Stefan Johansson

This winter has far warmer than usual. There's almost no ice in the Nordic sea, there's been hardly any snow in the Stockholm area. You may think this sounds good, but to tell the truth... without the brightening effect of snow Stockholm/Sweden gets really dark and unpleasent (that's my opinion anyway). Given the random variations in the climate I think one cannot only blaim the greenhouse effect, but something must be going on. Look what happened to our Christmas tree in our living room (started to grow) and the flowers in our garden (these flowers normally "show up" in March/April, the picture is taken around the 25th of Jan).

Aha, I thought the four images came from the same patient, I did not realize that they came from different patients! Sorry about that. I agree with JACK, different etiologies are quite likely. In general (and a bit off the topic ), I wished we had better tools for ruling out infections, reducing the load of antibiotics we give to non-infected infants. I/we commonly start infant with respiratory distress on antibiotics, and give treatment a few days while awaiting (negative) cultures and CRP responses. Noone (i.e. I/we) wants to be left behind an accelerating septic problem.

Hmm, complicated hemodynamics! The ASD and VSD seems pretty large from the measurements, given that the infant is rather small. The duct is clearly wide-open. I speculate now... could it be so that the duct shunts lots of blood, leading to high atrial pressure, which is drained back to the right ventricle. Increased right ventricular pressure would be the result of the volume load from the ductal shunt/left atrium. Seems like a far-fetched explanation though. The situation could be quite dynamic too, has shunt directions and velocities changed over time? We would do echos at least 2-3 times weekly.

Hi! Crocs (and cheap copies) are very popular in Sweden, as you probably know it was Swede Peter "Foppa" Forsberg, former NHL hockey player, who was/is (?) involved in the Crocs company. They are colled Foppa-slippers in Sweden. There was one report last spring from Norway that an apparatus for light therapy was short-cut, and one report from the southern part of Sweden that a CPAP-device stopped working. The cause was said to be static electricity generated in the person wearing Foppa-slippers (25.000 volts ) The Karolinska University Hospital banned Crocs last spring, but if I recall it correctly, the ban was lifted some months later. I found those links at the news magazine Medicine Today (in Swedish unfortunately...) http://www.dagensmedicin.se/nyheter/2007/03/20/plasttofflor-orsakar-norsk/ http://www.dagensmedicin.se/nyheter/2007/04/17/krav-att-tofflor-stoppas-e/ http://www.dagensmedicin.se/nyheter/2007/04/27/karolinska-forbjuder-foppa/

Generally the right ventricle is more like the left ventricle (i.e. hypertrophic) due to increased work load, for whatever reason (for example increased volume, structural outflow obstruction, or increased resistance in the pulmonary vascular bed). Unless there's any signs of generalized myocardial dysfunction or right ventricular outflow obstruction, I'd vote for increased pulmonary resistance as the underlying mechanism. A video would say more than 1000 words, but to start with, please add the cardiology report to this discussion, and there may be clues there what's going on!

Thanks for posting about this congress! Do you have link or a program (.pdf or .doc) which could be added?

This info makes the case more complicated than it appeared in your first post. Before you know more - you should probably leave the duct as it is, unless your pediatric cardiologist has another opinion! A right TO left shunt at ventricular level is not normal and indicates increased pulmonary resistance (i.e. primary or second pulmonary hypertension), in the absence of an outflow obstruction. It is a bit odd though that the ductal shunt has the reverse direction, left TO right. Is ductal flow only left TO right, or "predominantly" left-right (i.e. bidirectional)? What are the shunt velocities through the VSD and the PDA? What do the doppler profiles look like in the PDA and the main pulmonary artery? If you have digital video clips from the ultrasound investigation, please email those to me and I could help you to upload them.

Well, I'd say it depends on the hemodynamic impact of the shunts. From the clinical condition of the infants it appears that the volume load on the right ventricle (from the ASD/VSD) and lung circulation (from the ASD/VSD/PDA) is not very great. If the PDA-shunt is significant, there seems to be nothing to lose with pharmacological treatment although it is a bit late to have good odds for closure. If the child is well, and PDA is not very significant, you could probably just wait for spontaneous closure too.

I get the impression that the heart may look relatively large, but due to poor lung expansion (the first three pictures). On the fourth xray, lung expansion is better and the heart seem to have a normal size. Could you please give some more clinical info - was there an inflammatory response (incl elevated CRP)? How long did the respir distress endure? Was mechanical ventilation needed?!

That sentence will become a classic! And I agree, too.

Hi from Sweden! We use a white board as well, but it is placed in the staff office which parents do not have access to. I am not sure whether this is really according to (Swedish) regulations on patient integrity, but that's how we solve it. The board gives a great over-view of how days by the "production line" proceeds, and helps a lot in our every-day plans for discharges and transfers. In addition to the white board, we also keep a regular patient list (password-protected word-document on a intranet server) with info that's updated twice daily. This list is used during the "over-lap report" / when the shifts change.

Hi! I got an error message when trying to access the pictures. You can also upload the pictures as attachments to this thread (click on Edit/Go advanced and below the text box you find Additional Options and the button for attaching files). BW, Stefan

This is my list for 2007... Best research experience... our brilliant study on twins, their birth weights and later risk of type-2 diabetes Worst research experience... four rejections of the manuscript of the brilliant study above... (NEJM, Lancet, JAMA, Diabetes...) Best neonatal gossip... how the family Zlatan Ibrahimovic escaped the paparazzi photographers from the maternity ward... (well, this is from 2006, but I heard the story just recently) Most fascinating journey... Turkey, no doubt! Best gastronomic surprise... Dennis pizzeria in Turku (awarded "Best pizzeria in Finland") Best cultural event... (Dweezil) Zappa plays (Frank) Zappa: not a usual within-family show-biz event, but a fantastic consert! Most overrated family life happening... the introduction of Cable TV in our house Best sport event... the Wimbledon thriller/final: Federer-Nadal (on TV...)

International neonatal cardiorespiratory symposium, March 6-8 2008. Medical Education Center, Hamad Medical Corporation Doha, Qatar Download the attachments for more information. StableCourseSchedule March2008.doc program.pdf

I would also like to say Happy Holidays to everyone! And thanks for all support during this year! See you all (on the web...) next year!

In our hospital(-s), fathers are allowed into the actual operation theatre, and sit by the mother during the c-section, IF the mother is awake (no general anestesia). Only during strict emergencies (delivery within a few minutes after the alarm is sent to the or/anestesia/neo-teams) the father is not in the room by the mother (general anestesia), then he waits in the resuscitation room with the neo team. The father is almost always present during resuscitations, sitting in the background, with someone from the obsetr or neo staff by his side. The father wears like a overall over his cloeths, regular shoe "protection over-shoes" and the usual OR cover over the hair.

Ipokrates Seminar: Neonatal pulmonary critical care: State-of-the-art in respiratory assistance, delivery room care, prevention and treatment of chronic lung disease. March 13-15, 2008 Dubai, United Arab Emirates Find the programme attached below, and visit this web site for further info and online application. Program_Dubai_20081.pdf

When speaking to people in non-medical professions about daily life in neonatal care, many people wonder how we cope with everything. This remarkable mix of well-baby-nursery problems, medical and ethical issues in the NICU... and all parents... and their fear, anger and happiness. I do not really know what to respond to such questions, but a bit of the answer might be related to how we combine a rational mind with empathic capabilities. I mean, when standing in front of a newly delivered 25-weeker, immediate care is much driven by rational decision-making. But we (should…) also consider comfort issues already in the delivery room, and such strategies are probably based on what we believe the infant is really experiencing. Right there on the resuscitation table, medicated, intubated and on the ventilator. How we manage to cope with everything in our daily service in neonatal care may be related to how well we create a succesful synthesis of rationality and empathy. Not an easy task.

Great news! This is one of the nice aspects of neonatal care, happy endings!

Heard from a colleague of a rough weekend on-call, in a unit somewhere out there. Generally, for myself I like working really hard... I feel good after a bit of mental flow and manual work But the weekend I was told about must have been hard, as indicated by the number of pediatric subspecialties and units that were also involved: oncology surgery anestesiology nephrology radiology transfusion medicine infectious diseases ECMO... Reflections... professional networks are nothing but very important (no Network = no Care) team work around the patient is essential for success (no Team = no Life)

Our pre-med strategy usually includes a slow injection of morphine before intubation (0.1-0.2 mg/kg iv) and pentobarbital immediate before intubation (2-5 mg/kg iv).

Hi Sarah! I guess my Swedish perspective won't help much when it comes to specific advice, but I hope you can get input from our US members. But, you should not feel discouraged by a long educational journey, whatever will be your ultimate goal. Motherhood and academic achievements are not contrasting issues, you just need to be more organised than the average student. Maybe you could also post your questions at one of our partners: www.studentdoctor.net BW, Stefan PS. I moved your thread to the forum for education.

Unfortunately not! Finalizing my thesis right now. But in 2008 I plan to visit Hot Topics, maybe we could have a 99nicu meeting?!

Welcome to the 99nicu Blogs! Given the possibilities to share experiences, thoughts and opinions through a blog, we could not resist to add the latest feature of the software (vBulletin) used for the 99nicu forums. As a 99nicu member, you can start your own neonatal blog here! And write comments in blogs written by other members. Read the announcement in the News forum, download the blog manual and... get started! PS. If you are unfamiliar with blogging, take a look at blogbasics.com and Wikipedia for more information!