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Archives of Disease in Childhood - Fetal and Neonatal Edition 01/2013; · 3.05 Impact Factor
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ABSTRACT: The publication of Swiss guidelines for the care of infants at the limit of viability (22-25 completed weeks) was followed by increased survival rates in the more mature infants (25 completed weeks). At the same time, considerable centre-to-centre (CTC) differences were noted.
To examine the trend of survival rates of borderline viable infants over a 10-year-period and to further explore CTC differences.
Population-based, retrospective cohort study.
All nine level III neonatal intensive care units (NICUs) and affiliated paediatric hospitals in Switzerland.
6532 preterm infants with a gestational age (GA) <32 weeks born alive between 1 January 2000 and 31 December 2009.
Trends of GA-specific delivery room and NICU mortality rates and survival rates to hospital discharge were assessed. For CTC comparisons, centre-specific risk-adjusted ORs for survival were calculated in three GA groups: A: 23 0/7 to 25 6/7 weeks (n=976), B: 26 0/7 to 28 6/7 weeks (n=1943) and C: 29 0/7 to 31 6/7 weeks (n=3399).
Survival rates of infants with a GA of 25 completed weeks which had improved from 42% in 2000/2001 to 60% in 2003/2004 remained unchanged at 63% over the next 5 years (2005-2009). Statistically significant CTC differences have persisted and are not restricted to borderline viable infants.
In Switzerland, survival rates of infants born at the limit of viability have remained unchanged over the second half of the current decade. Risk-adjusted CTC outcome variability cannot be explained by differences in baseline demographics or centre case loads.
Archives of Disease in Childhood - Fetal and Neonatal Edition 09/2012; 97(5):F323-8. · 3.05 Impact Factor
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Pediatric Anesthesia 02/2012; 22(2):184-5. · 2.10 Impact Factor
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ABSTRACT: Caudal anesthesia is the single most important pediatric regional anesthetic technique. The technique is relatively easy to learn (1), has a remarkable safety record (2), and can be used for a large variety of procedures. The technique has been reviewed in the English (3) and French (4) literature, as well as in German guidelines (5) and in pediatric anesthesia textbooks (6).
Pediatric Anesthesia 08/2011; 22(1):44-50. · 2.10 Impact Factor
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Thomas M Berger
The Journal of pediatrics 01/2010; 156(1):7-9. · 4.02 Impact Factor
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Pediatric Anesthesia 11/2009; 20(1):105. · 2.10 Impact Factor
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ABSTRACT: Diagnosis of neonatal early-onset sepsis is difficult because clinical signs and laboratory tests are non-specific. Early antibiotic therapy is crucial for treatment success.
To evaluate the effect of procalcitonin (PCT)-guided decision-making on duration of antibiotic therapy in suspected neonatal early-onset sepsis.
This single-center, prospective, randomized intervention study was conducted in a tertiary neonatal and pediatric intensive care unit in the Children's Hospital of Lucerne, Switzerland, between June 1, 2005 and December 31, 2006. All term and near-term infants (gestational age >or=34 weeks) with suspected early-onset sepsis were randomly assigned either to standard treatment based on conventional laboratory parameters (standard group) or to PCT-guided treatment (PCT group). Minimum duration of antibiotic therapy was 48-72 h in the standard group, whereas in the PCT group antibiotic therapy was discontinued when two consecutive PCT values were below predefined age-adjusted cut-off values.
121 newborns were randomly assigned either to the standard group (n = 61) or the PCT group (n = 60). The two groups were similar for baseline demographics, risk factors for early-onset sepsis, likelihood of infection as assessed by the attending physician and early conventional laboratory findings. There was a significant difference in the proportion of newborns treated with antibiotics >or=72 h between the standard group (82%) and the PCT group (55%) (absolute risk reduction 27%; odds ratio 0.27 (95% CI 0.12-0.62), p = 0.002). On average, PCT-guided decision-making resulted in a shortening of 22.4 h of antibiotic therapy. Clinical outcome was similar and favorable in both groups but sample size was insufficient to exclude rare adverse events.
Serial PCT determinations allow to shorten the duration of antibiotic therapy in term and near-term infants with suspected early-onset sepsis. Before this PCT-guided strategy can be recommended, its safety has to be confirmed in a larger cohort of neonates.
Neonatology 09/2009; 97(2):165-74. · 2.66 Impact Factor
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ABSTRACT: Because ethical decision making in the care of extremely preterm infants varies widely across Europe, the Swiss Society of Neonatology decided to publish its own guidelines on the care of infants born at the limit of viability in 2002.
To examine the potential impact of the guidelines on survival rates, short-term complication rates and centre-to-centre outcome differences of extremely preterm infants (22-25 completed weeks).
Population-based, retrospective cohort study.
All nine level III neonatal intensive care units (NICU) and affiliated paediatric hospitals in Switzerland.
516 extremely preterm infants born alive between 1 January 2000 and 31 December 2004.
Delivery room and NICU mortality rates, survival to hospital discharge and incidence of short-term complications in survivors were assessed. To study the impact of the guidelines, two cohorts from two different time periods were compared (years 2000/2001, n = 220; years 2003/2004, n = 204) whereas patients born in the year of the publication (2002, n = 92) were excluded. For centre-to-centre comparisons, the entire population (n = 516) was analysed.
There was a significant increase in survival rates of extremely preterm infants from 31% to 40% (RR 1.24, 95% CI 1.02, 1.50) after the publication of the Swiss guidelines. This improvement was largely explained by significantly improved survival from 42% to 60% (p = 0.01) among infants born at 25 completed weeks because of decreased NICU mortality. Improved survival was not associated with statistically significant changes in the incidence of short-term complications. Despite national guidelines, considerable centre-to-centre outcome differences have persisted.
The publication of the Swiss guidelines was followed by significantly improved survival of extremely preterm infants but had no impact on centre-to-centre differences.
Archives of Disease in Childhood - Fetal and Neonatal Edition 05/2009; 94(6):F407-13. · 3.05 Impact Factor
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Pediatric Anesthesia 08/2008; 18(12):1221-2. · 2.10 Impact Factor
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Pediatric Anesthesia 07/2006; 16(6):697-8. · 2.10 Impact Factor
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Pediatric Anesthesia 03/2006; 16(2):218-20. · 2.10 Impact Factor
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ABSTRACT: Inhalation agents are amongst the mainstays of paediatric anaesthesia, as children are often induced by mask before venous access is obtained. Children do not like needles and obtaining venous access in an awake and moving child can be very demanding. Safety aspects are of particular importance in paediatric anaesthesia. Therefore, the possibility of monitoring end-tidal concentrations facilitates correct dosing in all patients, from the preterm infant weighing less than 1000 g to the adult-sized adolescent. For induction, sevoflurane has nearly universally replaced halothane, leading to increased cardiovascular safety. The main disadvantages of inhalation agents, especially sevoflurane and desflurane, are delirious behaviour and agitated states during emergence. In addition, there remains uncertainty regarding the relevance of the cerebral stimulating pattern of some of these agents. Inhalation anaesthesia has a long tradition, whereas the experience with propofol is comparatively small. The incidence and clinical relevance of the propofol infusion syndrome during clinical anaesthesia are still unknown. Inhalation anaesthesia is still considered to be the gold standard by the overwhelming majority of paediatric anaesthetists world-wide, however, intravenous techniques can be an attractive alternative in specific clinical situations.
Baillière' s Best Practice and Research in Clinical Anaesthesiology 10/2005; 19(3):501-22.
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Pediatric Anesthesia 08/2005; 15(7):622-3. · 2.10 Impact Factor
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ABSTRACT: In Switzerland, data are collected prospectively by collaborators from all nine neonatal intensive care units and their affiliated paediatric units caring for neonates, to determine survival and (pulmonary) outcome of infants with birth weights ranging from 501 to 1500 g. To assess the pulmonary outcome of very low birth weight (VLBW) infants in Switzerland in 1996 and 2000, factors associated with bronchopulmonary dysplasia (BPD) were identified and compared with pulmonary outcomes from the Vermont Oxford Network data. BPD was defined as a requirement for supplemental oxygen at 36 weeks postmenstrual age. Complete data were available for 600 and 636 VLBW infants in 1996 and in 2000, respectively. Mortality rates in Switzerland were significantly higher (1996: 19.2%, 2000: 20.8%) than in the Vermont Oxford Network (1996: 14%, 2000: 14%). Expressed as percentage of infants still hospitalised at 36 weeks postmenstrual age, 16.7% and 13.2% of Swiss VLBW infants were diagnosed with BPD in 1996 and 2000, respectively. These rates were significantly lower than in the Vermont Oxford Network (1996: 28%, 2000: 35%). Infants exposed to factors previously shown to be associated with BPD were investigated: in Switzerland, infants with a history of surfactant replacement therapy and/or mechanical ventilation had a significantly higher rate of BPD in both cohorts. Infants with postnatal transport, sepsis proven by positive blood culture and patent ductus arteriosus had a higher BPD rate only in the 1996 cohort. Between 1996 and 2000, mortality rates and incidence of BPD in VLBW infants remained unchanged in Switzerland. BPD rates in Switzerland are lower than those found in the Vermont Oxford Network whereas a mortality rate comparison displays an inverted picture. We suspect that these effects are interrelated and may be due in part to a selective approach of Swiss neonatologists to resuscitation of infants in the smallest birth weight stratum. CONCLUSION: The factors listed above have apparently become less important in the context of bronchopulmonary dysplasia and other influences, including prenatal conditions, will need to be investigated.
European Journal of Pediatrics 06/2005; 164(5):292-7. · 1.88 Impact Factor
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ABSTRACT: To present a case of fetal intracranial injuries in a preterm infant after maternal motor vehicle accident and to review the relevant literature.
Case report.
Neonatal and pediatric intensive care unit of a children's hospital.
Preterm infant (gestational age, 30-6/7 wks) with intracranial injuries after maternal motor vehicle accident.
Whereas the mother had only a closed femur fracture, her infant sustained subdural, subarachnoid, and intracerebral hemorrhages in the left parietal and temporal lobes most likely attributable to direct fetal trauma. Massive fetomaternal hemorrhage may have led additionally to hypoxia-ischemia contributing indirectly to the injury. At the last follow-up visit (chronological age, 20 months; corrected age, 18 months), there was evidence of a persistent right-sided hemiparesis in an otherwise normally developed infant.
Motor vehicle accidents during pregnancy can be associated with fetal mortality and significant morbidity, even in the absence of severe maternal injuries. Direct (hemorrhagic) and indirect (hypoxic-ischemic) intracranial injuries should be actively sought with appropriate imaging studies.
Pediatric Critical Care Medicine 08/2004; 5(4):396-8. · 3.13 Impact Factor
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Pediatric Anesthesia 08/2004; 14(7):614. · 2.10 Impact Factor
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ABSTRACT: This review will focus on recently published data concerning side effects and complications of paediatric regional anaesthesia, putting into perspective the currently used techniques.
Penile block is clearly a technique with a very large benefit and minimal side effects. Ilioinguinal nerve block, on the other hand, quite commonly leads to complications. Single-shot caudal anaesthesia is considered a safe and effective technique; however, even with this widely used block, complications such as sacral osteomyelitis can occur. Recent review articles have focussed on the role of additives for prolonging the duration of paediatric caudal anaesthesia. The use of ketamine or s-ketamine as an additive appears to be most promising for the future.
Paediatric regional anaesthesia is now widely used for postoperative pain relief in children. However, a careful risk-benefit analysis is always mandatory before such medical interventions are undertaken.
Current Opinion in Anaesthesiology 07/2004; 17(3):211-5. · 2.21 Impact Factor
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ABSTRACT: The goal of neonatal care is to optimise the outcome of term and preterm infants with minimal suffering. Neonates are rare patients for the anaesthetist, therefore personal and even global experiences are limited. This chapter focuses on strategies for dealing with common clinical situations, e.g. heel lancing, obtaining vascular access, circumcision, hernia repair and pyloric stenosis, as well as major neonatal surgery. With the exception of heel lancing, regional techniques are useful in all cases. However, a careful risk-benefit analysis is mandatory, especially when considering more invasive techniques such as epidural catheters.
Baillière' s Best Practice and Research in Clinical Anaesthesiology 07/2004; 18(2):357-75.
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ABSTRACT: It has been suggested that improved survival of very low birth weight (VLBW) infants may have resulted in increased numbers of patients with bronchopulmonary dysplasia (BPD).
To determine the impact of changes in mortality on the incidence and/or severity of BPD in three different time periods with distinct respiratory support strategies.
Retrospective single center cohort study of VLBW infants: Cohort A (1986-1990): pre-surfactant era, use of conventional intermittent mandatory ventilation (IMV); cohort B (1993-1994): use of synthetic surfactant, nasopharyngeal continuous positive airway pressure (CPAP) and conventional IMV; cohort C (2000-2001): use of natural surfactant, early nasal prong CPAP, synchronized IMV with tidal volume monitoring and high frequency oscillatory ventilation (HFOV). BPD was classified as mild, moderate or severe according to Jobe and Bancalari.
The median gestational ages and birth weights were 28 3/7 weeks and 1,120 g for cohort A (n = 97), 30 0/7 weeks and 1,340 g for cohort B (n = 100), and 29 1/7 weeks and 1,200 g for cohort C (n = 135). The use of partial or complete courses of antenatal corticosteroids (ANC) increased over time (58%, 72%, and 82%, p = 0.003). There was a 50% reduction of mortality between each time period with mortality rates of 30%, 14% and 7% in cohorts A, B and C, respectively (p < 0.001). The overall incidence of BPD was 26% in the pre-surfactant era, 11% during the mid-1990s and 19% in the most recent time period (r = -0.05, p = 0.36). Moderate and severe forms of BPD decreased over time and were seen in 11% in cohort A, 3% in cohort B and 2% in cohort C (p = 0.008).
Changes in neonatal care of VLBW infants, including increased use of ANC and modified respiratory support strategies, have resulted in dramatically improved survival rates over the past 15 years without increasing moderate to severe pulmonary morbidity.
Biology of the Neonate 01/2004; 86(2):124-30. · 1.90 Impact Factor
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New England Journal of Medicine 12/2003; 349(22):e21. · 53.30 Impact Factor
