Robert Schumacher - Academia.edu (original) (raw)
Papers by Robert Schumacher
Clinics in Perinatology, 1990
Technologic advances have allowed a means for more precise measurement of cutaneous bilirubin. Th... more Technologic advances have allowed a means for more precise measurement of cutaneous bilirubin. These advances have led investigators to examine the correlation between cutaneous and blood bilirubin in hopes of either replacing or reducing the number of serum bilirubin values obtained. In the past other investigators attempted to do the same, using visual estimates of jaundice with and without the help of reference devices. The establishment of an acceptable correlation between cutaneous and serum bilirubin requires (1) accurate measurement of serum bilirubin, (2) accurate measurement of cutaneous bilirubin, and (3) steady-state conditions between the blood-cutaneous bilirubin "compartments." The accuracy with which cutaneous bilirubin can be measured appears similar or better than that with which serum bilirubin is measured; with older transcutaneous devices significant interobserver variability may exist. Bias in the form of other skin chromogens also interferes with accuracy. Rapid changes in serum or cutaneous bilirubin concentration or nonhomogeneous distribution of cutaneous bilirubin interferes with our knowledge of cutaneous-blood bilirubin kinetics. At present transcutaneous bilirubinometry cannot replace routine serum measurements, but both new and old transcutaneous devices can serve as effective screening devices. The choice of which device to use depends on its cost-effectiveness in any given clinical setting.
Archives of disease in childhood. Fetal and neonatal edition, Jan 10, 2017
As the prescription opioid epidemic grew in the USA, its impact extended to pregnant women and th... more As the prescription opioid epidemic grew in the USA, its impact extended to pregnant women and their infants. This review summarises how increasing rates of neonatal abstinence syndrome resulted in a need to improve care to pregnant women and opioid-exposed infants. We discuss the variations in care delivery with particular emphasis on screening at-risk mothers, scoring systems for neonatal drug withdrawal, type and duration of pharmacotherapy, and discharge safety.
Manual of Neonatal Respiratory Care, 2012
Extracorporeal membrane oxygenation is still a relatively new technology that has recently achiev... more Extracorporeal membrane oxygenation is still a relatively new technology that has recently achieved recognition after initial clinical disappointment in the late 1970s. At present, it is considered standard therapy for the full-term infant with PPHN who fails CMV and extraordinary, heroic therapy for older children and adults with ARF or cardiac failure, or both. Currently, the emphasis is on developing new technologies for increasing safety and effectiveness. Areas of interest include heparinless circuits, carotid artery reconstruction, improved monitoring, and expanding applications of VV ECMO. As ECMO becomes safer and more effective, it is believed that new and expanding patient populations will emerge to include premature infants, earlier intervention in term infants, and more liberal application to pediatric and adult populations.
The Laryngoscope, 2006
To review incidence of, indications for, and outcomes of tracheotomy in very low birth weight (VL... more To review incidence of, indications for, and outcomes of tracheotomy in very low birth weight (VLBW) infants. Retrospective review in tertiary care hospital. Eighteen VLBW (<1,500 g) infants with bronchopulmonary dysplasia undergoing tracheotomy in the neonatal intensive care unit between October 1997 and June 2002 were studied. Controls consisted of 36 VLBW infants undergoing intubation without tracheotomy, two per study infant, matched by gestational age and weight. Outcome measures included duration and number of intubation events, time to decannulation, complications, comorbidities, length of stay, and speech, language, and swallowing measures. Infants undergoing tracheotomy had an average duration of intubation of 128.8 days with a median number of 11.5 intubation events, both significantly greater than those of controls. Percentage of those with laryngotracheal stenosis was 44% of study infants had laryngotracheal stenosis compared to 1.6% in all intubated VLBW infants. The tracheotomy group had a significantly higher incidence of gastroesophageal reflux, pulmonary hypertension, and gastrostomy tube placement. The overall tracheotomy-related complication rate was 38.9%. Three were lost to follow-up, and five deaths occurred, two possibly tracheotomy-related. Six of ten were decannulated by an average time of 3.8 years, two of six after laryngotracheal reconstruction. Four of ten remained cannulated for a variety of reasons. Disorders of speech, language, and swallowing were common. When considering tracheotomy in VLBW infants, the total number of intubation events should be monitored as well as the total duration of intubation. The relatively high incidence of laryngotracheal stenosis argues for earlier endoscopy and possibly earlier tracheotomy in infants with developing stenoses.
Seminars in Fetal and Neonatal Medicine, 2011
The practice of evidence-based medicine involves the judicious use of current best evidence in th... more The practice of evidence-based medicine involves the judicious use of current best evidence in the care of individual patients. Decisions about diagnosis, prognosis and treating patients require knowledge of the probability and value of outcomes. Decision analysis illustrates how probabilities and values help define one another, and each are important. Whereas initial probability estimates can be obtained by 'searching for the best evidence', values belong to individuals. Obtaining values from patients or parents is sometimes difficult and requires a respectful, thoughtful, systematic approach, but only after doing this is neonatal care evidence-based.
Journal of Perinatology, 2008
Journal of Pediatric Surgery, 1993
JAMA, 2012
Recently, analyses from Australia 12 and the Florida Medicaid program (D. Aronberg, JD, written c... more Recently, analyses from Australia 12 and the Florida Medicaid program (D. Aronberg, JD, written communication, November 30, 2011) found that Author Affiliations are listed at the end of this article.
Ear and Hearing, 1990
Brain stem auditory evoked responses (BAERs) were obtained in 25 infants who received extracorpor... more Brain stem auditory evoked responses (BAERs) were obtained in 25 infants who received extracorporeal membrane oxygenation (ECMO) for severe respiratory failure. Tracings were obtained by means of a Nicolet CA-2000 averager, using a conventional paradigm. The presence or absence of replicated responses at 35 and 75 dB nHL were recorded for each ear. Interpeak latencies I-III, III-V, and I-V were measured and differences between right and left ears were compared, using a matched pair t-test. Wave III-V latencies were longer on the left than right (p less than 0.05), but no significant right-left differences for latencies I-III were noted. Sixteen percent of the infants failed hearing sensitivity criteria, 45% (10/23) had prolonged I-V latencies. At follow-up (age 4 to 12 months) 6/10 infants with prolonged I-V latencies had additional neurologic abnormalities. In this population left ear III-V latencies are prolonged versus right, and the incidence of abnormal BAERs is high. Relative prolongation of left ear III-V latencies (generated from the right brain stem) may be result of right carotid artery and/or jugular vein ligation for ECMO, and abnormal I-V latencies prognosticate future neurologic abnormalities in this population.
Clinics in Perinatology, 2001
Extracorporeal membrane oxygenation was established as a standard of care by demonstrating its ab... more Extracorporeal membrane oxygenation was established as a standard of care by demonstrating its ability to save lives in moribund infants. The designs of early studies provided no living cohorts of similarly ill patients by which to measure accurately other (and perhaps to many more important) outcomes of interest: long-term neurodevelopmental outcomes or cost. Prospective cohort studies of neurodevelopmental outcomes post-ECMO demonstrate: (1) because ECMO, as used, saves lives, there will be an increase in the absolute number of handicapped children surviving; (2) there is little evidence that ECMO creates a relative increase in the percent of handicapped children surviving severe respiratory failure. The high direct costs of an ECMO program are measured and well publicized. When such costs are compared with similar therapies in other fields (in such terms as cost per survivor), the cost of ECMO does not seem to be an outlier. Trials of newer therapies, such as iNO, show the capacity to decrease the use of ECMO but have failed to demonstrate either cost-effectiveness or better long-term outcomes. It has not been shown that either society or individual patients have benefited from the decreased need for ECMO.
BMC Pediatrics, 2012
Background: Whether lumbar punctures (LPs) should be performed routinely for term newborns suspec... more Background: Whether lumbar punctures (LPs) should be performed routinely for term newborns suspected of having early onset neonatal sepsis (EONS) is subject to debate. It is unclear whether variations in performance of LPs for EONS may be associated with patient, hospital, insurance or regional factors. Our objective was to identify characteristics associated with the practice of performing LPs for suspected EONS in a nationally representative sample. Methods: Utilizing data from the 2003, 2006 and 2009 Kids' Inpatient Database (KID) compiled by the Agency for Healthcare Research and Quality, we examined the frequency and characteristics of term, normal-birth weight newborns receiving an LP for EONS. Survey-weighting was applied for national estimates and used in chi squared and multivariable regression analysis. Results: In 2009, there were 13,694 discharges for term newborns that underwent LPs for apparent EONS. Newborns having LPs performed were more likely to be covered by Medicaid vs. private insurance (51.9 vs. 45.1 percent; p < 0.001), be born in urban vs. rural hospitals (94.8 vs. 87.3 percent; p < 0.001), teaching vs. non-teaching (60.8 vs. 43.1 percent; p < 0.001) and children's hospitals vs. non-children's (23.0 vs. 11.2 percent; p < 0.001). Lastly, newborns having LPs performed were disproportionately born in the Northeast census region (p = 0.03). In multi-year adjusted analysis, infants with Medicaid coverage, and those born in urban or teaching hospitals, consistently had higher odds of having an LP performed. Conclusions: We found pronounced variation in LPs performed for EONS, even when adjusting for clinical conditions that would prompt LPs. These findings indicate practice variations in newborn care that merit further examination and explanation.
ASAIO Journal, 1993
Clinicians reserve ECMO for neonates at > 80% predicted mortality risk. The authors hypoth... more Clinicians reserve ECMO for neonates at > 80% predicted mortality risk. The authors hypothesized that ECMO instituted at lower (50%) mortality risk would result in fewer intensive care unit days and a lower hospital cost compared with conventional therapy (including ECMO at high mortality risk). This was a randomized control trial, cost-benefit analysis in an academic newborn intensive care unit. The patients were a prospectively studied, consecutive sample of 41 term neonates with 1) age 24-72 hours, 2) "maximal medical management" for > 6 hours, 3) oxygenation index (OI) values > 25 but < 40. (Severity of illness measured by OI = ((mean airway pressure x FiO2 x 100) PaO2)). All eligible patients entered. Thirty-two of 37 survivors were evaluated at 1 year. Intervention occurred when OI = 25. Patients were randomized to ECMO or continued medical management (ECMO possible at OI = 40). Planned primary outcome measures were ICU days and hospital charges. Secondary measures were pulmonary and neurologic outcomes at discharge and 1 year. Twenty-two early ECMO patients, 19 controls, 14/19 met late ECMO criteria. Four patients died (two each group). No statistically significant difference was seen in hospital charges (early ECMO = 49,500versuscontrol=49,500 versus control = 49,500versuscontrol=53,7000), (95% confidence intervals = -$3200 to +$5100 more for controls) or ICU days (early = 14 + 5 days versus control = 19 + 12 days) (95% CI = -0.8 to +10 more for controls). At 1 year the early group had a higher mental developmental index score (115 + 11) versus (103 + 18), (p = 0.07).(ABSTRACT TRUNCATED AT 250 WORDS)
Annals of Pharmacotherapy, 2008
Background: Preventing significant oxygen desaturation and hypotension through adequate analgesia... more Background: Preventing significant oxygen desaturation and hypotension through adequate analgesia and sedation during nonemergent Intubation In neonates is desirable. However, in many neonatal intensive care units, elective intubations occur without adequate premedication. There is significant variation In the choice of premedication agen(s) and doses, and an ideal regimen for use during nonemergent intubation has not been developed. Objective: To evaluate the efficacy of an algorithm developed for analgesia and sedation during nonemergent Intubation in neonates. Methods: Prospectively collected continuous quality Improvement data on a premedication algorithm for nonemergent intubation were analyzed following institutions] review board approval. Midazolam 0.1 mg/kg and fentanyl 2 μg/kg (if the patient was not already receiving morphine for sedation) were administered prior to nonemergent intubation. Heart rate, oxygen saturation, respiration rate, mean arterial pressure, and pain sc...
American Journal of Perinatology, 2009
Grade 3 intraventricular hemorrhage (IVH) (without parenchymal involvement) and grade 4 IVH (with... more Grade 3 intraventricular hemorrhage (IVH) (without parenchymal involvement) and grade 4 IVH (with parenchymal involvement) are often combined into description of a single entity, usually &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;severe&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot; IVH, despite different long-term neurodevelopmental outcome. Although risk factors for severe IVH have already been well described, it is not known if these risk factors and associated short-term neonatal morbidities are different for grade 3 and grade 4 IVH, and indeed, this clustering of grade 3 and grade 4 IVH into severe IVH precludes further delineation of the potential risk and protective factors that can be altered to reduce the incidence of grade 4 IVH, which is presumably associated with worse outcome compared with grade 3 IVH. We sought to characterize and compare commonly cited risk factors and associated short-term neonatal morbidities between grade 3 and grade 4 IVH in very low-birth-weight (VLBW) infants. We performed a retrospective review of VLBW (birth weight &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 1500 g) infants with severe IVH born between January 2001 and March 2007. Fifty-nine (10.5%) of 562 infants surviving beyond 3 days of age had severe IVH as recorded on routine cranial sonography during the first 7 to 10 days of life, 28 had grade 3, and 31 had grade 4 IVH. Infants with grade 4 IVH were younger [gestational age (weeks), grade 4 IVH versus grade 3 IVH: 25.5 +/- 1.7 versus 26.7 +/- 1.7, p = 0.02) and weighed less at birth [birth weight (g), grade 4 IVH versus grade 3 IVH: 860 +/- 214 versus 1007 +/- 253, p = 0.03) compared with infants with grade 3 IVH. Other commonly cited clinical factors that alter the risk for severe IVH, including mode of delivery, pregnancy-induced hypertension, premature and/or prolonged rupture of membranes, maternal fever, maternal bleeding, prenatal steroid administration, maternal magnesium sulfate therapy, 1-minute and 5-minute Apgar scores, need for delivery room resuscitation (epinephrine and chest compressions), surfactant therapy, presence of refractory hypotension, evidence of early onset culture-proven sepsis, use of high-frequency ventilation, presence of pneumothorax, and hemodynamically significant patent ductus arteriosus, were similar between infants with grade 3 and grade 4 IVH. Carbon dioxide tensions (minimum PaC (2), maximum PaCO(2), mean PaCO(2), standard deviation of PaCO(2), and coefficient of variation of PaCO (2)) in infants receiving mechanical ventilation during first 3 postnatal days were also not statistically dissimilar. To determine the variables differentiating grade 3 from grade 4 IVH in the study population, logistic regression analysis confirmed only the independent association of gestational age (odds ratio [OR] 0.6, 95% confidence interval [CI] 0.5 to 0.9, P = 0.012) and maternal magnesium sulfate therapy (OR 0.3, 95% CI 0.07 to 0.9, P = 0.04) with the development of grade 4 IVH. Short-term neonatal morbidities were also similar between infants with grade 3 and grade 4 IVH. Among VLBW infants, the risk of a grade 4 versus grade 3 IVH increases with declining gestational age, but does not appear to be related to other commonly cited clinical factors. This information may be useful for prognostication and may improve the quality of parental counseling.
Journal of Perinatology, 2007
… : The Journal of …, 1992
Extracorporeal membrane oxygenation (ECMO) may affect the pharmacokinetics of certain drugs. The ... more Extracorporeal membrane oxygenation (ECMO) may affect the pharmacokinetics of certain drugs. The objectives of this study were to determine (1) the pharmacokinetics of gentamicin in neonates on ECMO and compare them to reported values for a similar patient population not on ECMO, (2) i f the pharmacokinetics of gentamicin differ between venous-venous and venousarterial bypass, and (3) if the pharmacokinetics of gentamicin are affected by oxygenator surface area (0.6 m' vs 0.8 m' oxygenators). The medical records of 29 term neonates who received gentamicin while on ECMO were reviewed. Data collected included gentamicin dosage, peak and trough serum concentrations determined at steady state, duration of treatment, time on ECMO, daily weights, and pertinent laboratory values. An initial dosage of gentamicin 2.5 mg/kg every 18 hours is suggested for term neonates on ECMO. Dosage adjustments should be based on gentamicin serum concentrations, and modifications may also be required after ECMO. (Pharmacotherapy 1992;12(1):2&32) Extracorporeal membrane oxygenation (ECMO) involves the use of prolonged cardiopulmonary bypass in neonates with severe respiratory failure. This allows for a period of lung rest and recovery without the potentially damaging complications associated with prolonged mechanical ventilation, and is considered life saving for infants at high risk of dying from respiratory failure (Figure l).' Since the technique was pioneered in the mid-l970s, more than 4000 infants have received ECMO for respiratory failure. At present, approximately 1000 patients are being added to the National Registry in Ann Arbor, Michigan, each year.* Several ECMO-related factors can theoretically affect the pharmacokinetics of certain drugs. The ECMO circuit presents a large surface area for adsorption of drugs onto a foreign surface, theoretically increasing the volume of drug distribution and reducing the bioavailability of the first dose. Three different sizes of membrane
Journal of Perinatology, 2012
Objective: To determine whether phenobarbital (PB) given before therapeutic hypothermia to infant... more Objective: To determine whether phenobarbital (PB) given before therapeutic hypothermia to infants with hypoxic-ischemic encephalopathy (HIE) augments the neuroprotective efficacy of hypothermia. Study Design: Records of 68 asphyxiated infants of X36 weeks' gestation, who received hypothermia for moderate or severe HIE were reviewed. Some of these infants received PB prophylactically or for clinical seizures. All surviving infants had later brain magnetic resonance imaging (MRI). The composite primary outcome of neonatal death related to HIE with worsening multiorgan dysfunction despite maximal treatment, and the presence of post-hypothermia brain MRI abnormalities consistent with hypoxic-ischemic brain injury, were compared between the infants who received PB before initiation of hypothermia (PB group, n ¼ 36) and the infants who did not receive PB before or during hypothermia (No PB group, n ¼ 32). Forward logistic regression analysis determined which of the pre-hypothermia clinical and laboratory variables predict the primary outcome. Result: The two groups were similar for severity of asphyxia as assessed by Apgar scores, initial blood pH and base deficit, early neurologic examination, and presence of an intrapartum sentinel event. The composite primary outcome was more frequent in infants from the PB group (PB 78% versus No PB 44%, P ¼ 0.006, odds ratio 4.5, 95% confidence interval 1.6 to 12.8). Multivariate analysis identified only the PB receipt before initiation of hypothermia (P ¼ 0.002, odds ratio 9.5, 95% confidence interval 2.3 to 39.5), and placental abruption to be independently associated with a worse primary outcome. Conclusion: PB treatment before cooling did not improve the composite outcome of neonatal death or the presence of an abnormal post-hypothermia brain MRI, but the long-term outcomes have not yet been evaluated.
American Journal of Perinatology, 2010
The purpose of this observational study was to characterize the clinical course of newborn infant... more The purpose of this observational study was to characterize the clinical course of newborn infants with spontaneous pneumothorax and to identify those infants who eventually required further interventions. We performed a retrospective review of newborns with symptomatic spontaneous pneumothorax, born between January 2002 and December 2007. Seventy-six infants ≥36 weeks&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; gestation were identified with symptomatic spontaneous pneumothorax. Twenty-two (29%) of the 76 infants with spontaneous pneumothorax required either thoracentesis or/and thoracostomy drainage, and 54 (71%) were managed without such intervention. In all, 18 (24%) infants received mechanical ventilation and 12 (16%) infants developed persistent pulmonary hypertension (PPHN) during the course of illness. Ten of the 22 infants requiring thoracentesis and/or thoracostomy for progressively worsening respiratory distress developed PPHN. Seven of these 10 infants with PPHN received inhaled nitric oxide, and four infants subsequently required extracorporeal membrane oxygenation. In contrast, the majority of the infants (50 of 54, 93%) not requiring thoracentesis or/and thoracostomy could be managed simply with supplemental oxygen or close observation. Progressively worsening respiratory distress prompting intervention in infants with spontaneous pneumothorax may indicate presence of PPHN that needs prompt recognition and referral to tertiary-level neonatal units for escalating respiratory support.
Objective: To assess the effectiveness of furosemide therapy to prevent hemodynamic and respirato... more Objective: To assess the effectiveness of furosemide therapy to prevent hemodynamic and respiratory compromise in electively transfused preterm infants. Methods: Twenty preterm infants (birth weight: 878.5 ± 207 g; gestational age: 26 ± 1.3 weeks) with RDS requiring conventional mechanical ventilation were randomly assigned to receive either a single intravenous dose of furosemide (1 mg/kg) or an equivalent volume of placebo (normal saline) at the completion of an elective "top off" 3-hour transfusion (15 mL/kg) of packed red blood cells (PRBC) during the first 2 weeks of life. Multiple clinical and respiratory parameters were recorded during the transfusion. Results: Twelve of the 20 infants (60%) received furosemide while 8 infants received placebo at a median postnatal age of 6 days. The clinical parameters (SPO2, BP, HR, spontaneous RR), ventilatory parameters (minute ventilation, compliance, and resistance), PaCO2, or A-a DO2 were similar in the furosemide and placebo treated groups at the completion of the transfusion, and at 4 hours after completion of the transfusion. Conclusion: In this pilot study, a single dose of furosemide after PRBC transfusion did not alter the clinical or pulmonary parameters compared to placebo during the 4 hour period following the transfusion. Its continued use for this purpose may not be justified.
Clinics in Perinatology, 1990
Technologic advances have allowed a means for more precise measurement of cutaneous bilirubin. Th... more Technologic advances have allowed a means for more precise measurement of cutaneous bilirubin. These advances have led investigators to examine the correlation between cutaneous and blood bilirubin in hopes of either replacing or reducing the number of serum bilirubin values obtained. In the past other investigators attempted to do the same, using visual estimates of jaundice with and without the help of reference devices. The establishment of an acceptable correlation between cutaneous and serum bilirubin requires (1) accurate measurement of serum bilirubin, (2) accurate measurement of cutaneous bilirubin, and (3) steady-state conditions between the blood-cutaneous bilirubin "compartments." The accuracy with which cutaneous bilirubin can be measured appears similar or better than that with which serum bilirubin is measured; with older transcutaneous devices significant interobserver variability may exist. Bias in the form of other skin chromogens also interferes with accuracy. Rapid changes in serum or cutaneous bilirubin concentration or nonhomogeneous distribution of cutaneous bilirubin interferes with our knowledge of cutaneous-blood bilirubin kinetics. At present transcutaneous bilirubinometry cannot replace routine serum measurements, but both new and old transcutaneous devices can serve as effective screening devices. The choice of which device to use depends on its cost-effectiveness in any given clinical setting.
Archives of disease in childhood. Fetal and neonatal edition, Jan 10, 2017
As the prescription opioid epidemic grew in the USA, its impact extended to pregnant women and th... more As the prescription opioid epidemic grew in the USA, its impact extended to pregnant women and their infants. This review summarises how increasing rates of neonatal abstinence syndrome resulted in a need to improve care to pregnant women and opioid-exposed infants. We discuss the variations in care delivery with particular emphasis on screening at-risk mothers, scoring systems for neonatal drug withdrawal, type and duration of pharmacotherapy, and discharge safety.
Manual of Neonatal Respiratory Care, 2012
Extracorporeal membrane oxygenation is still a relatively new technology that has recently achiev... more Extracorporeal membrane oxygenation is still a relatively new technology that has recently achieved recognition after initial clinical disappointment in the late 1970s. At present, it is considered standard therapy for the full-term infant with PPHN who fails CMV and extraordinary, heroic therapy for older children and adults with ARF or cardiac failure, or both. Currently, the emphasis is on developing new technologies for increasing safety and effectiveness. Areas of interest include heparinless circuits, carotid artery reconstruction, improved monitoring, and expanding applications of VV ECMO. As ECMO becomes safer and more effective, it is believed that new and expanding patient populations will emerge to include premature infants, earlier intervention in term infants, and more liberal application to pediatric and adult populations.
The Laryngoscope, 2006
To review incidence of, indications for, and outcomes of tracheotomy in very low birth weight (VL... more To review incidence of, indications for, and outcomes of tracheotomy in very low birth weight (VLBW) infants. Retrospective review in tertiary care hospital. Eighteen VLBW (&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;1,500 g) infants with bronchopulmonary dysplasia undergoing tracheotomy in the neonatal intensive care unit between October 1997 and June 2002 were studied. Controls consisted of 36 VLBW infants undergoing intubation without tracheotomy, two per study infant, matched by gestational age and weight. Outcome measures included duration and number of intubation events, time to decannulation, complications, comorbidities, length of stay, and speech, language, and swallowing measures. Infants undergoing tracheotomy had an average duration of intubation of 128.8 days with a median number of 11.5 intubation events, both significantly greater than those of controls. Percentage of those with laryngotracheal stenosis was 44% of study infants had laryngotracheal stenosis compared to 1.6% in all intubated VLBW infants. The tracheotomy group had a significantly higher incidence of gastroesophageal reflux, pulmonary hypertension, and gastrostomy tube placement. The overall tracheotomy-related complication rate was 38.9%. Three were lost to follow-up, and five deaths occurred, two possibly tracheotomy-related. Six of ten were decannulated by an average time of 3.8 years, two of six after laryngotracheal reconstruction. Four of ten remained cannulated for a variety of reasons. Disorders of speech, language, and swallowing were common. When considering tracheotomy in VLBW infants, the total number of intubation events should be monitored as well as the total duration of intubation. The relatively high incidence of laryngotracheal stenosis argues for earlier endoscopy and possibly earlier tracheotomy in infants with developing stenoses.
Seminars in Fetal and Neonatal Medicine, 2011
The practice of evidence-based medicine involves the judicious use of current best evidence in th... more The practice of evidence-based medicine involves the judicious use of current best evidence in the care of individual patients. Decisions about diagnosis, prognosis and treating patients require knowledge of the probability and value of outcomes. Decision analysis illustrates how probabilities and values help define one another, and each are important. Whereas initial probability estimates can be obtained by &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;searching for the best evidence&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;, values belong to individuals. Obtaining values from patients or parents is sometimes difficult and requires a respectful, thoughtful, systematic approach, but only after doing this is neonatal care evidence-based.
Journal of Perinatology, 2008
Journal of Pediatric Surgery, 1993
JAMA, 2012
Recently, analyses from Australia 12 and the Florida Medicaid program (D. Aronberg, JD, written c... more Recently, analyses from Australia 12 and the Florida Medicaid program (D. Aronberg, JD, written communication, November 30, 2011) found that Author Affiliations are listed at the end of this article.
Ear and Hearing, 1990
Brain stem auditory evoked responses (BAERs) were obtained in 25 infants who received extracorpor... more Brain stem auditory evoked responses (BAERs) were obtained in 25 infants who received extracorporeal membrane oxygenation (ECMO) for severe respiratory failure. Tracings were obtained by means of a Nicolet CA-2000 averager, using a conventional paradigm. The presence or absence of replicated responses at 35 and 75 dB nHL were recorded for each ear. Interpeak latencies I-III, III-V, and I-V were measured and differences between right and left ears were compared, using a matched pair t-test. Wave III-V latencies were longer on the left than right (p less than 0.05), but no significant right-left differences for latencies I-III were noted. Sixteen percent of the infants failed hearing sensitivity criteria, 45% (10/23) had prolonged I-V latencies. At follow-up (age 4 to 12 months) 6/10 infants with prolonged I-V latencies had additional neurologic abnormalities. In this population left ear III-V latencies are prolonged versus right, and the incidence of abnormal BAERs is high. Relative prolongation of left ear III-V latencies (generated from the right brain stem) may be result of right carotid artery and/or jugular vein ligation for ECMO, and abnormal I-V latencies prognosticate future neurologic abnormalities in this population.
Clinics in Perinatology, 2001
Extracorporeal membrane oxygenation was established as a standard of care by demonstrating its ab... more Extracorporeal membrane oxygenation was established as a standard of care by demonstrating its ability to save lives in moribund infants. The designs of early studies provided no living cohorts of similarly ill patients by which to measure accurately other (and perhaps to many more important) outcomes of interest: long-term neurodevelopmental outcomes or cost. Prospective cohort studies of neurodevelopmental outcomes post-ECMO demonstrate: (1) because ECMO, as used, saves lives, there will be an increase in the absolute number of handicapped children surviving; (2) there is little evidence that ECMO creates a relative increase in the percent of handicapped children surviving severe respiratory failure. The high direct costs of an ECMO program are measured and well publicized. When such costs are compared with similar therapies in other fields (in such terms as cost per survivor), the cost of ECMO does not seem to be an outlier. Trials of newer therapies, such as iNO, show the capacity to decrease the use of ECMO but have failed to demonstrate either cost-effectiveness or better long-term outcomes. It has not been shown that either society or individual patients have benefited from the decreased need for ECMO.
BMC Pediatrics, 2012
Background: Whether lumbar punctures (LPs) should be performed routinely for term newborns suspec... more Background: Whether lumbar punctures (LPs) should be performed routinely for term newborns suspected of having early onset neonatal sepsis (EONS) is subject to debate. It is unclear whether variations in performance of LPs for EONS may be associated with patient, hospital, insurance or regional factors. Our objective was to identify characteristics associated with the practice of performing LPs for suspected EONS in a nationally representative sample. Methods: Utilizing data from the 2003, 2006 and 2009 Kids' Inpatient Database (KID) compiled by the Agency for Healthcare Research and Quality, we examined the frequency and characteristics of term, normal-birth weight newborns receiving an LP for EONS. Survey-weighting was applied for national estimates and used in chi squared and multivariable regression analysis. Results: In 2009, there were 13,694 discharges for term newborns that underwent LPs for apparent EONS. Newborns having LPs performed were more likely to be covered by Medicaid vs. private insurance (51.9 vs. 45.1 percent; p < 0.001), be born in urban vs. rural hospitals (94.8 vs. 87.3 percent; p < 0.001), teaching vs. non-teaching (60.8 vs. 43.1 percent; p < 0.001) and children's hospitals vs. non-children's (23.0 vs. 11.2 percent; p < 0.001). Lastly, newborns having LPs performed were disproportionately born in the Northeast census region (p = 0.03). In multi-year adjusted analysis, infants with Medicaid coverage, and those born in urban or teaching hospitals, consistently had higher odds of having an LP performed. Conclusions: We found pronounced variation in LPs performed for EONS, even when adjusting for clinical conditions that would prompt LPs. These findings indicate practice variations in newborn care that merit further examination and explanation.
ASAIO Journal, 1993
Clinicians reserve ECMO for neonates at > 80% predicted mortality risk. The authors hypoth... more Clinicians reserve ECMO for neonates at > 80% predicted mortality risk. The authors hypothesized that ECMO instituted at lower (50%) mortality risk would result in fewer intensive care unit days and a lower hospital cost compared with conventional therapy (including ECMO at high mortality risk). This was a randomized control trial, cost-benefit analysis in an academic newborn intensive care unit. The patients were a prospectively studied, consecutive sample of 41 term neonates with 1) age 24-72 hours, 2) "maximal medical management" for > 6 hours, 3) oxygenation index (OI) values > 25 but < 40. (Severity of illness measured by OI = ((mean airway pressure x FiO2 x 100) PaO2)). All eligible patients entered. Thirty-two of 37 survivors were evaluated at 1 year. Intervention occurred when OI = 25. Patients were randomized to ECMO or continued medical management (ECMO possible at OI = 40). Planned primary outcome measures were ICU days and hospital charges. Secondary measures were pulmonary and neurologic outcomes at discharge and 1 year. Twenty-two early ECMO patients, 19 controls, 14/19 met late ECMO criteria. Four patients died (two each group). No statistically significant difference was seen in hospital charges (early ECMO = 49,500versuscontrol=49,500 versus control = 49,500versuscontrol=53,7000), (95% confidence intervals = -$3200 to +$5100 more for controls) or ICU days (early = 14 + 5 days versus control = 19 + 12 days) (95% CI = -0.8 to +10 more for controls). At 1 year the early group had a higher mental developmental index score (115 + 11) versus (103 + 18), (p = 0.07).(ABSTRACT TRUNCATED AT 250 WORDS)
Annals of Pharmacotherapy, 2008
Background: Preventing significant oxygen desaturation and hypotension through adequate analgesia... more Background: Preventing significant oxygen desaturation and hypotension through adequate analgesia and sedation during nonemergent Intubation In neonates is desirable. However, in many neonatal intensive care units, elective intubations occur without adequate premedication. There is significant variation In the choice of premedication agen(s) and doses, and an ideal regimen for use during nonemergent intubation has not been developed. Objective: To evaluate the efficacy of an algorithm developed for analgesia and sedation during nonemergent Intubation in neonates. Methods: Prospectively collected continuous quality Improvement data on a premedication algorithm for nonemergent intubation were analyzed following institutions] review board approval. Midazolam 0.1 mg/kg and fentanyl 2 μg/kg (if the patient was not already receiving morphine for sedation) were administered prior to nonemergent intubation. Heart rate, oxygen saturation, respiration rate, mean arterial pressure, and pain sc...
American Journal of Perinatology, 2009
Grade 3 intraventricular hemorrhage (IVH) (without parenchymal involvement) and grade 4 IVH (with... more Grade 3 intraventricular hemorrhage (IVH) (without parenchymal involvement) and grade 4 IVH (with parenchymal involvement) are often combined into description of a single entity, usually &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;severe&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot; IVH, despite different long-term neurodevelopmental outcome. Although risk factors for severe IVH have already been well described, it is not known if these risk factors and associated short-term neonatal morbidities are different for grade 3 and grade 4 IVH, and indeed, this clustering of grade 3 and grade 4 IVH into severe IVH precludes further delineation of the potential risk and protective factors that can be altered to reduce the incidence of grade 4 IVH, which is presumably associated with worse outcome compared with grade 3 IVH. We sought to characterize and compare commonly cited risk factors and associated short-term neonatal morbidities between grade 3 and grade 4 IVH in very low-birth-weight (VLBW) infants. We performed a retrospective review of VLBW (birth weight &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 1500 g) infants with severe IVH born between January 2001 and March 2007. Fifty-nine (10.5%) of 562 infants surviving beyond 3 days of age had severe IVH as recorded on routine cranial sonography during the first 7 to 10 days of life, 28 had grade 3, and 31 had grade 4 IVH. Infants with grade 4 IVH were younger [gestational age (weeks), grade 4 IVH versus grade 3 IVH: 25.5 +/- 1.7 versus 26.7 +/- 1.7, p = 0.02) and weighed less at birth [birth weight (g), grade 4 IVH versus grade 3 IVH: 860 +/- 214 versus 1007 +/- 253, p = 0.03) compared with infants with grade 3 IVH. Other commonly cited clinical factors that alter the risk for severe IVH, including mode of delivery, pregnancy-induced hypertension, premature and/or prolonged rupture of membranes, maternal fever, maternal bleeding, prenatal steroid administration, maternal magnesium sulfate therapy, 1-minute and 5-minute Apgar scores, need for delivery room resuscitation (epinephrine and chest compressions), surfactant therapy, presence of refractory hypotension, evidence of early onset culture-proven sepsis, use of high-frequency ventilation, presence of pneumothorax, and hemodynamically significant patent ductus arteriosus, were similar between infants with grade 3 and grade 4 IVH. Carbon dioxide tensions (minimum PaC (2), maximum PaCO(2), mean PaCO(2), standard deviation of PaCO(2), and coefficient of variation of PaCO (2)) in infants receiving mechanical ventilation during first 3 postnatal days were also not statistically dissimilar. To determine the variables differentiating grade 3 from grade 4 IVH in the study population, logistic regression analysis confirmed only the independent association of gestational age (odds ratio [OR] 0.6, 95% confidence interval [CI] 0.5 to 0.9, P = 0.012) and maternal magnesium sulfate therapy (OR 0.3, 95% CI 0.07 to 0.9, P = 0.04) with the development of grade 4 IVH. Short-term neonatal morbidities were also similar between infants with grade 3 and grade 4 IVH. Among VLBW infants, the risk of a grade 4 versus grade 3 IVH increases with declining gestational age, but does not appear to be related to other commonly cited clinical factors. This information may be useful for prognostication and may improve the quality of parental counseling.
Journal of Perinatology, 2007
… : The Journal of …, 1992
Extracorporeal membrane oxygenation (ECMO) may affect the pharmacokinetics of certain drugs. The ... more Extracorporeal membrane oxygenation (ECMO) may affect the pharmacokinetics of certain drugs. The objectives of this study were to determine (1) the pharmacokinetics of gentamicin in neonates on ECMO and compare them to reported values for a similar patient population not on ECMO, (2) i f the pharmacokinetics of gentamicin differ between venous-venous and venousarterial bypass, and (3) if the pharmacokinetics of gentamicin are affected by oxygenator surface area (0.6 m' vs 0.8 m' oxygenators). The medical records of 29 term neonates who received gentamicin while on ECMO were reviewed. Data collected included gentamicin dosage, peak and trough serum concentrations determined at steady state, duration of treatment, time on ECMO, daily weights, and pertinent laboratory values. An initial dosage of gentamicin 2.5 mg/kg every 18 hours is suggested for term neonates on ECMO. Dosage adjustments should be based on gentamicin serum concentrations, and modifications may also be required after ECMO. (Pharmacotherapy 1992;12(1):2&32) Extracorporeal membrane oxygenation (ECMO) involves the use of prolonged cardiopulmonary bypass in neonates with severe respiratory failure. This allows for a period of lung rest and recovery without the potentially damaging complications associated with prolonged mechanical ventilation, and is considered life saving for infants at high risk of dying from respiratory failure (Figure l).' Since the technique was pioneered in the mid-l970s, more than 4000 infants have received ECMO for respiratory failure. At present, approximately 1000 patients are being added to the National Registry in Ann Arbor, Michigan, each year.* Several ECMO-related factors can theoretically affect the pharmacokinetics of certain drugs. The ECMO circuit presents a large surface area for adsorption of drugs onto a foreign surface, theoretically increasing the volume of drug distribution and reducing the bioavailability of the first dose. Three different sizes of membrane
Journal of Perinatology, 2012
Objective: To determine whether phenobarbital (PB) given before therapeutic hypothermia to infant... more Objective: To determine whether phenobarbital (PB) given before therapeutic hypothermia to infants with hypoxic-ischemic encephalopathy (HIE) augments the neuroprotective efficacy of hypothermia. Study Design: Records of 68 asphyxiated infants of X36 weeks' gestation, who received hypothermia for moderate or severe HIE were reviewed. Some of these infants received PB prophylactically or for clinical seizures. All surviving infants had later brain magnetic resonance imaging (MRI). The composite primary outcome of neonatal death related to HIE with worsening multiorgan dysfunction despite maximal treatment, and the presence of post-hypothermia brain MRI abnormalities consistent with hypoxic-ischemic brain injury, were compared between the infants who received PB before initiation of hypothermia (PB group, n ¼ 36) and the infants who did not receive PB before or during hypothermia (No PB group, n ¼ 32). Forward logistic regression analysis determined which of the pre-hypothermia clinical and laboratory variables predict the primary outcome. Result: The two groups were similar for severity of asphyxia as assessed by Apgar scores, initial blood pH and base deficit, early neurologic examination, and presence of an intrapartum sentinel event. The composite primary outcome was more frequent in infants from the PB group (PB 78% versus No PB 44%, P ¼ 0.006, odds ratio 4.5, 95% confidence interval 1.6 to 12.8). Multivariate analysis identified only the PB receipt before initiation of hypothermia (P ¼ 0.002, odds ratio 9.5, 95% confidence interval 2.3 to 39.5), and placental abruption to be independently associated with a worse primary outcome. Conclusion: PB treatment before cooling did not improve the composite outcome of neonatal death or the presence of an abnormal post-hypothermia brain MRI, but the long-term outcomes have not yet been evaluated.
American Journal of Perinatology, 2010
The purpose of this observational study was to characterize the clinical course of newborn infant... more The purpose of this observational study was to characterize the clinical course of newborn infants with spontaneous pneumothorax and to identify those infants who eventually required further interventions. We performed a retrospective review of newborns with symptomatic spontaneous pneumothorax, born between January 2002 and December 2007. Seventy-six infants ≥36 weeks&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; gestation were identified with symptomatic spontaneous pneumothorax. Twenty-two (29%) of the 76 infants with spontaneous pneumothorax required either thoracentesis or/and thoracostomy drainage, and 54 (71%) were managed without such intervention. In all, 18 (24%) infants received mechanical ventilation and 12 (16%) infants developed persistent pulmonary hypertension (PPHN) during the course of illness. Ten of the 22 infants requiring thoracentesis and/or thoracostomy for progressively worsening respiratory distress developed PPHN. Seven of these 10 infants with PPHN received inhaled nitric oxide, and four infants subsequently required extracorporeal membrane oxygenation. In contrast, the majority of the infants (50 of 54, 93%) not requiring thoracentesis or/and thoracostomy could be managed simply with supplemental oxygen or close observation. Progressively worsening respiratory distress prompting intervention in infants with spontaneous pneumothorax may indicate presence of PPHN that needs prompt recognition and referral to tertiary-level neonatal units for escalating respiratory support.
Objective: To assess the effectiveness of furosemide therapy to prevent hemodynamic and respirato... more Objective: To assess the effectiveness of furosemide therapy to prevent hemodynamic and respiratory compromise in electively transfused preterm infants. Methods: Twenty preterm infants (birth weight: 878.5 ± 207 g; gestational age: 26 ± 1.3 weeks) with RDS requiring conventional mechanical ventilation were randomly assigned to receive either a single intravenous dose of furosemide (1 mg/kg) or an equivalent volume of placebo (normal saline) at the completion of an elective "top off" 3-hour transfusion (15 mL/kg) of packed red blood cells (PRBC) during the first 2 weeks of life. Multiple clinical and respiratory parameters were recorded during the transfusion. Results: Twelve of the 20 infants (60%) received furosemide while 8 infants received placebo at a median postnatal age of 6 days. The clinical parameters (SPO2, BP, HR, spontaneous RR), ventilatory parameters (minute ventilation, compliance, and resistance), PaCO2, or A-a DO2 were similar in the furosemide and placebo treated groups at the completion of the transfusion, and at 4 hours after completion of the transfusion. Conclusion: In this pilot study, a single dose of furosemide after PRBC transfusion did not alter the clinical or pulmonary parameters compared to placebo during the 4 hour period following the transfusion. Its continued use for this purpose may not be justified.