Stefan Johansson

Hi Rennee! Our policy is to re-feed residuals if they consist of digested breastmilk, and substract the residual volume from the planned feed (keeping the total volume the same). If residuals looks greenish or otherwise "unfresh" we usually throw it away, and skip the planned feed. Depending on other clinical signs, residuals also later (despite the skipped feed) we handle each case individually. But we are quite scared of NEC in the ELBW infants, and it is not uncommon with a rather careful feeding strategy.

Dear ammar, difficult scenario! We would probably add epinephrine, while decreasing dobutamine slightly. If you have echo easily accessible one may also try to increase the NO dose, while doing doppler and see if it is possible to decrease pulm resistance.

Hesham Abdel-Hady sent us an email about the recent neonatal ventilation course at the Mansoura University Children's Hospital: He also enclosed two pictures from the conference. Do not forget that you can advertise your courses and conferences here on the message board, and also add these as events in our calender. If you need help, send us an email (info@99nicu.org)!

We have a dedicated neonatologist in our unit, running a project on simulation team training. That is, practising team communication during simulated resuscitation scenarios (in contrast to learning skills, such as intubations etc). As you know, complex resuscitation is nothing you do on your own, only together with a bunch of other people. The simulation 'system', a computer-connected doll, is really an excellent tool. I can assure every sceptic that this is good training with a great deal of adrenaline boost for all participants! The half-day session I participated in was as exhausting as a difficult night at work. Our 'clinical simulation center' was officially opened the other day, and the protector of the center is Christer Fuglesang, the Swedish astronaut. As you know, he and all other astronauts spend most of their working lives in simulation practise, before the do the real thing (spacewalk). The idea is bring simulation into medicine is an important principal step forward for patient security etc. Personally I have done quite a lot of space walking, without much of practise beforehand. Watch the webb-TV-cast, in Swedish, but still... http://webbtv.dn.se/index.aspx?id=2119

Thanks for encouraging words! We will do our best to do some better marketing, to get this ship of the ground. The bundle-of-books competition is only our first campaign!

The answer is yes, there are now guidelines for cooling, but all treated infants are included in an observational study. I don't have the guidelines at hand right now, but pathol CFM is NOT included as a criteria. Personally I feel more research is needed on this technique and thaht CFM seems to be a reasonable inclusion criteria. But I can also understand that one may argue that the treatment works, although I think the scientific evidence is a bit weak so far.

Yesterday we made a major upgrade of the forum software. Among other things, we fixed a problem with so-called cron-jobs, which take care of automatic technical things on the forum. If you subscribe on discussions you will now notice that subscriptions work! Everything looks the same after the upgrade, except for changes in our Chat facility. you enter the Chat through the alternative '99nicu Chat' in the QuickLinks menu above (top right). the Chat rooms are incorporated in the 99nicu web page and does no longer open in a separate window. For more info about our Chat, read this thread. (Why upgrades? Improved functionality! Bug fixes! To prepare for the upcoming major upgrade of vBulletin, which includes a blog function, i.e. enabling any member to start their own blog within our community. This upgrade is expected some time during the fall 2007.)

Dear all, 99nicu has now been online during one year. As being the informal team leader of the 99nicu Team, I take the freedom to express our thoughts about what we have achieved so far, and our ambitions for the future. *** *** *** *** *** *** *** *** *** *** The Past Internet is the technology for communication and dialogue, and I got the idea in 2005 that staff in neonatal medicine should also gain from those possibilities. I had been a member of a computer forum for several years and had experienced the great potential in the networks created in Internet communities. Colleagues and I processed our ideas and visions and in May 2006, we launched 99nicu.org with the ambition to create a friendly, busy and helpful Internet community for professionals in neonatal medicine. The Present During this first year online, I think we have reached our first goal, to attract members. Almost 100 members have registered every month. Today, 99nicu has more than 1100 members from all over the world! From the web statistics, we can also see a steadily increasing number of visitors. In April 2007 we reached a new all-time high, with >1500 unique visitors. However, we are still waiting for our community to “take off”, and to see more activity in the forums. We (i.e. the 99nicu Team) can provide the platform, but all of us (i.e. all members) create the contents. The future of 99nicu lies in your hands! One may argue that our marketing has been quite poor. I can only agree on such criticism. However, marketing costs money and we have had unexpected difficulties to attract advertising firms. We can only hope this will improve in the future. 99nicu needs to utilize the dog behaviour of man, so commonly used in marketing - if someone throws a bone, man will try to catch it*. In the near future, 99nicu will throw some small bones too… The Potential I believe 99nicu has a great potential! We just need to get used to this form of communication (the User Manual…) and to realize that we cannot just sit and wait for something to happen. The Neonatal World can improve and unite, and we make it happen, together! Don’t have respect for the technology! Share your questions, knowledge, opinions and experience in the forums. What do you expect from 99nicu in the future? What can we improve? What features do you want us to develop further? Your feedback is of great value! Wishing you all the best and see you around! *I am throwing a stone in the glass house here, but I think that we in the health care sector are keen to run for bones, just consider how the technology and drug companies do their marketing.

According to my experience, pain may also contribute to cardiovascular instability. Depending on the severity of the hypotension, we may still use a low dose of morphine-infusion, together with intravenous paracetamol. Ketamine may be an option as well, although I have no personal experience using that.

We are over-whelmed by all congratulations! Thanks to everyone! We really think that 99nicu has a great future and that our community will grow much more active with time. We will do some more "marketing" to encourage activity... stay tuned!

Alexander, a car is a good idea but as the team leader I would argue for new computers! I know a businessman in Nigeria, he just mailed me about some great opportunities. Cheers!

I cannot do anything but agree. One should do a study about the reliability of Apgar scoring in healthy term infants. It is quite likely that the 9-10-10-scores for well infants have problems with both sensitivity and specificity (says the perinatal epidemiologist in me). If someone put this idea into practise, please acknowledge 99nicu in the article

Dear Adrius, it is not possible to re-start the poll with different alternatives, you would need to start a new thread (by the way, you can add a poll yourself too, when starting a new thread!) But I suggest we continue the discussion about your second question below. I think Apgar scores are a quite crude marker of the condition of the infant at birth, but it gives some basic information about the unwell newborn infant. By using it on every child, midwifes and doctors do Apgar scoring "by automatic", also in cases where Apgar scores have some value. But I think you Adrius have a point, scoring the 9-10-10 infants may not be reasonable for its own sake!

Asked the pharmacist in charge of TPN at the Karolinska hospital pharmacy about this topic. The computer-aided mixing of the various components, does not take osmolarity into account... at all. In other words, we do not have osmolarity limits and we do not know about the osmolarity in our TPN solutions... Clearly, we could learn something here, will follow further posts in this thread with great interest!

We use the same TPN solutions regardless if we admin it in a peripheral catheter or a central line (although we mainly use central lines). Will check with our pharmacy tomorrow about our osmolarity limits. The hospital pharmacy prepares all our TPN, am not updated.

Do you have the URL to her web site (could not find it through google)? I raised the question since I think we can improve decision-making in those situations. A structural approach would be good, and improve the involvement of parents to critically ill patients. I personally have the opinion we should primarily treat the infant for his/hers own sake. But, in cases where severe neurodevelopmental sequele is a great risk, the impact of a very ill child on a family's situation should also be taken into account when we consider to continue intensive care or withdraw it. I know these are difficult questions, and maybe because of that we should discuss openly!

NEONATAL UPDATE 2007 “The Science of Newborn Care” 26-30 November 2007 at Imperial College London, South Kensington, London SW3 celebrating Imperial College London’s centenary and 10th anniversary of the Faculty of Medicine Informative, stimulating and thought provoking - this is a meeting that expands the horizons of neonatal medicine - a “must” for experienced clinicians and clinical scientists. FOR MORE INFORMATION AND ONLINE REGISTRATIONS, please visit the web site or contact The Symposium Office, Imperial College London Tel: 020 7594 2150; Fax: 020 7594 2155

I am not aware of any reference values either. Still ventilators keep us updated online about lung mechanics - my own view is to focus on relative changes rather than the actual figures for resistance and compliance. Our Swedish authority on lung mechanics (Kenneth Sandberg) has published a nice study about lung mechanics at 40 wks postkoncept age in preterm infants and compared with term born infants. Results as one would expect: the preterms have higher resistance and lower compliance. http://ajrccm.atsjournals.org/cgi/content/full/165/1/83 Please keep us updated if you find any interesting in your searches!

Well, I guess this is one of many areas where we rely on traditions and experience (and beliefs) as opposed to Evidence-based-medicine. But, it would be a true challenge to design a trial on abdominal massage. For example, how would outcome be measured!?

Workshop on Perinatal Circulation, Oslo Norway 14-15 June 2007 Ulleval University Hospital Download the programme and the registration form below for further information. oslo1.pdf oslo2.pdf

We have respect for abd massage in preterm infants. Have not seen an identical case as the one you present but I was involved in an infant with gut perforation after chest compression at birth. We believed this was a traumatic perforation. I do not have any golden-standard answers (are there any?!) to your questions but only share our gudielines: 1. we try to be even more minimalistic with regard to all handling, sometimes we try to decrease CPAP/peep, minimize ET airleaks etc. Sometimes, in stable and otherwise well infants, we do gentle massage. 2. sometimes the nurses stimulate the perianal area with cotton to help the infant to pass stools and air. Insertion of small tubes rectally is done sometimes but only after doctors "prescription" and only in non-NEC-patients. 3. no 4. feeding tube 5. see above

I think Adrius question was meant like a poll/survey. So, a poll has been added now, please submit your reply there and add any comments below! BTW, almost all infants born in Sweden have Apgar scores recorded. Midwifes set the scores in all infants who do not need any interventions by a pediatrician/neonatologist. Otherwise the ped/neo-dr set the scores.

Seems like a problematic case you had there. If we need to decrease PCO2 we try to increase ventilation by increasing the rate on the ventilator or switch to high freq ventilation. If you treat with HFV you could increase ventilation by decreasing the frequency of the oscillation. We rarely try to increase tidal volumes, since this could lead to more volutrauma. Well, I have a feeling that permissive hypercapnia is getting out of fashion. Take a look at this publication http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16554847&query_hl=1&itool=pubmed_docsum We try to keep the PaCO2 normal, in our eyes that would be 6-8 kPa. We would probably not extubate with a PCO2 >60 mmHg/>8 kPa... but sometimes I feel that the endotrach tube is more blocking the airway (due to high resistance from the actual tube) and disturbing the infant and its spontaneous breathing. So in selected patients with PCO2 >60 and if the infant is breathing fine, he/she may just feel better on nCPAP.

As I recall it, our cardiologists mainly use Sotalol and Flecainide for supraventricular takyarytmias.