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Dear Colleagues, We do not have such suction devices like the "neosucker" for nasal suctioning. We use atraumatic catheters. And here comes my question. Years ago i learned that one can insert a "atraumatic" catheter with applied suction. When i searched the internet and my literature i found no evidence to support that practice. They all seem to insert the catheter and apply suction when pulling back the catheter. Is there a bigger possibility to damage the nasal tissue by applying suction while inserting the catheter? Dont one "pushes" the mucus further down the nose when insertin a catheter without suction? Is there any Literature available which shows a benefit of one ore the other technique? Thanks for your Help. PS i do apply suction when i insert a catheter into an ETT. Just to get the secretions that are within the ETT. But we do not suction deeper as the ETT Tip. So this shouldn`t be a problem for damaging the Bronchial mucosa...

Dear Colleagues, i am currently concerned to see a new hype in managing preterm infants who are intubated and ventilated with no form of analgesia... For the last 5 years i can rememder we used to manage theese infants with morphine and midazolam by continuous infusion pumps (Morphine with 10micr/KG/h). We have had no problems with delayed extubations or children with respiratory depressions. Nowadays our children have to undergo all medical & nursing interventions without Morphine or Midazolam. Midazolam is no longer in use because of it`s effects on brain development. Althought i believe that we would get similar results for any other medication which makes our children sleepy... If the brain doesnt get enough stimuli, it simply cannot develop neuronal links. But thats my theory. The rational for not giving morphine is (said by our MD`s) that we could wean our children off the ventilators, sooner... Anyway. I am concerned about this kind of development in our field of work and i am wondering what you folks are doing regarding that matter. I think the detrimental effects of pain and stress are well documented in the literature and we should do something about it. I am quite sure, and the current literature supports my theory,that pain and distress leads to alterations in the brain. I am not quite sure which way is better. Not to give proper medications because we dont want to have the negative effects of midazolam on the brain development, accepting the fact, that the brain development is altered by pain and stress, or to give such medications and to accept the fact that the brain development is altered by the medication itself?!? Regarding the pain situation. Some of our MD`s believe that Morphine can cause or worsen NEC, by altering the intestinal motility. The fact that stress and pain for their part are major causes of NEC seems to play a secondary role... So children with NEC are often treatet without any pain medication. One simply cannot give glucose orally, because of the NEC, but we are also often not allowed to give Morphine or are ordered to give 0,1mg /KG no more than every 4 Hours... what a mess. Is this matter an issue in your institutions? How do you/would you handle the situation? Personally i dont think that this fashion, if it can establish, will not be seen as a glorious era of medical care in future times. But this is only my opinion. Cheers Norbert

Hello Susan, we have a chart that shows how we tune the humidification in our Giraffe Incubators in relation to the Gestational Age and the days of life. This sheet is attached below. hope that helps. We use the humidification as a standard method of care in our preemies, so i can´t tell you anything about an "increase" in infections but this works very well for us. hope that helps Norbert Incubator_humidification.pdf

Thank you for your fast reply, @rehman_naveed From my understandig, there is a link between VAP and the storage of the vent bags. In our case they are often found inside the beds at the foot end. This is the place that often comes in contact with diapers etc... They are often found without their dedicated masks, so the t-piece is contaminated and if a ventilated infant needs to be hand baged, the bacteria etc. are blown right into the lungs of the children... I had a few replies that told me that the bags are completely wrapped in plastic bags. I think this is a difficult practice, because it takes a time to unwrap them if they are needed quickly... Our Nursing staff has already problems with accepting the fact that they should be kept outside the bed. The time aspect is the bigges concern for them. Regards Norbert

i am wondering where you put your infants ventilation bags. Our nursing staff puts them inside the isolette or radiant warmer bed. Mostly you can find them hanging around at the end of the bed (feet). Sometimes the dedicated mask is connected to the bag, sometimes it is put in a different place of the same bed. Our bags and masks are changed every 7 days together with the vent. circuits for infection control. The rationale for that practice is that most of our nurses believe, that they can find and handle the bags faster and easier as if they were placed outside the beds, attached or clamped on the side of the bed or isolette where one can easily grab them if needed. Now I would love to know if there are any informations you can provide me with regarding that matter i.e. • Does this or that vent. bag management affects the development of ventilator associated pneumonias? • Is the vent. bag management part of any infection control bundle in your countries? • How do you handle / where do you place your vent. bags and why? Thank you for your input Regards Norbert

Dear Colleague, as far as i am informed, the infection issue is not a problem, you can give whatever drug/solution you want. But we usually don´t give blood products centrally because of the thought that the possible anaphylactic transfusion reaction (if there is one) could be limited when a peripheral line is used (the reaction isn´t triggered centrally). I know that there are institutions that give blood products in a separate central line (University of Freiburg, Germany). The fact, that the reaction rarely starts within minutes, but within days or weeks, weakens the theory mentioned above aswell... There are currently two good articles focussing on the subject of catheter related bloodstream infections. annie dixon (2009) infection and central vascular acces devices, Infant,5(2):55-60 this author states that the one of the indications for the use of an umbilical venous catheter would be administration of blood products... Curry S, Honeycutt M, Goins G, and Gilliam C (2009) Catheter-Associated Bloodstream Infections in the NICU: Getting to Zero, Neonatal network : NN 28(3):151-5, hope that helps

hello kloud, usually it is not a problem, but.... NCPAP has it´s indications. feeding infants by bottle, as you know, also has it´s prerequisites. Our recommendations are that the infants that can be fed by bottle have to be normopneic, with no other signs or symptoms of respiratory distress. It is well known that even for "healthy" premature infants, establishing a normal suck- swallow- breath- pattern with nutritive sucking is often challenging and energy consuming. So in our case, we only feed our NCPAP- Kids, when they are at the threshold between NCPAP and low- flow- nasal cannulae. For some infants the benefit of feeding them by bottle (or breast) is worth the limited time the infant experiences some degree of respiratory distress after feeding. Some of our infants in that group are simply much more quiet and satisfied, when they are fed by bottle instead of the feeding tube. hope that helps

Hi Shesu, we have the same problems, even with our CPAP- Systems (Alladin & SIPAP), there is a huge ammount of water in the heated part of the circuit.... We also have drops of water inside the babies noses with our low- Flow nasal cannulas. What i can`t understand is, why the newer Generation of F&P heaters (MR 850) have this two modes (invasive vs non invasive) although the company itself doesn`t recommend the use of the non ivasive mode..... If one uses the non- invasive mode, the baby will get warmer and more humidified air into his/her lungs as it would get when breathing room air.... Anyway, we have a serious problem with near drowning, which leads to apneas and bradycardias in our newborns and F&P seems to be unable to handle the situation properly.... Regards Norbert

Dear 99ers, i was wondering, what your practice is regarding patients with obstructive lung pathology, for example atypic varicella pneumonia, who need inahalative therapy with nebulized Albuterol (Ventolin) and are ventilated with high peak pressures >30cmH2O and high peep around 8cmH2O? My thesis is that every time one disconnects the patient from the ventilator to connect the nebulizer, one predisposes the patient for derecruitment of lung volume (atelectasis). My question is if this practice brings more harm then benefit for the patient? I am wondering what others do regarding that matter. Does anyone use inline nebulizing systems, which allows the system (nebulizer) to stay in the ventilator circuit for as long as the patient is ventilated? If so, what system are you using and are there any hot tips one should know using this systems? Regards Norbert

Hello from Switzerland, we are currently using the Ballard TRACH CARE System from Kimberley-Clark. We are using them for 3 Days (72h), before we change them. We are only using them, if it can be assumed, that our patient will be on the ventilator for more than one day... (reduces cost`s). We do not instillate water or sterile saline routinely. The pre oxygenation is usually 5% above the patients baseline oxygen requirement, if that works. If a patient desaturates despite this action, we use oxygen pro re nata. We use the same approach for our patients on HFOV and CMV. We do not use routine sustained inflation or recruitment maneuvers, because experience let us to the perception, that this maneuvers are not necessary in all our ventilated patients. Recruitment maneuvers are somewhat difficult and can vary from patient to patient (depending on the patients lung pathology) as needed and the practitioners experience, so a detailed description is hard for me to give. There exists a good presentation of how to run the HFOV and the sustained inflation method have a look at this: http://www.learnicu.org/Clinical_Practice/Fundamentals/PICU/Pages/Course_Presentations.aspx You can find some helpful presentations here.... have fun hope that helps

it´s been a while, but guess who i met today. The father, mentioned above and so i asked him about the helmets and he gave me the adress of his former employer as follows: STASTNY Orthopädie- und Rehatechnik AG (Ortho- Team) Rosenbergstrasse 16 CH-9000 St. Gallen FON: 071 222 63 44 FAX: 071 222 73 29 stgallen(at)ortho-team.ch The person who`s responsible for helmets is: Mr. Roth just in case you still want to get in touch with theese guys... hope that this helps.. Regards Norbert

Please check following literature: Tobin MJ. NEJM 344:1986-96, 2001 The ARDS Network Study has given some info about Peep Trials as follows FiO2 / PEEP Combination FiO2: 0,3 0,4 0,4 0,5 0,5 0,6 0,7 0,7 0,7 0,8 0,9 0,9 0,9 1,0 PEEP: 5 5 8 8 10 10 10 12 14 14 14 16 18 18-24 You have to titrate the peep under normal lung volumes 4-6ml/kg Pmax <30cmH20 titration of peep until normal PaO2 and Pco2 values are achieved hope that helps... Norbert

Hi Stefan, our institution is currently reviewing the literature regarding skin care and some of our nurses went to a german congress, where one of the speakers was reporting that there were several cases of contact allergies to colophonium inside the hydrocolloid patches they used. I talked to some representatives of hydrocolloid brands myself on a congress in Vienna, but no one ever heard of such a case before. I was told that there are people out there who are allergic to almost everything and that it can't be excluded that few people could becom contact allergic to a special ingredient of the hydrocollid. A few days ago we have spoken about our new skin care guideline and the theme arose again. The nurses that went to the congress were only able to tell me that the substance that could cause contact allergies would be colophonium..... Now i searched the literature and found no single article about contact allergies due to colophonium in hydrocolloids regarding infants but a lot of investigations and case reports about the relationship between colophonium and contact dermatitis. One articles abstract stated, that the numbers of allergic reactions due to colophonium are rising. The australasian Journal of Dermatology Vol. 48 (2) stated in one article : " We identified colophonium, fragrance mix and balsam of Peru, now known as MP resin, as the most common concomitant allergens". Somehow i was unable to read the whole text because when i activated the link that should direct me to the text, another study regarding tea tree oil popped up!?! I am not sure whether some folks just blew up a few informations that just got to their ears, but i found nothing very helpful regarding that matter. We recently had two ELBW Infants with contact erythema after using "Neo Bridges" (hydrocolloids for securing umbilical catheters) so... It was not my intention to irritate anyone here, i just wanted to know if anyone else has heard what my colleagues brought up from a conference in Duesseldorf (Germany). I will try to get in touch with the Lady who presented her findings at the congress and get back to you asap. Cheers Norbert

Hello 99ers, i heard about a investigation regarding colophonium as a source of allergies in premature babies and for that reason is no longer recommended for use in premature babies. This colophonium is a natural resin which is an ingredient in patches diapers and hydrocolloids. Has anyone experienced or heard of allergic reactions to varihesive or comfeel or other hydrocolloids? If so, have you banned these products from your unit? We have some hydrocolloids (for securing UAC`s & UAV`s) that are colophonium free, that`s what the manufacturer told us, but so far i haven`t heard of other hydrocolloid products especially for wound care that are free from this substance. We`re quite unsure if we can continue to use the hydrocolloids to protect our preemies noses from skin breakdown due to NCPAP, so i would be curious to know if anyone can give me more detailed informations about this matter. thank you in advance Cheers Norbert

Hi 99 ers, we are currently in the process of revising our policy regarding the management of catecholamine infusion (i.e. management of changing empty infusions via infusion pumps). Can anyone provide me with the latest literature / technique regarding that matter? I have read a lot about this issue (mostly anecdotal informations) and found that there exists various techniques, which are, in most cases, not based upon evidence. Are there any practice guidelines that you´re following in your unit ? any input is greatly appreciated . thank you in advance Cheers Norbert

Hello Susan, we are using the Radiometer MicroGas 7650 for all our children on vents or assisted ventilation (e.g. NCPAP). It´s a great device, if one is aware of it´s limitations... BROMLEY I.; Transcutaneous monitoring - understanding the principles, Infant, 4(3):95-98, 2008 gives a good overview (from a nursing perspective) In the neonatal population, one simply can´t use the EtCO2 devices. Neither the sidestream nor the mainstream devices are capable of providing reliable values in the NICU population. That is simply because in this population the tidal volumes aren´t big enough and the respiratory rates are usually too high to allow the baby to generate an end expiratory tidal plateau, which in turn almost reflects the alveolar PCO2. Healthy newborn (term) children may generate enough tidal volume at normal respiratory rates, but most children in the NICU are preemies or sick term born children which have decreased tidal volumes and/or are tachypneic, which further decreases the tidal volumes... Another thing is the handling of such devices. They are simply all heavy, are generating too much dead space and are bulky! HARIGOPAL S., SATISH H.P.; End-tidal carbon dioxide monitoring in neonates, Infant, 4(2): 51-53, 2008 provides an overview (again from a nursing perspective) The sidestream technology is tricky, because it needs/aspirates 50ml/min (Microstream) of gas from the circuit to function properly, which limits it´s use to the pediatric population. We recently bought such a device for our new transport incubator and weren´t able to use it without problems, so far. As i said before, we are happy with our TcCO2 monitor. We decreased the heat to 43°C and found no skin burns so far, even with the smallest preemies and if you remind yourself from time to time, that the device only represents the values under the skin surface and that this is the reason why it simply not always correlates with CO2 values in the blood, it´s a safe thing. Some people are arguing that the CO2 monitoring is overvalued because with the new ventilation modes one can choose "the right" tidal volume and respiratory rate and with stable conditions arterial blood gases should be enough. i hope that helps Cheers Norbert

Hi Stefan, our new Head- Nurse just saw a preemie with a probe on his belly and so she went to the nurse in charge to give her the "latest" but anecdotal information, that at the hospital where she formerly worked it was forbidden to put a probe on a childs belly because of the mechanisms mentioned above. As i said before, i serched the literature myself but wasn`t able to find anything neither supporting, nor invalidating her information. But thank you for your information. I talked to our consultant about this and he said, that he hasn`t heard anything like that so far. So we continued to use the bellies again... Cheers Norbert

Hello 99ers, i would be curious to know if you place the heated probe on the babies abdomen or not. If not, why not? I recently followed a discussion where a nurse argued, that the heated probe can lead to "inflammatory like" processes under the skin surface, because of the generated heat, which in turn can lead to a greater risk for NEC.... I cant imagine the mechanism of this theory and i havent heard of anything like that so far. I wouldn`t stick the probe onto a symptomatic belly, but i haven`t experienced anything in that direction when a probe was stuck onto a asymptomatic belly. I already searched my books and everything i found was always the same: Exclude bony areas such as the spine, the rib cage etc. exclude damaged skin areas, uneven areas and areas that need to be visibly assessed. Maybe one of you can help me out with that Cheers Norbert

Dear Sjbrott, No, our institution doesn`t pay for attending conferences... If a Nurse is interested in attending this or that continuing education, the hospital will pay for the cost`s, or at least a big part of the cost`s, but you won`t get payed just for attending a conference... Norbert

Hello Netters, i wonder what cord care practices are currently standard in your hospitals at the moment? Is anyone using alcohol and or other antimicrobials like chlorhexidine on a regular basis, or do you tend to use only sterile water with or without soap? If you don`t use any of the agents listed above, what do you use and how? If you do cord care this or that way, how often do you do cord care per day / week? Most interestingly why. Any references?

Hey there 99ers, i am currently searching for software for my pocket pc (runs with windows mobile). Is there anything like the epocrates software especially for neonatology or pediatric patients? Any reference is appreciated. Norbert

We are using the SM 3100 A and are measuring our Vte`s via Florian with the technique mentioned above. We are more than satisfied with our equipment and i think it is useful if you want to adjust the settings until you reach the "right" frequency. In CMV, ventilation is defined as: F x Vt, in HFOV, ventilation is defined as: F x Vt to the power of 1.5-2.5. Therefore changes in Vt have a larger impact on ventilation than changes in frequency ! The other thing is, that there exists a resonance frequency of the lung in which optimal ventilation (co2 removal) occurs. If you don´t measure the Vt, you can hardly be able to search for the "right" resonance frequency.... The resonance frequency varies by the size of the lungs and the degree of lung injury. For more detailed information pls see the powerpoint presentation of the PICU-COURSE at the Society of Critical Care Medicine homepage. Hope that helps Norbert

Dear tamsam0, We are using this monitors in our unit, and i´d love to take part in your study. Please email me if you want to send me more information about your study and the way you want to do it. Norbert

Dear Colleagues, I would be curious to know if anyone of you is using Albuterol (Ventolin) to treat children with severe respiratory secretions and atelectasis. I have noted an increase of this method during the past years, but i am not quite sure if this method works!? As far as i am informed the only cure against mucus is humidified, warmed air, physiotherapy,and administration of enough fluid. Ventolin has no qualities in thinning musus or enhancing the situation of the atelectated lung areas..... What is your opinion regarding that matter? Any thoughts are appreciated Cheers Norbert

We are currently using, Morphine 0.1mg/kg, Midazolam 0.1mg/kg and Tracrium (atracurium) 0.5mg/kg Regards Norbert