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  1. Yesterday
  2. Does anyone have a more recent article on acetate for acidosis in preterm neonates than the one by Olufunmi Peters and Steven Ryan 1997 (link below)? https://www.ncbi.nlm.nih.gov/pubmed/?term=acetate+for+acidosis+of+preterm+neonates Thanks
  3. A very nice article, thanks @Stefan Johansson
  4. Last week
  5. I had not even heard of the practice until I saw your post. I have worked in 5 large academic NICUs around the US without encountering this.
  6. Can a chest x-ray predict the future?

    If you work in Neonatology then chances are you have ordered or assisted with obtaining many chest x-rays in your time. If you look at home many chest x-rays some of our patients get, especially the ones who are with us the longest it can be in the hundreds. I am happy to say the tide though is changing as we move more and more to using other imaging modalities such as ultrasound to replace some instances in which we would have ordered a chest x-ray. This has been covered before on this site a few times; see Point of Care Ultrasound in the NICU, Reducing Radiation Exposure in Neonates: Replacing Radiographs With Bedside Ultrasound. and Point of Care Ultrasound: Changing Practice For The Better in NICU.This post though is about something altogether different. If you do a test then know what you will do with the result before you order it. If there is one thing I tend to harp on with students it is to think about every test you do before you order it. If the result is positive how will this help you and if negative what does it tell you as well. In essence the question is how will this change your current management. If you really can’t think of a good answer to that question then perhaps you should spare the infant the poke or radiation exposure depending on what is being investigated. When it comes to the baby born before 30 weeks these infants are the ones with the highest risk of developing chronic lung disease. So many x-rays are done through their course in hospital but usually in response to an event such as an increase in oxygen requirements or a new tube with a position that needs to be identified. This is all reactionary but what if you could do one x-ray and take action based on the result in a prospective fashion? What an x-ray at 7 days may tell you How many times have you caught yourself looking at an x-ray and saying out loud “looks like evolving chronic lung disease”. It turns out that Kim et al in their publication Interstitial pneumonia pattern on day 7 chest radiograph predicts bronchopulmonary dysplasia in preterm infants.believe that we can maybe do something proactively with such information. In this study they looked retrospectively at 336 preterm infants weighing less than 1500g and less than 32 weeks at birth. Armed with the knowledge that many infants who have an early abnormal x-ray early in life who go on to develop BPD, this group decided to test the hypothesis that an x-ray demonstrating a pneumonia like pattern at day 7 of life predicts development of BPD. The patterns they were looking at are demonstrated in this figure from the paper. Essentially what the authors noted was that having the worst pattern of the lot predicted the development of later BPD. The odds ratio was 4.0 with a confidence interval of 1.1 – 14.4 for this marker of BPD. Moreover, birthweight below 1000g, gestational age < 28 weeks and need for invasive ventilation at 7 days were also linked to the development of the interstitial pneumonia pattern. What do we do with such information? I suppose the paper tells us something that we have really already known for awhile. Bad lungs early on predict bad lungs at a later date and in particular at 36 weeks giving a diagnosis of BPD. What this study adds if anything is that one can tell quite early whether they are destined to develop this condition or not. The issue then is what to do with such information. The authors suggest that by knowing the x-ray findings this early we can do something about it to perhaps modify the course. What exactly is that though? I guess it is possible that we can use steroids postnatally in this cohort and target such infants as this. I am not sure how far ahead this would get us though as if I had to guess I would say that these are the same infants that more often than not are current recipients of dexamethasone. Would another dose of surfactant help? The evidence for late surfactant isn’t so hot itself so that isn’t likely to offer much in the way of benefit either. In the end the truth is I am not sure if knowing concretely that a patient will develop BPD really offers much in the way of options to modify the outcome at this point. Having said that the future may well bring the use of stem cells for the treatment of BPD and that is where I think such information might truly be helpful. Perhaps a screening x-ray at 7 days might help us choose in the future which babies should receive stem cell therapy (should it be proven to work) and which should not. I am proud to say I had a chance to work with a pioneer in this field of research who may one day cure BPD. Dr. Thebaud has written many papers of the subject and if you are looking for recent review here is one Stem cell biology and regenerative medicine for neonatal lung diseases.Do I think that this one paper is going to help us eradicate BPD? I do not but one day this strategy in combination with work such as Dr. Thebaud is doing may lead us to talk about BPD at some point using phrases like “remember when we used to see bad BPD”. One can only hope.
  7. Nitric Oxide in CDH

    Check this case-report: Moscatelli A, Pezzato S, Lista G, et al. Venovenous ECMO for Congenital Diaphragmatic Hernia: Role of Ductal Patency and Lung Recruitment. Pediatrics. 2016;138(5):e20161034 http://pediatrics.aappublications.org/content/138/5/e20161034
  8. Earlier
  9. pulseoximeter

    1. I remember that BMJ had a Christmas Appeal (for donations) about this device: http://www.lifebox.org/what-we-do/pulse-oximetry/ 2. I pass on this question... I read here http://www.lifebox.org/purchase-oximeter/ that the probe is from 3 months... but I suggest you email and ask specifically about neonatal use
  10. Nitric Oxide in CDH

    @spartacus007 the epoprostenol dose (in this paper: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3342750/) is: We have used the intermittent dose of 50 ng/kg (typically in term born infants on CPAP, with PPHN, and FiO2 ~0.9-1.0)
  11. Nitric Oxide in CDH

    Thanks guys we are already on Noradrenaline infusion and minimal ventilation with good CO2 clearance. Have you got a dose for inhaled epoprostenol Alok Also on Milrinone
  12. Nitric Oxide in CDH

    Good work @spartacus007, would you be kind enough to share with us the X-ray finding before surgery? Was the hypoplastic lung apical? or hilar or you couldn't identify it? Would you share the current BP and ECHO results? Failure or difficult weaning of inhaled NO for treating pulmonary hypertension in hypoplastic lungs in CDH and preterms is not uncommon . Concerning your presented case, In our NICU settings we would prefer using HFO using MAPs 2~3 higher than your MAP on conventional (Go slowly on the increase in MAP increase by 1). We would prefer the HFO not to injure the hyoplastic lung and to recruit the lung volume to improve oxygenation and ventilation. Continue to increase your MAP to lower the FIO2 to below or =30%, but be careful not to over inflate the lungs which would be seen by rebound increase of FIO2 needs during your gradual increase in MAP or by X-ray seeing the size of the heart and level of the diaphragm. In addition, in our NICUs setting for PPHN due to CDH we would start Dopamine (1st increase SVR ) and according to the ECHO findings on TR and direction of flow through the PDA we would start NO at 20 mpp (2nd) if TR is still persist. BPs, follow up ECHO heart to see the effect on TR + FIO2 needs would be our guides. If still PH persist, we would add Milrinone (3rd). Sildenafil is used in our setting to wean off NO or if the above 3 medications were not controlling the PH. In your current setting, still FIO2 is 50% , Still needs to go down on the FIO2 before withdrawing your NO. I would work on recurring the lungs first before weaning NO totally ( as presented above). Hoping our settings could help you with your patient. Good luck.
  13. pulseoximeter

    q1.can anybody suggest a good neonatal fingertip pulseoximeter or any lowcost pulseoximter working well for neonates for outpatient and postnatal ward use ? q2.what is the difficulty in making a fingertip pulseox for neonates when pediatric models are available ?any body know technical details,mechanism of finger pulseox/ links ?
  14. Feeding stable infant with right-sided CDH

    @tarekwow! It's cool! Thanks!
  15. Feeding stable infant with right-sided CDH

    Diaphragmatic disease usually manifests as elevation at chest radiography. Functional imaging with fluoroscopy (or ultrasonography or magnetic resonance imaging) is a simple and effective method of diagnosing diaphragmatic dysfunction, which can be classified as paralysis, weakness, or eventration. Diaphragmatic paralysis is indicated by absence of orthograde excursion on quiet and deep breathing, with paradoxical motion on sniffing. Diaphragmatic weakness is indicated by reduced or delayed orthograde excursion on deep breathing, with or without paradoxical motion on sniffing. Eventration is congenital thinning of a segment of diaphragmatic muscle and manifests as focal weakness. see the video E51_DC1_Movie4.mp4
  16. Feeding stable infant with right-sided CDH

    @tarek could you please specify the method more extensively? Thanks
  17. Nitric Oxide in CDH

    We have also had some success in this difficult scenario with nebulised prostacycline as an adjunct therapy to sildenafil. Has to be done two hourly...but has done the trick!
  18. Feeding stable infant with right-sided CDH

    @Andrej Vitushka There is By flouroscopy
  19. Feeding stable infant with right-sided CDH

    @tarekI am also think that is diaphragmatic eventration. But I know no way to prove it without operation 😊. Thanks for suggestions.
  20. Feeding stable infant with right-sided CDH

    @yalsaba @tarek very good point!
  21. Nitric Oxide in CDH

    @spartacus007 do you have reason to believe that there is a more severely growth restricted lung? Maybe a trial of inhaled epoprostenol? We use it infrequently (as we do not have NO in our level-2 unit) and sometimes with (surprisingly) good effect. https://www.ncbi.nlm.nih.gov/pubmed/22558521
  22. Feeding stable infant with right-sided CDH

    I think this isveventration of the diaphragm and not diaphragmatic hernia There is no problem to start feeding as we can see all the gut below the diaphragm If you are not going to operate now and patient RR is showing tachypnea start with OGT according feeding protocols regarding his weight If he is tolerating this eventration and not tachypnic start oral feeding if his wt> 1.5 kg and increase gradually Dig for the history as it may be traumatic delivery Check his moro reflex nicely to r/o Erb's
  23. Nitric Oxide in CDH

    What about his ECHO finding still have severe PHTN or improving from last ECHO If he is improving wait and see continue your weaning trials X ray chest is there is improvement in the hypoplastic side take care of sildenafil as some times causing lung collapse Just be patient
  24. Feeding stable infant with right-sided CDH

    Are you sure it is CDH OR diaphragmatic eventration. Differentiation is not easy ???
  25. Nitric Oxide in CDH

    Have you tried Milrinona?
  26. Nitric Oxide in CDH

    I have a a 30 day of neonate with CDH. never been extubated. Got him down to 50% and in 0.5-1ppm of Nitric Oxide. Have tried weaning him slowly of the NO on multiple occasions. Always go into 90% TO 100% Fio2. Already on maximum doses of Sildenafil. Not oedematous on PCAC 20/5 with good CO2 clearance. I cannot get the final bit of NO off. Any strategies from the forum would be greatly appreciated. PS Operated not paralysed synchronising well good drive
  27. Feeding stable infant with right-sided CDH

    OK, @Stefan Johansson. I've got the point. Thank a lot. Patient now is in the surgical center preparing for the operation.
  28. Feeding stable infant with right-sided CDH

    If you are close to the surgical unit (like same building), I would not necessarily do it. Especially if you know only the liver is in the thorax. If you need to go on the road (transportation), I would prefer intubation and mech vent regardless, to secure the airway, just in case. Probably they will operate soon after arrival anyway, so time on ventilator is not so much a critical factor.
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