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Hypothermia may be the only hope for asphyxiated infants. The evidence from 2 large RCTs supports the use of selective head cooling and total body hypothermia, However the evidence is not that clear and it is premature to recommend brain cooling until results of more trials like the TOBY trial are published and a metanalysis completed. 1- CooLCAP trial ( Gluckman PD, Wyatt JS, Azzopardi D, et al. Selective head cooling with mild systemic hypothermia after neonatal encephalopathy: multicentre randomised trial. Lancet 2005;365:663-70). 234 term infants with moderate to severe neonatal encephalopathy and abnormal amplitude integrated electroencephalography (aEEG) were randomly assigned to either head cooling for 72 h, within 6 h of birth, with rectal temperature maintained at 34–35°C (n=116), or conventional care (n=118). Primary outcome was death or severe disability at 18 months. Analysis was by intention to treat. We examined in two predefined subgroup analyses the effect of hypothermia in babies with the most severe aEEG changes before randomisation—ie, severe loss of background amplitude, and seizures—and those with less severe changes. Findings In 16 babies, follow-up data were not available. Thus in 218 infants (93%), 73/110 (66%) allocated conventional care and 59/108 (55%) assigned head cooling died or had severe disability at 18 months (odds ratio 0·61; 95% CI 0·34–1·09, p=0·1). After adjustment for the severity of aEEG changes with a logistic regression model, the odds ratio for hypothermia treatment was 0·57 (0·32–1·01, p=0·05). No difference was noted in the frequency of clinically important complications. Predefined subgroup analysis suggested that head cooling had no effect in infants with the most severe aEEG changes (n=46, 1·8; 0·49–6·4, p=0·51), but was beneficial in infants with less severe aEEG changes (n= 172, 0·42; 0·22–0·80, p=0·009). Interpretation These data suggest that although induced head cooling is not protective in a mixed population of infants with neonatal encephalopathy, it could safely improve survival without severe neurodevelopmental disability in infants with less severe aEEG changes. 2- NICDH Whole Body Hypothermia Trail (Shankaran S, Laptook AR, Ehrenkranz RA, et al. Whole-body hypothermia for neonates with hypoxic–ischemic encephalopathy.N Engl J Med 2005;353:1574-84. Of 239 eligible infants, 102 were assigned to the hypothermia group and 106 to the control group. Adverse events were similar in the two groups during the 72 hours of cooling. Primary outcome data were available for 205 infants. Death or moderate or severe disability occurred in 45 of 102 infants (44 percent) in the hypothermia group and 64 of 103 infants (62 percent) in the control group (risk ratio, 0.72; 95 percent confidence interval, 0.54 to 0.95; P=0.01). Twenty-four infants (24 percent) in the hypothermia group and 38 (37 percent) in the control group died (risk ratio, 0.68; 95 percent confidence interval, 0.44 to 1.05; P=0.08). There was no increase in major disability among survivors; the rate of cerebral palsy was 15 of 77 (19 percent) in the hypothermia group as compared with 19 of 64 (30 percent) in the control group (risk ratio, 0.68; 95 percent confidence interval, 0.38 to 1.22; P=0.20). Conclusions Whole-body hypothermia reduces the risk of death or disability in infants with moderate or severe hypoxic–ischemic encephalopathy. In developing countries economic methods for cooling like ice bags, electric fan may be used, however, the problem will be the availability of aEEG machines which are expensive, yet, very crucial for the selection of infants in hypothermia trials. We had difficulty in enrolling infants in multicenter trials because of that. Any suggestions for some research group that can provide us with aEEG and we can paricipate in a RCT that looks at economic methods of head cooling that can be applied in developing countires (where the problem of asphyxia is more common and number of babies who can benifit is larger)

Abnormalities in early aEEG (within 3 hours of birth) can be a useful adjunt to blood gas abnormalities (sepcifically a base deficit > 10 mEq/L) in umbilical or early arterial blood sample and clinical evidence (Apgar score at 5 minutes < 5; delayed first brith, antenatal evidence (Abnormalities in FHR tracing).

We still use Amp. and Gent. for early onset sepsis

Our experience with Babylog 8000+ is not bad. Yet it is not as powerful as sensormedics and SLE 5000 in the HFV mode

It is true Jes. That was your practice in Rigshospitalet, when I worked in your unit in the late 90s for 2 years. It is surprising that you experience resistant infections in your units (very low nosocomial sepsis rate). In developnig countries like Egypt we had greater problem with nosocomial sepsis, Klebseilla pneumonia is the commonest organism and about 66% of strains are ESBL producers according to a recent study we have just finnished. It is my practice to give meropenem + vancomycin whenever we encounter nosocmial sepsis pending results of C&S. This practice is exe=cellent according to our practice (Experience rather than evidence-based), we are actually in a situation where most neonatologist will not accept a RCT comparing this practice with other antibiotics. I woudl also add that the wide use of cefotaxime and other cephalosporines in our unit in the 80s and 90s was probably one factor for the development of ESBL gram negative strains. We do not expeience resistance to these antibiotic combination till now as 100% of our gram negative strains we sensitive to meropenem. I do not know what will happen in the future with the deveolpemnt of more resistant bugs.

Dear Stefan Lipids and multivitamines are particularliy involved in peroxides production on exposure to light. Using special bags or covering TPN solutions with alminum foil may be a good practice.

A number of researchers have demonstarted that covering TPN solutions would decrease peroxide load. We have just finnished a RCT in our institution and we had similar reults. We are updating our guidelines and we are searching for other institutions guidelines

Do you routinely cover TPN solution? How?

In your practice when managing a case of HIE, do you treat clinical seizures- electrical seizures?

IV form of Ibuprofen is expensive, not available in my country. We sometimes use oral ibuprofen. There are quiet few studies on that issue like: 1: Chotigeat U, Jirapapa K, Layangkool T. A comparison of oral ibuprofen and intravenous indomethacin for closure of patent ductus arteriosus in preterm infants.J Med Assoc Thai. 2003 Aug;86 Suppl 3:S563-9. 2: Heyman E, Morag I, Batash D, Keidar R, Baram S, Berkovitch M. Closure of patent ductus arteriosus with oral ibuprofen suspension in premature newborns: a pilot study. Pediatrics. 2003 Nov;112(5):e354. 3: Hariprasad P, Sundarrajan V, Srimathy G, Suthagar B, Ramadevi BS. Oral ibuprofen for closure of hemodynamically significant PDA in premature neonates. Indian Pediatr. 2002 Jan;39(1):99-100. But be ware of the reported complication of spontaneous intestinal perforation (we have not experienced it) but other had: Tatli MM, Kumral A, Duman N, Demir K, Gurcu O, Ozkan H. Spontaneous intestinal perforation after oral ibuprofen treatment of patent ductus arteriosus in two very-low-birthweight infants. Acta Paediatr. 2004 Jul;93(7):999-1001.

In our unit routine gastric suction is not recommended. However if there is MSAF we do recommend it. Please look at the following related refernces: Anand KJS, Runeson B, Jacobson B. Gastric suction at birth associated with long-term risk for functional intestinal disorders in later life. J Pediatr 2004;144:449-54. Conklin LS, Perlman JM, Wyckoff MH. Gastric suction at birth. J Pediatr. 2005 Jan;146(1):152-3; author reply 153. nand KJ, Jacobson B, Hall RW. Gastric suction at birth: not an innocent bystander.J Pediatr. 2004 Nov;145(5):714; Di Lorenzo C, Saps M. Gastric suction in newborns: guilty as charged or innocent bystander? J Pediatr. 2004 Apr;144(4):417-20. Regards

On behalf of the Egyptian society for neonatal and preterm care (ESNPC), it is my pleasure and honour to welcome you all to the 19th scientific congress of the society which will be in Sharm El-Sheikh, EGYPT from 28 February- 3 March 2007. I am delighted to extend an invitation to all our colleagues to actively participate in this distinguished event. The program is made as exciting and intersting and we have invited expert faculty members from USA, France, Italy and from other different countries . Our main thrust will be to encourage continuous medical education where both experts and delegates meet to share and learn. The city of Sharm El- Sheikh is one of the most beautiful diving and snorkling sites in the world. You can visit our website www.esnpc.org for more details. Also, you could contact me at drgamalsamy@ hotmail.com Finally, I hope to welcome you all in this distinguished congress and to enjoy meetings, discussions and your stay with us. President of the Society and Congress Professor Gamal Samy Aly

Dear Dr Stefan: Some educational videos can be purchased, Some are free. It is a good idea to help others to access these videos through 99 nicu forum

I meant Non-invasive CPAP

Thanks Stefan for the reply. I have the details of the techinque, what I realy wanted is a teaching video for residents and fellows as I'm preparing a course on NCPAP and this could be of great help. I've seen one in one of the ESPR meetings by a Swedish colleague, but I do not how to access.

Would you kindly help me to get access to teaching video on how to give surfactant via 'INSURE Technique'

In your practice, is there a place now for elective HFOV for VLBW infants with severe RDS?

How do you practice CPAP weaning?. Gradual weaning of pressure? Cycling time off CPAP?