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  • Blog Entries

    • By Jelli KA in Bubbly Girl in NICU
         2
      Excited for my first speaker oportunity to a peds audience.We a small group of about 20 I did expect a litlle more. The good Things and not so good that needed improving here.
      The conference wad set to be the first consist of primary care topics & community health. The second was solid peads with a special section of neonatology talks in the afternoon. The was also a poster competition in the mix.
      Lets start with the good I really enjoyed the networking oportunity over a nice healthy lunch with people. We happened most to NICU peps of bar various multidisciplinary backgrounds so we got talking about developmental outcomes of preemie at several stages. Thus we able to cross pollinate with ideas. The were several talk that were really relevant to my posdoc expecially organisation:community health better and those that NICU ones .The most thought provoking one was the method of management explained by the Arizona Prof. McGrath ,developmental psychologist working NICU on neonatal abtinense sindrome: how they reduced the stay to about weekish-ten days reduced the used of morphine derivates. Other talk were little lenghty.
          Personal I manage to give my talk to the small peds audience. I was a tad nervous but manage to give a somewhat seamless talk summary a few points as it overlap with the previous talk on the golden hour on my work in ethics in NLS  and generate some debate with those in room.
      I glad that my hotel was close by 10 walks away. A bonus on get macarons for mum on way back at the airport at Orly.
      On the otherhand, the organization of the event needed improving as it was a bit ad hoc from my experience organising .We totally underestimated how far it would be from the airports CDG and Orly : +2 hours using a mix public transport , I used my trusty app citymapper to get there.The conference site was a cute Holiday Inn @ Noisy le Grand, subburds well outside Paris .
       


    • By Stefan Johansson in Department of Brilliant Ideas
         0
      I just realized that the 99nicu community has grown to >7000 members.
      An amazing number for an independent grass-rotish project, that aims to create a virtual space for neonatal staff around the world.
      Naturally, there are members that registered more than 10 years ago who have completely forgotten about 99nicu. But still, we know that our newsletter is recieved by ~6200 members.
      Regardless of the exact number,  we have engaged a lot of people over the years, who have been connecting and sharing questions and expertise.
      And, in my dreams, I see 99nicu reaching its real potential. Let's hope that dream will come true.
       
    • By AllThingsNeonatal in All Things Neonatal
         0
      It has been a few months now that I have been serving as Chair of the Fetus and Newborn Committee for the Canadian Pediatric Society. Certain statements that we release resonate strongly with me and the one just released this week is certainly one of them. Guidelines for vitamin K prophylaxis in newborns is an important statement about a condition that thankfully so few people ever experience.  To read the statement on the CPS website click here.
      Similar story to vaccinations
      Prior to the American Academy of Pediatrics in 1961 proclaiming that all newborns should receive IM Vitamin K at birth the incidence of Vitamin K deficient bleeding was 0.25 – 1.7%. Think about that for a moment. A new parent could expect that 1/100 babies roughly might have intestinal bleeding or worse an intracranial hemorrhage due to an insufficient amount of vitamin K levels in the newborn. The types of bleeding could be categorized into three different time epochs. Early onset (occurring in the first 24 hours post-birth), classic (occurring at days 2 to 7) and late onset (at 2 to 12 weeks and up to 6 months of age).
      With a rate that high detractors of providing Vitamin K at birth would say “why should we give it; I haven’t heard of any baby getting such bleeding?” Looking at it another way though, why don’t you see congenital rubella or kids with measles much these days? It’s due to vaccination. Thankfully as a Neonatologist, I don’t see Vitamin K deficient bleeding since most parents provide Vitamin K to their babies at birth.  If you went back to the era prior to 1961 when widespread supplementation of Vitamin K began in the US, I imagine it would not have been too uncommon to hear about a baby who had bleeding issues after birth.  Just because we don’t hear about German Measles much anymore doesn’t mean the virus causing it doesn’t still exist!
      How Effective is Vitamin K?
      How effective is Vitamin K administration at birth in preventing hemorrhagic disease of the newborn (HDNB)? Studies estimate an incidence of 0.25 per 100000 live births or 1 in 400000 babies vs the 1/100 risk without any vitamin K. That is one effective intervention! At this point I would ask those families that are still concerned about giving Vitamin K to their infants if this is a risk they can accept? If they refuse Vitamin K and there is a significant bleed how will they react?
      The Change in this CPS Statement From the Past
      In the last statement on Vitamin K, the authors suggested that the oral route was a reasonable option. Instead of giving 1 mg of Vitamin K IM one would dose it as 2 mg orally and then repeat at 2-4 weeks and then 6-8 weeks. In looking at the effectiveness though it is worth noting that while we can assure that families will get the first dose, as with any medication that needs repeat dosing there is the risk of forgetfulness leading to missed dosing down the road. In fact when the authors looked at the risk of late HDNB they found the following “The relative risk for VKDB, when comparing PO versus IM vitamin K administration in these two studies, was 28.75 (95% CI 1.64 to 503.45) and 5.97 (95% CI 0.54 to 65.82), respectively [19][20].”
      The outcome of course remains rare but the risk based on two studies was almost 30 times higher than if IM dosing was given.
      On this basis IM is recommended.
      Having said all this I recognize that despite all this information, some families will choose for a number of reasons to still opt for the oral dose. As the statement suggests we need to encourage such use when a family refuses IM vitamin K. The 30 fold risk compared to IM administration is magnitudes lower than the approximate 1/100 risk of giving nothing at all!
      In the end I believe that one case of intracranial hemorrhage from inadequate vitamin K is too much. This one vitamin indeed could save a life.
    • By AllThingsNeonatal in All Things Neonatal
         5
      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
         3
      A catchy title for sure and also an exaggeration as I don’t see us abandoning the endotracheal tube just yet.  There has been a lot of talk about less invasive means of giving surfactant and the last few years have seen several papers relating to giving surfactant via a catheter placed in the trachea (MIST or LISA techniques as examples).  There may be a new kid on the block so to speak and that is aerosolized surfactant.  This has been talked about for some time as well but the challenge had been figuring out how to aerosolize the fluid in such a way that a significant amount of the surfactant would actually enter the trachea.  This was really a dream of many Neonatologists and based on a recently published paper the time may be now for this technique to take off.
      A Randomized Trial of Aerosolized Surfacant
      Minocchieri et al as part of the CureNeb study team published Nebulised surfactant to reduce severity of respiratory distress: a blinded, parallel, randomised controlled trial. This trial set out to obtain a sample size of 70 patients between 29 0/7 to 33 6/7 weeks to demonstrate a difference in need for intubation from 30% down to 5% in patients treated with CPAP (30% was based on the historical average).  The authors recognizing that the babies in this GA bracket might behave differently, further stratified the randomization into two groups being 29 0/7 – 31 6/7 weeks and 32 0/7 to 33 6/7 weeks.  Those babies who were on CPAP and met the following criteria for intubation were either intubated in the control group and given surfactant (curosurf) using the same protocol as those nebulized or had surfactant delivered via nebulisation (200 mg/kg: poractant alfa) using a customised vibrating membrane nebuliser (eFlow neonatal). Surfactant nebulisation(100 mg/kg) was repeated after 12 hours if oxygen was still required.  The primary dichotomous outcome was the need for intubation within 72 hours of life, and the primary continuous outcome was the mean duration of mechanical ventilation at 72 hours of age.
      Criteria for intubation
      1. FiO2 >0.35 over more than 30 min OR FiO2 >0.45 at
      anytime.
      2. More than four apnea/hour OR two apnea requiring BVM
      3. Two cap gases with pH <7.2 and PaCO2 >65 mm Hg (or) >60 mm Hg if arterial blood gas sample).
      4. Intubation deemed necessary by the attending physician.
      Did It Work?
      Eureka! It seemed to work as 11 of 32 infants were intubated in the surfactant nebulisation group within 72 hours of birth vs.22 out of 32 infants receiving CPAP alone (RR (95% CI)=0.526 (0.292 to 0.950)). The reduction though was accounted for by the bigger babies in the 32 0/7 to 33 6/7 weeks group as only 1 of 11 was intubated when given nebulized surfactant compared to 10 of 13 managed with CPAP.  The duration of ventilation in the first 72 hours was not different between the groups: the median (range) 0 (0–62) hour for the nebulization group and 9 (0–64) hours for the control group (p=0.220).  It is important in seeing these results that the clinicians deciding whether infants should be intubated for surfactant administration were blind to the arm the infants were in.  All administration of curosurf via nebulization or sham procedures were done behind a screen.
      The total number of infants randomized were 66 so they did fall shy of the necessary recruitment but since they did find a difference the results seem valid.  Importantly, there were no differences in complications although I can’t be totally confident there really is no risk as this study was grossly underpowered to look at rarer outcomes.
      Breaking down the results
      This study has me excited as what it shows is that “it kind of works“.  Why would larger babies be the ones to benefit the most?  My guess is that some but not a lot of surfactant administered via nebulization reaches the alveoli.  Infants with lesser degrees of surfactant deficiency (32 0/7 to 33 6/7) weeks might get just enough to manage without an endotracheal tube.  Those infants (in particular less than 32 0/7 weeks) who have more significant surfactant deficiency don’t get enough and therefore are intubated.  Supporting this notion is the overall delay in time to intubation in those who were intubated despite nebulization (11.6 hours in the nebulization group vs 4.9 hours in the control arm).  They likely received some deposition in the distal alveoli but not enough to completely stave off an endotracheal tube.
      One concerning point from the study though had to do with the group of infants who were intubated despite nebulization of surfactant.  When you look at total duration of ventilation (hours) it was 14.6 (9.0–24.8) in the control arm vs 25.4 (14.6–42.2) p= 0.029*.  In other words infants who were intubated in the end spent about twice as long intubated as those who were intubated straight away.  Not a huge concern if you are born at 32 weeks or more but those additional thousands of positive pressure breaths are more worrisome as a risk for CLD down the road.
      As it stands, if you had an infant who was 33 weeks and grunting with an FiO2 of 35% might you try this if you could get your hands on the nebulizer?  It appears to work so the only question is whether you are confident enough that the risk of such things as pneumothorax or IVH isn’t higher if intubation is delayed.  It will be interesting to see if this gets adopted at this point.
      The future no doubt will see a refinement of the nebulizer and an attempt to see how well this technique works in infants below 29 weeks.  It is in this group though that prolonging time intubated would be more worrisome.  I don’t want to dismiss this outright as I see this as a pilot study that will lead the way for future work that will refine this technique.  If we get this right this would be really transformative to Neonatology and just might be the next big leap.
  • Upcoming Events

    • 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
      2  
      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.
    • 31 January 2019 Until 01 February 2019
      0  
      Check this course out, 31/1-1/2 2019.
      Click on the topic below to get all info about the course, incl the registration link.
       
       
    • 07 April 2019 Until 10 April 2019
      0  
      Our 3rd 2019 Meetup will take place at Rigshospitalet in Copenhagen, Denmark,  7-10 April 2019.
      While we have the dates and venue set, we have just started to brainstorm about the program.
      Share your input on topics and speakers here! As previous years, we are specifically interested in topics with a high clinical relevance, shared by dedicated speakers.
      And yes, we will keep the same format, i.e. a rather short lecture of ~30 minutes, and a ~15 minutes interactive part with polls, questions and discussions IRL and through the sli.do smartphone app.
      See you in Copenhagen!



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