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  1. Yesterday
  2. rehman_naveed

    Was adding placement of EKG leads to NRP a good idea after all?

    We don't use EKG, we struggle to get the signals from Sat probe , what to talk about EKG leads lifting off the chest. Although one can say that wipe off vernix from chest but even then leads can't stick. I think too much research on useless things is sad in evidence based medicine. Make things simple in neonatology and think babies are born not only in developed world but also in poor developing countries with no access to even stethoscopes, what to talk about EKG leads and monitor. At that time one rely only on cord palpating for heart rate.
  3. The modern NICU is one that is full of patients on CPAP these days. As I have mentioned before, the opportunity to intubate is therefore becoming more and more rare is non-invasive pressure support becomes the mainstay of therapy. Even for those with established skills in placing an endotracheal tube, the number of times one gets to do this per year is certainly becoming fewer and fewer. Coming to the rescue is the promise of easier intubations by being able to visualize an airway on a screen using a video laryngoscope. The advantage to the user is that anyone who is watching can give you some great tips and armed with this knowledge you may be better able to determine how to adjust your approach. For those of you who have followed the blog for some time, you will recall this is not the first time video laryngoscopy has come up. I have spoken about this before in Can Video Laryngoscopy Improve Trainee Success in Intubation. In that piece, the case was made that training residents how to intubate using a video laryngoscope (VL) improves their success rate. An additional question that one might ask though has to do with the quality of the intubation. What if you can place a tube using a video laryngoscope but the patient suffers in some way from having that piece of equipment in the mouth? Lucky for us some researchers from the Children's Hospital of Philadelphia have completed a study that can help answer this additional question. Video Laryngoscopy may work but does it cause more harm than good? Using a video laryngoscope requires purchasing one first and they aren't necessarily cheap. If they were to provide a better patient experience though the added cost might well be worth it. Pouppirt NR et al published Association Between Video Laryngoscopy and Adverse Tracheal Intubation-Associated Events in the Neonatal Care Unit. This study was a retrospective comparison of two groups; one having an intubation performed with a VL (n=161 or 20% of the group) and the other with a standard laryngoscope (644 or 80% of the group). The study relied on the use of the National Emergency Airway Registry for Neonates (NEAR4NEOs), which records all intubations from a number of centres using an online database and allows for analysis of many different aspects of intubations in neonates. In this case the data utilized though was from their centre only to minimize variation in premedication and practitioner experience. Tracheal intubation adverse events (TIAEs) were subdivided into severe (cardiac arrest, esophageal intubation with delayed recognition, emesis with witnessed aspiration, hypotension requiring intervention (fluid and/or vasopressors), laryngospasm, malignant hyperthermia, pneumothorax/pneumomediastinum, or direct airway injury) vs non-severe (mainstem bronchial intubation, esophageal intubation with immediate recognition, emesis without aspiration, hypertension requiring therapy, epistaxis, lip trauma, gum or oral trauma, dysrhythmia, and pain and/or agitation requiring additional medication and causing a delay in intubation. Looking at the patient characteristics and outcomes, some interesting findings emerge. Patients who had the use of the VL were older and weighed more. They were more likely to have the VL used for airway obstruction than respiratory failure and importantly were also more likely to receive sedation/analgesia and paralysis. These researchers have also recently shown that the use of paralysis is associated with less TIAEs so one needs to bear this in mind when looking at the rates of TIAEs. There were a statistically significant difference in TIAEs of any type of 6% in the VL group to 19% in the traditional laryngoscopy arm but severe TIAEs showed not difference. Given that several of the baseline characteristics might play a role in explaining why VL seemed superior in terms of minimizing risk of TIAEs by two thirds, the authors performed a multivariable analysis in which they took all factors that were different into account and then looked to see if there was still an effect of the VL despite these seemingly important differences. Interestingly, us of VL showed an Odds ratio of 0.43 (0.21,0.87 95% CI) in spite of these differences. What does it mean? Video laryngoscopy appears to make a difference to reducing the risk on TIAEs as an independent factor. The most common TIAE was esophageal intubation at 10% and reducing that is a good thing as it leads to fewer intubation attempts. This was also sen as the first attempt success was 63% in the VL group vs 44% in the other. Now we need to acknowledge that this was not a randomized controlled trial so it could indeed be that there are other factors that the authors have not identified that led to improvements in TIAEs as well. What makes this study so robust though is the rigour with which the centre documents all of their intubations using such a detailed registry. By using one centre much of the variability in practice between units is eliminated so perhaps these results can be trusted. Would your centre achieve these same results? Maybe not but it would certainly be interesting to test drive one of these for a period of time see how it performs.
  4. Last week
  5. AntoineBachy

    Skin to Skin - Guideline

    Excellent topic again! A lot to discuss about. In the same vein, do you have skin-to-skin experiences when your mom is in ICU? that she is in a state of coma? We do practice skin to skin but adult intensivists are not very sensitive to these practices and are anxious about the risk of infection (multiresistant bugs). Do you have knowledge of any articles in this regard? Many thanks in advance for your comments, thoughts and opinions.
  6. En Mexico si utilizamos la Vitamina K rutinariamente, en algunas ocasiones se ha agotado la vitamina k parenteral y vemos casos de Enfermedad hemorragica del recien nacido que practicamente cuando existe no las vemos, por lo que en cierto momento hasta vitamina K oral hemos utilizado....
  7. ali

    Skin to Skin - Guideline

    Excellent reading. Many thanks vvegamontes1 馃槉
  8. Earlier
  9. Hamed

    Skin care of the tiniest

    @NICU RN 7 thanks, could you please clarify this sentence " clean skin with chlorhexidine 2% without" ?
  10. vvegamontes1

    Empiric Antibiotics for NEC

    Empirically Ampi/Amika....
  11. vvegamontes1

    Skin to Skin - Guideline

    maybe help a little volume10_issue05. News Perspectives of Kangaroo Care.pdf blomqvist2010.pdf carbasse2013.pdf
  12. Petri Mansvelt

    Skin care of the tiniest

    We are cleaning the skin with chlorhexidine 2% for the insertion of UVC /UAC in extreme premature neonates. After cleaning let the skin dry for at least 30 seconds befor turning any light on the abdomen. We have almost no leasions at the unit.
  13. Petri Mansvelt

    Hy tape

    Looking for better materials to fixate our endotracheal (nasal) tubes, I came upon Hy-tape; not available in Europ but never the less. What are your experiences with the pink tape? Stays in place even when on HFO or with a lot of moist?
  14. Stefan Johansson

    Breast milk messes in the NICU

    Relevant questions indeed! I will check with our nursing care specialist also but I think our replies (Sachs Childrens, Stockholm/Swe) are regular hygien guidelines apply, i.e. cleaning with surface alcohol detergent on paper cloth our surface alcohol detergent (70% alc) nursing and our cleaning staff share responsibility for all cleaning (but parents commonly help out too)
  15. Hamed

    Surfactant lavage!

    Yes, please check my writings above @M C Fadous Khalife if you have further concerns, I would be happy to help out.
  16. JRojas

    Was adding placement of EKG leads to NRP a good idea after all?

    I see people in Delivery Rooms more worried about placing leads and getting a decent EKG than listening to the baby and feeling pulses. It is sad when we think "technology" is the answer to everything. Around the NICU nowadays nurses do Vital Signs on the monitors, and forgot how to write true nurses notes that have value, just because we are using technology. It is sad!
  17. Stefan Johansson

    Ibuprofen

    Dear @Dr Khalil Ahmad, we would consider use up to ~14 days of life. I have some personal experiences of using it up to 21 days of life (relapses after early initial closure) but this was some 10+ years back. Nowadays we have a more conservative approach for late relapses.
  18. Dr Khalil Ahmad

    Ibuprofen

    Hi Stefan, any recommendation about timing of ibuprofen use, means up to what post natal age it can be given to get good results for PDA closure.
  19. Dr Khalil Ahmad

    Surfactant lavage!

    I have found timely use of surfactant very useful in MAS, not in all cases only those on very high vent settings and not responding, it help in weaning off from ventilator.
  20. JRojas

    Is paralysis for intubation really needed?

    I agree that the data is not convincing, but what bothers me the most is that nobody ever talks about the experience and expertise of the "intubator", I know I can intubate a baby in a few seconds without a problem, been doing it for 40 years, and our group of RT's have been trained carefully and extensively to do the same. Some centers, especially academic centers, allow first year residents to do it with not such good results. I have never used intubation and in the majority of cases nor sedation. I an appropriate intubation, the baby thanks you immediately!!!
  21. bimalc

    AVEA VG

    Does anyone have experience using a proximal flow sensor with an AVEA ventilator in Volume Guarantee mode? What is the smallest volume that can be reliably delivered?
  22. NICU RN 7

    Skin care of the tiniest

    49 57 posts Report post Posted June 10 Resuscitation: 路 Receive baby in sterile towel (pre-warmed) and place in plastic sheet (NeoWrap or household plastic wrap) on warmer (Giraffe Poptop) with a warming mattress in place and activated. Our focus at delivery is on keeping the baby warm and limiting movement as much as possible, so a sterile thermal hat is also put in place. 路 We use gel pad leads in micropreemie size for ECG (NeoTech Micro) and temp probe (Accutemp Plus), and velcro/cloth pulse oximeter probes (LNCS NeoPT-3) Gel pads lose adhesion very quickly in humidiity, and probe positions are changed Q12 hours with cares 路 Lines are placed and respiratory support tubing is secured before lowering top of Giraffe to isolette position. Humidity is added to 80%, and the ambient temperature is put on "skin" to keep skin temp at 36.5. 路 Once humidity is effective, plastic sheet is removed and infant is placed in supportive cotton wraps (Snuggle). Linens are changed Q24 hours 路 UVC, UAC insertion using checklist; clean skin with chlorhexidine 2% without and rinse with sterile saline. For 1st72 hrs of life 路 Humidity in isolette: 80%. 路 No bath. 路 No tape except for ETT securement 路 Routine diaper care with water wipes. 路 Score skin health with a skin care score Q6 hours No weights, touch only Q6 hours or when necessary 路 Transition to PICC at 48 hours of life if no signs of infection.; If skin condition poor, keep UVC if in good position, until skin condition permits PICC (max 14 days). We continue daily linen changes until PICC Is DC'd We continue Q6 hour cares until approximately 32 weeks, or until infant is consistently uncomfortable more quickly
  23. I'm working on a practice change for our unit with regard to the human milk spills that are a normal part of pumping for and feeding infants. The obvious solution is to wipe them with paper towels and then sanitize the area, but what do you do when the spot is dried before you see it? Our mothers pump at bedside, and we are often faced with dried spots of milk on the plastic chairs and bedside shelves after mothers have left. Our sanitizers: Sani-Cloth and Oxycide, do not lift the milkfat, and one of them even crystalizes it, making removal extremely difficult.My questions are as follows: 1. What does your infection control say about spilled milk? 2. What solutions do you use to clean dried spilled milk 3. Whose responsibility is it to clean such spots? Environmental services, Nutrition, Nursing, Parents?
  24. Schumz

    Facial congestion

    Thank you for your comments. @Stefan Johansson and @Francesco Cardona yes he had a probable seizure but no further seizures. CFM for 48 hours all satisfactory. Baby is now extubated and we are normalising his care. I think waiting and watching worked.
  25. It is hard to believe but it has been almost 3 years since I wrote a piece entitled A 200 year old invention that remains king of all tech in newborn resuscitation. In the post I shared a recent story of a situation in which the EKG leads told a different story that what our ears and fingers would want us to believe. The concept of the piece was that in the setting of pulseless electrical activity (where there is electrical conductance in the myocardium but lack of contraction leaves no blood flow to the body) one could pick up a signal from the EKG leads when there is in fact no pulse or perfusion to vital organs. This single experience led me to postulate that this situation may be more common than we think and the application of EKG leads routinely could lead to errors in decision making during resuscitation of the newborn. It is easy to see how that could occur when you think about the racing pulses of our own in such situations and once chest compressions start one might watch the monitor and forget when they see a heart rate of 70 BPM to check for a corresponding pulse or listen with the stethoscope. I could see for example someone stopping chest compressions and continuing to provide BVM ventilation despite no palpable pulse when they see the QRS complex clearly on the monitor. I didn鈥檛 really have much evidence to support this concern but perhaps there is a little more to present now. A Crafty Animal Study Provides The Evidence I haven鈥檛 presented many animal studies but this one is fairly simple and serves to illustrate the concern in a research model. For those of you who haven鈥檛 done animal research, my apologies in advance as you read what happened to this group of piglets. Although it may sound awful, the study has demonstrated that the concern I and others have has is real. For this study 54 newborn piglets (equivalent to 36-38 weeks GA in humans) were anesthetized and had a flow sensor surgically placed around the carotid artery. ECG leads were placed as well and then after achieving stabilization, hypoxia was induced with an FiO2 of 0.1 and then asphyxia by disconnecting the ventilator and clamping the ETT. By having a flow probe around the carotid artery the researchers were able to determine the point of no cardiac output and simultaneously monitor for electrical activity via the EKG leads. Auscultation for heart sounds was performed as well. The results essentially confirm why I have been concerned with an over reliance on EKG leads. Of the 57 piglets, 14 had asystole and no carotid flow but in 23 there was still a heart rate present on the EKG with no detectable carotid flow. This yields a sensitivity of only 37%. Moreover, the overall accuracy of the ECG was only 56%. Meanwhile the stethoscope which I have referred to previously as the 鈥渒ing鈥 in these situations had 100% sensitivity so remains deserving of that title. What do we do with such information? I think the results give us reason to pause and remember that faster isn鈥檛 always better. Previous research has shown that signal acquisition with EKG leads is faster than with oximetry. While a low heart rate detected quickly is helpful to know what the state of the infant is and begin the NRP pathway, we simply can鈥檛 rely on the EKG to tell us the whole story. We work in interdisciplinary teams and need to support one another in resuscitations and provide the team with the necessary information to perform well. The next time you are in such a situation remember that the EKG is only one part of the story and that auscultation for heart sounds and palpation of the umbilical cord for pulsation are necessary steps to demonstrate conclusively that you don鈥檛 just have a rhythm but a perfusing one. I would like to thank the Edmonton group for continuing to put out such important work in the field of resuscitation!
  26. I'm not sure whether the issue is equipment vs. us not really understanding what sorts of 'events' it is safe to have at home. The CHIMES study clearly shows that even well past term corrected many babies will have minor events that no one really ever notices because they aren't looking. There is reasonable evidence that you can ignore brief events without compromising safety (probably because many brief events reflect monitor limitations as opposed to actual biology) [see https://www.researchgate.net/publication/308756008_Clinically_significant_cardiopulmonary_events_and_the_effect_of_definition_standardization_on_apnea_of_prematurity_managementfor example]. My experience has been that the biggest issues are not, at their heart, technological but social and professional: We get parents who stare at the bedside monitor for weeks on end and are terrified to go home and we also get bedside nurses who either document every time the monitor alarms (often without enough context overnight for the team the next morning to figure out if the baby is actually any different) or nurses who document only the most severe episodes when a kid is getting ready to go home. One of my prior units started a program to standardize the approach of our nurses to these cases and, from a physician perspective, it Wass an unbelievably positive change
  27. Francesco Cardona

    Facial congestion

    Cerebral sinovenous Thrombosis comes to mind. What do you mean by abnormal movements? Were you suspecting a seizure?
  28. Stefan Johansson

    Facial congestion

    Is there a history that the head was 鈥漵tuck鈥 outside while the body was about to be delivered? If yes, watchful waiting sounds good.
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