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  1. Today
  2. IVH

    @bimalc and @tarek Thank you both for your comments and sharing your experiences. I do understand your points and concerns. Our standard starting point for TFII is 50 ml/kg/d on day 0 for micro preemies, but we tailor the TFI for each case depending on mean arterial blood pressure, cardiac size on chest X-ray, ECHO heart findings, and urine output. Thus one preem may be receiving a TFI of 50 ml/kg/day on day 0 and another preem with the same GA and BW receiving a TFI of 80 ml/kg/d. Each case is different. In addition, our rate of increase is 10 ml/kg/d as a basic standard, but still, it could be higher depending on how the same factors mentioned above go In an NICU in Canada, the TFI was 60~80 ml/kg/d for micro preemies < 26 weeks GA, and 100 ml/kg/d for < 24 weeks GA, as a standard, and when these fluid volumes were not enough to maintain the BPs and there was poor peripheral perfusion indicated by high Lac and prolonged CRT, saline boluses were given and inotropes were considered. The daily rate of increase was as a standard 20 ml/kg, unless the prem was puffy or chest X-ray showed increased lung fluids, then daily increase in TFIs was decreased or skipped. I do not imply that one strategy is better than the other, however, tailoring the fluids and inotropes given per each preem`s condition for me sounds practical. We have a special session on tailoring IV fluids and inotropes for preterms next month in the 62nd annual conference of the Japanese society of neonatal health and development http://jsnhd62.umin.jp/en/abstract.html . This could be an important topic to be also discussed in next 99NICU meeting @Stefan Johansson
  3. Yesterday
  4. IVH

    I have done 80/kg in the past; I think we agree on the importance of uop,etc. and adjusting fluids based on weight, output and labs. 50/kg just seems unlikely to be sufficient in my experience, but if there is international experience suggesting otherwise, I might need to reassess my practice
  5. Last week
  6. IVH

    @bimalc One of my friends in Minnesota i discussed this issue with her they are starting with 80 ml/kg and checking of sodium ,uop and adjust ivf accordingly so not all in US starting with 100 ml/kg And i am in favour of restricted intake initially and adiustement according UOP ,Na and Urea More fluids more IVH PDA and pulmonary hge So the most important is follow up and adjust accordingly allowing for physiological wt loss in the first 5 days
  7. IVH

    @Hamed I am interested to hear your fluid management for micro preemies is quite different than practice in the US. I do not imply that one is superior to the other, but I must ask what difficulties (if any) you have in maintaining normal fluid electrolyte balance with only 50mL/kg/day of fluids in the smallest babies? In the two units I currently work in, such a baby would typically receive 100mL/kg/d on day 0 and increase 10-30mL/kg/d. My experience has been that even with humidified isolettes (or at least the ones I have used over the years) such babies can lose massive amounts of weight/water and become very hypernatremic if we are overly cautious with fluids early on.
  8. As someone with an interest in neonatal abstinence (NAS) I am surprised that I missed this study back in May. Anyone who says they aren’t interested in NAS research must be turning a blind eye to the North American epidemic of patients filling neonatal units or postpartum wards in need of treatment for the same. News feeds such as CNN have covered this story many times with concerning articles such as this published “Opioid Crisis Fast Facts” even the Trump White House has officially declared it as an emergency at this point. With NICU resources stretched and care providers fatigue levels wearing thin (these patients are typically very challenging to take care of due to the crying and agitation with neurological excitability that is at the core of the symptoms, something needs to be done. The vast majority of neonatal care providers treat such patients with an approach that promotes first non pharmacologic strategies such as keeping mom and baby together when possible, breast feeding and disturbing these infants as little as possible to name a few points. For those patients though who require pharmacologic support though, the mainstay has been oral morphine. At least in our units though once a patient is admitted and undergoes treatment we are still looking at anywhere from 3-4 weeks on average that they will occupy a hospital bed. If only there was a better way. Could Buprenorphine do the trick? While morphine is widely used to treat NAS symptoms unresponsive to other non pharmacologic methods of control, buprenorphine has a similar profile as an opioid but has less risk of respiratory depression as a partial agonist. A small but important trial has been published directly comparing the use of morphine to buprenorphine for treatment of NAS symptoms with the primary outcome being days of treatment and the second important point being length of stay. The trial, Buprenorphine for the Treatment of the Neonatal Abstinence Syndrome.by Kraft WK et al was entitled the BBORN trial for short. This was a single centre trial in which a double blind/double dummy approach was used. By double dummy this meant that after randomization those babies randomized to morphine received morphine plus a buprenorphine placebo and the other arm received a buprenorphine dose and a morphine placebo. In total 33 infants were randomized to buprenorphine and 30 to morphine (hence my comment about this being a small study). Their power calculation had called for 40 infants per arm to detect a 28% difference in the primary end point of duration of treatment but in the end that didn’t matter so much as they found a significant difference exceeding their estimate anyway. A lack of power would have become important mind you had they not found a difference as they wouldn’t have actually had the numbers to do so. A strength of the study up front was that all care providers scored NAS symptoms the same way (need to take into account there is some subjectivity in scoring altogether though) and escalations and decreases of medication were done following a strict protocol both ways. In both arms, once a maximal dose of 60 mcg/kg of body weight for buprenorphine and 1.2 mg/kg for morphine was reached phenobarbital was added. When comparing the two groups at the outset there were no significant differences in characteristics so two generally similar populations of infants were being treated. The Results Were Indeed Impressive Before launching into the table, there were 21 babies in both groups that were bottle fed and 12 in the burprenorphine group and 9 in the morphine group that breastfed. Outcome Buprenorphine Morphine p Median days of treatment 15 (3-67) 28 (13-67) <0.001 Bottle feeding 15 (3-67) 28 (13-67) Breast feeding 20 (3-55) 28 (16-52) Hospital stay in days 21 (7-71) 33 (18-70) <0.001 Bottle feeding 21 (7-71) 33 (18-70) Breast feeding 26 (7-58) 32 (20-58) No difference was seen in those who needed phenobarbital. Looking at the table, a couple things really stand out to me. They were looking for a 28% reduction in days of treatment. The results came in far excess of that at a 46% reduction. Curiously, breastfeeding which has classically been associated with a reduction in scores and therefore faster weaning due to less symptoms seemed to have the opposite effect here. Does this imply that breastfeeding slows down both duration of treatment and length of stay as a result? With a study this small it is difficult to say with so few breastfed babies but if I had to guess I would suggest those mothers that worked at breastfeeding may have had longer stays. Should we all jump on the buprenorphine train? For now I would give this a big maybe. One of the concerns about burprenorphine is that it comes as a solution of 30% alcohol. Giving multiple doses (3 per day in this study) of such a solution could in part contribute to these results of lower NAS symptoms. Is giving alcohol to reduce symptoms a good idea here? Not sure if there are any long term effects and moreover if the cumulative dose of this medication would be of a concern. Definitely something to check with your local pharmacist before rolling this out. On the other hand if the dose of alcohol provided was truly significant I might have expected the burprenorphine group to be poorer feeders due to intoxication which we certainly did not see. With increasing volumes of newborns afflicted with symptoms of NAS we do need to find a way to stem the tide. Ideally, primary preventative strategies would be best but until that solution is found could burprenorphine be the next step in tackling this epidemic?
  9. IVH

    Thanks a lot @Hamed really its great help Thanks a lot @Stefan Johansson
  10. IVH

    @Stefan Johansson Thanks a lot, no I wasn't aware of this recent Cochrane review. Thanks a lot. I will share it with my coworkers and colleagues.
  11. IVH

    @Hamed Thanks for sharing valuable info. however, on head positioning, have you seen recent Cochrane review?
  12. Pain control in preterms. Umbilical cord milking. Management of seizures during cooling and rewarming. Targeted ECHO and Ultrasound for neonatologists. Decision making in case of ELGAN ( how to help parents decide their baby`s management pathway). Methods for breaking hard news to parents about their baby or in an antenatal consultation. Including families in NICU rounds and care of their infant. Latest updates on modes of ventilation. Effective with time and effort efficient policy for daily rounds (How to make it successful for the patients, their parents, and medical staff).
  13. IVH

    Hi Tarek, Your experience with this 600 g ELBW is not uncommon. It is important to mention the gestational age in your description of the case. It can help the reader give you a more practical answer. I am assuming this was a 24 ~ 25 weeker infant unless it was also an IUGR. To minimize IVH you have special concerns to cover: A- Before birth giving mom Antenatal steroids. B- Delivery: 1-With minimal handling as possible. 2- Cord milking and delay cord clamping C- After delivery: 1- Positioning the head and body in same line ie not tilting the head to one direction lt or rt which will kink the neck (Jugular) veins and cause congestion of the bain of that side. 3-Prophylactic indomethacin (indicated in Japan if BW less than 1000 g + GA below 28 wks/ and in some NICUs in Canada if GA is less than 26+0 wks whatever the body weight is). 4- Correcting acidosis. 5- Maintain a good circulatory volume and start low IV fluids with a TFI at 50 ml/kg/d on DOL 0 and increase fluids by 10 ml/kg/day, unless the circulatory volume is low then you have to balance it. 6- Minimal handling. First 3 days are the highest risk time for IVH development. As for your concerns about intubation especially when there is no experienced medical team member (physician or RT), that depends on your unit`s policy for staff coverage. However, I recommend you not to jump quickly to intubation, a lot of 23, 24 and 25 weekers manage to escape from being intubated using CPAP and NIPPV.
  14. IVH

    IVH and ELBW It is really a bad experience having a 600 gms baby with IVH grade 3 or 4 What is your best practice to minimize the risk of IVH? Management of hypotension and risk of IVH Intubation and IVH who should intubate it is not always the most expert will be there Delayed cord clamping really we should not miss its benifits Painful procedures and IVH is it helpful to give morphine before any painul and irritant procedure like suctioning PDA and IVH should i give prophylactic endomethacin in first few hours of life
  15. Transfusion guidlines in neonates Ultrasound chest and TTN diagnosis(double lung point) Prevention of IVH in ELBW
  16. Video Assisted Intubation using a C-Mac

    BTW and slightly OT - a study on the usefulness of video-laryngoscopy: http://pediatrics.aappublications.org/content/136/5/912
  17. Video Assisted Intubation using a C-Mac

    I am not sure, but think that the C-Mac system has Miller0-blades but not smaller. But the Accutronic system goes down to Miller 00: https://www.acutronic-medical.ch/products/infantview.html Again not sure, but I think that one of the Karolinska NICUs (Huddinge) has an Accutronic system @wackdi am I right?
  18. I am cross-posting this from our FB-page. Anyone have experience?
  19. Earlier
  20. I got this on my radar, through the Twitter feed from @EBNEO - whether surfactant could be administered as easy as an oropharyngeal squirt? Have look in the latest issue of @Acta Paediatrica here: http://onlinelibrary.wiley.com/doi/10.1111/apa.14060/full´ And, here's a video demo posted by the article authors:
  21. Helping Babies Breathe - it works!

    This is an important step to reduce neonatal mortality and morbility in developing countries,especially in resource-limited districts.
  22. Helping Babies Breathe - it works!

    This is such beautiful news!
  23. Is our approach to ventilation really harming babies?

    When I read this publication with my clinical epidemiology-glasses, I wonder if the results (and conclusions) are just an example of the cohort effect. @AllThingsNeonatal you are very nicely referring to that possibility, when you discuss the possibility of a changing distribution of gestational age over time, and mortality differences over time (that probably reflect change in care over time).
  24. Helping Babies Breathe - it works!

    Came across this paper in @Acta Paediatrica about the Helping Babies Breathe (HBB) program in Kenya. 10 months post-training, there was a >50% reduction in the rate of hypoxic ischemic encephalopathy, from 1.6% to 0.7% of live-births. The mortality rates decreased in numbers from 0.4% to 0.2%, but this was not statistically significant. However, the study was not powered to find this difference. The paper is available in full-text here. And, related editorials are available here and here. Does anyone here have hands-on-experience from working with the HBB-program? Would be interesting to hear about it!
  25. We can always learn and we can always do better. At least that is something that I believe in. In our approach to resuscitating newborns one simple rule is clear. Fluid must be replaced by air after birth and the way to oxygenate and remove CO2 is to establish a functional residual capacity. The functional residual capacity is the volume of air left in the lung after a tidal volume of air is expelled in a spontaneously breathing infant and is shown in the figure. Traditionally, to establish this volume in a newborn who is apneic, you begin PPV or in the spontaneously breathing baby with respiratory distress provide CPAP to help inflate the lungs and establish FRC. Is there another way? Something that has been discussed now for some time and was commented on in the most recent version of NRP was the concept of using sustained inflation (SI) to achieve FRC. I have written about this topic previously and came to a conclusion that it wasn’t quite ready for prime time yet in the piece Is It Time To Use Sustained Lung Inflation In NRP? The conclusion as well in the NRP textbook was the following: “There are insufficient data regarding short and long-term safety and the most appropriate duration and pressure of inflation to support routine application of sustained inflation of greater than 5 seconds’ duration to the transitioning newborn (Class IIb, LOE B-R). Further studies using carefully designed protocols are needed” So what now could be causing me to revisit this concept? I will be frank and admit that whenever I see research out of my old unit in Edmonton I feel compelled to read it and this time was no different. The Edmonton group continues to do wonderful work in the area of resuscitation and expand the body of literature in such areas as sustained inflation. Can you predict how much of a sustained inflation is needed? This is the crux of a recent study using end tidal CO2 measurement to determine whether the lung has indeed established an FRC or not. Dr. Schmolzer’s group in their paper (Using exhaled CO2 to guide initial respiratory support at birth: a randomised controlled trial) used end tidal CO2 levels above 20 mmHg to indicate that FRC had been established. If you have less CO2 being released the concept would be that the lung is actually not open. There are some important numbers in this study that need to be acknowledged. The first is the population that they looked at which were infants under 32 6/7 weeks and the second is the incidence of BPD (need for O2 or respiratory support at 36 weeks) which in their unit was 49%. This is a BIG number as in comparison for infants under 1500g our own local incidence is about 11%. If you were to add larger infants closer to 33 weeks our number would be lower due to dilution. With such a large number though in Edmonton it allowed them to shoot for a 40% reduction in BPD (50% down to 30%). To accomplish this they needed 93 infants in each group to show a difference this big. So what did they do? For this study they divided the groups in two when the infant wouldn’t breathe in the delivery room. The SI group received a PIP of 24 using a T-piece resuscitator for an initial 20 seconds. If the pCO2 as measured by the ETCO2 remained less than 20 they received an additional 10 seconds of SI. In the PPV group after 30 seconds of PPV the infants received an increase of PIP if pCO2 remained below 20 or a decrease in PIP if above 20. In both arms after this phase of the study NRP was then followed as per usual guidelines. The results though just didn’t come through for the primary outcome although ventilation did show a difference. Outcome SI PPV p BPD 23% 33% 0.09 Duration of mechanical ventilation (hrs) 63 204 0.045 The reduction in hours of ventilation was impressive although no difference in BPD was seen. The problem though with all of this is what happened after recruitment into the study. Although they started with many more patients than they needed, by the end they had only 76 in the SI group and 86 in the PPV group. Why is this a problem? If you have less patients than you needed based on the power calculation then you actually didn’t have enough patients enrolled to show a difference. The additional compounding fact here is that of the Hawthorne Effect. Simply put, patients who are in a study tend to do better by being in a study. The observed rate of BPD was 33% during the study. If the observed rate is lower than expected when the power calculation was done it means that the number needed to show a difference was even larger than the amount they originally thought was needed. In the end they just didn’t have the numbers to show a difference so there isn’t much to conclude. What I do like though I have a feeling or a hunch that with a larger sample size there could be something here. Using end tidal pCO2 to determine if the lung is open is in and of itself I believe a strategy to consider whether giving PPV or one day SI. We already use colorimetric devices to determine ETT placement but using a quantitative measure to ascertain the extent of open lung seems promising to me. I for one look forward to the continued work of the Neonatal Resuscitation–Stabilization–Triage team (RST team) and congratulate them on the great work that they continue doing.
  26. What do YOU want for the next 99nicu Meetup (Vienna; April 2018)?

    Hello!! I want to listen about the hipotermia results, the notice about other applications as like resuscitation in newborn into NICU
  27. What do YOU want for the next 99nicu Meetup (Vienna; April 2018)?

    Interesting indeed! For clarification, do you mean EEG or aEEG?
  28. Application of EEG monitoring in Nicu
  29. Swedish Dads FTW!

    The photographer Johan Bävman is touring around the world with a photo exhibition about "Swedish Dads". The exhibition shows fathers on parental leave. Swedish newspapers recently wrote about the reactions in Sydney, Australia (see exhibition before 26/9). A (female) columnist in Sydney Morning Herald referred to the exhibition like "porn for stressed moms". I wouldn't agree on that headline but the column itself is interesting, and the reasoning about how the society could/should become more equal. The photos are nothing but fantastic! See some below and visit Bävmans web site to see them all here. I touched upon this topic long ago, in a short blog post here in 2012, that "it's not all about motherhood in the maternity wards and NICUs". Our family-centered neonatal care includes all parents, i.e. expect the father to be as present and care-giving as the mother. For myself, being a "Swedish Dad", I never considered NOT taking parental leave when we had our children. When our son was born in 1996, it was more easy as I was a pediatric fellow. But even in 2011 when our daughter was born, going off work during ~6 months was a natural thing to do for me despite being a consultant neonatologist. We work such a lot during our life-time, and we don't have too much ice-cream with our little ones (but it's great when we do ) I am well aware that many countries have less generous systems for parental leave (especially regarding the amount of time funded but welfare systems). But, I strongly recommend all father to take leave with children, and manage the household while the mother is going back to work. It is an investment for life. Have a look at the video about the photo project below and enjoy some of the photos, embedded with permission from Johan Bävman. If you visit Stockholm later this year, the "Swedish Dads" exhibition comes to Galleri Kontrast in Stockholm (30/9 - 29/10).
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