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Hamed last won the day on February 20

Hamed had the most liked content!

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About Hamed

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    Assistant professor of Neonatology
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  1. Hemangioma ? Next steps ?

    @tarek & @rehman_naveed Well, there is no clear national pre-screening guidelines for the use of propranolol. However, we do the following screening parameters: Full clinical examination, CBC, electrolytes, urea and creatinine, bl glucose, T3, T4 and TSH, Abdominal ultrasound (in case of multiple lesions), cranial U/S, ECG and ECHO. In addition to photos of the hemangiomas and their diameters. I believe every unit will follow their own screening guideline until we have a clear statement. Agree with both of you, the Golden hour and the expected magic bullets of the golden hour will be a really nice subject talk. Unfortunately, I am not able to join the meeting also. Looking forward to hearing your feedback and the recommendations coming out of the meeting.
  2. Hemangioma ? Next steps ?

    Thanks for sharing your case Ayman. As @rehman_naveed clearly recommended concerning CBC. Reassure the infant`s family, the size may increase in the first few months and is expected to decrease later on. In similar cases in our unit we would consider propranolol after a normal cardiac examination and ECG, to be started in the NICU and if the infant tolerates it, will be D/C to home on oral propanolol and followed in outpatient. Good luck.
  3. Hi, concerning morphine and fentanyl during cooling, smaller doses as potentially toxic serum concentrations of morphine may occur with hypothermia with doses above 10 mcg/kg/h. Start 5 mcg/kg/h and not exceed 10 mcg/kg/h. Another option is boluses 50 mcg/kg/4hrs. As for Fentanyl 0.5 mcg/kg/h max is 1 mcg/kg/h or boluses 0.5mcg/kg every 2 ~4 hs. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3552186/ I am not sure about the better action of morphine, but what I know that fentanyl shows a rebound increase in serum levels during rewarming. on the other hand, in cooling Morphine glucuronidation is inhibited in cooling and thus M3G (a product of morphine glucuronidation) is less produced which is a potent opiate receptor antagonist. http://neoreviews.aappublications.org/content/14/1/e22?sso=1&sso_redirect_count=1&nfstatus=401&nftoken=00000000-0000-0000-0000-000000000000&nfstatusdescription=ERROR%3a+No+local+token Although, fentanyl is 80 times more potent to morphine, we usually use fentanyl in our unit with doses less than 1 mcg/kg/h.
  4. There is a lot of debate when it comes to marijuana and breastfeeding. Although, it has been reported that breastfeeding from mothers who smoke marijuana during lactation showed a delay in motor development at 1 year of age, It can be hard to draw any conclusions because mothers who smoke marijuana during lactation are much likely to have smoked during pregnancy, as well. This means we can’t always determine whether exposure in utero through smoking marijuana during pregnancy, or from exposure through breastfeeding causes changes in the baby’s development. One must weigh the pros and cons, On one hand, there are many benefits to breastfeeding babies, that is well established. On the other hand, the risks of using marijuana while breastfeeding are under debate. I would recommend, sharing the decision with the mom, explain to her the benefits of breastfeeding vs. formula and the debate on the risks of using marijuana while breastfeeding. Advocate for her baby by encouraging mom to wean-off the marijuana she is taking by 5 ~10 % during pregnancy and every 2 to 3 weeks after and to get professional help for her weaning-off.
  5. Cap and Mask for PICC Line

    I think the question can contemplate both meanings 1- The infant already has a PICC in place. 2- In some units the PICCs are being inserted with the infant inside a closed isolette (incubator) through the arm side windows, as our NICU in Japan. Thus the question of putting on a mask and overhead could be more questionable. I don't know a study which compared using /or not masks and overheads for inserting PICCs, but here we always put them on during PICCs insertion, but during sampling and handling we don't.
  6. IV Caffeine early after birth (DOL0) for preterm newborns.
  7. CLD, volumen gurarantee

    @tarek and @Zsofia Dombi You are very much welcome, I hope I could be of any help. Concerning@tarek questions: Yes, this our policy for ELGANs, and majority of cases follow through the policy smoothly. However, as you know you could have the preterm on conventional ventilation (CMV) (A/C or SIMV) within the first 3days, and due to uncontrolled high PC02 in blood gas on CMV the mode is changed to HFO, without really making enough effort for troubleshooting and adjuesting the settings on CMV. I think that majority of preterms could be ventilated with A/C if you are comfortable with changing in the different components of the ventilator`s settings. This policy was implemented due a group of weak evidence: 1- The peak for IVH development is within the first 3 days of life. + 2- HFO has a slightly higher risk of IVH, and severe IVH. ==> Thus we try to avoid HFO during the first 3 days of life. On the other hand, CMV has a slightly higher risk of BPD, ROP and CLD/death at 36wks corrected age. Thus we shift to HFO after the first 3 days of life. Another opinion can state, that really all the evidence of increased risks on both arms are so low ranging from 0.02 to 0.05, and thus it doesn't really make a major difference to switch from one mode to another. Well may answer would be, It really depends on which mode you and your colleagues in the unit are comfortable with. This is true so long as your preterm has a homogeneous lung, but once it has a significantly heterogeneous lung eg PIEs or has a lot of secretions due to infection you will have to contemplate which ventilator and which mode is best for your patient. eg: in PIEs: HFO low frequency and low MAP with accepting higher FIO2. Or if a lot of secretions the Jet-HFV could be the best choice. @Zsofia Dombi Concerning CPAP, it would be always nice to mention how high was the PEEP. There are many reasons for CPAP failure, setting a low PEEP or unable to reach the desired PEEP (eg: try closing the baby`s moth with a pacifier), poor nursing care of CPAP, unfit nasal prong (try nasal mask), evolving BPD, PDA, increased apnea, and sepsis. Your departments dexamethason course sounds like a modified DART protocol for extubating babies who are stuck on ventilators for more than 7 to 21 days, if I follow you correctly your unit is using a total dose of dexamethason of 0.53 mg/kg over 10 days. It is smaller than what is used in some units in Canada which is a total dose of 0.89 mg/kg over 10 days. Best of luck.
  8. Considering a contemporary definition of BPD that correlates with respiratory morbidity in childhood.
  9. Maybe we shouldn’t be in such a rush to stop caffeine.

    Very interesting and a good discussion and analysis of results. Thanks. There is a small mistake in the 4th line of the last paragraph entitled "Putting it into context" "........but the amount of time at 36, 27 and 38 weeks was 229, 118 and 84 seconds respectively..." 27 weeks should be 37 weeks.
  10. CLD, volumen gurarantee

    Thanks for sharing your 24wk`s case. To truly be able to give advice, its better to share the current setting which the baby is on her Sats and transCO2. From your question, she is now on conventional ventilation (AC or SIMV) without VG. You have several ventilation maneuvers you can follow: 1- If the ventilator you are using does not have VG, use PIPs which give you volumes of 4~5.5 ml/kg, however, if you have a big leak around the ET tube, it will be hard to follow volumes and you will depend then on your blood gas CO2 or transcu. Co2 or end tidal CO2 and saturation to give a sufficient PIP. 2- if the ventilator has VG, adjust your volumes as above at 4~5.5 /kg the ventilator will provide PIPs to give your selected volumes. Again if the ET tube has a big leak, VG will not work and then you better switch the VG off and do as in # 1 , Or you can change the ET tube with a wider one. 3- In our unit we keep these ELGANs during the first 3 days of life on A/C (after giving surfactant and if intubated) to lower the risk of IVH, then we switch to HFO for several days using gentle ventilation settings until the MAP drops to 10 or 9 in room air, then we consider switching to A/C again or just go down on the MAP and extubate from HFO. Lastly, you mentioned hypoxic episodes, to decrease that start Caffeine and if you are using SIMV switch to AC. Good luck.
  11. Does anyone have a more recent article on acetate for acidosis in preterm neonates than the one by Olufunmi Peters and Steven Ryan 1997 (link below)? https://www.ncbi.nlm.nih.gov/pubmed/?term=acetate+for+acidosis+of+preterm+neonates Thanks
  12. A very nice article, thanks @Stefan Johansson
  13. Nitric Oxide in CDH

    Good work @spartacus007, would you be kind enough to share with us the X-ray finding before surgery? Was the hypoplastic lung apical? or hilar or you couldn't identify it? Would you share the current BP and ECHO results? Failure or difficult weaning of inhaled NO for treating pulmonary hypertension in hypoplastic lungs in CDH and preterms is not uncommon . Concerning your presented case, In our NICU settings we would prefer using HFO using MAPs 2~3 higher than your MAP on conventional (Go slowly on the increase in MAP increase by 1). We would prefer the HFO not to injure the hyoplastic lung and to recruit the lung volume to improve oxygenation and ventilation. Continue to increase your MAP to lower the FIO2 to below or =30%, but be careful not to over inflate the lungs which would be seen by rebound increase of FIO2 needs during your gradual increase in MAP or by X-ray seeing the size of the heart and level of the diaphragm. In addition, in our NICUs setting for PPHN due to CDH we would start Dopamine (1st increase SVR ) and according to the ECHO findings on TR and direction of flow through the PDA we would start NO at 20 mpp (2nd) if TR is still persist. BPs, follow up ECHO heart to see the effect on TR + FIO2 needs would be our guides. If still PH persist, we would add Milrinone (3rd). Sildenafil is used in our setting to wean off NO or if the above 3 medications were not controlling the PH. In your current setting, still FIO2 is 50% , Still needs to go down on the FIO2 before withdrawing your NO. I would work on recurring the lungs first before weaning NO totally ( as presented above). Hoping our settings could help you with your patient. Good luck.
  14. Feeding stable infant with right-sided CDH

    Hi @Andrej Vitushka This is interesting, we usually avoid using CPAP in CDHto avoid dilatation of guts loops and further herniation with cardiovascular compromisation, however, this case seems to only have it`s liver herniation in the chest. I see the OG tube is somewhat in a high position in the lower 1/3 of the esophagus. Concerning feeding, in our setting, we start feeding after surgical repair of CDH and not before. However, this case`s X-ray seems like lt. sided diaphragmatic paralysis or paresis and is already on CPAP, thus I would start feeding if surgery is not expected within a few days
  15. IVH

    @rehman_naveed Thanks for sharing the experience from your unit. Have you came along another RCT for the use of acetate for metabolic acidosis in preterms beside the one from Liverpool 1997: Randomised controlled trial of acetate in preterm neonates receiving parenteral nutrition. Arch Dis Child Fetal Neonatal Ed. 1997 Jul;77 I agree with you concerning the use of albumen for giving volumes in preterms with or without low serum albumen, there is a limited number of studies to answer whether giving albumin helps babies in the short or long-term or to show any benefit above crystalloids.