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Showing content with the highest reputation since 11/17/2018 in all areas

  1. 3 points
    Hello 99ers, how is your experiance with iNO via nCPAP in premies? Do you use it at your ward? We got some good and bad experiances at our Department and i would like some unbiased experiances/opinions from your side before i tell our stories 😀 Best, Lukas
  2. 2 points
    Look around an NICU and you will see many infants living in incubators. All will eventually graduate to a bassinet or crib but the question always is when should that happen? The decision is usually left to nursing but I find myself often asking if a baby can be taken out. My motivation is fairly simple. Parents can more easily see and interact with their baby when they are out of the incubator. Removing the sense of “don’t touch” that exists for babies in the incubators might have the psychological benefit of encouraging more breastfeeding and kangaroo care. Both good things. Making the leap For ELBW and VLBW infants humidity is required then of course they need this climate controlled environment. Typically once this is no longer needed units will generally try infants out of the incubator when the temperature in the “house” is reduced to 28 degrees. Still though, it is not uncommon to hear that an infant is “too small”. Where is the threshold though that defines being too small? Past research studies have looked at two points of 1600 vs 1800g for the smallest of infants. One of these studies was a Cochrane review by New K, Flenady V, Davies MW. Transfer of preterm infants for incubator to open cot at lower versus higher body weight. Cochrane Database Syst Rev 2011;(9). This concluded that early transition was safe for former ELBWs at the 1600g weight cut off. What about the majority of our babies? While the ELBW group takes up a considerable amount of energy and resources the later preterm infants from 29 to 33 6/7 weeks are a much larger group of babies. How safe is this transition for this group at these weights? Shankaran et al from the NICHD published an RCT on this topic recently; Weaning of Moderately Preterm Infants from the Incubator to the Crib: A Randomized Clinical Trial. The study enrolled Infants in this gestational age range with a birth weight <1600g were randomly assigned to a weaning weight of 1600 or 1800 g. Within 60 to 100 g of weaning weight, the incubator temperature was decreased by 1.0°C to 1.5°C every 24 hours until 28.0°C. Weaning to the crib occurred when axillary temperatures were maintained 36.5°C to 37.4°C for 8 to 12 hours. Clothing and bedcoverings were standardized. The primary outcome was LOS from birth to discharge. What did they find? A total of 366 babies were enrolled (187 at 1600g and 179 at 1800g. Baseline characteristics of the two groups revealed no statistical differences. Mean LOPS was a median of 43 days in the lower and 41 days in the higher weight group (P = .12). After transition to a crib weight gain was better in the lower weight group, 13.7 g/kg/day vs 12.8 g/kg/ day (P = .005). Tracking of adverse events such as the incidence of severe hypothermia did not differ between groups. The only real significant difference was a better likelihood of weaning from the incubator in the higher group at 98% success vs 92% on the first attempt. Putting. That in perspective though, a 92% success rate by my standards is high enough to make an attempt worthwhile! Concluding thoughts The authors have essentially shown that whether you wean at the higher or lower weight threshold your chances of success are pretty much the same. Curiously, weight gain after weaning was improved which seems counter intuitive. I would have thought that these infants would have to work extra hard metabolically to maintain their temperature and have a lower weight gain but that was not the case. Interestingly, this finding has been shown in another study as well; New K, Flint A, Bogossian F, East C, Davies MW. Transferring preterm infants from incubators to open cots at 1600 g: a multicentre randomised controlled trial. Arch Dis Child Fetal Neonatal Ed 2012;97:F88-92. Metabolic rate has been shown to increase in these infants but skin fold thickness has been shown to increase as well in infants moved to a crib. How these two things go together is a little beyond me as I would have thought that as metabolic rate increases storage of tissue would slow. Not apparently the case but perhaps just another example of the bodies ability to overcome challenges when put in difficult situations. A case maybe of “what doesn’t kill you makes you stronger?” The authors do point out that the intervention was unmasked but the standardization of weaning procedure and garments used in the cribs should have overcome that. There were 36% of parents who did not consent to the study so their inclusion could have swayed the results perhaps but the sample size here was large despite that. That the final results agree with findings in ELBW infants suggests that the results are plausible. What I think this study does though is tell us overall that weaning at a smaller weight is at least alright to try once one is at minimal settings in an incubator. Will this change your units practice? It is something that at least merits discussion.
  3. 2 points
    For infants with sepsis/ septic shock due to their third spacing secondary to capillary leaks plus they require multiple fluids blouses/ colloids etc, we use weight prior to sepsis call it as dry weight till he or she is back to dry weight. If the kid is still puffy for few wks or month, we take 25th percentile for that age and calculate all fluids based on it. I hope it helps Naveed
  4. 2 points
    Hi, can anyone help me with a topic that I can't found and it's about " Neonatal Cerebral Depression". Already all I know about the theme is when the neonatal asphyxia criteria are not well established, in a patient with low apgar and border gasometric criteria. Regards. Edgar Samuel Aguilar-Figueroa, Resident of Pediatric's: Second Year. Tacubaya's Pediatrics Hospital. Mexico City.
  5. 2 points
    Yes, we use it.. BiPAP initial setting peep 5, pip 8 above peep, T high 1 sec and frequency is 20 - 30 Sent from my MHA-L29 using Tapatalk
  6. 1 point
    neonatologa of San Luis PotosÍ MÉxico, we have a thesis about the weight to which we can thermoregulate to the low weight RN we compared 1500g vs 1600g and we did not find differences between the two groups but if we observe that there is a decrease of days stay when they are put to thermoregulatory early. I will publish it soon Dra Carolina Villegas Alvarez
  7. 1 point
    Hi Everybody, Greetings from Canada I have a quick question, in case of mom presented with severe abruption placenta, can the baby present with severe anemia? will you arrange O-ve blood ahead before delivery or standby? Thnaks
  8. 1 point
    Can anyone share his experience in using iNO in PT with Pulmonary hypertension in BPD Sent from my MHA-L29 using Tapatalk
  9. 1 point
    According to our (Dräger) experience weaning from the incubator varies a lot. There are many different weaning protocols around. In order to wean babies faster from the incubator a new automatic Weaning Mode has been developed for the Babyleo IncuWarmer. The Weaning Mode is designed to support different weaning strategies. It reduces the air temperature in controlled steps and intervals while monitoring the skin temperature to automatically wean the baby off the incubator.
  10. 1 point
    We are now moving to a dedicated email service for our newsletter. From now on, we will use Sendinblue. With this professional provider of email services, including dedicated IP's, we will be more certain that members actually recieve our emails Given that our terms of use also includes that members need to have a valid email address, we will also be clearing the members' database from those with invalid email addresses. If you want to quit your email subscription, there will be bullet proof link in every email. If you also want to close your membership, you can also email info@99nicu.org and we'll erase your membership data promptly
  11. 1 point
    We used it in crisis during my fellowship with the goal, obviously, of transitioning to some combination of sildenafil, trepostinil, bosentan etc. Was there a specific aspect of therapy you had questions on? My experience with using iNO in this circumstance is that many, if not most of the 'bad BPD' we saw, the clinical manifestations of pulmonary hypertension were more helped by aggressive respiratory support as opposed to pulmonary vasodilator therapy. We would get many patients as transfers from level IIIs to our BPD program at the level IV ICU and these babies would be been on non-invasive support for very long periods of time and, in retrospect they had been retaining CO2 and were on far too much FiO2. These babies ended up in pulmonary hypertensive crisis around transport and needed iNO for a period, but it wasn't the iNO that 'fixed' things, it was choosing an appropriate ventilatory strategy with things like much higher PEEP, including possible use of peep titration during bronchoscopy, transitioning to a higher tidal volume and lower rate strategy (very different strategies designed to prevent BPD and much more like what our colleagues in PICU are used to doing). Steve Atman gave an excellent talk on this point at PAS a couple of years ago and has published quite a bit in this area.
  12. 1 point
    The European Neonatal Ethics Conference is one of the premier events discussing issues involving ethical care around a variety of aspects in neonatal care. It is held every 3 years and is being held in Southampton United Kingdom this year. Besides addressing a number of different topics including issues of neonatal palliative care, organ donation and extremes of viability it is opportunity to share ethical practice across Europe. Venue -St Mary's Stadium Southampton UK Dates 14th & 15th November 2019 Initial Flyer Call for Abstracts-We are calling for abstracts for oral presentations, poster presentations, debates and round table discussions. More details are available here Website-http://www.wonepedu.com/NeoEthics-Conference.html Video-
  13. 1 point
    I have no personal experience. In very severe cases of BPD we sometimes try sildenafil and/or inhal iloprost, assessing pulm pressure before/after with echo.
  14. 1 point
    This is an interesting dialogue. I just had a long disuccussion about fluid management from the delivery room with our neonatal response team nurses. They see quite a bit of variability from our physicians. When we talk about fluids on the first day, we are usually thinking of so much more than just the dextrose/ nutrition containing fluids. We have to consider the "to keep open" fluids running in additional lumens of our UVC and UAC lines. Premature babies are often on antibiotics the first 2 days. Some get saline boluses or blood products. It is very easy to give 20-40mL/kg/d of fluid above the baseline nutrition containing fluid before you even realize it. The 2014 cochrane review of fluid restriction in preterm infants (https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD000503.pub3/full) includes only 5 trials done in 1980-2000. The fluid restricted arm in the individual studies ranged from 50mL/kg/d to 120mL/kg/d. "Fluid restriction" had more PDAs close and less NEC. The incidence of BPD, IVH, and death were in the right direction (favoring fluid restriction) but not significant. Trying to tie all these factors together and deliver an adequate GIR, I start with D10 fluid at 65mL/kg/d. I presume that flushes and medications will add an additional volume that will quickly put my total fluids in the range of 80 - 110 mL/kg/d, which I think is acceptable on the first day. If I have a low glucose, I first increase GIR by going up on the D10 to 80mL/kg/d, but thereafter I try to concentrate the dextrose containing fluids to deliver more GIR over increaseing the rate of administration. In subsequent days I use weight and sodium values to guide increasing total fluid targets. For almost all circumstances i use birthweight for calculations and continue to use it until the baby is back above birthweight. If the baby has edema and is above birthweight in the first week I stick with birthweight until the edema is resolved. I'm interested in others initial fluid strategies when leaving the delivery room. Where do you start - 60, 80, or more? Do you use D10 or D5 or something else? Thanks in advance for the replies.
  15. 1 point
    It works very well. We extubated two patients against CPAP under ongoing iNO therapy. Both patients did fine. CPAP and iNO is probably no option in a severe respiratory failure, but ongoing iNO therapy shouldn't be a reason for no extubation. I'm very sensitive to iNO exposure, so I can tell iNO on CPAP with less than 10 ppm are possible, but keep the windows open and the flow as low as possible.
  16. 1 point
    This is what we do here in Canada as mentioned above by nashwa. There are no fixed numbers in short. naveed
  17. 1 point
    For maintainace fluid in FT we start on 60 ml/kg/d and according to weight measures, s. Na , UOP... We calculate the coming days. In PT babies we start on 80 ml /kg/d, in ELBW we calculate on 90 and we measure wt, UOP, s. Na every 12hrs in acute stage till stabilized(if s. Na is high, wt loss... we increase IVF) In FT we calculate fluid on BW till first 7 days, in PT till 10 days. Sent from my MHA-L29 using Tapatalk
  18. 1 point
    The placental circulation brings into close relationship 2 curculation systems: the maternal and the fetal in severe abruptio the mother will present with shock and fetus may die detection of fetal blood in a maternal bleeding is worrisome The clinical manifestations and prognosis depends on the amount of fetal blood and the rapidity with which it occurs see the attached study 25-30.pdf
  19. 1 point
    If you from the history that there is antepartum hemorrhage and you have the time to arrange O -ve PRBCs It will be more superior than NS If the baby deliverd and resuscitation was required and O- ve blood not there you will give 10 ml/ kg NS over 5-10 minutes In side nicu after stabilization of the baby you can arrange for cross matched PRBCs if the baby us really anaemic
  20. 1 point
    As you have heard, our 3rd conference aka "99nicu Meetup" and "Future of Neonatal Care", will take place 7-10 April 2019, at Scandic Sluseholmen in Copenhagen, Denmark. We are very glad to open the registration today! Given that we already have 100+ pre-registrations from 30+ countries, we recommend you to sign today! From the pre-registrations, we also know that workshops will be popular. As workshops have a limited number of places, you should register ASAP if you plan to attend a workshop. Click here to register! Click here to download the program folder! If you have any questions about the registration, please email reg@meetingplanners.dk See you in Copenhagen!
  21. 1 point
    I've only rarely used that particular term/code and then in the context Stefan mentioned. If a patient is truly encephelopathic without obvious antecedent asphyxial event, though, I will code neonatal encephalopathy P91.819. My one comment if you're trying to learn about this patient population is that, at least where I did my fellowship, maternal SSRI exposure seemed to be significantly over-represented in this population and I can recall cooling several babies who in retrospect probably had SSRI exposure not hypoxic insult.
  22. 1 point
    Dear Edgar, we rarely use that diagnosis (ICD-10, P91.4) , but do it sometimes if a baby has had somewhat low apgar (like 6-7) and has been admitted due to some irritability. Like an "asphyxia light" diagnosis. However, I would regard it the diagnosis as a bit subjective. Am not aware of any formal definition of "Neonatal Cerebral Depression".
  23. 1 point
    @spartacus007: Sorry for slow response. Yes we would use AC and avoid heavy sedation. Only use paralysis if despite good NG tube placement we are unable to keep gut decompressed, meaning we use it rarely. Evidence-free zone, for the most part, but muscle relaxation has many downsides and I am a believer in making the baby breathe as much as they can, which minimizes intrathoracic pressure and adverse hemodynamic consequences of PPV. As for SPO2 target, the goal is NOT 100%. Gentle support with minimal PIP needed to get the heart rate up and SPO2 into the low 90s. Generally start with FiO2 around 0.6 and wean if SPO2 is >92-93%. @bimalc : We do not use cuffed tubes, though it would be appropriate if you did not have a ventilator that has excellent leak compensation capability, like the Draeger VN 500, which can accurately compensate for leak of up to 60-70%. If you have a leak anywhere near that large, the baby need a larger tube. @tarek: I love the HFOV + VG. It works very nicely, but in the USA, the HFOV option is not yet approved by the FDA, so I was only able to use it in the context of our preeemie study that will hopefully lead to approval. Given that CO2 removal with HFOV is proportional to F x VT squared, the ability to maintain a constant VT in the face of changing lung compliance is particularly attractive. In my 27 babies we used it on it worked beautifully! Cheers, Martin
  24. 1 point
    @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.
  25. 1 point
    Here are some articles which may help to decide initial settings for duopap on Fabian ventilator. Duopap in vlbw RDS china study 2014.pdf Duopap review article.pdf
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