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  2. A first look at the programme for the European Neonatal Ethics Conference 2019 Final Programme.pdf Final Programme.docx
  3. Last week
  4. Thank you, Stefan, for reminding me of my one major criticism of the PINT trial: They did not include NEC (or at least surgical NEC) in their composite outcome. As for why we, as a profession, continue to worry about TANEC, it is mostly recall bias (we all remember the case of NEC shortly after transfusion but we never stop to think of all the transfusions we have given without NEC appearing) I've often wondered if there isn't already enough data out there to answer these questions (or at least get a start). Supervised learning techniques have advanced sufficient that if you were willing to invest in combining and curating multiple datasets of ELBWs you could probably train a binary classifier to predict risk of NEC with or without transfusion.
  5. Choosing to provide postnatal systemic steroids to preterm infants for treatment of evolving BPD has given many to pause before choosing to administer them. Ever since K Barrington published his systematic review The adverse neuro-developmental effects of postnatal steroids in the preterm infant: a systematic review of RCTs. and found a 186% increase in risk of CP among those who received these treatments, efforts have been made to minimize risk when these are given. Such efforts have included shortening the exposure from the length 42 day courses and also decreasing the cumulative dose of dexamethasone. Fortunately these efforts have led to findings that these two approaches have not been associated with adverse neurodevelopmental outcomes. Having said that, I doubt there is a Neonatologist that still doesn’t at least think about long term outcome when deciding to give dexamethasone. The systemic application certainly will have effects on the lung but the circulating steroid in the brain is what occupies our thoughts. What About Applying it Directly to the Lung If you wanted to prevent BPD the way to do it would be to minimize the time infants are exposed to positive pressure ventilation. Rather than giving steroids after a week or two maybe it would be best to give them early. Recent evidence supports this for systemic steroids and has been written about recently. Hydrocortisone after birth may benefit the smallest preemies the most! This still involves providing steroid systemically. Over the years, inhaled steroids have been tried as have intratracheal instillation of steroid with and without surfactant as a vehicle for distribution to the lung. This month colleagues of mine anchored by Dr. G. t’Jong (a founding member of the “Tall Men of Pediatrics #TMOP) published a systematic review and meta-analysis of all such RCTs in their paper Efficacy and safety of pulmonary application of corticosteroids in preterm infants with respiratory distress syndrome: a systematic review and metaanalysis. The results of the study suggest that there may well be a role for this approach. All of the included studies used a prophylactic approach of giving between the first 4 hours and the 14th day of postnatal age doses of pulmonary steroids with the goal of preventing death or BPD. The GA of enrolled infants ranged from 26 to 34 weeks, and the birth weight ranged from 801 to 1591 g. Out of 870 possible articles only 12 made the cut and compromised the data for the analysis. Routes of steroid were by inhalation, liquid instillation though the endotracheal tube or by mixing in surfactant and administering through the ETT. What Did They Find? Using 36 weeks corrected age as a time point for BPD or death, the forrest plot demonstrated the following. A reduction in risk of BPD or death of 15% with a range of 24% to only a 4% reduction. Looking at the method of administration though is where I find things get particularly interesting. What this demonstrates is that how you give the steroids matters. If you use the inhalational or intratracheal instillation (without a vehicle to distribute the steroids) there is no benefit in reduction of BPD or death. If however you use a vehicle (in both Yeh studies it was surfactant) you find a significant reduction in this outcome. In fact if you just look at the studies by Yeh the reduction is 36% (CI 34 – 47%). In terms of reduction of risk these are big numbers. So big one needs to question if the numbers are real in the long run. Why might this work though? In the larger study by Yeh, budesonide was mixed with surfactant and delivered to intubated infants every 8 hours until FiO2 was less than 30%, they were extubated or a maximum of 6 doses were reached. We know that surfactant spreads throughout the lung very nicely so it stands to reason that the budesonide could have been delivered evenly throughout the lung. Compare this with inhalational steroid that most likely winds up on the plastic tubing or proximal airway. The anti-inflammatory nature of steroids should decrease damage in the distal airways offsetting the effects of positive pressure ventilation. Future Directions I am excited by these findings (if you couldn’t tell). What we don’t know though is whether the belief that the steroid stays in the lung is true. Are we just making ourselves feel better by believing that the steroid won’t be absorbed and move systemically. This needs to be tested and I believe results of such testing will be along in the near future. Secondly, we need a bigger study or at least another to add to the body of research being done. Such a study will also need long term follow-up to determine if this strategy does at least have equal neurodevelopmental outcomes to the children who don’t receive steroid. The meta-analysis above does show in a handful of studies that long term outcome was no different but given the history of steroids here I suspect we will need exceptionally strong evidence to see this practice go mainstream. What I do believe is whether you choose to use steroids prophylactically using hydrocortisone or using intratracheal surfactant delivered budesonide, we will see one or both of these strategies eventually utilized in NICUs before long.
  6. I really liked this blog post! I guess many of us have seen devastating cases of post-transfusion NEC that stay with us and therefore add "bias" to our judgements on this topic. There are still questions though right? Like the severity of the anaemia (how low do we leave the Hb and is that threshold different for certain babies?), the duration of anaemia (how long do we leave it before we transfuse?) and then, if the mechanism is a re-perfusion injury post-transfusion, how do we prevent it?!
  7. Check out this blog post by Keith Barrington whether transfusions trigger NEC. Or does anemia. https://neonatalresearch.org/2019/04/16/do-transfusions-trigger-nec-or-does-anemia/ I would say that there are enough clinical research data out there to say that there seems to be NO association. Just check out the PINT trial, the RCT comparing a liberal vs a restrictive Hb level for transfusion in preterm infants. If anything, the more liberally transfused group of infant had less NEC. And read this paper by Patel et al that nicely demonstrates that there seems to be confounding of indication coming into play, i.e. it is not the transfusion but the underlying anemia is the problem. Despite research findings, this question (whether transfusions "lead to" NEC) is still troubling us. Why so?
  8. A week ago, we met up at the Future of Neonatal Care conference, AKA the #99nicuMeetup, in Copenhagen, DK. There were four day intensive days for myself, @Francesco Cardona and more than 200 people travelling from 32 countries - neonatal staff members, speakers and workshop leaders, and partner representatives. Topics included outcomes and ethics at the viability border, NEC prevention, neonatal transports, use of inotropes, hyperglycemia, cord clamping, high flow and pain management. And much much more! In short, everything went really well. Given that our vision is to "make the world smaller" and create a space for networking (in addition to a great learning experience) , I would like to share our sincere Thank You to all all delegates, faculty members and Partners for making the #99nicuMeetup the event it has become. Without You coming to "share and care", there would be no dynamics, no laughter, and no #99nicuMeetup. We did our best to share the conference over Twitter (see hashtag #99nicuMeetup). We also video-recorded the lectures, and we plan publish the set of lectures on Youtube in a few weeks time. If you attended and have photos you want to share, please add to the Gallery below (or email them to info@99nicu.org and I upload). See you next year !
  9. Hi . the patient is already better. the problem was that it should lower the frequency to the maximum and return to high values of delta p. I think the problem is the draguer vn500 that is not powerful enough to ventilate a patient of 4500 gs by passing it to the sle500 put down the pco2
  10. @juan carlos vidal sorry that I did not see that you posted this question in this thread - but have shared over our social channels now. Anyway, it seems that you have adjusted the HFV as possible, with reduced freq and a higher d-P. Does your ventilator give tidal volumes? What approx levels of PCO2 (kPa) do you have? Have you tested regular tidal support, like SIPPV?
  11. Thanks for the share- this had been on my to-listen list. The article is an interesting read as well (link below). I am interested in the Staffing Models of high performing NICUs which include: "Neonatologists rounded on fewer patients, less nurse turnover, better nurse: patient ratios and neonatal nurse practitioners rounding on VLBW infants" Definitely someone for next years line up 😉 https://fn.bmj.com/content/104/1/F13?rss=1&utm_source=feedburner&utm_medium=feed&utm_campaign=Feed%3A bmj%2FqEtm %28Archives of Disease in Childhood - Fetal and Neonatal Edition current issue%29
  12. Great podcast! In fact, we almost had the interviewed author Joe Kaempf as speaker at this years "Future of Neonatal Care conference (last week in CPH). Let's hope he can come next year
  13. Stefan Johansson

    DIC

    @Francesco Cardona great paper! And reminds me of medical studies when I struggled with the coagulation pathways... (like the embedded image below) @Marina22 Did you have something special in mind?
  14. Francesco Cardona

    DIC

    Start reading here maybe: https://www.nature.com/articles/nrdp201637
  15. Earlier
  16. Marina22

    DIC

    Requesting explaining the pathophysiology underlying DIC
  17. @bimalc I will reach out to Susan. Thank you!
  18. I would recommend reaching out to Susan.Slattery@northwestern.edu who helped develop weight-based standardized feeding pathways with me when I was in Chicago. The broad outlines of our approach were weight-based stratification, q12h advancement of volumes by nurses without waiting for the rounding team to arrive (in babies with expected course). When I left that unit, I think we were advancing ELBWs ~24mL/kg/d after a few days of trophic feeds, but I heard through the grape vine that they either slowed that down for all ELBWs or subdivided the ELBWs around 600-700g and slowed down just the absolute smallest babies, but either way, she would have the most recent information. Outcomes showing improvements in enteral nutrition without increased NEC were presented at PAS last year.
  19. Of course! I have attached a publication of the work done at Southampton, which includes the nutritional assessment tool- I do not think there is anything there that would be too surprising, but it does mean that our late preterm/term infants do not get stuck on the same feed increases as ELBW, or really slow establishment of feeds. The nurses use this tool on Monday night shifts, ready for our nutrition ward round on Tuesday mornings. This specialist ward round comprises of Consultants, Neonatal pharmacist, Dietitian and surgical representatives. Hope it is helpful. 🙂 My question back to the group: How do people feed babies (or not!) with HIE undergoing Therapeutic Hypothermia.......??? Johnson_et_al-2015-nutritional screening tool.pdf
  20. @Vicki Payne would you be able to share your screening tool? Currently our protocol is to start out with any available colostrum. The problem is we don't deliver babies currently at this hospital so we rely on the transport team to bring us colostrum to start feeds with and that rarely happens (too busy with infant stabilization, outside hospital hasn't started mom pumping yet, indifferent attitude, etc.). We will start delivering at the end of the year and should see a huge increase in available colostrum for first feeds. If colostrum is not available and the mother has consented, then we start feeds with donor milk. We do advance at 10-20 mL/kg/day currently, but we're looking at new evidence and current practices at other facilities to see if we need to change our guidelines. I was intrigued by this article (https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD001241.pub7/full) that discussed faster enteral feeding volumes possibly preventing NEC in the ELBW population. Since I'm on the ELBW committee and haven't worked in a NICU that followed those guidelines I thought I'd reach out to see what everyone's thoughts were.
  21. Stefan Johansson

    99nicu Meetup 2019

    Share photos from the Copenhagen Meetup here!
  22. Hi, In the hospitals I worked in Austria, the rule was to increase by 10-20ml/kg/d and start on first day. If Colostrum is available this is fed as well. We start with enteral feeds right away on the first day. We give 2-3 hourly feeds. @Vicky Payne who is high/medium/low risk according to your tool?
  23. Hello everyone, I would like to know what you think of this case a patient with meconium aspiration syndrome, which developed pulmonary hypertension. It is found in high frequency with a draguer v500. 4000g weight with the following setting, 6hz 16 map 80fio2 deltap 50, dco2 800, with good oxygenation but persistence of hypercapnia. what allowed me to download fio2 and map but not the rest. What strategy would you use? the last eab the co2 was 78, this ventilates with a volume of 3kg and by the weight the dco2 of 800 is fine, Question until value would rise the parameters and how they would change for better ventilation
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  • Latest Posts

    • A first look at the programme for the European Neonatal Ethics Conference 2019 Final Programme.pdf Final Programme.docx
    • Thank you, Stefan, for reminding me of my one major criticism of the PINT trial: They did not include NEC (or at least surgical NEC) in their composite outcome.   As for why we, as a profession, continue to worry about TANEC, it is mostly recall bias (we all remember the case of NEC shortly after transfusion but we never stop to think of all the transfusions we have given without NEC appearing) I've often wondered if there isn't already enough data out there to answer these questions (or at least get a start).  Supervised learning techniques have advanced sufficient that if you were willing to invest in combining and curating multiple datasets of ELBWs you could probably train a binary classifier to predict risk of NEC with or without transfusion.
    • I really liked this blog post! I guess many of us have seen devastating cases of post-transfusion NEC that stay with us  and  therefore add "bias" to our judgements on this topic. There are still questions though right? Like the severity of the anaemia (how low do we leave the Hb and is that threshold different for certain babies?), the duration of anaemia (how long do we leave it before we transfuse?) and then,  if the mechanism is a re-perfusion injury post-transfusion, how do we prevent it?!
    • Check out this blog post by Keith Barrington whether transfusions trigger NEC. Or does anemia. https://neonatalresearch.org/2019/04/16/do-transfusions-trigger-nec-or-does-anemia/  I would say that there are enough clinical research data out there to say that there seems to be NO association. Just check out the PINT trial, the RCT comparing a liberal vs a restrictive Hb level for transfusion in preterm infants. If anything, the more liberally transfused group of infant had less NEC. And read this paper by Patel et al that nicely demonstrates that there seems to be confounding of indication coming into play, i.e. it is not the transfusion but the underlying anemia is the problem. Despite research findings, this question (whether transfusions "lead to" NEC) is still troubling us. Why so?
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