal medicine over the last 20 years and the recent emergence of fetal surgery has resulted in anesthesia providers caring for a growing number of infants born at the margin of viability. Anesthetic management in this patient population has to take into consideration the immature function of many vital organ systems as well as the effects of the underlying disease processes, which can frequently lead to severe physiological derangements. Accordingly, premature infants presenting for major surgeries early in life can represent a significant anesthetic challenge. However, even with advanced anesthetic and surgical management and optimal intensive care, extremely premature infants face substantial postoperative morbidity and mortality, as well as prolonged hospital courses. In this article, we will discuss the following questions: How far have we come in improving outcomes of extreme prematurity? And what will the future medical and societal challenges be, as we continue to redefine the limits of viability?
- SourceAvailable from: Vidya ChidambaranInternational anesthesiology clinics 01/2012; 50(4):66-82. DOI:10.1097/AIA.0b013e31826f3284
- [Show abstract] [Hide abstract]
ABSTRACT: Evidence-based guidelines do not indicate when ventricular reservoirs should be placed in children with neonatal hydrocephalus, and delayed intervention is common. We hypothesize that delayed ventricular drainage has adverse effects on structural development and functional outcomes. Using a well-established animal model of kaolin-induced obstructive hydrocephalus, we evaluated neurologic deficit after early (~1 week post-kaolin) or late (~2 weeks post-kaolin) placement of ventricular reservoirs which were tapped according to strict neurologic criteria. Progressive ventriculomegaly was similar in early- and late-reservoir implantation groups. The average neurologic deficit scores (NDSs) over the experimental period were 0 (n = 6), 2.74 (n = 5), and 2.01 (n = 3) for the control, early-, and late-reservoir groups, respectively. At reservoir placement, early-group animals displayed enlarged ventricles without neurologic deficits (mean NDS = 0.17), while the late group displayed ventriculomegaly with clinical signs of hydrocephalus (mean NDS = 3.13). The correlation between ventriculomegaly severity and NDS in the early group was strongly positive in the acute (before surgery to 3 weeks post-reservoir placement) (R (2) = 0.65) and chronic (6 to 12 weeks post-reservoir placement) (R (2) = 0.65) phases, while the late group was less correlated (acute R (2) = 0.51; chronic R (2) = 0.19). Current practice favors delaying reservoir implantation until signs of elevated intracranial pressure and neurologic deficit appear. Our results demonstrate that animals in early and late groups undergo the same course of ventriculomegaly. The findings also show that tapping reservoirs in these neonatal hydrocephalic animals based on neurologic deficit does not halt progressive ventricular enlargement and that neurologic deficit correlates strongly with ventricular enlargement.Child s Nervous System 07/2012; 28(11):1849-61. DOI:10.1007/s00381-012-1848-z · 1.16 Impact Factor
- [Show abstract] [Hide abstract]
ABSTRACT: AIM: To compare causes and rates of mortality among infants admitted to 10 Australian neonatal intensive care units (NICUs) between 1995 and 2006. METHODS: De-identified perinatal data from the Neonatal Intensive Care Units' (NICUS) Data Collection for 24,131 infants were examined for causes and rates of death. The study period was divided into two epochs: I (1995 - 2000, n=11,185 infants) and II (2001-2006, n=12, 946 infants). RESULTS: A total of 2,224 (9.2%) infants died in hospital. Mortality decreased from 10.3% (1,152/11,185) in epoch I to 8.3% (1,072/12,946) in epoch II (p<0.001) due to improved survival in term infants. Extreme prematurity also decreased as a primary cause of death (118 (10.2%) v 76 (7.1%), p = 0.008). No infant >42 weeks gestation was admitted in epoch II. Congenital abnormalities were the most common cause of death (>20%) in both epochs, mostly in term rather than preterm infants (40.7% v 13.9%, p<0.001). Age of death was unchanged between the two epochs (median 4, 1(st) , 3(rd) quartiles: 1,16 days). CONCLUSION: Mortality rates have continued to decrease but improvement is predominantly due to improved survival of term infants and prevention of post-date deliveries. Congenital abnormalities continue to be the most common cause of death. © 2012 The Author(s)/Acta Paediatrica © 2012 Foundation Acta Paediatrica.Acta Paediatrica 09/2012; 102(1). DOI:10.1111/apa.12039 · 1.84 Impact Factor