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Showing content with the highest reputation since 05/25/2019 in all areas

  1. 3 points
    We practise pre-med for INSURE (atropin+fentanyl+pento and some use celo) - my experience is good with regards to cardiovasc and respiratory stability. But as @Nathan Sundgren says, we don't premed if we need to do INSURE right after delivery. Around here, the INSURE procedure also means pre-med, while LISA/MIST is the term used when surfactant is given without pre-med. Originally, when LISA/MIST was first done and studied by Angela Kribs and co-workers (https://www.ncbi.nlm.nih.gov/pubmed/17359406; https://www.ncbi.nlm.nih.gov/pubmed/18298776; https://www.ncbi.nlm.nih.gov/pubmed/18298776) I think their idea was to minimize any drug-related impact on the breathing drive. So they tested with no drugs and it worked well for them. I know many share this experience, that surfactant can be instilled without any pre-med. I personally feel concerned about the laryngoscopy as such, I believe atropine and analgesics would still have a place also in LISA/MIST. And for younger colleagues less experienced with laryngoscopy and intubation, I think the procedure may also be more uncomfortable for infants not given analgesia.
  2. 3 points
    If you are to read one paper on neonatal ethics this year, I'd argue that this is the one. Late last year, John Lantos, pediatrician and a leading medical ethicist, published a review in NEJM on the ethics around decision-making in the NICU. The paper is not open-access... but you can surely get it from within your hospital intranet or your university/hospital library. We have a fantastic toolbox in the NICU. We can provide live-saving treatments and support. Most newborns in the NICU survive to good long-term health. However, we also operate in a high-risk environment where some infant may suffer, some infants will die, and some infants will survive with difficult sequele. Which raises the question, by staff and by parents, what is the "right" thing to do in complex situations. When withholding and withdrawing life-sustaining therapies becomes a option to decide upon. How could we navigate in this landscape? IMHO, the review by Lantos is a good starting point on how to form a local practise. Lantos shares his reasoning about we cannot "solve" these discussion with "information" as such. Despite how hard we try, data alone does not lead the whole way. Outcomes is hard to measure, they change over time and we all percieve risks differently. Therefore, information is difficult to standardize. Furthermore, those of us sharing the information will filter our presentation through our subjective selves, coping with opinions, experiences and our expertise in different ways. The better alternative around ethical questions is shared decision-making. Two central quotes of the review is that and that Certainly, the future of neonatal care will bring more ethical questions to us. Refined prenatal diagnostics, the down-shifting boundary of viability and new treatment technologies in the future (like the artificial placenta) will impact how we think about fetal life and postnatal life, what is the "periviable grey zone" and what our fantastic toolbox can do. While improving our skills, from a medical/technical viewpoint, we also need to improve how we cope with the ethics around decision-making processes. Besides reading the review by John Lantos, I can recommend you to see this lecture from theh #99nicuMeetup in Copenhagen 2019, by Eduard Verhagen. (Feature Photo : Cropped photo by Liane Metzler on Unsplash)
  3. 2 points
    We usually don't use any sedation for LISA. If the baby is big and vigorous, I prepare some remyfentanyl and use it only if needed.
  4. 1 point
    We've been using remyfentanil previous to LISA, but we've experienced some undesirable side effects (apnea) needing naloxone to revert. Previously we used small doses of propofol, but it has been abandoned due to the concerns about its neurotoxicity...This was the last topic of discussion in the last session of Catalan Neonatal Studies Group...a lot of variability in practice, fears, lack of evidence and safety data... What about bolus of dexmedetomidine? Seems safe but still few studies..
  5. 1 point
    Just about all of our preterm infants born at <29 weeks start life out the same in terms of neurological injury. There are of course some infants who may have suffered ischemic injury in utero or an IVH but most are born with their story yet to be told. I think intuitively we have known for some time that the way we resuscitate matters. Establishing an FRC by inflating the lungs of these infants after delivery is a must but as the saying goes the devil is in the details. The Edmonton group led by Dr. Schmolzer has had several papers examined in these blogs and on this occasion I am reviewing an important paper that really is a follow-up study to a previous one looking at the impact of high tidal volume delivery after birth. I have written on this previous paper before in It's possibile! Resuscitation with volume ventilation after delivery. On this occasion the authors have published the following paper; Impact of delivered tidal volume on the occurrence of intraventricular haemorrhage in preterm infants during positive pressure ventilation in the delivery room.This observational study had a simple enough premise. Will the use of Vt > 6 mL/kg in infants given PPV for at least two minutes lead to worse rates of IVH? All infants were < 29 weeks and if they had chest compressions or epinephrine were excluded. All infants were treated equally in terms of delayed cord clamping and antenatal steroid provision. Ventilation was done with a t-piece resuscitator and Vt measured with an NM3 monitor connected to the face mask. First ultrasounds were done for all at 3 days of age. What did the authors find? One hundred and sixty five infants comprised this cohort. Overall, 124 (75%) infants were in the high volume group compared to 41 (25%) with a mean VT<6 mL/kg. Median Vt were 5.3 (4.6-5.7) ml/kg for the low group and 8.7(7.3-10.6) mL/kg which were significantly different. When looking at the rates of IVH and the severity of those affected the results are striking as shown in the table. Hydrocephalus, following IVH developed in 7/49 (14%) and 2/16 (13%) in the >6 mL/kg and <6 mL/kg VT groups. Looking at other factors that could affect the outcome of interest the authors noted the following physiologic findings. Oxygen saturations were lower in the low volume group at 6, 13 and 14 min after birth while tissue oxygenation as measured by NIRS was similarly lower at 7,8 and 25 min after birth (P<0.001). Conversely, heart rate was significantly lower in the VT>6 mL/kg group at 5, 20 and 25 min after birth (P<0.001). Fraction of inspired oxygen was similar in both groups within the first 30 min. Systolic, diastolic and mean blood pressure was similar between the groups. What these results say to me is that despite having lower oxygen saturations and cerebral oxygen saturation at various time points in the first 25 minutes of life the infants seem to be better off given that HR was lower in those given higher volumes despite similar FiO2. Rates of volume support after admission were slightly higher in the high volume group but inotrope usage appears to be not significantly different. Prophylactic indomethacin was used equally in the two cohorts. Thoughts for the future Once a preterm infant is admitted to the NICU we start volume targeted ventilation from the start. In the delivery room we may think that we do the same by putting such infants on a volume guarantee mode after intubation but the period prior to that is generally done with a bag and mask. Whether you use a t-piece resuscitator or an anesthesia bag or even a self inflating bag, you are using a pressure and hoping not to overdistend the alveoli. What I think this study demonstrates similar to the previous work by this group is that there is another way. If we are so concerned about volutrauma in the NICU then why should we feel any differently about the first few minutes of life. Impairment of venous return from the head is likely to account for a higher risk of IVH and while a larger study may be wished for, the results here are fairly dramatic. Turning the question around, one could ask if there is harm in using a volume targeted strategy in the delivery room? I think we would be hard pressed to say that keeping the volumes under 6 mL/kg is a bad idea. The challenge as I see it now is whether we rig up devices to accomplish this or do the large medical equipment providers develop an all in one system to accomplish this? I think the time has come to do so and will be first in line to try it out if there is a possibility to do a trial.
  6. 1 point
    Dear @Akash Sharma, thanks for posting about this! We spend much time on nutrition, but personally, I tend to feel confused on this higher level. Some infants grow well, while some infants grow poorly whatever we do... We use a computerized program (https://www.nutrium.se/) and make individual fortification to every preterm infant. Weights are plotted on a growth curve (starting at 24 wks) and we aim to achieve a "normal growth velocity". For SGA infants we tend to think about the patophysiology, if it is IUGR due to placental reasons (like pre-eclampsia), we think there is a potential for this baby to be AGA. So we expect catch-up growth and (if needed) try to promote that with fortifications. We don't use the term EUGR in our unit, but we strive to get all infant withn the "normal" weight range, for us that means that we want infants within +/- 2 SD on the growth chart. Coming to your question... we tend to use the growth-chart-definition of poor growth rather than body-composition analyses or clinical endpoints (which are also more like outcomes of growth)
  7. 1 point
  8. 1 point
    To my knowledge: around here, parental feedback is not collected in a structured way. However, we have a strategy for cross-checking with parents after arrival to us. Our experience is that it takes some time for parents to "overcome" a transfer, even when their infant is well and doing fine and transferred to a lower-level NICU.
  9. 1 point
    @Francesco Cardona thanks for sharing this! I I posted this URL on our FB page (https://www.facebook.com/99nicu) and that post has already been shared 60 times and reached 3000 people (new impact record I think!)
  10. 1 point
    First announcement of Recent advances in neonatal medicine IXth International symposium honoring prof. Richard B. Johnston, MD, Denver, US 26-28 April 2020, in Würzburg, Germany Find more information in the attached folder. First_Announcement_01.2020.pdf
  11. 1 point
    Dose & administration Prevention of iron deficiency: Preterm infants: 2-4 mg/kg/day of elemental iron in divided oral doses; initiate no later than 1 month of age and continued through at least 1 year of age, depending on nutritional context and other iron intake. Maximum of 15 mg/day. Term infants: 1 mg/kg/day of elemental iron orally; may not need to initiate until 4 months of age. Low birth weight infants (<2500 g): 2-3 mg/kg/day of elemental iron in divided oral doses during the first 6 months of life. Treatment of iron deficiency: 4-6 mg/kg/day of elemental iron in divided oral doses until serum markers of iron deficiency have normalized. Supplement during epoetin administration: 6 mg/kg/day of elemental iron in divided oral doses. Indications Prevention of iron deficiency. Treatment of iron deficiency. Contraindications and special considerations (incl incompatibilities) Oral products are available in many formulations- verify concentration and dose before use. Consider monitoring iron storage via serum ferritin levels, especially in infants who have received many blood transfusions. If the ferritin level is >350 microgram/L, halt iron supplementation until the level has decreased to <350 microgram/L. Hypersensitivity to iron or any component of the formulation. Hemolytic anemia. Adverse effects Common side effects include nausea, vomiting, constipation, upset stomach, and black stools. Iron toxicity may include an increase in free radical formation, thus increasing oxidative stress. Pharmacological aspects Iron is an essential part of the heme groups forming hemoglobin, the oxygen-binding metalloprotein of red blood cells. Onset of action for oral administration is about 5-10 days. Effects on hemoglobin may be seen in 2-4 weeks. Enteral absorption is about 30%. Iron is not actively excreted in the stool or urine, so virtually all absorbed iron remains in the body. References Baker RD, Greer FR, and Committee on Nutrition American Academy of Pediatrics, "Diagnosis and Prevention of Iron Deficiency and Iron-Deficiency Anemia in Infants and Young Children (0-3 Years of Age)," Pediatrics, 2010, 126(5):1040-50. PMID 20923825. Berglund S, Domellof M, “Meeting iron needs for infants and children,” Curr Opin Clin Nutr Metab Care, 2014, 17(3):267-72. PMID: 24535217. Meyer MP, Haworth C, Meyer JH, et al, "A Comparison of Oral and Intravenous Iron Supplementation in Preterm Infants Receiving Recombinant Erythropoietin," J Pediatr, 1996, 129(2):258-63. PMID 8765624. Rao R and Georgieff MK, "Iron Therapy for Preterm Infants," Clin Perinatol, 2009, 36(1):27-42. PMID 19161863. United Nations Children's Fund, United Nations University, World Health Organization. Iron deficiency anaemia assessment, prevention, and control. A guide for programme managers, 2001. Available from: http://www.who.int/nutrition/publications/en/ida_assessment_prevention_control.pdf?ua=1 Document version history Created 2017-01-14 / Maegan Wells
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