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Though there is a protocol in place to premedicate with fentanyl for elective intubation and INSURE in the unit, not really sure how to go about it if the baby does not have a iv line in place and requires surfactant but not iv fluids. Most of our babies would be started on full feeds if there are no contraindications(aggressive enteral nutrition). Should a iv cannula be inserted for administering analgesia before INSURE!? and then removed.
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In our unite we routinely give premedication to all elective intubation, but I wondered about given medication before INSURE, is it needed. Because I think it prolong duration on mechanical ventilation. We are not able to wean baby quickly. We give usually atropine, fentanyl and suxammethonium Sent from my MHA-L29 using Tapatalk
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I have never practiced with a group that did INSURE, but I've often wondered about premedication, especially after the study from Albany with an astonishingly high failure rate when using morphine as the premedication. Helpfully, that same group now provides data on use of remifentanyl instead: https://www.ncbi.nlm.nih.gov/m/pubmed/29789465/ Personally, the biggest change for me once we go to INSURE (assuming we don't just skip to MIST/LISA) is that I've routinely muscle relaxed for intubation for a number of years.
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We talk about it. I want to get there, but one not so great experience makes me hesitant. If we are doing INSURE in our delivery room, I don't think it is practical enough and leans more to emergent in those cases. But if we are admitted in our unit, then I think it is the best. I'm convinced its better for babies getting intubated in general, but not consistent in my practice yet. FYI, we don't routinely use muscle relaxant and our standard is atropine and fentanyl.
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Any one practice to give premedication before INSURE techniques or no need Sent from my MHA-L29 using Tapatalk
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Just about all of our preterm infants born at <29 weeks start life out the same in terms of neurological injury. There are of course some infants who may have suffered ischemic injury in utero or an IVH but most are born with their story yet to be told. I think intuitively we have known for some time that the way we resuscitate matters. Establishing an FRC by inflating the lungs of these infants after delivery is a must but as the saying goes the devil is in the details. The Edmonton group led by Dr. Schmolzer has had several papers examined in these blogs and on this occasion I am reviewing an important paper that really is a follow-up study to a previous one looking at the impact of high tidal volume delivery after birth. I have written on this previous paper before in It's possibile! Resuscitation with volume ventilation after delivery. On this occasion the authors have published the following paper; Impact of delivered tidal volume on the occurrence of intraventricular haemorrhage in preterm infants during positive pressure ventilation in the delivery room.This observational study had a simple enough premise. Will the use of Vt > 6 mL/kg in infants given PPV for at least two minutes lead to worse rates of IVH? All infants were < 29 weeks and if they had chest compressions or epinephrine were excluded. All infants were treated equally in terms of delayed cord clamping and antenatal steroid provision. Ventilation was done with a t-piece resuscitator and Vt measured with an NM3 monitor connected to the face mask. First ultrasounds were done for all at 3 days of age. What did the authors find? One hundred and sixty five infants comprised this cohort. Overall, 124 (75%) infants were in the high volume group compared to 41 (25%) with a mean VT<6 mL/kg. Median Vt were 5.3 (4.6-5.7) ml/kg for the low group and 8.7(7.3-10.6) mL/kg which were significantly different. When looking at the rates of IVH and the severity of those affected the results are striking as shown in the table. Hydrocephalus, following IVH developed in 7/49 (14%) and 2/16 (13%) in the >6 mL/kg and <6 mL/kg VT groups. Looking at other factors that could affect the outcome of interest the authors noted the following physiologic findings. Oxygen saturations were lower in the low volume group at 6, 13 and 14 min after birth while tissue oxygenation as measured by NIRS was similarly lower at 7,8 and 25 min after birth (P<0.001). Conversely, heart rate was significantly lower in the VT>6 mL/kg group at 5, 20 and 25 min after birth (P<0.001). Fraction of inspired oxygen was similar in both groups within the first 30 min. Systolic, diastolic and mean blood pressure was similar between the groups. What these results say to me is that despite having lower oxygen saturations and cerebral oxygen saturation at various time points in the first 25 minutes of life the infants seem to be better off given that HR was lower in those given higher volumes despite similar FiO2. Rates of volume support after admission were slightly higher in the high volume group but inotrope usage appears to be not significantly different. Prophylactic indomethacin was used equally in the two cohorts. Thoughts for the future Once a preterm infant is admitted to the NICU we start volume targeted ventilation from the start. In the delivery room we may think that we do the same by putting such infants on a volume guarantee mode after intubation but the period prior to that is generally done with a bag and mask. Whether you use a t-piece resuscitator or an anesthesia bag or even a self inflating bag, you are using a pressure and hoping not to overdistend the alveoli. What I think this study demonstrates similar to the previous work by this group is that there is another way. If we are so concerned about volutrauma in the NICU then why should we feel any differently about the first few minutes of life. Impairment of venous return from the head is likely to account for a higher risk of IVH and while a larger study may be wished for, the results here are fairly dramatic. Turning the question around, one could ask if there is harm in using a volume targeted strategy in the delivery room? I think we would be hard pressed to say that keeping the volumes under 6 mL/kg is a bad idea. The challenge as I see it now is whether we rig up devices to accomplish this or do the large medical equipment providers develop an all in one system to accomplish this? I think the time has come to do so and will be first in line to try it out if there is a possibility to do a trial. -
Yes , I do feel that is the case. Maybe the anatomy is also slightly malformed and it will need more pathological details .
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I also have an exceedingly low success rate in SUA cases (I am credentialing at a new facility and reviewed 3 years of my umbilical lines and I had only one successful UAC in SUA listed over a 3 year period)
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On Twitter:
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Is it more difficult than usual to insert a UAC catheter in 2 vessel cord and are there any reasons why the procedure is more likely to fail in 2 vessel cord situation?
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@bimalc Yes, we use the Miris milk analyzer. Our hospital runs the Milk Bank for the Stockholm region , so we have all this inhouse (and do milk analyses for all other hospitals as well). Mothers start pumping usually day.1 so after a week or so, most preterm infants get their own mother's milk. Until then, from the milk bank. All milk bank batches are analysed, and mother's own milk is analysed after ~10 days and then weekly or bi-weekly. A small amount of each pumping (1-2 ml I think) is collected during 24h and this selection is analysed. With the software Nutrium (https://www.nutrium.se/, also a small Swe company BTW, started by a neonatologist in Umeå) we input the milk spec's and then "add" the fortifications in the software, to tailor it per baby. We are directed by the growth curve and also the recommendations (ESPGHAN etc). The software gives a very detailed feedback, all macro and micro-nutrients are marked red, yellow and green depending if ("too little/much", "close", and "within recommendations"). If milk is not analysed, we use a "sham" specification, one for "immature/early" and one for "mature/late" breast milk until we have data on the actual batch of breast milk. So, we spend a some time and resources on nutrition although it sometimes feel we over-engineer, we really aim to optimize nutrition on an individual basis. And the whole setup has become integrated in our daily routines, so it works smoothly. There are some publications where this detailed nutrition data (extracted from this software) has been used, the second ref also showing that many extrem preterm infants get malnourished during the first weeks of life. https://www.ncbi.nlm.nih.gov/pubmed/26690864 https://www.ncbi.nlm.nih.gov/pubmed/23855971
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The approach these authors suggest is really only implementable for moderate to late preterm infants. The overall approach is tempting to extend to more extreme premature infants, but I'm not aware of anyone pulling together the data to do this (Presumably the NRN in the US has the underlying data and VON may as well, though both are limited datasets in terms of post-discharge data. CHNC has a much higher risk and outworn population but does have a validated PHIS linkage as well as (theoretically) neonatal follow-up data). Stefan - when you say individual fortification, are you looking solely at patient characteristics or are you assessing (for milk fed babies) the caloric density and relative macronutrient composition of the milk (mother's own or donor) in order to guide degree of fortification? At the Pediatric Academic Society Meeting in the US this year there was a Swedish vendor (https://www.mirissolutions.com) selling an FDA-approved solution for human milk analysis: Do you have experience with this device? -
Thanks for sharing your views @Stefan Johanssonsir. What growth charts does your unit follow for extreme preterm and very preterms as norms. I would like to cite the article by Villar etal for the purpose of discussion about what postnatal growth standards to follow for preteen babies. "Villar J, Giuliani F, Barros F, et al. Monitoring the Postnatal Growth of Preterm Infants: A Paradigm Change. Pediatrics. 2018;141(2):e20172467. doi:10.1542/peds.2017-2467". Even after the Intergrowth 21 data the growth of less than 32 weeks babies still remain unanswered. By selection of an appropriate comparator only one can conclude whether increment in calorie and protein intake should be done or not. Currently we use Fenton's charts for the same. (which I feel isn't the right way to about it) -
Dear @Akash Sharma, thanks for posting about this! We spend much time on nutrition, but personally, I tend to feel confused on this higher level. Some infants grow well, while some infants grow poorly whatever we do... We use a computerized program (https://www.nutrium.se/) and make individual fortification to every preterm infant. Weights are plotted on a growth curve (starting at 24 wks) and we aim to achieve a "normal growth velocity". For SGA infants we tend to think about the patophysiology, if it is IUGR due to placental reasons (like pre-eclampsia), we think there is a potential for this baby to be AGA. So we expect catch-up growth and (if needed) try to promote that with fortifications. We don't use the term EUGR in our unit, but we strive to get all infant withn the "normal" weight range, for us that means that we want infants within +/- 2 SD on the growth chart. Coming to your question... we tend to use the growth-chart-definition of poor growth rather than body-composition analyses or clinical endpoints (which are also more like outcomes of growth)
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That’s really tough to answer it velocity of growth and lean body mass should be the priority probably. -
Akash Sharma changed their profile photo
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It is not uncommon to have extreme preterm babies being under weight and stunted at 36 or 40 weeks PMA. Our standard of care for postnatal nutrition has traditionally been to provide nutrients which matches fetal accretion rate. But is it really wise to give the same quantity of nutrients. Preterm birth and exposure to postnatal life in itself would cause epigenetic changes in how a neonate shoudl. Metabolize and assimilate the nutrients administered. So what really constitutes as EUGR. Is it only the 10 th centile at 36 weeks and 40 weeks PMA or is it standard deviation scores below expected (like 1SD below the 10 th centile - considering that some amount of postnatal growth restriction is acceptable and expected due to the loss in the first 2 weeks ) For us its a complex issue of allowing the neonates to grow at their own centile (even below the 3 rd centile) as providing excess nutrition for catchup might result in more fat mass instead of fat free mass. (ultimate goal being adequate and appropriate body composition, linear and mass growth) On a bigger picture the question that needs to be answered is - Should EUGR be determined by a statistical definition alone based on anthropometric parameters OR should it be based on the adverse body composition analysis and neurodevelopmental outcomes at a prespecified time (which is obviously more difficult)
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i got it -
To my knowledge: around here, parental feedback is not collected in a structured way. However, we have a strategy for cross-checking with parents after arrival to us. Our experience is that it takes some time for parents to "overcome" a transfer, even when their infant is well and doing fine and transferred to a lower-level NICU.
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Link for parents on the NICU
Stefan Johansson replied to Francesco Cardona's topic in family support
@Francesco Cardona thanks for sharing this! I I posted this URL on our FB page (https://www.facebook.com/99nicu) and that post has already been shared 60 times and reached 3000 people (new impact record I think!)- 1 reply
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Developmental outcomes for extreme preemies after delivery room CPR.
bimalc commented on AllThingsNeonatal's blog entry in All Things Neonatal
I would object to the interpretation that the CIs crossing 1 for several secondary outcomes suggests that these results are likely due to chance. On the contrary, the available evidence suggests that it is more likely these are real associations (though potentially with small effect sizes particularly for non-motor outcomes). First, all of the presumably mechanistically related outcomes have the same qualitative effect (ie CPR has the worse outcome) whereas if these were truly random, we might see some outcomes favor the CPR group. Second, for the outcomes where the CI does cross 1, most of the 'mass' of the CI still favors the no-CPR group. Third, the one contrary study you cited aside, the prevalence of pre-existing evidence favored the no-CPR before this study was even done (ie the prior was not non-informative). -
Persistent neonatal hypoglycemia insulin glucose ratio
bimalc replied to ashok's topic in metabolic disorders
I've never seen this, but my first instinct would be to work the child up for diabetes (assuming this isn't sepsis or iatrogenic). If a biochemical diagnosis was not immediately obvious and you are in the UK, I would see if the genomic medicine service in Cambridge would accept your patient for neonatal whole genome sequencing. In terms of actually lowering the blood glucose, you could try increasing protein intake (if calories are adequate already, you could even reduce carbohydrate calories). Branched chain AAs are a key signal for energy balance and can stimulate a more robust insulin. -
If you are to read one paper on neonatal ethics this year, I'd argue that this is the one. Late last year, John Lantos, pediatrician and a leading medical ethicist, published a review in NEJM on the ethics around decision-making in the NICU. The paper is not open-access... but you can surely get it from within your hospital intranet or your university/hospital library. We have a fantastic toolbox in the NICU. We can provide live-saving treatments and support. Most newborns in the NICU survive to good long-term health. However, we also operate in a high-risk environment where some infant may suffer, some infants will die, and some infants will survive with difficult sequele. Which raises the question, by staff and by parents, what is the "right" thing to do in complex situations. When withholding and withdrawing life-sustaining therapies becomes a option to decide upon. How could we navigate in this landscape? IMHO, the review by Lantos is a good starting point on how to form a local practise. Lantos shares his reasoning about we cannot "solve" these discussion with "information" as such. Despite how hard we try, data alone does not lead the whole way. Outcomes is hard to measure, they change over time and we all percieve risks differently. Therefore, information is difficult to standardize. Furthermore, those of us sharing the information will filter our presentation through our subjective selves, coping with opinions, experiences and our expertise in different ways. The better alternative around ethical questions is shared decision-making. Two central quotes of the review is that and that Certainly, the future of neonatal care will bring more ethical questions to us. Refined prenatal diagnostics, the down-shifting boundary of viability and new treatment technologies in the future (like the artificial placenta) will impact how we think about fetal life and postnatal life, what is the "periviable grey zone" and what our fantastic toolbox can do. While improving our skills, from a medical/technical viewpoint, we also need to improve how we cope with the ethics around decision-making processes. Besides reading the review by John Lantos, I can recommend you to see this lecture from theh #99nicuMeetup in Copenhagen 2019, by Eduard Verhagen. (Feature Photo : Cropped photo by Liane Metzler on Unsplash)
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We have all been there. After an uneventful pregnancy a mother presents to the labour floor in active labour. The families world is turned upside down and she goes on to deliver an infant at 27 weeks. If the infant is well and receives minimal resuscitation and is on CPAP we provide reassurance and have an optimistic tone. If however their infant is born apneic and bradycardic and goes on to receive chest compressions +/- epinephrine what do we tell them? This infant obviously is much sicker after delivery and when the family asks you “will my baby be ok?” what do you tell them? It is a human tendency to want to reassure and support but if they ask you what the chances are of a good outcome it has always been hard to estimate. What many of us would default to is making an assumption that the need for CPR at a time when the brain is so fragile may lead to bleeding or ischemia would lead to worse outcomes. You would mostly be right. One study by Finer et al entitled Intact survival in extremely low birth weight infants after delivery room resuscitation.demonstrated that survival for infants under 750g was better if they had a history of CPR after delivery. The thought here is that more aggressive resusctiation might be responsible for the better outcome by I would presume establishing adequate circulation sooner even if the neonates did not appear to need it immediately. The Canadian Neonatal Network In Canada we are fortunate to have a wonderful network called the Canadian Neonatal Network. So many questions have been answered by examining this rich database of NICUs across the county. Using this database the following paper was just published by Dr. A. Lodha and others; Extensive cardiopulmonary resuscitation of preterm neonates at birth and mortality and developmental outcomes. The paper asked a very specific and answerable question from the database. For infants born at <29 weeks gestational age who require extensive resuscitation (chest compressions, epinephrine or both) what is the likelihood of survival and/or neurodevelopmental impairment (NDI) at 18-24 months of age vs those that did not undergo such resuscitation? For NDI, the authors used a fairly standard definition as “any cerebral palsy (GMFCS1), Bayley-III score <85 on one or more of the cognitive, motor or language composite scores, sensorineural or mixed hearing impairment or unilateral or bilateral visual impairment.” Their secondary outcomes were significant neurodevelopmental impairment (sNDI), mortality, a Bayley-III score of <85 on any one of the components (cognitive, language, motor), sensorineural or mixed hearing loss,or visual impairment.sNDI was defined as the presence of one or more of the following: cerebral palsy with GMFCS 3, Bayley-III cognitive, language or motor composite score <70, hearing impairment requiring hearing aids or cochlear implant, or bilateral visual impairment” What did they discover? It is a fortunate thing that the database is so large as when you are looking at something like this the number of infants requiring extensive resuscitation is expected to be small. The authors collected data from January 1, 2010 and September 30, 2011 and had a total number of infants born at less than 29 weeks of 2760. After excluding those with congenital anomalies and those who were born moribund they were left with 2587. From these 80% had follow-up data and when applying the final filter of extensive resuscitation they were left with 190 (9.2%) who received delivery room CPR (DR-CPR) vs 1545 who did not receive this. Before delving into the actual outcomes it is important to note that neonates who did not receive DR-CPR were more likely to be born to mothers with hypertension and to have received antenatal steroids (89 vs 75%). With these caveats it is pretty clear that as opposed to the earlier study showing better outcomes after DR-CPR this was not the case here. The results are interesting in that it is pretty clear that receiving DR-CPR is not without consequence (higher rate of seizures, severe neurological injury, BPD). Looking at the longer term outcomes though is where things get a little more interesting. Mortality and mortality or neurodevelopmental impairment are statistically significant with respect to increased risk. When you take out NDI alone however the CI crosses one and is no longer significant. Neither is CP for that matter with the only statistically significant difference being the Bayley-III Motor composite score <85. The fact that only this one finding came out as significant at least to me raises the possibility that this could have been brought about by chance. It would seem that while these infants are at risk of some serious issues their brains in the long run may be benefiting for the neurological plasticity that we know these infants have. The study is remarkable to me in that an infant can have such a difficult start to life yet hope may remain even after dealing with some of the trials and tribulations of the NICU. Parents may need to wade through the troubling times of seizures, long term ventilation and CPAP and then onto a diagosis of BPD but their brains may be ok after all. This is one of the reasons I love what I do!
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Parent's resources - new cateogory in our Links Directory
99nicu.org posted an article in 99nicu News
The link shared below, to the NY Times parental information on how to handle a NICU stay, sparkled the idea to create a special category for parent's resources in out. Find the Links Directory here: https://99nicu.org/links/ If you have valuable URLs that you want to share, please submit to our Link Dir, or email to info@99nicu.org and we add the link.
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By Akash Sharma · Posted
Though there is a protocol in place to premedicate with fentanyl for elective intubation and INSURE in the unit, not really sure how to go about it if the baby does not have a iv line in place and requires surfactant but not iv fluids. Most of our babies would be started on full feeds if there are no contraindications(aggressive enteral nutrition). Should a iv cannula be inserted for administering analgesia before INSURE!? and then removed. -
In our unite we routinely give premedication to all elective intubation, but I wondered about given medication before INSURE, is it needed. Because I think it prolong duration on mechanical ventilation. We are not able to wean baby quickly. We give usually atropine, fentanyl and suxammethonium Sent from my MHA-L29 using Tapatalk -
I have never practiced with a group that did INSURE, but I've often wondered about premedication, especially after the study from Albany with an astonishingly high failure rate when using morphine as the premedication. Helpfully, that same group now provides data on use of remifentanyl instead: https://www.ncbi.nlm.nih.gov/m/pubmed/29789465/ Personally, the biggest change for me once we go to INSURE (assuming we don't just skip to MIST/LISA) is that I've routinely muscle relaxed for intubation for a number of years.
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By Nathan Sundgren · Posted
We talk about it. I want to get there, but one not so great experience makes me hesitant. If we are doing INSURE in our delivery room, I don't think it is practical enough and leans more to emergent in those cases. But if we are admitted in our unit, then I think it is the best. I'm convinced its better for babies getting intubated in general, but not consistent in my practice yet. FYI, we don't routinely use muscle relaxant and our standard is atropine and fentanyl.
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