TMohns

Before 2007 the primary medication in our department was atropine, midazolam, morfine and rocuronium. Our main population are (extreme) prematures needing short time ventilation and we have no surgery. Problem was that is was not possible to get patients (premature intubated for RDS) fast from the ventilator. To optimize this and support early extubation we switched to combination atropine, fentanyl (5/kg), rocuronium (0,3) if necessary, based on literature, and used this for about 10 years. Not everyone was happy with this combination, sometimes Tx rigidity occured needing extra relaxation and so one of my collegues started a research project on this. Today we use primarely propofol (1-6 mg/kg) titrating by effect (intubation readyness score) and combine this with rocuronium (0,3) if needed. Atropine is not standard medication and depends on attendend performing procedure, is used by some collegues more than others ;-). For patients with (potential) circulation problem (PPHN, sepsis, …) we use ketamine S 0,5 - 1 mg/kg alone. An opioid (fentanyl) we only add if we expect the patient staying on ventilator for longer period. Atropine, Fentanyl, rocuronium we still have as secondary combination - and is used especially by (older) colleagues still not trusting safety of propofol in our population 🙂 I think the strongest improvement in our department was focussing on effect of medication (intubation redyness score) and working on standardisation of medication and timing effect and dosing as we don’t have a lot of “crash intubations”.

Dear Katja, I am german neonatologist working Head of department on a Dutch level 3 NICU and I’m also CMIO (Chief Medical Information officer) of the hospital. We have done a lot of work to search for the right choice and learned that is really depending on your local needs and architecture. Main question is how your hospital is making choices (what are the leading principles): 1. Integration in clinical workflows and interaction with equipment (eg Philips, Draeger). 2. Integration in hospital system / EHR (integration). 3. Best for ward (individualisation). In the international market for individual PDMS solution Metavision is one of the leaders - the software is flexible and gives a lot of freedom to adapt to your department. Other systems are more solutions where PDMS is part of hardware as monitoring (eg Philips, Draeger). In the Netherlands it is common to chose a suite for the hospital with fully integration (EPIC, Chipsoft) wher PDMS is a functionality within the EHR / hospital information system. A last but not least it is always also a business decision - so costs are important :-( I don’t know what you really needs are and automation is a complex field. If you have further questions you can contact me and I can try to give you Tips and possible advice. Regards, Thilo

I enjoyed the meeting in Copenhagen and would like to meet again 😉 Thilo, Veldhoven (NL)

Dear Vicky, we have a slightly different approach: Our approach was (4 years ago) to stop at 48 Hours. First step was to stop at 36 Hours what we do for all Patients in our Population (also ELGAN) if the other parameters (CRP, WBC) stay normal. the Last 3 years we focused on optimalization to decrease use of antibiotics and length of stay. 1. In Term Babies with indication for antibiotic Treatment (>2 risk factors, red flag) we start treatment en check CRP + PCT two times within 24 Hours. If PCT is low we stop antibiotics at 24 Hours. Approach is based on Lancet publication over NEOPINS trial (we participated). 2. For Babies below 37 weeks we still try to implementatie same approach but until now there is less evidence so we still discuss safety 😏 3. For use in our NICU we also would like to implement PCT and other markers to optimize treatment Not only to stop earlier but to start less 🤗 It’s tricky stuff and we Hope to improve further by using “new technologies “ as smart algorithms based on vitals procent other datasets 😎 Gr. Thilo

Sidestream is highly accurate in optimal conditions (homogene lung perfusion, no leakage, evident end-tidal plateau,...) so from technological point of view it is very good. But there are some limitations and you have to do a lot of training to increase knowledge in your hole team to work with it. The numbers are worthless without looking for other parameters to interpret them ;-). So we use it regularly and do in the beginning a bloods sample. We use standard ventilation mode SIPPV+Vg so the situation should be stable and we follow the trend. If trend follows our expectations we don't do routine bloods check. If we see changes we first look on the flow curve and percentage leak before interpreting the number. Then we try to solve problem logical (in-, decrease tidal volume, suctioning, ...) and if the patientt doesn't respond wel we do further diagnostics (X-ry, bloodgas, ...) The mainstream technology is more stable because you have less trouble with leakage ;-) Gr. Thilo

Dear Andrej, We run a third level NICU without surgery. So our main focus is on premature babies and we are really focused on “minimal invasive”. On our ward we use continuous Co2-monitoring ventilated patiënts. We don’t use CO2 measurements in not intubated patiënts. In (our) ideal situation Tc and eT are parallel monitored because both are effected differently by patiënt conditions (eg skin perfusion, lung perfusion, …) and we really want to get trends were we can trust. So I think there is not one technology preferent or delivers more accuracy because the patient conditions are relevant. We only take extra bloedsamples if the measurements are not consistent or for other reasons. As technology we use the Tc sensor from Philips/radiometer and for eT we use Mainstream (Philips/respironics) and sidestream (Oridion) technology. Because of sensorweight and deadspace Mainstream is used in (near)term patients (>2500gr) and sidestream in premature pat. (From 500gr). Tc is used for all patiënts behalve extreme premature (<26 wk.) - there we first look for skin condition and decide individually what is best (risk for skin leasions vs. Hypocapnia). In severe ill patiënts (in our situation mostly sepsis, MAS, PPHN, HIE with hypothermia) we standard use aEEG, NIRS and ventilatory monitoring (Tc of eT-CO) in all patiënts. From clinical perspective we use CO2 monitoring primary to prevent extreme situations causing problems (eg hypercapnia in PPHN, hypocapnia in HIE). Hope this gives you a bit more ideas 🙂 Kind regards, Thilo

@Monivent: I'm really interested in your product for training (1) and clinical use(2). Could you please contact me?

1. DR c, NICU c or d. We don't have heater integrated in our T-Piece setting so on the ward NICU we prefer warm and humidified gas (ventilator) if possible. 2. Not now in DR - we asked for budget to implement RFM next year but it's formal only for research ;-). Main issue is that there is no one with full approval/certification for clinical use in our population. Is well CE (technical) but a grey zone for our purpose (high risk intervention while stabilisation/resuscitation). If we use ventilator we can use measurements from this devices (Fabian). 3. We regularly start with a (facemask) and place the baby as soon as possible on binasal nCPAP with mask (Bi-nasal with flowdriver). In some cases we start with bij-nasal mask and in case of expected difficult airway we use c (LAM) or d (ETT). I would be very intersted in more information about a "legal" RFM for use in our population. Did anyone find a device? And also if someone is using EIT combined with RFM in the stabilisation of premature babies :-)

We admit patients with bronchiolitis ore other viral infections which are spread aerogen on our NICU from home, regional hospitals or other wards in our hospital. I'm working in The Netherlands where Intensive Care is highly centralized in 10 NICU's and 7 PICU's. We had trouble with the nationally bed capacity (PICU) and transport distances. So we started in our department treating these patients to solve this problem although we were not really happy about the risk we had to accept. This happend from 2006 in an "Open Bay" unit and we used strict protocols which we developed together with our department for hospital infection control. The incubator is a goed first step for isolation and the next is distance of minimal 3 meters (1 bedplace) and very strict hand desinfection and management of contaminated equipment. Since 2012 we have a new NICU unit with single rooms (2 for really isolation) where we admit also patients with RSV. Our population is up to 3 months if there is lack of PICU beds but we try to avoid as much as possible these patients on our unit. We had no proven transfer from one patient to another in the last 13 years.