99nicu... Your Forum in Neonatology!

Welcome to 99nicu, the web community for staff in neonatal medicine!

Become a member for full access to all features: get and give advice in the forums, start your own blog and enjoy benefits! Registration is free :) - click here to register!

Greetings from the 99nicu HQs

Blogs

Our community blogs

  1. scrubbing-the-hub.jpg?w=648

    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
  2. There is now only 24 hours until until the 99nicu Meetup starts. The roll-up arrived in time :)

    Today, I and @Francesco Cardona are printing and packing delegate folders, preparing USB-sticks and getting snacks for the welcome reception tomorrow night. 

    We are very excited to meet some of you tomorrow IRL, it will be a great meeting!

    Now back to our work here in the HQ's!

    IMG_3048.JPG

  3. The PREMILOC trial was a multi-center RCT of hydrocortisone, 0.5mg/kg twice per
    day for 7 days followed by 0.5 mg/kg per day for 3 days, given starting within 24 hours of age to infants of 24 to less than 28 weeks gestation.

    Neurological and developmental follow-up has just been published (Baud O, et al. Association between early low-dose hydrocortisone therapy in extremely preterm neonates and neurodevelopmental outcomes at 2 years of age. JAMA. 2017;317(13):1329-37.)
    There were 523 infants initially enrolled and 406 who survived to 2 years of age, 93% of those were seen at between 21 and 23 months corrected age, for examination and evaluation with standardized instruments.

    You probably remember that the primary outcome of the trial was survival without BPD, which was somewhat reduced by the intervention (51% compared to 60% in controls). This was as a result of fewer deaths (18% compared to 23%) and less BPD (22% compared to 26%) neither of which component of the primary outcome was individually significant. In this follow-up study the authors not that after the 36 week end of the main data collection there were a further 8 deaths, 7 in the control group and 1 in the hydrocortisone group, 5 of which were from severe BPD (4 vs 1). (These deaths were also reported as the deaths before discharge in the initial publication, but I don't think the causes were noted).

    All of the babies followed had a standardized neurologic evaluation, but unfortunately only 80% of them had the revised Brunet-Lézine evaluation of developmental progress, which gives a developmental quotient, standardized, as usual, with a population mean of 100 and SD of 15.

    Basically there were no differences between the groups on neurological signs of impairment, or developmental scores. For example there were 6% of the hydrocortisone and 5% of the control group who developed cerebral palsy. Mean Global Development score was 91.7 in the hydrocortisone group and 91.4 in the control group.

    I guess one could say that if there is less BPD and no increase in neuro or developmental adverse effects, we should think of using this as routine therapy?

    But the group also report clinically important respiratory outcomes up to 2 years of age :

    image1.png

    You can see from their table 2 that there is no sign of better respiratory health (or incidentally any effect on growth outcomes) among the survivors, with some of the minor differences being in one direction, some in the other direction.

    Which calls into question again the use of oxygen at 36 weeks, as an outcome for RCTs even when combined with an oxygen reduction test, as in this trial. If kids are more likely to be out of oxygen at 36 weeks, but no more likely to go home on oxygen (14 babies in each group) and not more likely to have respiratory problems in follow-up, then the significance of getting extubated earlier, or needing oxygen for fewer days is questionable, at least the significance to families.

    I think those outcomes are indeed benefits to families, its much better to see your baby with CPAP or non-invasive ventilation than intubated, but if there is on clear long-term benefit then we should be pretty certain that there is no harm before instituting this as routine therapy.

    Currently, is there any other evidence of harm from this approach?

    In the initial data from this trial, late onset sepsis was higher (31% vs 25% had at least one episode), NEC was higher (7% vs 5%) GI perforation was higher (5% vs 4%) use of insulin for hyperglycemia was higher (38% vs 34%) and severe RoP was higher (2% vs 1%) all of which could be due to chance effects, but the study was not powered to detect such small, but potentially important, differences; indeed in one subgroup, the most immature infants, the impact of steroids on late onset sepsis was, indeed quite different, 40% vs 23%, and their analysis showed this was unlikely due to chance. Its interesting in the on-line supplementary appendix that the major difference in late onset sepsis arose after the end of the treatment period.

    It is also interesting that this dose of hydrocortisone had no evident impact on blood pressures, nor on the use of dopamine.

    I think that all of these worrying differences between the groups, favoring control, with no evidence of long-term benefit, and the only evidence of short-term benefit being shorter intubation and shorter duration of oxygen therapy, that we should not introduce this regime as a routine in our patients.

    There is a minor difference in survival with the hydrocortisone treatment though, with 19% mortality before discharge (and before 2 years) compared to 25% in the control group. I calculate the 95% confidence intervals of this 6% difference as being between 13% fewer deaths and 1% more deaths, using early low dose hydrocortisone in similar babies.

    Unfortunately, I think I have to say that this therefore warrants further study. A larger trial with enough power to detect a 5% difference in mortality, perhaps in a region where the survival at 24 and 25 weeks is above 65% (as in this French multi-center trial; compared to for example 78% in the CNN database from 2015) should be performed.

    I think a future trial should not use this as a definition of bronchopulmonary dysplasia, other definitions have been suggested, such as this recent publication from the CNN (Isayama T, et al. Revisiting the Definition of Bronchopulmonary Dysplasia: Effect of Changing Panoply of Respiratory Support for Preterm Neonates. JAMA Pediatr. 2017;171(3):271-9.) In this study the best discrimination between those who had serious respiratory morbidity after discharge (when seen at 18 month follow up) from data collected during the neonatal period, was the need for oxygen or respiratory support (anything that gave positive pressure including high-flow cannulae at more than 1.5 litres per minute) at 40 weeks post-menstrual age.

    Serious respiratory morbidity was defined as either (1) 3 or more rehospitalizations after NICU discharge owing to respiratory problems (infectious or noninfectious); (2) having a tracheostomy; (3) using respiratory monitoring or support devices at home such as an apnea monitor or pulse oximeter; and (4) being on home oxygen or continuous positive airway pressure at the time of assessment between 18 and 21 months corrected age.

    Just as important, a recognition that lung injury in the newborn is a continuous spectrum, and that artificially dividing that into 2 categories, with and without lung injury is an artificial distinction designed to aid research design, not to help babies, or their families. A description of long term respiratory morbidity between groups is essential, rather than a label based on an intermediate outcoem. Mortality, in contrast, is truly a dichotomous outcome, and if it can possibly be improved by low dose early hydrocortisone, than we should pursue that possibility with more studies.

  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

    • 1
      entry
    • 1
      comment
    • 1263
      views

    Recent Entries

    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.

    • 1
      entry
    • 1
      comment
    • 1828
      views

    Recent Entries

    hi

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

    • 1
      entry
    • 16
      comments
    • 3516
      views

    Recent Entries

    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

    • 1
      entry
    • 3
      comments
    • 1919
      views

    Recent Entries

    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

    • 1
      entry
    • 1
      comment
    • 1842
      views

    Recent Entries

    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

    • 1
      entry
    • 1
      comment
    • 1924
      views

    Recent Entries

    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

    • 1
      entry
    • 2
      comments
    • 1790
      views

    Recent Entries

    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.

    • 1
      entry
    • 2
      comments
    • 1908
      views

    Recent Entries

    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

    • 0
      entries
    • 0
      comments
    • 927
      views

    No blog entries yet

  11. shesu

    • 0
      entries
    • 0
      comments
    • 1138
      views

    No blog entries yet

    • 0
      entries
    • 0
      comments
    • 510
      views

    No blog entries yet