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Showing content with the highest reputation since 10/21/2013 in all areas

  1. 5 points
    For those of you having follow-up clinics with children born preterm and affected by BPD, check out these European guidelines. A very thorough document. In short, most recommendations (screen shot below) are graded as low or even very low evidence. So there are lots of room for good research! Find the full document here (and yes, it is available as open-access): http://doi.org/10.1183/13993003.00788-2019
  2. 4 points
    different feeding regimens- How much and how fast/slow, gastric residuals
  3. 4 points
    99nicu has become 12 years The first public post (screen shot below) was done on the 11th of May in 2006 by myself and a small group of neonatal friends. Thanks to everyone participating in discussions, sharing great advice and being supportive during these years!
  4. 3 points
    After watching a documentary in ARTE about bacteriophages it made me think about how else is antibiotic resistance in NICU.? It available french / German Here the story phages was told. First discovered use by Felix Derrel to combat infections in the pre-antibiotics era and was later discredited and forget about in the western world Historically they worked rather well, so there is an attempt to bring them back in the light of increasing antibiotics resistance. This rediscovery started with lab study that showed that the phages were effective at clearing infection in rats population sample. Phagoburn Recently, a French team took it to human and show it feasible despite the many challenges. This study was a RCT which a specific process approval and protocols were established. The aim in *Phagoburn*was to see if phages could be useful using to fight infection in burn victims. It was lead by Dr. Patrick Jault and large team .Jerôme Gabbard head Start up tells Pherecydes provided the synthesis of phages. control got standard treatment {silver salts +antiobiotics} and othe got phages.This got published in nature. The was a reduction in the infection rate in phage group, a loading dosing issue among other practical things. Researchers in france say that there a scaling issue to produce larger amounts, as well a regulatory framework. From bioethical point of view it is possible, a more detail informed consent will be necessary.These days research still going a la Croix de Lion Hospital, France. University Hospital ~CHU Lyon~. ( initial used - discovered @pasteur Institute) https://www.arte.tv/fr/videos/078693-000-A/l-incroyable-histoire-des-tueurs-de-bacteries/ Thus what do think any future of phage in NICU?
  5. 3 points
    Oral immune therapy (OIT) has really taken off at least in our units. The notion here is that provision of small amounts (0.2 mL intrabucally q2or 24 hours) can prime the immune system. Lymphoid tissue present in the oropharynx and intestine exposed to this liquid gold in theory will give the immune system a boost and increase levels of IgA. Such rises in IgA could help improve the mucosal defence barrier and therefore lessen the incidence of late onset sepsis. Rodriguez et al described this in their paper Oropharyngeal administration of colostrum to extremely low birth weight infants: theoretical perspectives in 2009. They followed it up the next year with a pilot study demonstrating how to actually administer such therapy. The fact that this approach has been adopted so quickly I think speaks to the principle that this kind of therapy falls into the category of “can’t hurt and might help”. The real question though is does it actually make a difference? Recently, authors from Brazil presented their findings from a single centre double blind RCT entitled Randomized Controlled Trial of Oropharyngeal Colostrum Administration in Very-low-birth-weight Preterm Infants. This authors are commended for studying this practice in such a fashion and included infants <34 weeks who were <1500g at birth to receive the above mentioned intervention. These infants were compared to placebo who received the same intervention except instead of mother’s own colostrum they were given sterile water. In total there were 149 infants randomized with 81 receiving OIT vs 68 who received a placebo. The primary outcome of interest on which a power calculation was performed was the incidence of late onset sepsis. Other typical outcomes including NEC, ROP, BPD, IVH and death were also followed. Did they find a difference? Sadly to many of you I am sure they did not as is shown in the table below. Surprisingly the authors also looked at levels of IgA in infants in both arms and also found no difference. There is a big problem with this study however that no doubt will lead to a repeat version at some point. While the authors enrolled the numbers above, the numbers that were analyzed in the table are 34 lower in the OIT arm and only 2 lower in the placebo group. In essence, a large number of mothers after enrollment were not able to provide the colostrum that was needed for the study. The study called for 48 applications over a 48 hour period and a little more than half of the mothers were able to do it. Do not be dismayed then that no difference was found here. There is no need to “throw the baby out with the bathwater” and abandon OIT based on this one study. I think what is needed in the future though is a study that enrolls far more than needed to account for attrition due to loss of mothers who can complete the study. Without another study I think the practice will continue but does it really make a difference to rates of sepsis? Who knows but there is no doubt it helps parents who are feeling that they have lost control of a pregnancy that has gone wrong, a positive experience and the feeling that they are doing something for their child.
  6. 3 points
    We practise pre-med for INSURE (atropin+fentanyl+pento and some use celo) - my experience is good with regards to cardiovasc and respiratory stability. But as @Nathan Sundgren says, we don't premed if we need to do INSURE right after delivery. Around here, the INSURE procedure also means pre-med, while LISA/MIST is the term used when surfactant is given without pre-med. Originally, when LISA/MIST was first done and studied by Angela Kribs and co-workers (https://www.ncbi.nlm.nih.gov/pubmed/17359406; https://www.ncbi.nlm.nih.gov/pubmed/18298776; https://www.ncbi.nlm.nih.gov/pubmed/18298776) I think their idea was to minimize any drug-related impact on the breathing drive. So they tested with no drugs and it worked well for them. I know many share this experience, that surfactant can be instilled without any pre-med. I personally feel concerned about the laryngoscopy as such, I believe atropine and analgesics would still have a place also in LISA/MIST. And for younger colleagues less experienced with laryngoscopy and intubation, I think the procedure may also be more uncomfortable for infants not given analgesia.
  7. 3 points
    While at the #99nicuMeetup, I and @Francesco Cardona were filmed by Miris (one of our exhibiting partners). It was a one-time shot without rehearsal, so we spoke from the heart
  8. 3 points
    Thanks for sharing your 24wk`s case. To truly be able to give advice, its better to share the current setting which the baby is on her Sats and transCO2. From your question, she is now on conventional ventilation (AC or SIMV) without VG. You have several ventilation maneuvers you can follow: 1- If the ventilator you are using does not have VG, use PIPs which give you volumes of 4~5.5 ml/kg, however, if you have a big leak around the ET tube, it will be hard to follow volumes and you will depend then on your blood gas CO2 or transcu. Co2 or end tidal CO2 and saturation to give a sufficient PIP. 2- if the ventilator has VG, adjust your volumes as above at 4~5.5 /kg the ventilator will provide PIPs to give your selected volumes. Again if the ET tube has a big leak, VG will not work and then you better switch the VG off and do as in # 1 , Or you can change the ET tube with a wider one. 3- In our unit we keep these ELGANs during the first 3 days of life on A/C (after giving surfactant and if intubated) to lower the risk of IVH, then we switch to HFO for several days using gentle ventilation settings until the MAP drops to 10 or 9 in room air, then we consider switching to A/C again or just go down on the MAP and extubate from HFO. Lastly, you mentioned hypoxic episodes, to decrease that start Caffeine and if you are using SIMV switch to AC. Good luck.
  9. 3 points
    Are you sure it is CDH OR diaphragmatic eventration. Differentiation is not easy ???
  10. 3 points
    Find great to gearbeitet about - preventing NEC - ultrasound of the lung - CMV, pasteurisation yes or No. - Mother Milk Banking, ist it worth
  11. 3 points
    The ProPrems Trial investigated the use of probiotics in very preterm infants. The study has been reported at meetings, but the full article will be published in Pediatrics in December. The primary outcome was late onset sepsis, but the finding given most publicity was reduction of NEC. Keith Barrington, neonatologist in Canada and blogging at neonatalresearch.org, argued that probiotics should now be used as NEC prevention and that future research should focus on refining probiotic therapy, not comparing it with placebo. In the new 99nicu Poll we ask about your practise regarding probiotics as NEC prevention. Please also comment your votes. If you use probiotics, please share your experience.
  12. 2 points
    We use this system on an ongoing basis. Very comfortable and does not damage the nasal septum.
  13. 2 points
    This article in NY Times came on my radar, written by a parent whom is also an obstetrician. Very well written piece and I would really recommend it. Sparkles a lot of thoughts on what we do, what we achieve, and the parental perspective. Find the article here: https://parenting.nytimes.com/newborn/prematurity-baby-burden
  14. 2 points
    every time I check my email and find 99nicu in the list I feel too much excited every time I visit this site I gain new information and add new knowledge thanks @Stefan Johansson and all 99nicu members love you all❤️❤️❤️❤️❤️
  15. 2 points
    Interesting subject. In Vienna, we prime insulin infusion systems before use. The insulin is prepared as ordered, we start off with 0.05-0.1 IE/kg/h. After 30min, the insulin in the infusion system is discarded and the same amount/dilution prepared with the same system before use. Let me know if you need more information @ChantalNICU
  16. 2 points
    we do see these cases, and usually they respond in a week or 10 days time. difficult to say how common but its not very uncommon too.
  17. 2 points
    I must say the meetup conference 2019, was outstanding. Is there a chance that the video recording from 2018 meeting will be also available on you tube ? Talat
  18. 2 points
    Hi Bimalc thanks for your reply. This is exactly why I am asking, we do have one center where hyperconcentrated platelets are administered, but need more data if we want to assess their effect on clinical outcomes. So I am hoping to find another 3 or 4 centers in which hyperconcentrated platelets are administered, so we can share our data, analyze the results and hopefully generate more reliable evidence regarding the efficacy of this product in neonates.
  19. 2 points
    We used Protovit for some months when Soluvit wasnt available for us.
  20. 2 points
    Thank you, Stefan, for reminding me of my one major criticism of the PINT trial: They did not include NEC (or at least surgical NEC) in their composite outcome. As for why we, as a profession, continue to worry about TANEC, it is mostly recall bias (we all remember the case of NEC shortly after transfusion but we never stop to think of all the transfusions we have given without NEC appearing) I've often wondered if there isn't already enough data out there to answer these questions (or at least get a start). Supervised learning techniques have advanced sufficient that if you were willing to invest in combining and curating multiple datasets of ELBWs you could probably train a binary classifier to predict risk of NEC with or without transfusion.
  21. 2 points
    A friendly reminder - this is the last week you can register as an Early Bird for our 3rd "Future of Neonatal Care" conference (AKA the 99nicu Meetup), 7-10 April in Copenhagen, Denmark. The program includes important topics such as BPD prevention, cord clamping, HFNC, neonatal transports, transfusions, pain management, NEC-reducing strategies, and management around the border of viability. Furthermore, the last day there will be workshops on EBM, transports, family-centered care and echocardiography. Click here for more information, and to register! Looking fw to meet up in Copenhagen!
  22. 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.
  23. 2 points
    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
  24. 2 points
  25. 2 points
    I find it very interesting but speaking of is not like watching it! For the moment I will not dare do it !
  26. 2 points
    Sounds like pushing the skin-to-skin care to its boundaries! Personally, I think it is not a bad idea as such, I guess one just needs to get used to it. However, it is not uncommon that intubation is not just something isolated, but part of a stabilizing efforts that includes more procedures/medications etc. In other words, I am not sure skin-skin-care is the right thing to do in an infant with respiratory failure, whatever its cause. My personal experience is that I have used parents to comfort the infant (holding support) on the open bed while intubating, i.e. including them in the team doing the stabilization.
  27. 2 points
    Dose & administration Lidocaine should be administered intravenously and can be diluted in dextrose and normal saline solutions. Dose per kg varies according to the duration after the first maintenance dose, and depends on the body temperature when administered: Loading dose – 2 mg/kg over 10 minutes Maintenance dose for normothermic infants: The loading dose is followed by 6 mg/kg/hour over 4 hours, 4 mg/kg/hour over 12 hours, and 2 mg/kg/hour over 12 hours. Hypothermic infants: The loading dose is followed by 7 mg/kg/hour over 3.5 hours, 3.5 mg/kg/hour over 12 hours, and 1.75 mg/kg/hour over 12 hours. Indications Refractory seizures despite first-line treatments in term infants > 2.5kg. Contraindications and special considerations (including incompatibilities) Lidocaine is contraindicated in complete AV block III and wide QRS complex tachycardia. Further, risk factors for cardiotoxicity are unstable potassium serum levels, (congenital) cardiac dysfunction and concurrent phenytoin use. Should not be used with phenytoin. Compatible at terminal injection site with aminophylline, ampicillin, caffeine citrate, calcium (chloride and gluconate), dexamethasone, digoxin, dobutamine, dopamine, fentanyl, heparin, hydrocortisone, insulin, micafungin, morphine, penicillin G, potassium chloride, and sodium bicarbonate. Adverse effects Arrhytmias (rare). Pharmacological aspects Mechanism of action uncertain, probably acts as a membrane stabilizer. Metabolized in liver into its active metabolites and excreted in urine. Tends to accumulate in tissues with high blood flow and to redistribute later. T½ 200 minutes. Use should not be longer than the recommended schedule above. References Anticonvulsant treatment of asphyxiated newborns under hypothermia with lidocaine: efficacy, safety and dosing. Arch Dis Child - Fetal Neonatal Ed. 2013;98(4):F341–F345. PMID 23303304 Weeke LC, Toet MC, van Rooij LGM, et al. Lidocaine response rate in aEEG-confirmed neonatal seizures: Retrospective study of 413 full-term and preterm infants. Epilepsia. 2016;57(2):233–242. PMID 26719344 Weeke LC, Schalkwijk S, Toet MC, van Rooij LGM, de Vries LS, van den Broek MPH. Lidocaine-Associated Cardiac Events in Newborns with Seizures: Incidence, Symptoms and Contributing Factors. Neonatology. 2015;108(2):130–136. PMID 26111505 Lundqvist M, Ågren J, Hellström-Westas L, Flink R, Wickström R. Efficacy and safety of lidocaine for treatment of neonatal seizures. Acta Paediatr. 2013;102(9):863–867. PMID 23738612 Slaughter LA, Patel AD, Slaughter JL. Pharmacological treatment of neonatal seizures: a systematic review. J Child Neurol. 2013;28(3):351–364. PMID 23318696 Document version history Created 2016-10-03 / André M. Graça
  28. 2 points
    Thank you for your detailed comments. The baby did receive surfactant as part of the normal practice. Oxygen requirement was 26% when I got handed over the baby. As mentioned in the first instance ...I couldn't understand those settings at all and thought maybe I do not know the intricacy of HFOV this may be a strategy. But because I was uncomfortable, I read and found out, mostly what that you guys have mentioned above. This has given me so much clarity... cheers to all the gurus' (You all). Much appreciated.
  29. 2 points
    Agree that 6 hz is too slow. Appropriate MAP is key to successfully ventilating and oxygenating. Axiom #1: The best ventilator is the one you have the most expertise with. New (to the user) forms of ventilation open the door for errors of inexperience. Axiom #2: HFOV has a checkered past in many studies. Sun et al demonstrated strongly positive results in VLBW infants receiving HFOV vs pressure support ventilation. Why the discrepancy? Consider the adjunct care. Hypothesis: Whenever an infant is disconnected from an oscillating device, the lungs instantly deflate. Consider that extremely premature infants have little, if any, alveolar surface area.Temporary ventilation is usually provided by a manual resuscitation device that cannot match the oscillator. This act in itself likely contributes to barotrauma and subsequent CLD. Terminal bronchioles are “bubbled up” by attempts to mimic the ventilation we see in term infants. Evidence includes the observation that it can take a half hour after reconnecting the infant to HFOV to fully achieve reinflation. Thus, any interruption in oscillatory MAP can be considered iatrogenic. Axiom#3: The role of manual resuscitation in the development of CLD has not been adequately studied (almost completely ignored). Disconnection from high MAP ventilation is rarely a point of focus. These omissions skew most of the observations and conclusions in neonatal ventilation studies. ref: Sun et al ClinicalTrials.govNCT01496508 Respiratory Care Feb 2014, 59(2) 159- 169
  30. 2 points
    Although we have not yet nailed the venue or date for the next 99nicu Meetup (April 2018, in Vienna!), we want to start to crowdsource the program In short, we are searching for topics YOU want to see in the program! No matter how controversial, evidence-based, or big or small, we want your input on topics that help you perform better in the NICU, thereby improving long-term outcomes infants you care for. Also share your dream team of speakers from any corner of the world, who are dedicated, engaging and know how to convey take-home messages! Of note, we are not only looking for superstars. We also want to offer the 99nicu Meetup stage for raising stars. Maybe YOU should come and give a talk
  31. 2 points
    @Hamed, thanks a lot!. It is a tricky case. CDH wasn't detected prenatally. CPAP was started because of mild RDS and CDH on Xray was somewhat surprising. As the baby was doing well on CPAP we decided do not intubate. Feeding tube was corrected and now CPAP is withdrawn.
  32. 2 points
    @amirmasoud2012 well... not all photos/videos says more than 1000 words
  33. 2 points
    Sorry I cannot share anything valuable about this Have only experience from low-volume strategy on HFO only (but have good experience with HFO for any air leaks incl PIE)
  34. 2 points
    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 www.jpeds.com/article/S0022-3476(17)30781-3/
  35. 2 points
    As a Neonatologist I doubt there are many topics discussed over coffee more than BPD. It is our metric by which we tend to judge our performance as a team and centre possibly more than any other. This shouldn't be that surprising. The dawn of Neonatology was exemplified by the development of ventilators capable of allowing those with RDS to have a chance at survival. As John F Kennedy discovered when his son Patrick was born at 34 weeks, without such technology available there just wasn't much that one could do. As premature survival became more and more common and the gestational age at which this was possible younger and younger survivors began to emerge. These survivors had a condition with Northway described in 1967 as classical BPD. This fibrocystic disease which would cripple infants gave way with modern ventilation to the "new bpd". The New BPD The disease has changed to one where many factors such as oxygen and chorioamnionitis combine to cause arrest of alveolar development along with abnormal branching and thickening of the pulmonary vasculature to create insufficient air/blood interfaces +/- pulmonary hypertension. This new form is prevalent in units across the world and generally appears as hazy lungs minus the cystic change for the most part seen previously. Defining when to diagnose BPD has been a challenge. Is it oxygen at 28 days, 36 weeks PMA, x-ray compatible change or something else? The 2000 NIH workshop on this topic created a new approach to defining BPD which underwent validation towards predicting downstream pulmonary morbidity in follow-up in 2005. That was over a decade ago and the question is whether this remains relevant today. Benchmarking I don't wish to make light of the need to track our rates of BPD but at times I have found myself asking "is this really important?" There are a number of reasons for saying this. A baby who comes off oxygen at 36 weeks and 1 day is classified as having BPD while the baby who comes off at 35 6/7 does not. Are they really that different? Is it BPD that is keeping our smallest babies in hospital these days? For the most part no. Even after they come off oxygen and other supports it is often the need to establish feeding or adequate weight prior to discharge that delays things these days. Given that many of our smallest infants also have apnea long past 36 weeks PMA we have all seen babies who are free of oxygen at 38 weeks who continue to have events that keep them in hospital. In short while we need to be careful to minimize lung injury and the consequences that may follow the same, does it matter if a baby comes off O2 at 36, 37 or 38 weeks if they aren't being discharged due to apnea or feeding issues? It does matter for benchmarking purposes as one unit will use this marker to compare themselves against another in terms of performance. Is there something more though that we can hope to obtain? When does BPD matter? The real goal in preventing BPD or at least minimizing respiratory morbidity of any kind is to ensure that after discharge from the NICU we are sending out the healthiest babies we can into the community. Does a baby at 36 weeks and one day free of O2 and other support have a high risk of coming back to the hospital after discharge or might it be that those that are even older when they free of such treatments may be worse off after discharge. The longer it takes to come off support one would think, the more fragile you might be. This was the goal of an important study just published entitled Revisiting the Definition of Bronchopulmonary Dysplasia: Effect of Changing Panoply of Respiratory Support for Preterm Neonates. This work is yet another contribution to the pool of knowledge from the Canadian Neonatal Network. In short this was a retrospective cohort study of 1503 babies born at <29 weeks GA who were assessed at 18-21 months of age. The outcomes were serious respiratory morbidity defined as one of: (1) 3 or more rehospitalizations after NICU discharge owing to respiratory problems (infectious or noninfectious); (2) having a tracheostomy (3) using respiratory monitoring or support devices at home such as an apnea monitor or pulse oximeter (4) being on home oxygen or continuous positive airway pressure at the time of assessment While neurosensory impairment being one of: (1) moderate to severe cerebral palsy (Gross Motor Function Classification System ≥3) (2) severe developmental delay (Bayley Scales of Infant and Toddler Development Third Edition [Bayley III] composite score <70 in either cognitive, language, or motor domains) 3) hearing aid or cochlear implant use (4) bilateral severe visual impairment What did they find? The authors looked at 6 definitions of BPD and applied examined how predictive they were of these two outcomes. The combination of oxygen and/or respiratory support at 36 weeks PMA had the greatest capacity to predict this composite outcome. It was the secondary analysis though that peaked my interest. Once the authors identified the best predictor of adverse outcome they sought to examine the same combination of respiratory support and/oxygen at gestational ages from 34 -44 weeks PMA. The question here was whether the use of an arbitrary time point of 36 weeks is actually the best number to use when looking at these longer term outcomes. Great for benchmarking but is it great for predicting outcome? It turns out the point in time with the greatest likelihood of predicting occurrence of serious respiratory morbidity is 40 weeks and not 36 weeks. Curiously, beyond 40 weeks it becomes less predictive. With respect to neurosensory impairment there is no real difference at any gestational age from 34-44 weeks PMA. From the perspective of what we tell parents these results have some significance. If they are to be believed (and this is a very large sample) then the infant who remains on O2 at 37 weeks but is off by 38 or 39 weeks will likely fair better than the baby who remains on O2 or support at 40 weeks. It also means that the risk of neurosensory impairment is largely set in place if the infant born at < 29 weeks remains on O2 or support beyond 33 weeks. Should this surprise us? Maybe not. A baby who is on such support for over 5 weeks is sick and as a result the damage to the developing brain from O2 free radical damage and/or exposure to chorioamnionitis or sepsis is done. It will be interesting to see how this study shapes the way we think about BPD. From a neurosensory standpoint striving to remove the need for support by 34 weeks may be a goal worth striving for. Failure to do so though may mean that we at least have some time to reduce the risk of serious respiratory morbidity after discharge. Thank you to the CNN for putting out what I am sure will be a much discussed paper in the months to come.
  36. 2 points
    I like to share this article about neonatal pain management I consider it amazing I hope you will enjoy it Neonatal pain policy.pdf
  37. 2 points
    Dear Colleagues We have produced videos for percutaneous long line, scalp long lines and umbilical venous and arterial line insertion. They are available on the MPROvE website http://www.wonepedu.com/MPROvE.html There are also videos on human factors. Alok
  38. 2 points
    In the UK an "intensive care" day for a newborn is defined as a day where the baby is intubated and ventilated, or is on non-invasive respiratory support (CPAP of non-invasive ventilation) AND parenteral nutrition, or on the day of surgery, or on the day of death, or a day when they have any of the following: Presence of an umbilical arterial line Presence of an umbilical venous line Presence of a peripheral arterial line Insulin infusion Presence of a chest drain Exchange transfusion Therapeutic hypothermia Prostaglandin infusion Presence of replogle tube Presence of epidural catheter Presence of silo for gastroschisis Presence of external ventricular drain Dialysis (any type) The next level of care is referred to as "high-dependency" and includes for example CPAP with full enteral feeds, or parenteral nutrition without positive pressure respiratory support. The British Association of Perinatal Medicine standards state that on an intensive care day a baby should have a 1:1 nurse ratio, on a high-dependency day they should have 1 nurse per 2 babies. A new publication from a group in the UK has found that in 2008 only 9% of intensive care days had 1:1 staffing, and in 2012 that had fallen to 6%, when examining data from 30 to 40 NICUs around the country. As you are all aware, the severity of illness of babies who would be classified as "intensive care" using the BAPM criteria varies hugely. In order to determine whether there is an impact of nursing ratios on outcomes, it is necessary to try to adjust for this severity. But just crudely, if the reduction of days of 1:1 ratio is because the babies are less sick (and someone thought they didn't really need 1:1) then mortality should have fallen. In fact it increased. Over the years where the proportion of days with less 1:1 nursing was falling mortality increased from 4 out of every 100 babies receiving intensive care to 4.5, passing a peak of 5.3 in 2010 and 2011. Of course the authors have much more sophisticated analysis than that, and after doing all the adjustments that they could, they calculate that, from a median mortality rate of 4.5, every time you decrease the proportion of 1:1 days by 10% you increase mortality by 0.6, that is, to 5.1, then to 5.7... An accompanying editorial says it all: The data may not be directly applicable to other health care systems, where some of the roles of NICU nurses in the UK are covered by other professionals, in the UK, for example they do not have respiratory therapists, and it is the nurses who do the tasks that RTs do in our NICU. Nevertheless I am convinced that the same principle applies in North American NICUs, when the workload is higher, and we can provide fewer 1:1 nurse assignments, then infection rates are higher, and probably, mortality also. I also think that maybe the BAPM should rethink their criteria. Does every child with an Umbilical Venous Line really need 1:1 nursing? A full term baby with hypoglycemia who has a UVC placed for glucose administrator would be classified as "intensive care" and would be supposed to have 1:1. A nurse could probably safely look after 2 babies whose only criteria for "intensive care" was the presence of a chest tube. If you could rationalize the criteria you would probably be able to put more pressure on the system to provide 1:1 for those babies that really need it. On the other hand a baby who no longer needs parenteral nutrition, but who has just been extubated to CPAP would not be "intensive care" but really needs expert dedicated nursing at a high ratio to prevent re-intubation, and should maybe be considered "intensive care" if they are under 28 weeks for the first 48 hours at least. I have said many times that I think the most important factor in mortality and morbidity of the extremely immature babies is the quality of the nursing care they receive. In order to give care of good quality, as this study shows, you need adequate quantity.
  39. 2 points
    We have decided to restrict site access for temporary visitors. From now on it is possible to read only a few articles and posts without logging in. We have taken this step to increase the number of members who are logging in. It is as easy to log in here as to log in on Facebook If you have a membership but need help to login, first try to reset your password. If you need more assistance - please email info@99nicu.org and we will assist you further. If you are not a member but work in the context of neonatal medicine or research, sign up for a membership. It is free of charge!
  40. 2 points
    First and foremost - I would like to wish you the best for the upcoming New Year 2016! During 2015, I think 99nicu thrived really well. Especially memorable moments were: our first virtual journal club the comeback of the 99nicu Polls plenty of great blog posts from Keith Barrington and Michael Narvey our upgrades that resulted in a great new interface (finally fully responsive on mobiles), made possible by educational grants from Acta Paediatrica and the ROP trial. our sharing of the Orphan-Europe webcast on PDA echo assessment For 2016, I hope 99nicu reaches its full potential as the busy community needed by professional in neonatal medicine. This is what I personally think about for 2016: future journal clubs, (next is scheduled 12 January) more active discussions in the forums more blogs (email me on info@99nicu.org if you need help to start a blog) a crowd-sourced Pharmacopedia (Neonatal Formulary) the 99nicu 10year anniversary, in May 2016! New Years Greetings from the early frosty winter in Stockholm! Stefan Johansson, MD PhD
  41. 2 points
    Originally posted at: https://winnipegneonatal.wordpress.com/ Facebook Page: https://www.facebook.com/allthingsneonatal/ The journey from conception to the labour floor and then for some to the NICU is not a straight one. There are times of joy, interspersed with sadness, denial, anger and eventually acceptance, as initial news of being pregnant leads to complications in pregnancy and then eventual admission of an infant to the NICU. Much has been said in recent years about the building of partnerships with parents and in fact there is a new catchphrase attached to the concept "shared decision making" (SDM). There is no question that in the perfect world this is exactly the relationship that we should be striving for with all of our patients. The world however is not perfect and although this may not be the most popular opinion I have given, I question how applicable this really is in many situations. A Reality Check Take for instance the parents who present to the labour floor of their local hospital in advanced labour at 24 weeks. Proponents of this SDM model would suggest that a meeting take place and pertinent information be given to a family and together with the assistance of literature applicable to their situation (possibly a pamphlet) the health care providers and families come to a mutually agreeable decision as to what the best course of action is for them and their unborn infant. This all sounds wonderful but examining the real life situation a little more closely is it actually reasonable to assume we can obtain this? I have not been, nor will I ever be pregnant and certainly have never experienced contractions and felt the veil clouding my vision as the first dose of analgesia enters my veins to deal with the discomfort a woman experiences during labour. Not to mention there are people admitting this couple, taking histories, establishing IV access, scanning bellies and a whole host of other pokes and prods along the way. My Role Better Defined Then I come in. Among all this chaos I deliver the information, pass along a pamphlet and do the best job I can to inform said couple of the upcoming decision. The trouble of course is how do we come to this mutual decision in the 15 - 30 minutes I spend with them during this crisis? The answer sadly is we do our best but don't for a minute think that SDM has occurred. I don't believe this is possible unless the family has prior experience with a preterm birth or perhaps is a HCP working with newborns or children with disabilities themselves. In fact Boss RD et al in their own research on the subject identified that in hindsight religion, spirituality and hope are what motivated parents rather than what was said at the time. In essence their minds are already made up. It doesn't mean we shouldn't strive for the SDM but at least in my opinion, unless their contractions settle, a calmness ensues, they have time to digest the information being given and then meet again under less stressful circumstances, the SDM is a nice idea but for many not a reality. Shifting To The NICU I recall a significant moment in my training when I saw how the SDM model can actually cause more grief than help. Dr. Keith Barrington a fellow blogger (if you haven't discovered him, his work is fascinating over at Neonatal Research) published one of the most impactful pieces of research of the decade during my fellowship. The adverse neuro-developmental effects of postnatal steroids in the preterm infant: a systematic review of RCTs. Following this analysis there was a near moratorium on the use of post natal steroids. The issue this created was that to now receive them you had to be close to the end of the limits of care. At this point you either died (thereby concluding they are of no help) or you survived with disability that was due in part no doubt to how sick you had become (thereby concluding they are dangerous). The moment I am referring to was a conversation with a family in which the attending managing the unit presented the risks and benefits of postnatal steroids to the family when the FiO2 was at 40% one day. The language used was non directive and the parents asked for another day to decide. The next day and each of the following two days they were unable to choose between giving the steroids and the perceived risk of brain damage versus not and watching the FiO2 climb by about 10% per day. By the time the FiO2 several days later was at 80-90% they were distraught, teary and feeling helpless. What they needed was direction; someone to give them some advice or more simply an educated opinion. We can strive to share in the decision making but I continue to believe there is a time and place to help our families by taking a stance or side. We can equip them with as much information as we want but is there really any replacement for actually taking care of these infants, experiencing the ups and downs and hearing how they have done in follow-up? We simply can't expect the average parent to understand the true long term consequences of their decisions. I am not saying we go back to a paternalistic time in medicine but I am saying that one size does not fit all. We owe it to our families to pursue SDM when we can but we have an equal obligation to recognize when this ideal state is simply not possible. At this point we have to use the experiences and knowledge we have to provide them with the best advice we can. We have gone through medical training, and gone down these paths so many times. We can avoid biased opinion and rely on the facts as they are in our institutions but to not take a stand when it is needed at least for me is doing a disservice to those we are so eager to help.
  42. 2 points
    Hello, I don't have a good answer but I think there are some things more important than others. Like Japan we have almost full coverage of antenatal care (free service for all). About 95% of pregnancies are ultrasound-dated, i.e. we have a uniform estimate of gestational age. Obstetric and neonatal services are fairly well "coordinated" and available to all. Level-3 NICU care is centralized to (7?) regional/university hospitals and the vast majority small infants are transferred in utero to their level-3 hospital. And, we have a relatively low proportion of really socially disadvantaged parents. Apart from that we also have a tradition of non-invasive ventilation (nCPAP) also in tiny infants - I am not sure but it is likely this was a strategy that was developed due to less staffing and budgets initially... The National Board of Health issued national guidelines recently on some key topics: those are only available in Swe though.... but here they are: http://www.socialstyrelsen.se/publikationer2014/2014-9-10 However, I think there is a greater room for improvements in Sweden: we don't use probiotics our transportation services are rather regional "initiatives" than a results of a national strategy there are no national consensus whether 22-weekers should be resuscitated we could still "do less" of things that lack evidence but has potential side-effects we need to combat nosocomial infections better Most importantly, despite the structure of care/society that enables really large observational studies (we can track /link individual data from birth to death, data in several national registries), we do hardly no intervention research. Greetings from Sweden
  43. 2 points
    Does being rude stimulate people to do better, or does it have adverse effects on performance, and team functioning? And how to prove it on way or another? This really interesting, innovative paper from a team in Israel has performed an RCT to address the problem. Riskin A, et al. The Impact of Rudeness on Medical Team Performance: A Randomized Trial. Pediatrics. 2015. The authors created 24 NICU teams and arranged for them to receive some comments from a supposed visiting expert from the USA. Half of them included some mildly rude comments, which the team received either just before or midway through a simulated resuscitation of a newborn manikin. Just before the simulation, to the rudeness exposed group, the "expert" stated that he was "not impressed with the quality of medicine in Israel". Ten minutes later the simulation was stopped and the participants heard that "medical staff like those observed wouldn’t last a week in his department". He added that he "hoped that he would not get sick while in Israel". The study found substantial negative effects of what they refer to as "mild incivility" on both diagnosis of problems during the simulation and on procedural performance. For example the subjects were much less likely to correctly verify the position of a tube when they had been the target of the rudeness. They also showed that the rude comments affected information sharing within the team, and on whether the team members sought help from each other. I must say I have been exposed to rudeness, sometimes much more direct and biting than the comments in this research, at many times during my career, and have, to be honest, also occasionally been rude to others myself. Sometimes a transient irritation or annoyance can lead to comments or attitudes that are negative and to "incivility". In a very high stress environment like the NICU, making snarky comments when things don't go well is a common reaction. I think that we should all try even harder to avoid such responses, not just because they may hurt feelings and harm morale, but because it actually looks like they can have adverse effects on the medical care that our patients receive.
  44. 2 points
    Very practical issue..... We use Vygon UVC as routinely. In case of nonavailability of non affording patient, w use NG tube, same as you do. Practically it is encountered vry often that UVC is not advancing or have resistance. In that case we follow 2 techniques. 1. If we are using Vygon UVC and not advancing, we sometimes switch over to NG tube. Bcs Conventional UVC, including Vygon has opening at tip, while NG tube has blunt tip with side openings. This BLUNT TIP of NG tubes helps to pass through the resistence in LIVER. 2. IF we still have issues with advancing the NG tube, while inserting NG slowly with one hand, we give slight pressure on liver with another hand. The pressure is being given on the skin overlying Liver in downward direction while slowly advancing the NG as UVC. Most of the times, this proves helpful, even with Vygon UVC. Another technique is slowly advancing UVC in cork screw manner, if resistence is felt. But somehow, I have not fount this working. Pressure over Liver, many times has solved problem for us. Hope this proves useful to you. Do let me know for anything else, at manan179@yahoo.com
  45. 2 points
    As Internet is everywhere (sort of), 99nicu.org has become a truly global network! From Google analytics we could see that people browsing 99nicu the past month (May 9 - June 8) comes from all over the world. The final goal for our outreach is Greenland and countries in Central Africa.
  46. 2 points
    Hai, can anyone help me to get freely downloadable TPN calculator
  47. 2 points
    Three recent articles have investigated whether we should wait until a week or so after birth to perform brain imaging in infants with encephalopathy, or whether earlier imaging might be just as predictive. The three articles have consistent findings, which is remarkable in itself! All three note that infants at high risk, most of whom have undergone hypothermia treatment, when they have MRI at 2 to 4 days of age, the results are very similar to the findings if you wait until a week or so to do the study. Agut T, et al. Early identification of brain injury in infants with hypoxic ischemic encephalopathy at high risk for severe impairments: accuracy of MRI performed in the first days of life. BMC Pediatrics. 2014;14(1):177. Boudes E, et al. MRI obtained during versus after hypothermia in asphyxiated newborns. Archives of Disease in Childhood - Fetal and Neonatal Edition. 2015;100(3):F238-F42. Skranes JH, et al. Brain imaging in cooled encephalopatic neonates does not differ between four and 11 days after birth. Acta Paediatrica. 2015. Now I think you could say the same about many of these type of studies as about the studies of brain imaging in very preterm babies. Which is, that if the reason that you want to do the study is to aid in medical decision making (which is explicitly stated in the first of the 3 articles) we need much better data of the positive predictive value of the findings for profoundly adverse outcomes. The best data I think come from the analysis of the TOBY trial, Rutherford M, et al. Assessment of brain tissue injury after moderate hypothermia in neonates with hypoxic-ischaemic encephalopathy: a nested substudy of a randomised controlled trial. The Lancet Neurology. 2010;9(1):39-45. That study used a scoring system, created by the same group, and showed that the positive predictive value of moderate or severe lesions in the basal ganglia and thalami, severe white matter lesions, or an abnormal posterior limb of the internal capsule for death or severe disability at 18 months of age was 0·76 (95% CI 0·65–0·87). Severe disability was defined as at least one of: mental development index (MDI) less than 70 (2 or more SD below the mean) on the Bayley infant scales (BSID II) at 2 years; cerebral palsy with a GMFCS of 3–5 (unlikely to be ambulant) or bilateral cortical visual impairment with no useful vision. There is some evidence that a 2 year Bayley is more predictive of limited longer term functioning after HIE than it is for former extreme preterm infants, for example this article from the follow up of the NRN trial, Pappas A, et al. Cognitive outcomes after neonatal encephalopathy. Pediatrics. 2015;135(3):e624-34. Of 30 babies with a Bayley 2 MDI less than 70, 27 of them had a full scale IQ less than 70 at 6 to 7 years of age. (Most of the infants with an MDI less than 70 were below 55, 24 of the 30; also 23 of the 31 babies with an IQ below 70 were below 55). If we put all this together it seems that it might be possible to have a reasonably accurate prediction of severely abnormal outcome using MRI shortly after, or even during the final day of, therapeutic hypothermia. I think before we rush to performing early MRI, and use them for decision making, we should have more, and more direct, evidence that a certain severity of abnormality on the early MRI, accurately predicts profound impairment, and that this is better than clinical examination, or other predictive indices.
  48. 2 points
    Thank you for contacting us. We usually do not give medical advice nor counsel in this forum. However we will try our best to help you and your baby. From your post, I see that your baby has received therapeutic hypothermia which is the current standard practice in neonatology for management of Perinatal Asphyxia cases. Other than supportive care and careful follow-up and early intervention if any neurological sequlae are detected, currently there is no other evidence based therapeutic intervention specific for perinatal asphyxia. Your neonatologist and the pediatric neurologist are the best persons to guide you regarding this matter. If you have any further querries, please do ask us. Though I remind you again that your doctors in your unit are the best persons to answer your querries as they have the case in front of them and know all the case details We wish you and your baby all the best.
  49. 2 points
    It sounds simple, but actually it turns out to be very complicated and controversial. The question is are we improving our NICU ? Has our NICU performance remained the same for the past few years? What about the performance of our NICU staff members (Medical and Nursing ) ? Are they improving themselves? That was the easy part. Now the difficult part. We can only improve a thing which can be measured. So to improve our NICU, we have to monitor some parameters of our NICU and then trend it and then find what we want to improve in that measure and then plan an intervention and then implement that intervention and then monitor the performance after the implementation of the interventions. (phew that was difficult to type right !) So lets see....if we heard that NICU in XYZ hospital had mortality of ELBW babies 5 years back of 50 % and that now they are reporting ELBW mortality of 20%...we definitely know they have improved themselves. How about nosocomial infection rate in a NICU in XYZ hospital was 5 per 1000 patient-days 5 years back and now was 1.5 per 1000 patient-days...we definitely know they have improved. One very nice example to illustrate this improvement is here: http://www.lafayettegeneral.com/pavilion/Level-III-Neonatal-Intensive-Care-Unit-1/Key-Performance-Indicators-3 There are so many parameters to be monitored in a NICU..I think we just have to select what is suitable in our setup balancing our resources. We have to be cautious not to overdo it...as then it will only be on paper and have no actual benefit for the NICU. the other (more difficult part) is to monitor the performance of NICU staff. Here also there are many options. One beloved one is compliance with infection control practices (especially ...hand hygiene). Success rate of intubations could be used for residents. How about IV infiltration (IV burns) rate for nurses? Morbidity/Mortality outcomes for consultants/attending ? Once staff know that they are being monitored...performance automatically improves. Once you start rewarding good performance......then people start having a healthy competition to improve themselves....the ultimate winner is the patient...NICU performance measures improve.....And thats the ultimate aim...to improve patient outcomes... The floor is open.
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