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Stefan Johansson

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Everything posted by Stefan Johansson

  1. Dear Petri Mansfelt, I think that most of these problems could be prevented by careful nursing - our nurses are catious about of the risk of pressure induced necrosis and keep an extra eye on position and pressure of the nasal prong. For some sensitive infants we use a different prong. It is a not really a 'nasal prong', but rather a small triangular 'hood' which covers the nose. If this 'hood' is positioned well (with not too much leakage of air) I think it works just as good as the regular prongs.
  2. We have a dedicated neonatal nurse in our unit, writing her thesis on enteral feeding. After this study, we now use continuous nasogastric feeding in our smallest infants.
  3. We sell one remaining multimedia CD-rom from our course in neonatal ultrasound: "Practical echocardiography for the Neonatologist - normal 2D imaging and Doppler. CD-rom 1", by Nick Evans and Girvan Malcolm, Sydney, Australia. This the first version of this CD (a new version is available now, for 150 USD). Price including postage is 25 euro (32 USD). Payment is only accepted through PayPal. Please visit the web site of Royal Prince Alfred Hospital for more information: http://www.cs.nsw.gov.au/rpa/neonatal/echo/echo.html Please send a PM or email info@99nicu.org if you want to purchase the CD or have any questions! * * * * * * * * * * * * * Donated to Egypt!
  4. Dear all, I have been asked to post the following clinical case born in a Swedish hospital: Term infant, normal pregnancy and delivery. The infant has a "ridge" of umbilical-like tissue, stretching from the umbilicus and to sternal tip. The ridge is freely movable from the deeper structure. No secretion. There are no external malformation apart from this ridge. The infant is well, breast-feeding normally, has passed meconium and urine, not vomiting etc. A plain abdominal x-ray has shown no pathologies. It seems that the infant has some kind of abdominal wall defekt, but what is the diagnosis? Has anyone seen something similar?
  5. Check this out! http://www.adhb.govt.nz/newborn/TeachingResources/Ventilation/Ventilation.htm
  6. Do you still have a "feeling" that this is primarely a pulmonary disorder? If so, have you considered performing a computer tomography of the lungs or a lung biopsy (histopathology)? Or do you have any indications that the breathing problems are secondary to dysfunction in a a different organ system; such as a neurological or neuromuscular disease?
  7. Dear billyvega, do you mean how base deficit could be used as a predictive factor of encephalopathy? Could the two articles/abstracts below be of interest? ******* Threshold of metabolic acidosis associated with neonatal encephalopathy in the term newborn. Wayenberg JL. J Matern Fetal Neonatal Med. 2005 Dec;18(6):381-5. OBJECTIVE: To determine the threshold of metabolic acidosis associated with neonatal encephalopathy (NE) in the term newborn. METHODS: Term patients were included on the basis of abnormal hemodynamic, respiratory or neurological signs still persisting 30 min after birth. Base deficit (BD30) was measured in arterial blood between the 30th and the 45th min of life and correlated with the occurrence of NE during the first days of life using receiver operating characteristics (ROC) methodology. RESULTS: Moderate or severe NE occurred in 26% of patients whose BD30 was higher than 10 mmol/L and in 79% of patients whose BD30 was higher than 18 mmol/L. No infants developed moderate or severe NE when BD30 was less than 10 mmol/L. The apex of ROC curve related to moderate or severe NE corresponds to a BD30 of 14 mmol/L. At this threshold, the sensitivity of BD30 is 73.2% and the specificity 82%. CONCLUSION: The threshold of metabolic acidosis that provides the best combination of sensitivity and specificity in relation to the occurrence of moderate or severe NE was a BD30 higher than 14 mmol/L. Significant birth asphyxia should be considered if BD30 exceeds 10 mmol/L. Combination of early perinatal factors to identify near-term and term neonates for neuroprotection. Talati AJ, Yang W, Yolton K, Korones SB, Bada HS. J Perinatol. 2005 Apr;25(4):245-50. OBJECTIVE: To determine early predictors of abnormal outcome at > or =24 months' age in neonates at risk for hypoxic-ischemic brain injury. STUDY DESIGN: A prospective cohort study with developmental follow-up of > or =24 months. Infants were selected based on risk factors, and neurologic outcome was determined. Variables affecting the outcome were evaluated with univariate and multivariate methods, and a scoring system was devised to predict adverse outcome. RESULTS: A total of 41 infants born > or =35 weeks' gestational age with possibility of hypoxic-ischemic insult were enrolled. In all, 39 (95%) had known outcomes, of whom 17 (48%) had an abnormal neurologic outcome, including five deaths. The variables within the first hour of life correlating with the adverse outcome were 1- and 5-minute Apgar scores, intubation in the delivery room and cord/initial base-deficit > or =20 mmol/l. A scoring system was derived based on significant variables, and a score > or =5 had a 90% positive predictive value for abnormal outcome. Seizures, multiorgan failure and abnormal imaging studies were also significantly associated with abnormal outcome. CONCLUSIONS: The proposed scoring system, being highly predictive of outcome at 24 months' age, may be potentially useful in selecting subjects for preventive or therapeutic interventions to prevent or minimize neurologic morbidity due to hypoxic brain injury.
  8. Dear all, consider the following scenario: a non-immune pregnant woman is incubated with morbilli around the time of birth. I'd be happy to hear about your experience/guidelines about maternal/congenital morbilli, especially your policies regarding immunoglobulin and immunization of the mother/child.
  9. Dolphine liu have mailed the following x-ray pictures. 8th of June 11th of June 14th of June 22nd of June 26th of June
  10. It seems that the baby did not have RDS and that apneas is the predominant symtom. Therefore, I think CLD/BPD is an unlikely diff diagnosis. * Could you please upload the x-ray picture?
  11. Dear Kishore, Good news! Did you ever find out the etiology of the hypoalbumenia?
  12. Could there be increased protein loss from the intestines? http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=Abstract&list_uids=11158480&query_hl=2&itool=pubmed_docsum Turner syndrome (45X) may also have congenital hypoalb; http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=Abstract&list_uids=3465177&query_hl=6&itool=pubmed_docsum
  13. Dear Manuel and Dolphine, I completely agree with both of you; 1) mechanical ventilation may get somewhat "mechanical" 2) inspiratory time is individual and may change breath by breath Please have a look at the link below, it explain the lung mechanics in relation to IT well. http://www.adhb.govt.nz/newborn/TeachingResources/Ventilation/RespiratoryFunctionMonitoringAndGraphics.htm We tried a Drager babylog 8000 some time ago and if I remember correctly this machine could adjust IT breath by breath. On a term infant we saw that IT ranged up to 0.55 sec. Manuel, do you use a ventilator, where you could monitor the flow curves, as in the Drager Babylog?
  14. Most (all?) baies I've come across were managed conservatively. Does the CCAM in your infant have any mass (compression) effects?
  15. Dear all, I'd like to forward this link to a web based atlas on congenital heart disease, from Yale Universtiy, US. http://info.med.yale.edu/intmed/cardio/chd/contents/index.html
  16. I guess we're all familiar with situations when we withdraw intensive care for infants for which further care is considered futile. In our units all such decisions are taken in consensus with the neo-staff team and the parents. Although it is rather obvious when intensive care becomes futile, the actual process of decision-making may vary from patient to patient. I would be interested to hear about how you make end-of-life decisions. Have you formalized decision-making? How are the parents involved in this process?
  17. I have only experience of the Ecutronics Fabian; we're about to buy new ventilators for our nicu at Karolinska and had a Fabian over a trial period. We're currently using a Sechrist machine with a "Florian" module added, "Fabian" is a new generation of the "Florian" system I guess. Anyway; the "Fabian" was nice to handle - easy to get started and quit when running. It has a kind of max volume option but it does not have a volume garantuee algorithm as the latest Drager ventilators. As far as I understood is cuts the inspiratory time, when the set max volume is delivered to the infant. The price for "Fabian" (on the Nordic market) was very competitive, and we did seriously consider to buy it (although we'll probably buy Stephanie ventilators when we'll upgrade).
  18. Dear Andrew, you're absolutely right that the latest ILCOR document gives no strict guidelines regarding O2 during resuscitation, although ILCOR explicitely say that room air could be used at the initiation of resuscitation (see quoted section below). I'd guess the new upcoming Swedish guidelines will contain similar statements as to the British recommendation you refer to, ie joining at the same fence! ******* From the ILCOR report: "Although the standard approach to resuscitation is to use 100% oxygen, it is reasonable to begin resuscitation with an oxygen concentration of less than 100% or to start with no supplementary oxygen (ie, start with room air). If the clinician begins resuscitation with room air, it is recommended that supplementary oxygen be available to use if there is no appreciable improvement within 90 seconds after birth. In situations where supplementary oxygen is not readily available, positive-pressure ventilation should be administered with room air."
  19. Dear Manuel, we have Sensormedic HFV ventilators in our unit. My personal opinion is that the Sensormedics are great and powerful machines, for any-sized infant <500g to >5000g. However, tubes (ventilator-ET tube) is short and rather rigid, which makes turning the child a bit tricky, but one gets used to this. Sensormedics (if you run several in the same room as we frequently do) may also be regarded as a bit noisy. I have also used the HFV option in the Stephanie ventilator, in small preterm infants. I really liked the Stephanie, flexible tubing, possibility to switch from MV to HFV without changing machine, less noise and the smaller format of the actual machine. We have not tried or used the Vip Bird you're referring to. Good luck with your purchase!
  20. Well, I don't think the new guidelines will differ at any major points. The conclusion of the workshop last year was that the (Swedish) working group needed to await the ILCOR report.
  21. Did you check immune status of the staff caring for this child? I understand that infants with congenital rubella excrete large amounts of viruses. There is a national database (in Swedish unfortunately) on infections during pregnancy, www.infpreg.com. This info on Rubella (in Swedish..) but at the bottom you'll find references which you may find useful.
  22. Check this out, from todays issue of NEJM! Clinical research at its best! Caffeine Therapy for Apnea of Prematurity, Barbara Schmidt et al Editorial comment by Eduardo Bancalari Caffeine as BPD treatment!? I think this finding was a bit surprising for the research group, given that authors stress the possibility of a potential harmful effect of xantines in the Intro of the paper. I think the (ongoing) follow-up studies will be of great interest, I hope they'll publish results soon.
  23. As far as I know, there's only supportive treatment for thromobocytopenia related to congenital rubella, i.e. I would transfuse if platelet levels got critically low (<15-20). Anyone else with recent experience of congenital rubella?
  24. There's a revision in pipeline, of the Swedish guidelines on resuscitation. There were quite a lot of discussion regarding the evidence of using O2 immediately after birth, at the workshop discussing this revision. The data from Saugstads group in Norway and others would suggest that room air would be fine, but practises vary a lot. I'd reckon our new (Swedish) guidelines will be suggesting less/no extra oxygen from the start of the resuscitation, but vaguely suggest that oxygen may me added/increased later during the resuscitation. Now, while awaiting the new guidelines we use 40% in our unit. PS. I added a poll to this discussion. DS.
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