Publications by authors named "Stefano Martinelli"

13 Publications

  • Page 1 of 1

Neonatal Septic Shock and Hemodynamic Monitoring in Preterm Neonates in a NICU: Added Value of Electrical Cardiometry in Real-Time Tailoring of Management and Therapeutic Strategies.

Am J Perinatol 2021 Mar 15. Epub 2021 Mar 15.

Neonatal Intensive Care Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy.

Objective:  Electrical cardiometry is an impedance-based monitoring technique that provides data on several hemodynamic parameters in a noninvasive way. There is limited information on clinical utility of the application of this technique in neonates.

Study Design:  In this study, we describe the case of a preterm neonate born at 30 weeks of gestational age who developed severe systemic infection with fluid refractory septic shock on day 2 of life.

Discussion:  Electrical cardiometry was used and proved very helpful in real-time guiding the choice and the dosing of the most appropriate inotrope drugs in this patient. In addition, it promptly underlined an abrupt drop of systemic vascular resistances occurring after administration of the first dose of antibiotic, thus warning the attending neonatologist to institute appropriate treatment before the clinical conditions could further worsen.

Conclusion:  This case report suggests that electrical cardiometry could be a useful tool in assessing, monitoring, and guiding care of neonates who develop severe septic shock. We suggest that electrical cardiometry is a promising approach in the management strategies of such patients that warrants informative clinical trials.

Key Points: · Electrical cardiometry was helpful in real-time decision-making.. · Electrical cardiometry reported hemodynamic perturbations before worsening of clinical conditions.. · Electrical cardiometry should be included in the management of critical patients..
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http://dx.doi.org/10.1055/s-0041-1726123DOI Listing
March 2021

Is NIRS enough to improve hemodynamic monitoring in the neonatal intensive care?

J Matern Fetal Neonatal Med 2021 Mar 10:1-2. Epub 2021 Mar 10.

Neonatal Intensive Care Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy.

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http://dx.doi.org/10.1080/14767058.2020.1843625DOI Listing
March 2021

Noninvasive Cardiac Output Monitoring in Newborn with Hypoplastic Left Heart Syndrome.

Am J Perinatol 2020 09 8;37(S 02):S54-S56. Epub 2020 Sep 8.

Neonatal Intensive Care Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy.

Objective: This study aimed to describe the first two cases of electrical cardiometry applied to newborn with hypoplastic left heart syndrome for hemodynamical assessment in the first days of life before surgical correction and see if this can help decision making process in these patients.

Study Design: We describe two case series of two full-term newborn with hypoplastic left heart syndrome in the Neonatal Intensive Care Unit, ASST Grande Ospedale Metropolitano Niguarda, between December 2019 and January 2020.

Results: Case 1 was persistently hemodynamically stable with prostaglandin E1 infusion at 0.01 mcg/kg/min, showing good capillary refill time, good diuresis, no difference between pre- and postductal values of oxygen saturation or blood pressure. Electrical cardiometry monitoring constantly showed cardiac output values higher than 300 mL/kg/min. Case 2 showed poor clinical condition needing prostaglandin E1 infusion up to 0.05 mcg/kg/min, intubation and septostomy associated with low cardiac output around 190 mL/kg/min. Once cardiac output has begun to rise and reached values constantly over 300 mL/kg/min, clinical condition improved with amelioration in oxygen saturation, diuresis, blood pressure, and blood gas analysis values. She was then extubated and finally clinically stable until surgery with minimal infusion of prostaglandin E1 at 0.01 mcg/kg/min.

Conclusion: This case highlights how hemodynamic information provided by electrical cardiometry can be used to supplement the combined data from all monitors and the clinical situation to guide therapy in these newborns waiting surgery.

Key Points: · This is the first report of electrical cardiometry (EC) use in newborn with hypoplastic left heart syndrome (HLHS).. · In HLHS patients, it is impossible to measure cardiac output without being invasive.. · EC helps in guiding therapy in HLHS patients in a noninvasive way..
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http://dx.doi.org/10.1055/s-0040-1713603DOI Listing
September 2020

Lung recruitment before surfactant administration in extremely preterm neonates with respiratory distress syndrome (IN-REC-SUR-E): a randomised, unblinded, controlled trial.

Lancet Respir Med 2021 02 17;9(2):159-166. Epub 2020 Jul 17.

Centre for Child Health Research and School of Human Sciences, The University of Western Australia, Perth, WA, Australia.

Background: The importance of lung recruitment before surfactant administration has been shown in animal studies. Well designed trials in preterm infants are absent. We aimed to examine whether the application of a recruitment manoeuvre just before surfactant administration, followed by rapid extubation (intubate-recruit-surfactant-extubate [IN-REC-SUR-E]), decreased the need for mechanical ventilation during the first 72 h of life compared with no recruitment manoeuvre (ie, intubate-surfactant-extubate [IN-SUR-E]).

Methods: We did a randomised, unblinded, controlled trial in 35 tertiary neonatal intensive care units in Italy. Spontaneously breathing extremely preterm neonates (24 + 0 to 27 + 6 weeks' gestation) reaching failure criteria for continuous positive airway pressure within the first 24 h of life were randomly assigned (1:1) with a minimisation algorithm to IN-REC-SUR-E or IN-SUR-E using an interactive web-based electronic system, stratified by clinical site and gestational age. The primary outcome was the need for mechanical ventilation in the first 72 h of life. Analyses were done in intention-to-treat and per-protocol populations, with a log-binomial regression model correcting for stratification factors to estimate adjusted relative risk (RR). This study is registered with ClinicalTrials.gov, NCT02482766.

Findings: Of 556 infants assessed for eligibility, 218 infants were recruited from Nov 12, 2015, to Sept 23, 2018, and included in the intention-to-treat analysis. The requirement for mechanical ventilation during the first 72 h of life was reduced in the IN-REC-SUR-E group (43 [40%] of 107) compared with the IN-SUR-E group (60 [54%] of 111; adjusted RR 0·75, 95% CI 0·57-0·98; p=0·037), with a number needed to treat of 7·2 (95% CI 3·7-135·0). The addition of the recruitment manoeuvre did not adversely affect the safety outcomes of in-hospital mortality (19 [19%] of 101 in the IN-REC-SUR-E group vs 37 [33%] of 111 in the IN-SUR-E group), pneumothorax (four [4%] of 101 vs seven [6%] of 111), or grade 3 or worse intraventricular haemorrhage (12 [12%] of 101 vs 17 [15%] of 111).

Interpretation: A lung recruitment manoeuvre just before surfactant administration improved the efficacy of surfactant treatment in extremely preterm neonates compared with the standard IN-SUR-E technique, without increasing the risk of adverse neonatal outcomes. The reduced need for mechanical ventilation during the first 72 h of life might facilitate implementation of a non-invasive respiratory support strategy.

Funding: None.
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http://dx.doi.org/10.1016/S2213-2600(20)30179-XDOI Listing
February 2021

Neonatal gastrointestinal involvement and congenital cytomegalovirus.

Pediatr Med Chir 2016 Nov 28;38(3):134. Epub 2016 Nov 28.

Pediatric, Neonatal and Neonatal Pathology Units, G. Fornaroli Hospital, Magenta (MI), Civil Hospital of Legnano (MI).

Cytomegalovirus (CMV) is the most common cause of congenital viral infection, affecting 0.2 to 2.3% of all live births in developed countries. Very low birth weight and extremely low birth weight newborns are at higher risk of symptomatic CMV infection, most commonly secondary and acquired through breast milk. Gastrointestinal involvement is rare in acquired CMV infections, but it could be an important manifestation of postnatal infection in preterm infants admitted to neonatal intensive care units. Early onset of CMV gastrointestinal signs/symptoms is very rare. In a review of the literature it is described in 5 newborns in the first 24 hours of life, and 6 considering the onset in the first week of life. This review describes also a case report of congenital CMV in an immunocompetent newborn with onset of gastrointestinal signs immediately after birth: a possible association between viral infection and enteric manifestations was considered in the differential diagnosis. A review of the literature of the different case reports found has done, with description and comparison of the different patients and clinical presentations.
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http://dx.doi.org/10.4081/pmc.2016.134DOI Listing
November 2016

Efficacy of a new technique - INtubate-RECruit-SURfactant-Extubate - "IN-REC-SUR-E" - in preterm neonates with respiratory distress syndrome: study protocol for a randomized controlled trial.

Trials 2016 08 18;17:414. Epub 2016 Aug 18.

Ospedale Santa Maria di Ca' Foncello di Treviso, Treviso, Italy.

Background: Although beneficial in clinical practice, the INtubate-SURfactant-Extubate (IN-SUR-E) method is not successful in all preterm neonates with respiratory distress syndrome, with a reported failure rate ranging from 19 to 69 %. One of the possible mechanisms responsible for the unsuccessful IN-SUR-E method, requiring subsequent re-intubation and mechanical ventilation, is the inability of the preterm lung to achieve and maintain an "optimal" functional residual capacity. The importance of lung recruitment before surfactant administration has been demonstrated in animal studies showing that recruitment leads to a more homogeneous surfactant distribution within the lungs. Therefore, the aim of this study is to compare the application of a recruitment maneuver using the high-frequency oscillatory ventilation (HFOV) modality just before the surfactant administration followed by rapid extubation (INtubate-RECruit-SURfactant-Extubate: IN-REC-SUR-E) with IN-SUR-E alone in spontaneously breathing preterm infants requiring nasal continuous positive airway pressure (nCPAP) as initial respiratory support and reaching pre-defined CPAP failure criteria.

Methods/design: In this study, 206 spontaneously breathing infants born at 24(+0)-27(+6) weeks' gestation and failing nCPAP during the first 24 h of life, will be randomized to receive an HFOV recruitment maneuver (IN-REC-SUR-E) or no recruitment maneuver (IN-SUR-E) just prior to surfactant administration followed by prompt extubation. The primary outcome is the need for mechanical ventilation within the first 3 days of life. Infants in both groups will be considered to have reached the primary outcome when they are not extubated within 30 min after surfactant administration or when they meet the nCPAP failure criteria after extubation.

Discussion: From all available data no definitive evidence exists about a positive effect of recruitment before surfactant instillation, but a rationale exists for testing the following hypothesis: a lung recruitment maneuver performed with a step-by-step Continuous Distending Pressure increase during High-Frequency Oscillatory Ventilation (and not with a sustained inflation) could have a positive effects in terms of improved surfactant distribution and consequent its major efficacy in preterm newborns with respiratory distress syndrome. This represents our challenge.

Trial Registration: ClinicalTrials.gov identifier: NCT02482766 . Registered on 1 June 2015.
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http://dx.doi.org/10.1186/s13063-016-1498-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4991115PMC
August 2016

How to motivate newborn hearing screening in the absence of a national programme: a collaboration between parents and professionals.

J Matern Fetal Neonatal Med 2012 Oct;25 Suppl 4:114-5

Global Coalition of Parents of Children who are Deaf and Hard of Hearing, Italy.

The establishment of the Italian Pediatric Federation Newborn Hearing Screening Network and the Italian Society of Neonatology Infant Hearing Study Group is the result of an international collaboration between Parents and Medical Professionals in order to promote an effective model in developing Early Hearing Detection Intervention Programs that recognize the role of parents as partners in the process. Among other factors, one important component frequently underestimated in most early intervention programs, both in the USA and other countries, involves the role of parental involvement within the Early Hearing Detection Intervention (EHDI) process. When a parent receives the news of their child's hearing loss, reactions may include, but are not limited to denial, grief, guilt, shame, fear and impotency. A parent may begin to ask certain questions: How do we know if the professionals in our children's lives are capable, educated, trained, up to date in their chosen fields of expertise? Do they respect our children and us as parents? Do they understand the needs of children who are deaf or hard of hearing? A life-long health professional - parental collaboration begins at the moment of the diagnosis of that child. When analyzing the habilitation process of a deaf child, the relationship between health professionals and the crucial role of parents in raising that child is a 50-50 shared responsibility. An objective of EHDI programs must be to empower parents by providing support from the beginning of the process. Distributing informative literature regarding the newborn hearing screening process and providing parents with access to resources such as parental support groups upon diagnosis equips parents with the tools necessary to immediately begin advocating for their children. The Italian Federation Pediatric Audiology Network was created by combining the parental perspective and medical protocols in order to establish the roots for stronger EHDI programs.
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http://dx.doi.org/10.3109/14767058.2012.715016DOI Listing
October 2012

SpO2 and retinopathy of prematurity: state of the art.

J Matern Fetal Neonatal Med 2012 Oct;25 Suppl 4:108-10

Neonatology and Neonatal Intensive Care Unit, Niguarda Ca' Granda Hospital, Milan, Italy.

Aim: To evaluate the relationship between arterial saturation values determined by pulse oximetry in the first weeks of life on the incidence of retinopathy of prematurity (ROP).

Methods: Randomized and observational studies were sought that compare the incidence of ROP in babies with high or low oxygen saturation targeting assisted by pulse oximetry.

Results: Over the last 15 years, evidence from experimental models of ROP and clinical studies, albeit not randomized trials, has shown a reduction in the incidence of ROP and other neonatal morbidities when very preterm newborns were targeted to a lower level of arterial oxygen saturation during their hospitalization, particularly in the first few weeks after birth. More recent evidence from randomized controlled trials confirms that targeting to a lower vs higher level of oxygenation from birth to 36 weeks postmenstrual age (PMA) or to hospital discharge reduces the incidence of ROP requiring treatment by 50% but is correlated with higher mortality rates.

Conclusion: Future randomized, controlled trials should be designed including a cohort of infants in which a more dynamic approach to saturation targeting is adopted, i.e. lower saturation levels in the first few weeks of life and higher saturation levels after the 32 weeks of PMA.
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http://dx.doi.org/10.3109/14767058.2012.714982DOI Listing
October 2012

Transport as a system: reorganization of perinatal assistance in Northern Lombardy.

J Matern Fetal Neonatal Med 2011 Oct;24 Suppl 1:122-5

Neonatology and Neonatal Intensive Care Unit, Niguarda Ca' Granda Hospital, Milan, Italy.

The organization of perinatal care has been a pivotal mean for improvement in neonatal survivals. Despite the excellent standard of assistance in Lombardy, Obstetrics and Neonatal Units of MBBM Foundation-Monza, Manzoni Hospital-Lecco and Niguarda Hospital-Milan put forward a pilot project proposing reorganization of perinatal care in the northern part of Lombardy. The main goals of the project are implementation of maternal transport system and use of neonatal back transport as a system to increase the availability of intensive care beds. The project's fundamental steps and critical points will be discussed.
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http://dx.doi.org/10.3109/14767058.2011.607670DOI Listing
October 2011

Prophylactic or early selective surfactant combined with nCPAP in very preterm infants.

Pediatrics 2010 Jun 3;125(6):e1402-9. Epub 2010 May 3.

Dipartimento Materno-Infantile, Ospedale Maggiore, Bologna, Italy.

Objective: Early surfactant followed by extubation to nasal continuous positive airway pressure (nCPAP) compared with later surfactant and mechanical ventilation (MV) reduce the need for MV, air leaks, and bronchopulmonary dysplasia. This randomized, controlled trial investigated whether prophylactic surfactant followed by nCPAP compared with early nCPAP application with early selective surfactant would reduce the need for MV in the first 5 days of life.

Methods: A total of 208 inborn infants who were born at 25 to 28 weeks' gestation and were not intubated at birth were randomly assigned to prophylactic surfactant or nCPAP within 30 minutes of birth. Outcomes were assessed within the first 5 days of life and until death or discharge of the infants from hospital.

Results: Thirty-three (31.4%) infants in the prophylactic surfactant group needed MV in the first 5 days of life compared with 34 (33.0%) in the nCPAP group (risk ratio: 0.95 [95% confidence interval: 0.64-1.41]; P = .80). Death and type of survival at 28 days of life and 36 weeks' postmenstrual age and incidence of main morbidities of prematurity (secondary outcomes) were similar in the 2 groups. A total of 78.1% of infants in the prophylactic surfactant group and 78.6% in the nCPAP group survived in room air at 36 weeks' postmenstrual age.

Conclusions: Prophylactic surfactant was not superior to nCPAP and early selective surfactant in decreasing the need for MV in the first 5 days of life and the incidence of main morbidities of prematurity in spontaneously breathing very preterm infants on nCPAP.
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http://dx.doi.org/10.1542/peds.2009-2131DOI Listing
June 2010

Congenital heart block not associated with anti-Ro/La antibodies: comparison with anti-Ro/La-positive cases.

J Rheumatol 2009 Aug 30;36(8):1744-8. Epub 2009 Jun 30.

Medicina Interna, Ospedali Riuniti, Bergamo, Italy.

Objective: To study anti-Ro/La-negative congenital heart block (CHB).

Methods: Forty-five fetuses with CHB were evaluated by analysis of anti-Ro/La antibodies using sensitive laboratory methods.

Results: There were 9 cases of anti-Ro/La-negative CHB; 3 died (33.3%). Only 3 (33.3%) were complete in utero and 5 (55.5%) were unstable. No specific etiology was diagnosed. Six infants (66.6%) were given pacemakers. There were 36 cases of anti-Ro/La-positive CHB. All except 2 infants (94.4%) had complete atrioventricular block in utero. Ten died (27.8%), one (2.7%) developed severe dilated cardiomyopathy, and 26 (72.2%) were given pacemakers.

Conclusion: Nine of the 45 consecutive CHB cases (20%) were anti-Ro/La-negative with no known cause. They were less stable and complete than the anti-Ro/La positive cases.
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http://dx.doi.org/10.3899/jrheum.080737DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2798588PMC
August 2009

Biomarkers of oxidative stress in babies at high risk for retinopathy of prematurity.

Front Biosci (Elite Ed) 2009 Jun 1;1:547-52. Epub 2009 Jun 1.

Department of Pediatrics, Obstetrics and Reproductive Medicine, University of Siena, Siena, Italy.

Oxygen-induced oxidative stress (OS) has damaging effects in the perinatal period. For now there is a lake of evidence that OS occurs in babies with retinopathy of prematurity (ROP) We tests the hypothesis that a strict oxygen policy may minimize postnatal OS reducing severity of ROP. Multicenter prospective cohort study (72 newborns), using a common clinical management protocol with a strict control of oxygen administration. Assessment of biochemical markers of OS in blood samples at birth and on days 7, 14, and 21. Sixteen babies (22.2 per cent) developed ROP stage 1-2. No severe form of ROP was observed. Birth weight and O2 administration in delivery room were the factors significantly associated with the development of ROP stage 1-2. Prematurity and O2 administration in delivery room are the main factors coming into play in the course of ROP. Because room air is richer in oxygen than intrauterine environment, higher OS can be minimized, as well as incidence and severity of ROP, using standardized management with a restricted oxygen breathing policy.
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http://dx.doi.org/10.2741/e52DOI Listing
June 2009

Aplasia cutis congenita: an association with vanishing twin syndrome.

Eur J Dermatol 2009 Jul-Aug;19(4):372-4. Epub 2009 May 25.

Division of Neonatology and Neonatal Intensive Care Unit, S.C. Neonatologia e Terapia Intensiva Neonatale, A.O. Ospedale Niguarda "Ca' Granda", P.zza Ospedale Maggiore 3, 20162 Milano, Italy.

Aplasia cutis congenita (ACC) is an inborn skin defect, variably associated with absence of the underlying subcutaneous fat and bone. Frieden IJ proposed a classification system for ACC consisting of 9 groups according to lesion distribution and associated malformations. We report a child resembling ACC group 5, with extensive truncal and limb skin defects and fetus papyraceous, the so-called vanishing twin syndrome. According to our experience, the risk of developing ACC with fetus payraceous is unpredictable, although twin abortion occurred during the first weeks of gestation. This case emphasizes the importance of a team approach to patients affected by wide skin lesions, and the usefulness of a precise anamnesis in order to clarify the etiology of this rare but often dramatic disorder.
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http://dx.doi.org/10.1684/ejd.2009.0681DOI Listing
September 2009