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Showing content with the highest reputation since 03/20/2018 in all areas

  1. 1 point
    Anyone have experience with atraumatic lumbar puncture? Does anyone know if there is a needle available for puncture in neonates? After reading this I am very curious: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)32451-0/fulltext
  2. 1 point
  3. 1 point
    We for maternity ward stay for infants at 35+0 wks and onwards. I don't know the exact NICU admission rate for 35+0 -- 35+6 infants but the majority stays only at the maternity ward for ~4-6 days, until feeding works and till we know there is no signif jaundice. The midwifes usually add a followup visit after another few days to check weight, jaundice, feeding etc, and then the family only goes to the regular well-baby-clinics (as any other infant) But, we need to support (from the NICU) with planning etc, sometimes we invest relatively much time to make this work. But we feel that non-separation and "non-medicalization" of this group of infants works best in the maternity ward.
  4. 1 point
    We have different practice in our unit may be due to the load of work and high rate of deliveries in our hospital which may reach to 700_ 900 deliveries per month we are just keeping them with mother and monitoring RBS if the weight is below 2.5 kg Other wise we are not admitting them unless only if there is poor feeding unable to suck ,respiratory distress ,hypoglycemia or any significant problem Some
  5. 1 point
    @RasmusR In fact those needles do not have a stylet that's why we are shifting to a stylet-equipped atraumatic needle. Will post a photo once I get back on clinical service!
  6. 1 point
    We are mainly using regular needles (used for sc injections), a "blue" needle that is 23G (0.6 x 30 mm). Don't know if this truly makes sense, but we teach to direct the "eye" of the needle in 90 degrees angle to the back of the infant, to cut the dural fibers as little as possible. We recently got an atraumatic needle on our shelfes though, but have not had the chance to test it myself - but will post a picture of it in after the Future of Neonatal Care (in case someone misunderstands the "Future...", after the Vienna meeting next week)
  7. 1 point
    Tricky question. This review paper may give some insights (into the limitations of the topic...) https://www.ncbi.nlm.nih.gov/pubmed/24477225 We would probably also get the advice from our transfusion medicine dept to give low-molecular-weight heparin (LMWH) for a limited time while performing repeated ultrasounds. If the inferior vena cava flow is not clearly obstructed when the thrombus stabilize, my (limited) experience is that the long-term outcome is good. Although the likely explanation is a previous intra-vessel catheter, I'd follow the advice by @rehman_naveed to screen for abnormalities in the coag system.
  8. 1 point
    Dear all, I would be grateful for your advice/opinion regarding the following case. We admitted a preterm baby 28 weeks gestation with oesophageal atresia and tracheo-oesophageal fistula in our unit in October. The baby was severely IUGR weighted only 600 g at birth. He had a fistula closure on day 1. Due to his cardiovascular and respiratory instability the full correction was delayed. He had a difficult time following the surgery. He was stabilised, weaned of the ventilator and the correction surgery was planned when he developed sepsis. We looked for the source of the infection so among other investigations we did an Echo. His Echo showed a mass in his right ventricle, which we thought to be a thrombosis. We started him on LMWH treatment. He deteriorated couple of days after the treatment was started and required ventilation again. The repeated Echo didn't show the thrombus in the right ventricle anymore. Abdominal Us scan was done, which showed a mass in the inferior v. cava. The mass is about 4 cm long, seems to be attached to the wall of the vein above the renal vein, but in other places it is not connected to the wall of the vein. It didn't cause any disruption in the blood flow. (had good urine output and he was not oedematous). The most likely diagnosis was the thrombosis (as a consequence of previous umbilical/femoral catheter or longline) so I continued the LMWH. The correction surgery was done and he came off the ventilator and reached full feeds. On the repeated scans the inferior v. cava mass didn't show any change (not even attachment to the wall), according to the Chest guideline on thrombosis we should discontinue the treatment with LMWH after 3 month. Would you recommend to stop the treatment even if the mass didn't change? Can we give aspirin to an ex-preterm as a prophylaxis? Is it necessary? Do you have experience with a thrombus which didn't show any change? Can you think of anything else as a differential? Thank you, Judit
  9. 1 point
    Hi Judit Interesting case. in your case description, you mentioned last US showed mass even not attached to wall, it means thrombus is detached, in case it may obstruct the IVC flow, can you make it clear. Did you consult hematologist? What about thrombocytopenia? ( Yes/No), Coagulation profile, Anti Xa level monitoring, did you follow it to guide therapy of LMWH, Did you consult plastic surgeons? Did you screen for thrombosis workup, protein C, and S, factor V leiden deficiency There are no set guidelines to guide treatment for thrombosis in newborn, but here in canada we do treat with LMWH, follow serial anti Xa level, to guide therapy ,involve hematology/thrombosis team, and follow serial US with doppler . Length of treatment varies with size of thrombosis. Strange that in spite of thrombosis, patient went for surgery. was he on LMWH at that time? Keep us updated. Thanks Naveed
  10. 1 point
    Our conference the Future of Neonatal Care is now only a 2 weeks away, and we are really looking forward to welcome everyone attending. We expect around 130 delegates, Faculty members and Partner representatives, as of today representing 32 countries around the globe. A truly international group of people, from East to West, from North to South. We are excited and truly honoured to welcome you all to Vienna! And yes, we still have a few seats available. But only a few. Click here to see if one is available for you
  11. 1 point
    Skin to skin care or kangaroo care is all the rage and I am the first one to offer my support for it. Questions persist though as to whether from a physiological standpoint, babies are more stable in an isolette in a quiet environment or out in the open on their mother or father’s chests. Bornhorst et al expressed caution in their study Skin-to-skin (kangaroo) care, respiratory control, and thermoregulation. In a surprising finding, babies with an average gestational age of 29 weeks were monitored for a number of physiological parameters and found to have more frequent apnea and higher heart rates than when in an isolette. The study was small though and while there were statistical differences in these parameters they may not have had much clinical significance (1.5 to 2.8 per hour for apnea, bradycardia or desaturation events). Furthermore, does an increase in such events translate into any changes in cerebral oxygenation that might in turn have implications for later development? Tough to say based on a study of this magnitude but it certainly does raise some eyebrows. What if we could look at cerebral oxygenation? As you might have guessed, that is exactly what has been done by Lorenz L et al in their recent paper Cerebral oxygenation during skin-to-skin care in preterm infants not receiving respiratory support.The goal of this study was to look at 40 preterm infants without any respiratory distress and determine whether cerebral oxygenation (rStO2)was better in their isolette or in skin to skin care (SSC). They allowed each infant to serve as their own control by have three 90 minute periods each including the first thirty minutes as a washout period. Each infant started their monitoring in the isolette then went to SSC then back to the isolette. The primary outcome the power calculation was based on was the difference in rStO2 between SSC and in the isolette. Secondary measures looked at such outcomes as HR, O2 sat, active and quiet sleep percentages, bradycardic events as lastly periods of cerebral hypoxia or hyperoxia. Normal cerebral oxygenation was defined as being between 55 to 85%. Surprising results? Perhaps its the start of a trend but again the results were a bit surprising showing a better rStO2 when in the isolette (−1.3 (−2.2 to −0.4)%, p<0.01). Other results are summarized in the table below: Mean difference in outcomes Variable SSC Isolette Difference in mean p rStO2 73.6 74.8 -1.3 <0.01 SpO2 (median) 97 97 -1.1 0.02 HR 161 156 5 <0.01 % time in quiet sleep 58.6 34.6 24 <0.01 No differences were seen in bradycardic events, apnea, cerebral hypoexmia or hyperoxemia. The authors found that SSC periods in fact failed the “non-inferiority” testing indicating that from a rStO2 standpoint, babies were more stable when not doing SSC! Taking a closer look though one could argue that even if this is true does it really matter? What is the impact on a growing preterm infant if their cerebral oxygenation is 1.3 percentage points on average lower during SSC or if their HR is 5 beats per minute faster? I can’t help but think that this is an example of statistical significance without clinical significance. Nonetheless, if there isn’t a superiority of these parameters it does leave one asking “should we keep at it?” Benefits of skin to skin care Important outcomes such as reductions in mortality and improved breastfeeding rates cannot be ignored or the positive effects on family bonding that ensue. Some will argue though that the impacts on mortality certainly may be relevant in developing countries where resources are scarce but would we see the same benefits in developed nations. The authors did find a difference though in this study that I think benefits developing preterm infants across the board no matter which country you are in. That benefit is that of Quiet Sleep (QS). As preterm infants develop they tend to spend more time in QS compared to active sleep (AS). From Doussard- Roossevelt J, “Quiet sleep consists of periods of quiescence with regular respiration and heart rate, and synchronous EEG patterns. Active sleep consists of periods of movement with irregular respiration and heart rate, and desynchronous EEG patterns.” In the above table one sees that the percentage of time in QS was significantly increased compared to AS when in SSC. This is important as neurodevelopment is thought to advance during periods of QS as preterm infants age. There may be little difference favouring less oxygen extraction during isolette times but maybe that isn’t such a good thing? Could it be that the small statistical difference in oxygen extraction is because the brain is more active in laying down tracks and making connections? Totally speculative on my part but all that extra quiet sleep has got to be good for something. To answer the question of this post in the title I think the answer is a resounding yes for the more stable infant. What we don’t know at the moment except from anecdotal reports of babies doing better in SSC when really sick is whether on average critically ill babies will be better off in SSC. I suspect the answer is that some will and some won’t. While we like to keep things simple and have a one size fits all answer for most of our questions in the NICU, this one may not be so simple. For now I think we keep promoting SSC for even our sick patients but need to be honest with ourselves and when a patient just isn’t ready for the handling admit it and try again when more stable. For the more stable patient though I think giving more time for neurons to find other neurons and make new connections is a good thing to pursue!
  12. 1 point
    Nicutools.org is pretty helpful!
  13. 1 point
    @bimalc Thanks for further input in this topic. Well yes, your setup seems to be great and to me, proving that you in the US have understood the importance to invest in time for research and development. Around here, positions combining clinical work and (hospital-funded) academic work is rare. Unless it was such a big thing to become accredited as a clinician in the US, I'd be happy to take the leap over the Atlantic (given that family could be convinced), with a luggage of clinical epi skills and top-notch ideas
  14. 1 point
    @Amir Fassihi Thanks so much for your kind words. Let's hope we as a large community can support your venture to create something very innovative! Looking fw to meet up, in Vienna in April or at our 2019 meeting
  15. 1 point
    One of our fellows showed me these two videos on Youtube, on how to learn brain ultrasound. Both videos are very good! Enjoy Part 1 - anatomy and protocol Part 2 - IVH and PVL
  16. 1 point
    The APTS (Australian placental transfusion study) trial has just appeared on line. This was a high-quality multicenter, international RCT of immediate cord clamping (less than 10 seconds) compared to delayed clamping (60 seconds) for babies born less than 32 weeks gestation. (Tarnow-Mordi W, et al. Delayed versus Immediate Cord Clamping in Preterm Infants. the FPNEJM 2017.) Another trial arriving almost simultaneously is a smaller trial from the UK, which compared cord clamping at less than 20 seconds to clamping at at least 2 minutes, with reuscitation staring with the cord intact in the intervention group. (Duley L, et al. Randomised trial of cord clamping and initial stabilisation at very preterm birth. Archives of disease in childhood Fetal and neonatal edition. 2017.) I will come back to that trial in part 2. The benefits of delayed cord clamping for term babies are quite obvious from the RCTs, and basically show a significantly improved Hemoglobin/Iron status for the first year of life, which seems to lead to some improvement in fine motor function, in the long term, with no important down-side. The higher bilirubin levels among late-clamped babies do not lead to more phototherapy, if modern restrictive phototherapy guideline are followed. The only real disadvantage is that it is much harder to give blood to a public cord blood bank after delayed clamping. Public banks have been the source of stem cells for bone marrow transplants for hundreds of children (and as far as I know adults as well) so this should not be dismissed... For the preterm baby I thought that much of the evidence had been over-hyped, with claims of reduced IVH, and reduced NEC, based on tiny numbers from tiny trials, with no robust evidence of benefit, apart from higher hemoglobins, probably leading to fewer transfusions. What we really needed was a large RCT with enough power to answer questions about efficacy and safety. The APTS trial gives that power, with over 1500 babies randomized, and, although much smaller, the trial from England is the second largest trial, with over 260 babies. The remaining trials that have been quoted as the justification for the worldwide movement for delayed clamping in the preterm, have mostly been tiny, with sample sizes between 32 and 200. What did the APTS trial show? Speaking in the strictest sense it showed no difference between groups in the primary outcome. The primary outcome was a composite outcome of death, serious brain injury, late-onset sepsis, necrotising enterocolitis or severe retinopathy. When the study was planned bronchopulmonary dysplasia was also part of the primary outcome, but with changes in practice the authors found that the incidence of "BPD" was much higher than expected (many babies were on respiratory support with positive pressure and 21% oxygen at 36 weeks post-menstrual age), so during the trial, before the final data were analysed, BPD was deleted from the composite outcome. When you look at the individual components of the composite outcome, there is no sign of a benefit for any of the components of that composite, except one, that is mortality. When only one part of a composite outcome is positive, but it is much less frequent than the remaining parts, the overall composite may well be negative. This is one of the problems with composite outcomes, you can actually lose power for the most important part of the composite, whereas these composites are usually being used to try to increase power! The outcome of death should therefore strictly be considered to be a secondary outcome, and therefore treated with some scepticism. I'll come back to this point. Also important is the fact that 26% of the delayed clamping group did not get 60 seconds of delay, which was most often due to concerns about the neonatal status (70% of the time). This was unavoidable given the design, as most centers were not resuscitating babies with the cord intact. 20% of the delayed clamping group got the cord clamped before 30 seconds, the other 6% who did not follow protocol it was between 30 and 60 seconds. It would be interesting to have a "per-protocol" analysis of mortality results, which I would guess would show a greater difference between groups, as babies who had the delayed clamping interrupted because of concerns about neonatal status might well have a higher mortality. There is an analysis of the per-protocol effects on the primary outcome (in the supplementary appendix) which shows a difference (which may just be due to chance, p=0.2) : 37% with immediate clamping, and 33% with delayed clamping, but no mention of the components of that outcome. There is also a report of the causes of death in the supplementary appendix, causes which cover the entire range of causes of death among very preterm babies. The biggest single cause was septicemia, which was also the cause that showed the biggest difference between groups, 2.2% immediate clamping, and 0.5% delayed clamping. There is also an analysis in detail of head ultrasound findings which show no tendency to be different in any aspect between groups. Finally there were many fewer babies who needed blood transfusions with the delayed clamping (61% with immediate clamping, 52% with delayed clamping) but more babies with polycythemia (2% had hematocrit >65% with immediate clamping, 6% with delayed clamping, 1% over 70% immediate, 2% with delayed). There was no clinically important difference in bilirubin concentrations (mean was 3 micromoles higher with delayed). Overall then, a potential decrease in mortality, a decrease in the number of babies receiving transfusion, with a very small increase in polycythemia, which was probably not due to chance (p<0.001). What to do with these results? Well, as yet there is no signal for a clinically important harm of delayed cord clamping; with the proviso that babies who are intended to have delayed cord clamping may often have the cord clamped early. I think that a clinical approach planning for delayed clamping at, or perhaps after 60 seconds, is consistent with the best evidence, it will decrease the number of babies receiving transfusions, and might decrease mortality. We also need an updated systematic review and meta-analysis. But for that you will have to wait for part 3!
  17. 1 point
    We have a new Babylog 8000 plus ventilator in our NICU for the first time and I have 2 questions about it: 1- What is the commonly used values regarding volume triggering ? 2- what is the acceptable percentage of leak ? ــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ Mohamad Ismail, Neonatology resident, Mansoura, Egypt .
  18. 1 point
    Looks strange! Bulleaous skin changes or flat? Erythematoues (compressable)? History sounds like some kind of Harlequin phenomena but the images does not really look like it I think.
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