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  • Blog Entries

    • By AllThingsNeonatal in All Things Neonatal
         1
      It is hard to believe but it has been almost 3 years since I wrote a piece entitled A 200 year old invention that remains king of all tech in newborn resuscitation. In the post I shared a recent story of a situation in which the EKG leads told a different story that what our ears and fingers would want us to believe. The concept of the piece was that in the setting of pulseless electrical activity (where there is electrical conductance in the myocardium but lack of contraction leaves no blood flow to the body) one could pick up a signal from the EKG leads when there is in fact no pulse or perfusion to vital organs. This single experience led me to postulate that this situation may be more common than we think and the application of EKG leads routinely could lead to errors in decision making during resuscitation of the newborn. It is easy to see how that could occur when you think about the racing pulses of our own in such situations and once chest compressions start one might watch the monitor and forget when they see a heart rate of 70 BPM to check for a corresponding pulse or listen with the stethoscope. I could see for example someone stopping chest compressions and continuing to provide BVM ventilation despite no palpable pulse when they see the QRS complex clearly on the monitor. I didn’t really have much evidence to support this concern but perhaps there is a little more to present now.
      A Crafty Animal Study Provides The Evidence
      I haven’t presented many animal studies but this one is fairly simple and serves to illustrate the concern in a research model. For those of you who haven’t done animal research, my apologies in advance as you read what happened to this group of piglets. Although it may sound awful, the study has demonstrated that the concern I and others have has is real.
      For this study 54 newborn piglets (equivalent to 36-38 weeks GA in humans) were anesthetized and had a flow sensor surgically placed around the carotid artery.  ECG leads were placed as well and then after achieving stabilization, hypoxia was induced with an FiO2 of 0.1 and then asphyxia by disconnecting the ventilator and clamping the ETT.  By having a flow probe around the carotid artery the researchers were able to determine the point of no cardiac output and simultaneously monitor for electrical activity via the EKG leads.  Auscultation for heart sounds was performed as well.
      The results essentially confirm why I have been concerned with an over reliance on EKG leads.

      Of the 57 piglets, 14 had asystole and no carotid flow but in 23 there was still a heart rate present on the EKG with no detectable carotid flow. This yields a sensitivity of only 37%.  Moreover, the overall accuracy of the ECG was only 56%.
      Meanwhile the stethoscope which I have referred to previously as the “king” in these situations had 100% sensitivity so remains deserving of that title.
      What do we do with such information?
      I think the results give us reason to pause and remember that faster isn’t always better.  Previous research has shown that signal acquisition with EKG leads is faster than with oximetry.  While a low heart rate detected quickly is helpful to know what the state of the infant is and begin the NRP pathway, we simply can’t rely on the EKG to tell us the whole story.  We work in interdisciplinary teams and need to support one another in resuscitations and provide the team with the necessary information to perform well.  The next time you are in such a situation remember that the EKG is only one part of the story and that auscultation for heart sounds and palpation of the umbilical cord for pulsation are necessary steps to demonstrate conclusively that you don’t just have a rhythm but a perfusing one.
      I would like to thank the Edmonton group for continuing to put out such important work in the field of resuscitation!
    • By AllThingsNeonatal in All Things Neonatal
         1
      A few weeks back I wrote about the topic of intubations and whether premedication is really needed (Still performing awake intubations in newborns? Maybe this will change your mind.) I was clear in my belief that it is and offered reasons why. There is another group of practitioners though that generally agree that premedication is beneficial but have a different question. Many believe that analgesia or sedation is needed but question the need for paralysis. The usual argument is that if the intubation doesn’t go well and the patient can’t spontaneously ventilate could we be worse off if the patient loses their muscle tone.
      Neonatal Intubation Registry
      At the CPS meeting last month in Quebec City. I had the pleasure of listening to a talk by Dr. Elizabeth Foglia on the findings from a Neonatal intubation registry that many centres have been contributing to. The National Emergency Airway Registry for Neonates (NEAR4NEOs), records all intubations from a number of centres using an online database and allows for analysis of many different aspects of intubations in neonates.
      This year, J. Krick et al published Premedication with paralysis improves intubation success and decreases adverse events in very low birth weight infants: a prospective cohort study. This study compared results from the registry of two centres, the University of Washington Medical Center (UWMC) and Seattle Children’s Hospital where the former rarely uses paralysis and the latter in almost all instances of non-emergent intubation. In all, 237 encounters were analyzed in the NICU for babies < 1500g with the majority of encounters (181) being from UWMC. The median PMA at intubation was 28 completed weeks (IQR: 27, 30), chronological age was 9 days (IQR: 2, 26) and weight was 953 g (IQR: 742,1200). The babies were compared based on the following groups. Premedication with a paralytic 21%, without a paralytic 46% and no premedication 31%.
      This was an observational study that examined the rates of adverse events and subdivided into severe (cardiac arrest, esophageal intubation with delayed recognition, emesis with witnessed aspiration, hypotension requiring intervention (fluid and/or vasopressors), laryngospasm, malignant hyperthermia, pneumothorax/pneumomediastinum, or direct airway injury) vs non-severe (mainstem bronchial intuba- tion, esophageal intubation with immediate recognition, emesis without aspiration, hypertension requiring therapy, epistaxis, lip trauma, gum or oral trauma, dysrhythmia, and pain and/or agitation requiring additional medication and causing a delay in intubation.).
      How did the groups compare?
      It turns out paralysis seems to be a big deal (at least in this group of infants). Use of paralysis resulted in less attempts to intubate (median 1 attempt; IQR: 1, 2.25 vs. 2; IQR: 1, 3, p < 0.05)). In fact success was no different between the groups with no paralysis or no premedication at all! When it comes to  tracheal intubation adverse events the impact of using paralysis becomes more evident.   Paralysis does make a difference in reducing the incidence of such events and moreover when only looking at the rate of severe adverse events as defined above the finding was that none occurred when paralysis was used vs 9 when no paralysis was employed and 5 when no premedication was used at all.  The rate of bradycardic events was less in the paralytic group but rates of oxygen desaturation between the three arms were no different.
      How do we interpret the results?

      Based on the results from the registry it looks like paralysis is a good thing here when electively intubating infants.   If we try to determine the reason for it I suspect it may have much to do with the higher likelihood of success on the first attempt at placing an ETT. The longer it takes to place the ETT or the more number of attempts requiring intermittent PPV in a patient who truly needs a tube the greater the likelihood that you will see adverse events including bradycardia.  It may simply be that a calm and still patient is an easier intubation and getting the tube in faster yields a more stable patient.
      I am biased though and I think it is worth pointing out another possible reason for the differing results.  One hospital in this study routinely used premedication and the other did not.  Almost 3/4 of the patients came from one hospital which raises the possibility that skill set could be playing a role.  If the skill of providers at the two hospitals differed, the results could reflect the variable skill in the practitioners versus the difference in the medications used themselves.  What I don’t know though is whether the two share the same training program or not.  Are the trainees the same at both sites (google maps says the two sites are 11 minutes away by car)?  The difference still might be in local respiratory therapists or Neonatologists intubating as well.  Regardless, the study provides evidence that paralysis makes a difference.  To convince those out there though who remain skeptical I think we are going to need the registry to take part in a prospective trial using many centres.  A format in which several centres that don’t use paralysis are compared to several who do routinely would help to sort out the concern in skill when looking only at two centres.  This wouldn’t be randomized of course but I think it would be very difficult at this point to get a centre that strongly believes in using paralysis to randomize so a prospective study using groups chosen by the individual centre might be the next best thing.  If anyone using the registry is reading this let me know what you think?
    • By Jelli KA in Bubbly Girl in NICU
         0
      Alarms in NICU are part of the environment  and with more advanced model appear to be more present.  As one walks through the unit one is going off, creating annoyance to staff.Thus, raising the issue have reached a 'fatigue alarm'. Among I and some of the NICU professionals in my twitter Community belief. An article by Belteki and Morley give some answers.
      COPYRIGHTED THE Child &Fetal Archives Here the link below :
      https://bmj.altmetric.com/details/28352250
    • By AllThingsNeonatal in All Things Neonatal
         0
      This post is very timely as the CPS Fetus and Newborn committee has just released a new practice point:
      Managing infants born to mothers who have used opioids during pregnancy
      Have a look at discharge considerations as that section in the statement speaks to this topic as well!
      As bed pressures mount seemingly everywhere and “patient flow” becomes the catch-word of the day, wouldn’t it be nice to manage NAS patients in their homes?  In many centres, such patients if hospitalized can take up to 3 weeks on average to discharge home off medications.  Although done sporadically in our own centre, the question remains is one approach better than the another?  Nothing is ever simple though and no doubt there are many factors to consider depending on where you live and what resources are available to you.  Do you have outpatient follow-up at your disposal with practitioners well versed in the symptoms of NAS and moreover know what to do about them?  Is there comfort in the first place with sending babies home on an opioid or phenobarbital with potential side effects of sedation and poor feeding?  Nonetheless, the temptation to shift therapy from an inpatient to outpatient approach is very tempting.
      The Tennessee Experience
      Maalouf Fl et al have published an interesting account of the experience with outpatient therapy in their paper Outpatient Pharmacotherapy for Neonatal Abstinence Syndrome.  The authors were able to take advantage of the Tennessee Medicaid program using administrative
      and vital records data from 2009 to 2011 to capture a cohort of 736 patients who were treated for NAS.  Forty five percent or 242 patients were treated as outpatients vs 290 cared for in hospital for the duration of treatment.  It is worth mentioning at this point that when the authors say they were cared for as outpatients it really is a hybrid model as the duration of hospitalization for the inpatients was a median of 23 days (IQR 14-35) versus 11 days (IQR 7-18) for inpatients (P < .001).  This practice isn’t much different than my own in which I start therapy in hospital and then discharge home with a period of home therapy.
      The strength of the study is the volume of patients and the ability to follow-up with these babies for the first 6 months of life to determine what happened to them after discharge.  In terms of duration of treatment, the differences are significant but perhaps not surprising. The median length of treatment for outpatients was 60 days (IQR 38-92) compared with 19 days (IQR 10-31) for inpatients (P < .001).  What was interesting as well is that 82% of babies were discharged home on phenobarbital and 9.1% on methadone and 7.4% with both.  A very small minority was discharged home on something else such as morphine or clonidine.  That there was a tripling of medication wean is not surprising as once the patients are out of the watchful eye of the medical team in hospital it is likely that practitioners would use a very slow wean out of hospital to minimize the risk of withdrawal.
      An Unintended Consequence
      This study found a statistically significant increase in risk for presenting to the emergency department for those patients treated as outpatients.

      What this graph demonstrates is that there was no increase risk in the first month but there was for the first 6 months.  Despite the increased risk of presentation to the ED the rate of hospitalization was not different.  Drilling down the data further, the reason for coming to the ED was not for withdrawal which was 10% in the outpatient and 11% in the inpatient group.  The other major reason was The most common diagnoses were upper respiratory infections; 80% outpatient vs 71% inpatient.  So while there was a significant difference (which was not by much) my take on it is that it was most likely by chance as I can’t think of how infections in the first 6 months could be linked to choice of medication wean.
      What about phenobarbital?
      Phenobarbital has been used for many years in Neonatology for control of seizures, sedation (taking advantage of a side effect) and management of NAS.  The problem with a median use of phenobarbital for 2 months is its potential to affect development.

      An animal study by Diaz in 1999 in which rat pups were given two weeks of phenobarbital starting on day 5 of life and then euthanized demonstrated the following weight reductions when high dose phenobarbital was utilized.  In human data, children with febrile seizures treated with phenobarbital in the paper Late cognitive effects of early treatment with phenobarbital. had decreased intelligence than those not exposed to phenobarbital.
      The issue here for me is not necessarily whether babies can be treated successfully as outpatients for NAS.  The concern is at what cost if the choice of drug is phenobarbital.  The reason phenobarbital was chosen is likely due to compliance.  We know that the more frequently a drug is dose the less likely compliance will be achieved.  Phenobarbital being dosed either q12h or q24h is an ideal drug from a compliance point of view but the ramifications of this treatment deserve reconsideration.
      I look forward to seeing further studies on this topic and hope that we see the results of an opioid outpatient treatment program.  I know these exist and would welcome any information you as the readers of this blog can offer.  Treating patients in the home makes great sense to me but we need to do it with the right drugs!
    • By AllThingsNeonatal in All Things Neonatal
         0
      Much has been written about methylxanthines over the years with the main questions initially being, “should we use them?”, “how big a dose should we use” and of course “theophylline vs caffeine”. At least in our units and in most others I know of caffeine seems to reign supreme and while there remains some discussion about whether dosing for maintenance of 2.5 -5 mg/kg/d of caffeine base or 5 – 10 mg/kg/d is the right way to go I think most favour the lower dose. We also know from the CAP study that not only does caffeine work to treat apnea of prematurity but it also appears to reduce the risk of BPD, PDA and duration of oxygen therapy to name a few benefits. Although initially promising as providing a benefit by improving neurodevelopmental outcomes in those who received it, by 5 and 11 years these benefits seem to disappear with only mild motor differences being seen.
      Turning to a new question
      The new query though is how long to treat? Many units will typically stop caffeine somewhere between 33-35 weeks PMA on the grounds that most babies by then should have outgrown their irregular respiration patterns and have enough pulmonary reserve to withstand a little periodic breathing. Certainly there are those who prove that they truly still need their caffeine and on occasion I have sent some babies home with caffeine when they are fully fed and otherwise able to go home but just can’t seem to stabilize their breathing enough to be off a monitor without caffeine. Then there is also more recent data suggesting that due to intermittent hypoxic episodes in the smallest of infants at term equivalent age, a longer duration of therapy might be advisable for these ELBWs. What really hasn’t been looked at well though is what duration of caffeine might be associated with the best neurodevelopmental outcomes. While I would love to see a prospective study to tackle this question for now we will have to do with one that while retrospective does an admirable job of searching for an answer.
      The Calgary Neonatal Group May Have The Answer
      Lodha A et al recently published the paper Does duration of caffeine therapy in preterm infants born ≤1250 g at birth influence neurodevelopmental (ND) outcomes at 3 years of
      age? This retrospective study looked at infants under 1250g at birth who were treated within one week of age with caffeine and divided them into three categories based on duration of caffeine therapy. The groups were as follows, early cessation of caffeine ≤ 14 days (ECC), intermediate cessation of caffeine 15–30 days (ICC), and late cessation of
      caffeine >30 days (LCC).  In total there were 508 eligible infants with 448 (88%)  seen at 3 years CA at follow-up. ECC (n = 139), ICC (n = 122) and LCC (n = 187).  The primary outcome here was ND at 3 years of age while a host of secondary outcomes were also examined such as RDS, PDA, BPD, ROP as typical morbidities.  It made sense to look at these since provision of caffeine had previously been shown to modify such outcomes.
      Did they find a benefit?
      Sadly there did not appear to be any benefit regardless of which group infants fell in with respect to duration of caffeine when it came to ND. When looking at secondary outcomes there were a few key differences found which favoured the ICC group.  These infants had the lowest days of supplemental oxygen, hospital stay ROP and total days of ventilation.  This middle group also had a median GA 1 week older at 27 weeks than the other two groups.  The authors however did a logistic regression and ruled out the improvement based on the advanced GA.  The group with the lowest use of caffeine had higher number of days on supplemental oxygen and higher days of ventilation on average than the middle but not the high caffeine group.  It is tempting to blame the result for the longer caffeine group on these being babies that were just sicker and therefore needed caffeine longer.  On the other hand the babies that were treated with caffeine for less than two weeks appear to have likely needed it longer as they needed longer durations of oxygen and were ventilated longer so perhaps were under treated. What is fair to say though is that the short and long groups having longer median days of ventilation were more likey to have morbidities associated with that being worse ROP and need for O2.  In short they likely had more lung damage.  What is really puzzling to me is that with a median GA of 27-28 weeks some of these kids were off caffeine before 30 weeks PMA and in the middle group for the most part before 32 weeks!  If they were in need of O2 and ventilation for at least two weeks maybe they needed more caffeine or perhaps the babies in these groups were just less sick?
      What is missing?
      There is another potential answer to why the middle group did the best.  In the methods section the authors acknowledge that for each infant caffeine was loaded at 10 mg/kg/d.  What we don’t know though is what the cumulative dose was for the different groups.  The range of dosing was from 2.5-5 mg/kg/d for maintenance.  Lets say there was an over representation of babies on 2.5 mg/kg/d in the short and long duration groups compared to the middle group.  Could this actually be the reason behind the difference in outcomes?  If for example the dosing on average was lower in these two groups might it be that with less respiratory drive the babies in those groups needed faster ventilator rates with longer durations of support leading to more lung damage and with it the rest of the morbidities that followed?
      It would be interesting to see such data to determine if the two groups were indeed dosed on average lower by looking at median doses and total cumulative doses including miniloads along the way.  We know that duration may need to be prolonged in some patients but we also know that dose matters and without knowing this piece of information it is tough to come to a conclusion about how long exactly to treat.
      What this study does though is beg for a prospective study to determine when one should stop caffeine as that answer eludes us!
  • Upcoming Events

    • 05 September 2018 Until 08 September 2018
      0  
      https://www.mcascientificevents.eu/ecpm2018/
      MAIN TOPICS
      Abnormal placentation
      Cesarean section
      Diabesity
      Doctors and Midwives; care or cure
      Epigenetics and metabolomics in perinatology
    • 05 September 2018 Until 07 September 2018
      0  
      The 6th International Conference on Human Milk Science and Innovation is a distinctive international forum covering the latest discoveries and scientific and clinical research related to human milk. Renowned scientists and clinicians from around the world are invited to attend this annual event to discuss the scientific potential of human milk and raise awareness of its clinical relevance.
      Click for more information: http://www.humanmilkscience.org/conference
    • 03 October 2018 Until 05 October 2018
      0  
      https://www.mcascientificevents.eu/uenps2018/
      MAIN TOPICS
      Neonatal respiratory disorders and management
      Nutrition of the preterm infant
      Nosocomial infection
      New fortifiers of breast milk
    • 18 October 2018 05:00 AM Until 05:00 PM
      1  
      Our Port Said Neonatology Society is honored to invite you to its
                                                9th Neonatology Conference 18th October 2018
                                                                 NEONATOLOGY IN PRACTICE
      Venue: Tolip golden plaza (Omar Ibn El-Khattab- Masaken Al Mohandesin, Nasr City, Cairo Governorate Egypt)
      Conference honorary president : prof Salah Nassar (Pediatric department - Cairo university)
      Conference president: dr Osama Hussein (President of Port said neonatology society)
      Conference sessions: Thursday 18th of October 
      Registration on Port said Neonatology society Email: portsaidnicus@gmail.com
      Deadline of participation and submission of abstracts : 1/10/2018
      Language: English & Arabic languages
      Presentation: Papers will be invited for oral  with datashow presentation
      Abstracts: should be sent to the group mail: portsaidnicus@gmail.com
      Conference reservation: contact Spark travel office: 201007557666  - Spark.acc@hotmail.com
       
       


       
       

    • 30 October 2018 Until 03 November 2018
      0  
      7th Congress of the European Academy of Paediatric Societies (EAPS 2018) 
      Click here for more info: http://www.eaps.kenes.com/2018
       
    • 17 November 2018
      1  
      The 17th of November each year is the World Prematurity Day. Originally started by parent organisations in Europe in 2008, the World Prematurity Day is an international event aiming at high-lighting the ~15 million infants born preterm each year.
      Read more about this day on the March of Dimes web site, and on Facebook.
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