Francesco Cardona

Finally: In term infants receiving resuscitation at birth with positive-pressure ventilation, it is best to begin with air rather than 100% oxygen. If despite effective ventilation there is no increase in heart rate or if oxygenation (guided by oximetry) remains unacceptable, use of a higher concentration of oxygen should be considered. and the European Version is here: http://www.resuscitationjournal.com/article/S0300-9572(10)00455-7/fulltext

Here a look on how patients networks work http://www.slate.com/id/2270169/pagenum/all/#p2

Not quite the same topic but in nature about internet sites like 99nicu - and probably the idea behind the virtual nicu: Should you crowdsource your medical problems? http://www.slate.com/id/2270169/pagenum/all/#p2 Interesting especially the part of patients starting their own little informal drug trial.

Anyone going to be in Copenhagen besides myself? Anyone taking part in the Pre-congress courses?

That's where I came across the company ;-)

While surfing the net I came across this product from a non-profit organization. Anyone have experience with it? http://embraceglobal.org/

We are having an ongoing discussion on our ward about blood pressure drops when changing catecholamine infusions (dopamine, adrenaline..). We often observe that even if new infusions are slowly started while slowly discontinuing the old infusion (over a couple of hours) we encounter drops in blood pressure every so often. Some argue that it is best to just quickly exchanging the syringe is just as effectful in mainting adequate pressure. What are your experiences with that? how do you deal with this issue?

I cant wait!

Might be an interesting poll to see who uses alternatives to soy based lipid emulsions: omegaven, clinoleic etc.

I am very interested - I am currently enrolled as a distance learner for a Masters degree in Epidemiology.

Could you quote the article you base your numbers on? We - admittingly - rarely perform a lumbar puncture at our ward and I am interested to read up on the available data.

1) We use up to 33% Dextrose (it is the recommendation of the company) and will lower % if the PICC line lies in a peripheral vein to 15% (evidence?). 2) We keep them about 4 weeks and change them after that - sort of a trade off as every day increases the risk of an infection (read this 3) This article doesnt quite answer your question, but might give a you a basic idea of the problem.

I agree with Omer. Before blaming long-time parenteral nutrition I would try to find out if there is any underlying disease responsible for liver failure. Are there any anatomical intestinal or hepatic problems? - Do ultrasound of the liver (-> you definitely want to exclude biliary atresia), try barium enemas and contrast studies to see if intestines are patent Is there an underlying metabolic disease? - Do workup for aminoacidopathies, organic acidopathies, metabolic screen, carnitine pathway Infectious screen? - bacterial, fungal or viral Any medications you are giving that may cause liver failure? if all is negative look for more severe diseases (admittingly the list is endless..) Ascites would make me worried in any case.. Gastroenterology consult is definitely indicated If you still cant figure it out - I would suggest explorative laparotomy

Regarding your first question on omega3: I guess the scientific basis for use is amongst others this article by Gupa et al. http://www.ncbi.nlm.nih.gov/pubmed/18310188 There are a couple of ongoing trials in neonatal and pediatric patients and preliminary data look very promising http://www.clinicaltrials.gov/ct2/results?term=omegaven Another option being contemplated is clinoleic based on olive emulsion which seems to be beneficial as well. If I may make a bold prediction I believe soy-based emulsions will be almost gone within the next 10-15 years. I would say the way to go is to join big randomized trials and see if the short term promises can be upheld in good large trials.

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..

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 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.

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...

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. 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?