Francesco Cardona

One major difference between these two studies is that blood withdrawal from umbilical vein and umbilical artery catheters were studies, respectively. I think the point is rather that sampling may matter (volume and/or time). For a tiny premiee drawing 2 ml of blood may correspond to several % of the total blood volume.

I am afraid I cant follow you. What do you mean by saying that the two studies were studies? My idea was that these studies tried to find the best way to sample blood from umbilical artery catheters. I presume that in general we might try to keep loss through sampling to a minimum. On the other hand you might find inaccuracies if you draw not enough blood as well. I wonder if you could trust values if you only draw 0.2ml through an UAC as suggested in the study by Roll et al.

Hi

I am not familiar with the 2 in 1 or 3 in 1 TPN system, could you briefly explain the concept?

There are a couple of programs in the US that offer intestinal transplant (Pittsburgh, Georgetown, Childrens in Boston,..). They all have ambitious programs and are usually very supportive in helping to evaluate. Maybe you want to contact them directly?

Intestinal Transplant Programs Worldwide

I see there are also people in Argentina, Brazil and Chile.

Here is the link to the European guidelines by the ERC from 2005 (the most current version)

ERC guidelines

look under 6c: Air or 100% oxygen

At present, the standard approach to resuscitation

is to use 100% oxygen. Some clinicians may

elect to start resuscitation with an oxygen concentration

less than 100%, including some who

may start with air. Evidence suggests that this

approach may be reasonable.

To admit we dont comply with the recommendation and start off with 40% oxygen - so we are somewhere in the middle..

BTW, right now I am spending two days with the Swe Med Journal at http://en.djuronaset.com/

Really nice place, they have a lecture room for 400 people, and can house 280 people in single rooms. A bit outside Stockholm but in the archipelag.

Looks very nice indeed..

Interestingly the two paper you quoted come to different conclusions: Claudia Roll et al recommend drawing less blood to minimize drop in cerebral oxygenation while Schulz et al believe it is just a matter of time - 40s being adequate to keep cerebral oxygenation stable. Level of prematurity might be the difference as median gestational age was lower in Roll's study (27wks) compared to Schulz (30wks).

I like the time frame.

Something that I always found compelling was cross-talk of two speakers arguing on one subject, say PDA therapy and each speaker arguing for or against therapy (prophylactic, surgery options etc.) and citing the evidence for each situation. This done well is very educative - it needs the right speakers though..

I cant say with 100% certainty, but I do think they check for HEV and HAV as well. I guess the concern with Bilirubin is that there is something going on with the liver you dont want to transmit to anyone else under any circumstances.

Time: Definitely summer if you want people to come to Stockholm..

Topics:

- PDA therapeutic options

- Management of apnea

- Neonatal seizures

- HIE - is there a standard of treatment?

- resuscitation of the extremely preterm newborn

- fluid therapy in the first week of life

- nutritional additives (vitamin A, E etc.)

- pain management

- the "right" ventilator settings

- nitric oxide

- transfusion and erythropoietin

- perfusing the newborn brain

- How to conduct a "good" trial in neonatology

speakers:

Gorm Greisen

Barbara Schmidt

Martin Kluckow

Marianne Thoresen

Henry Halliday

Istvan Seri

David Field

Haresh Kirpalani

Linda de Vries

Our blood bank personnel have asked me the following questions;

1.Can we bleed a person who has a bilirubin value of above 2 mgs% ? Do we avoid blood donation from persons having serum bilirubin above the normal of < 1 mgs %?

2. Do we need to avoid blood donation from those who have recently been immunised with Hepatitis B vaccination ? if so , upto how many days ?

thanks

selvanr4

According to the NIH blood bank donors with jaundice are not allowed to donate.

The NIH blood bank has no objections against being vaccinated and donating blood (see here).

A very useful ressource by the way. I guess it is because Hep B Immunization is an active immunization with non-infectious Hbs-Antigen.

I admit one paper is just little evidence, but as a young member to the field of neonatology I do not have a lot of experience so I resort to the best evidence I can find. The association seen in older papers might be due to confounding as various people in this thread have pointed out. I am interested in your experience though: are all neonates covered with foil when they are subject to phototherapy. And have you seen differences in rates of PDA at your ward?

At our ward residents routinely attend cs unless difficulties are expected. Our NICU is right next to the delivery room, so in case there is trouble, the attending neonatologist will be available within seconds.

We don't do it unfortunately - even though we have echo service at our hospital. I guess our level of evidence is still on this level. Interestingly all children with CHD could be detected clinically in this study, I am not sure if that would apply to many other hospitals around the world...

As simple, cost effective and evidence based way to prevent this is to cover the ductal area with a reflective (tin foil) material. [see Jack Sinclaire's book on evidence based neonatal medicine)

It doesnt seem to work for extreme premature infants though (see Travadi's paper). Additionally, phototherapy has changed as well as LED-powered phototherapy is being used more and more which seems to be producing less heat and is a lot more effective (Vreman et al.) - so maybe the effects seen in Rosenfeld's paper might not be applicable today.

the PDA do open up during phototheraphy probably due to extra fluids 40-60 ml /kg given in addition to normal maintainance.

We tend to give 20ml/kg additionally, but who knows what the right fluid management is?

Additionally I might want to remark that even though phototherapy is widely used, no one really knows what long-term effects might arise from phototherapy (DNA mutations?). At least it seems that aggressive therapy is better than a conservative approach (Morris et al.), but at what Bilirubin level do we have to worry about worse neurological outcome due to bilirubin toxicity?

I am sceptical for now about SVC flow as there is poor interobserver repeatability (among others Groves et al. (2008)) and I have seen other reports that showed great variability in results as well. Maybe in the future it will be possible to standardize measurements, definitely an interesting area.

Do you routinely measure SVC flow? I I may be relieved of my scepticism though some day...

I would follow the WHO's pain ladder recommendation, i.e. first non-opioids (+adjunctive if necessary), then weak opioids and use frequent CRIES (or PIPP) scores to assess if pain is adequately adressed.

I guess the type of fractured bone would play a role in how much discomfort/pain one has to expect. I would also put in a good effort to find out the cause of the fracture.

Functional echo!

Reading the evidence I am also very compelled not to use Bicarbonate as I am really concerned that we are harming the baby even more. The blood value might be fixed (mostly not for long) and intracellularly things are just getting worse. Yet with my back against the wall I might try it for effect, especially if I am suspecting Bicarbonate loss (renal, intestinal).

Just curious: are you buffering complete or half - do you dilute with destillated water and over what time do you give it?

I agree a lot is about personal preference when treating hypotension in the newborn. The "classical" way is to use dopamin or dobutamin and use epinephrine as second line. Newer studies show epinephrine just as good in elevating blood pressure (see this). There is some evidence that dopamin might lead to pulmonary hypertension, maybe only transient but there are no good studies on that matter or the superiority of a different inotrope (this).

Needless to say, hypotension in the newborn is still hotly debated as probably arterial blood pressure is not a means to measure cerebral perfusion (what we really want to know) efficiently. A good read on this is this article by Gorm Greisen (link)