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  3. ONTOP learning from AIIMS will be very good. i am attaching the screen shot of the web page you need to send an e mail to puneet.nagi@yahoo.com
  4. Thanks for an interesting question! I think you will be able to find some useful resources in our Link Directory https://99nicu.org/links/, like some very nice blogs, NICUniversity etc. You should become a member (free) in EBNEO https://ebneo.org/ and you can also view all lectures still from the 1st conference in Stockholm (see link in this post https://ebneo.org/ebneo-2011/). On EBNEO web site you also find the web casts of most lectures from the 3rd conference in Philadelphia https://ebneo.org/?s=EBNEO+2015 We hope the 99nicu Meetup will also be video recorded, hope to provide most lectures as films (on Youtube), we will let everyone know. Another new idea - maybe it would be possible to have a mentor outside Libya, that you could discuss with over Skype - just to connect with people outside your context and get some new input! I am sure someone here would be interested
  5. hi >> thanks in advance for your help and responses i know i ve asked a big question but i will tell you in the meanwhile in my country libya we are having a real challenges and obstacles ( mean income for a physician now in libya 170 dollars , and most of embassy are closed so its a dream to travel outside and attend conferences ) as a physician interested in the neonate i want to attend conferences and to participate in activities to update my knowledge and to improve level of care provided for the babies . so .. i was looking for websites / online conferences / webinars / ...ect so if you have any website or if you have any previous online activity regarding neonatal care let me know
  6. We switched last year. Generally it is pretty comparable, although there are quite a few extra alarms when comparing the two. Once, when you need to bag the patient intermittingly, the system alarms almost every minute, secondly when starting with iNO there are - in my opinion - unnecessary alarms as the iNO delivery overshoots initially before settling at the desired dose.
  7. Earlier
  8. A programme is now available Annual Neonatal Simulation & TEL Conference .pdf
  9. Hello, I would be grateful for experiences or opinions on the NOX Box delivery system. We currently use the INO Therapeutic delivery system and I am interested as to any differences noted by Units that have switched from INO over to NOX Box. Many thanks Ali
  10. Posted on May 7, 2017 by winnineo In our journey as Neonatologists and interdisciplinary teams we are forever seeking to rid or at least reduce the plague of BPD in the patients we care for. The PREMILOC trial was a double-blind, multicenter, randomized, placebo-controlled trial designed to test just that concept by introducing a low dose of hydrocortisone within 24 hours of birth. They enrolled infants born between 24 – 26+6 weeks of gestation and assigned them to receive either placebo or low-dose hydrocortisone 0.5mg/kg twice per day for 7 days, followed by 0.5 mg/kg per day for 3 days. The trial has been the subject of a previous post A Shocking Change in Position. Postnatal steroids for ALL microprems? Although the trial was stopped early due to financial concerns the authors demonstrated a 9% reduction in BPD using this strategy. The theory here in part is that the presence of hydrocortisone reduces inflammation and that this in turn may allow for better growth of lungs with time. Why Not Adopt The Results Based on These Fantastic Results? Steroids in preterm infants have a bad name. As discussed in previous posts on the topic the concern in all trials has been the potential impact of such medications on the developing brain. A nice summary of these concerns can be found in a paper in the CMAJ by the other “Canadian Neonatal Blogger” from 2001 in which he quoted the risk of cerebral palsy increasing from about 1 in 6 babies to 1 in 3 if babies born at < 28 weeks were exposed to postnatal steroids. Neurodevelopmental impairment overall would change from 1 in 4 to 1 in 3 if such exposure occurred. This paper and others expressing concerns over the effect of postnatal steroids led to a change in practice from more ubiquitous use to one restrained to only in those cases where the patient was nearing the end of all other options. This meant holding out for such therapy until such patients were at 90% or more O2 and on high mean airway pressures. Although not formally studied I was very concerned at the time with using this approach as I felt it was a “fait de complet” that they would either die or have significant developmental impairment should they survive due to the complications of having such severe BPD. It is critical to note though that the outcomes from these long term studies were in infants exposed to much longer courses of dexamethasone and at high doses that are used today. Over the years with the development of the DART protocol and other more gentle approaches to steroids we as a group relaxed and certainly rescue courses of lower dose steroids have crept into practice when patients seem to be “stuck” on the ventilator. Drumroll Please… The results of the PREMILOC follow-up study are now here and in short they look good. Patients were followed up at an average age of 22 months and included a medical history, anthropometric measures, respiratory status, standardized neurological examination based on specific definitions of disabilities, and quantitative neurodevelopmental assessment using the revised Brunet-L.zine (RBL) scale. Follow-up was 93% in the hydrocortisone and 90% in the placebo arm which is important as we need not worry about the missed patients influencing the results to a significant degree if they had been included. Although some post-hoc analyses were done what I am most interested in is the primary outcome which is shown below. There was no difference in either neurodevelopment overall or any of the subcategories. This provides a great deal of reassurance to those who provide steroids this way. There will be those however that argue the study is too small. While a larger study might be better able to address whether there is a small difference in outcome I don’t think we will see one anytime soon. It is one of the challenges we face in Neonatology. Unlike the adult world with studies of thousands of patients, due to the small number of patients born at <28 weeks it is always a challenge to recruit into such large volume trials. We can compare trials by doing meta analyses or systematic reviews and perhaps that is where we will head with this study although given that different steroids will have been used (thinking dexamethasone as in the DART study) this will always be left open to question. Is it worth it? I suppose the real question here is the following for a parent to consider. “Would you like your baby to receive hydrocortisone shortly after birth with a 7% reduction in the risk of BPD at 36 weeks bearing in mind that although we don’t think there is an impact on long term development we aren’t certain yet”. I guess to answer this question you need to think about the first part of the question. Is BPD at 36 weeks a good outcome to look at for benefit? The Canadian Neonatal Network has recently called for a rethink on this The New BPD That Matters. It turns out that it is 40 weeks and not 36 weeks that has the greatest prediction for respiratory morbidity after discharge. If you were to move the goal post to 40 weeks from 36 I strongly suspect one would see the 9% reduction in BPD as shown in the PREMILOC trial vanish. If that is the case, would a slightly earlier extubation time be enough to motivate families to take the plunge? Although I often cringe at the expression “more trials are needed”, I think at least a combination of studies to achieve greater confidence in outcome may be needed. Barring that, we might just have to sit tight and accept that while there may be a little bit to be gained with the use of the PREMILOC protocol it may just not be enough to be clinically warranted at this time. May want to wait for the next big thing to tackle BPD…
  11. I am interested in joining the whatsapp group. Information required already sent to the email address provided.
  12. @Bajabz You can also join the Slack group, send me or @Francesco Cardona a DM is you would an invite
  13. Interested in joining.
  14. There was an interesting discussion in the 99nicu Slack channel, we'd like to share here, posted by @rehman_naveed The following comments reported a similar episode with a UVC, but alternative explanations were the human factor (was the PICC really backed as intended) and the possibility of material stretching (could the PICC line plastic be stretched while backing?) Also, the possibility of PICC line displacement with arm position was also raised (see https://www.ncbi.nlm.nih.gov/pubmed/16758187) If you have further comments to this episode, please share here!
  15. Hi @matok - an invite is sent to you now!

  16. Dear Sir, I wish to join the new 99nicu Slack Channel. I have already downloaded the app into my phone. looking forward to hearing from you. Dr. Okposio Matthias (matok). email: mattokmatok@yahoo.com Nigeria
  17. Dear Sir,

    I wish to join the new 99nicu Slack Channel. I have already downloaded the app into my phone.

    looking forward to hearing from you.

    Dr. Okposio Matthias (matok)


  18. I got an email from a former research colleague now working for WHO. She works with ENAP (Every newborn action plan), and they are developing criteria or "signal functions" for hospitals/birth units managing deliveries and newborns. She shared this short survey where practitioners around the world are invited to share their views on how standard of care should be available at different levels of care. Here's link, please participate: https://www.surveymonkey.com/r/D9HZVT5
  19. During final preparations for the 99nicu Meetup (yes, there are still empty seats, so you can still register ), we have discussed how to think out-of-the-box for future Meetups. Is it really the best idea for us to run by the classic conference format and setup? Given the experience for this years Meetup, maybe not. Especially since regular meetings are connected to larger financial risks, and 99nicu is still an project that runs on philanthropic fuels. One idea is that the 2018 Meetup would be a more crowd-sourced event, and much much cheaper, like #FOAMed but IRL. In addition to one or two high-profiled keynote speakers, the program would include lectures by attending delegates, who volunteer to give talks on a subject they suggest themselves. I have heard so many great lectures by fellows and young consultants and believe we should get a fantastic program with a great variety of topics. However, as you know there is no free lunches, a small fee to cover lunches would still be needed. But without any real budget work, I think a full three day CME-accredited meeting should be possible to run for ~150 euros/USD. Delegates contributing with a lecture should of course be coming free of charge. And naturally, all delegates would need to cover and arrange their own travels and accommodation. Just some thoughts from the 99nicu HQs! Please share feedback below.
  20. We would like to share one of our most recent EBNEO commentaries, on the recently published HIPSTER trial on whether HFNC is noninferior to nCPAP. Please find full commentary on ebneo.org
  21. Not possible as there are 12 workshops and multiple plenary sessions
  22. I think my first training in resuscitation began with the principles outlined in the NRP 3rd edition program. As we have moved through subsequent editions with the current edition being number 7, I can’t help but think about how many changes have occurred over that time. One such change has been the approach to using medications as part of a resuscitation. Gone are such things as calcium gluconate, naloxone and sodium bicarbonate but something that has stood the test of time is epinephrine. The dosing and recommendations for administering epinephrine have changed over time as well with the dose of endotracheal medication increasing from 0.01 to 0.03 and now to 0.05 – 0.1 mg/kg. While this dosing has increased, that of IV administration has remained the same at 0.01 to 0.03 mg/kg. The change in dosing for the ETT route was due to an increasing awareness that this route just isn’t as effective as IV. Having said that with only 0.1% of resuscitations requiring such support the experience with either route is fairly limited. What is the concern? Giving a medication directly via the IV route ensures the dose reaches the heart in the amount desired. In the case of ETT administration there are a few potential issues along the way. The first is that one needs to push the dose down the ETT and this presumes the ETT is actually in the trachea (could have become dislodged). Secondly, if the medication is sent to the lung what effect does the liquid component in the airways have in terms of dilution and distribution of the medication? Lastly, even if you get the epinephrine to the lung it must be picked up at the capillary level and then returned to the left side of the heart. In the absence of significant forward pulmonary blood flow this is not assured. What is the evidence? In terms of human clinical research it remains fairly limited. Barber published a retrospective review of 47 newborns who received epinephrine via the endotracheal route. The study Use and efficacy of endotracheal versus intravenous epinephrine during neonatal cardiopulmonary resuscitation in the delivery room found that spontaneous circulation was restored in 32% of this cohort. Following the first dose, a subsequent dose of intravenous epinephrine restored circulation in 77%. This study provided the first suggestion that the IV route may be better than endotracheal. Keep in mind though that this study was retrospective and as the authors conclude in the end, prospective studies are needed to confirm these findings. The question really is what is the likelihood of restoring circulation if the first dose is given IV? Eleven years later we have a second study that attempts to answer this question although once again it is retrospective. Efficacy of Intravenous and Endotracheal Epinephrine during NeonatalCardiopulmonary Resuscitation in the Delivery Room by Halling et al. This study really was designed to answer two questions. The study group looked at the period from July 2006 to July 2014. During this period the dose of IV epinephrine remained unchanged as per NRP recommendations but the dose of endotracheal epinephrine increased from 0.01 to 0.03 and then to 0.05 mg/kg endotracheally. The increase was in response to both NRP and site observations that the lower doses were not achieving the effect they were hoping for. The Results ETT epinephrine IV Epinephrine Number 30 20 Return of circulation 23 15 1 dose 6 4 2 dose 5 8 3 doses 9 0 4 doses 3 3 In the ETT group all doses except for 3 after the first dose were given as IV. There was no difference in the response rate over time suggesting that higher doses do not truly increase the chance of a better response. The authors noted that the effectiveness of the two arms were not that different despite a significantly higher dose of epinephrine being administered to the group receiving ETT epinephrine first which is not surprising given the higher recommended dosages. What I find interesting though is that giving the first dose of epinephrine was given IV in 20 of the paitents, if it is indeed the better route one might expect a better response than in the ETT group. The response from one dose of ETT epi was 20% while that from the IV first group was in fact also only 20%! We do indeed need to be careful here with small numbers but the results at least to me do not suggest strongly that giving IV epi first ensures success. What the study suggests to me is that two doses of epinephrine may be needed to restore circulation. If you choose to start with IV it certainly does not seem unwise but if you have any delays I don’t see any reason to avoid ETT epinephrine as your first line. The reality is that for many individuals a UVC is a procedure that while they may have learned in an NRP class they may have never actually placed one. Having an ETT in place though seems like a good place to start. I doubt we will ever see a randomized trial of ETT vs IV epinephrine in Neonatology at this point given the stance by the NRP so these sorts of studies I suspect will be the best we get. For now, based on what is out there I suggest use the route that you can get first but expect to need additional doses at least one more time to achieve success. Lastly remember that even if you do everything correct there will be some that cannot be brought back. Rest assured though that if the first dose was given via ETT you have still done your best if that was the route you had.
  23. Good job. Thanks Stefan Sent from my iPad using Tapatalk
  24. Thanks a lot for this interesting knowledge. I will propose an update to our protocol for hypothermia-HIE.
  25. no.Baby didn't have UVC
  26. Click on this link for author updates- http://createsend.com/t/d-48647D6A56FF9751
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