gopan2596

I think pain management is becoming better with improved understanding of the same of recent , and having objective measures in place in the form of pain scoring for guidance Although pain management is a very important concept , please be aware of the results of the NOPAIN trial for preterm babies as well , which cautions on overzealous pain management with Morphine with risk of adverse outcome who were on the same . Also , about the risk of low respiratory drive with attend extubation difficulties Cheers Gopan

We use duoderm applied to either side of the cheek close to the alae nasi and the angle of mouth . Then the tapes wound around the ETT are fixed on to the duoderm . We havent found a problem with duoderm and apparently is soft on the neonatal skin . This has worked well so far and presumably safer than other options , I would imagine ' Thanks Gopan

Dear Margaret Bates Walker Thanks a lot for the post . It was very valid experience shared In the unit that I previously worked , we used to make a recipe for parenteral nutrition daily , and then send it off to the pharmacy . However , I now realise a potent problem associated with this practise . We have started trialling standardised prepacked ( low sodium , high sodium etc preparations ) at the moment . Hence , for most clinical situations , there is a prepacked solution that could be used . However , the variety of such packets can make the whole process a bit tedious .. But most of the time it works . If things go astray , we can always manage with add on electrolytes and fluids through a separate line . Although cumbersome , I found this a bit safer option ( especially after I read your post on the incident that happened ) . Thank you very much Regards Gopan

Hello Stefan Thanks for the fabulous presentation .... The slides are very impressive Gopan

Hi Accidental extubations are always very annoying . My suggestions to avoid this would be 1) Try nasal intubation if there is expertise and the staff is comfortable with that . However , if there is no experience in the same , its best avoided 2) It would be worthwhile looking into nursing allocation . I dont think this could be a problem in well established units , however its worthwhile looking into this and putting experienced staff in care of sick babies expecially very low birth weight babies . If the event has followed arrival of new nursing staffs , frequent educational sessions on ETT care would be of benefit 3) Identify preceding situations that has led to these events . Data on this could throw light on how to improve upon this situation .Then changes could be made one at a time and then see what improvement had occured after the introduction of that change . 4)there are supporting scaffolds available to hold oral tubes in position . This could be tried I think , data collection on the preceding events that lead on to accidental extubation would be best starting point . That way , there is some direction towards the area of improvement Hope this helps Kind regards Gopan

Hi Good to know that you are interested in persuing Neonatology I personally would suggest Fanaroff . I found the layout and readability extremely good I would first of all go through the protocols of the institute where you like to persue Fellowship , before embarking on textbooks . I have learnt this aspect the hard way .. Once the protocols are familiarized , reading textbook will be fun because we would know something about everything .. Bye Gopan

Hi This is an interesting topic of discussion . The cochrane review by philips cool and Martin Offringa , reviewed in 2009 indicates that there is no conclusive evidence for benefit of using muscle relaxants in ventilated babies . There are a few perceived benefits like reduced risk of intraventricular hemorrhage as well as less serious forms of IVH and reduced airleaks . Studies by Greenough in 1984 , has shown that air leaks were more frequent in struggling babies , and that muscle relaxation reduced the risk ( 1985 ) . Perlman in 1985 demonstrated that there was wide fluctuation in anterior cerebral artery blood flow predisposing to IVH in struggling babies . So far , on some benefits related to muscle relaxation However , when comparing multiple randomized and quasi randomized trials , there is no difference in morbidity , mortality or outcome in babies who were administered muscle relaxants and who were not . There was also no much difference in incidence of CLD or oxygen requirement . Hence , it is hard to recommend routine muscle relaxants as there is no definite evidence towards same . I couldnt find any recent studies on it . Other complications related to muscle relaxants included risk for hypotension , hypoxemia , deafness , prolongation of ventilation ( controversial ) etc .. I would basically try for selective paralysis , as in babies with risk for air leaks or who are struggling a lot . But , It seems that babies calm down well with sedatives like Fentanyl , which would suffice in most cases . Hence , In my opinion , muscle relaxation is best used judiciously ; and sedatives tried initially in struggling baby before considering relaxants .. Hope this makes sense Bye Gopan

Dear Stefan Thanks a lot .. The information was useful Gopan

Hi Leonara desposito I havent heard of keeping Et tube in freezer to stiffen it up . Do you use straight out of freezer for intubating .. or just keep it there for some time and then warm it up .... Seems interesting .. I wonder whether it could cause laryngospasm during insertion . Since , we have not done it , I am not able to comment on the same . Looking forward to hear from you Regards Gopan

Hi We regulary use oral Ibuprofen for PDA closure . The cochrane review has also concluded that oral Ibuprofen is equally efficacious as Indomethacin , and had favourable profile on renal function and on gut ( lesser incidence of NEC . We give it at 10 mg / kg on day 1 and then 5 mg / kg for two more doses at 24 hours interval . We have found excellent results with the same . Oral preparation is available as a suspension and could be given by ryles tube . I think the baby is generally NPO regardless when we decide to treat PDA in the neonatal period . Late admin has limited success , in which case the baby is best kept NPO and then feeds started later once clinical condition is satisfactory . Hope this helps Regards Gopan

Hi Deena In our unit , I have found nurses working during the entire pregnancy period . There are no restrictions , unless the nurse co ordinator feels that the nurse is not able to discharge her duties appropriately . However , nurses working in retrieval scenario is different . Once they are past 30 weeks or so , they are allocated to ground co ordination duties , and are exempted from on road or flight retrievals . Hence , basically this is upto the nurse to make a responsible decision . If she feels that her duties cant be performed optimally in her situation , she should abstain from it ( rather than someone else pointing that she is not doing it right ) . However , she would not look after a highly infectious baby .. taking into consideration the risks associated with it . I am not quite sure about looking after babies on NO .. theoretically I feel it shouldnt matter , as there is a good inbuilt NO scavenging system . But shall get back after clarification Regards Gopan

Hi I felt that glucometers that we use in NICU basically work in the same way , regardless of the make . However , I may be wrong I am presently in retrieval services , and hence use the iSTAT machine for getting the entire electrolytes , blood gas and glucose . This is fantastic as far as retrieval services are concerned . Even in NICU , where we do regular blood gases , the blood glucose value that appears on the gas result is often relied upon . It seems its reliable to an extend .. And the amount of blood required for glucometer and for ISTAT , capillary blood gas dont differ much .... Regards Gopan

Hi Jack In australia , the citizens and permenant residents are covered under medicare , which means that the government pays for all the hospital expenses . The beneficiary needs to pay a small amount towards medicare .. In case of others , there is rules in place whereby whoever comes over to work in australia is mandated to get private insurance . This is mandatory when the visa is lodged . Hence , it should be assumed that virtually all people in australia are insured ... The medical care is extremely expensive and could easily come to 1000 dollars / day during hospital stay ... Bye Gopan

Hi Nilan Yes .. thats what I meant . But I was wondering about the red blood cells in the CSF . We are not usually expected to find that in a normal atraumatic LP . However , otherwise , for all practical purposes , the CSF values that you gave appears to be well within normal limits ... provided the general condition of the baby is improving as well Regards Gopan

Hi I think the CSF values are benign at the moment . At 30 weeks of gestation , in the first week of life , the following CSF values are generally acceptable Leukocytes - 4 +/- 4 ( 1 to 10 ) PMN - 4 +/_ 10 ( 0 - 28 % ) Glucose - 74 +/- 19 ( 50 - 96 ) Protein - 136 + / - 5 ( 85 - 176 ) The values may vary from article to article ... but this appeared to be a reasonable one . Since the antigen studies are normal , and the baby is presumably doing well ( I hope ) , we could rule out meningitis for the time being given the values Regards Gopan