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Showing content with the highest reputation since 07/16/2017 in all areas

  1. 2 points
    Port Said Neonatology Society is honored to invite you to its Eighth Neonatology Conference 18-21 October 2017 Venue: Al Fayrouz resort Port Said Six Pre -conference workshops: Wednesday 18th & Friday 20th of October Conference sessions: Thursday 19th & Friday 20th of October Registration link
  2. 2 points
    When I think back to my early days as a medical student, one of the first lessons on the physical exam involves checking central and peripheral perfusion as part of the cardiac exam. In the newborn to assess the hemodynamic status I have often taught that while the blood pressure is a nice number to have it is important to remember that it is a number that is the product of two important factors; resistance and flow. It is possible then that a newborn with a low blood pressure could have good flow but poor vascular tone (warm shock) or poor flow and increased vascular tone (cardiogenic shock or hypovolemia). Similarly, the baby with good perfusion could be in septic shock and be vasodilated with good flow. In other words the use of capillary and blood pressure may not tell you what you really want to know. Is there a better way? As I have written about previously, point of care ultrasound is on the rise in Neonatology. As more trainees are being taught the skill and equipment more readily available opportunities abound for testing various hypotheses about the benefit of such technology. In addition to my role as a clinical Neonatologist I am also the Medical Director of the Child Health Transport Team and have pondered about a future where ultrasound is taken on retrievals to enhance patient assessment. I was delighted therefore to see a small but interesting study published on this very topic this past month. Browning Carmo KB and colleagues shared their experience in retrieving 44 infants in their paper Feasibility and utility of portable ultrasound during retrieval of sick preterm infants. The study amounted to a proof of concept and took 7 years to complete in large part due to the rare availability of staff who were trained in ultrasound to retrieve patients. These were mostly small higher risk patients (median birthweight, 1130 g (680–1960 g) and median gestation, 27 weeks (23–30)). Availability of a laptop based ultrasound device made this study possible now that there are nearly palm sized and tablet based ultrasound units this study would be even more feasible now (sometimes they were unable to send a three person team due to weight reasons when factoring in the ultrasound equipment). Without going into great detail the measurements included cardiac (structural and hemodynamic) & head ultrasounds. Bringing things full circle it is the hemodynamic assessment that I found the most interesting. Can we rely on capillary refill? From previous work normal values for SVC flow are >50 ml/kg/min and for Right ventricular output > 150 ml/kg/min. These thresholds if not met have been correlated with adverse long term outcomes and in the short term need for inotropic support. In the absence of these ultrasound measurements one would use capillary refill and blood pressure to determine the clinical status but how accurate is it? First of all out of the 44 patients retrieved, assessment in the field demonstrated 27 (61%) had evidence using these parameters of low systemic blood flow. After admission to the NICU 8 had persistent low systemic blood flow with the patients shown below in the table. The striking finding (at least to me) is that 6 out of 8 had capillary refill times < 2 seconds. With respect to blood pressure 5/8 had mean blood pressures that would be considered normal or even elevated despite clearly compromised systemic blood flow. To answer the question I have posed in this section I think the answer is that capillary refill and I would also add blood pressure are not telling you the whole story. I suspect in these patients the numbers were masking the true status of the patient. How safe is transport? One other aspect of the study which I hope would provide some relief to those of us who transport patients long distance is that the head ultrasound findings before and after transport were unchanged. Transport with all of it’s movement to and fro and vibrations would not seem to put babies at risk of intracranial bleeding. Where do we go from here? Before we all jump on the bandwagon and spend a great deal of money buying such equipment it needs to be said “larger studies are needed” looking at such things as IVH. Although it is reassuring that patients with IVH did not have extension of such bleeding after transport, it needs to be recognized that with such a small study I am not comfortable saying that the case is closed. What I am concerned about though is the lack of correlation between SVC and RVO measurements and the findings we have used for ages to estimate hemodynamic status in patients. There will be those who resist such change as it does require effort to acquire a new set of skills. I do see this happening though as we move forward if we want to have the most accurate assessment of clinical status in our patients. As equipment with high resolution becomes increasingly available at lower price points, how long can we afford not to adapt?
  3. 1 point
    Hello, I am a 3rd year medical student interested in neonatology, but have heard that the work-life balance is pretty difficult and it can be hard to be a good husband/father (or wife/mother) because of the schedule. Most of the practices that I have seen or heard about generally have doctors work ten 24hr shifts per month, which is a 24hr shift every 3 days so you're either on call, post-call, or pre-call all the time. I have talked with a handful of neonatologists about this but I was wondering if I could get a broader perspective on this topic? Thank you!
  4. 1 point
    I know how to bag a baby. At least I think I do. Providing PPV with a bag-valve mask is something that you are taught in NRP and is likely one of the first skills you learned in the NICU. We are told to squeeze the bag at a rate of 40-60 breaths a minute. According to the Laerdal website, the volume of the preterm silicone bag that we typically use is 240 mL. Imagine then that you are wanting to ventilate a baby who is 1 kg. How much should you compress the bag if you wish to delivery 5 mL/kg. Five ml out of a 240 mL bag is not a lot of squeeze is it? Think about that the next time you find yourself squeezing one. You might then say but what about a t-piece resuscitator? A good choice option as well but how much volume are you delivering if you set the initial pressures at 20/5 for example? That would depend on the compliance of the lung of course. The greater the compliance the more volume would go in. Would it be 5 mL, 10 ml or even 2.5 mL based on the initial setting? Hard to say as it really depends on your seal and the compliance of the lung at the pressure you have chosen. If only we had a device that could deliver a preset volume just like on a ventilator with a volume guarantee setting! Why is this holy grail so important? It has been over 30 years since the importance of volutrauma was demonstrated in a rabbit model. Hernandez LA et al published Chest wall restriction limits high airway pressure-induced lung injury in young rabbits. The study used three models to demonstrate the impact of volume as opposed to pressure on injuring the lung of preterm rabbits. Group 1 were rabbit ventilated at pressures of 15/30/45 cm H2O for one hour, group 2 rabbits with a cast around their thorax to limit volume expansion and group 3 sets of excised lungs with no restriction to distension based on the applied pressures. As you might expect, limitation of over distension by the plaster cast led the greatest reduction in injury (measured as microvascular permeability) with the excised lungs being the worst. In doing this study the authors demonstrated the importance of over distension and made the case for controlling volume more than pressure when delivering breaths to avoid excessive tidal volume and resultant lung injury. The “Next Step” Volume Ventilator BVM Perhaps I am becoming a fan of the Edmonton group. In 2015 they published A Novel Prototype Neonatal Resuscitator That Controls Tidal Volume and Ventilation Rate: A Comparative Study of Mask Ventilation in a Newborn Manikin. The device is tablet based and as described, rather than setting a PIP to deliver a Vt, a rate is set along with a volume to be delivered with a peep in this case set at +5. This study compared 5 different methods of delivering PPV to a 1 kg preterm manikin. The first was a standard self inflating bag, the next three different t-piece resuscitators and then the Next Step. For the first four the goal was to deliver a pressure of 20/5 at a rate of 40-60 breaths per minute. A test lung was connected to the manikin such that each device was used for a one minute period at three different levels of compliance (0.5 ml/cmH2O, 1.0 ml/cmH2O and then 2.0 ml/cm H2O representing increasing compliance. The goal of the study was to compare the methods in terms of delivering a volume of 5 mL to this 1 kg model lung. The order in which the devices were used was randomized for the 25 participants in the study who were all certified in NRP and included some Neonatologists. Some Concerning Findings As I said at the beginning, we all like to think we know how to ventilate a newborn with BVM. The results though suggest that as compliance increases our ability to control how much volume we deliver to a lung based on a best guess for pressures needed is lacking. One caveat here is that the pressures set on the t-piece resucitators were unchanged during the 1 minute trials but then again how often during one minute would we change settings from a starting point of 20/5? Vt (mL) 0.5 mL/cmH20 1.0 mL/cmH20 2.0mL/cmH20 Self inflating 11.4 17.6 23.5 Neo-Tee 5.6 11.2 19.3 Neopuff 6.1 10 21.3 Giraffe 5.7 10.9 19.8 Next Step 3.7 4.9 4.5 Without putting in all the confidence intervals I can tell you that the Next Step was the tightest. What you notice immediately (or at least I did) was that no matter what the compliance, the self inflating bag delivers quite an excessive volume even in experienced hands regardless of compliance. At low compliance the t-piece resuscitators do an admirable job as 5-6 ml/kg of delivered Vt is reasonable but as compliance improves the volumes increase substantially. It is worth pointing out that at low compliance the Next Step was unable to deliver the prescribed Vt but knowing that if you had a baby who wasn’t responding to ventilation I would imagine you would then try a setting of 6 ml/kg to compensate much like you would increase the pressure on a typical device. How might these devices do in a 29 week infant for example with better compliance than say a 24 week infant? You can’t help but wonder how many babies are given minutes of excessive Vt after birth during PPV with the traditional pressure limited BVM setup and then down the road how many have BPD in part because of that exposure. I wanted to share this piece as I think volume resuscitation will be the future. This is just a prototype or at least back then it was. Interestingly in terms of satisfaction of use, the Next Step was rated by the participants in the study as being the easiest and most comfortable to use of all the devices studied. Adding this finding to the accuracy of the delivered volume and I think we could have a winner.
  5. 1 point
    Dear Colleagues We are organising the next Neonatal Ethics and Difficult Situations Course 2017 in Southampton. There are a host of excellent topics which include 1. Disagreement between teams -Achieving Consensus 2. Disagreement with Parents-When consensus is not possible? 3. Parental decision making in End of Life Care 4. The Law and End of Life Care: Land Mark Decisions Influencing Management 5. Simulated scenarios with professional actors 6. Neonatal death and Surrogacy 7. Ethical Cases A programme is attached. For more information go to To register go to An over view of how we conduct the simulations is provided here Best Wishes Dr Alok Sharma Consultant Neonatologist Princess Anne Hospital Southampton United Kingdom Email NEDS6.pdf
  6. 1 point
    I subscribe to the small Youtube channel Science Showcase curated by Andrew Maynard, a very enthusiastic researcher! Science Showcase collect video clips with scientific content aimed for a broader (public) audience. There is a contest going on and the best video will win 2000 USD. Just wanted share two interesting clips that are sort of relevant for neonatal staff. The first video is about epidemiology and its basic concepts. As you know, there are tons of clinical studies in neonatal medicine based on observational data, many of which suffer from major limitations as researchers did not really grasp some basic concepts how to handle their data... In the first video, there is one mistake though - the illustration of confounding is not entirely correct, instead the video illustrates mediation which is different thing. Small mistake though, as the error in the video is rather that the arrow is flipped 180 degrees. See and find out what I mean The second video is about Big Data, a coming major thing in neonatal research as we get access and collect more and more data. The video is about genetic data, but the same principal idea ("so much data you don't know how to handle it") applies to health register data, and the richness of data that could be tanked down from from our monitors, ventilators etc. Enjoy!
  7. 1 point
    Welcome to the 4th international Conference for Evidence-Based Neonatology, 10-12 November 2017, in Hyderabad India! As the number of articles world-wide in the medical press explodes, the importance of understanding and disseminating the principles of Evidence Based Medicine becomes greater. This is a central focus of the Society of EBNEO. At this Fourth international meeting of our young society, as in prior meetings – we include talks with both neonatal contents and clinical epidemiological methodology. We hope that this meeting will facilitate an international on-going collaboration and interchange. This meeting will be in association with Indian Association of Pediatrics Neonatology Chapter. There are two organizational features that are new at this year’s meeting. Firstly, we will have two workshops: one on advanced methods for meta-analysis. Secondly a workshop on running randomized controlled trials in the less well-resourced countries. In addition we have now almost 2 years after having launched the “EBNEO Journal Club”. The intent of this was to provide a structured synopsis of studies to allow a quick methodologically based over-view. It follows the model of the American College of Physicians Journal Club – which has proven an effective leaning and dissemination tool. These are now being published with pubmed referencing at Acta Paediatrica. In all of these ventures – there is ample opportunity for all neonatologists interested in methodologically based Neonatal care – to participate – from the ground level! Register to the conference by following the instructions below. We hope to see you at this exciting venture! Dr. Srinivas Murki and Dr. Vasudeva Murli on behalf of IAP Neochap Associate professor Stefan Johansson, professor Haresh Kirpalani, professor Mikael Norman and associate Professor Clyde Wright; on behalf of EBNEO Conference folder and program Click here to download the conference folder with general information. Click here to download the preliminary program.
  8. 1 point
    There is now three more videos from the 99nicu Meetup posted on the "Meetup17" page about: NAVA-ventilation Probiotics Perinatal care differences in EU Find the Meetup17 page in the navigation bar above. Enjoy !
  9. 1 point
    This paper was recently published in J of Pediatr, read it Thanks to @EBNEO that promoted it in this tweet. The headline and study question are both great, but I am sceptical to the design: SGA infant with brain sparing was (as I See it from my vacation balcony in Greece ) compared with a small group of term AGA infants. (96 + 32 infants) Not surprisingly, this small study found mostly no differences. but as you know - abscense of evidence is not evidence of abscense. would have been better if SGA infants with brain sparing had been compared with SGA infants without it (or study whether degree of SGA would be associated with outcomes). Not supernew (has been done before if I recall it correctly) but still relevant to replicate Below - URL to the paper in J of Pediatr
  10. 1 point
  11. 1 point
    Almost all lectures on the 99nicu Meetup were videorecorded and will be made available on Youtube. Over the summer, we will be adding lectures on the Meetup page ( Right now you can see David Sweet lecturing about RDS management and Rebeccah Slater lecturing about pain in preterm infants, but more will come...
  12. 1 point
    Another case is shared in the Virtual NICU: a 36w infant with poor feeding and dysmorpic features. The posting member seeks advice on possible differential diagnoses. Please find the case history and photos here. Please note that you must log in to access the virtual NICU and read/post about this case.
  13. 1 point

    From the album 99nicu album

    This is an acrylic and ink painting by @Ryan McAdams. Read his thoughtful essay about the painting below.
  14. 1 point
    Dose & administration Three doses at 24-hour intervals, as intravenous injections over 15 minutes, or by oro-gastric administration: 1st dose: 10 mg/kg 2nd and 3rd dose: 5 mg/kg Indications Closure of the patent ductus arteriosus. Contraindications and special considerations (incl incompatibilities) Contraindications include: duct-dependent cardiovascular malformation active bleeding, including intracranial, gastrointestinal or lung bleeding necrotizing enterocolitis (confirmed or suspected) significant thrombocytopenia or coagulation defects significantly reduced renal function significant hyperbilirubinemia Pulmonary hypertension has been reported when ibuprofen was given within 6 hours after birth. Concomitant use the following pharmaceuticals products is not recommended: diuretics: ibuprofen may reduce the effect of diuretics, and diuretics may increase the risk of renal insufficiency in dehydrated patients. anticoagulants: ibuprofen may inhibit platelet function and concomitant use with anticoagulants may increase the risk of bleeding corticosteroids: concomitant use with ibuprofen may increase the risk of gastrointestinal bleeding nitric oxide: since both nitric oxide and ibuprofen inhibit platelet function, concomitant use may in theory increase the risk of bleeding other NSAIDs: concomitant use of more than one NSAID should be avoided because of the increased risk of adverse reactions aminoglycosides: ibuprofen may reduce clearance of aminoglycosides, concomitant use may increase the risk of nephrotoxicity and ototoxicity, and surveillance of serum levels of aminoglycides should be performed Ibuprofen should not be administrated with any acidic solution. Adverse effects Oligura and transient renal insufficiency. Ibuprofen has less renal side-effects than indomethacin. Pharmacological aspects Ibuprofen is an anti-inflammatory drug (NSAID) that reduces the synthesis of prostaglandins through a non-selective inhibition of cyclo-oxygenase. Prostaglandins are involved in the persistence of the ductus arteriosus after birth, through relaxation of the muscle layer of the ductus arteriosus. The reduction of prostaglandins by ibuprofen is believed to be the main mechanism of action. The estimated T1/2 is 30 (16-43) hours. References Summary of product characteristics. Pedea -EMEA/H/C/000549 -IG/392. (URL) Ibuprofen for the treatment of patent ductus arteriosus in preterm or low birth weight infants. Cochrane Database of Systematic Reviews 2015, Issue 2. Art. No.: CD003481. 
PMID: 25692606 Pulmonary hypertension after ibuprofen prophylaxis in very preterm infants. Lancet 2002; 359: 1486–88. PMID: 11988250 Document version history 2017-02-10 / Stefan Johansson
  15. 1 point
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