Francesco Cardona

Continuing a topic started on twitter, I would like to ask the 99nicu community. What muscle relaxant do you use in preterms and neonates primarily? Tell us about your experiences? What dose do you use?

We have used intralipid in the past and had no problem with premicath. These days we have changed to smoflipid though.

This new guidance is going to be published in Australia. Have your say: Managing extremely preterm birth at 22-25 weeks’ gestation To help give babies born extremely early the best chance of surviving, we have developed evidence-based clinical guidance to manage pregnant women and their babies. Babies born between 22+0 to 24+6 weeks’ gestation require intensive support for months after birth and those who survive are at risk of disabilities including problems with walking, talking, thinking, seeing and hearing. How we manage at-risk women and extremely preterm babies varies across the state, as do outcomes for these babies. How to provide feedback The draft guidance is now available for feedback before Friday 14 August 2020. After reading our draft guidance and supporting documents, take our quick survey https://www.bettersafercare.vic.gov.au/news-and-media/have-your-say-extreme-prematurity-guidance

There is an ongoing study (in EU, Canada, Australia) trying to help with this question: https://bmjopen.bmj.com/content/9/11/e032122 I have seen both happen - short therapy and longer therapy with sildenafil.

Can you elaborate on what is new?

Sounds like a promising approach if preparation is aseptic. I wonder how many neonatology wards get the same service as you do in the Netherlands!

I also believe higher Frequencies should be used in this patient - this is taken from Zannin et al. on the use of different frequencies https://www.nature.com/articles/pr2017151.pdf: At lower frequencies - a lot more pressure reaches (and damages) the alveoli. This is dampened a lot more at higher frequencies (>12-15 Hz): so even if you set higher pressures - a lot less reaches the alveoli, but ventilation remains same. We have used this approach in a few patients. In the end it was a combination of using the minimal ventilation (accepting lower Sats and higher CO2s) acceptable, giving steroids & extubating as soon as possible - even if that necessitated reintubation in some cases. In one sided PIE we have also used thoracic bandaging to limit lung excursions. In two cases we have also resected the destructed lobe to allow for better ventilation of the rest of the lung with success. Taken from the paper of Zannin et al. You can see that lower set P (pressure) levels at low frequencies lead to a lot higher alveolar pressures than if higher frequencies are used. This means you are injuring the lungs more by using lower frequencies - even if you think you are using lower pressures. In comparison a pressure set at 40 at a freq of 15 Hz leads to lower alveolar pressure.

https://mhnpjournal.biomedcentral.com/articles/10.1186/s40748-018-0093-1 This is the protocol of a recently finished trial that has not been published to by knowledge.

I like this as a starting point https://ep.bmj.com/content/104/1/43.long Maybe this is too basic though?

great series, thanks!

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

The CDC has come out with recommendations: It is unknown whether newborns with COVID-19 are at increased risk for severe complications. Transmission after birth via contact with infectious respiratory secretions is a concern. To reduce the risk of transmission of the virus that causes COVID-19 from the mother to the newborn, facilities should consider temporarily separating (e.g., separate rooms) the mother who has confirmed COVID-19 or is a PUI from her baby until the mother’s transmission-based precautions are discontinued, as described in the Interim Considerations for Disposition of Hospitalized Patients with COVID-19. See the considerations below for temporary separation: The risks and benefits of temporary separation of the mother from her baby should be discussed with the mother by the healthcare team. A separate isolation room should be available for the infant while they remain a PUI. Healthcare facilities should consider limiting visitors, with the exception of a healthy parent or caregiver. Visitors should be instructed to wear appropriate PPE, including gown, gloves, face mask, and eye protection. If another healthy family or staff member is present to provide care (e.g., diapering, bathing) and feeding for the newborn, they should use appropriate PPE. For healthy family members, appropriate PPE includes gown, gloves, face mask, and eye protection. For healthcare personnel, recommendations for appropriate PPE are outlined in the Infection Prevention and Control Recommendations. The decision to discontinue temporary separation of the mother from her baby should be made on a case-by-case basis in consultation with clinicians, infection prevention and control specialists, and public health officials. The decision should take into account disease severity, illness signs and symptoms, and results of laboratory testing for the virus that causes COVID-19, SARS-CoV-2. Considerations to discontinue temporary separation are the same as those to discontinue transmission-based precautions for hospitalized patients with COVID-19. Please see Interim Considerations for Disposition of Hospitalized Patients with COVID-19. If colocation (sometimes referred to as “rooming in”) of the newborn with his/her ill mother in the same hospital room occurs in accordance with the mother’s wishes or is unavoidable due to facility limitations, facilities should consider implementing measures to reduce exposure of the newborn to the virus that causes COVID-19. Consider using engineering controls like physical barriers (e.g., a curtain between the mother and newborn) and keeping the newborn ≥6 feet away from the ill mother. If no other healthy adult is present in the room to care for the newborn, a mother who has confirmed COVID-19 or is a PUI should put on a facemask and practice hand hygiene1 before each feeding or other close contact with her newborn. The facemask should remain in place during contact with the newborn. These practices should continue while the mother is on transmission-based precautions in a healthcare facility. https://www.cdc.gov/coronavirus/2019-ncov/specific-groups/pregnant-women-and-children.html Breast feeding Breast milk provides protection against many illnesses. There are rare exceptions when breastfeeding or feeding expressed breast milk is not recommended. CDC has no specific guidance for breastfeeding during infection with similar viruses like SARS-CoV or Middle Eastern Respiratory Syndrome (MERS-CoV). Outside of the immediate postpartum setting, CDC recommends that a mother with flu continue breastfeeding or feeding expressed breast milk to her infant while taking precautions to avoid spreading the virus to her infant. Breast milk is the best source of nutrition for most infants. However, much is unknown about COVID-19. Whether and how to start or continue breastfeeding should be determined by the mother in coordination with her family and healthcare providers. A mother with confirmed COVID-19 or who is a symptomatic PUI should take all possible precautions to avoid spreading the virus to her infant, including washing her hands before touching the infant and wearing a face mask, if possible, while feeding at the breast. If expressing breast milk with a manual or electric breast pump, the mother should wash her hands before touching any pump or bottle parts and follow recommendations for proper pump cleaning after each use. If possible, consider having someone who is well feed the expressed breast milk to the infant.

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/

https://wwwnc.cdc.gov/eid/article/26/6/20-0287_article?deliveryName=USCDC_333-DM21761 Lack of Vertical Transmission of Severe Acute Respiratory Syndrome Coronavirus 2, China I wonder what the ideal management of newborns born to COVID19+ mothers is. I hope there will be more information coming.

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.

https://www.sciencedirect.com/science/article/abs/pii/S1553725008340197?via%3Dihub http://rc.rcjournal.com/content/58/7/1237

Please help researchers from Germany with their study: https://www.umfrageonline.com/s/175a5bb

Thanks for sharing, looking forward to the results!

Hi @olamedmac Do you know if there is a protocol for delayed cord clamping available online? I have looked into the ressource you recommended at the 99nicu meetup in Copenhagen this year, [https://www.frontiersin.org/articles/10.3389/fped.2018.00372/full] but I havent found answers for the following questions: * best way to keep infants warm during DCC born by caesarean? * is the infant placed on or next to the mother during DCC? Thanks! Francesco

And if you havent seen Ola Andersson's lecture from the 99nicu meetup, go and check it out here:

As I understand it, MRI is better at detecting who will NOT develop severe developmental abnormalities, so that might be of comfort to parents. But as so often - very few things are black and white...

Interesting subject. In Vienna, we prime insulin infusion systems before use. The insulin is prepared as ordered, we start off with 0.05-0.1 IE/kg/h. After 30min, the insulin in the infusion system is discarded and the same amount/dilution prepared with the same system before use. Let me know if you need more information @ChantalNICU

You might want to share this link with parents on your NICU: https://parenting.nytimes.com/health/nicu-care