goosman

Hi Katja, We use COMFORTNeo in all Dutch NICU's. There are national guidelines on education and (re-)validation for health care providers as well as a flowchart that guides professionals in interventions based on the sumscores. We have however never evaluated to what extend these guidelines are being followed in the 9 Dutch NICU's. COMFORTNeo has its pros and cons, as all painscales do. My personal opinion is that PIPP (-R) is the tool with the best/most evidence for acute episodic pain. PIPP(-R) has been translated in several languages. COMFORTNeo is suited for measuring distress which can arise from stressfull situations or pain. There are concerns about the validity of COMFORTNeo in extreme preterm infants, neurologically impaired infants and infants treated with therapeutic cooling. The main problems with all pain assessment tools are that they measure pain or discomfort only a few times a day, dependant on local protocols, beliefs and or experience. Ideally, a pain assessment tool should measure continuously and unobtrusivly. It should measure emotion, not behavior. To date, this is not possible. Concerning analgesia we use non pharmacological interventions such as sucrose combined with non-nutritive sucking, breastfeeding, containment, skin-to-skin care, facilitated tucking. Pharmacological interventions in our NICU comprise acetaminophen (preferably i.v.), morphine and fentanyl. In the Netherlands, use of EMLA is restricted to term born infants. Best regards, Christ-jan van Ganzewinkel, PhD Neonatal Nurse Practitioner Member of the Dutch National Studygroup for Pain in NICU's

http://www.ncbi.nlm.nih.gov/pubmed/24296909 Epub ahead of print. Since I did not ask the source participants came from I cannot give an estimate of how many members of 99NICU completed the survey, sorry about that....

I am happy to inform you that our manuscript with the results of the survey has been accepted for publication in The Clinical Journal of Pain.

We hardly use it anymore. There seems to be no evidence that administration of bicarbonate improves outcome. In fact, it can be detrimental. Wat does improve outcome is adequate treatment of the underlying cause of acidemia. http://pediatrics.aappublications.org/content/122/4/831.long Best regards Christ-jan van Ganzewinkel Neonatal Nurse Practitioner NICU Máxima Medical Centre, Veldhoven The Netherlands

We perform lasertherapy in the OR, though once we had it done on the ward (but we don't have wards anymore, just 1-, 2- and 3- patient rooms).

One slide shows the sources I recruited the experts from, so don't worry....

The main problem with paracetamol/acetaminophen in PO/PR formulations is that there is only sparse data on efficacy. There is no evidence (to my knowledge) on the dose we should use to attain analgesic effect as measured by validated pain scales. I know of four studies that looked at the efficacy of paracetamol PR but failed to show analgesic effect. One study looked at paracetamol PO and also failed to show analgesic effect (if someone is interested in the references I will be glad to give them, but I don't have them at home right now) . In a study by Sinno Simons et al paracetamol failed to reduce the need for morphine post-op. The only study on paracetamol i.v. showing analgesic effect was published in 2004 (Allegaert K, Anderson BJ, Naulaers G, de HJ, Verbesselt R, Debeer A, Devlieger H, Tibboel D. Intravenous paracetamol (propacetamol) pharmacokinetics in term and preterm neonates. Eur J Clin Pharmacol. 2004;60:191–197).

The survey has been completed succesfully, and we have submitted our results for publication. The results will also be presented at EAPS 2012 in Istanbul. @ Stefan: I cannot tell you how many of our original participants found the way to the survey through this forum, we simply didn't ask that in the demographic section of the survey.

I will be in Istanbul to present the results of a study that was announced on this forum in 2010. The presentation will be held on 06.10.2012, 09:00-11:00, Nurses Program, Neurology, HALL J. Exciting !

As soon as we start fat, typically between 12 and 24 hours after birth, in all age groups.

from: http://www.nichd.nih.gov/cochrane/brion5/brion.htm. In our NICU there is a trend towards prescribing less diuretics, furosemide as well as daily doses of thiazides and spironolactone. There is a trend to decrease fluid intake (to 130-150 ml/kg/day), while taking care to maximize caloric intake to promote growth. If we use diuretics typical doses are: furosemide 1 mg/kg thiazide 1 - 2 mg/kg in 1 or 2 dose(s) a day spironolactin 1 -2 mg/kg in 1 or 2 dose(s) a day. Best regards, Christ-jan van Ganzewinkel Neonatal Nurse Practitioner

I know that in the Dutch NICU's there is no expericence with this kind of analgesia. The Dutch NICU's mainly use morphine (also in non-ventilated infants), and/or acetaminophen. Most use lidocaine as a local analgesic for thoracentesis. Interesting topic though ! Best regards, Christ-jan van Ganzewinkel Neonatal Nurse Practitioner Máxima Medical Centre, Veldhoven The Netherlands

My experience with the Drager machine is somewhat limited, since we have mainly used SLE the last years. We still have some Babylogs 8000 plus, but they are mainly gathering dust. To my knowledge hyperventilation can still occur when using volume guarantee combined with SIPPV. Volume guarantee with the Babylog (as I recall) is set with tidal volume, not minute volume. To my knowledge the machine does give an alarm when minute volumes are too high (this alarm has to be set by the user). So if the alarms are set correctly the risk should be low. If the minute volume alarm is set too high the patient is able to hyperventilate by means of a high breathing frequency. Hope this answer helps ! Best regards, Christ-jan

We never use SIPPV. The reason for this is that there is a risk of hyperventilation and airtrapping. I think the only theoretical advantage of SIPPV over SIMV is that every trigger will be awarded with a breath leading to less stress, as opposed to SIMV, in which only the set frequency will be rewarded with a breath. This can be handled by combining SIMV with PSV, however with this mode there also is a risk of hyperventilation since the infant will receive a breath with every trigger. Of course this risk can be minimised by carefull observation of tidal volumes and minute volumes and by inline ETCO2 measurement. A specific risk when using SIPPV in infants with MAS is air-trapping: when expiratory times are too short for a complete exhalation (as shown by the flow-time curves) the infant will build up inadvertant PEEP with a risk of pneumothorax. This risk is very low in RDS since inspiratory times can be relatively short in the non-compliant lung, so you get more time for each cycle. In our NICU we mainly use SIMV with typical frequencies of 40 - 60, dependent on gestational age, the breathing frequency of the infant and the respiratory mechanics. In full terms we sometimes use PSV as a weaning mode. Personally I think combining PSV with some kind of volume controlled mode is preferable, but these kinds of ventilation modes depend greatly on the abillity of the machine to compensate for tube leakage. However, all ventilatory strategies should be chosen with one goal in mind: to minimize side effects of artificial ventilation (chronic lung disease, air leaks, intra ventricular hemorrhage, leucomalacia). In literature, to date I have found no evidence of SIPPV or PSV being superior to SIMV in this aspect. What literature does show is that caregivers should concentrate on patient-triggered ventilation or HFV and stick to the chosen mode. Building your experience with the chosen mode of ventilation might yield the best results. Best regards, Christ-jan van Ganzewinkel Neonatal Nurse Practitioner Máxima Medical Centre, Veldhoven The Netherlands

Round 1 of the survey closed today with 125 participants from 33 countries, mostly from the anglosaxon countries (US, Canada, New Zealand, UK) and the Netherlands. This result exceeded my expectations, so I am thrilled to carry on with the subsequent rounds. Round 2 will be opened on wednesday April 14th, and it will still be possible to register as a participant and value the statements extracted from the answers on the open answers from round 1. Christ-jan van Ganzewinkel www.ceepain.org