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Premature infants commonly receive adult packed red blood cells (pRBCs) during their hospital stay. As adult erythrocytes differ substantially from those of preterm infants, transfusion of adult pRBCs into preterm infants can be considered inappropriate for the physiology of a preterm infant. An absence of standardisation of transfusion protocols makes it difficult to compare and interpret pertinent clinical data, as reflected by unclear associations between pRBC transfusion and complications related to prematurity, such as bronchopulmonary dysplasia, neurodevelopmental impairment, retinopathy of prematurity, or necrotising enterocolitis. The difficulty in interpreting clinical data is further increased by differences in study designs that either overestimate pRBC-associated complications of prematurity or have not yet been designed to directly link pRBC transfusions to their respective complications. Thus, neonatal transfusion practice has become an ongoing difficulty, in which differences in transfusion guidelines hinder the ability to generate comparable clinical data, and heterogeneity in clinical data prevents the implementation of standardised transfusion protocols. To overcome these issues, novel approaches with biochemical-clinical translational designs could enable clinicians to gather causal evidence instead of circumstantial correlation.

ObjectiveTo assess the reliability, accuracy and precision of distal end-tidal capnography (detCO2) in neonates compared with transcutaneous (tcCO2) carbon dioxide measurements.DesignObservational, prospective clinical study.SettingNeonatal intensive care unit at Medical University of Vienna.ParticipantsConventionally ventilated neonates with a body weight between 1000 g and 3000 g.InterventionEnd-tidal partial pressure of CO2was measured in distal position using the separate lumen of a double-lumen endotracheal tube connected to an external side-stream capnometer. Three consecutive detCO2and tcCO2values were recorded simultaneously and compared with simultaneous arterialised partial pressure of CO2(paCO2) measurements in each patient.Main outcome measuresReliability, accuracy and precision of detCO2and tcCO2measurements compared with paCO2in neonates.ResultsTwenty-five neonates were included with a median (range) weight at enrolment of 1410 (1010–2980) g, from which 81 simultaneous measurements of detCO2, tcCO2and paCO2were obtained. The mean (SD) of paCO2, detCO2and tcCO2was 45.0 (8.6) mmHg, 42.4 (8.4) mmHg and 50.4 (20.4) mmHg, respectively. The intraclass correlation between paCO2and detCO2and between paCO2and tcCO2reached 0.80 (95% CI 0.71 to 0.87, p<0.001) and 0.59 (95% CI 0.43 to 0.72, p<0.001), respectively. In the Bland-Altman analysis, bias and precision of detCO2with respect to paCO2amounted to −2.68 mmHg and 10.62 mmHg (95% CI 8.49 to 14.51), respectively. Bias and precision of tcCO2with respect to paCO2amounted to 5.39 mmHg and 17.22 mmHg (95% CI 13.21 to 23.34), respectively.ConclusionDetCO2had better reliability, accuracy and precision with paCO2than tcCO2in ventilated neonates without severe lung diseas.Trial registration numberNCT03758313.

Pregnant women with influenza-A have an increased risk of developing acute respiratory distress syndrome (ARDS). Extracorporeal membrane oxygenation (ECMO) can be used as salvage therapy, with lung transplantation as a therapeutic option. However, successful bilateral lung transplantation during pregnancy has never been reported before. We herein report the case of a 34-year-old primipara, who was diagnosed with ARDS caused by influenza-A-induced pneumonia at early gestation. After considering all possible therapeutic options and being fully dependent on VV-ECMO support, she underwent bilateral lung transplantation. The transplantation with intraoperative central VA-ECMO support was successfully performed with good recovery after an initial primary graft dysfunction. The pregnancy was prolonged until 29+5gestational weeks. The newborn exhibited growth retardation and was initially stabilized, but later died due to severe, hypoxic respiratory failure and pulmonary hypertension. In conclusion, lung transplantation is a possible salvage therapy for patients with severe lung failure following ARDS during pregnancy. However, it places the mother and unborn child at risk. A multi-professional approach is warranted to diagnose and treat complications at an early stage.

Pregnant women with influenza‐A have an increased risk of developing acute respiratory distress syndrome (ARDS). Extracorporeal membrane oxygenation (ECMO) can be used as salvage therapy, with lung transplantation as a therapeutic option. However, successful bilateral lung transplantation during pregnancy has never been reported before. We herein report the case of a 34‐year‐old primipara, who was diagnosed with ARDS caused by influenza‐A‐induced pneumonia at early gestation. After considering all possible therapeutic options and being fully dependent on VV‐ECMO support, she underwent bilateral lung transplantation. The transplantation with intraoperative central VA‐ECMO support was successfully performed with good recovery after an initial primary graft dysfunction. The pregnancy was prolonged until 29+5gestational weeks. The newborn exhibited growth retardation and was initially stabilized, but later died due to severe, hypoxic respiratory failure and pulmonary hypertension. In conclusion, lung transplantation is a possible salvage therapy for patients with severe lung failure following ARDS during pregnancy. However, it places the mother and unborn child at risk. A multi‐professional approach is warranted to diagnose and treat complications at an early stage. This case report of successful bilateral lung transplantation during pregnancy shows that lung transplantation is a possible salvage therapy for pregnant women with severe lung failure.

The gut microbiome is associated with pathological neurophysiological evolvement in extremely premature infants suffering from brain injury. The exact underlying mechanism and its associated metabolic signatures in infants are not fully understood. To decipher metabolite profiles linked to neonatal brain injury, we investigate the fecal and plasma metabolome of samples obtained from a cohort of 51 extremely premature infants at several time points, using liquid chromatography (LC)-high-resolution mass spectrometry (MS)-based untargeted metabolomics and LC-MS/MS-based targeted analysis for investigating bile acids and amidated bile acid conjugates. The data are integrated with 16S rRNA gene amplicon gut microbiome profiles as well as patient cytokine, growth factor, and T cell profiles. We find an early onset of differentiation in neuroactive metabolites between infants with and without brain injury. We detect several bacterially derived bile acid amino acid conjugates in plasma and feces. These results provide insights into the early-life metabolome of extremely premature infants.

Fetal/neonatal thyrotoxicosis is a rare but potentially life-threatening condition. It is most commonly observed in poorly controlled Graves disease during pregnancy.

ObjectiveTo investigate whether monitoring of cerebral tissue oxygen saturation using near infrared spectroscopy in addition to routine monitoring combined with defined treatment guidelines during immediate transition and resuscitation increases survival without cerebral injury of premature infants compared with standard care alone.DesignMulticentre, multinational, randomised controlled phase 3 trial.Setting11 tertiary neonatal intensive care units in six countries in Europe and in Canada.Participants1121 pregnant women (<32 weeks’ gestation) were screened prenatally. The primary outcome was analysed in 607 of 655 randomised preterm neonates: 304 neonates in the near infrared spectroscopy group and 303 in the control group.InterventionPreterm neonates were randomly assigned to either standard care (control group) or standard care plus monitoring of cerebral oxygen saturation with a dedicated treatment guideline (near infrared spectroscopy group) during immediate transition (first 15 minutes after birth) and resuscitation.Main outcome measureThe primary outcome, assessed using all cause mortality and serial cerebral ultrasonography, was a composite of survival without cerebral injury. Cerebral injury was defined as any intraventricular haemorrhage or cystic periventricular leukomalacia, or both, at term equivalent age or before discharge.ResultsCerebral tissue oxygen saturation was similar in both groups. 252 (82.9%) out of 304 neonates (median gestational age 28.9 (interquartile range 26.9-30.6) weeks) in the near infrared spectroscopy group survived without cerebral injury compared with 238 (78.5%) out of 303 neonates (28.6 (26.6-30.6) weeks) in the control group (relative risk 1.06, 95% confidence interval 0.98 to 1.14). 28 neonates died (near infrared spectroscopy group 12 (4.0%) vcontrol group 16 (5.3%): relative risk 0.75 (0.33 to 1.70).ConclusionMonitoring of cerebral tissue oxygen saturation in combination with dedicated interventions in preterm neonates (<32 weeks’ gestation) during immediate transition and resuscitation after birth did not result in substantially higher survival without cerebral injury compared with standard care alone. Survival without cerebral injury increased by 4.3% but was not statistically significant.Trial registrationClinicalTrials.gov NCT03166722.