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About Padkaer

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    Jesper Padkær
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    Aarhus, Denmark
  1. In Aarhus (as tweeted) Ampi/Cefuroxim, gentamycin and metronidazole 😊. We are considering a switch to meropenem though. What are your experience with this Stefan ?
  2. No experience with buble cpap, but check out the benveniste valve for CPAP. http://www.dameca.dk/produkter/neonataludstyr/ventilen-med-studs.aspx It has been the primary mode of ventilatory support for neonates in Denmark for three decades. Very easy to use, the valve is comparatively cheap (aprox 300 $ ) and made to be reused ( I don`t know if its still copyright protected, but i think manufacturing should be quite simple and feasible in most corners of the world) . The danish pediatric society has a cooperation with Cuba helping introducing it there, and I think it has been used in India as well. What part of the world are you practicing in ?
  3. That very much depends on the type of ventilator you are using, and on whether it offers volume guarantee/limitation or not. Very shortly summarized your inspiratory time should be long enough for the child to have a small plateau period during inspiration, and in a not to sick babylung an i-time somewhere between 0.35 s and 0.42 s probably won`t be to far of the mark. A somewhat longer answer could be : To my knowledge ventilators injures the lung in 4 ways (worst first) 1) Volume 2) Pressure 3) Oxygen 4) Atelectasis Ventilator strategy should aim at reducing all 4. Worst first. The amount of volume given by a ventilator is a function of your delta-pressure ( peak minus peep), the inspiratory time and the compliance of the lung your ventilating. So (not going into the whole open-lung strategy) given that you want to reach an ordinary tidalvolume of 4-6 ml/kg you have two ways of doing this - going up on the delta-pressure or the inspiratory time. Going with too low inspiratory times (with out adequate plateau) will cause you to use excessive high delta-pressure which will damage the lung. Using to long i-times with fixed delta-pressure, and no volume limitation/guarantee on the ventilator, will cause to high tidal volumes and injure the lung even worse. Generally, a ventilator with a volume limitation/guarantee mode that ensures your tidal volumes and delta-pressures are kept down as the lungs compliance betters (especially when treating IRDS, where this can happen quite quickly) is IMHO recommendable - as long as it is not used as an autopilot. A ventilator in volume guarantee mode should never ever be set with max possible pressures more than 3-4 mBar above, what is needed for the child to reach adequate tidal volumes at any given time. Kind regards Jesper
  4. Not knowing your set-up and technical possibilities, its a bit hard giving specific advice, but on a general basis i agree with everything Stefan has said. If you have a working nasal CPAP set-up, i would try very hard to avoid intubation and ventilator treatment. I would accept pH values down to at least 7.2 og pCO2 up to 8.5-9.5 (even higher if the pH is okay and the baby isn`t showing signs of carbondioxid narcosis). It will be of little avail to a poor child if you save its life, for now, but render it oxygen dependent for a prolonged period secondary to VILI and BPD. If you do not already have a working nasal CPAP system you could, for future cases, look into the danish Benveniste venturi valve. It has been the first choice in respiratory support of neonates in DK since the late seventies. http://books.google.dk/books?id=Z5JEcDj3pCEC&pg=PA129&lpg=PA129&dq=beneviste+venturi+valve&source=bl&ots=Du2yZCWeYk&sig=IPpkICE9wv4drWO906bTL9KpQFY&hl=da&ei=8A2XTM-GIIuMOPuusYgJ&sa=X&oi=book_result&ct=result&resnum=1&ved=0CBQQ6AEwAA#v=onepage&q&f=false http://indianpediatrics.net/sep2002/sep-851-855.htm Its very effective, easy to use and cheap. To my knowledge all patents ran out decades ago and you should be able to manufacture it locally. Jens Kamper, who introduced the valve to clinical use, is still head of the neonatal unit in Odense, if you contact him, there is a chance he will take interest. Steroids are always a tough call to make, but after 2 weeks i would consider them, if the baby is tied to a ventilator and, depending on the circumstances, even to avoid an intubation. I would also prioritize to get the baby on enteral feeds as quickly as possible, preferably with the mothers own milk (HIV status ?) and a fortifier. Kind regards Jesper
  5. We tested the Leoni Plus, the SLE 5000 and the Stephanie in our unit in December. The process was a bit forced as our administration delightfully had found unexpected funds for the acquisition of 2 new neonatal ventilators, but with the catch that the deal had to be sealed in the budget year 2009 – meaning we had 3 weeks to make up our minds…. We ended up buing two Stephanies, a decision that was done with a rare and almost unanimously, agreement amongst the registrars. It was however a close race and given more time, I can’t say that, we wouldn’t have chosen differently. Basically all 3 machines are very good and dedicated neonatal ventilators that should do the job in most tertiary neonatal units. I can’t speak for all, but my main reasons for ending up on the side off the Stephanie where these 1) Technical back-up. Stephanies organization made by far the most convincing effort on demonstrating the will and capability on not just selling us a ventilator, but also making it work in our unit afterwards. So far they haven’t disappointed. 2) Design. While the exteriors of the Stephanie indisputably are dated and the user interface almost as user unfriendly as that of the old babylog 8000, an experienced neonatologist should still be able to use it after a couple off hours training. The machine has all the ventilatory possibilities that comes with the Leoni (except HFO volume guaranty – returning to that later) and the SLE, and it has some major design advantages compared to those two machines. Naming a couple –we have found that the building in of the humidifier and the flow-sensor into the interior off the machine is not just an technical oddity, but a real advantage in every day ventilation as is substantially reduces the pressure damping in the tubing system and combined with direct control of the temperature in the tubing enables us to deliver almost a 100% moisturized air into our patients with minimal rainout. 3) Economics – not being able to go into details, I can say as much as they gave us a very good deal…. So right now our two new Stephanies are running in our unit along with the 7 old babylog 8000s . The later will however still need replacement in the eminent future so I am reading with great interest when comments arise on all the possible candidates. I am especially interested to hear if anyone has hands on experience with both the Stephanie and the Leoni and is able to compare them head to head ? Kind Regards Jesper PS. Concerning volume guarantee in HFO, I agree that it could possibly be huge and perhaps the most interesting new thing in neonatal ventilation in a decade. I am very enthusiastic about HFO and if this new technology works ( we didn`t have the time to properly test the mode) it should IMHO substantially minimize the risks of hypocapnia and associated PVL when using HFO and could be the factor that tilted the scale to the side of HFO in invasive ventilation of neonates.
  6. Dear Jack and Stefan Thank you for the links. The abstracts look very promising. I´ll get back to you once I have read the full articles. Kind Regards
  7. When using inotropics in PPHN many guidelines advocate the primary use off dopamine up from 5-15 (20) μg/kg/min and if that fails the add on of dobutamine. While it makes perfect sense for me to start with dopamine I fail to understand the argument for dobutamine. It is almost exclusively a β1 active sympathomimetic with very little, if any, effect on α receptors and on blood pressure. That makes it very attractive in the setting of cardiac failure, where one wishes to increase the contractility of the heart with out burdening the strained pump with an increased after load. Its use in PPHN however, where you presumably have a normally functioning myocardium and primarily want to raise the peripheral blood pressure, seems illogical to me. Instead of going with dopamine and dobutamine in high doses, I would consider a) Switch to adrenaline Add noradrenalin to dopamine Or c) Switch to dobutamine and noradrenalin more logical choices. I am aware that noradrenalin for many good reasons is considered an unattractive drug, but in this one very specific situation I think good arguments could be found for its use. If any one could explain to me the logical argument for the use off dobutamine, or guide me to the trials, that has documented its efficacy in PPHN, I would be very thank full. Kind regards
  8. My unit will need new ventilators in the not to distant future. We are currently using Babylog 8000s for conventional ventilation and have a single Sensormedics for rescue HFO. We would like our new ventilators to be able to handle the full spectrum of neonatal ventilation including HFO. If it is suitable to be used by our transportation team as well, that would be a big plus. It must be able to vibrate babys < 5 kg effectively and if it can handle bigger than that, it would also be an advantage, as we also serve as PICU. The candidates so far are the SLE 5000, the Stephanie and the Leoni. I have only encountered the Stephanie shortly but my impression is, that while being a technically very competent ventilator, it seems very hard to learn to use “well”. The SLE 5000 I have some experience with and am quite enthusiastic about it, especially the HFO modus which seems just as powerful as the Sensormedics and much easier to use. The touch screen controls work beautifully and it is the closest to a “plug and play” ventilator I have ever encountered. This weekend however I was introduced to the Leoni plus ventilator, and at first glance it seems it might be even better than the SLE 5000. It caries the advantage of all the ventilation modes being named the same as in the Babylog, it is even easier to use than the SLE and the noise level is very, very low. Comments and thoughts on the three ventilators would be very welcome. Are there other candidates we also need to consider? I have heard rumours that Karolinska currently are using seven Leoni in their unit and three on their transportation teams. Does anyone know if that is true, and whom we might contact at their unit, to learn about their experiences with the model? Kind Regards
  9. Dear All, I´m am new to this forum. In my unit we very rarely use NaHCO3. In the extremely premature mechanicaly ventilated child with an BE below -10 and a pH below 7,25 NaCHO3 is sometimes uses for a short time.
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