Journal of Pediatric and Neonatal Individualized Medicine (JPNIM)

A systematic review and meta-analysis on the safety and efficacy of premedication prior to elective intubation in neonates

Ilias Chatziioannidis — 2024-08-23

Objective: Endotracheal intubation, as an emergent but also as an elective procedure, can be stressful and painful, causing hypoxemia, bradycardia, acidosis or increased intracranial pressure. We aimed to investigate the safety and efficacy of premedication prior to elective intubation in order to contribute to the development of a more standardized strategy.

Method: A systematic review and meta-analysis was conducted. The PubMed database was searched using the PICO method and keywords according to MeSH terms were used. Only studies with control groups were included (randomized controlled trials, prospective observational and case-control studies).

Results: Our search procedure yielded 722 potentially eligible studies. Finally, 26 studies were included for qualitative and quantitative analysis. Blood pressure during intubation was found lower for neonates that received premedication compared to controls (SMD = -1.27; 95% CI [-2.59; 0.05]; p < 0.01). Heart rate change was found higher in the control group (SMD = -0.26; 95% CI [-1.07; 0.55]; p = 0.54). Intervention groups were found to have higher odds for bradycardia (OR = 1.13; 95% CI [0.79; 1.62]; p = 0.51), and less odds for desaturation compared to control groups (OR = 0.69; 95% CI [0.33; 1.45]; p = 0.33). The odds for adverse events were found 3 times lower in the intervention group, in relation to controls (OR = 0.71; 95% CI [0.55; 0.73]; p = 0.012). Intubation time for the intervention groups was lower than controls (SMD = -0.59; 95% CI [-1.06; -0.11]; p < 0.02). Intubation attempts were found marginally increased in the intervention group (ROM = 1.10; 95% CI [0.79; 1.53]; p = 0.57). No difference was found regarding mortality rate between groups.

Conclusion: Most Neonatal Intensive Care Units should consider premedication prior to intubation for vigorously and active term and preterm infants as a safe and efficient procedure that buffers serious physiological responses and assures better procedural conditions.

Laryngomalacia and failure to thrive – A case report

Rita Barroca Macedo — 2024-08-27

Introduction: Laryngomalacia (LGM) is the most common congenital anomaly of the larynx and the most frequent cause of stridor in the newborn. Even though it can be a source of concern and anxiety to parents, a large majority of cases usually resolve spontaneously within 18 months of life. However, in infants with signs of severity, a multidisciplinary approach and surgical intervention might be necessary.

Case report: We report the case of a full-term 7-week-old infant girl, previously hospitalized in the Neonatal Intensive Care Unit and diagnosed with type II LGM (Olney’s classification). She presented to the Paediatric Emergency Department with stridor at rest, vigorous chest wall retractions and poor weight gain (increase of 10 g/day, weight under the 3^rd percentile). The infant was admitted to monitor respiratory symptoms and investigate her failure to thrive. However, irrespective of feeding modifications, and after exclusion of other causes of failure to thrive, the infant maintained an insufficient weight gain. Additionally, respiratory symptoms remained exuberant and surgical intervention was determined as the optimal treatment. At 3 months old, supraglottoplasty was performed. At 18 months, she has a weight in the 3^rd-15^th percentile range (WHO curves) and is clinically asymptomatic.

Conclusion: LGM is a remarkably frequent cause of stridor in infants, but only a rare number of cases require other interventions beyond symptomatic measures. In this report, surgical intervention was of paramount importance to ensure normal growth, emphasising the impact of a multidisciplinary approach in such cases.

Hemodynamics guided care during extracorporeal membrane oxygenation (ECMO): a case report

Mohamed Al Kanjo — 2024-08-28

Congenital diaphragmatic hernia (CDH) represents a population of high risk of major cardiopulmonary decompensation. Maintenance of patency of the patent ductus arteriosus (PDA), using intravenous prostaglandin, is a strategy used by some clinicians to decrease the risk of right ventricular dysfunction. A term infant with CDH presented with pulmonary hypertension unresponsive to aggressive hemodynamic support. Within 12 hours of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) initiation, circuit chugging occurred that was refractory to multiple volume boluses. Targeted neonatal echocardiography (TnECHO) revealed a high-volume left-to-right shunt across the PDA, resulting in decreased blood return to the right atrium. Interventions aimed at reducing the left-to-right PDA shunt led to the resolution of circuit chugging. This report highlights the unique challenge of VA-ECMO flow in the setting of a large PDA and the consequences of interventions, increasing PDA diameter or lowering pulmonary vascular resistance, on the magnitude of systemic-pulmonary shunting and systemic blood flow. TnECHO played a vital role in monitoring hemodynamics and guiding ECMO adjustments.