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  1. I met the author of this article at a CPS meeting a few years ago, she immediately impressed me with her unique perspective. Paige is a developmental pediatrician who does long-term follow-up of preterms, and is involved in developmental evaluation and intervention of children with other challenges, including Spina Bifida.

    Church P. A personal perspective on disability: Between the words. JAMA Pediatrics. 2017.

    As you will see if you read the article, Paige has a form of Spina Bifida herself, a Lipomyelomeningocele, with a neurogenic bladder and neurogenic bowel, requiring life-long interventions. She discusses the poor tolerance many medical people have of disability, and such how things are often discussed as black or white, whereas having a profound personal experience of disability has made her much more nuanced.

    She recounts being involved in a discussion regarding a "selective reduction" of a twin pregnancy where the twin being considered for "reduction", i.e. abortion, had a similar lesion to her own.

    That is an experience that I can barely understand: how would I react if a family was considering terminating  a pregnancy because of a condition that I had? Paige recounts the episode with tact and humanity.

    I can imagine, as I have heard them many times, the words of the other physicians involved in such a decision, I am sure they talked about handicaps and limitations, poor quality of life, pain, and restrictions on family life. Most of which is said with good intentions but with no real knowledge of the literature, or of the range of experiences of families living with the challenges.

    Just as with similar discussions regarding extreme preterm infants, a list of complications, interventions, disabilities, and long-term problems is often presented, but with no similar list of benefits, achievements, abilities, long-term adaptation, and happiness.

    Near the end of her moving piece Paige writes:

    Like most things in life, and medicine, disability is sharp, painful, humbling, as well as tremendous, giving, awe-inspiring. It is human. It is not easily distilled to an all or none discussion. Medicine sets the tone for this discussion and, to date, has done a miserable job. More is needed to appreciate the incredible opportunities that disability poses. More education is needed to provide the counselling families deserve: balanced, sensitive, thoughtful, and individualized rather than “objective.”

    I sincerely hope that this piece by Paige will be part of a new discussion about these issues.

    (Of note, even though the article is behind a paywall, JAMA lets you see the first page of the article before buying, in this case there is only one page, so you can read the whole thing for free!)

  2. It’s possible! Resuscitation with volume ventilation after delivery.

    I know how to bag a baby.  At least I think I do.  Providing PPV with a bag-valve mask is something that you are taught in NRP and is likely one of the first skills you learned in the NICU.  We are told to squeeze the bag at a rate of 40-60 breaths a minute.  According to the Laerdal website, the volume of the preterm silicone bag that we typically use is 240 mL.  Imagine then that you are wanting to ventilate a baby who is 1 kg.  How much should you compress the bag if you wish to delivery 5 mL/kg.  Five ml out of a 240 mL bag is not a lot of squeeze is it?  Think about that the next time you find yourself squeezing one.  You might then say but what about a t-piece resuscitator?  A good choice option as well but how much volume are you delivering if you set the initial pressures at 20/5 for example?  That would depend on the compliance of the lung of course.  The greater the compliance the more volume would go in. Would it be 5 mL, 10 ml or even 2.5 mL based on the initial setting?  Hard to say as it really depends on your seal and the compliance of the lung at the pressure you have chosen.  If only we had a device that could deliver a preset volume just like on a ventilator with a volume guarantee setting!

    Why is this holy grail so important?

    It has been over 30 years since the importance of volutrauma was demonstrated in a rabbit model. Hernandez LA et al published Chest wall restriction limits high airway pressure-induced lung injury in young rabbits. The study used three models to demonstrate the impact of volume as opposed to pressure on injuring the lung of preterm rabbits.  Group 1 were rabbit ventilated at pressures of 15/30/45 cm H2O for one hour, group 2 rabbits with a cast around their thorax to limit volume expansion and group 3 sets of excised lungs with no restriction to distension based on the applied pressures.  As you might expect, limitation of over distension by the plaster cast led the greatest reduction in injury (measured as microvascular permeability) with the excised lungs being the worst.  In doing this study the authors demonstrated the importance of over distension and made the case for controlling volume more than pressure when delivering breaths to avoid excessive tidal volume and resultant lung injury.

    The “Next Step” Volume Ventilator BVM

    Perhaps I am becoming a fan of the Edmonton group.  In 2015 they published A Novel Prototype Neonatal Resuscitator That Controls Tidal Volume and Ventilation Rate: A Comparative Study of Mask Ventilation in a Newborn Manikin.  The device is tablet based and as described, rather than setting a PIP to deliver a Vt, a rate is set along with a volume to be delivered with a peep in this case set at +5.  fped-04-00129-g002_figure2This study compared 5 different methods of delivering PPV to a 1 kg preterm manikin.  The first was a standard self inflating bag, the next three different t-piece resuscitators and then the Next Step.  For the first four the goal was to deliver a pressure of 20/5 at a rate of 40-60 breaths per minute.  A test lung was connected to the manikin such that each device was used for a one minute period at three different levels of compliance (0.5 ml/cmH2O, 1.0 ml/cmH2O and then 2.0 ml/cm H2O representing increasing compliance.  The goal of the study was to compare the methods in terms of delivering a volume of 5 mL to this 1 kg model lung.  The order in which the devices were used was randomized for the 25 participants in the study who were all certified in NRP and included some Neonatologists.

    Some Concerning Findings

    As I said at the beginning, we all like to think we know how to ventilate a newborn with BVM.  The results though suggest that as compliance increases our ability to control how much volume we deliver to a lung based on a best guess for pressures needed is lacking.  One caveat here is that the pressures set on the t-piece resucitators were unchanged during the 1 minute trials but then again how often during one minute would we change settings from a starting point of 20/5?

        Vt (mL)  
      0.5 mL/cmH20 1.0 mL/cmH20 2.0mL/cmH20
    Self inflating 11.4 17.6 23.5
    Neo-Tee 5.6 11.2 19.3
    Neopuff 6.1 10 21.3
    Giraffe 5.7 10.9 19.8
    Next Step 3.7 4.9 4.5

    Without putting in all the confidence intervals I can tell you that the Next Step was the tightest.  What you notice immediately (or at least I did) was that no matter what the compliance, the self inflating bag delivers quite an excessive volume even in experienced hands regardless of compliance.  At low compliance the t-piece resuscitators do an admirable job as 5-6 ml/kg of delivered Vt is reasonable but as compliance improves the volumes increase substantially.  It is worth pointing out that at low compliance the Next Step was unable to deliver the prescribed Vt but knowing that if you had a baby who wasn’t responding to ventilation I would imagine you would then try a setting of 6 ml/kg to compensate much like you would increase the pressure on a typical device. How might these devices do in a 29 week infant for example with better compliance than say a 24 week infant?  You can’t help but wonder how many babies are given minutes of excessive Vt after birth during PPV with the traditional pressure limited BVM setup and then down the road how many have BPD in part because of that exposure.

    I wanted to share this piece as I think volume resuscitation will be the future.  This is just a prototype or at least back then it was.  Interestingly in terms of satisfaction of use, the Next Step was rated by the participants in the study as being the easiest and most comfortable to use of all the devices studied.  Adding this finding to the accuracy of the delivered volume and I think we could have a winner.

  3. I subscribe to the small Youtube channel Science Showcase curated by Andrew Maynard, a very enthusiastic researcher!

    Science Showcase collect video clips with scientific content aimed for a broader (public) audience. There is a contest going on and the best video will win 2000 USD.

    Just wanted share two interesting clips that are sort of relevant :) for neonatal staff. The first video is about epidemiology and its basic concepts. As you know, there are tons of clinical studies in neonatal medicine based on observational data, many of which suffer from major limitations as researchers did not really grasp some basic concepts how to handle their data... In the first video, there is one mistake though - the illustration of confounding is not entirely correct, instead the video illustrates mediation which is different thing. Small mistake though, as the error in the video is rather that the arrow is flipped 180 degrees. See and find out what I mean ;) 

    The second video is about Big Data, a coming major thing in neonatal research as we get access and collect more and more data. The video is about genetic data, but the same principal idea ("so much data you don't know how to handle it") applies to health register data, and the richness of data that could be tanked down from from our monitors, ventilators etc.

    Enjoy!

     

     

  4. Presenting the 2nd Presentation of Neonatal CME @ Jamnagar on 25th October. Its : " NEONATAL JAUNDICE- Current Concepts by Dr.Maulik Shah MD. Video link on You Tube: https://www.youtube.com/watch?v=hLMP4FHOdIk. Comments and feedback most welcome.Neonatal_jaundice_maulik.thumb.png.54d6d

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    What is the diagnosis?

    35 gestation weeks, IUGR, preterm gemini B babygirl has dyspnoe and multiplex fibroma around both ears. She is fed via nasogastric tube, because she can not swallow. She has peripapillary pigment ring, hepato-splenomegaly with abnormal ribs, vertebrae and spine morphology (X-ray attached). Other findings were normal. Her brother is well, he only has hydronephrosis on one side without any symptoms.

    Any suggestions are welcome.

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    hi

    Is adrenalin better than dopamine for maintaining/elevating BP in PPHN. Please tell me about your practice

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    Preterm baby 35 week was admitted to NICU for total 5 days

    All investigations were normal including blood C/S , CRP CBC And serum Electrolytes

    In day 4 , Baby develop this rash only for 20 minutes then disappear without treatment

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    What are the indicators we can use to check the quality of care in a neonatal unit?

  5. Mortality rates of congenital heart disease has fallen dramatically over the years, nicely demonstrated by a cohort British study. The annual numbers of deaths decreased from 1460 in 1959 to 154 in 2009. Survival was especially improved in infancy. Infants comprised 63% of all CHD deaths during 1959-63, but only to 22% in 2004-08.

    Naturally, the development of pediatric cardiology, thoracic surgery and pediatric intensive care have been essential for this dramatic improvement.

    The improved situation for infants with congenital heart disease is quite similar and parallel to improved outcomes for preterm infants. Only a few decades ago, the majority of today's survivors would have had a poor prognosis.

    With this growing generation of "new survivors" comes new challenges. In neonatal and adult medicine we know little about aging individuals born preterm, and I believe the same applies to aging individuals born with congenital heart disease.

    Knowles RL, Bull C, Wren C, & Dezateux C (2012). Mortality with congenital heart defects in England and Wales, 1959-2009: exploring technological change through period and birth cohort analysis. Archives of disease in childhood, 97 (10), 861-5 PMID: 22753769

  6. Blog ali

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    ali
    Latest Entry
    Hi everyone,

    Blindingly obvious I know, but our visitor numbers seem to have recently exploded. Today we topped 150 at one point. I know membership is increasing but visitor numbers seem to have changed up a gear as well, very exciting. Are we recording visitor numbers? It wouldn't be neonates without a number :)

    Best wishes

    Alistair

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    It sounds simple, but actually it turns out to be very complicated and controversial.

    The question is are we improving our NICU ? Has our NICU performance remained the same for the past few years?

    What about the performance of our NICU staff members (Medical and Nursing ) ? Are they improving themselves?

    That was the easy part.

    Now the difficult part.

    We can only improve a thing which can be measured. So to improve our NICU, we have to monitor some parameters of our NICU and then trend it and then find what we want to improve in that measure and then plan an intervention and then implement that intervention and then monitor the performance after the implementation of the interventions. (phew that was difficult to type right !)

    So lets see....if we heard that NICU in XYZ hospital had mortality of ELBW babies 5 years back of 50 % and that now they are reporting ELBW mortality of 20%...we definitely know they have improved themselves. How about nosocomial infection rate in a NICU in XYZ hospital was 5 per 1000 patient-days 5 years back and now was 1.5 per 1000 patient-days...we definitely know they have improved.

    One very nice example to illustrate this improvement is here: http://www.lafayettegeneral.com/pavilion/Level-III-Neonatal-Intensive-Care-Unit-1/Key-Performance-Indicators-3

    There are so many parameters to be monitored in a NICU..I think we just have to select what is suitable in our setup balancing our resources. We have to be cautious not to overdo it...as then it will only be on paper and have no actual benefit for the NICU.

    the other (more difficult part) is to monitor the performance of NICU staff. Here also there are many options. One beloved one is compliance with infection control practices (especially ...hand hygiene). Success rate of intubations could be used for residents. How about IV infiltration (IV burns) rate for nurses? Morbidity/Mortality outcomes for consultants/attending ?

    Once staff know that they are being monitored...performance automatically improves. Once you start rewarding good performance......then people start having a healthy competition to improve themselves....the ultimate winner is the patient...NICU performance measures improve.....And thats the ultimate aim...to improve patient outcomes...

    The floor is open.

  7. selvanr4
    Latest Entry

    hello to everyone,

    we are leaving Stockholm today after a wonderful educative and progressive conference of evidence based neonatology.

    We had nice interactive sessions lectured by topclass professionals. Had a nice boat trip coupled with a nice welcome function.

    Got into touch with new friends. Personally had direct interaction with the team members who have been known to us only through cyberspace.

    Nice experience and we like to thank everyone.

    see you next time with more to learn.

    bye now

    selvan

    Lotus Hospital

    Erode, Indai

  8. hi every one happy new year where is the image library

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    Dear colleagues....

    Our neonat medicine started in my town Gaza in the 70's, thanks to my professor DR. salwa Aman who alone started the work that time,,,it is was a sort of primitive stuff, she started to collect donations from here and there to build ,buy incubators and other equipment....things went further but slowly on....many of our staff got the training and experience from neighbouring countriers..so we progressed further...forgot to say that i joined dr salwa inطher syruggle to build a neonatal service in early 80's....finally here we are with well-built NICU: 30 incubators, 18 are intensive care, 15 ventilators not so advanced but ok...a staff of 16 physicians, 34 nurse serving 1000 deliveries a month in our hospital,Shifa Hospital..so what do think of our professional journey?..write t o me much like to hear from you...

  9. as a traveler, you meet all kinds of people, experience all kinds of locations, learn different ways of handling the same issue, as well as being in a position to teach and share. while i have been traveling now for 3 yrs, never have i had the last part of this brought home to me as strongly as my currently ending contract, especially the teaching part.

    as a general rule, i don't mind teaching. i enjoy sharing my knowledge and experience, as long as i have time to do it. however, in the middle of coding a baby is not when i prefer to have to be giving instructions to less experienced nurses about removing drapes to maintain warmth, chosing iv sites, how fast to push amp or how to dilute gent (or reminding peds who don't frequently work with neonates about nrp guidelines for bagging...).

    i have missed the level III NICU (this being a low level II Nursery). i have missed being surrounded by peers who know how to hold a baby for iv starts and how to help tape the iv once it's in place. or who know how to mix antibiotics and administer them. or even someone who knows appropriate technique for a heelstick. the little things. and i've missed "sick" babies.

    yes, it's been an invaluable experience. i have revisited skills that i have not had an opportunity to practice as frequently being in larger units where everybody is wanting the experience. i have gained an appreciation for the new grads and their openness for learning, as well as being thankful the more experienced nurses who know when to worry and when not to about a healthy term kid.

    and i have been given the gift of thanks. from parents. from other nurses, both new and seasoned. from techs. and from the peds.

    i have been reminded of my own start in working in this specialty, often laughing at seeing myself in the new grads, and becoming disgusted with myself when i recognize some of the harsher behavior i exhibit towards ignorance that was once visited upon me by those with more experience.

    so, as another contract winds down, i stop to think, and reflect. at the people i have worked with. a few particular cases. the geographical area i'll be leaving. but mostly that i am heading back to a level III NICU where my heart is.

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    First time blogger!! I am finally gaining real clarity now about how I want to be a 'nurse' alongside parents and other caregivers who have babies in the neonatal unit. The concept family centred care needs to be fully integrated into my being. So how do I achieve this? I see colleagues genuinely trying to 'help' families by their nursing actions and yet it continues to frustrate me that some of these actions take away the parents choices and impacts on their ability to fully engage with their neonate. I thought empowerment was the key but that still implies I have the power to give away to the families. Whether I like it or not this may be true purely because of the nature of the NICU environment but it fails to truly show how I work alongside or with the families. I am now convinced that if I can integrate an enabling focus into how I want to be as a nurse I can then be a partner in the care. Any thoughts from colleagues??

    Marpsie

  10. Medhaw

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  11. shesu

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