amgraca

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?

I agree with Stefan. We should be very careful with copy-paste temptations from Neofax, since they developed from a drug-company offered book into a more complex profit-seeking solution. Would you agree on splitting the editorial responsibility between the editors for different areas? Regards

Dear all I wish an excellent 2016 for all 99nicu members! Concerning the dosing book it could be a good idea to select a group of editors, each one with reponsability for one or two chapters (like in Neofax - antibiotics, respiratory, CNS...) and start working. I also beleive a pharmacologist editor would be advisable, as previously suggested. Could this be based online in the forum and in the future translated into a smartphone app? Best regards Andre

Fantastic idea. Really our old paper-based Neofax are now probably outdated and the new distribution is not easy to get outside a hospital-based subscription. I am available to help with your idea of constructing an open-access dosing book for 99nicu's members.

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).

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.