Skysurfer

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

I just have attached our spreadsheet "Tuning of the Humidification (Isolette) in relation to the Gestational Age and Days of live". The temperature taken at the central part of the body is directly dependent upon the peripheral temperature until the peripheral temp. reaches a “higher” level around 35.5-36.5°C. Then, the “central” temperature reflects a “real” core temperature, because the core temp. can remain stable even though the child is in a cold stress with heightened warmth production…. That`s why the temp. taken centrally most likely reflects the core temperature when the child has a warm periphery. So from my point of view, the Temperature gradient method, where you have to use 2 temp. probes is the best method available to keep the infants in a thermal neutral environment. Hope that helps Norbert Temp&Feuchte.doc

Dear Antares, You are definitely right regarding the studies, but if a mother is hypothermic she´ll have her own problem to regain a normal temperature. This talk isn´t about the proper way to "heat" the mother up or how to stimulate the mothers temperature to increase. The mothers body is already stimulated by her hypothermia, there is no further cold stress necessary to stimulate her. I assumed this talk was about whether or not it is safe for the baby to lie on a "cold", shaking mother. Cangaroo care, as we all know, is a method where a mother and her child can get in touch with each other and this is a very unique an fragile moment in the relationship between two individuals. And if this unique relationship begins with the experience of having to freeze, then i for myself would prefer to live without this kind of experience..... Regards Norbert

Hello everybody, it´s a little late i know, but i would be concerned about having a baby on it´s mothers belly while this belly is a little cold. I assume that the mother´s skin temp. is below the normal values when she´s in a cold stress. It is well known, that the baby´s and the mother´s skin are interacting during Kangaroo Care in a way that they exchange heat through vasodilation and constriction in order to maintain a stable temperature. If the Baby is too cold the mother´s skin will dilate and more (warm) blood will enter the dermal region where the Baby is lying to heat it up. I think the mother will have a hard time to heat her baby up, or keep it warm when she´s hypothermic herself. I don´t think it´s a good idea to stress both individuals, when the mother has her own problems to maintain a stable temperature....... Regards Norbert

Hello to everybody, We start to use a humidity of 85% for the first 7 days of life. Then, we try to reduce the humidity during the following 21 days to 70% similar to the maturation of the skin, which begins at birth regardless of the gestational age. After the child reaches the age of 3 Weeks, we reduce the humidity further to 60%. According to his/her stability, the infant can be dressed and once it is dressed we atart to use 50% humidity. The Temperature is controlled by the isolette in the skin (auto-) mode. When the Baby reaches 1200 - 1400grams, we place him/her in a bed which is heated under the matrass to help the infant maintain a stable core temperature 36.5°- 37.5°C. We have a written policy which shows every step according to weight and the age and if you are interesten i can mail it to you privately. Hope that helps Norbert

HI Stefan, sorry, but i just received the first newsletter today....that`s because my email address wasn`t listed correct in this forum (we talked about it privately). Your newsletter looks a bit different from the one the pflegeboard uses, but it is as helpful as the one the pflegeboard uses. Anyway, i will send you a copy when i receive the next newsletter. The RSS Feed is a good idea, i haven`t used this feature at all until now, but now i`m going to change my practice a little to see how it works and if it`s usefull for me.... Thank`s for your advise... Norbert

Hi Stefan, first of all i wanna thank you for the lovely Mouse Pads! They`re great There is a Forum (Nursing) in germany called Pflegeboard http://www.pflegeboard.de/. It hase some features which are missing here... they send you an overview of all newly started discussions with a direct link to the discussions monthly. So one can decide whether or not to participate and you don`t have to search the Forum for new discussions....I`ll send you the next mail they send me, just to let you know how it looks like. I know the button "new post`s" does failry the same job, but the mail kind of reminds me to go and take a look. Hope that helps. Regards Norbert PS: This Forum is on a verry good way, there is not a single neonatal or pediatric Forum i know of, that got so many members and such a big reply by it`s members. Especially not that fast! The German speaking Countries are much bigger than Sweden, but weren`t able to establish a Forum like this.

Dear Colleagues, our unit (Ped/Neonat. ICU) is currently in the process of re- structuring the interdisciplinary teamwork. We like to see our work as a relational triangle between Nurses, Physicians and Patients (& Parents) which can (and should) be optimised. We are focussing on optimising our feedback culture, roles and competencies, decision making, as well as our working procedures. We are searching for a model which focuses on the topics mentioned above. The goals which should be achieved by implementing such a model are: Ø To ensure an outstanding care of our patients & their parents Ø To optimise the interdisciplinary teamwork Ø To bring a flat hierarchy into use Ø To increase communication skills between the disciplines Ø To shorten the decision making process Ø To warrant a higher job satisfaction Ø To rise the climate of reciprocal estimation Ø Responsibility should be carried collectively Ø The model should be adaptable and viable If someone feels that his/her unit reflects and lives the philosophy mentioned above and has a written policy regarding a certain model which could help us to implement it at our unit, please feel free to contact me privately or via this forum. We would like to send someone to your unit “as a spy” to see what the secret of your success is…

We just had a father on our unit, who develops these helmets. He told me that they have good outcomes, but i don^t know if the procedure is limited by a certain age or a certain degree of deformation....If you like i can see if i can get in touch with him again, or if he can direct me to a homepage or something like that.. regards Norbert

We also use the neobar for our orally intubated patients, but most of our kids are nasally intubated! Then, we have a verry unique technique. The pictures with an short explanation can be downloaded here....http://www.intensivmedicus.de/downloads/Tubusfixation.pdf It requires some training, but it´s almost bomb proof Please note, the pictures are of old origin and not optimal. They show a white tape on the left cheek that has been placed is too low on the baby´s lips.... For ELBW´s we usually use Tegaderm under the brown tape to protect the vulnerable skin....The explanations given are in german language, if somebody wants them in english, please feel free to email me privately Regards Norbert

Hello Stefan, thanks for that, i am going to read it this afternoon...... Cu Norbert

Hello Stefan, yes, you are right, it would be challenging to do a trial about this issue. And you are also right regarding the traditions and evidence based medicine..... We are currently doing Infant massages, Abdominal massages (since last week, it`s forbidden), Foot massages (reflexology), because a nurse read an artikle about infant massage in Tibet. It is practiced there for decades, with no advers effects, they say. But.......we`re talking about infants in Tibet and i dont think they mean premature infants <34 Weeks GA!?! Regarding the foot reflexology for example, there exists a whole body of literature (adults). But again, no data for the patients we`re talking about. There is a well described link between some pressure points at the foot and corresponding organs in the body, so one can stimulate the intestine by pressing certain points at someones feet. But we all know that the nerval system of our tiny patients is very immature and it is not clear whether or not the "message" reaches it`s destination and in what intensity......... So there is a lot of research necessary for the years to come..... thanks for your reply norbert

Hi Stefan, thank you for your fast reply. as you may have read in the Nicu- Net, the english speaking countries are all very much against any rectal stimulations or tubes inserted rectally...... Some haven´t even heard of massages as a therapy at all! I just don´t know how they´ll get the sometimes huge amount of air out of their babies bellies??? In this case, the baby has not had a malrotation of the intestine and was quite well for weeks, despite neurological abnormalities like seizures and pathologic EEG (burst suppression). I was on night shift, when i realized that the baby had a massive distended abdomen, so i performed a gentle massage, as i always do in such cases, followed by a massage of the feet ( reflex zones). The Baby had huge amounts of flatus, then and everything seemed to be alright again. When i returned to duty 3 days later, the baby had only 30 cm of ileum left........ I just can´t see any other reason for the intestinal volvulus. This baby was placed on nasal cpap for weeks and has had some air problems before (caused by the cpap device, i think) which resolved after massages and rectally placed tubes. As far as i am informed abdominal massages are commonly used nursing practices in the european countries and placing a tube into a childs rectum to releas flatus is not a rare issue aswell. I talked to american nurses and they told me that they don´t even measure temperatures rectally ( a practice which is being used sinces years in our unit) because they fear to damage gut tissue that way. We see that thoughts are very uneven regarding some practices. From what i know now, i think that it is possible to cause a volvulus(even though it might be rare) by abdominal wall massages, but what´s the alternative? Two Members of the Nicu- Net told me " it´s best to leave those bellies alone".....

Hi everybody. i am trying to find some information about lung compliance and resistance in the neonatal/premature population. So far my research in that matter led me to an article where someone studied 7 preterm infants with RDS and different lung diseases!!! But i am searching for "normal" values in the "healthy" population for teaching purposes.... I know that this is a hairy thing, because i haven´t seen such statements in any of the books i have read so far, and we all know how fast this values change in the preterm an neonatal population, but maybe one of you experts can provide me with something i haven´t found. Thank you in advance Norbert

Dear 99´ers, i would be curious to know about cases where abdominal wall massages led to intestinal volvulus. We have had a 26 weeker with massive air distension of the abdomen and visible bowel loops. A feeding tube was placed rectally to relieve flatus, followed by an abdominal wall massage which reduced the abdominal distension significantly. One day later the abdomen presented livid and distended again. Following surgery a volvulus of the small intestine was diagnosed and 90 centimeters of the intestine were already necrotic and had to be resected. The child now has 30 centimeters of ileum left. Has anyone experienced anything similar so far? In (Arch Pediatr. 2001 Nov;8(11):1181-4.) there is an article which states that there could be a link between abd. wall massages and volvulus........ The swiss society of neonatology has also published a case of the month to that matter, you can read the article here http://www.neonet.ch/en/03_Case_of_the_month/introduction.asp?navid=18 So far i wouldn`t feel save applying abdominal wall massages to infants with a distended bowel or visible bowel loops, unless i heard the opinion of others of this board........ We stopped abdominal massages unless there is more certainty wherther or not massages can lead to intestinal volvulus. What is considered to be the best practice in cases where there are visible bowel loops and air distention of the abdomen? Are you considering air drainage via rectally placed tubes? Are the Nurses performing abdominal wall massages routinely? What types of tubes are being used to perform air drainage, if at all. (We are using 8 Ch woman urinary catheters....) Has anyone seen similar cases? Thank you in advance. Norbert

Yes, i just registered online..... thx for your help. norbert

Thx a lot

Hello everybody, i tried to register to the ADC Journal for a free trial as i was informed by mail. "There was an error which prevented the page you requested from being served. Please try again in a few minutes." This is wat is displayed every time i try to register. Does anyone else has have this problem?

Hi everybody, How would you apply the bromhexine or any other medication to the lungs? Every method that i know is in need for a disconnection of the Ventilator Circuit before and after the Inhalation. So even if inhaling medications would have a beneficial effect, one would destroy this "short" effect by disconnecting the Vent. Circuit after Inhalation. Isn´t that correct? The only way i know to treat and prevent a Lung from atelectasis is to open the lung and keep it open by maintaining a normal FRC. Physiotherapy and various positioning techniques should help just as well.

Hello Liliroom, try this out, the link refers to the Society Of Critical Care Medicine (The Pediatric Section). There you´ll find some good Powerpoints regarding this Issue. If you need them in German Language they´re available here The Society has planned to translate the Powerpoints into various speeches, the german was done by me. They told me that they´re planning to publish them, soon....... hope that helps. Norbert PS. try to open the files, then you have to choose the menue notes or comments, there are good explanations for the slides which can be read there.

Hello all, yes, Mr. Johansson is right with meticulous care, such damages should no longer be a problem. I experienced lot of mistakes one can make alone with the right/or wrong placement of the device that´s being used! Wrong caps, usually the wrong sizes, wrong fastening of the pressure tubes and the exhalation pipe wrong Prong(size) etc. Then, you should change the device q6 hours at minimum if possible and the use of a colloid plate cut in a T form to prevent skin damage by pressure would also be a good choice. Most problems can be solved by paying attention to the issues listed above. Nevertheless, some problems like extremely prematurity can lead to damages by deforming the bridge of the nose by using Masks. Then you should use the Prongs more frequently (as possible) or try to make small breaks if possible. Our technical advisor is one of the leading professionals in this matter and teaches various clinical specialists for one of the manufacturers of the SIPAP device. She has done some Powerpoints regarding this issue with good photos to illustrate what can be done wrong and what should be done the "right" way to prevent damage to the skin. This will be downloadable, soon on my Homepage. I will let you know when....... Hope that helps. Norbert

Hello Hehady, We usually ventilate our neo´s with BIPAP (Evita XL). Then, we cycle the Pinsp pressure down as much as we can to maintain normal Ventilation (4-6ml/Kilogram/weight). Once that goal is reached and the baby doesn´t need much FiO2 <35%, we would rapidly decrease the mandatory frequence in steps of 5 frequences applied by the ventilator until we have a Frequence of 10-15. We dont let the small preemies breath on CPAP, because of their periodic breathing. We usually apply ASB (Assisted Spontaneous Breathing) to help the baby to overcome the dead space of the Ventilator Circuit and the Resistance of the small Tube (a kind of Tube compensation). The ASB is set high enough to maintain a spontaneous Vte mentioned above. We usually extubate that way with a Peep of 5mbar. I say usually, because it happens that we have to choose another way sometimes, as we set the ventilator settings the way our patients need it That´s one way to Rome..... I dont say one can´t let preemies breath on CPAP(assumed that we´re talking about the Invasive CPAP Ventilation), sure you can, all you have to do is to assist the child´s efforts enough to overcome the dead space and the Resistance of the tube. We are applying ASB for that reason. In children with apnea or periodic breathing it might be helpfull to set the alarm settings right, then. In our case we dont use the apnea ventilation, so we use this kind of backup frequences (10-15). Most preemies end up on a Non-Invasive-CPAP device like our SIPAP´s just right after extubation. We usually extubate very rapidly and in combination with early Non-Invasive-CPAP Methods, this technique has worked very well for us. Older children are usually weaned by reducing the BIPAP Frequences until zero, then the ventilator automatically changes into CPAP-ASB Mode. i would be curious to know how others tend to wean their children off the Vent´s. And, are ventilator checks and setting changes done by your Nursing Staff as in our case or is it something the Neo´s do? thanks in advance Norbert

My Name is Norbert Lutsch, i just made a presentation abou myself in the Member Presentation Section of this Forum...... As i know from my own experience with starting up neonatal Nursing Forums, every start is hard!!! It takes time to build up a going Forum and it is kept alive with dedicated people just like YOU . Nevertheless it is necessary for our profession to get in touch with other professionals and the expertise of colleagues around the world to improve our knowledge and work.... So i hope to read some other post´s, soon. Norbert