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  1. 5 points
    I just want to share some brief news about our next Meetup, 7-10 April 2019 at Rigshospitalet in Copenhagen/Denmark. We (i.e myself, @Francesco Cardona @RasmusR @Christian Heiring , Gorm Greisen and Morten Breindahl) are currently working on the program lectures and workshops. I just want to share the first five confirmed speakers and their topics: Morten Breindahl: Neonatal transports – how to do them safe and easy Ola Andersson: Cord Clamping, 1.0 and 2.0 Ravi Patel: How to explain when NEC rates persist – even when a NICU does everything “Right” Ulrika Ådén: Infants surviving at the limit of viability, what are the outcomes? What shall we do? Gorm Greisen: Ethical decision making around the limit of viability- lessons from Scandinavia I'll update you all with more names and topics as they are confirmed Looking forward to meet up in Copenhagen!
  2. 4 points
    It has to be one of the most common questions you will hear uttered in the NICU. What were the cord gases? You have a sick infant in front of you and because we are human and like everything to fit into a nicely packaged box we feel a sense of relief when we are told the cord gases are indeed poor. The congruence fits with our expectation and that makes us feel as if we understand how this baby in front of us looks the way they do. Take the following case though and think about how you feel after reading it. A term infant is born after fetal distress (late deceleration to as low as 50 BPM) is noted on the fetal monitor. The infant is born flat with no heart rate and after five minutes one is detected. By this point the infant has received chest compressions and epinephrine twice via the endotracheal tube. The cord gases are run as the baby is heading off to the NICU for admission and low and behold you get the following results back; pH 7.21, pCO2 61, HCO3 23, lactate 3.5. You find yourself looking at the infant and scratching your head wondering how the baby in front of you that has left you moist with perspiration looks as bad as they do when the tried and true cord gas seems to be betraying you. To make matters worse at one hour of age you get the following result back; pH 6.99, pCO2 55, HCO3 5, lactate 15. Which do you believe? Is there something wrong with the blood gas analyzer? How Common Is This Situation You seem to have an asphyxiated infant but the cord gas isn’t following what you expect as shouldn’t it be low due to the fetal distress that was clearly present? It turns out, a normal or mildly abnormal cord gas may be found in asphyxiated infants just as commonly as what you might expect. In 2012 Yeh P et al looked at this issue in their paper The relationship between umbilical cord arterial pH and serious adverse neonatal outcome: analysis of 51,519 consecutive validated samples. The authors sampled a very large number of babies over a near 20 year period to come up with a sample of 51519 babies and sought to pair the results with what they knew of the outcome for each baby. This is where things get interesting. When looking at the outcome of encephalopathy with seizures and/or death you will note that only 21.71% of the babies with this outcome had a gas under 7.00. If you include those under 7.10 as still being significantly distressed then this percentage rises to 34.21%. In other words almost 66% of babies who have HIE with seizures and/or death have a arterial cord pH above 7.1! The authors did not look at encephalopathy without seizures but these are the worst infants and almost 2/3 have a cord gas that you wouldn’t much as glance at and say “looks fine” How do we reconcile this? The answer lies in the fetal circulation. When an fetus is severely stressed, anaerobic metabolism takes over and produces lactic acid and the metabolic acidosis that we come to expect. For the metabolites to get to the umbilcal artery they must leave the fetal tissues and enter the circulation. If the flow of blood through these tissues is quite poor in the setting of compromised myocardial contractility the acids sit in the tissues. The blood that is therefore sitting in the cord at the time of sampling actually represents blood that was sent to the placenta “when times were good”. When the baby is delivered and we do our job of resuscitating the circulation that is restored then drives the lactic acid into the blood stream and consumes the buffering HCO3 leading to the more typical gases we are accustomed to seeing and reestablishing the congruence our brains so desire. This in fact forms the basis for most HIE protocols which includes a requirement of a cord gas OR arterial blood gas in the first hour of life with a pH < 7.00. Acidosis May Be Good For the Fetus To bend your mind just a little further, animal evidence suggests that those fetuses who develop acidosis may benefit from the same and be at an advantage over those infants who don’t get acidemia. Laptook AR et al published Effects of lactic acid infusions and pH on cerebral blood flow and metabolism. In this study of piglets, infusion of lactic acid improved cerebral blood flow. I would suggest improvement in cerebral blood flow of the stressed fetus would be a good thing. Additionally we know that lactate may be used by the fetus as additional metabolic fuel for the brain which under stress would be another benefit. Finally the acidemic fetus is able to offload O2 to the tissues via the Bohr effect. In case you have forgotten this phenomenon, it is the tendency for oxygen to more readily sever its tie to hemoglobin and move into the tissues. I hope you have found this as interesting as I have in writing it. The next time you see a good cord gas in a depressed infant, pause for a few seconds and ask yourself is this really a good or a bad thing?
  3. 2 points
    We now have 13 confirmed speakers for the Copenhagen Meetup 7-10 April next year! Generally, we'll stick to the successful format we have had at the previous meetings: 45 min slots split into a 30 min lecture and a 15 min discussion. We'll continue to use the sli.do smartphone app to facilitate the discussion and allow every delegate to share questions and comments. In addition to the lecture program 7-9 April, we are also planning workhops and mini-symposia on the 10th of April. We'll share more info about those soonish, but if you want ONE cliff-hanger... we plan one symposium about the infant microbiome etc-etc Confirmed topics and speakers Neonatal transports - safe and easy, Morten Breindahl (Sweden) Treating pain in neonates, Karel Allegaert (Belgium) How to improve quality on the NICU, Joseph Kaempf (US) Hyperglycemia - how to manage and why, Kathryn Beardsal (UK) Why we should rehearse simulated scenarios, Ruth Gottstein (UK) Go with the (high) flow, Brett Manley (Australia) News in the updated ESPGHAN guidelines, Nadja Haiden ( Austria) Prevention of BPD, Christian Poets (Germany) The many inotropes - what to use when, Yogen Singh (UK) Cord Clamping, 1.0 and 2.0, Ola Andersson (Sweden) When NEC rates persist , despite everything done “Right”, Ravi Patel (US) Outcomes in infants surviving at the limit of viability, Ulrika Ådén (Sweden) Ethical decision making around the limit of viability, Gorm Greisen (Denmark)
  4. 2 points
    One of the first things a student of any discipline caring for newborns is how to calculate the apgar score at birth. Over 60 years ago Virginia Apgar created this score as a means of giving care providers a consistent snapshot of what an infant was like in the first minute then fifth and if needed 10, 15 and so on if resuscitation was ongoing. For sure it has served a useful purpose as an apgar score of 0 and 0 gives one cause for real worry. What about a baby with an apgar of 3 and 7 or 4 and 8? There are certainly infants who have done very well who initially had low apgar scores and conversely those who had higher apgar scores who have had very significant deleterious outcomes including death. I don’t mean to suggest that the apgar scores don’t provide any useful predictive value as they are used as part of the criteria to determine if a baby merits whole body cooling or not. The question is though after 60+ years, has another score been created to provide similar information but enhance the predictive value derived from a score? The Neonatal Resuscitation and Adaptation Score (NRAS) Back in 2015 Jurdi et al published Evaluation of a Comprehensive Delivery Room Neonatal Resuscitation and Adaptation Score (NRAS) Compared to the Apgar Score. This new score added into a ten point score resuscitative actions taken at the 1 and 5 minute time points to create a more functional score that included interventions. The other thing this new score addressed was more recent data that indicated a blue baby at birth is normal (which is why we have eliminated asking the question “is the baby pink?” in NRP. Knowing that, the colour of the baby in the apgar score may not really be that relevant. Take for example a baby with an apgar score of 3 at one minute who could have a HR over 100 and be limp, blue and with shallow breathing. Such a baby might get a few positive pressure breaths and then within 10 seconds be breathing quite well and crying. Conversely, they might be getting ongoing PPV for several minutes and need oxygen. Were they also getting chest compressions? If I only told you the apgar score you wouldn’t have much to go on. Now look at the NRAS and compare the information gathered using two cardiovascular (C1&2), one neurological test (N1) and two respiratory assessments (R1&2). The authors in this study performed a pilot study on only on 17 patients really as a proof of concept that the score could be taught and implemented. Providers reported both scores and found “superior interrater reliability (P < .001) and respiratory component reliability (P < .001) for all gestational ages compared to the Apgar score.” A Bigger Study Was Needed The same group in 2018 this time led by Witcher published Neonatal Resuscitation and Adaptation Score vs Apgar: newborn assessment and predictive ability. The primary outcome was the ability of a low score to predict mortality with a study design that was a non-inferiority trial. All attended deliveries were meant to have both scores done but due to limited numbers of trained personnel who could appropriately administer both scores just under 90% of the total deliveries were assigned scores for comparison. The authors sought to recruit 450 infants to show that a low NRAS score (0–3) would not be inferior to a similar Apgar at predicting death. Interestingly an interim analysis found the NRAS to be superior to Apgar when 75.5% of the 450 were enrolled, so the study was stopped. What led the apgar score to perform poorly in predicting mortality (there were only 12 deaths though in the cohort) was the fact that 49 patients with a 1 minute apgar score of 0-3 survived compared to only 7 infants with a low NRAS score. The other interesting finding was the ability of the NRAS to predict the need for respiratory support at 48 hours with a one minute apgar score of 0-3 being found in 39% of those on support compared to 100% of those with a low NRAS. Also at 5 minutes a score of 4-6 for the apgar was found in 48% of those with respiratory support at 48 hours vs 87% of those with a similar range NRAS. These findings were statistically significant while a host of other conditions such as sepsis, hypoglycemia, hypothermia and others were no different in terms of predictive ability of the scores. An Even Bigger Study is Needed To be sure, this study is still small and missed just over 90% of all deliveries so it is possible there is some bias that is not being detected here. I do think there is something here though which a bigger study that has an army of people equipped to provide the scoring will add to this ongoing story. Every practitioner who resuscitates an infant is asked at some point in those first minutes to hour “will my baby be ok?”. The truth is that the apgar score has never lived up to the hope that it would help us provide an accurate clairvoyant picture of what lies ahead for an infant. Where this score gives me hope is that a score which would at the very least help me predict whether an infant would likely still be needing respiratory support in 48 hours provides the basic answer to the most common question we get in the unit once admitted; “when can I take my baby home”. Using this score I could respond with some greater confidence in saying “I think your infant will be on support for at least 48 hours”. The bigger question though which thankfully we don’t have to address too often for the sickest babies at birth is “will my baby survive?”. If a larger study demonstrates this score to provide a greater degree of accuracy then the “Tipping Point” might just be that to switching over to the NRAS and leaving the apgar score behind. That will never happen overnight but medicine is always evolving and with time you the reader may find yourself becoming very familiar with this score!
  5. 2 points
    We have a ABL900 that is managed by our hospital lab department and they say that the analyses are validated. Meaning that we should trust the values (whether it is S-electrolytes, lactate or hematocrite) as if they had run the test in the "big lab machine". So, I'd say that we generally trust our ABL (as with all tech, it sometimes fails...)
  6. 2 points
    We also use the PINT cut-offs. However, I want to call people's attention to the problem is knowing what device you are using to measure H/H If your institution has POC or on-unit Hgb/hct available (for example on an I-stat or similar device or on a blood gas analyzer in the ICU) you need to ask your lab what the accuracy of those devices is compared to a formal H/H in the main lab, particularly at the low end of the Hgb range where you will be making transfusion decisions. The chemistry for some of the POC devices is influenced by what else is in the sample. For example the I-Stat (the POC device I am most familiar with) only calculates a Hct, not a Hgb (it just divides the Hct by 3 and reports that number as the Hgb). The Hct it 'measures' is corrected for Na (but not other electrolytes which may affect conductivity - the method by which Hct is calculated/measured), there is no correction for leukocytosis and the machine does not adjust for low TP or hyperlipidemia (but there are published manual corrections you can use). There is also the problem that these devices are validated for their correlation with a gold standard over either a normal range or a 'clinically relevant' range. Unfortunately, accuracy is really not relevant over most of that range. What we, in the ICU, care about is accuracy specifically down at the transfusion threshold. I don't really care if my pt's Hgb is 14 or 14.5 but I might care a great deal if it is 7 vs 7.5. To my knowledge, there is no such data for the I-Stat (nor any other POC device that I know)
  7. 2 points
    I could not find any data from newborns, but this study on healthy (young) volonteers showed only a slight diff: https://www.ncbi.nlm.nih.gov/pubmed/11553055 This correlation study in adults in intensive care also suggest a good correlation: http://www.thejh.org/index.php/jh/article/view/231/186 We only take venous blood (or arterial from UAC), but good to keep in mind that capillary hemoglobin levels are ~10% higher than central values.
  8. 1 point
    While we are still finalizing the program for the 2019 Meetup, we cannot wait to share what we know already The "Future of Neonatal Care" conference will be held 7-10 April 2019, in the Auditorium at the Rigshospitalet in Copenhagen, Denmark. The program will include a great set of lectures and workshops with high clinical relevance. If you want to secure a seat, we advise you to make a non-binding pre-registration. On the conference web site, you can also subscribe to the dedicated conference newsletter. See you in Copenhagen next year!
  9. 1 point
    We proudly present MONIVENT as a new Supporting Partner of 99nicu! MONIVENT is a young medtech company dedicated to improve the emergency ventilatory care given to newborn babies in need of respiratory support at birth. About 3-6 % of all newborns end up in this situation, where healthcare personnel today are lacking tools to determine how effective their manual ventilation really is. Monivent® Neo is a non-invasive monitoring device to be used during manual ventilation, measuring the air volume given to the baby with sensors wirelessly built-into the face mask, providing the caregiver with continuous feedback on several critical parameters. A target volume is presented and any volume given outside the recommended interval is clearly indicated by a color change on an intuitive display. MONIVENT recently introduced its first product - Monivent Neo training - used within simulation training on a manikin while a clinical product is currently under development. Learn more about MONIVENT on: http://monivent.se/
  10. 1 point
    Hello, I am paediatric trainee currently working in Level 2 NICU in UK. I am doing the journal club presentation about the use of LMA for administration of surfactant in preterm babies. During my previous placements in Level 3 NiCUs, I never seen anyone using LMAs and I was wondering what experience do the rest of you have with using LMAs in neonates. What training did you undergo? Thank you. Lenka
  11. 1 point
    After the last round of articles .How about a little debate around NLS & Ethics
  12. 1 point
    The air-Qsp LMA from Cookgas is available in size 0.5. The packaging says for use <4kg. It is obviously smaller than the size 1 and certainly works when used on the prem sim babies.
  13. 1 point
  14. 1 point
  15. 1 point
    Hamed, thank you! Is there any difference between venous and arterial Hb/Ht?
  16. 1 point
    Hi @Andrej Vitushka you can use both central or capillary. For cutoffs please check the PINT study. We use table 1 low threshold cutoffs for transfusion. https://www.ncbi.nlm.nih.gov/pubmed/16939737 PINT trial.pdf
  17. 1 point
    I've used an LMA for the specific indication of 'can't ventilate, can't intubate' in somewhat larger neonates (not for surfactant); we do have size 0.5 available now (I've never used them). The only time I've used them in a DR setting was once when called emergently to a non-birthing hospital for premature triplets and I wasn't confident everyone could be intubated if BMV wasn't working. Even in that case we ended up not giving surfactant until back in NICU and intubated. The single biggest use case I've used an LMA for was palliative where patient is DNR/I and we're waiting for family to come in because of a decompensation and the patient REALLY needs PPV, we've placed an LMA and hooked it up to a vent until family can get in. My experience is that families (and frankly staff) perceive this as less invasive/harmful than intubating and then pulling the ET tube when parents are there. How was I trained? Sim sessions in residency and fellowship and at PAS the past few years it seems there has been an airway skills workshop that I try to attend it there isn't a conflict.
  18. 1 point
    It has been a few months now that I have been serving as Chair of the Fetus and Newborn Committee for the Canadian Pediatric Society. Certain statements that we release resonate strongly with me and the one just released this week is certainly one of them. Guidelines for vitamin K prophylaxis in newborns is an important statement about a condition that thankfully so few people ever experience. To read the statement on the CPS website click here. Similar story to vaccinations Prior to the American Academy of Pediatrics in 1961 proclaiming that all newborns should receive IM Vitamin K at birth the incidence of Vitamin K deficient bleeding was 0.25 – 1.7%. Think about that for a moment. A new parent could expect that 1/100 babies roughly might have intestinal bleeding or worse an intracranial hemorrhage due to an insufficient amount of vitamin K levels in the newborn. The types of bleeding could be categorized into three different time epochs. Early onset (occurring in the first 24 hours post-birth), classic (occurring at days 2 to 7) and late onset (at 2 to 12 weeks and up to 6 months of age). With a rate that high detractors of providing Vitamin K at birth would say “why should we give it; I haven’t heard of any baby getting such bleeding?” Looking at it another way though, why don’t you see congenital rubella or kids with measles much these days? It’s due to vaccination. Thankfully as a Neonatologist, I don’t see Vitamin K deficient bleeding since most parents provide Vitamin K to their babies at birth. If you went back to the era prior to 1961 when widespread supplementation of Vitamin K began in the US, I imagine it would not have been too uncommon to hear about a baby who had bleeding issues after birth. Just because we don’t hear about German Measles much anymore doesn’t mean the virus causing it doesn’t still exist! How Effective is Vitamin K? How effective is Vitamin K administration at birth in preventing hemorrhagic disease of the newborn (HDNB)? Studies estimate an incidence of 0.25 per 100000 live births or 1 in 400000 babies vs the 1/100 risk without any vitamin K. That is one effective intervention! At this point I would ask those families that are still concerned about giving Vitamin K to their infants if this is a risk they can accept? If they refuse Vitamin K and there is a significant bleed how will they react? The Change in this CPS Statement From the Past In the last statement on Vitamin K, the authors suggested that the oral route was a reasonable option. Instead of giving 1 mg of Vitamin K IM one would dose it as 2 mg orally and then repeat at 2-4 weeks and then 6-8 weeks. In looking at the effectiveness though it is worth noting that while we can assure that families will get the first dose, as with any medication that needs repeat dosing there is the risk of forgetfulness leading to missed dosing down the road. In fact when the authors looked at the risk of late HDNB they found the following “The relative risk for VKDB, when comparing PO versus IM vitamin K administration in these two studies, was 28.75 (95% CI 1.64 to 503.45) and 5.97 (95% CI 0.54 to 65.82), respectively [19][20].” The outcome of course remains rare but the risk based on two studies was almost 30 times higher than if IM dosing was given. On this basis IM is recommended. Having said all this I recognize that despite all this information, some families will choose for a number of reasons to still opt for the oral dose. As the statement suggests we need to encourage such use when a family refuses IM vitamin K. The 30 fold risk compared to IM administration is magnitudes lower than the approximate 1/100 risk of giving nothing at all! In the end I believe that one case of intracranial hemorrhage from inadequate vitamin K is too much. This one vitamin indeed could save a life.
  19. 1 point
    Alternative medicine - part of a modern nicu?
  20. 1 point
    @uvbogden We teach our ped fellows in our neonatal team simulations (those sessions also include some skill training, although team communication is the core) how to use the LMA. So, we "prime" them that LMA is an easy option unless they have some experience with neonatal intubation (or until a neonatologist or anestesiologist comes and support/do the intubation). Maybe that explains why LMAs are occasionally used. I'd estimate 1-2 infants a month get one for ventilation support in the delivery room, but given our 8500 inborns, that also means they are rarely used despite our "priming"
  21. 1 point
    According to NRP textbook What are the limitations of a laryngeal mask? Laryngeal masks have several limitations to consider during neonatal resuscitation. •The device has not been studied for suctioning secretions from the airway. •If you need to use high ventilation pressures,air may leak through the seal between the pharynx and the mask, resulting in insufficient pressure to inflate the lungs. •Few reports describe the use of a laryngeal mask during chest compressions. However, if endotracheal intubation is unsuccessful, it is reasonable to attempt compressions with the device in place. •There is insufficient evidence to recommend using a laryngeal mask to administer intratracheal medications. Intratracheal medications may leak from the mask into the esophagus and not enter the lung. •Laryngeal masks can not be used in very small newborns. Currently, the smallest laryngeal mask is intended for use in babies who weigh more than approximately 2,000 g. Many reports describe its use in babies who weigh 1,500 to 2,000 g. Some reports have described using the size-1 laryngeal mask successfully in babies who weigh less than 1,500 g. This study by Prof Kary Roberts in USA Laryngeal Mask Airway for Surfactant Administration in Neonates:A Randomized,ControlledTrial
  22. 1 point
    Hi Al, I came across this article only just this morning. It is an interesting read on the subject. I also love this YouTube from the March of Dimes Taking the Evidence Based Case for Kangaroo Care into the Clinical Setting Cheers Trish 2018_Lim_Neonatal nurses perceptions of supportive factors and barriers to the implementation of skin-to-skin care in ELBW.pdf
  23. 1 point
    Thanks @mahmoud very informative This is another article taking about Advances in Diagnosis and Management of Hemodynamic instability in Neonatal Shock https://files.acrobat.com/a/preview/1d78eae5-940a-407d-970a-7461f06d4629
  24. 1 point
    This is great! Thanks so much. I was in Toronto for the NeoHemodynamics 2018 Conference and Workshop and one of the main take-home messages was that both transitional hemodynamics and knowledge of its physiology are key to tailoring therapeutic interventions both in preemies and term babies. The slides from the talks are available at neohemodynamics.com
  25. 1 point
    In collaboration with my long-time colleague, Dr. Richard J Schanler we monitored the oral feeding performance of Late Preterm Infants (LPT) at his hospital using the Oral Feeding Skill (OFS) scale we developed a few years ago (1). The OFS scale helps differentiate between infant oral feeding skills and endurance (2). As mentioned above, depending upon individual hospital policies, LPT may be transferred to different levels of care. However, due to their relatively short hospital stay, it remains at times difficult to identify those that may be at risk for oral feeding issues. In our study, we observed that assessing the OFS maturity levels of LPTs at their first oral feeding can help identify these at-risk infants early on. We speculated that provision of evidence-based efficacious interventions that improve OFS may shorten hospital stay and decrease future re-admission. (1). Lau C, Bhat J, Potak D, Schanler RJ. Oral Feeding Skills of Late Preterm Infants are correlated with Hospital Length of Stay. J Ped Moth Care 2015; 1:102; (2). Lau C, Smith EO. A novel approach to assess oral feeding kills of preterm infants Neonatology 2011;100:64-70 (doi: 10.1159/000321987) Lau et al'15 (LPT).pdf Lau & Smith '11.pdf
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