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

  1. 12 points
    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
  2. 11 points
    I found this consensus on neonatal management of infants born to mothers infected or suspected COVID19. It's free online access. http://atm.amegroups.com/article/view/35751/html
  3. 9 points
    Great question, Juan Carlos. I am partial to the VN500, but I'm sure both devices can deliver VG quite well. The problem is that babies don't like to be acidotic. Consequently, there is a problem with permissive hypercapnea in the first days of life in small preemies, because their kidneys are not able to compensate for respiratory acidosis. Therefore, the baby will try to generate a tidal volume sufficient to bring the PCO2 down and normalize the pH. As you know when the tidal volume exceeds the target value, PIP will come down and pretty soon, your baby may be on endotracheal CPAP with rising oxygen requirement (due to the drop in MAP), tachypnea and increased work of breathing. You would have to sedate the baby sufficiently to suppress their respiratory drive, which is a bad idea. People find all kinds of ways to reduce the support for the baby's effort, for example changing from AC to SIMV at a low rate, so the baby is unable to generate adequate minute ventilation and correct the acidosis. So, the baby is struggling, but the doctor is happy, because the PCO2 is where he or she wants it. If you can buffer the acidosis by adding some acetate to your TPN and get the pH up to near normal, you might be able to let the CO2 rise gradually. The focus needs to be on pH, not PCO2, because it's the pH that is the primary stimulus for respiratory drive. Basically it is better to support the baby's effort to maintain normal pH and avoid the mistake of looking only at the PCO2. Ultimately, it is the perivascular pH that controls cerebral circulation, but unfortunately all studies keep focusing on PCO2 and ignoring pH. What we know is that rapid fluctuations in PCO2 confer the greatest risk of IVH. Once the baby is a bit older and the kidneys are more mature, it'a s lot easier to allow permissive hypercapnia if they still need mechanical ventilation. I hope this helps, MK
  4. 8 points
    I wanted to let the 99nicu community have the first look at my latest video. It is based on a ground rounds talk I gave on delayed cord clamping several months ago. I updated it and added lots of animation. You can find the video by following this link: https://youtu.be/6qA3CVGp5Sw The video is not public, meaning you can not search for it, but you can follow the link to view it. I'd appreciate any thoughts on the video, especially mistakes you see or if you felt anything I said was misleading about the evidence. Post your comments to this forum and I will respond. I'm hoping to make the video public depending on this communities comments. Also, I feel a bit weird posting or doing anything not COVID19 related these days, but maybe this can be one thing that takes the mind off of the current pandemic for about 16 minutes of your time. -Nathan
  5. 7 points
    It has to be one of the most common questions you will hear uttered in the NICU. What were the cord gases? You have a sick infant in front of you and because we are human and like everything to fit into a nicely packaged box we feel a sense of relief when we are told the cord gases are indeed poor. The congruence fits with our expectation and that makes us feel as if we understand how this baby in front of us looks the way they do. Take the following case though and think about how you feel after reading it. A term infant is born after fetal distress (late deceleration to as low as 50 BPM) is noted on the fetal monitor. The infant is born flat with no heart rate and after five minutes one is detected. By this point the infant has received chest compressions and epinephrine twice via the endotracheal tube. The cord gases are run as the baby is heading off to the NICU for admission and low and behold you get the following results back; pH 7.21, pCO2 61, HCO3 23, lactate 3.5. You find yourself looking at the infant and scratching your head wondering how the baby in front of you that has left you moist with perspiration looks as bad as they do when the tried and true cord gas seems to be betraying you. To make matters worse at one hour of age you get the following result back; pH 6.99, pCO2 55, HCO3 5, lactate 15. Which do you believe? Is there something wrong with the blood gas analyzer? How Common Is This Situation You seem to have an asphyxiated infant but the cord gas isn’t following what you expect as shouldn’t it be low due to the fetal distress that was clearly present? It turns out, a normal or mildly abnormal cord gas may be found in asphyxiated infants just as commonly as what you might expect. In 2012 Yeh P et al looked at this issue in their paper The relationship between umbilical cord arterial pH and serious adverse neonatal outcome: analysis of 51,519 consecutive validated samples. The authors sampled a very large number of babies over a near 20 year period to come up with a sample of 51519 babies and sought to pair the results with what they knew of the outcome for each baby. This is where things get interesting. When looking at the outcome of encephalopathy with seizures and/or death you will note that only 21.71% of the babies with this outcome had a gas under 7.00. If you include those under 7.10 as still being significantly distressed then this percentage rises to 34.21%. In other words almost 66% of babies who have HIE with seizures and/or death have a arterial cord pH above 7.1! The authors did not look at encephalopathy without seizures but these are the worst infants and almost 2/3 have a cord gas that you wouldn’t much as glance at and say “looks fine” How do we reconcile this? The answer lies in the fetal circulation. When an fetus is severely stressed, anaerobic metabolism takes over and produces lactic acid and the metabolic acidosis that we come to expect. For the metabolites to get to the umbilcal artery they must leave the fetal tissues and enter the circulation. If the flow of blood through these tissues is quite poor in the setting of compromised myocardial contractility the acids sit in the tissues. The blood that is therefore sitting in the cord at the time of sampling actually represents blood that was sent to the placenta “when times were good”. When the baby is delivered and we do our job of resuscitating the circulation that is restored then drives the lactic acid into the blood stream and consumes the buffering HCO3 leading to the more typical gases we are accustomed to seeing and reestablishing the congruence our brains so desire. This in fact forms the basis for most HIE protocols which includes a requirement of a cord gas OR arterial blood gas in the first hour of life with a pH < 7.00. Acidosis May Be Good For the Fetus To bend your mind just a little further, animal evidence suggests that those fetuses who develop acidosis may benefit from the same and be at an advantage over those infants who don’t get acidemia. Laptook AR et al published Effects of lactic acid infusions and pH on cerebral blood flow and metabolism. In this study of piglets, infusion of lactic acid improved cerebral blood flow. I would suggest improvement in cerebral blood flow of the stressed fetus would be a good thing. Additionally we know that lactate may be used by the fetus as additional metabolic fuel for the brain which under stress would be another benefit. Finally the acidemic fetus is able to offload O2 to the tissues via the Bohr effect. In case you have forgotten this phenomenon, it is the tendency for oxygen to more readily sever its tie to hemoglobin and move into the tissues. I hope you have found this as interesting as I have in writing it. The next time you see a good cord gas in a depressed infant, pause for a few seconds and ask yourself is this really a good or a bad thing?
  6. 6 points
    the first 99nicu Webinar - assistant professor Nathan C. Sundgren will lecture on Delayed Cord Clamping, on May 14, 2020 16:00 (CEST) Nathan C. Sundgren, MD, PhD, is medical director of neonatal resuscitation education and assistant professor of Neonatology at Texas Children's Hospital, Houston, Texas, USA. He is concerned about all things related to delivery room care and has published quality improvement work and clinical trials related to delivery room team communication and performance of resuscitation. As an educator, he seeks to use global platforms to spread information on neonatal resuscitation such as on his YouTube channel "TexSun NeoEd." This is our first webinar, and if it works well, we aim to run a series of educational webinars during 2020. Stay tuned!
  7. 6 points
    In Wuhan and outside Wuhan cities, the local neonatologists/Pediatricians reported only a few cases. No severe cases, All of the infants have no symptoms or only mild symptoms,and also,no death cases.
  8. 6 points
    We recommend stopping breast-feeding until the mothers' COVID-19 test negative for two times . And also we stop vaccinated the suspected infants until the mothers' COVID-19 test negative for two times in the next 2 days.
  9. 6 points
    I visited Hot Topics last year and one of the best lectures (according to me!) was held by Judy Aschner, about the use of sodium bicarbonate being principally useless (and could even have adverse effects). Please click here to read an excellent review article on the topic by Aschner and Poland. Unfortunately only the abstact is available for free, but the article is worth to order! As many other units, we have a strong tradition to consider the use buffer, if pH is less than 7.25 and BE less than -5 (at least in in ELBW infants) The article by Aschner and Poland has been subjected to some debate in our units. The major argument in favour of buffer is that we do not use sodium bicarbonate but Tribonat, which is a combination of trometamol (THAM), bicarbonate och acetate. The theoretical idea behind Tribonat is to achieve intracellular (THAM), extracellular (bicarb & acetate). Personally, I have switched to a quite restrictive approach and rarely use buffer, but try to consider the etiology of the base deficit in the management of acid-base. What's your experience and view upon the use of buffer?!
  10. 6 points
    It’s been some time since I last posted here. Many things have changed in my life since then- the most important transition being my decision to move to Finland to work as a research fellow with the Baby-friendly Ventilation Study Group in Turku. The life of a beginning clinical researcher deserves a separate post here (it may even come at some point). To celebrate my first anniversary in Finland I would like to share 3 things I wish somebody had told me before I moved here. Enjoy! 1.Get nylon pants. The weather in Finland is truly whimsical. We have had a kind spring, warm summer, and lovely, colorful autumn. I was able to enjoy each of these seasons, biking in the Archipelago, watching sun that never sets, traveling north to see ruska, and finally seeing Northern Lights for the first time in my life. My only concern here is rain. It doesn’t follow laws of gravity AT ALL. How is that possible, that those raindrops are not falling DOWN from the sky, but they are literally attacking you from every direction? It took me some time to overcome my frustration and find a solution. I have closely observed (relatively) happy Finns and discovered that the most important clothing item here is… nylon waterproof pants. The trick is they have to be big enough that you can pull them over your regular pants to keep you dry and warm when it rains. This small thing has definitely improved my comfort here. It has also created that precious feeling of belongingness- I could finally proudly join the rustling and swishing sisterhood of waterproof pants. 2. Drop in the fertility rate is a real thing. Ok, I am a doctor and I KNOW it is a real thing. I know that statistics don’t lie. I know. But I kind of didn’t want to acknowledge that it may actually impact my study. We have had a fairly good start of the patient recruitment, which had kept me busy in spring. But then summer had arrived, and the recruitment slowed down. I kept thinking that maybe it’s just because of the summertime in general (like preemies would be able to pick a season when they want to arrive early, right?). But then autumn has come, and it was time to face the music- I have a problem. In order to recruit the desired number of infants, I may either stay here forever OR I need to come up with a clever solution very soon. Thankfully, I have amazingly supportive supervisors here and we decided- we are expanding! That means more traveling for me (and possibly more blog posts for you)! 3. Compulsive talking about 99nicu may help you to dance more salsa. That statement may seem rather weird, but there is a logical explanation. Very recently I’ve had a chance to attend a regional neonatal meeting in Finland. I was asked to present highlights from the 99nicu Meetup in Copenhagen. Since I like the whole concept of 99nicu.org and loved two conferences I had attended, I took that task very seriously- meticulously prepared my PowerPoint presentation and practiced my performance out loud at home. I decided to tell participants about lectures I remembered the best- neonatal transports, simulations in the NICU and infants surviving at the limit of viability. You may argue that there were more important lectures there, but those were the ones that still “spark joy” after all these months. Do you remember that sim scenario of postpartum seizures in a birthing pool that Ruth Gottstein talked about? I’ve discussed it with so many people in so many places already, that it might have become my favorite topic of random conversations with strangers. Anyways, I think the presentation went well- participants awarded me the prize for the best presentation of the evening! I received a gift card that I can use for cultural or fitness activities in Turku- including more salsa classes in my favorite dance school. Voila! Thank you 99nicu!
  11. 6 points
    Hi all, we have published the fifth edition of our e-book “NEOQUESTIONS 1to1” . Please feel free to distribute among your other colleagues to help them gain the knowledge of neonatology. https://docs.wixstatic.com/ugd/92a170_54197b618fb34a39a7702b7679a085ec.pdf With Best Regards NAVEED
  12. 6 points
    Our tiny babies have very tiny tracheas. So far you are probably all with me. Putting that tube in the right position is therefore tricky. In particular avoiding the right mainstem bronchus, which is the wrong position, is important. So first of all; where should the tip be? That seems obvious, it should be in the trachea, high enough above the carina that the tube never slips into the carina, but low enough that it doesn't slip out. On a plain AP radiograph, however, it isn't always clear exactly where the tube tip should be. In general ,studies have suggested that on the radiograph the tip of the tube should be T1-T2. That is based on studies where the position was directly observed, such as in post-mortem studies, and compared with an X-ray. A study from 7 years ago (Thayyil S, et al: Optimal endotracheal tube tip position in extremely premature infants. American journal of perinatology 2008, 25(1):13-16.) noted that babies who had a tube tip lower than T1-T2 were more likely to have right upper lobe collapse, localized PIE and pneumothorax. I think that confirms that T1-T2 is the appropriate location. Now how do we ensure that the tube tip is in that, optimal, position? The NRP (which clearly is not focussed on very preterm babies) suggests to add 6 cm to the infants weight in kg, which leads to tube insertion depths which are too low for most babies under 1 kg (see for example : Peterson J, et al: Accuracy of the 7-8-9 Rule for endotracheal tube placement in the neonate. J Perinatol 2006, 26(6):333-336.) I think it is clear we should not use that rule for babies under 1 kg. Various methods of calculation have been suggested, some are based on calculations using the babies weight, some on gestation, one on foot length (which actually seems to be a good idea, and relatively easy to get to during resuscitation, but I don't know if anyone does that. Embleton ND, et al: Foot length, an accurate predictor of nasotracheal tube length in neonates. Archives of Disease in Childhood - Fetal and Neonatal Edition 2001, 85(1):F60-F64) maybe Nick Embleton will let me know if anyone uses it. A newly published trial from Colm O'Donnel in Dublin (Flinn AM, et al: Estimating the Endotracheal Tube Insertion Depth in Newborns Using Weight or Gestation: A Randomised Trial. Neonatology 2015, 107(3):167-172.) randomly compared weight and gestational age based standards, unfortunately the weight based standard they used was depth= weight + 6, and they compared this to a table based on gestational age. The number of ET tubes in the right place was higher with the weight calculation, but it was not statistically significant, and there were very many that were malpositioned in both groups, 50% with the weight based calculation, and 60% with the GA table. Another study, which also trashed the 7-8-9 rule promoted by NRP, (Kempley ST, et al: Endotracheal tube length for neonatal intubation. Resuscitation 2008, 77(3):369-373) was a report of a quality improvement initiative in London. It is interesting in part because they showed that intubating the baby and then doing a clinical exam to see if it was in the right place was associated with more than half of the ETTs being mal-positioned. While using a table of distances (either GA based or weight based) was much better, with less than 20% needing repositioning. Colm O'Donnell has also published a letter with photos of endotracheal tubes (Gill I, O'Donnell CP: Vocal cord guides on neonatal endotracheal tubes. Archives of disease in childhood Fetal and neonatal edition 2014, 99(4):F344.) which clearly shows that you can't rely on the ETT marks to decide where to put the tube. Non-one ever evaluated this previously, as far as I can tell in the literature, but using those marks will lead to many being in the wrong place. I think it should be obvious that all babies who are intubated with a 2.5 tube do not have the same length of trachea! So using the same ETT tube marking wll often be wrong. So how best to do this? I think that the first step should be to use a table of insertion depth against body weight. (we are a center which attracts a lot of extremely growth restricted babies, so I would be wary of using a GA standard). I think the table below looks to be the best (the table below is from the study which I refer to above by Stephen Kempley) , I have added a column for nasal intubation based on the demonstration (autopsy study,with body weights down to 500 g) that the distance from nostril to carina is almost exactly 1.2 cm on average longer than the distance from lip to carina (Rotschild A, Chitayat D: Optimal Positioning of Endotracheal Tubes for Ventilation of Preterm Infants. AJDC 1991, 145:1007.) During the intubation procedure, prior to fixing the tube, palpation in the supra-sternal notch can confirm good tube position with very good accuracy, once you have been trained to do it. A randomized trial from Neil Finer's group (Jain A, et al: A randomized trial of suprasternal palpation to determine endotracheal tube position in neonates. Resuscitation 2004, 60(3):297-302.) who showed me the technique when I was his fellow) found a much higher proportion of tubes in the right position after adequate training, and another RCT (Saboo AR, et al: Digital palpation of endotracheal tube tip as a method of confirming endotracheal tube position in neonates: an open-label, three-armed randomized controlled trial. Pediatric Anesthesia 2013, 23(10):934-939) had a high proportion of tubes in good position, 83%, following a process such as I have just described, a table of insertion depths, accompanied by palpation to validate position. Here is that table: (sorry but I can't figure out how to make this table a good size, so click on it to view.). ((This is the initial length to which the tube should be inserted, followed by palpation of the tube to ensure good position, and then a chest radiograph to check its position. The tube length should then be adjusted to align its tip with the thoracic vertebrae T1–T2.)) Another important point, flexion of the neck advances the end of the ETT, but, in fact, the sze of the effect is fairly minor. A severe flexion of 55 degrees only advances the tube tip by about 3 mm (Rost JR, Frush DP, Auten RL: Effect of neck position on endotracheal tube location in low birth weight infants. Pediatric Pulmonology 1999, 27(3):199-202). So if the tube is on the carina when you do the x-ray and the head is flexed, you still need to reposition the tube, you can't rely on good head position to move the tube tip up much. Finally there are some data to support using ultrasound to confirm tube position, (Chowdhry R, Dangman B, Pinheiro JM: The concordance of ultrasound technique versus X-ray to confirm endotracheal tube position in neonates. J Perinatol 2015. Dennington D, Vali P, Finer NN, Kim JH: Ultrasound confirmation of endotracheal tube position in neonates. Neonatology 2012, 102(3):185-189.) It looks like this could be a reliable way of identifying malposition of the tube, and we should consider maybe training everyone to do this, including me!
  13. 5 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
  14. 5 points
    The NOTE programme (collaboration between ESPR and University of Southampton) are opening a Pharmacology module in June, led by Karl Allegaert and Sinno Simons, using virtual/remote teaching. More information in attachment and via link below 🙂 https://www.espr.eu/news/news-detail/e-learning-neonatology-paediatrics/186 Proposal NOTE module DINA4 v3 (1).pdf
  15. 5 points
    The professional communication during the Covid-19 pandemic really shows the potential to share expertise and experience through web-based channels. Journals, societies, regular news media, social media platforms etc-etc play an important role for us to keep updated, and many web sites have also opened up their content free of charge. We will learn many things from facing and tackling this pandemic, but one major change will certainly be our communication channels. Many are discovering the web-based possibilities to learn and discuss. We will do our best to facilitate professional communication within the neonatal community. And, finally it seems that the company providing our software (IPB) will finally roll out a smartphone app. Which means that 99nicu will literally become available in your pocket through a "99nicu App". The screen shots below comes from the beta-version of the app now used by the company providing our software. And yes, there will be light-mode and dark-mode Stay tuned!
  16. 5 points
    The recommendation from the Austrian/German Society for neonatology is as follows: mother COVID-19 positive: isolation of mother and child and no breastfeeding until mother is COVID-19 negative.
  17. 5 points
    A collective of the world’s leading newborn brain care providers have come together and launched the https://newbornbrainsociety.org/ (NBS). This new organization is focused on advancing newborn brain care through international multidisciplinary collaboration, education, and innovation. With founding leadership representation from prestigious programs such as Yale, Duke, Harvard, and UCSF, international representation from Canada, Brazil, and Ireland, and parent collaboration through the Hope for HIE Foundation, the goal is to bring together the resources of many programs to move the field forward in previously unattainable ways. “We started this idea originally through an existing group that was started in 2015 through the Neonatal Neuro Critical Care Special Interest Group (NNCC-SIG). We wanted to facilitate multidisciplinary, international collaboration between clinicians, parents, scientists, and others with a focus on newborn brain care; and no other society or organization currently exists in this structure and philosophy,” stated Mohamed El-Dib, MD, founding member and President of the organization. NBS has plans to sponsor, host and participate in educational events that will expand the field of neonatal neurocritical and neuroprotective care, and develop consensus publications including best practice guidelines and expert opinions in the field of newborn brain care. “We are also looking to provide a platform for members to exchange clinical practice guidelines and parent resources related to newborn brain care, and to support multi-center collaborative activities, quality improvement and research projects related to the field of neonatal neurology and brain development,” stated Donna Ferriero, MD, MS, chair of the NBS Steering Committee. Membership is now open for interested clinicians, researchers, trainees, parents and other community members. For more information, visit Newbornbrainsociety.org
  18. 5 points
    This is not an uncommon dilemma. We have developed a one paged trigger/ assessment tool for babies who meet criteria for monitoring for moderate or severe encephalopathy. It seems to work most times and one of our fellows is conducting an audit to see if we miss any babies with this tool. Based on this case, it sounds like the baby would have met criteria for clinical monitoring for moderate or severe HIE i.e. prolonged resuscitation and possibly Apgar scores? but not pH or BE related values and we would have then assessed this baby hourly for the first 6 hours of life for clinical signs of moderate or severe encephalopathy. TH would have been started as per the trigger tool thresholds. The problem comes when these babies don't meet clinical criteria for moderate or severe HIE and clinical monitoring is ceased and then go on to have seizures some time later - as is seen in this case. The current trend in our unit would be to not cool them at the 12hr mark but I have personally cooled a baby who did not meet criteria for moderate or severe encephalopathy in the 1st 6hrs but then went on to have seizures at ~8hrs of life. We would just optimise other medical intervention and use anti-convulsants (levetiracetam, topiramate and midazolam or lignocaine) to treat seizure burden. I'm not sure if that helps! Cheers Richard HIE trigger tool.pdf
  19. 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
  20. 5 points
    I must admit that it is a bit exciting to think about that 99nicu.org went live 12 years ago, at a time when Facebook and other “social media” web sites was yet to be invented. (@Zuckerberg, no offense here. Obviously, you created something far greater than 99nicu, still a grass rot project. BTW – could we apply for funding from you Foundation?) When starting 99nicu.org in 2006, we nourished an idea that experiences and expertise should not be hindered by geographical boundaries. In some sense, this was a statement, that we as medical professionals could help each other through other channels than journals and conferences, with inclusive and open mindsets, and new technologies. Back then we knew little about the powerful potential of the Internet. Neither could we foresee how the Internet would change our private and professional lives. We were just a group of young staff in Sweden, wanting to create a web based platform for discussions within a global group of neonatal pro’s. When I read this blog post by @AllThingsNeonatal (on his web site allthingsneonatal.com) where he reflects on how sharing and caring in social media has created a global village, I am struck by the thought - a global village was what we envisioned back in 2006. Coming from a small village myself, I think that also 99nicu.org parallells the village symbolism: a setting with small communication gaps (everyone knows everything about everyone, so we don't need formalities to get in touch and speak out), and where giving and taking advice is a bilateral process that may ultimately lead to “the best solution”. Or simply, that we find out that there are several good solutions for a given problem. Has 99nicu become as global village for neonatal staff on the Internet? Although biased, I’d say YES . Data also supports that. During January through April, the web site had 18.000 visitors from all over the globe, making 45.200 pageviews. From the Google Analytics dashboard we can all see that 99nicu reaches almost every corner of the world! Our principal idea has always been that the virtual space is where we operate. It is the Internet that creates the possibility to connect and exchange experience as expertise from where we are. However, meeting up IRL is also a powerful way to maintain sustainable networks and that idea is the driving force behind the “99nicu Meetups”. For the 1st and 2nd Meetup conferences in Stockholm and Vienna (in June 2017 and in April 2018), delegates came from 17 and 33 countries, respectively. Let’s hope we can have even a larger geographical representation at our IRL Meetup next year. Stay tuned for dates and location
  21. 5 points
    Hello, I am paediatric trainee currently working in Level 2 NICU in UK. I am doing the journal club presentation about the use of LMA for administration of surfactant in preterm babies. During my previous placements in Level 3 NiCUs, I never seen anyone using LMAs and I was wondering what experience do the rest of you have with using LMAs in neonates. What training did you undergo? Thank you. Lenka
  22. 5 points
    I just want to share some brief news about our next Meetup, 7-10 April 2019 at Rigshospitalet in Copenhagen/Denmark. We (i.e myself, @Francesco Cardona @RasmusR @Christian Heiring , Gorm Greisen and Morten Breindahl) are currently working on the program lectures and workshops. I just want to share the first five confirmed speakers and their topics: Morten Breindahl: Neonatal transports – how to do them safe and easy Ola Andersson: Cord Clamping, 1.0 and 2.0 Ravi Patel: How to explain when NEC rates persist – even when a NICU does everything “Right” Ulrika Ådén: Infants surviving at the limit of viability, what are the outcomes? What shall we do? Gorm Greisen: Ethical decision making around the limit of viability- lessons from Scandinavia I'll update you all with more names and topics as they are confirmed Looking forward to meet up in Copenhagen!
  23. 5 points
    This is great! Thanks so much. I was in Toronto for the NeoHemodynamics 2018 Conference and Workshop and one of the main take-home messages was that both transitional hemodynamics and knowledge of its physiology are key to tailoring therapeutic interventions both in preemies and term babies. The slides from the talks are available at neohemodynamics.com
  24. 5 points
    The lungs of a preterm infant are so fragile that over time pressure limited time cycled ventilation has given way to volume guaranteed (VG) or at least measured breaths. It really hasn’t been that long that this has been in vogue. As a fellow I moved from one program that only used VG modes to another program where VG may as well have been a four letter word. With time and some good research it has become evident that minimizing excessive tidal volumes by controlling the volume provided with each breath is the way to go in the NICU and was the subject of a Cochrane review entitled Volume-targeted versus pressure-limited ventilation in neonates. In case you missed it, the highlights are that neonates ventilated with volume instead of pressure limits had reduced rates of: death or BPD pneumothoraces hypocarbia severe cranial ultrasound pathologies duration of ventilation These are all outcomes that matter greatly but the question is would starting this approach earlier make an even bigger difference? Volume Ventilation In The Delivery Room I was taught a long time ago that overdistending the lungs of an ELBW in the first few breaths can make the difference between a baby who extubates quickly and one who goes onto have terribly scarred lungs and a reliance on ventilation for a protracted period of time. How do we ventilate the newborn though? Some use a self inflating bag, others an anaesthesia bag and still others a t-piece resuscitator. In each case one either attempts to deliver a PIP using the sensitivity of their hand or sets a pressure as with a t-piece resuscitator and hopes that the delivered volume gets into the lungs. The question though is how much are we giving when we do that? High or Low – Does it make a difference to rates of IVH? One of my favourite groups in Edmonton recently published the following paper; Impact of delivered tidal volume on the occurrence of intraventricular haemorrhage in preterm infants during positive pressure ventilation in the delivery room. This prospective study used a t-piece resuscitator with a flow sensor attached that was able to calculate the volume of each breath delivered over 120 seconds to babies born at < 29 weeks who required support for that duration. In each case the pressure was set at 24 for PIP and +6 for PEEP. The question on the authors’ minds was that all other things being equal (baseline characteristics of the two groups were the same) would 41 infants given a mean volume < 6 ml/kg have less IVH compared to the larger group of 124 with a mean Vt of > 6 ml/kg. Before getting into the results, the median numbers for each group were 5.3 and 8.7 mL/kg respectively for the low and high groups. The higher group having a median quite different than the mean suggests the distribution of values was skewed to the left meaning a greater number of babies were ventilated with lower values but that some ones with higher values dragged the median up. Results IVH < 6 mL/kg > 6 ml/kg p 1 5% 48% 2 2% 13% 3 0 5% 4 5% 35% Grade 3 or 4 6% 27% 0.01 All grades 12% 51% 0.008 Let’s be fair though and acknowledge that much can happen from the time a patient leaves the delivery room until the time of their head ultrasounds. The authors did a reasonable job though of accounting for these things by looking at such variables as NIRS cerebral oxygenation readings, blood pressures, rates of prophylactic indomethacin use all of which might be expected to influence rates of IVH and none were different. The message regardless from this study is that excessive tidal volume delivered after delivery is likely harmful. The problem now is what to do about it? The Quandry Unless I am mistaken there isn’t a volume regulated bag-mask device that we can turn to to control delivered tidal volume. Given that all the babies were treated the same with the same pressures I have to believe that the babies with stiffer lungs responded less in terms of lung expansion so in essence the worse the baby, the better they did in the long run at least from the IVH standpoint. The babies with the more compliant lungs may have suffered from being “too good”. Getting a good seal and providing good breaths with a BVM takes a lot of skill and practice. This is why the t-piece resuscitator grew in popularity so quickly. If you can turn a couple dials and place it over the mouth and nose of a baby you can ventilate a newborn. The challenge though is that there is no feedback. How much volume are you giving when you start with the same settings for everyone? What may seem easy is actually quite complicated in terms of knowing what we are truly delivering to the patient. I would put to you that someone far smarter than I needs to develop a commercially available BVM device with real time feedback on delivered volume rather than pressure. Being able to adjust our pressure settings whether they be manual or set on a device is needed and fast! Perhaps someone reading this might whisper in the ear of an engineer somewhere and figure out how to do this in a device that is low enough cost for everyday use.
  25. 5 points
    I know - many of us want less emails... But the emails from Evidence Updates are great! Evidence Updates (a collaboration project by the BMJ Group and McMaster University) assists your reading of new research by grading articles by "Relevance" and "News-worthiness". For example, this trial on D-vitamin supplementation of preterm infants showed up in an email alert, an article I had missed otherwise. 1. You need to Register (here!) 2. Choose your clinical interest ("Pediatric Neonatology", I guess) 3. Set a minimum score for new articles you want to read about (set a higher minimum score to get fewer emails ) 4. Watch your inbox! Link to like: Evidence Updates.
  26. 5 points
    Originally posted at: https://winnipegneonatal.wordpress.com/ Facebook Page: https://www.facebook.com/allthingsneonatal/ As I read through the new NRP recommendations and began posting interesting points on my Facebook Page I came across a section which has left me a little uneasy. With respect to a newborn 36 weeks and above who is born asystolic and by ten minutes of age continues to remain so and has an apgar score of zero the recommendation that has been put forward is this: An Apgar score of 0 at 10 minutes is a strong predictor of mortality and morbidity in late-preterm and term infants. We suggest that, in babies with an Apgar score of 0 after 10 minutes of resuscitation, if the heart rate remains undetectable, it may be reasonable to stop resuscitation; however, the decision to continue or discontinue resuscitative efforts should be individualized. Variables to be considered may include whether the resuscitation was considered to be optimal, availability of advanced neonatal care, such as therapeutic hypothermia, specific circumstances before delivery (eg, known timing of the insult), and wishes expressed by the family (weak recommendation, very-low-quality evidence). There are some significant problems with this part of the statement. They claim that the apgar score at ten minutes is a strong predictor but when you look at the analysis of the evidence presented in the body of the paper it is weak at best. I am not clear how one declares the prediction is strong in the face of poor evidence but I will acknowledge intuitively that this makes some sense but do challenge them on the use of the word "strong". 2. They are correct in acknowledging that the introduction of hypothermia in such settings has changed the landscape in as much as I find it quite difficult to prognosticate unless a child is truly moribund after resuscitation. Given such uncertainty it is concerning to me that this recommendation may be committed to memory incorrectly in some places that do have access to cooling and may be used more rigidly as though shalt stop at 10 minutes. 3. In the middle of a resuscitation it is quite difficult to process all of the facts pertaining to a particular newborn while orders for chest compressions, emergency UVCs and epinephrine are being given. Can we really individualize within ten minutes accurately and take the families wishes truly into account? This just does not seem practical. 4. The families wishes are taken into account but inserted as a "weak recommendation". How can the wishes of the family in any family centred model of care be minimized in such a way even if we believe the situation to be dire? 5. Since the introduction of hypothermia there appears to be a near 50% survival rate in such newborns and as the authors state 27% of survivors who received cooling had no moderate or severe disability. Here in lies my greatest issue with this guideline and that is the hypocrisy this position takes when you compare populations at 23 and 24 weeks gestational age. Survival at these GA in the recent NEJM study of almost 5000 preterm infants under 27 weeks were 33 and 57 % respectively at 23 & 24 weeks with rates of survival without moderate or severe disability being 16 and 31% in the two groups. The fallout from this and other studies at the extremes of gestational age have been that we should be more aggressive as the outcomes are not as bad as one would predict. How can we argue this for the 23-24 week infants and for term infant with the same likelihood of outcomes we would unilaterally stop in many centres?! So Now What Do We Do? We are supposed to be practising family centred care and much like the argument at the edge of viability the same should apply here. The wishes of the family should never be minimized. Arguably it may be very difficult in such an unexpected scenario to appraise a family of the situation and have clarity around the issue but if a heart rate can be restored after a few more minutes do we not owe it to the family and the child to bring the infant back to the NICU and see what transpires especially if cooling is available? The million dollar question of course is where do we draw the line? No heart rate at 15, 20 minutes? Based on the evidence thus far it seems to me that a little longer than 10 minutes is reasonable especially in well equipped centres with access to cooling and modern ventilation and treatments for pulmonary hypertension. How long though must be individualized and should be determined in partnership with the team caring for the patient which must include the family.
  27. 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 )
  28. 4 points
    Join experts in the field of neonatal neurology as they speak on clinical and research guidelines, educate on new techniques, and answer your questions! April Speakers: April 2nd: Betsy Pilon - Supporting HIE Families April 9th: Seetha Shankaran, MD - Hypothermia for HIE, Updates and Controversies April 16th: Gerda Meijler, MD - Neonatal Head Ultrasonography: How to Scan a Baby, Normal Anatomy of the Neonatal Brain April 23rd: Linda de Vries, MD - Neuroimaging in the Full Term Infant April 30th: Trainee Session RSVP below to confirm your attendance: https://is.gd/RSVP_NBS_Ed_Webinar_April_2 Contact info@newbornbrainsociety.org with any questions.
  29. 4 points
    hi.i live in iran,i have two neonate that mothers are suspected covid -19,what s advice for breastfeeding and vaccination?!
  30. 4 points
    I'd like to clarify that comment a bit: Chile is entering its 6th week since the first COVID19 case was detected. There are areas with a high number of cases, so partial lockdowns are being put in place for 2 to 3 weeks. Those are being lifted (or not) depending on the number of new cases on a daily basis. There is an issue with availability of testing as is the case with most LA countries, but Chile is steadily increasing PCR testing availability country-wide. Recently, universal use of face masks when outside of home was recommended and made mandatory when using public transportation on April 8. People are encouraged to use homemade or commercial cloth face masks and leave surgical masks and N95s for healthcare workers. At my public hospital, we were issued cloth masks to use outside of the hospital, surgical masks for clinical work at the NICU, and plastic gowns, face shields and N95s when there is likelihood to be exposed to aerosols. We are expecting peak contagion to hit us by the end of April-early May and are trying, just like everybody else to flatten the curve. It's still too early to tell how it will go for Chile.
  31. 4 points
    This is an extract from Prof Jane Pillow's book on HFOV and its applications: You can access the entire publication free of charge from this website - https://www.draeger.com/Library/Content/hfov-bk-9102693-en.pdf - most definitely worth reading! I hope that is helpful! Kind regards
  32. 4 points
    This new paper just came onto my radar - on "State-of-the-art neonatal cerebral ultrasound: technique and reporting" in Pediatric Research. Great read! (and if those of us who cannot read, we can look at the pictures like the one below 😛 ) Open access here: https://www.nature.com/articles/s41390-020-0776-y
  33. 4 points
    I find these posters very helpful as well. We will all have to look after eachother in the upcoming crisis. https://www.ics.ac.uk/ICS/Education/Wellbeing/ICS/Wellbeing.aspx?hkey=92348f51-a875-4d87-8ae4-245707878a5c #staffwellbeing
  34. 4 points
    British Association of perinatal medicine has issued guidance today https://www.rcpch.ac.uk/resources/covid-19-guidance-paediatric-services Sent from my iPhone using Tapatalk
  35. 4 points
    UK is not that drastic in isolating neonate from mom https://www.rcog.org.uk/en/news/national-guidance-on-managing-coronavirus-infection-in-pregnancy-published/
  36. 4 points
    @Jose Ramon Fernandez thanks for sharing this link - very helpful.
  37. 4 points
    In Linköping we have developed a structure on how to do this in deliveryroom on ELBW less than GW28. It works pretty well if you manage to deal well with the logistic. Receive on the foot-end of deliverybed between the legs of the mother, put the baby in a nest covered by plastic, using a mobile Neopuff with humidified warm gas, Starting with CPAP only awaiting the respond of heartrate and spontaneous breathing, ventilating only if bradycardia, delayed cordclamping. Incubator Close to the bed, connected to mobile CPAP/Ventilator. If intubation immediate Surfactant instillation. We have planned to enhance it into all Babies less than GW32 (33?). Working on a video on it. Apart from a mobile neopuff, an incubator in Place and a mobile CPAP/ventilator you don´t need any extra equippment. But a well trained team and clear logistic is crucial (protocol). /Per
  38. 4 points
    Dose & administration Three doses at 24-hour intervals, as intravenous injections over 15 minutes, or by oro-gastric administration: 1st dose: 10 mg/kg 2nd and 3rd dose: 5 mg/kg Indications Closure of the patent ductus arteriosus. Contraindications and special considerations (incl incompatibilities) Contraindications include: duct-dependent cardiovascular malformation active bleeding, including intracranial, gastrointestinal or lung bleeding necrotizing enterocolitis (confirmed or suspected) significant thrombocytopenia or coagulation defects significantly reduced renal function significant hyperbilirubinemia Pulmonary hypertension has been reported when ibuprofen was given within 6 hours after birth. Concomitant use the following pharmaceuticals products is not recommended: diuretics: ibuprofen may reduce the effect of diuretics, and diuretics may increase the risk of renal insufficiency in dehydrated patients. anticoagulants: ibuprofen may inhibit platelet function and concomitant use with anticoagulants may increase the risk of bleeding corticosteroids: concomitant use with ibuprofen may increase the risk of gastrointestinal bleeding nitric oxide: since both nitric oxide and ibuprofen inhibit platelet function, concomitant use may in theory increase the risk of bleeding other NSAIDs: concomitant use of more than one NSAID should be avoided because of the increased risk of adverse reactions aminoglycosides: ibuprofen may reduce clearance of aminoglycosides, concomitant use may increase the risk of nephrotoxicity and ototoxicity, and surveillance of serum levels of aminoglycides should be performed Ibuprofen should not be administrated with any acidic solution. Adverse effects Oligura and transient renal insufficiency. Ibuprofen has less renal side-effects than indomethacin. Pharmacological aspects Ibuprofen is an anti-inflammatory drug (NSAID) that reduces the synthesis of prostaglandins through a non-selective inhibition of cyclo-oxygenase. Prostaglandins are involved in the persistence of the ductus arteriosus after birth, through relaxation of the muscle layer of the ductus arteriosus. The reduction of prostaglandins by ibuprofen is believed to be the main mechanism of action. The estimated T1/2 is 30 (16-43) hours. References Summary of product characteristics. Pedea -EMEA/H/C/000549 -IG/392. (URL) Ibuprofen for the treatment of patent ductus arteriosus in preterm or low birth weight infants. Cochrane Database of Systematic Reviews 2015, Issue 2. Art. No.: CD003481. 
PMID: 25692606 Pulmonary hypertension after ibuprofen prophylaxis in very preterm infants. Lancet 2002; 359: 1486–88. PMID: 11988250 Document version history 2017-02-10 / Stefan Johansson
  39. 4 points
    Found this discussion on Researchgate! Did not know they also had a forum there. Lots of good comments. I was taught during my training that reducing dead space is the reason for vittring tubes. But as pointed out, the volume of the cut tub piece is so small that it would have no practical significance, even for an ELBW infant. But I still do it, it is in my ”auto-pilot”... https://www.researchgate.net/post/Will_it_be_better_to_cut_the_ET_tube_a_few_centimeters_after_tube_is_in_place_and_then_place_the_connector
  40. 4 points
    For infants in need of follow up - criteria for our follow up program with neurodevelopmental examination at term, corrected: 3 month, 1 year, 2 year and 5,5 year - we do an examination according to Hammersmith neurological examination. At those intervals we then do Hammersmith, Alberta infant motor scale, Bayley and physical examination by a neonatologist and a physiotherapist and for Bayley a developmental psychologist. For infants with known cerebral injury we also do brain stem audiography and a refferal to an occupational therapist. / Stina, Karolinska University Hospital, Stockholm Sweden.
  41. 4 points
    If you are to read one paper on neonatal ethics this year, I'd argue that this is the one. Late last year, John Lantos, pediatrician and a leading medical ethicist, published a review in NEJM on the ethics around decision-making in the NICU. The paper is not open-access... but you can surely get it from within your hospital intranet or your university/hospital library. We have a fantastic toolbox in the NICU. We can provide live-saving treatments and support. Most newborns in the NICU survive to good long-term health. However, we also operate in a high-risk environment where some infant may suffer, some infants will die, and some infants will survive with difficult sequele. Which raises the question, by staff and by parents, what is the "right" thing to do in complex situations. When withholding and withdrawing life-sustaining therapies becomes a option to decide upon. How could we navigate in this landscape? IMHO, the review by Lantos is a good starting point on how to form a local practise. Lantos shares his reasoning about we cannot "solve" these discussion with "information" as such. Despite how hard we try, data alone does not lead the whole way. Outcomes is hard to measure, they change over time and we all percieve risks differently. Therefore, information is difficult to standardize. Furthermore, those of us sharing the information will filter our presentation through our subjective selves, coping with opinions, experiences and our expertise in different ways. The better alternative around ethical questions is shared decision-making. Two central quotes of the review is that and that Certainly, the future of neonatal care will bring more ethical questions to us. Refined prenatal diagnostics, the down-shifting boundary of viability and new treatment technologies in the future (like the artificial placenta) will impact how we think about fetal life and postnatal life, what is the "periviable grey zone" and what our fantastic toolbox can do. While improving our skills, from a medical/technical viewpoint, we also need to improve how we cope with the ethics around decision-making processes. Besides reading the review by John Lantos, I can recommend you to see this lecture from theh #99nicuMeetup in Copenhagen 2019, by Eduard Verhagen. (Feature Photo : Cropped photo by Liane Metzler on Unsplash)
  42. 4 points
    Hi All, I am working as part of a student-team at the University of Cambridge on the idea of developing wireless sensor technology for neonates in the NICU. The overarching goal of this is to progress the technology to a point where it serves to reduce the barrier to kangaroo care. In addition it is hoped the lack of attached wires will have a positive impact on the delivery of care from NICU nurses and doctors in emergency situations. There is also potential to develop the technology to be useful to low and medium income country NICUs. As part of the development we are trying to get opinions from a broad range of healthcare professionals working in NICUs all over the world. Here we have a survey which is aimed at medical professionals. It should only take 10 minutes of your time but all comments are greatly appreciated and will help a great deal towards maximising the clinical impact of the sensor technology. Thanks in advance for any possible comments / advice / insights you can offer - we really appreciate it!! If you have any questions feel free to ask below, Antonio The link again: https://goo.gl/forms/6jpOUd1jUDlTtpVA3 NOTE: We aren't actually associated with the group who published on wireless neonatal sensors in Science last week - and if you haven't seen that paper I would recommend giving it a read!
  43. 4 points
    This is an interesting dialogue. I just had a long disuccussion about fluid management from the delivery room with our neonatal response team nurses. They see quite a bit of variability from our physicians. When we talk about fluids on the first day, we are usually thinking of so much more than just the dextrose/ nutrition containing fluids. We have to consider the "to keep open" fluids running in additional lumens of our UVC and UAC lines. Premature babies are often on antibiotics the first 2 days. Some get saline boluses or blood products. It is very easy to give 20-40mL/kg/d of fluid above the baseline nutrition containing fluid before you even realize it. The 2014 cochrane review of fluid restriction in preterm infants (https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD000503.pub3/full) includes only 5 trials done in 1980-2000. The fluid restricted arm in the individual studies ranged from 50mL/kg/d to 120mL/kg/d. "Fluid restriction" had more PDAs close and less NEC. The incidence of BPD, IVH, and death were in the right direction (favoring fluid restriction) but not significant. Trying to tie all these factors together and deliver an adequate GIR, I start with D10 fluid at 65mL/kg/d. I presume that flushes and medications will add an additional volume that will quickly put my total fluids in the range of 80 - 110 mL/kg/d, which I think is acceptable on the first day. If I have a low glucose, I first increase GIR by going up on the D10 to 80mL/kg/d, but thereafter I try to concentrate the dextrose containing fluids to deliver more GIR over increaseing the rate of administration. In subsequent days I use weight and sodium values to guide increasing total fluid targets. For almost all circumstances i use birthweight for calculations and continue to use it until the baby is back above birthweight. If the baby has edema and is above birthweight in the first week I stick with birthweight until the edema is resolved. I'm interested in others initial fluid strategies when leaving the delivery room. Where do you start - 60, 80, or more? Do you use D10 or D5 or something else? Thanks in advance for the replies.
  44. 4 points
    Here are some articles which may help to decide initial settings for duopap on Fabian ventilator. Duopap in vlbw RDS china study 2014.pdf Duopap review article.pdf
  45. 4 points
    Our guidelines in Sweden (infpreg.se) is to give oral acyklovir, 10 mg/kg x 4 over 14 days when VZIG is delayed. I guess the same would apply if VZIG is not available at all.
  46. 4 points
    Here is a bundle we use for skin care in ELGANs below 24 wks. I will not be able to provide supporting articles to most of what is done for this population and written here below. Hoping you can find it useful for your team and ELGANs. Resuscitation: · Receive baby in OR sheet (pre-warmed) and place in plastic bag from the OR sheet. Plastic bag an opening to deliver the head from the bag (pre-made) and an opening to over the umbilical stump to be made. Try to keep the bag closed as possible. https://www.ncbi.nlm.nih.gov/pubmed/24042134 · Incubator to be pre-wormed with humidity of 85~90% and temp around 37 ~ 38 C. · No ECG lead; use UAC to obtain vitals or Sa02 probe to get HR · If no UAC, BP frequency on case-by-case basis; change site every time, do not leave cuff on. · Once out of plastic bag, place baby on Biatain Alginate sheet(s) (change sheet every 1 week); avoid skin contact with baby blankets, use Huck towel or OR sheet underneath Biatain. · Use disposable saturation probe. · Semi-sterile conditions: sterile gloves, hat and mask for all resuscitation team members. · ETT to be handled with sterile gloves only. · UVC, UAC insertion using checklist; clean skin with chlorhexidine 2% without alcohol swabsticks and rinse with sterile water. · Plastic bag; hat; warming mattress. Keep plastic bag on until baby in isolette with temperature within normal limits (36.5-37.5 C measured at axillary or back) and humidity level is stable (2-4h). For 1st72 hrs of life · Humidity in isolette: 90 ~ 85%. · In case of skin breakdown: apply Adaptic (non-adherent) and Nu-Gel Hydrogel and cover with hydrofiber wound dressing. · No bath until 7 days. · Minimize use of tape. · Routine diaper care with disposable wipes soaked in sterile water. · Open diaper. · No ECG leads. · Score skin health with a skin care score. From 4 to 7 DOL · Humidity in isolette: 85%; wean by 5% daily after day 7 as temperature allows and based on skin condition. · In case of skin breakdown: apply Adaptic (non-adherent) and Nu-Gel Hydrogel and cover with hydrofiber wound dressing. · Delay bath until day 7. · Minimize use of tape. · Lay baby on Biotain Alginate sheet; change every 1 week until skin condition no longer requires. · Transition to PICC by day 7; If skin condition poor, keep UVC if in good position, until skin condition permits PICC (max 14 days). · Discontinue UAC by day 7. Good luck.
  47. 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!
  48. 4 points
    Caffeine has been used for over 30 years to treat episodes of apnea in preterm infants. Caffeine citrate is considered one of the most safety and effective drugs, with few or no side effects, used in our Neonatal Intensive Care Units (NICU). Many randomized studies describe the use and benefits of caffeine in the preterm population. Studies based on caffeine prophylactic use in preterm infants, as well as new indications out of apnea of prematurity have been recently published. Despite being one of the drugs most used in our NICU, are not yet available clinical practice guidelines and / or protocols in many of our NICU. Therefore, I invite you to participate in a study to determine the use of caffeine and its indications in NICUs around the world through the following survey. Once analyzed all the surveys, I promise to send you the results. Those you are interested you can send me your email adress and I will send you the survey. Dr. Laura Castells Vilella lauracastellsvilella@gmail.com Neonatologist and NICU’s Manager IDC Salud Hospital General de Catalunya (Barcelona, Spain)
  49. 4 points
    Dose & administration Initial dose: 0.05 to 0.1 microgram/kg/min via continuous IV infusion. Titrate to response, then decrease rate to provide the lowest dose while maintaining effect. Maximum dose: 0.4 microgram/kg/min. Higher initial infusion rates do not produce greater effects and are associated with more adverse effects Indications To maintain patency of the ductus arteriosus in congenital heart diseases dependent on shunting for oxygenation Contraindications and special considerations (incl incompatibilities) There are no known contraindications or incompatibilities. Adverse effects Apnea is experienced by 10-12% of infants with congenital heart defects treated with alprostadil, especially those weighing <2 kg at birth. Apnea usually occurs during the first hour of infusion. Respiratory status should be monitored during treatment. Staff trained in resuscitation and intubation should be available. Other common side-effects: fever, seizures, flushing, bradycardia, hypotension, tachycardia, leukocytosis, diarrhea, hypokalemia Uncommon side-effects (<1%): respiratory distress, wheezing, hyperbilirubinemia, anemia, bleeding, thrombocytopenia, hematuria Pharmacological aspects Alprostadil, or prostaglandin E1, causes vasodilation, inhibits platelet aggregation, and stimulates intestinal and uterine smooth muscle. As much as 80% may be metabolized in the first pass of the lungs. Metabolites are excreted via the kidneys within 24 hours. The half-life is <1 minute, thus necessitating a continuous infusion. References Arav-Boger R, Baggett HC, Spevak PJ, Willoughby RE: Leukocytosis caused by prostaglandin E1 in neonates. J Pediatr 2001;138:263-265. PMID 11174627 Browning Carmo KA, Barr P, West M, et al: Transporting Newborn Infants With Suspected Duct Dependent Congenital Heart Disease on Low-Dose Prostaglandin E1 Without Routine Mechanical Ventilation. Arch Dis Child Fetal Neonatal Ed 2007;92(2):F117-9. PMID 16905574 Cawello W, Schweer H, Muller R, et al: Metabolism and pharmacokinetics of prostaglandin E1 administered by intravenous infusion in human subjects. Eur J Clin Pharmacol 1994;46:275-7. PMID 8070511 Prostin VR Pediatric [package insert]. New York, NY: Pharmacia and Upjohn Company; 2013. Talosi G, Katona M, Turi S: Side-effects of long-term prostaglandin E1 treatment in neonates. Pediatr Int 2007;49:335-340. PMID 17532831 Document version history Created 2016-11-10 / Maegan Wells
  50. 4 points
    It is one of the first things that a medical student pledges to do; that is to do no harm. We are a fearful lot, wanting to do what is best for our patients while minimizing any pain and suffering along the way. This is an admirable goal and one which I would hope all practitioners would strive to excel at. There are times however when we can inadvertently cause more harm than good when we try to avoid what we perceive is the greater harm. This is the case when it comes to collecting a sample of urine for culture as part of a full septic workup. If you ask most healthcare providers they will freely acknowledge that the gold standard for determining whether an infant has a UTI is a supra pubic aspirate (SPA). We so rarely do them these days however due to a whole host of reasons. Problems with collection include the timing and accuracy of needle placement both of which may often lead to an empty tap. Secondly after a number of missed attempts and a crying infant who appears to be in pain it is understandable why bedside nurses may become frustrated with the entire experience and urge the person performing such procedures to settle on a bladder catheterization (BC) to obtain the specimen. The Study That Compares BC and SPA Head to Head A recent Turkish study by Eliacik K et al published A Comparison of Bladder Catheterization and Suprapubic Aspiration Methods for Urine Sample Collection From Infants With a Suspected Urinary Tract Infection and should give us all cause for concern. The authors performed SPA on 83 infants under 12 months with a positive urine culture by BC but who had not yet started antibiotics. The outcome of interest was both the comparison with the culture result and to see if urinalysis from the BC could increase the strength of the information gleaned from a BC. All in all the BC performed quite poorly when compared to the gold standard. The false positive rate compared to SPA was 71.1%! That is to say that only 28.9% of SPA samples were positive compared to BC. Similarly urinalysis sensitivity and specificity from BC were 66.7% (95% CI, 44.68% to 84.33%) and 93.22% (95% CI, 83.53% to 98.08%), respectively. This means that only 2/3 of the time was the urinalysis abnormal on a BC in the presence of a true UTI. Somewhat reassuring is that when there really was no UTI the urinalysis was mostly negative but in almost 1/10 patients it would not by itself rule out a UTI. What Is The Harm in Continuing BC Instead of SPA? When we try to avoid the perceived painful experience of a SPA we are going to wind up treating a large number of patients for a presumed UTI who don't have one. The harm in this is the exposure of such infants to prolonged courses of antibiotics which has been a subject discussed many times over on this site. We put our patients at risk of antibiotic resistance and shifts in the gut microbiome which in the case of the preterm infant puts them at risk of necrotizing enterocolitis. There are many other concerns with prolonging antibiotics but these few should be reason enough to strive for accuracy in obtaining the right specimen in the right way. Putting it in a slightly different perspective, would you settle for an alternative test to a lumbar puncture which claimed to miss 1 in 10 cases and also found meningitis where there was none 71.1% of the time?! A Way Forward - A Recipe For Success As the saying goes, measure twice and cut once. With the use of bedside ultrasound there should be no need to guess as to whether the bladder is full or not. Secondly the placement of the needle should no longer need to rely on landmarking but actually seeing where the best place for needle placement is. Assessing the bladder by ultrasound is easy and is already employed at the bedside by nurses in many areas of the hospital. There should no longer be a reason for the empty tap as the practitioner can be called when the baby is ready as evidenced by a good amount of urine in the bladder. Given that we have some time to do the blood culture and LP, while we wait for the SPA to be done either sucrose in the premature infant or IV analgesic may be given for the SPA while in the term or older infant there is an opportunity to put a topical analgesic cream over the site. There really is little need for pain to factor into this any longer. Ask any health care provider and they will tell you they want to do the best they can for their patient. This study shows us that performing a BC is failing to meet that goal. We need to change our ways and return to the practice of the SPA but this time we have to get it right.
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