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therapeutic hypothermia - do you ventilate just for cooling?
Hamed replied to Schumz's topic in hematology
Concerning the need for intubation and Mech. vent. I concord with @bimalc, @Stefan Johansson and @rehman_naveed and once in during cooling it will remain in until the end of cooling or until an MRI is taken at 4~5 days of life. As for comfort, we do as @rehman_naveed, we give low dose morphine infusion 5 mcg/kg/h not exceeding 10 mcg/kg/h or fentanyl 0.5 mcg/kg/h not exceeding 1 mcg/kg/h (fentanyl preferable for hemodynamic compromised infants). Coming to the timing of MRI, it may vary according to each hospital`s protocol. In addition, it really depends on what you want to see, diffusion and metabolic changes preferably 4~5 days of life, and that concord with 24 to 72 hrs after cooling as @bimalc. Brain injury changes continue to develop as late as the 2nd week of life. That is why you find some units do the MRI at day 4~5 or day 7 or end of 2nd week of life. -
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Don’t let the cord gas fool you
Stefan Johansson commented on AllThingsNeonatal's blog entry in All Things Neonatal
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It has to be one of the most common questions you will hear uttered in the NICU. What were the cord gases? You have a sick infant in front of you and because we are human and like everything to fit into a nicely packaged box we feel a sense of relief when we are told the cord gases are indeed poor. The congruence fits with our expectation and that makes us feel as if we understand how this baby in front of us looks the way they do. Take the following case though and think about how you feel after reading it. A term infant is born after fetal distress (late deceleration to as low as 50 BPM) is noted on the fetal monitor. The infant is born flat with no heart rate and after five minutes one is detected. By this point the infant has received chest compressions and epinephrine twice via the endotracheal tube. The cord gases are run as the baby is heading off to the NICU for admission and low and behold you get the following results back; pH 7.21, pCO2 61, HCO3 23, lactate 3.5. You find yourself looking at the infant and scratching your head wondering how the baby in front of you that has left you moist with perspiration looks as bad as they do when the tried and true cord gas seems to be betraying you. To make matters worse at one hour of age you get the following result back; pH 6.99, pCO2 55, HCO3 5, lactate 15. Which do you believe? Is there something wrong with the blood gas analyzer? How Common Is This Situation You seem to have an asphyxiated infant but the cord gas isn’t following what you expect as shouldn’t it be low due to the fetal distress that was clearly present? It turns out, a normal or mildly abnormal cord gas may be found in asphyxiated infants just as commonly as what you might expect. In 2012 Yeh P et al looked at this issue in their paper The relationship between umbilical cord arterial pH and serious adverse neonatal outcome: analysis of 51,519 consecutive validated samples. The authors sampled a very large number of babies over a near 20 year period to come up with a sample of 51519 babies and sought to pair the results with what they knew of the outcome for each baby. This is where things get interesting. When looking at the outcome of encephalopathy with seizures and/or death you will note that only 21.71% of the babies with this outcome had a gas under 7.00. If you include those under 7.10 as still being significantly distressed then this percentage rises to 34.21%. In other words almost 66% of babies who have HIE with seizures and/or death have a arterial cord pH above 7.1! The authors did not look at encephalopathy without seizures but these are the worst infants and almost 2/3 have a cord gas that you wouldn’t much as glance at and say “looks fine” How do we reconcile this? The answer lies in the fetal circulation. When an fetus is severely stressed, anaerobic metabolism takes over and produces lactic acid and the metabolic acidosis that we come to expect. For the metabolites to get to the umbilcal artery they must leave the fetal tissues and enter the circulation. If the flow of blood through these tissues is quite poor in the setting of compromised myocardial contractility the acids sit in the tissues. The blood that is therefore sitting in the cord at the time of sampling actually represents blood that was sent to the placenta “when times were good”. When the baby is delivered and we do our job of resuscitating the circulation that is restored then drives the lactic acid into the blood stream and consumes the buffering HCO3 leading to the more typical gases we are accustomed to seeing and reestablishing the congruence our brains so desire. This in fact forms the basis for most HIE protocols which includes a requirement of a cord gas OR arterial blood gas in the first hour of life with a pH < 7.00. Acidosis May Be Good For the Fetus To bend your mind just a little further, animal evidence suggests that those fetuses who develop acidosis may benefit from the same and be at an advantage over those infants who don’t get acidemia. Laptook AR et al published Effects of lactic acid infusions and pH on cerebral blood flow and metabolism. In this study of piglets, infusion of lactic acid improved cerebral blood flow. I would suggest improvement in cerebral blood flow of the stressed fetus would be a good thing. Additionally we know that lactate may be used by the fetus as additional metabolic fuel for the brain which under stress would be another benefit. Finally the acidemic fetus is able to offload O2 to the tissues via the Bohr effect. In case you have forgotten this phenomenon, it is the tendency for oxygen to more readily sever its tie to hemoglobin and move into the tissues. I hope you have found this as interesting as I have in writing it. The next time you see a good cord gas in a depressed infant, pause for a few seconds and ask yourself is this really a good or a bad thing?
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therapeutic hypothermia - do you ventilate just for cooling?
bimalc replied to Schumz's topic in hematology
24-72 hours after cooling. I try to use spontaneous breathing modes in this setting whenever I can to try and get more information to guide counseling if I am concerned there will be an extubation failure. For example, the draeger VN500 has mandatory minute ventilation mode and has some lovely graphics that you can show a parent so they can see their child go apneic or hypopneic (CPAP/PS can be used to a similar but not identical end) -
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therapeutic hypothermia - do you ventilate just for cooling?
Stefan Johansson replied to Schumz's topic in hematology
@ashok we would do it around 7 days of age (i.e. a few days after warming). -
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While we are still finalizing the program for the 2019 Meetup, we cannot wait to share what we know already The "Future of Neonatal Care" conference will be held 7-10 April 2019, in the Auditorium at the Rigshospitalet in Copenhagen, Denmark. The program will include a great set of lectures and workshops with high clinical relevance. If you want to secure a seat, we advise you to make a non-binding pre-registration. On the conference web site, you can also subscribe to the dedicated conference newsletter. See you in Copenhagen next year!
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therapeutic hypothermia - do you ventilate just for cooling?
ashok replied to Schumz's topic in hematology
@bimalc ,when r u taking mri after cooling -
Nazir joined the community
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We proudly present MONIVENT as a new Supporting Partner of 99nicu! MONIVENT is a young medtech company dedicated to improve the emergency ventilatory care given to newborn babies in need of respiratory support at birth. About 3-6 % of all newborns end up in this situation, where healthcare personnel today are lacking tools to determine how effective their manual ventilation really is. Monivent® Neo is a non-invasive monitoring device to be used during manual ventilation, measuring the air volume given to the baby with sensors wirelessly built-into the face mask, providing the caregiver with continuous feedback on several critical parameters. A target volume is presented and any volume given outside the recommended interval is clearly indicated by a color change on an intuitive display. MONIVENT recently introduced its first product - Monivent Neo training - used within simulation training on a manikin while a clinical product is currently under development. Learn more about MONIVENT on: http://monivent.se/
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International Neonatal Multispecialty Conference
htawakol posted a calendar event in Community Calendar
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Learn Neonatal Brain Ultrasound on Youtube!
mahmoud replied to Stefan Johansson's topic in neurology
Thank you -
therapeutic hypothermia - do you ventilate just for cooling?
bimalc replied to Schumz's topic in hematology
I must agree with the others that therapeutic hypothermia is not, in and of itself, an indication for intubation. However, given the known natural history of HIE, even in the era of cooling, I certainly have a lower threshold to intubate when the respiratory status is marginal. Also, must agree with @Stefan Johansson once the ET tube goes in, it does not come out (In our case, not until we get the MRI). -
In our Interview series, we are grateful to present this interview with @Ryan McAdams , US, a neonatologist who is also a painter. We were curious to speak with Ryan about his art work, and the intersection of neonatology, child health and arts. Our previous interviews: Mats Blennow; Sweden Ruth Davidge, South Africa - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Could you please introduce yourself and where you currently work? I am Ryan McAdams, the Neonatology Division Chief and Neonatal-Perinatal Medicine Fellowship Program Director at the University of Wisconsin School of Medicine and Public Health in Madison, Wisconsin. I’m married and have two wonderful children. How did your professional career lead you to this spot? After my fellowship training in San Antonio, Texas, I worked on a naval base in Okinawa, Japan, as an officer and neonatologist in the United States Air Force. I was the Air Transport director responsible for orchestrating and often going on flights to transport critically ill neonates throughout the Western Pacific who required care in the NICU. I met some amazing people in the military and learned a lot about other cultures. While in Japan, I became passionate about global neonatal health and did volunteer medical work in Mongolia, Cambodia, Zambia, and Malawi. After leaving the Air Force, my wife and I moved to Seattle, Washington, where I accepted a job at the University of Washington and Seattle Children’s Hospital. I continued to do global health work with colleagues in Seattle, mainly working in Uganda, with a focus on using education to empower local providers to deliver quality neonatal care. This global health work helped reinforce my strong belief that every baby everywhere is valuable and deserves the best opportunities to thrive. While in Seattle, I worked with a talented team of neonatologists, and was fortunate to have numerous opportunities to conduct translational and clinical research focused on understanding perinatal lung and brain injury. After eight enlightening years in Seattle, I was recruited to be the Neonatology Division Chief at the University of Wisconsin, Madison. Since I was born and raised in Wisconsin, I was thankful to be close to my family again. You are also a painter - please tell us what led you into painting? As a child, my aunt gave me an oil paint set, which encouraged me to start painting. I have always had a keen interest in the myriad of colors and subtle details that abound in nature, so exploring the world through art has been a gratifying experience. In medical school, I decided painting would be a healthy creative outlet to stay well-rounded in the midst of intense studying. Short on money, I drove my grandmother to a local craft store and used her senior citizen discount to buy a plethora of art supplies. I built an easel and began to paint. At the time, I was a big fan of Salvador Dali, so his surrealistic style influenced my initial approach to painting. Throughout medical school, I often stayed up all night long painting, a method not always ideal for the rigorous demands of medical school. With my first big canvas painting, I entered an art contest in JAMA magazine and my painting “A Grasshopper Which Sprang From Indecision While a 3-Day-Old Peeled Banana Waited to Be Painted (JAMA. 1998; 280:1189) was a Grand Prize winner. This germinal success misinformed my understanding of how complicated, competitive, and cultivated the art world was, a realization that I learned while in my pediatric residency in northern California. I developed a quick sense of humility after peddling my painting portfolio around the art galleries in San Francisco where the exorbitant price tags of authentic Chagall and Miró prints led me to a somewhat disheartening assimilation of my place outside the circle of established artists. This epiphany led to introspection and a self-declaration that my painting needed to serve a purpose to bless others in a way unhindered by any motivation for supplemental income. While living in Japan, inspired by the woodblock masterpieces of Hokusai, I painted a contemporary series of acrylic paintings featuring a hybrid of themes from famous Japanese prints. I also began working on a collection of paintings illustrating the teachings and ministry of Christ described in the Gospel of Luke, a book written by Luke, who was a physician. As I became more involved in global health, the focus of my art centered on the plight of the impoverished and marginalized children of our world. Do you have art school training or are you an auto-didact? While I am certain formal training would have been advantageous, I am a self-taught painter. Can you expand on your themes in your paintings? As a neonatologist who has been privileged to do global health medicine and work in large medical centers NICUs, I have witnessed a substantial amount of suffering and death. I have also witnessed the incredible resilience of children and the awe-inspiring dedication and love of their families. These experiences shape why and what I now paint. Themes of social injustice, survival, pain, and grief are the basis for my art since these ageless motifs are still globally preeminent today. What messages to you want to convey to those viewing your paintings with neonatal themes? My paintings are an amalgamation of emotions constructed with colors, lines, and textures into a tangible declaration aimed at validating the importance of children who have struggled or died, regardless of the brevity of their life. My hope is that my art will validate the existence of these amazing children and provide insight for the viewer, who can contemplate the stories I have tried to capture in acrylics. Do you direct the painting to the general public or a more niched "neonatal audience"? I paint for the general public, recognizing that the medical community may be more accessible to share my work with, but hopeful that any viewer will pause to consider my art. Are those painting also part of your own processing of experiences? When I paint a subject or theme related to an intense event, such as the death of a child that I was privileged to care for, this experience provides me a way to work through my emotions and cope with grief. Engaging in this process often requires me to relive difficult experiences in a vivid and immersed manner, which can be quite overwhelming, at times resulting in tears, frustration, scrutiny, and speculation. When I paint a baby or child who died, I approach each painting with deep reverence, often engrossed in deep reflection and prayer about the child’s family, wondering what things would have been like had the child survived. In some ways, the final painting becomes a testimony that substantiates an otherwise untold story, a story that I hope will help others. After the unexpected death of my father, at a time when my neonatology work schedule was especially onerous and severe sciatica from my herniated disc was a constant torment, I used painting as I means to deal with my pain and grief. My painting, “Self-Portrait” conveys a period of darkness I experienced and now reminds me that my resilience prevailed despite my trying circumstances. I feel that all people have seasons of struggle and sorrow, so finding constructive coping mechanisms is key to overcome anticipated or unexpected adversity. Right before moving to Wisconsin, my mother, a comical and quick-witted woman who was avid reader and art lover, was diagnosed with lung cancer. A year later, after multiple bouts of chemotherapy, she died days after her birthday. Both my parents encouraged my creativity, so although I can no longer show my latest paintings to them, they still inspire me in a way that I feel I am able to share my work with them. Where have you presented your art? I have presented my work at small venues including a café, hair salon, church, and at a medical conference. No museums yet, but hopefully someday. And, those of us wanting to see more of your work - when to we go where? I have had 8 paintings published in medical journals (see links below), but I do not have a website to view my work, since I have not had sufficient time to develop and maintain a quality site. A Grasshopper Which Sprang From Indecision While a 3-Day-Old Peeled Banana Waited to Be Painted (acrylic on canvas). JAMA. 1998; 280:1189. https://jamanetwork.com/journals/JAMA/articlepdf/1838997/jms1007-5-1.pdf Original painting entitled “Transposition.” Academic Medicine 2010 Nov; 85(11): Cover Art. https://journals.lww.com/academicmedicine/Fulltext/2010/11000/Artist_s_Statement__Transposition.36.aspx Original painting entitled “Champei’s Petals.” Academic Medicine. 2012 Oct: 87 (10): Cover Art. https://journals.lww.com/academicmedicine/Fulltext/2012/10000/Artist_s_Statement___Champei_s_Petals.34.aspx Original painting and poem entitled “The Abruption.” Obstetrics & Gynecology. 2013 Dec: Cover Art (http://links.lww.com/AOG/A450). http://download.lww.com/wolterskluwer_vitalstream_com/PermaLink/AOG/A/AOG_122_6_2013_10_22_MCADAMS_000000_SDC1.pdf Original painting entitled “Wait and See.” Academic Medicine. 2014 Feb;89(2): Cover Art. https://journals.lww.com/academicmedicine/Fulltext/2014/02000/Artist_s_Statement___Wait_and_See.21.aspx Original painting entitled “The Orphans.” Academic Medicine. 2014 Sep;89(9): Cover Art. https://journals.lww.com/academicmedicine/Fulltext/2014/09000/Artist_s_Statement___The_Orphans.13.aspx Original painting entitled “The Girl in Blue.” Academic Medicine. 2016 May;91(5): Cover Art. https://journals.lww.com/academicmedicine/Pages/toc.aspx?year=2016&issue=05000 Original painting entitled “In the Face of Hunger.” Academic Medicine. 2017 Aug;92(8): Cover Art. https://journals.lww.com/academicmedicine/toc/2017/08000 For newly graduated colleagues around the world - what would be your advice for their future professional and personal development, with regards to mixing of NICU work and creative work? I encourage anyone to explore the value of painting from a wellness perspective. Painting is an amazing way to engage your mind and body in an emotional outlet that provides mechanisms to relax, laugh, grieve, reflect, share, process, and cope with the variety of experiences we face in life. I feel everyone has creativity they can express and that a blank canvas should not be a daunting endeavor, but an amicable invitation to express yourself. And finally, what about your own future plans? While living in Japan, I conceptualized a way to help support orphans using art. I would love to develop a nonprofit organization where people can purchase online prints of original paintings and then choose a non-governmental organization of their preference to dedicate 100% of the profits to benefit children in need. My grander vision is to establish an international museum dedicated to orphans that would include donated art from global artists and would feature art from orphans around the world. This museum, which would serve as a voice for our most vulnerable children and represent a place where their importance is highlighted, could generate financial resources to support constructive programs, such as academic scholarships, that will help future generations thrive. I am grateful to be a neonatologist, a husband, a father, and an artist, so I look forward to further applying my talents to advocate for children. - - - - - - - - - - - - - - - - - Please find a selection of nine paintings by Ryan McAdams below.
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therapeutic hypothermia - do you ventilate just for cooling?
Stefan Johansson replied to Schumz's topic in hematology
@Schumz we also cool infants without keeping them intubated (for the sake if it), and we have good experience (PO2- and PCO2-wise ) that infants can do just fine even without CPAP, despite cooling and relatively large doses of analgesia / sedation. But of course, one needs to think both once and twice, especially not to be keep infants "breathing" but not giving sufficient analgesia and sedation. Also, if we do use mechanical ventilation, we do not extubate during cooling even if spont breathing is restored. -
What does the world think of ankyloglossia? A relevant question!
RafaOcejo replied to Stefan Johansson's topic in breastfeeding and breast milk
We do frenulotomies in our unit as needed. This topic is difficult to be objective about. Generally if the frenulum is short and anterior, it does interfere with breast feeding and later in life with speech develoment. We find it is better to do it early than require an ENT, dentist or general surgeon do it when the child is 2 or 3. By then the tongue is used to some movement restriction and does not regain its function right away so speech therapy needs to continue. Of interest is the genetics of the condition. Not unusual to find that a parent, a sibling or an aunt/uncle also had it or still has it and has a lisp. We anesthetize the frenulum with 4% lidocaine solution using 2 sterile Q-tips and cut the frenulum with very fine curved scissors. I have trained our pediatricians and NP’s to do it and we have not had any problems related to the procedure. Is it needed? That is where the subjective part of indications comes into play. One always feels unsure of the need.- 1 reply
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Learn Neonatal Brain Ultrasound on Youtube!
vvegamontes1 replied to Stefan Johansson's topic in neurology
Thanks -
therapeutic hypothermia - do you ventilate just for cooling?
Schumz replied to Schumz's topic in hematology
Thank you ...I thought so and did the right thing! -
therapeutic hypothermia - do you ventilate just for cooling?
rehman_naveed replied to Schumz's topic in hematology
There should be no reason to intentionally ventilate babies while cooling. How can ventilation cause comforts? we use low dose morphine infusion to keep them calm Naveed -
@Schumz thanks for closing the loop with those good news!
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Guys do you ventilate, SVIA (self ventilating in air) babies just for cooling? If not what strategies do u use for making them comfortable?
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Just to let you know baby's comgestion settled on its own ...waiting and watching was a good idea indeed.
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First 13 confirmed speakers at our Meetup 2019!
Stefan Johansson posted a blog entry in Department of Brilliant Ideas
We now have 13 confirmed speakers for the Copenhagen Meetup 7-10 April next year! Generally, we'll stick to the successful format we have had at the previous meetings: 45 min slots split into a 30 min lecture and a 15 min discussion. We'll continue to use the sli.do smartphone app to facilitate the discussion and allow every delegate to share questions and comments. In addition to the lecture program 7-9 April, we are also planning workhops and mini-symposia on the 10th of April. We'll share more info about those soonish, but if you want ONE cliff-hanger... we plan one symposium about the infant microbiome etc-etc Confirmed topics and speakers Neonatal transports - safe and easy, Morten Breindahl (Sweden) Treating pain in neonates, Karel Allegaert (Belgium) How to improve quality on the NICU, Joseph Kaempf (US) Hyperglycemia - how to manage and why, Kathryn Beardsal (UK) Why we should rehearse simulated scenarios, Ruth Gottstein (UK) Go with the (high) flow, Brett Manley (Australia) News in the updated ESPGHAN guidelines, Nadja Haiden ( Austria) Prevention of BPD, Christian Poets (Germany) The many inotropes - what to use when, Yogen Singh (UK) Cord Clamping, 1.0 and 2.0, Ola Andersson (Sweden) When NEC rates persist , despite everything done “Right”, Ravi Patel (US) Outcomes in infants surviving at the limit of viability, Ulrika Ådén (Sweden) Ethical decision making around the limit of viability, Gorm Greisen (Denmark) -
untilCome to the Neonatal Update 2018, 19-23 November 2018. This annual 5 day international meeting has grown to become one of the largest annual speciality meetings in neonatal medicine. As a forum for the discussion of state of the art clinical practice and new research, it attracts senior neonatal and paediatric clinicians from around the world. The Neonatal Update 2018 will be held at BMA House, Tavistock Square, London WC1H 9JP. It is a grade II listed building which was designed by Sir Edwin Lutyens, and has been the home to the British Medical Association since 1925. It is conveniently located only a few minutes’ walk from Kings Cross, St Pancras, Euston and Russell Square stations, providing easy access around London, the rest of the UK and with Europe via Eurostar. Find more info on this URL: https://www.symposia.org.uk/neonatal/home.html
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XII International Conference on Kangaroo Mother Care, Columbia
Stefan Johansson posted a calendar event in Community Calendar
untilThe XII International Conference on Kangaroo Mother Care will take place 14-17 November 2018, in Bogota, Columbia. The workshop (November 14-15, 2018), for about 300 participants working on KMC implementation at country level. The objective is to present, discuss in detail and share experiences that will lead to a better understanding of the difficulties and needs for KMC implementation at country level. The congress (November, 16-17, 2018), in which we expect 400 participants, will focus on neuro-protection of the brain of the premature and LBW infant through KMC. We will invite speakers and discussants for keynote lectures, symposia and panel discussions on this topic. There will also be a call for abstracts and among the accepted ones; the Scientific Committee will select some for oral as well as poster presentations. See the web site for more information: http://www.inkmc.net/
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Concerning the need for intubation and Mech. vent. I concord with @bimalc, @Stefan Johansson and @rehman_naveed and once in during cooling it will remain in until the end of cooling or until an MRI is taken at 4~5 days of life. As for comfort, we do as @rehman_naveed, we give low dose morphine infusion 5 mcg/kg/h not exceeding 10 mcg/kg/h or fentanyl 0.5 mcg/kg/h not exceeding 1 mcg/kg/h (fentanyl preferable for hemodynamic compromised infants). Coming to the timing of MRI, it may vary according to each hospital`s protocol. In addition, it really depends on what you want to see, diffusion and metabolic changes preferably 4~5 days of life, and that concord with 24 to 72 hrs after cooling as @bimalc. Brain injury changes continue to develop as late as the 2nd week of life. That is why you find some units do the MRI at day 4~5 or day 7 or end of 2nd week of life.
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24-72 hours after cooling. I try to use spontaneous breathing modes in this setting whenever I can to try and get more information to guide counseling if I am concerned there will be an extubation failure. For example, the draeger VN500 has mandatory minute ventilation mode and has some lovely graphics that you can show a parent so they can see their child go apneic or hypopneic (CPAP/PS can be used to a similar but not identical end)
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By Stefan Johansson · Posted
@ashok we would do it around 7 days of age (i.e. a few days after warming). -
@bimalc ,when r u taking mri after cooling
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