How non-invasive NAVA could really reduce neonatal bradycardia.
Check out new great blog post by Michael Narvey.
Virtual NICU Alert: infant with severe anemia - could it be an atypical HUS?
Please share your input.
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Picked ByStefan Johansson,
"A new system for managing serum glucose with less pokes. This is a good thing."
Check out this new blog post on continuous glucose monitoring by Michael Narvey.
New IRL case in our Virtual NICU: a very preterm infants and challenges related to ventilation strategy (infant is on MV). Please note the Virtual NICU is a member's only section (ie you need to log in to read and comment).
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Physiological-based cord clamping (PBCC) in preterm infants. Experiences of resusc with intact cord?
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By Jelli KA in Bubbly Girl in NICUThis September I had the opportunity to go to BAPM-EBNEO to kept Learning a out Neonatology and hopefully network with the EBNEO, so glad I was to see peeps face to face. This kept motivated to finish my PhD as I re-embark in find a new supervisor _only 1.5 yrs to go. I was real hard to let of the clinician in me as , this is my comfort zone. As a budding academic I get explore ideas and ways to implement them. Last year, I took a small detour as jr.posdoc and spent time studying system thinking, process and how to improve health using design thinking.
An important fact , I beat my fear of being back in UK .I had mild anxious feeling about going to bapm but Northerners are such lovely folks. Those at the Conference where quite welcoming.
Pro-prems finally available in individual sachets pre-dose sachets that in my opinion provide a higher security and is more practical. Only maltodextrin .
Need mixing with 3 ml in H20. This has more of a track record as it collaboration with a company who been working bio culture for a long time pharmaceuticals grade certified.
Vegan alternative for well babies is Labinic drop available liquid bottle comes in 5mls flask_recommended dose 0.2ml( a syringe is needed). Ideally given with maternal milk ( EBM ).
* free off dairy, soya, sweetener, presevatives. Good for neonates with intolerances.
Both have different formula of microbiota but have a 1 bifidobacterium probiotic in common. Amount of bacteria are specified in the ingredientes list of of proprems on the box.
Nëo from ant neuro aEEG
The most distinctive item to provide EEG monitoring to Neonate at the bed side. It features a user friendly screen, allowing NICU professionals easy access to interpret resulting brain waves. Electrode are applied through a cap, as I understand help to give a clearer signal.
finally got to nicu mile stone card which are such lovely way to involve parents and make progress. Favorite is parent centered care poster.
Bili bluelight .
Compared to the standard it is small portable and easily stored . complement comes with a stand.Practical and can carried around, easily stored in the unit.
As one who had to deal a lot of of documentation I found Li-lac EBM labeling, sorting and tracking useful from quality & safety point of view. I found quite easy to use and track on a smartphone,and it builds an audit trail.Not sure how easy the set up is .
Especial mention to SHED/S/upport & H/elp for E/very D/ad : providing specific support for dad whose babies are admitted to NICU.
Disclaimer: I have no ties to any of companies. Review Health devices enthusiasts academic. Permission for all pics .
By AllThingsNeonatal in All Things NeonatalNeurally adjusted ventilatory assistance or NAVA is something that has been around for awhile. Available as a mode on the Maquet ventilator it uses an esophageal probe to sense myoelectrical activity in the diaphragm and provide assistance with postive pressure when detected. This is supposed to be better than the more traditional Graseby capsules or sensing based on airflow. Conceptually then if a preterm infant had a typical mixed apneic event with a component of both central and obstructive apnea this technology could sense an attempt to breath and assist the infant with positive pressure when the diaphragm indicates it is time for a breath. Such support should work to maintain functional residual capacity. A better ventilated lung could lead to less systemic oxygen desaturation and bradycardia correct?
Retrospective review in Virginia
Tabacaru CR et al just published NAVA—synchronized compared to nonsynchronized noninvasive ventilation for apnea, bradycardia, and desaturation events in VLBW infants. This is a retrospective study and non randomized looking at a single centres experience in 108 VLBW infants in which the attending providers were free to choose the type of respiratory support infants received after extubation. The authors from this group examined 61 epochs of time on niNAVA compared to 103 for the non invasive positive pressue ventilation nIPPV group. niNAVA patients received an initial level (the factor by which the electric diaphragmatic signal intensity (edi) is multiplied) of 1.0 and a PEEP of 5 to 6 cm H2O. NIPPV was initiated at a positive inspiratory prrssure (PI)P of 14 to 16 cm H2O, PEEP of 5 to 6 cm H2O and a rate of 20 breaths per minute. Adjustments were dictated by oxygenation and blood gases and were not described as protocolized but rather left up to clinicians. All events were recorded manually by nursing.
What impact did niNAVA have on apnea and bradycardia?
There were no significant differences noted between the two study groups including such important parameters as birthweight, day of life of extubation, sepsis or whether they needed to be reintubated. All of these could be markers of worse lungs in one group or the other so at least them seem pretty much the same.
What about the effect on apnea and bradycardia? The bold numbers in the table indicate that only the number of bradycardias per day differed between the groups. Whether patients desaturation events or not was not affected. Also not effected was whether or not patients had apnea.
Why might these results make sense?
First off since the study was not randomized and is small there is always the possibility that these results are not real and occurred just by chance. There could be variables for example that we are not taking into account to explain why some patients were chosen for one modality or the other than affect the outcomes here. Having said that let’s look at the three outcomes.
Apnea – why would this be different at all? Both modalities provide support when needed. If the infant decides to stop breathing I would see the lack of neural output not being affected by either modality so perhaps if the primary issue is lack of respiratory drive for most we wouldn’t expect a difference. Desaturation – if pulmonary reserve is kept about the same with both approaches it seems reasonable that we might not see a difference here either. Bradycardia – here there was a difference. Can this be explained as something plausible. I think there might be something here. Use of NAVA just might have a faster and more accurate response time than nIPPV that relies on airflow. Due to leaks around the prongs or mask it is possible that while background pressures are relatively maintained, not all needed positive pressure helping breaths are received in as timely a fashion as when they are detected via electrical activity. The ability of niNAVA to help the infant overcome the obstructive component of breathing might be reason why bradycardia is reduced. The interruption of ventilation is briefer with less reflexive bradycardia. What is needed of course next is a randomized prospective controlled trial. Who knows when that will come but for the infants that we see with seeminly methylxanthine resistant apnea might niNAVA be the path to avoiding reintubations? Time will tell
By AllThingsNeonatal in All Things NeonatalGlucose metabolism in the newborn can be a tricky thing to manage. Neonates can have significant fluctuation in their serum glucose in the first few days of life which can lead heels to look like pin cushions. How many times have you been asked as a physician if there is anything we can do to reduce the number of pokes? That something may have arrived at least in a feasibility study that could pave the way for this becoming the standard approach to hypo/hyperglycemia in the newborn. This is an important area to improve tightness of control as hyperglycemia has been associated in VLBW infants with such adverse outcomes as IVH, ROP and NEC.
Continuous glucose monitoring (CGM) with closed loop insulin delivery
The principle here is that a meter is inserted subcutaneously that detects blood glucose fluctuations and responds by either increasing infusion of dextrose for low glucose or delivery of insulin. The technology has been around for some time and used in the adult population but is relatively new in this population. I have written about it before in Continuous glucose monitoring in NICU may be around the corner. What follows is the latest pilot study to test this out coupled with glucose or insulin delivery in a closed loop system. The study in this case is out of Cambridge in the UK and entitled Feasibility of automated insulin delivery guided by continuous glucose monitoring in preterm infants .
What did they do?
The study was a pilot of 20 patients randomized to have an automated system to regulate glucose based on CGM data from 48-72 hours of age vs a paper based algorithm to manage dextrose or insulin infusion rates during the same period. The sample size was one of convenience to test the concept and the period was chosen to allow for time to recruit patients. The sensor used was an Enlite attached to a laptop with software capable of delivering infusion rates to two alaris pumps (one with 20% dextrose and the other with insulin). Target serum glucose levels were set to be between 4-8 mmol/L. The babies included were all under 1200g and had mean weights of 962g in the closed loop and 823g in the control arm.
The Results were fairly dramatic in my mind at least. A remarkable 91% of the infants in the closed loop system had glucose levels in the target range vs 26% in the control arm. Nutritional intakes and mean insulin dosing were not any different between groups. No harm in addition was noted from use of the CGMs. You don’t escape pokes all together though as the device does require q6h checks to calibrate and ensure it is reading properly. Every 6 hours is better though than every three for those with brittle control!
Tightly regulating blood glucose and avoiding both lows and highs has benefits on the low end to neurological preservation. On the high end some complications such as IVH, NEC and ROP may be avoided by better control. The challenge with the system as is at the moment is that it is not widely available. I am eager for a company out there to create software for mass distribution that would enable us to try this out. While the calibration is still required I can’t help but think this is an improvement over what we have at the moment. Stay tuned as I think this one is for real and will appear in NICUs sooner than you think!
By Stefan Johansson in Department of Brilliant IdeasMany of you already know about my engagement in Neobiomics, a startup company now launching ProPrems® in Europe.
I was asked recently if there was a specific event that made me committed to close the gap between need and availability of a safe way to support the intestinal microbiota. Yes, there was a “Tipping Point” that I can share a few words about, without disclosing patient data.
The photo below shows the place in my NICU where a preterm infant stayed some years back, being well on full feeds and expected to have an easy journey with us. When things went into new and unfortunate directions.
Although difficulties and suffering is part of what we work with, this event made me feel that I did not provide the best care for my patients. I mean, compared to all interventions we make every other day, and the lack of good evidence for many of them, probiotics supplementation was already in 2014 a no-brainer from an EBM perspective. So, I set off to find a suitable product. But became increasingly frustrated. I thought that manufacturing probiotics could not be rocket science but I experienced that no company could provide what I was looking for. Specifically, when it came to documentation around quality.
I discussed this matter with colleagues and realized that I shared my concerns with others. An idea came to my mind that maybe we should just work out a solution ourselves, within the neonatal community. Philipp Novak, a life-science entrepreneur in Austria, was brave enough to get convinced and off we went. Backed by a group of clinicians and researchers.
In 2016 we founded the startup company Neobiomics and initiated our collaboration with Chr.Hansen, world-leading manufacturer of bacterial cultures. And now, after 1000s of work hours (pro bono BTW) and with very limited funds, we have now reached the first goal. With ProPrems® there is now a premium product available, with manufacturing quality as we want it (single-dose-packaging, 2y stability in room temp, tested against an extended panel of contaminants, no risk of antibiotic resistance gene transfer).
What’s next? To speak in symbols, our plane is on the takeoff strip at full throttle while we are still putting the wings together. So times are both hectic and thrilling. But like when standing in front of a very ill infant in the NICU, I feel that this is something we can manage by systematic and hard work. But of course, ProPrems® needs to find the way out to NICUs. Without a costly "old-school" organization of sales rep’s etc, this may seem challenging. But given the collegial feedback so far, we feel confident our project will sustain.
If you get interested to learn more, find more in the attached folder. You can also visit the web sites neobiomics.eu and proprems.eu, or get in touch with me directly at email@example.com.
But please note that ProPrems® will be only available in Europe (that’s why access to ProPrems.eu is restricted from non-EU countries).
20 October 2019 Until 23 October 2019
0Investing in a Healthy Future for All: Research, Education, Policy.
Participate in the 11th DOHaD World Congress which will be held in Melbourne, Australia in October 2019. The Congress is hosted by the DOHaD Society of Australia and New Zealand.
The Congress theme is Investing in a Healthy Future for All: Research, Education, Policy. The Congress will bring together basic and clinical researchers and health care professionals from around the world to address the many challenges that currently impact the health of mothers and fathers, babies in the womb, infants, children and adolescents, as well as explore solutions, interventions and policies to optimise health across the lifespan.
Click here to reach the conference web site!
14 November 2019 Until 15 November 2019
1The European Neonatal Ethics Conference is one of the premier events discussing issues involving ethical care around a variety of aspects in neonatal care. It is held every 3 years and is being held in Southampton United Kingdom this year. Besides addressing a number of different topics including issues of neonatal palliative care, organ donation and extremes of viability it is opportunity to share ethical practice across Europe.
Venue -St Mary's Stadium Southampton UK Dates 14th & 15th November 2019
Call for Abstracts-We are calling for abstracts for oral presentations, poster presentations, debates and round table discussions. More details are available here
17 November 2019
1The 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.
26 April 2020 Until 28 April 2020
0First announcement of
Recent advances in neonatal medicine
IXth International symposium honoring prof. Richard B. Johnston, MD, Denver, US
26-28 April 2020, in Würzburg, Germany
Find more information in the attached folder.