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  1. 3 points
    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
  2. 3 points
    Are you sure it is CDH OR diaphragmatic eventration. Differentiation is not easy ???
  3. 2 points
    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.
  4. 2 points
  5. 2 points
    @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
  6. 2 points
    OK, @Stefan Johansson. I've got the point. Thank a lot. Patient now is in the surgical center preparing for the operation.
  7. 2 points
    @Hamed, thanks a lot!. It is a tricky case. CDH wasn't detected prenatally. CPAP was started because of mild RDS and CDH on Xray was somewhat surprising. As the baby was doing well on CPAP we decided do not intubate. Feeding tube was corrected and now CPAP is withdrawn.
  8. 2 points
    @amirmasoud2012 well... not all photos/videos says more than 1000 words
  9. 2 points
    Excellent discussion. Yes here in Canada it is true what you said. It's unique that your unit start TFI at 50ml/kg but it depends on gestation and others factors. My question to you 1. how frequently you monitor electrolytes and suppose Na is 151, urea is 12 and Cr is 86, urine output is 6ml/kg/hr, there is metabolic acidosis and child is on 80 humidity, 2. how do you increase his fluids and which type of fluids you use to increase the TFI. 3. how much do you put Na in TPN considering you have to give acetate for acidosis. 4. Do you keep the TPN to run in at constant rate and Y in D5 to make up TFI? I am curious to know your unit practice. Thanks naveed
  10. 2 points
    Dear Drs, Are you aware of studies done by Christensen et al connecting IVH to blood products transfusion after birth, recommending giving PRBC if needed slowly. We are now giving for symptomatic anemia (hypotension+HTC<35%) after birth only 10cc\kg of PRBC over 3 hours (not evidence based practice)
  11. 2 points
    I have done 80/kg in the past; I think we agree on the importance of uop,etc. and adjusting fluids based on weight, output and labs. 50/kg just seems unlikely to be sufficient in my experience, but if there is international experience suggesting otherwise, I might need to reassess my practice
  12. 2 points
    BTW and slightly OT - a study on the usefulness of video-laryngoscopy: http://pediatrics.aappublications.org/content/136/5/912
  13. 1 point
    I visited Hot Topics last year and one of the best lectures (according to me!) was held by Judy Aschner, about the use of sodium bicarbonate being principally useless (and could even have adverse effects). Please click here to read an excellent review article on the topic by Aschner and Poland. Unfortunately only the abstact is available for free, but the article is worth to order! As many other units, we have a strong tradition to consider the use buffer, if pH is less than 7.25 and BE less than -5 (at least in in ELBW infants) The article by Aschner and Poland has been subjected to some debate in our units. The major argument in favour of buffer is that we do not use sodium bicarbonate but Tribonat, which is a combination of trometamol (THAM), bicarbonate och acetate. The theoretical idea behind Tribonat is to achieve intracellular (THAM), extracellular (bicarb & acetate). Personally, I have switched to a quite restrictive approach and rarely use buffer, but try to consider the etiology of the base deficit in the management of acid-base. What's your experience and view upon the use of buffer?!
  14. 1 point
    A very nice article, thanks @Stefan Johansson
  15. 1 point
    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
  16. 1 point
    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
  17. 1 point
    Dear colleagues, We have now 34 weeks girl with mild RDS and right-sided congenital diaphragmatic hernia. Her vitals is stable, RDS is managed well by nasal CPAP. There is a liver in right thorax proven by CT. The Xray is below. My question is should we feed this baby enterally and how? Many thanks.
  18. 1 point
    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
  19. 1 point
    @tarek could you please specify the method more extensively? Thanks
  20. 1 point
    @Andrej Vitushka There is By flouroscopy
  21. 1 point
    Have you tried Milrinona?
  22. 1 point
    Interesting case - I'd guess that "our" surgeons would opt for early repair also for a 34-weeker. What is the birth weight? We'd do the same as in @Hamed's unit, i.e. put on mechanical ventilation (until surgery is done) and feed post-surgically. @Andrej Vitushka hope this helps and that you did not unexpected suggestions Please share feedback how things develop
  23. 1 point
    Hi @Andrej Vitushka This is interesting, we usually avoid using CPAP in CDHto avoid dilatation of guts loops and further herniation with cardiovascular compromisation, however, this case seems to only have it`s liver herniation in the chest. I see the OG tube is somewhat in a high position in the lower 1/3 of the esophagus. Concerning feeding, in our setting, we start feeding after surgical repair of CDH and not before. However, this case`s X-ray seems like lt. sided diaphragmatic paralysis or paresis and is already on CPAP, thus I would start feeding if surgery is not expected within a few days
  24. 1 point
    I got this on my radar, through the Twitter feed from @EBNEO - whether surfactant could be administered as easy as an oropharyngeal squirt? Have look in the latest issue of @Acta Paediatrica here: http://onlinelibrary.wiley.com/doi/10.1111/apa.14060/full´ And, here's a video demo posted by the article authors:
  25. 1 point
    @rehman_naveed http://neonatal.cochrane.org/what-has-cochrane-neonatal-done-babies-download-site
  26. 1 point
    I would like to hear about "Evidence of evidence in NICU treatment and management" where are we heading, limited evidence for most of the NICU disease, all based on opinion based still in this century.
  27. 1 point
    Hi Hamed Thanks for the comments. Sorry I forgot to mention the gestation age but you assume it being 23 weeker, DOL 2-3 days. 1. We usually put 2mmol/kg Na in TPN and about 1mmol/kg baby get Na via UAC having heparin saline in 0.45% saline. we also give K as well in 1mmol/kg dose. so it is very challenging to split both Na and K between acetate and Phosphate as we have to give some phosphate to this preterm baby. 2. It is new to me that you in Japan give immunoglobulin's to newborn if their level is <100, and also you mentioned albumin which we never give in our setting here in Canada. 3. Also usual recomendations for humidity for <30wks is 65-70% but we go upto 85% if Na is high but never above 85% as it get showers in incubator and it will then make overhead phototherapy ineffective and also chest electrodes will not stick to baby chest plus sepsis risks etc. Yes I agree management is mostly similar between Canada, Egypt and Japan. we do also TnEcho at bedside occasionally. Hi Tarek thanks for your comments. it is interesting to see the above mentioned guidelines. I think @hamed explained much detail on this topic. to summarize it in 2 lines, start at 80-100ml/kg, high humidity, frequently checking electrolytes, put as much acetate in TPN as you can, increase fluids in 20ml/kg as Y in D5, monitor sugar and tailor your TFI and dextrose.
  28. 1 point
    @rehman_naveed Thanks for opening up a practical discussion. I am not sure if forgot to mention the GA and DOL in your example or you meant same as the above case. By the numbers, you have given this is not fitting a DOL0. I am not sure why in this example case the incubator`s humidity is only 80%? Usually, we start at 100% for ELGANs and go down slowly. If we consider this was a whatever DOL premature, with a high Na level, urine output is at a high level as you explained 6 ml/kg/h, normal Cr, high Urea most probably due to catabolic state (consider adjusting amino acids in TPN), Your answer in the clinical practice in Japan would be: Need to know: 1-The K level, because if you need to add acetate for acidosis you can put it in as K-acetate and not Na-acetate. 2- The blood pressures. Although is expected to be ok, due to your good urine output, unless your case is also hyperglycemic and thus polyuric. In that scenario you would consider the level of BS and if you would give insulin or not. 3- IVC diameter, SVC flow, a 4 chamber view to the cardiac filling, cardiac contractility (part of targeted ECHO done by neonates MDs and fellows). To estimate your circulatory volume. From the data collected above: * If circulatory volume (by ECHO) and BP is low (for example), increase the TFI with an additional 20 ml/kg , by Y in D5 and/or IVIG if the baby`s immunoglobulins level is below 100, to compensate for your additional 20 ml/kg/d increase TFI. If Na was not high could also give albumen. Restrict the Na given to lower limits of daily needs 2 mmol/kg/d, replace Na-acetate with K-acetate. *If volumes are good (detected as above by targeted ECHO), but BP is low: start an inotrope according to what your ECHO showed to select, ie Dopamine 5 microgram/kg/min, no need to increase the TFI as much as the case above. * Electrolytes are usually taken from of the bl gas which, if the Na was higher than 160, would then consider sending to hospital`s lab a sample to confirm. Another blood gas in 12hrs if ventilated, if not then with AM sampling Your answer in practice in NICU Canada or Egypt: Good urine output, increase TFI to 80 ml/kg/d by Y in D5%, restrict the Na given to lower limits 2 mmol/kg/d, replace the additional Na-acetate with K-acetate. Check BS and as above for hyperglycemia. If blood pressures are low, elevated Lac and prolonged CRT, give a bolus of 1/2 saline to D5% and Y in D5% to the TPN used to increase TFI by 10 ~20 ml/kg. Adjust TPN Na content at AM to 2 mmol/kg/d. BS as above. If still blood pressures are low considered starting dopamine. As for electrolytes chicking as above almost no difference, except in some units, you have to order the electrolytes results off the gas to get them, and can only use it to direct you to withdraw a sample to the hospital lab or not. I think in both ways of practice, the management could be somewhat similar in case of increase TFI, but what comes in different is that targeted ECHO here comes in as a decision-making tool for tailoring whether to start inotropes or give higher TFI volumes.
  29. 1 point
    Association for Paediatric Palliative Medicine (APPM) issues a Master Formulary on medications used for palliative care in pediatrics. In 2017, APPM issued the 4th edition, available as a PDF-download from this website. Although most drugs are used in paediatric care of children older than infants, there are several drugs and dosages suitable also for infants.
  30. 1 point
    Hi Francesco and Stefan, we are using a C-Mac laryngoscope. The smallest blade is 0. The company told us that a 00-blade is on the way ... but by now we haven't seen it. The view with the C-Mac is fantastic, so I hope that we could see the 00-blade soon. Greetings from Stockholm Dirk
  31. 1 point
    Thanks too much Naveed I was following what i will post now because this was very big dilemma and i find this helpful for me If you kindly read it and give me your valuable comments https://uichildrens.org/health-library/fluid-and-electrolyte-management-newborn
  32. 1 point
    @harnon are you referring to this paper: https://www.ncbi.nlm.nih.gov/pubmed/21166684
  33. 1 point
    Acta Paediatrica October 2017 We have highlighted some of October issue's articles and most of them you can access freely in the journal below. Helping Babies Breathe training can improve neonatal resuscitation Helping Babies Breathe (HBB) is a neonatal resuscitation programme that is designed to train health professionals in low-resource settings. A study by Amy Rule et al showed that 10 months after HBB training in a rural referral hospital in Kenya, the suspected hypoxic–ischaemic encephalopathy (SHIE) rate had decreased by 53% to 7.1/1000. However, the rates increased after the initial decline and investigations revealed that half of the midwives who received HBB training had been transferred. When the data were presented to healthcare administration personnel, this improved staff retention and the SHIE rate then decreased again. Christabel Enweronu-Laryea and Nicola Robertson comment on the study. Readers may also be interested in the editorial by Susan Niermeyer, who comments on Johan Wrammert et al’s paper on an HBB project in Nepal, which was published in a previous issue. Nipple temperature may help guide newborns to breastfeed Newborn babies instinctively have the ability to crawl to the breast when placed skin-to-skin on the mother's abdomen. A new Italian study by Vincenzo Zanardo et al indicates that a higher temperature around the mother’s nipple with respect to the surrounding breast skin may facilitate this process. The study conducted on 41 full-term infants and their mothers showed that a temperature gradient may support mother-infant thermal identification and communication in the breast crawl process. One breath of oxygen may shorten the return to spontaneous circulation Asphyxiated newborn infants should be resuscitated with air, but it has been unclear whether supplementary oxygen is needed when effective ventilation cannot be provided immediately during resuscitation. In this study, Rikard Linner et al found that one single breath of oxygen shortened the time to return of spontaneous circulation in asphyxiated newborn piglets. Small but critical amounts of oxygen was essential for sustained circulatory recovery in this experimental model of asphyxia. The clinical applicability of these findings should be further investigated, according to the accompanying editorial by Anne Lee Solevåg and Georg Schmölzer. Recorded maternal voices reduced pain in preterm infants undergoing heel lance procedures This study evaluated whether recorded maternal voices limited pain in preterm infants undergoing heel lance procedures. Gaetano Chirico et al enrolled 40 preterm infants at a gestational age of 26–36 weeks and randomised them to listen to, or not listen to, a recording of their mother’s voice during the procedure. Infants in the intervention group had significantly lower pain scores and fewer decreases in oxygen saturation, with no significant side effects. Readers may also be interested in the brief article by Ellyn Hamm et al, who report that a parent–infant music therapy intervention improved neurodevelopment after neonatal intensive care. Using a standardised protocol reduced hospitalisation for childhood immune thrombocytopenia Childhood immune thrombocytopenia (ITP) is an immune-mediated disorder, with a platelet count of less than 100 9 109/L an no underlying cause. Although current guidelines suggest that most patients are just observed, children still receive platelet-enhancing therapy because of concerns about complications related to bleeding. Roxane Labrosse et al report that introducing a standardised protocol with a step-down approach reduced hospitalisation and the length of prednisolone treatment in children with newly diagnosed ITP, without any increase in disease complications. Ljung comments on the findings. Severe postwar malnutrition did not have a negative impact on subsequent earnings and pensions Hermanussen et al explored whether German men born and raised shortly after World War Two, during severe and long-standing nationwide malnutrition, had lower earnings and subsequent pension payments. They found that being born in postwar Germany in 1945–1948 was only associated with a tiny impairment in work-related earnings, which was not visible in the at-riskof-poverty rates. The findings question previous statements associating early childhood malnutrition and lower lifetime earnings.
  34. 1 point
    @bimalc and @tarek Thank you both for your comments and sharing your experiences. I do understand your points and concerns. Our standard starting point for TFII is 50 ml/kg/d on day 0 for micro preemies, but we tailor the TFI for each case depending on mean arterial blood pressure, cardiac size on chest X-ray, ECHO heart findings, and urine output. Thus one preem may be receiving a TFI of 50 ml/kg/day on day 0 and another preem with the same GA and BW receiving a TFI of 80 ml/kg/d. Each case is different. In addition, our rate of increase is 10 ml/kg/d as a basic standard, but still, it could be higher depending on how the same factors mentioned above go In an NICU in Canada, the TFI was 60~80 ml/kg/d for micro preemies < 26 weeks GA, and 100 ml/kg/d for < 24 weeks GA, as a standard, and when these fluid volumes were not enough to maintain the BPs and there was poor peripheral perfusion indicated by high Lac and prolonged CRT, saline boluses were given and inotropes were considered. The daily rate of increase was as a standard 20 ml/kg, unless the prem was puffy or chest X-ray showed increased lung fluids, then daily increase in TFIs was decreased or skipped. I do not imply that one strategy is better than the other, however, tailoring the fluids and inotropes given per each preem`s condition for me sounds practical. We have a special session on tailoring IV fluids and inotropes for preterms next month in the 62nd annual conference of the Japanese society of neonatal health and development http://jsnhd62.umin.jp/en/abstract.html . This could be an important topic to be also discussed in next 99NICU meeting @Stefan Johansson
  35. 1 point
    @bimalc One of my friends in Minnesota i discussed this issue with her they are starting with 80 ml/kg and checking of sodium ,uop and adjust ivf accordingly so not all in US starting with 100 ml/kg And i am in favour of restricted intake initially and adiustement according UOP ,Na and Urea More fluids more IVH PDA and pulmonary hge So the most important is follow up and adjust accordingly allowing for physiological wt loss in the first 5 days
  36. 1 point
    @Hamed I am interested to hear your fluid management for micro preemies is quite different than practice in the US. I do not imply that one is superior to the other, but I must ask what difficulties (if any) you have in maintaining normal fluid electrolyte balance with only 50mL/kg/day of fluids in the smallest babies? In the two units I currently work in, such a baby would typically receive 100mL/kg/d on day 0 and increase 10-30mL/kg/d. My experience has been that even with humidified isolettes (or at least the ones I have used over the years) such babies can lose massive amounts of weight/water and become very hypernatremic if we are overly cautious with fluids early on.
  37. 1 point
    Thanks a lot @Hamed really its great help Thanks a lot @Stefan Johansson
  38. 1 point
    Came across this paper in @Acta Paediatrica about the Helping Babies Breathe (HBB) program in Kenya. 10 months post-training, there was a >50% reduction in the rate of hypoxic ischemic encephalopathy, from 1.6% to 0.7% of live-births. The mortality rates decreased in numbers from 0.4% to 0.2%, but this was not statistically significant. However, the study was not powered to find this difference. The paper is available in full-text here. And, related editorials are available here and here. Does anyone here have hands-on-experience from working with the HBB-program? Would be interesting to hear about it!
  39. 1 point
    @bimalc we had a LISA-like lecture this year but we may find a way with another perspective. Great talk by Kajsa Bohlin below BTW, you find it as the final lecture here: https://99nicu.org/meetup2017/ I think we should also have a session on ethics, would be fantastic to have Annie Janvier and/or Dominic Wilkinson to speak about the grey zone of viability. BTW, you can listen to Janvier in the ADC podcast.
  40. 1 point
    At last, all video recordings* of the Meetup lectures are now posted on Youtube! Sorry about the DIY quality Next year we hope to have budget for more professional recordings, but I hope that you will find the lectures good enough. If you value the videos as a good learning experience, please consider to make a small donation here. No matter how small, all donations are mostly welcome to help us fund IT-costs for the 99nicu web site. And here - the 99nicu Meetup playlist! Click on the symbol in the upper left corner to switch/change to another video. *not all videos are included as not the recording failed in a few instances
  41. 1 point
    Orphanet is a web portal for rare diseases and orphan drugs. Orphanet was established in France in 1997 at the advent of the internet in order to gather scarce knowledge on rare diseases so as to improve the diagnosis, care and treatment of patients with rare diseases. This initiative became a European endeavour from 2000, supported by grants from the European Commission: Orphanet has gradually grown to a Consortium of 40 countries, within Europe and across the globe. Over the past 20 years, Orphanet has become the reference source of information on rare diseases. As such, Orphanet is committed to meeting new challenges arise from a rapidly evolving political, scientific, and informatics landscape. In particular, it is crucial to help all audiences access quality information amongst the plethora of information available online, to provide the means to identify rare disease patients and to contribute to generating knowledge by producing massive, computable, re-usable scientific data.
  42. 1 point
    The database of rare diseases, like congenital syndromes, by the National Board of Health, Sweden. the database is in English
  43. 1 point
    Evidence-based protocols and reviews by the Cochrane Collaboration
  44. 1 point
    Whatever side we take...the most important point to remember is that ventilation should be excellent when using Bicarbonate...if ventilation is not optimal...then the CO2 released from Bicarb in vivo goes nowhere and paradoxically leads to increased acidosis !!!
  45. 1 point
    Interesting point Agnieszka. I have heard this argument as well, but do you know of any evidence for this hypothesis? Still I find it surprising with all the lack of evidence but possibly wide spread use, that no one has come up with a study so far (neither in adults or newborn..) This is the only study I found (in adults), but I cant see if the study really ever started: http://clinicaltrials.gov/ct2/show/study/NCT01377337
  46. 1 point
    well, We sort of agree about not to use it in the Delivery room. Instead of finding a very convincing answer regarding the soidium bicarb, and after reading all the posts, I find myself facing more questions : 1- If not to use it in the DR ..would you consider it in resusitation of a newborn in the NICU ? 2-I personally rarley use it, and I try to buffer the base deficit by using blood or NS boluses, but then even NS boluses may cause IVH if were given quickly, so the question is shall we tolreate lower PH even down to 7.0 and deficit of -16 ? and shall the criteria of the PH and BE numbers change by different gestational ages or birht weight? I.e Full term resusitaion vs. VLBW. 3- how about increasing the TPN Acetate in kids with persisitent metabolic acidosis (like with mod to large PDA) or kids with continious NG suction like Gastroschisis ones? 4- using bicarb looks like using a big band-aid on a deep wound cut to cover it up to stop bleeding, but the cut may bleed again ..and we use bigger bandaid(more bicarb) ..until bleeding stops, now do u thing the bandaid did it ? or it was just a matter of time(with the help of fluid, dopa, fixing the respiratory acidosis, etc..) regardless of the bandaid-bicarb? Thank you !
  47. 1 point
    sodium bicarbonate correction has been in use and it is a habit and habit does not change easily, even if there are evidence of harmful side effects. try and correct the underlying cause- fluid deficit / hypotension/ circulatory insufficiency and then if the pH is still low even with respiratory compensation use sodium bicarbonate, that is what we have been doing I would pick the pH number <7.1, which more likely correlates with absolute hydrogen concentration rather than the base deficit, which is useful when you want correction to be done.
  48. 1 point
    Check this out: http://pediatrics.aappublications.org/cgi/content/abstract/122/4/831 The issue raised by the authors is rather that bicarbonate is useless. Even, the authors write:
  49. 1 point
    personally i also feel that treatment should be directed at the cause,however in our unit it is still sometimes used,when ph is <7.2 or bicarb is <10
  50. 1 point
    This topic is worth to be bumped. And I added a poll too!
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