Both extremes and fluctuations of PaCO2 are associated with severe intraventricular hemorrhage. It may be prudent to avoid extreme hypocapnia and hypercapnia during the period of risk for intraventricular hemorrhage.
Objectives
To identify variables associated with successful elective extubation, and to determine neonatal morbidities associated with extubation failure in extremely preterm neonates.
Study design
This study was a secondary analysis of the National Institute of Child Health and Human Development Neonatal Research Network’s Surfactant, Positive Pressure, and Oxygenation Randomized Trial that included extremely preterm infants born at 240/7 to 276/7 weeks’ gestation. Patients were randomized either to a permissive ventilatory strategy (continuous positive airway pressure group) or intubation followed by early surfactant (surfactant group). There were prespecified intubation and extubation criteria. Extubation failure was defined as reintubation within 5 days of extubation.
Results
Of 1316 infants in the trial, 1071 were eligible; 926 infants had data available on extubation status; 538 were successful and 388 failed extubation. The rate of successful extubation was 50% (188/374) in the continuous positive airway pressure group and 63% (350/552) in the surfactant group. Successful extubation was associated with higher 5-minute Apgar score, and pH prior to extubation, lower peak fraction of inspired oxygen within the first 24 hours of age and prior to extubation, lower partial pressure of carbon dioxide prior to extubation, and non-small for gestational age status after adjustment for the randomization group assignment. Infants who failed extubation had higher adjusted rates of mortality (OR 2.89), bronchopulmonary dysplasia (OR 3.06), and death/bronchopulmonary dysplasia (OR 3.27).
Conclusions
Higher 5-minute Apgar score, and pH prior to extubation, lower peak fraction of inspired oxygen within first 24 hours of age, lower partial pressure of carbon dioxide and fraction of inspired oxygen prior to extubation, and nonsmall for gestational age status were associated with successful extubation. Failed extubation was associated with significantly higher likelihood of mortality and morbidities.
Trial registration
ClinicalTrials.gov: NCT00233324.
Objective
To characterize actual achieved patterns of oxygenation in appropriate (AGA) versus small (SGA) for gestational age infants randomized to a lower (85–89%) versus higher (91–95%) oxygen saturation target in the Surfactant, Positive Pressure and Oxygen Trial (SUPPORT). To determine the association between achieved oxygen saturation levels and survival in AGA and SGA infants enrolled in SUPPORT.
Study design
Median oxygen saturation and intermittent hypoxemia events (<80%, 20sec–5min) were documented in 1054 infants of 24–27 6/7wks gestation while receiving supplemental oxygen during the first three days of life.
Results
Lower target SGA infants had the lowest oxygen saturation and highest incidence of IH during the first three days of life. The lowest quartile of oxygen saturation (≤92%) during the first three days of life was associated with lower 90 day survival for both AGA and SGA infants. An increased incidence of IH events during the first three days of life was associated with lower 90 day survival only in SGA infants.
Conclusion
Lower achieved oxygen saturation during the first three days of life was associated with lower 90 day survival in extremely preterm infants. SGA infants had enhanced vulnerability to lower oxygen saturation targets as evidenced by lower achieved oxygen saturation and an association between increased IH events and lower survival.
Objective
To estimate risk of NEC for ELBW infants as a function of preterm formula and maternal milk (MM) intake and calculate the impact of suboptimal feeding on NEC incidence and costs.
Design
We used adjusted odds ratios (aORs) derived from the Glutamine Trial to perform Monte Carlo simulation of a cohort of ELBW infants under current suboptimal feeding practices, compared to a theoretical cohort in which 90% of infants received at least 98% MM.
Results
NEC incidence among infants receiving ≥98% MM was 1.3%; 11.1% among infants fed only preterm formula; and 8.2% among infants fed a mixed diet (p=0.002). In adjusted models, compared with infants fed predominantly MM, we found an increased risk of NEC associated with exclusive preterm formula (aOR=12.1, 95% CI 1.5, 94.2), or a mixed diet (aOR 8.7, 95% CI 1.2-65.2). In Monte Carlo simulation, current feeding of ELBW infants was associated with 928 excess NEC cases and 121 excess deaths annually, compared with a model in which 90% of infants received ≥ 98% MM. These models estimated an annual cost of suboptimal feeding of ELBW infants of $27.1 million (CI $24million, $30.4 million) in direct medical costs, $563,655 (CI $476,191, $599,069) in indirect nonmedical costs, and $1.5 billion (CI $1.3 billion, $1.6 billion) in cost attributable to premature death.
Conclusions
Among ELBW infants, not being fed predominantly MM is associated with an increased risk of NEC. Efforts to support milk production by mothers of ELBW infants may prevent infant deaths and reduce costs.
Few VLBW infants use an entire RBC unit. One dedicated unit shared by two or more infants should meet their transfusion needs. GA, BW, and markers of illness severity predict increased RBC volume requirements.
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