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Showing content with the highest reputation since 07/10/2020 in all areas

  1. 4 points
    https://onlinelibrary.wiley.com/doi/epdf/10.1111/apa.15495 With kind permission from Luigi Gagliardi. And as mentioned: the "official" accepted Ms. It is marked as "free download", so it is perfectly legal. (As soon as the final version is available, I will post the link )
  2. 3 points
    I recently had the honour of being asked to present grand rounds at the University of Manitoba. My former Department Head during the question period stumped me when he asked me what role angiotensin converting enzyme 2 receptor (ACE2) has in pediatric COVID19. Like all great teachers, after I floundered and had to confess that while I was aware there is a role in COVID19 I wasn’t sure of the answer, he sent me a paper on the subject. The reality is that a very small percentage of COVID19 illness is found in children. Some estimates have it at 2%. Why might that be? It’s what’s in the nose that matters What has been known for some time know is that the point of entry for SARS-CoV-2 is the nasal epithelium. What is also known is that the receptor that the virus binds to in order to gain access to the host. Such binding and what happens after the virus gains entry to the body is shown in this figure depicting the life cycle of SARS-CoV-2. In a research letter by Bunyavanich et al Nasal Gene Expression of Angiotensin-Converting Enzyme 2 in Children and Adults looked at 305 patients from ages 4-60 years to examine biomarkers of asthma. In the course of looking at the nasal epithelium of these patients, they found age related differences in the expression of ACE2 receptors as shown in the following figure. I think the results somewhat speak for themselves. The younger you are the less receptors you have. If you have less receptors maybe you are less likely to contract the virus! What we don’t know This research leads to some interesting questions. Drugs such as losartan and valsartan already exist and function by blocking he ACE2 receptor. Could blockade help to limit the spread of infection? I am not aware of any such trials going on at the moment but something worth looking at. The other point that needs to be raised is that the most vulnerable group of ages >60 were not looked at in this study. The trend would certainly indicate that with age we would expect the receptor numbers to increase but since we don’t actually have the data in the older groups we don’t know if receptor numbers start to fall again with age. Similarly we don’t know below the age of 4 what receptor numbers are like. In examining risk of vertical transmission it is worth noting that the recent placental positive RT-PCRs as in Detection of SARS-COV-2 in Placental and Fetal Membrane Samples. In that study while 3 of 11 placental membranes tested positive, none of the newborns were infected. Could it be the fetus and newborn is protected by having very little density of ACE2 receptors? Something to look at and will be no doubt. Regardless, in the fight against COVID19 maybe one direction for therapeutic targeting should be addressing this receptor and seeing if there is something we can’t do to make it less susceptible to binding.
  3. 3 points
    https://journals.lww.com/pidj/Abstract/9000/INTRAUTERINE_TRANSMISSION_OF_SARS_COV_2_INFECTION.96099.aspx A case report of likely vertical transmission as well.
  4. 3 points
    Just a few days ago, Professor de Luca in Paris showed a paper with a scientific evidence of vertical transmission of Sars-Cov-2. An excellent (although sad) news by an excellent professor. Coincidentally, yesterday the National Perinatal Institute, in Mexico made a webinar about this topic. In this slide, what you can see, they are showing in the left, that 17 of 86 placenta tested positive to Covid PCR; that 11 of 22 amniotic fluids tested positive and that 6 of 17 human milk the same. All in mothers positive to Covid-19. Hope this will be of interest for you all.
  5. 3 points
    Hi, We always synchronise CC and ventilation 3:1. We found out, by measuring Tv during unsynchronized CC - Ventilation using our ventilator, that compression at the same time as a Ventilation breath leads to no lung ventilation. Birth in Simulation setting as in Resuscitation setting. Using BMV, LMA or uncuffed tube doesn’t make any difference. Please let me know if someone has the same experience.
  6. 2 points
    Considering hygiene you should not do it, but I do it 1. if I need a blood culture and the line may be responsible for the infection, 2. if I need blood and the PICC line is about to be withdrawn, 3. in emergencies. The technique is to withdraw with a 1 ml syringe using a constantly changing negative pressure of 0,5 ml maximum. Stop if the blood column does not move constantly (and slowly) and immediately flush with a prepared saline syringe. It works 90% of the time. Erythrocytes are a lot smaller (7,5µm) than the inner diameter of a PICC line (28G = 1Fr has 0,17mm = 170µm). A study has shown that you can give blood via a PICC line without hemloysis (Pediatr Crit Care Med. 2004 Jan;5(1):69-74. PMID: 14697112). See also nice experiments in https://chartermedical.com/wp-content/uploads/2015/09/TexasChildrensPDF.pdf. There it is stated that you should not do it with platelets because of clotting. In an emergency we gave 80 ml FFP via 28G PICC line with no problems. It needs a pump with pressure cut of set to max - you can not do it by hand.
  7. 2 points
    Intubate-Surfactant- Extubate or INSURE has been around for awhile. The concept is to place an ETT while an infant is first on CPAP and then after pushing surfactant in quickly remove the ETT and put back on CPAP. This does not always go as planned though. If after surfactant the FiO2 remains above 30% many people would keep the ETT in place as they would surmise that the infant would fail if the tube was removed. They would probably be right. Sustained inflations have fallen out of favour ever since the SAIL trial results were published and written about here . Having said that, the concept of using sustained inflation is to open the lung and expand closed alveoli to improve both oxygenation and gas exchange. Much like giving inhale nitric oxide to a collapsed lung is unlikely to make much difference, the question could be asked whether giving surfactant to a lung that is most collapsed will fail to deliver this compliance improving medication to the areas of the lung that most sorely need it. Our Italian colleagues therefore decided to undertake a study to look at providing surfactant to lungs after a recruitment manouver and see if this made a difference to the meaningful outcome of extubation failure after surfactant provision. The results are intriguing and as such here we go in looking at the study. Optimizing Lung Expansion The trial is the Lung recruitment before surfactant administration in extremely preterm neonates with respiratory distress syndrome (IN-REC-SUR-E): a randomised, unblinded, controlled trial and involved 35 NICUs in Italy. All infants enrolled were born from 24 + 0 weeks to 27 6/7 weeks gestational age at birth and all < 24 hours of age at enrollment. Each baby had to be on CPAP at the time of randomization and meet prespecified failure criteria of FiO2 of 0·30 or greater for target SpO2 of 87% to 94% for at least 30 min or in 10 Infants for rapid deterioration of clinical status or if pCO2 was > 65 mm Hg with a pH less than 7·20. Regardless of which arm they were randomized to all infants received 1-2 sustained inflation breaths using 25 cm H2O for 10-15 secs using a t-piece resuscitator after being started on CPAP as was the practice at the time. After randomization which could not be blinded, patients were then either given surfactant via INSURE without any further strategy for opening the lung or received the IN-REC-SUR-E approach. The latter involved putting the infant on high frequency oscillation starting with settings of mean airway pressure 8 cm H2O; frequency 15 Hz; ΔP15 cm H2O; and inspiration to expiration ratio of 1:2. Using this modality infants underwent stepwise recruitment methods prior to administering surfactant (poractant). The primary outome was the need for mechanical ventilation within the first 72 h of life. Infants met the primary outcome if they were not extubated within 30 min after surfactant administration or required reintubation before 72 h of life. The Results Based on a power calculation the authors needed 103 infants in each arm and they recruited 107 in the treatment and 111 in the control arm. In the per-protcol allocation 101 received the treatment and 111 the contol. While the strategies for extubation were not set out to be equal (units were allowed to extubate to anywhere from +6 to +8 for pressure levels), the groups were not different 7·0 cm H2O, SD 0·4 for the experimental group and control arms. Given the steps taken to open the lung in the lung recruitment arm, the FiO2 was lower at 28% prior to surfactant provision in the treatment group than in the usual INSURE approach at 42% prior to surfactant provision. All infants were extubated within 30 minutes of receiving surfactant. As the results demonstrate, whether there was an intention to treat analysis or per-protocol analysis the babies who received the intervention were more likely to remain extubated. The number needed to treat was 7 which is a pretty powerful measure. Interestingly, looking at secondary outcomes there are some interesting trends as well including less mortality which on a per-protocol analysis was significant but also a trend towards more PVL at 9% in the treatment arm and 4% in the control. The mean times to surfactant administration were 4 hours in the treatment group and 3 hours in the control but the high frequency manoeuvre had a mean duration of only 30 minutes. It is possible that the use of high frequency could have blown off CO2 to very low levels but I am uncertain if the short reduction in pCO2 could have contributed significantly to reduced cerebral perfusion if that trend is representative of something. Interestingly, pneumothroaces were not different between groups as no doubt as a reader you might wonder if use of high pressures to recruit the lungs when they are non compliant might have led to air leaks. So it worked, now what? First of all, the results to me make a lot of sense. Opening the lung before delivering surfactant and then seeing better chances of staying extubated doesn’t really surprise me. Some questions that come up now for me would be how this strategy would fare in those who are older at birth. I suspect given the greater chest wall support and lower likelihood of severe RDS this strategy might be even more effective at reducing FiO2 or perhaps CPAP need in terms of duration after extubation. I would think it unlikely to make a difference in reintubation though as most would remain extubated regardless. That is for another study though with a different outcome. There will be centres that don’t like the use of HFOV for recruitment so what other strategies could be used in lieu of this? I hate to say it but there will also be calls to have a much larger study specifically designed to look at the secondary outcomes. Would a larger study find a significant increase in PVL or demonstrate that it was just a random finding? Might mortality be proven to be lower and even more so? Regardless of the above what I think this paper does is give us reason to pause before giving INSURE and ask ourselves if we have done what we can to open the lung after intubating before rushing to squirt the surfactant in. Maybe increasing the provided PEEP and lowering the FiO2 somewhat before giving surfactant will help with distribution and increase your chances of first being able to extubate and secondly when you do keeping the tube out!
  8. 2 points
    I just wanted to share a link about inotropes, a blog post on a British FOAMed* web site: https://www.paediatricfoam.com/2017/01/inotropes-made-simple/ Managing circulatory failure with potent cardio- and vasoactive drugs can be a challenge, and it is necessary to understand the pathophysiology of the problem to choose the right set of interventions and drugs. *FOAMed = Free Open Access Medical Education
  9. 2 points
    https://www.frontiersin.org/articles/10.3389/fped.2018.00088/full https://www.frontiersin.org/articles/10.3389/fped.2018.00086/full https://www.frontiersin.org/articles/10.3389/fped.2018.00084/full And one more fascinating article on cardiovascular supportive therapies for the neonates with asphyxia: https://www.frontiersin.org/articles/10.3389/fped.2018.00363/full fped-06-00363.pdf
  10. 2 points
    These are brilliant! Sent from my iPhone using Tapatalk
  11. 2 points
    My pleasure. Couldn't resist to share three of my most favourite articles on the same topic from Frontiers in Pediatrics. Might-be of your interest. fped-06-00088.pdf fped-06-00086.pdf fped-06-00084.pdf
  12. 2 points
    This new guidance is going to be published in Australia. Have your say: Managing extremely preterm birth at 22-25 weeks’ gestation To help give babies born extremely early the best chance of surviving, we have developed evidence-based clinical guidance to manage pregnant women and their babies. Babies born between 22+0 to 24+6 weeks’ gestation require intensive support for months after birth and those who survive are at risk of disabilities including problems with walking, talking, thinking, seeing and hearing. How we manage at-risk women and extremely preterm babies varies across the state, as do outcomes for these babies. How to provide feedback The draft guidance is now available for feedback before Friday 14 August 2020. After reading our draft guidance and supporting documents, take our quick survey https://www.bettersafercare.vic.gov.au/news-and-media/have-your-say-extreme-prematurity-guidance
  13. 2 points
    Recent studies says it is no more recommended to do corrected wbc in bloody csf samples,and it is better to rely on csf culture , antigen detection tests and gram stain
  14. 2 points
  15. 2 points
  16. 1 point
    We sometimes culture infants for herpes simplex born through a normal vaginal delivery and maternal herpes simplex is discovered late during or after delivery (typically recurring herpes). In case of a positive herpes PCR, for example in the upper airway, but negative PCR in blood and cerebrospinal fluid - how would you outline management How do you reason around "colonization" vs "infection" with herpes simplex? My experience over the years, is that a more active management are now adviced from our virology consultants, i.e. iv acyklovir for a relatively long time period.
  17. 1 point
    I understand that it may be a long time ago you had issues w this baby but I would point out couple of things. Hope you weathered the storm and baby survived. It appeared that from the beginning baby had poor chance. It is important to have good recruitment of the lung before you give surfactant. You dont want it to go only to opened alveoli as the ones closed will be very stiff and eventually end up w PIEs. Undoubtedly Jet is superior to HFOV for PIEs. Jet doesn’t ventilate PIE alveoli allowing them to heal. Ask Dr. Keszler for advices when in question. Next, when you cant oxygenate, like last few CXR shown, and kid is hyperexpanded you are decreasing preload and at the same time obstructing pulmonary flow. You have to drop MAP on HFOV. You need to learn POCUS to look at the heart filling while managing tough cases like this. Also lung US helps a lot. Read Australian and McNamara studies on POC ECHO as well as Kurepa et al. paper on lung US. Finally using higher or lower Hz depends on each baby. See what works for your kid. Remember CXR is just one quick shot in time. All the best.
  18. 1 point
    Greetings everyone Do you draw blood samples from PICC line?
  19. 1 point
    POCUSNEO Canada is pleased to announce the first e-workshops in advanced hemodynamics starting from 1️⃣5️⃣ August 2️⃣0️⃣2️⃣0️⃣ https://pocusneo.org/e-workshops/ https://pocusneo.org/e-conferences/ Yasser Elsayed (University of Manitoba) Muzafar Gani (McMaster University) Emailing E-conference Flyer final R.pdf
  20. 1 point
    Here you are. Please find the attached pdf. Which inotrope for which baby.pdf Arch Dis Child Fetal Neonatal Ed 2006;91:F213–F220. N Evans. Which inotrope for which baby?
  21. 1 point
  22. 1 point
    Article appears to have moved. Here’s the fix https://www.paediatricfoam.com/2017/05/inotropes/ Sent from my iPhone using Tapatalk
  23. 1 point
  24. 1 point
    We practically only use our PICC lines for parenteral nutrition. The small diameter (28G) only makes it possible to infuse only.
  25. 1 point
  26. 1 point
    How do you interpret traumatic LP in a neonate with suspected meningitis? If you re-adjust number of WBC then how do you do it? Please post any reference if you have any. Thanks.
  27. 1 point
    IN some NICUs,If WBC in a neonate with suspected meningitis = A,traumatic LP result in RBC number in CSF = B, the re-adjust number of WBC = A — B/400(B/500)
  28. 1 point
    Phenobarbital at least where I work has been first line treatment for seizure control for as long as I can recall. We dabbled with using phenytoin and fos-phenytoin in the past but the go to tried and true has been phenobarbital for some time. The use of this drug though has not been without trepidation. Animal studies have linked phenobarbital to increases rates of cerebral apoptosis. Additionally, in a retrospective comparison of outcomes between seizures controlled with phenobarbital vs Levetiracetam, the latter came out ahead in terms of better long term developmental outcomes. This study from 2013 was entitled Adverse neurodevelopmental outcomes after exposure to phenobarbital and levetiracetam for the treatment of neonatal seizures. Purists of course would argue the need for a prospective trial and that is what we have to chat about here. Levetiracetam vs Phenobarbital The study in question was a multicenter randomized phase IIb trial (searches for a dose that provides biological activity with the minimal side effect profile) that compared two doses 40 mg/kg and 60 mg/kg of Levetiracetam with standard doses of phenobarbital. The study was done by Sharpe C et al and called Levetiracetam Versus Phenobarbital for Neonatal Seizures: A Randomized Controlled Trial. In this study patients were randomized to receive levetiracetam or control phenobarbital treatment group in a 60:40 allocation ratio by using a block randomization strategy and stratified by site. The trial design is shown in the diagram below. The study was designed to not delay institution of the accepted treatement with phenobarbital as usual first line treatment of seizures by more than 1 hour. The strength of this study was that the authors used electrographic seizures confirmed by continuous EEG monitoring. The efficacy of medication effect was blindly interpretted by two independent electrophysiologists. in other words the authors went out of their way to ensure these were real seizures and moreover that any changes to medications were decided upon after interpretation of effect by people remote from the study. The primary outcome though in comparison to the aforementioned retrospective study was a short one. In this study the primary outcome was initialy absense of seizures for 48 hours but then was changed part way through the study to 24 hours. The change was a practical one since it was noted after data collection that in many cases EEG monitoring had been stopped prior to 48 hours. The Results Honestly it is the results that led me to want to talk about this study. They are the exact opposite of what i thought they would be. Based on my own experience with Levitiracetam seeming like a wonder drug when it comes to seizure control I expected the results to favour it. Not the case. To say that phenobarbital crushed the competition is an udnerstatement. Having said that the incidence of side effects were higher with phenobarbital as well. Hypotension, respiratory suppression, sedation, and requirement for pressor support, were more common. Nonetheless, this study also included patients with HIE and found even in this subgroup phenobarbital was superior. This is important information as one could speculate that earlier seizure cessation in those with anoxic injury already could be especially beneficial. What do we do with these results? As the authors point out this is a study of short term outcomes. In the trial about long term outcome it was clear that treatment with phenobarbital leads to worse outcome than with levitiracetam. Having said that it was a retrospective study so the next step will be to conduct long term outcome studies to see effects. This presents the possibility of an interesting conundrum. What if the newer drug is inferior to tried and true phenobarbital at controlling seizures but leads to better long term outcome? Would you consider allowing seizures to persist longer than you might otherwise want to in the short term but then be able to reassure families that the long term outlook is bettter? The side effect profile of levitiracetam is such that I think neurologists want to use it but the other possibility is that there is another newer anticonvulsant that will need to be tested as wouldn’t it be great not to have to choose either poor acute seizure control but better long term outcome vs better seizure control with concerning long term outcome? As a parent I have no doubt watching a child eize would be terrifying and you would want it to end as soon as possible but the question with phenobarbital is at what cost?
  29. 1 point
    Dear all, I want to share a website that I have created - www.perinatalcovid19.org Please share widely. It has resources to help all of us manage the covid-19 situation we are all facing. I am open to suggestions on how to make it more useful. K.S. Gautham, MD, DM, MS, FAAP Professor of Pediatrics, Baylor College of Medicine Section Head and Service Chief of Neonatology Texas Children's Hospital 6621 Fannin, Suite W6104 Houston, TX 77030
  30. 1 point
    We are living in challenging times but, as a community caring for neonates and their families, we will get through this together. Canadians and others around the world are digesting a great deal of information in order to come up with a best approach to caring for mothers and infants with either suspected or confirmed COVID-19 infections. It is an imperfect science for sure as we have scarce information to go on but you may find it helpful to look at what centres are doing in terms of their approaches to delivery and care in the NICU. Please note that these are being posted in an attempt to share our collective efforts but that referral to your local health authority protocols is recommended. Protocols and other relevant information including sim/ education and processes can be shared from sites across Canada and accessed through the COVID-19 menu at the top of the site. There will no doubt be geographic differences which may be due to unit layout (single/double rooms, open bay concept, negative pressures rooms), local IPC and health authority protocols. Hopefully, though, our community can share useful resources, algorithms, videos, etc that can serve as a framework for others to use or modify to suit their needs. Thanks to all of you for your dedication, your hard work and for your caring. Please stay safe and stay healthy – we will get through this – together. Useful Links Provincial Approaches to Newborn Care COVID19 Provincial Approaches Literature Review COVID19 Literature Additional Organizational Information Ontario “Provincial Council for Maternal and Child Health – Covid 19 Practice Support Tools Interim Considerations for Infection Prevention and Control of Coronavirus Disease 2019 (COVID-19) in Inpatient Obstetric Healthcare Settings
  31. 1 point
    @alyelayyat Have a look at this video: http://www.neoknowledge.org/chest-tube-pigtail/ Regarding knowing when you enter the pleural space - you'll feel it As you insert the tube rather high on the chest you will be certain that the tube is in the pleural cavity when you insert it, the "reciept" will be that you can aspirate air.
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