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  8. When I think back to my early days as a medical student, one of the first lessons on the physical exam involves checking central and peripheral perfusion as part of the cardiac exam. In the newborn to assess the hemodynamic status I have often taught that while the blood pressure is a nice number to have it is important to remember that it is a number that is the product of two important factors; resistance and flow. It is possible then that a newborn with a low blood pressure could have good flow but poor vascular tone (warm shock) or poor flow and increased vascular tone (cardiogenic shock or hypovolemia). Similarly, the baby with good perfusion could be in septic shock and be vasodilated with good flow. In other words the use of capillary and blood pressure may not tell you what you really want to know. Is there a better way? As I have written about previously, point of care ultrasound is on the rise in Neonatology. As more trainees are being taught the skill and equipment more readily available opportunities abound for testing various hypotheses about the benefit of such technology. In addition to my role as a clinical Neonatologist I am also the Medical Director of the Child Health Transport Team and have pondered about a future where ultrasound is taken on retrievals to enhance patient assessment. I was delighted therefore to see a small but interesting study published on this very topic this past month. Browning Carmo KB and colleagues shared their experience in retrieving 44 infants in their paper Feasibility and utility of portable ultrasound during retrieval of sick preterm infants. The study amounted to a proof of concept and took 7 years to complete in large part due to the rare availability of staff who were trained in ultrasound to retrieve patients. These were mostly small higher risk patients (median birthweight, 1130 g (680–1960 g) and median gestation, 27 weeks (23–30)). Availability of a laptop based ultrasound device made this study possible now that there are nearly palm sized and tablet based ultrasound units this study would be even more feasible now (sometimes they were unable to send a three person team due to weight reasons when factoring in the ultrasound equipment). Without going into great detail the measurements included cardiac (structural and hemodynamic) & head ultrasounds. Bringing things full circle it is the hemodynamic assessment that I found the most interesting. Can we rely on capillary refill? From previous work normal values for SVC flow are >50 ml/kg/min and for Right ventricular output > 150 ml/kg/min. These thresholds if not met have been correlated with adverse long term outcomes and in the short term need for inotropic support. In the absence of these ultrasound measurements one would use capillary refill and blood pressure to determine the clinical status but how accurate is it? First of all out of the 44 patients retrieved, assessment in the field demonstrated 27 (61%) had evidence using these parameters of low systemic blood flow. After admission to the NICU 8 had persistent low systemic blood flow with the patients shown below in the table. The striking finding (at least to me) is that 6 out of 8 had capillary refill times < 2 seconds. With respect to blood pressure 5/8 had mean blood pressures that would be considered normal or even elevated despite clearly compromised systemic blood flow. To answer the question I have posed in this section I think the answer is that capillary refill and I would also add blood pressure are not telling you the whole story. I suspect in these patients the numbers were masking the true status of the patient. How safe is transport? One other aspect of the study which I hope would provide some relief to those of us who transport patients long distance is that the head ultrasound findings before and after transport were unchanged. Transport with all of it’s movement to and fro and vibrations would not seem to put babies at risk of intracranial bleeding. Where do we go from here? Before we all jump on the bandwagon and spend a great deal of money buying such equipment it needs to be said “larger studies are needed” looking at such things as IVH. Although it is reassuring that patients with IVH did not have extension of such bleeding after transport, it needs to be recognized that with such a small study I am not comfortable saying that the case is closed. What I am concerned about though is the lack of correlation between SVC and RVO measurements and the findings we have used for ages to estimate hemodynamic status in patients. There will be those who resist such change as it does require effort to acquire a new set of skills. I do see this happening though as we move forward if we want to have the most accurate assessment of clinical status in our patients. As equipment with high resolution becomes increasingly available at lower price points, how long can we afford not to adapt?
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  10. There is a new case posted in the Virtual NICU - an infant with nCPAP got a nasal burn injury. The posting member wants to hear if other member has experience from similar rare events. Log in and you will be able to read the history and view photos here: https://99nicu.org/forums/topic/2029-unique-case-with-catastrophic-end-1st-reported/
  11. Another two videos of the lectures from the 99nicu Meetup is now available on the Meetup17-page! Click on the "Meetup17" tab in the meny above to see: Amir Kuperman lecturing about "Developmental Hemostasis - Practical Aspects For The Neonatologist" Kristine Karlsen lecturing about "21 years of S.T.A.B.L.E. Program Education: History and Module Overview"
  12. thank you very much its great to have them online iam watching ..
  13. Workshops Debates and Round Tables published https://mprove.createsend.com/campaigns/reports/viewCampaign.aspx?d=d&c=127B2231470F756D&ID=1639AB11C8335C81&temp=False&tx=0 Click on the link to view each workshop. Each image opens to explain the workshop content.
  14. During the last few weeks, we have had some very interesting discussions in the Virtual NICU, about an infant with 22q11 syndrome, about one infant with osteogenesis imperfecta, and one infant with a yet undiagnosed congenital syndrome. The Virtual NICU can only be accessed when you are logged in, i.e. you can only read and post in that section if you have logged in with your username and password. Further, unless you are logged in, the content in the Virtual NICU won't be displayed in the Activity Feed on our landing page. I add two screen shots below, as an illustration what the feed looks like as not logged in and as logged in. If you don't want to log in every time, just tick "Remember me" when you log in, and you will be automatically logged in every time you visit 99nicu
  15. Things aren’t the way they used to be. When I was training, opportunities abounded for opportunities to intubate infants. Then we did away with intubating vigourous infants born through meconium and now won’t be electively intubating them at all. Then you can add in the move towards use of non-invasive respiratory support instead of intubating and giving surfactant and voila…you have the perfect barrier for training residents and others how to intubate. On top of all of this the competition for learning has increased as the skill that was once the domain of the physician has now spread (quite rightly) to respiratory therapists, nurses in some places and with the growth of residency programs (ours is now 2.5X larger than when I trained) the scarce chances are divided among many. Enter the Video Laryngoscope To be clear this isn’t a post to promote a product but rather an examination of the effectiveness of a tool. I am putting this out there recognizing the possibility that someone out there might have heard of or have been contemplating purchasing one of these items. Those that are quite proficient at intubation (likely trained in the “good old days”) would likely question the need for such a device but I believe the device isn’t really aimed at that group except to use perhaps as a teaching tool. It really is targeted (at least I think) for those who don’t perform the skill often. Does use of the video laryngoscope improve success rates at intubation? This question has had an attempt now at being answered by Parmekar S et al in their paper Mind the gap: can videolaryngoscopy bridge the competency gap in neonatal endotracheal intubation among pediatric trainees? a randomized controlled study. The study involved taking 100 pediatric residents and randomizing them into two groups. The first would use the videolaryngoscope (VL group) and then intubate using the standard technique of direct laryngoscopy (DL group). The second group started with DL and then changed to VL. Both groups took part in a training session on intubation and then participated in three simulation scenarios from NRP. The findings demonstrated a couple interesting things. The first as shown in the graph was that the group that started with the laryngoscope had a near 90% success rate compared to about 60% for the traditional approach. When the groups swapped though they were both equal in effectiveness. This suggests that by visualizing the airway with the VL students were able to identify structures better after doing so such that success was improved simply by having used the device. The other finding worth mentioning was that when the times to intubation were looked at, there was no difference between the two groups at all. If the intubation success is no different, why might the times be the same? Having used the video laryngoscope myself it does take some getting used to. Rather than looking directly at the airway you find yourself looking off to the side and adjusting the approach that is in front of you to place the ETT. No doubt this does take some getting used to. What I would have liked to see is a repeat assessment a week later after using a few more trials with the VL as I suspect once you are used to it the speed of intubation would improve as well. I suppose though we will have to wait a little while until someone does such work but as a means of improving success in intubation I believe this tool has something to add.
  16. Another case is shared in the Virtual NICU: a 36w infant with poor feeding and dysmorpic features. The posting member seeks advice on possible differential diagnoses. Please find the case history and photos here. Please note that you must log in to access the virtual NICU and read/post about this case.
  17. great to have the videos available!
  18. Sorry for delay i did not see the reply First you should be a provider NRP provider after that you will do the instructor course Regarding travel i think is not difficult I will ask my Boss for the course and i will let you know about her reply
  19. Almost all lectures on the 99nicu Meetup were videorecorded and will be made available on Youtube. Over the summer, we will be adding lectures on the Meetup page (https://99nicu.org/meetup2017/). Right now you can see David Sweet lecturing about RDS management and Rebeccah Slater lecturing about pain in preterm infants, but more will come...
  20. First of all, my sincere thanks to everyone involved in the 99nicu Meetup, delegates for attending, speakers for giving great lectures, and partners for support! Despite a lower number of delegates than we had planned for (we did not pick the perfect dates for the Meetup...), I think we managed very well. We needed to downsize and slimline a lot, including changing the venue. But, content was king thanks to great lectures, and all interactions and networking. Given the great feedback we had from delegates, we are committed to continue with this IRL forum for the 99nicu members. Stay tuned for information about the next Meetup, preliminary scheduled for April 2018 in Vienna. Almost all lectures were videorecorded and they will be added over the summer on the Meetup page here: https://99nicu.org/meetup2017/ Right now you can see David Sweet lecturing about RDS management and Rebeccah Slater lecturing about pain in preterm infants. The only downside was the financial results, not yet definite but estimated to be a loss of ~5000 USD. Despite "the pain to open the purse" and our original plan to raise funds for IT work for this web site, I believe we shall regard this first meeting as an investment for future Meetups. We will also be trying to crowd-fund to cover some of the deficit. Those who value the videos as a learning experience are able to make a small donation. That was all my reflections for now. Until we meet in Vienna, see you here on 99nicu.org
  21. The latest admission to the Virtual NICU is resolved, the infant has a 22q11 deletion syndrome. Warm regards to everyone adding input into this tricky case and special thanks to @Jose Ramon Fernandez who suggested the diagnosis, confirmed by genetic testing. As the Virtual NICU is a closed members-only area for 99nicu, you need to be logged in to read and add input in discussion. Please find the URL below (if logged in you can just click on it, otherwise you need to log in first)
  22. Just few hours back a very important news article came out on the pages of 'The Washington Post'; slightly beyond the domain of pure academics of the Neos it somehow made a full circle. A must read: https://www.washingtonpost.com/news/worldviews/wp/2017/06/29/against-his-parents-wishes-this-terminally-ill-infant-will-be-allowed-to-die/?utm_term=.e207844d7153
  23. Both I and @Francesco Cardona are back to regular NICU work after the few intensive weeks of conference work before, during and after the 99nicu Meetup. First of all, we would like to thank everyone - delegates, speakers and partners - for coming and contributing to great event! The feedback was very good and we feel committed to repeat the Meetup in 2018. In short, we are planning a 99nicu Meetup in April, in Vienna, and hope to make a first announcement in September. We are also working to get the recorded lectures on Youtube, this should be done by the end of this week. If you would like to see a few more photos of the event, check out the Meetup Gallery below
  24. Net Essential for the Neos: https://www.nichd.nih.gov/cochrane/Pages/cochrane.aspx https://public.vtoxford.org/database-qi-research/trials/
  25. We do not use it and rely on echo (and clinical scenario). but I found this systematic review - hope that helps http://pediatrics.aappublications.org/content/early/2015/01/13/peds.2014-1995 looking fw to hear others experience!
  26. Good morning everyone, On occasion we have taken note of the Pro BNP level in an infant with an hHsPDA who may or may not warrant Ibuprofen. Does anyone use BNP as a guide to the treatment or current state of the PDA as a point of care? Any thoughts on the role of BNP greatly appreciated. Kind regards Al
  27. I had the pleasure of meeting the author of a paper I am about to comment on this week while at the 99 NICU conference in Stockholm. Dr. Ohlin from Orebro University in Sweden presented very interesting work on their unit’s “scrub the hub” campaign. As he pointed out, many places attempt to reduce coagulase negative staphylococcal infections by introducing central line bundles but seldom is there one thing that is changed in a bundle that allows for a before and after comparison like his team was able to do. I was so impressed by this work and at the same time concerned about another strategy to reduce infection that I felt compelled to make a comment here. Scrub the hub! Dr. Ohlin and the first author Dr. Bjorkman published Scrubbing the hub of intravenous catheters with an alcohol wipe for 15 sec reduced neonatal sepsis back in 2015. They compared a 16.5 month period in their unit when they rolled out a CLABI reduction bundle to a period of 8.5 months afterwards when they made one change. Nurses as is done in the units I work in were commonly scrubbing the hub before they injected the line with a medication but in the second epoch the standard changed to be a specified 15 second scrub instead of being left up to the individual nurse. With permission from Dr. Ohlin here is a picture of the hubs highlighting bacterial growth without scrubbing, then for a duration less than 15 seconds and then with 15 seconds. In the first epoch they had 9 confirmed CLABSIs and 0 confirmed in the second after their intervention. The rate of CLABSI then in the first epoch was 1.5% vs 0% in the second group. As with any study looking at sepsis, definitions are important and while they didn’t do paired cultures to rule out contamination (one positive and one negative as is the definition in our hospitals) they did refer each patient to a senior Neonatologist to help determine whether each case should be considered a true positive or not. Given that they made no changes to practice or other definitions in diagnosing infections during that time perhaps the results were indeed real. Presumably if they had missed an infection and not treated it in the second epoch the patient would have declared themselves so I think it is reasonable to say that 8.5 months without a CLABSI after their intervention is a success. As Dr. Ohlin points out the scrub duration may also help due to the abrasion of the hub surface removing a bacterial film. Regardless of the reason, perhaps a 15 second scrub is a good idea for all? The lazy person’s solution – the SwabCap One way to get around human nature or people being distracted might be to cover each luer lock with a cap containing 70% isopropyl alcohol. In this way when you go to access the line there should be no bacteria or labour required to scrub anything since the entry of the line is bathed in alcohol already. This was the subject of a systematic review from the Netherlands entitled Antiseptic barrier cap effective in reducing central line-associated bloodstream infections: A systematic review and meta-analysis. The reviews ultimately examined 9 articles that met their inclusion criteria and found the following; use of the antiseptic barrier cap was effective in reducing CLABSIs (IRR = 0.59, 95% CI = 0.45–0.77, P < 0.001). Moreover, they concluded that this was an intervention worth adding to central-line maintenance bundles. Having said that, the studies were mostly adult and therefore the question of whether minute quantities of isopropyl alcohol might be injected with medications was not a concern when they made their conclusion. What about using such caps in ELBW infants Sauron et al in St. Justine Hospital in Montreal chose to look at these caps more carefully after they were implemented in their NICU. The reason for taking a look at them was due to several luer valves malfunctioning. The authors created an in-vitro model to answer this question by creating a closed system in which they could put a cap on the end of a line with a luer lock and then inject a flush, followed by a simulated medication (saline) and then a flush and collect the injected materials in a glass vial that was sealed to prevent evaporative loss of any isopropyl alcohol. They further estimated the safe amount of isopropyl alcohol from Pediatric studies would be 1% of the critical threshold of this alcohol and using a 500g infant’s volume of distribution came up with a threshold of 14 mmol/L. The study then compared using the SwabCap over two different valve leur lock systems they had in their units (SmartSite and CARESITE valves) vs. using the strategy of “scrub the hub”. The results were quite concerning and are shown below. Circuit Type Temperature Sample 1 Sample 2 Sample 3 Mean SwabCap on Smart Site Valve Room 49.5 58.4 46.8 51.6 Incubator 35 degrees 45.16 94.7 77.9 72.6 SwabCap on CARESITE valve Room 14.1 5.7 5.2 8.34 Incubator 35 degrees 7.0 8.1 5.9 7.0 Isopropyl alcohol pad on CARESITE Valve Room 0 0 0 0 Certainly, the Smart Site valve allowed considerable amounts of isopropyl alcohol to enter the line but the CARESITE while better still allowed entry compared to the control arm which allowed none. Beyond the introduction of the alcohol into the system in all cases considerable clouding of the valves occurred with repeated capping of the system with new caps as was done with each med injection since each was single use. In lines that were not accessed contact with the cap was left for 96 hours as per recommendations from the manufacturer and these changes occurred as well. Conclusion While a reduction in CLABSI is something we all need to strive to obtain, it is better to take the more difficult path and “scrub the hub” and by that for 15 seconds which incidentally is the same recommended duration for hand hygiene in both of our units. Perhaps in larger term infant’s seepage of isopropyl alcohol into the lines would not be as concerning as their larger volume of distribution would lead to lower levels but I would ask the question “should any isopropyl alcohol be injected into any baby?”. I think not and perhaps by reading this post you will ask the same thing if your unit is using these caps. Thank you to Örebro University Hospital for their permission in using the photo for the post
  28. Very touching story and a great painting to express this drastic contrast.
  29. We still haven´t been able to provide donor human milk in our Unit, so if we have a PT < 33 weeks GA or an SGA <p3 infant who is also <34 wks GA, we will consider either starting parenteral nutrition until the mother can produce milk or give aminoacids 10% plus 12.5% dextrose and some form of IV phosphate via peripheral vein. For us, it has more to do with maturity than birth weight. We also try to use as little formula as possible, favoring own mother's breast milk.
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