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Everything posted by richmaus

  1. A problem that most units would see when looking after babies at the extremes of viability. We have used HFOV + VG (VG 1-3mL/kg) to manage these babies and generally don't have to reduce the frequency below 10Hz. Using "Sigh Breathes" can also be useful in these babies but like another poster suggested, using an early DART course may be useful as well as treating other underlying co-morbidities e.g. anaemia, VAP, PDA etc. This is taken from Prof Jane Pillow's manual on the use of HFOV that is published by Drager. Just thought it would be worth sharing. Let us know how you get on with this wee little one! Richard
  2. 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
  3. Hi Antoine Thank you for the reply. Yes - outborn infants will always remain a problem for us, as we have many referral centres that look after newborn babies and refer to our tertiary centre for ongoing management. I live in Brisbane, Queensland and the state of Queensland has an area of 1.853 million square kilometres. It is nearly five times the size of Japan, seven times the size of Great Britain and two and half times the size of Texas. The states total population is just over 5 million. We only have 4 NICU's in the state that are capable of providing therapeutic hypothermia for moderate or severe HIE. We do have a state wide guideline, online for HIE which includes flow charts, policies and educational tools (which includes the HIE trigger tool) in order that peripheral centres can up-skill themselves with regards to management of a baby suspected of having moderate or severe HIE and therefore refer then early in their postnatal course (https://www.health.qld.gov.au/qcg/publications). Outside the 4 level 6 NICU's scattered throughout the state (3 of them are in the SE corner of the state) no other facility that delivers newborn babies has the capability of doing aEEG monitoring so that is not an option for us. We have recently improved our TeleHealth service so that we are able to dial in to these peripheral centres and we are able to see these babies that we are getting calls about whether we should cool them or not - which is not the same as examining them ourselves - but is better than just getting the information over the phone. The retrieval service is managed medically by a level 6 Neonatologist, 24/7 and so this has definitely helped in the situation where there is a questionable neurological examination - again this is only dedicated to the first 6hrs of life as it was in the original cooling trials (see attached). With regards to the above-mentioned case, if a baby like that was delivered in our level 6 hospital, then it would have been commenced on the HIE trigger tool because of the cord gas results (pH 7.0 and BE > -12) and would have had hourly clinical monitoring for moderate or severe HIE using the Sarnat scoring system. If the baby did not meet clinical criteria for moderate or severe HIE in the first 6 hrs then we would have stopped these hourly assessments and if the baby was otherwise systemically well (no respiratory support and planned to established feeding) then it would have been discharged to the postnatal ward. So the outcome may have unfortunately been the same as it was in this case! We certainly do see these cases in our hospital from time to time. The questions therefore arise: 1. Could there be benefit of therapeutic hypothermia for babies with mild HIE? (One could argue that this baby would have been diagnosed with mild/ stage 1 HIE based on the information provided in the case - I have attached some interesting information from Terrie India and her group out of Boston, USA, regarding this topic) 2. Is there benefit from initiating cooling beyond the 6hr time frame that was introduced after the original cooling studies were performed? (I have attached a nice RCT attached looking at this!) Sorry, I know this probably doesn't answer your questions but we have a similar problem here to. I think getting more information on these 2 questions will be very helpful when trying to manage a baby like this one. I hope everyone is managing OK with the current COVID-19 pandemic. Keep safe! Best wishes Richard Whole-body hypothermia for term and near-term newborns with HIE.pdf Selective head cooling with mild systemic hypothermia after neonatal encephalopathy - a multicentre randomised trial.pdf Due to limitations of upload size I haven't been able to upload all of the articles. This is the title of the article from Terrie Inder's group: "Should therapeutic hypothermia be offered to babies with mild neonatal encephalopathy in the first 6 h after birth?" This is the title of the article regarding cooling for moderate or severe HIE after 6hrs of life: "Effect of Therapeutic Hypothermia Initiated After 6 Hours of Age on Death or Disability Among Newborns With Hypoxic-Ischemic Encephalopathy A Randomized Clinical Trial"
  4. 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
  5. I am one of the co-site PI's on a RCT called PAEAN (https://clinicaltrials.gov/ct2/show/NCT03079167). It is a multi centre, RCT looking at the use of EPO in babies with moderate or severe HIE that receiving therapeutic hypothermia. We are approximately 2/3 through recruiting for this study and hopefully these results can answer your question! Sorry, no answers but thought I would share that!
  6. I would have to agree with previous comments regarding abnormal position of this UVC. We also do cross-table lateral views when inserting our umbilical lines but if we have any doubt with that we will get an USS done to confirm position and then withdraw to a low position in the umbilical vein if other access is proving tricky!
  7. I was wondering if anyone had experience with using the AccuVein in the NICU at all? It looks like it used a lot in the adult and paediatric populations but I haven't been able to find any information regarding its use or suitability in the NICU? Would be great to hear feedback from anyone that has used it!! I have attached an information sheet as well as link to their website. Thanks Richard https://www.mundipharma.com.au/products/accuvein/? AccuVein info sheet.pdf
  8. Interesting discussion. Given we have had a explosion of 23 weeker a of late we are also having issues with chlorhexidine burns (use 2% solution). Very interested to hear that some centres only use 0.9% sodium chloride. This might be a very interesting practice to adopt!
  9. @spartacus007 I haven't as yet used it in a preterm infant but I could imagine there being difficult in getting the tapered dilator into the skin entry site over the guidewire. I think possibly a gentle twisting motion of the introducer over the guidewire might help get it into the entry site. Let me know if you come up with any other tricks when you try it again - trial and error I suppose!
  10. @spartacus007 do you mean the yellow tapered insertion needle that is in the microsite kit? I haven't had any experience of having this problem directly as the tip is tapered and so if the vein is of a generous size it should advance over the guidewire. I think twisting the tapered dilator that comes in the microsite kit as you advance it over the guidewire towards the skin insertion point may overcome that issue. As I mentioned previously we are using it in the bigger babies that require 24Fr double lines but have smallish veins! I hope that helps! Cheers Richard
  11. Our standard drug protocol is for semi-elective and elective intubations in the NICU include atropine, fentanyl and suxamethonium. The atropine to negate the associated bradycardia that this babies experience with laryngoscope insertion, fentanyl because it has a faster onset of action (although chest wall rigidity has been seen if administered to rapidly - we give it as a slow push over 2 mins & suxamethonium because of it's rapid onset of action and very short T1/2). I have not had any experience with the use of rocuronium or sugammadex in the neonatal population. I facilitate on the PaediatricBASIC course and the Paediatric Intensivists and Paediatric Anaesthetists are amazed that we still use suxamethonium in the neonatal population. There is definitely a trend in the "PICU world" seemingly towards the use of rocuronium. In saying that our "neonatal" (i.e. <28 days old) cardiac patients who go to PICU pre-op. are electively intubated with rocuronium I am told by our rotating registrars. I suppose this is a different scenario given that these patients will be maintained on a continuous infusion of muscle relaxation in the post-operative period. The literature on the subject seems a bit sparse - some interesting articles attached......................... Rocuronium and sugammadex in a 3 day old neonate for draining an ovarian cyst - neuromuscular management and review of the literature.pdf Sugammadex in the neonatal patient.pdf Reversal of rocuronium-induced NMB by sugammadex in neonates.pdf
  12. Thanks very much for that @spartacus007- that is a great video! Are you happy for me to share this with our junior staff?
  13. We are now using the Vygon micro-sites in our unit and with great success. Given the cost per pack we are using it for the bigger babies that require a 2Fr catheter because of the volumes. We have both 20 & 30 cm Premicath catheters for those babies less than 1500g and these seem to be working well. Thanks for the previous comments. I can highly recommend the Microsite packs!
  14. I was wondering if anyone had come across any evidence for the use of pigtail catheters and/or Seldinger technique for the insertion of intercostal catheters in the Neonatal population? @chandas - I was also just wondering what product brand you use? Does it comes as a set? Thanks
  15. @chandas that is extremely useful-thank you for sharing that. I suppose it would be relatively easy to make a VOLT using a manikin. What brand are you using?
  16. Hi All I just had a question regarding the insertion of pigtail intercostal catheters using the seldinger technique. Our unit currently doesn't use pigtail catheters for ICC and we use the traditional method of blunt dissection down to the parietal pleura then entering the pleural space using curved forceps. Some of the Neonatologists in our unit do use the trochar that comes with the intercostal catheters to enter the pleural space. Our PICU colleagues have recently commented about the this technique and the problems they have found with air leaking around the entry site despite adequate securing of the catheter and dressings. They have suggested we switch to using pigtail catheters especially in our bigger babies and I am just curious about others experience. This would obviously require some upskilling and training of the staff in the unit and I was also wondering if anyone had any good instructional videos available detailing the pigtail catheter insertion using the Seldinger technique in the neonatal population. Any comments or suggestions would be useful! Many thanks RichMaus
  17. Our unit does not lock our CVL or PICC's. We run heparinized saline at 1.0ml/hr to keep them patent or we remove them as soon as they are longer needed.
  18. Our unit uses the DART regimen (with dexamethasone sodium phosphate) when starting postnatal steroids to facilitate extubation or they are sometimes started in cases where the baby is in extremis and receiving maximal other supportive care with respect to respiratory and cardiovascular support. This is the dosing regimen we use: 75 micrograms/kg/dose 12 hourly for 3 days* 50 micrograms/kg/dose 12 hourly for 3 days* 25 micrograms/kg/dose 12 hourly for 2 days* 10 micrograms/kg/dose 12 hourly for 2 days* *Dose based on working weight of patient on Day 1 of regimen. Total of 10 days of steroids. Can be given IV or PO. We do not increases or decrease the dose outside of these regimens irrespective of any change in clinical practice. We aim to extubate babies between D3 and D5 of the steroid course in order that there is still a "tail-off" period of weaning steroid cover while they are on non-invasive respiratory support. We do counsel parents prior to starting steroids about both the short-term and perceived long-term side effects of the steroid use. We very rarely do back-to-back steroid courses. If we are unable to extubate the baby on the 1st course of steroids we will generally ensure optimisation of nutrition and ensure adequate growth, treat anaemia and any associated VAP before trying another course of steroids several weeks later if they are still unable to be extubated with the above. I hope that helps. Kind regards
  19. Hi All i was just curious as to whether anyone had any experience with the Vygon micro site & it's successful use in siting double lumen 2Fr catheters in ELBW? Any experience in general would be greatly appreciated! Many thanks RichMaus
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