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amgraca last won the day on October 10 2016

amgraca had the most liked content!

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About amgraca

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  • Birthday 01/14/1974

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  • Occupation
    Consultant Neonatologist
  • Affiliation
    NICU - Hospital Santa Maria
  • Location
    Lisboa, Portugal
  • Interests
    Neonatal neurology

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  1. amgraca

    Lidocaine (CNS)

    Dose & administration Lidocaine should be administered intravenously and can be diluted in dextrose and normal saline solutions. Dose per kg varies according to the duration after the first maintenance dose, and depends on the body temperature when administered: Loading dose – 2 mg/kg over 10 minutes Maintenance dose for normothermic infants: The loading dose is followed by 6 mg/kg/hour over 4 hours, 4 mg/kg/hour over 12 hours, and 2 mg/kg/hour over 12 hours. Hypothermic infants: The loading dose is followed by 7 mg/kg/hour over 3.5 hours, 3.5 mg/kg/hour over 12 hours, and 1.75 mg/kg/hour over 12 hours. Indications Refractory seizures despite first-line treatments in term infants > 2.5kg. Contraindications and special considerations (including incompatibilities) Lidocaine is contraindicated in complete AV block III and wide QRS complex tachycardia. Further, risk factors for cardiotoxicity are unstable potassium serum levels, (congenital) cardiac dysfunction and concurrent phenytoin use. Should not be used with phenytoin. Compatible at terminal injection site with aminophylline, ampicillin, caffeine citrate, calcium (chloride and gluconate), dexamethasone, digoxin, dobutamine, dopamine, fentanyl, heparin, hydrocortisone, insulin, micafungin, morphine, penicillin G, potassium chloride, and sodium bicarbonate. Adverse effects Arrhytmias (rare). Pharmacological aspects Mechanism of action uncertain, probably acts as a membrane stabilizer. Metabolized in liver into its active metabolites and excreted in urine. Tends to accumulate in tissues with high blood flow and to redistribute later. T½ 200 minutes. Use should not be longer than the recommended schedule above. References Anticonvulsant treatment of asphyxiated newborns under hypothermia with lidocaine: efficacy, safety and dosing. Arch Dis Child - Fetal Neonatal Ed. 2013;98(4):F341–F345. PMID 23303304 Weeke LC, Toet MC, van Rooij LGM, et al. Lidocaine response rate in aEEG-confirmed neonatal seizures: Retrospective study of 413 full-term and preterm infants. Epilepsia. 2016;57(2):233–242. PMID 26719344 Weeke LC, Schalkwijk S, Toet MC, van Rooij LGM, de Vries LS, van den Broek MPH. Lidocaine-Associated Cardiac Events in Newborns with Seizures: Incidence, Symptoms and Contributing Factors. Neonatology. 2015;108(2):130–136. PMID 26111505 Lundqvist M, Ågren J, Hellström-Westas L, Flink R, Wickström R. Efficacy and safety of lidocaine for treatment of neonatal seizures. Acta Paediatr. 2013;102(9):863–867. PMID 23738612 Slaughter LA, Patel AD, Slaughter JL. Pharmacological treatment of neonatal seizures: a systematic review. J Child Neurol. 2013;28(3):351–364. PMID 23318696 Document version history Created 2016-10-03 / André M. Graça
  2. PHVD tratment, now that ELVIS trial ended recrutiment. As happened with cooling, could it be acceptable that participating units could assume earlier treatment as a better treatment. I suggest to invite someone from the Netherlands with experience in "early tratment" to speak on this. Transport for hypothermia - passive vs. controlled. Most countries did not implement controlled devices on transport. Should they change their attitude? What is the evidence on this? Cooling babies with grade 1 HIE - despite no evidence on this, many units cool babies with evidence of asphyxia but mild HIE and sometismes even a normal aEEG. Should this practice be implemented as a reccomendation or should there be a reccomendation on the other direction?
  3. aEEG is much simpler but it requires some formal training. Besides the excellent tools provided by Prof Azzopardi at his site, I think Prof. Thoresen at Bristol are providing teaching on aEEG and hypothermia regularly. I would say that it required at least one year of training of our staff to have absolutely reliable aEEG interpretation by our medical team. As this was more than 5 years ago it became easier to implement cooling according to the TOBY protocol. Concerning the therapeutic window I would say that we should stick to less than 6 hours until a neuroprotective temperature is reached but this does not mean that we should exclude a baby that arrives at 9 hours, provided that a temperature between 34-35 was reached before 6 hours (during transport or at the referring hospital).
  4. Those moderate cases are sometimes difficult to decide clinically in terms of B criteria and that is the reason why we still use the aEEG criteria as was done during the TOBY trial. As most our patients are outborn, we recommend maintaining "passive" hypothermia (34-35ºC) during transport, and on arrival we monitor aEEG for a while. If it is normal voltage (alNaqeeb criteria) and we see no seizures we do not cool the baby. If aEEG is not normal voltage or if there are seizures we will cool the baby for sure. This approach is much more objective than the B criteria, and using it allows us not to overtreat patients that will probably be normal and also trat babies that despite having a reasonable clinical picture have an abnormal aEEG and definitely benifit from treatment.
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