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  1. Today
  2. Good morning 99ers, I am in discussion with my nursing colleagues over the seemingly ad hoc approach to getting our extreme premmies out for S2S (particularly early on when ventilated/lines/temp instability etc), and whether a more formalised guideline may help (worked for feeding, hasn’t it?). Grateful for thoughts/opinions. Regards Al
  3. This has been roughly my experience in3 different surgical NICUs in US
  4. Yesterday
  5. Last week
  6. The OG tube in postoperative oesophageal atresia is placed by the pediatric surgeon and is kept as long as possible until oral feed. This is to avoid injury of the anastomosis site if the OG is replaced blindly.
  7. Hamed

    Surfactant lavage!

    Up to my knowledge from our unit`s practice and consulting a friend from another NICU in Tokyo. Concentration: using 1 vial of surfactant (120 mg) to 6 CC up to 10 CC of saline (ie, making a concentration of 12mg/ml ~ 20mg/ml) Administration: administered via a size 3 Fr OG tube, 2CC of the prepared surfactant concentration mentioned above is injected and pulled out using 2~ 5 CC syringe and repeated with another 2CC until the 6 ~10 CC is all used. Indications include: MAS requiring intubation and mech. vent. with high settings. Pulmonary Hemorrhage. RDS with evolving BPD, intubated and mech. vent. using high settings with X-ray showing a heterogeneous distribution of lung atelectasis. Concerning my experience: I can say it shows a beneficial effect in MAS and pulmonary hemorrhage, but less effective in RDS with evolving BPD. However, I don't think it shows more beneficial effect than surfactant administration as a practice used in all NICUs. Although that been said, an RCT is warranted to reach an evidence-based conclusion. Hoping to know if other countries have such a practice. We didn't use in Canada though.
  8. yangw126

    Surfactant lavage!

    I have no experience .No neonatologist used surfactant lavage in my NICU .
  9. We change NG tube every week in preterm infants in general We change NG tube every week in preterm infants
  10. Stefan Johansson

    Surfactant lavage!

    To the best of my knowledge, I don't think this is used in Sweden. What are the indications for lavage in Japan? Meconium aspiration? Or also preterm RDS?? Would be great to hear also HOW you do this and your experience.
  11. @yangw126 but do you change NG tube every week also if the infant is postop esofageal atresia? We also change tube every week in preterm infants in general. But, postop esofageal atresia, our surgeons want us to leave the NG tube as long it is needed, i.e. take it out when the infant can feed orally
  12. In my NICU, the nurses change the NG tube every 7 days.
  13. Hamed

    Surfactant lavage!

    Surfactant lavage, a therapeutic intervention used in Japan, although I have doubts about this intervention, it would be nice to know whether other NICUs out there use it. Do you use surfactant lavage in your unit? If “Yes” What are the possible indications? What surfactant/saline ratio do you use? Would you use in atelectatic changes in BPD cases suspecting thick secretions to be causing the atelectasis?
  14. Over here, in Japan Famotidine (Gaster 10) for 2 weeks is almost a standard postoperative regimen after esophageal atresia advocated by Pediatric surgeons. However, almost all the cases continue on it for a month or more.
  15. Much has been written about methylxanthines over the years with the main questions initially being, “should we use them?”, “how big a dose should we use” and of course “theophylline vs caffeine”. At least in our units and in most others I know of caffeine seems to reign supreme and while there remains some discussion about whether dosing for maintenance of 2.5 -5 mg/kg/d of caffeine base or 5 – 10 mg/kg/d is the right way to go I think most favour the lower dose. We also know from the CAP study that not only does caffeine work to treat apnea of prematurity but it also appears to reduce the risk of BPD, PDA and duration of oxygen therapy to name a few benefits. Although initially promising as providing a benefit by improving neurodevelopmental outcomes in those who received it, by 5 and 11 years these benefits seem to disappear with only mild motor differences being seen. Turning to a new question The new query though is how long to treat? Many units will typically stop caffeine somewhere between 33-35 weeks PMA on the grounds that most babies by then should have outgrown their irregular respiration patterns and have enough pulmonary reserve to withstand a little periodic breathing. Certainly there are those who prove that they truly still need their caffeine and on occasion I have sent some babies home with caffeine when they are fully fed and otherwise able to go home but just can’t seem to stabilize their breathing enough to be off a monitor without caffeine. Then there is also more recent data suggesting that due to intermittent hypoxic episodes in the smallest of infants at term equivalent age, a longer duration of therapy might be advisable for these ELBWs. What really hasn’t been looked at well though is what duration of caffeine might be associated with the best neurodevelopmental outcomes. While I would love to see a prospective study to tackle this question for now we will have to do with one that while retrospective does an admirable job of searching for an answer. The Calgary Neonatal Group May Have The Answer Lodha A et al recently published the paper Does duration of caffeine therapy in preterm infants born ≤1250 g at birth influence neurodevelopmental (ND) outcomes at 3 years of age? This retrospective study looked at infants under 1250g at birth who were treated within one week of age with caffeine and divided them into three categories based on duration of caffeine therapy. The groups were as follows, early cessation of caffeine ≤ 14 days (ECC), intermediate cessation of caffeine 15–30 days (ICC), and late cessation of caffeine >30 days (LCC). In total there were 508 eligible infants with 448 (88%) seen at 3 years CA at follow-up. ECC (n = 139), ICC (n = 122) and LCC (n = 187). The primary outcome here was ND at 3 years of age while a host of secondary outcomes were also examined such as RDS, PDA, BPD, ROP as typical morbidities. It made sense to look at these since provision of caffeine had previously been shown to modify such outcomes. Did they find a benefit? Sadly there did not appear to be any benefit regardless of which group infants fell in with respect to duration of caffeine when it came to ND. When looking at secondary outcomes there were a few key differences found which favoured the ICC group. These infants had the lowest days of supplemental oxygen, hospital stay ROP and total days of ventilation. This middle group also had a median GA 1 week older at 27 weeks than the other two groups. The authors however did a logistic regression and ruled out the improvement based on the advanced GA. The group with the lowest use of caffeine had higher number of days on supplemental oxygen and higher days of ventilation on average than the middle but not the high caffeine group. It is tempting to blame the result for the longer caffeine group on these being babies that were just sicker and therefore needed caffeine longer. On the other hand the babies that were treated with caffeine for less than two weeks appear to have likely needed it longer as they needed longer durations of oxygen and were ventilated longer so perhaps were under treated. What is fair to say though is that the short and long groups having longer median days of ventilation were more likey to have morbidities associated with that being worse ROP and need for O2. In short they likely had more lung damage. What is really puzzling to me is that with a median GA of 27-28 weeks some of these kids were off caffeine before 30 weeks PMA and in the middle group for the most part before 32 weeks! If they were in need of O2 and ventilation for at least two weeks maybe they needed more caffeine or perhaps the babies in these groups were just less sick? What is missing? There is another potential answer to why the middle group did the best. In the methods section the authors acknowledge that for each infant caffeine was loaded at 10 mg/kg/d. What we don’t know though is what the cumulative dose was for the different groups. The range of dosing was from 2.5-5 mg/kg/d for maintenance. Lets say there was an over representation of babies on 2.5 mg/kg/d in the short and long duration groups compared to the middle group. Could this actually be the reason behind the difference in outcomes? If for example the dosing on average was lower in these two groups might it be that with less respiratory drive the babies in those groups needed faster ventilator rates with longer durations of support leading to more lung damage and with it the rest of the morbidities that followed? It would be interesting to see such data to determine if the two groups were indeed dosed on average lower by looking at median doses and total cumulative doses including miniloads along the way. We know that duration may need to be prolonged in some patients but we also know that dose matters and without knowing this piece of information it is tough to come to a conclusion about how long exactly to treat. What this study does though is beg for a prospective study to determine when one should stop caffeine as that answer eludes us!
  16. We had the discussion recently about long-term use of anti-reflux medications after esophageal atresia repair. Drugs like lansoprazol can really clogg the NG tube (like concrete!)... and from what I read in this systematic review (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5899117/) it seems that there is no clear benefit. Although the quality of evidence is classified as low, and that "more research is needed". Do your pediatric surgeons advocate the use of anti-reflux medications after esophageal atresia repair? If yes, for how long? If the infant needs NG tube feeding for a longer period time (like 4-8 weeks), how often do you change the NG tube? Asking for a friend
  17. Hamed

    Empiric Antibiotics for NEC

    Empirically in both NICUs in Japan and Canada ampicillin and aminoglycoside: (Gentamycin in Japan & Tobramycin in Canada).
  18. M C Fadous Khalife

    Would you dare? Intubation on parent's chest

    I find it very interesting but speaking of is not like watching it! For the moment I will not dare do it !
  19. bimalc

    Chorioamnionitis

    1) Our institutional practice (High volume, high acuity delivery service, 12k births/year) is to have a 'Chorio' nursery monitored and staffed by NICU RN and, covered by a pediatric hospitalist. Babies are admitted there for culture, antibiotics and screening CBC and CRP. Post-partum mothers are roomed on the same floor so they can more easily see their baby and feed. Assuming child is clinically well, antibiotics are stopped at 24-36h depending on biomarkers and the baby is transferred to the mother's room for remainder of stay. 2) We are studying the use of the Kaiser calculator, but there is lots of hesitancy about sending these babies directly to the normal nursery service as there is the perception (right or wrong) that a clinical decompensation in a baby would not be noticed by the normal nursery nurses in a timely manner. The other thing which is relevant for members of this forum is to understand that the Kaiser calculator is based on Likelihood ratios and knowledge of the background rate of neonatal sepsis in the population in question. While the calculator allows you to select a range of baseline risks, it is tuned (roughly) based on the US CDC baseline risk of 0.5/1000. If your local epidemiology is very different from the kaiser assumptions, the recommendations from the calculator may be wrong (disastrously so).
  20. M C Fadous Khalife

    Empiric Antibiotics for NEC

    Thx Dr johanssen
  21. Stefan Johansson

    Empiric Antibiotics for NEC

    Although it seems more simple with one antibiotic, it may not be the best strategy, for reasons related to resistance development. Carbapenems (like meropenem) are typically used as the treatment option when other antibiotics fails due to (known or assumed) resistance. So, depending on the bacteriological context, it may or may not be a reasonable 1st-line choice. And carbapenem resistance is worrysome thing for health care beyond the NICU. So, a reasonable bottomline would be along the lines "If it works, don't fix it"
  22. M C Fadous Khalife

    Empiric Antibiotics for NEC

    From the above , I like the idea of Dr johansson about giving only one antibiotic instead of keeping with 3 to 4 antibiotics; can we discuss using meropenem only for NEC? Do we have infectious disease neonatologists in the team? I always feel like keeping meropenem for the next step , but using 4 antibiotics is not the best option even if most of us are doing so . What do you think?
  23. Earlier
  24. Stefan Johansson

    Chorioamnionitis

    @Abdul kasim jaleel ahmed I guess you are thinking about the Kaiser Newborn Sepsis Calculator. Here http://newbornsepsiscalculator.org
  25. Stefan Johansson

    Empiric Antibiotics for NEC

    I don't know if/how things have improved after the change. And since I left Karolinska a few years ago (for "the other hospital" ) I don't know the exact rationale. Will lunch with @Alexander Rakow tomorrow, will ask him for details. OT and IMHO: But despite using almost only breast milk (donated or expressed) for very preterm infants, NEC is a reality around here A fact that is the driving force for the academic startup Neobiomics I started with a few EU-based colleagues.
  26. Stefan Johansson

    hepatitis B prevention

    Infants to mothers with "high-risk" status (HBeAg+, OR anti-HBeAg+ and high load of HBV-DNA), we administer immunoglobulin soon after birth. Since mothers are screened for chronic infections at the maternal antenatal care center, ab-status it is usually known at the time of delivery. The pediatrician/neonatologist on call are informed over the telephone and the delivering midwife gives the injection. Infants to mothers with "high-risk" status should be sampled at birth with regards to HBsAg and antiHBc (indicative for intrauterine infection), and at the age of 18 months the child is sampled for anti-HBs (vaccineffect) och HBsAg och antiHBc (detection of infection), as the risk of vertical infection is not eliminated despite postpartum proph and early vaccination. @M C Fadous Khalife thanks for the recent reference!
  27. M C Fadous Khalife

    hepatitis B prevention

    if you want to be sure, try to reevaluate the newborns with delay of doing Ig ! But it must be at least 2-3 months after birth because surface HB ag must not be measured within 1 month of vaccination. It would even be interesting to try to measure surface antibodies and Ag to all these babies . We rarely do it . Do you do it for your babies?
  28. M C Fadous Khalife

    hepatitis B prevention

    A new article published in 2018 says that 2-5% of newborns from mothers infected with hepatitis B will be infected despite immediate vaccination and Ig ! But tgey don’t speak about the delay for IgHB .https://www.ncbi.nlm.nih.gov/m/pubmed/29688415/?i=15&from=Neonatal Hepatitis you can read it .may be it can help
  29. M C Fadous Khalife

    Procalcitonin (PCT)

    From my experience , only viral vs bacterial
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  • Latest Posts

    • Good morning 99ers, I am in discussion with my nursing colleagues over the seemingly ad hoc approach to getting our extreme premmies out for S2S (particularly early on when ventilated/lines/temp instability etc), and whether a more formalised guideline may help (worked for feeding, hasn’t it?). Grateful for thoughts/opinions. Regards Al
    • This has been roughly my experience in3 different surgical NICUs in US
    • The OG tube in postoperative oesophageal atresia is placed by the pediatric surgeon and is kept as long as possible until oral feed. This is to avoid injury of the anastomosis site if the OG is replaced blindly.
    • Up to my knowledge from our unit`s practice and consulting a friend from another NICU in Tokyo. Concentration: using 1 vial of surfactant (120 mg) to 6 CC up to 10 CC of saline (ie, making a concentration of 12mg/ml ~ 20mg/ml) Administration: administered via a size 3 Fr OG tube, 2CC of the prepared surfactant concentration mentioned above is injected and pulled out using 2~ 5 CC syringe and repeated with another 2CC until the 6 ~10 CC is all used. Indications include:  MAS requiring intubation and mech. vent. with high settings. Pulmonary Hemorrhage. RDS with evolving BPD, intubated and mech. vent. using high settings with X-ray showing a heterogeneous distribution of lung atelectasis.  Concerning my experience: I can say it shows a beneficial effect in MAS and pulmonary hemorrhage, but less effective in RDS with evolving BPD. However, I don't think it shows more beneficial effect than surfactant administration as a  practice used in all NICUs. Although that been said, an RCT is warranted to reach an evidence-based conclusion.  Hoping to know if other countries have such a practice. We didn't use in Canada though. 
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