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  3. Dear collagues In our nursery we use BabyFlow from Dräger to provide NIV via VN500. We are planning to introduce the Seattle-PAP system (a bubble CPAP system) from Dräger to deliver nCPAP. Previously we have used beneveniste-CPAP. So moving to BabyFlow is quite a big step as the headgear and interface is quite different and much more bulky compared to what we have used for many years. Is there anyone out there using BabyFlow who would be willing to share experience? Our nurses are working hard to get used to the nasal interface and fixation system and especially when using bubbleCPAP we have lots of difficulties with leakage. many thanks in advance cheers Christian A few words about the unit: Level 3 NICU in Denmark. From 23 weeks GA to term+, noninvasive resp support and Conventional and HFO ventilation, iNO, ECMO, cardiac and pediatric surgery on site in addition to ENT, ortho and neurosurgical surgery and retrieval service
  4. thank you very much for your reply and in the narrow range of weight and gestational age, which values of ph make reference as the minimum objective
  5. Last week
  6. I have observed this repeatedly in babies whose mothers were taking SSRI antidepressants, specifically Zoloft. Happy baby who does not cry. Cheers, MK
  7. Great question, Juan Carlos. I am partial to the VN500, but I'm sure both devices can deliver VG quite well. The problem is that babies don't like to be acidotic. Consequently, there is a problem with permissive hypercapnea in the first days of life in small preemies, because their kidneys are not able to compensate for respiratory acidosis. Therefore, the baby will try to generate a tidal volume sufficient to bring the PCO2 down and normalize the pH. As you know when the tidal volume exceeds the target value, PIP will come down and pretty soon, your baby may be on endotracheal CPAP with rising oxygen requirement (due to the drop in MAP), tachypnea and increased work of breathing. You would have to sedate the baby sufficiently to suppress their respiratory drive, which is a bad idea. People find all kinds of ways to reduce the support for the baby's effort, for example changing from AC to SIMV at a low rate, so the baby is unable to generate adequate minute ventilation and correct the acidosis. So, the baby is struggling, but the doctor is happy, because the PCO2 is where he or she wants it. If you can buffer the acidosis by adding some acetate to your TPN and get the pH up to near normal, you might be able to let the CO2 rise gradually. The focus needs to be on pH, not PCO2, because it's the pH that is the primary stimulus for respiratory drive. Basically it is better to support the baby's effort to maintain normal pH and avoid the mistake of looking only at the PCO2. Ultimately, it is the perivascular pH that controls cerebral circulation, but unfortunately all studies keep focusing on PCO2 and ignoring pH. What we know is that rapid fluctuations in PCO2 confer the greatest risk of IVH. Once the baby is a bit older and the kidneys are more mature, it'a s lot easier to allow permissive hypercapnia if they still need mechanical ventilation. I hope this helps, MK
  8. We use this system on an ongoing basis. Very comfortable and does not damage the nasal septum.
  9. There has been a recent narrative review of cooling outside of "standard" criteria here: https://www.sciencedirect.com/science/article/abs/pii/S1355184118301595 I agree with above comments- I think given need for resuscitation at 10 mins (ventilated) and evidence of encephalopathy on clinical assessment (+/1 aEEG/CFAM) then we would have cooled on admission. We generally do not cool > 6 hrs but have on occasions, including late preterms. We had an interesting situation a few years ago where a baby ended up being resuscitated after an unplanned extubation (ex-preterm, difficult to get chest movement, difficult to intubate, long period of bradycardia and poor oxygenation) and there was a decision made to cool. What happened in your case?
  10. until
    Welcome to Vienna and the 4th Future of Neonatal Care conference AKA the 99nicu Meetup! Find all info here: https://99nicu.org/meetup/
  11. Stockholm Conference on Ultra-Early Intervention is a scientific conference on Infant and Family Centered Developmental Care (IFCDC) organized by Karolinska NIDCAP Training and Research Center. In 2020, the 11th conference is scheduled for 19 March 2020. Check out the web site: https://www.karolinska.se/ultraearly the-2020-stockholm-conference-on-ultra-early-intervention_191120.pdf
  12. until
    Visit Conference website: http://www.lutonneocon.co.uk
  13. Earlier
  14. Please help researchers from Germany with their study: https://www.umfrageonline.com/s/175a5bb
  15. Hello every body 

    what is the practice regarding administration of surfactant ? Prophylactic or rescue surfactant you use ? For the age groups below 32 weeks and more than 32 weeks . 

  16. Not routinely, but for high risk extubations we often coordinate with ENT and make plans for things like race epi at extubation to Heliox. I've also used it many times as rescue therapy when there is post-extubation stridor and I am trying to buy time for airway steroids to kick in.
  17. This is not an uncommon dilemma. We have developed a one paged trigger/ assessment tool for babies who meet criteria for monitoring for moderate or severe encephalopathy. It seems to work most times and one of our fellows is conducting an audit to see if we miss any babies with this tool. Based on this case, it sounds like the baby would have met criteria for clinical monitoring for moderate or severe HIE i.e. prolonged resuscitation and possibly Apgar scores? but not pH or BE related values and we would have then assessed this baby hourly for the first 6 hours of life for clinical signs of moderate or severe encephalopathy. TH would have been started as per the trigger tool thresholds. The problem comes when these babies don't meet clinical criteria for moderate or severe HIE and clinical monitoring is ceased and then go on to have seizures some time later - as is seen in this case. The current trend in our unit would be to not cool them at the 12hr mark but I have personally cooled a baby who did not meet criteria for moderate or severe encephalopathy in the 1st 6hrs but then went on to have seizures at ~8hrs of life. We would just optimise other medical intervention and use anti-convulsants (levetiracetam, topiramate and midazolam or lignocaine) to treat seizure burden. I'm not sure if that helps! Cheers Richard HIE trigger tool.pdf
  18. Despite the burgeoning body of knowledge specific to toxic stress, medical trauma and maternal separation, the delivery of developmentally supportive, neuroprotective care for hospitalized infants is inconsistent at best. Bedside clinicians struggle to integrate evidence-based best practices in neurodevelopmental care. Challenges include competing priorities, knowledge gaps, staffing demands, access to appropriate therapeutic resources, and documentation limitations.This book addresses these challenges in a thoughtful, comprehensive and practical way. The author provides evidence-based strategies and resources to improve not only the quality of the neurodevelopmentally supportive care provided but, also the consistency and coherence in which the care is documented. Clear, concise, comprehensive documentation has been proven to positively impact patient outcomes,The INDIA EBUS platform, a forward thinking, trans-disciplinary interface for improved documentation, opens the door for future innovations in digital platforms and artificial intelligence that improve the delivery of safe, high quality, patient-focused healthcare.
  19. Just for the purpose of recall.(Cochrane 2013, Jacobs) Evidence of peripartum asphyxia, with each enrolled infant satisfying at least one of the following criteria: i) Apgar score of 5 or less at 10 minutes; ii) mechanical ventilation or resuscitation at 10 minutes; iii) cord pH < 7.1, or an arterial pH < 7.1 or base deficit of 12 or more within 60 minutes of birth. AND Evidence of encephalopathy according to Sarnat staging (Sarnat 1976; Finer 1981): i) Stage 1 (mild): hyperalertness, hyper-reflexia, dilated pupils, tachycardia, absence of seizures; ii) Stage 2 (moderate): lethargy, hyper-reflexia, miosis, bradycardia, seizures, hypotonia with weak suck and Moro; iii) Stage 3 (severe): stupor, flaccidity, small to mid position pupils that react poorly to light, decreased stretch reflexes, hypothermia and absent Moro. AND abnormal standard EEG or aEEG findings(this in addition to above as in NeoNeuro Network RCT by Simburner, Germany). Evidence Laptook etal. Effect of therapeutic hypothermia initiated after 6hours of age on death or disability among newborns with Hypoxic-ischemic encephalopathy, Jama 2017 October 24;318(16): 1550-1560. •Randomized clinical trial •April 2008 –june 2016 •Moderate or severe HIE enrolled at 6-24 hours after birth. •Twenty one US neonatal research network centers •There were 168 participants and 83 were randomly assigned to hypothermia and 85 to noncooling. Results 76% probability of any reduction in death or disability.(Biasian Statistics and analysis) 64% probability of at least 2% less death or disability at 18 to 22 months. Hypothermia initiated at 6 to 24 hours after birth may have benefit but there is uncertainty in its effectiveness. Gist: TH can be tried for its benefit though not greater than that of starting early but with due consideration of parents participation and Consultant in decision making.
  20. Thanks for sharing this (not uncommon!) clinical scenario. Will be interesting to follow the discussion. Actually, this topic will be one of the interactive lecture sessions on the #99nicuMeetup in Vienna next year , one of the real experts in this field has semi-confirmed. I find this tricky myself, I like to stick to our guidelines. In practise, we typically handle a case like this with an inter-collegial discussion (sometimes also involving our neighbouring level-3 NICU) and reach consensus how to act that way. In this case, I think the jury would be out for some time before deciding. What we'd decide in this case, an open question in my view.
  21. Have a case: Stat CS for maternal abruption and decels Term baby. Poor tone and resp effort. Suspected blood aspiration. Needed PPV and 100% FiO2 for hypoxia. Intubated in DR. Cord gases pH 7.22 BE -8 Baby H/H: 18/50 Baby gas 7.18 / -8 at ~50 min of life Started having clinical seizures at 12 HOL. Electrical seizures on EEG. Normal HUS. Would you start late therapeutic hypothermia? Did not meet mod/severe sarnat encephalopathy on exam but was hypotonic, was intubated, and required prolonged resuscitation. TH is often fairly well tolerated and there's not much else to do. 2017 Laptook paper suggests potential benefit with late cooling. The baby had a perinatal event and clinical signs of possible HIE but no acidosis. Could be stroke or other. Some papers looking retrospectively at cooled infants who went on to have perinatal stroke had seizure reduction with TH. So far has received phenobarb, keppra, fospheny for refractory seizures.
  22. No not yet, planning work visit.
  23. Welcome to our conference Future of Neonatal Care- advancing the management of newborns Your neonatal web community goes live again - 15-19 April 2020 in Vienna, Austria. The exciting program includes a wide range of lectures and workshops by neonatal staff with real expertise. Topics include ethics at the viability border, renal function impairment, treatment of seizures, intubation practices and outcomes, maternal medication and breastfeeding, and how to make great QI project. And more! See you in Vienna! Subscribe here to the conference to newsletter so you don't miss when we open registration this December.
  24. The Dept of Brilliant Ideas proudly presents this 90 sec video about Neobiomics and the vision and mission of ProPrems®. I am grateful and also proud that what the network of people around Neobiomics has achieved. It has been a journey and now is the time to "arrive" at the point we headed for. If you want more info - send me a DM or email stefan@neobiomics.eu. Please note that we only deliver ProPrems® in Europe.
  25. I am a neonatologist working in a low-income country in a hospital with 6000 + births a year. The hospital also functions as the only neonatal referral center for a region that has 17,000 births a year. Due to being a public institution the mothers of our newborns are mostly from extremely low-income households thus we have high rates of congenital malformations and premature births with the corresponding elevated rates of morbidity and mortality. We are interested in implementing Point of Care Echocardiagram for monitoring pulmonary pressure, cardiac function and PAD as well as implementing Point of Care Ultrasound for pleural effusions, line placement, and to perform transfontanellar ultrasound. On of the cheaper options I found was the Butterfly IQ Ultrasound which connects to iphones and Ipads. While i have talked to other medical practitioners in other countries about their positives experiences in pediatric patients using the Butterfly IQ, I have not come across someone with experience using the Butterfly IQ in neonatal patients. I would welcome any feedback pertaining to this topic and welcome other affordable solutions of POCUS that can be used in the neonatal population.
  26. Have you trialed this interface yet? How did it go?
  27. 404/5000 Hi all. I would like your experience in ventilation with guaranteed volume in premature babies under 750 grams. In my ucin I have a drager vn500 ventilator and a sle5000. Which one looks better ventilator for this function? What pco2 values do they tolerate? How to manage hypercapnia with this strategy? What maximum pressures do you tolerate at these weights before going into vafo?
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    • Dear collagues In our nursery we use BabyFlow from Dräger to provide NIV via VN500. We are planning to introduce the Seattle-PAP system (a bubble CPAP system) from Dräger to deliver nCPAP.  Previously we have used beneveniste-CPAP. So moving to BabyFlow is quite a big step as the headgear and interface is quite different and much more bulky compared to what we have used for many years.    Is there anyone out there using BabyFlow who would be willing to share experience? Our nurses are working hard to get used to the nasal interface and fixation system and especially when using bubbleCPAP we have lots of difficulties with leakage.    many thanks in advance   cheers Christian   A few words about the unit: Level 3 NICU in Denmark. From 23 weeks GA to term+, noninvasive resp support and Conventional and HFO ventilation, iNO, ECMO, cardiac and pediatric surgery on site in addition to ENT, ortho and neurosurgical surgery and retrieval service
    • thank you very much for your reply and in the narrow range of weight and gestational age, which values of ph make reference as the minimum objective
    • I have observed this repeatedly in babies whose mothers were taking SSRI antidepressants, specifically Zoloft. Happy baby who does not cry. Cheers, MK
    • Great question, Juan Carlos. I am partial to the VN500, but I'm sure both devices can deliver VG quite well. The problem is that babies don't like to be acidotic. Consequently, there is a problem with permissive hypercapnea in the first days of life in small preemies, because their kidneys are not able to compensate for respiratory acidosis. Therefore, the baby will try to generate a tidal volume sufficient to bring the PCO2 down and normalize the pH. As you know when the tidal volume exceeds the target value, PIP will come down and pretty soon, your baby may be on endotracheal CPAP with rising oxygen requirement (due to the drop in MAP), tachypnea and increased work of breathing. You would have to sedate the baby sufficiently to suppress their respiratory drive, which is a bad idea. People find all kinds of ways to reduce the support for the baby's effort, for example changing from AC to SIMV at a low rate, so the baby is unable to generate adequate minute ventilation and correct the acidosis. So, the baby is struggling, but the doctor is happy, because the PCO2 is where he or she wants it. If you can buffer the acidosis by adding some acetate to your TPN and get the pH up to near normal, you might be able to let the CO2 rise gradually.  The focus needs to be on pH, not PCO2, because it's the pH that is the primary stimulus for respiratory drive.  Basically it is better to support the baby's effort to maintain normal pH and avoid the mistake of looking only at the PCO2. Ultimately, it is the perivascular pH that controls cerebral circulation, but unfortunately all studies keep focusing on PCO2 and ignoring pH. What we know is that rapid fluctuations in PCO2 confer the greatest risk of IVH.  Once the baby is a bit older and the kidneys are more mature, it'a s lot easier to allow permissive hypercapnia if they still need mechanical ventilation. I hope this helps,  MK  
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