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Found 11 results

  1. until
    It is an online course which lasts 3 months, starting in July, 2019. 28 topics avilable 24/24 and 7/7. 22 mexican professors and 8 international ones.
  2. Much has been written about methylxanthines over the years with the main questions initially being, “should we use them?”, “how big a dose should we use” and of course “theophylline vs caffeine”. At least in our units and in most others I know of caffeine seems to reign supreme and while there remains some discussion about whether dosing for maintenance of 2.5 -5 mg/kg/d of caffeine base or 5 – 10 mg/kg/d is the right way to go I think most favour the lower dose. We also know from the CAP study that not only does caffeine work to treat apnea of prematurity but it also appears to reduce the risk of BPD, PDA and duration of oxygen therapy to name a few benefits. Although initially promising as providing a benefit by improving neurodevelopmental outcomes in those who received it, by 5 and 11 years these benefits seem to disappear with only mild motor differences being seen. Turning to a new question The new query though is how long to treat? Many units will typically stop caffeine somewhere between 33-35 weeks PMA on the grounds that most babies by then should have outgrown their irregular respiration patterns and have enough pulmonary reserve to withstand a little periodic breathing. Certainly there are those who prove that they truly still need their caffeine and on occasion I have sent some babies home with caffeine when they are fully fed and otherwise able to go home but just can’t seem to stabilize their breathing enough to be off a monitor without caffeine. Then there is also more recent data suggesting that due to intermittent hypoxic episodes in the smallest of infants at term equivalent age, a longer duration of therapy might be advisable for these ELBWs. What really hasn’t been looked at well though is what duration of caffeine might be associated with the best neurodevelopmental outcomes. While I would love to see a prospective study to tackle this question for now we will have to do with one that while retrospective does an admirable job of searching for an answer. The Calgary Neonatal Group May Have The Answer Lodha A et al recently published the paper Does duration of caffeine therapy in preterm infants born ≤1250 g at birth influence neurodevelopmental (ND) outcomes at 3 years of age? This retrospective study looked at infants under 1250g at birth who were treated within one week of age with caffeine and divided them into three categories based on duration of caffeine therapy. The groups were as follows, early cessation of caffeine ≤ 14 days (ECC), intermediate cessation of caffeine 15–30 days (ICC), and late cessation of caffeine >30 days (LCC). In total there were 508 eligible infants with 448 (88%) seen at 3 years CA at follow-up. ECC (n = 139), ICC (n = 122) and LCC (n = 187). The primary outcome here was ND at 3 years of age while a host of secondary outcomes were also examined such as RDS, PDA, BPD, ROP as typical morbidities. It made sense to look at these since provision of caffeine had previously been shown to modify such outcomes. Did they find a benefit? Sadly there did not appear to be any benefit regardless of which group infants fell in with respect to duration of caffeine when it came to ND. When looking at secondary outcomes there were a few key differences found which favoured the ICC group. These infants had the lowest days of supplemental oxygen, hospital stay ROP and total days of ventilation. This middle group also had a median GA 1 week older at 27 weeks than the other two groups. The authors however did a logistic regression and ruled out the improvement based on the advanced GA. The group with the lowest use of caffeine had higher number of days on supplemental oxygen and higher days of ventilation on average than the middle but not the high caffeine group. It is tempting to blame the result for the longer caffeine group on these being babies that were just sicker and therefore needed caffeine longer. On the other hand the babies that were treated with caffeine for less than two weeks appear to have likely needed it longer as they needed longer durations of oxygen and were ventilated longer so perhaps were under treated. What is fair to say though is that the short and long groups having longer median days of ventilation were more likey to have morbidities associated with that being worse ROP and need for O2. In short they likely had more lung damage. What is really puzzling to me is that with a median GA of 27-28 weeks some of these kids were off caffeine before 30 weeks PMA and in the middle group for the most part before 32 weeks! If they were in need of O2 and ventilation for at least two weeks maybe they needed more caffeine or perhaps the babies in these groups were just less sick? What is missing? There is another potential answer to why the middle group did the best. In the methods section the authors acknowledge that for each infant caffeine was loaded at 10 mg/kg/d. What we don’t know though is what the cumulative dose was for the different groups. The range of dosing was from 2.5-5 mg/kg/d for maintenance. Lets say there was an over representation of babies on 2.5 mg/kg/d in the short and long duration groups compared to the middle group. Could this actually be the reason behind the difference in outcomes? If for example the dosing on average was lower in these two groups might it be that with less respiratory drive the babies in those groups needed faster ventilator rates with longer durations of support leading to more lung damage and with it the rest of the morbidities that followed? It would be interesting to see such data to determine if the two groups were indeed dosed on average lower by looking at median doses and total cumulative doses including miniloads along the way. We know that duration may need to be prolonged in some patients but we also know that dose matters and without knowing this piece of information it is tough to come to a conclusion about how long exactly to treat. What this study does though is beg for a prospective study to determine when one should stop caffeine as that answer eludes us!
  3. until
    https://www.mcascientificevents.eu/iccn2018/ MAIN TOPICS Hypothermia in preterms: what’s new? Teamworking in the NICU EPO and neuroprotection: an update NIDCAP and family-centered care Delivery of fetal CHD patients
  4. If you work in the NICU then you have seen your fair share of septic workups for late onset sepsis. Sepsis is such a common diagnosis that if I had to guess I would say that at least 50% of all discharge summaries would include this in a list of final diagnoses for any VLBW infant. If you were to look through the chart though you would find that while workups are common, the recovery of a pathogenic bacterium is not as much. This is in part due to the low threshold that many people have for doing such workups. A little bit of temperature instability, a few more apneic events than normal or a rise in O2 requirements may all trigger such investigations. When they come back negative we all feel good that we looked but we also are then quick to blame the etiology on something else. Mild fluctuations in temperature are written off as overbundling, apnea due to outgrowth of caffeine and a rise in FiO2 to evolving CLD. Maybe though the explanation at least in some cases is that there was a pathogen but we didn’t test for it. Viruses are everywhere Tis the season so to speak so everyone is on high alert for viruses in our homes, schools, malls etc but many of us consider the NICU to be mostly free of such pathogens. The truth is we mostly are provided that we all wash our hands well, keep sick contacts from visiting and put on a mask when our coughing starts. Alas, if you have done a handwashing audit as we have you would know that when looking at technique and duration of handwashing, we don’t always hit 100%. These audits are for health care practitioners but I have often wondered what sort of results we would see were we to do the same for parents and visitors. When we know the viruses are out there such as during outbreaks of RSV and influenza we can’t help but send off our samples for respiratory viruses more frequently but what if we did this with intention for every late onset septic workup? Lucky For Us Someone Did Just That! Back in 2014 the following study was published. Viral respiratory tract infections in the neonatal intensive care unit: the VIRIoN-I study. This was a simple prospective and elegant study in which any infant in the NICU who had never been home and was greater than 72 hours had respiratory samples sent for viral panels within 72 hours of starting antibiotics for presumed late onset sepsis. The findings were certainly interesting in that 6% of 135 sepsis evaluations tested positive for a virus. In the analysis, the infants had the following characteristics: tended to be older (41 vs 11 days; P = .007) exposed to individuals with respiratory tract viral symptoms (37% vs 2%; P = .003) lower total neutrophil counts (P = .02) best predictor of viral infection was the caregivers’ clinical suspicion of viral infection (P = .006) What interests me about these results are a couple things. The first is that as I was once told, the sensitivity of asking if someone has been around sick people is low during peaks in viral outbreaks as who hasn’t? Perhaps what this study tells us is that within the NICU environment we actually do a reasonable job of keeping such contacts away but when they slip through infections happen. The second point worth mentioning is that a low neutrophil count is associated which is interesting given how often neutropenia is pointed to as a reason to start antibiotics. These viruses are troublesome creatures indeed! Further Evidence Arrives At the end of last year a similar study was published by the same group Viral Respiratory Infections in Preterm Infants during and after Hospitalization. They took a different approach this time out and took nasopharyngeal samples from 189 infants in the NICU (96 term and 93 preterm) within 7 days of birth and then sent samples weekly while in hospital followed by monthly for four months after discharge. In this collection of infants a mere 4 patients tested positive in NICU and all of them under 28 weeks of age at birth! How do we account for the remarkable reduction in risk while in hospital? To answer that you can read through the NICU environment in the full article if you have access. In short, they had a very rigorous infection control set of precautions set up. Interestingly only one of the infections was with RSV and the unit did not provide prophylaxis for infants in hospital. Perhaps with precautions like theirs they felt it was unnecessary. Once discharged a little over a third of patients acquired a viral infection in the first four months at home. Given the potential risk for readmission and with that to a PICU this rate of viral infection is concerning. Vision for the future! Taken together we can state that viruses do make their way into the NICU but fortunately not as commonly as one might think. What the last study in particular does remind us though is that we need to ensure that as part of discharge teaching parents take home many of the practices that we have used in the hospital with respect to hand hygiene, limiting visitors and not being afraid to holster some hand sanitizer for those times when soap and water are not so easy to come by. To be sure viruses are out there but at least for the first few months after discharge for our most vulnerable babies a little paranoia about viruses could go a long way.
  5. This is a title that I hope caught your eye. In the nearly twenty years I have been in the field of Pediatrics the topic of parking being a barrier to parental visitation has come up again and again. A few years ago the concern about the cost of parking was so great that I was asked if I could find a pool of donors to purchase parking passes to offset the burden to the family. The theory of course is based on the idea that if parking were free in the NICU parents would visit more. If parents visit more they will be more involved in the care of their baby, more likely to breastfeed and with both of these situations in play the infant should be discharged earlier than other infants whose parents don’t visit. Try as I might it was a tough sell for donors who tend to prefer buying something more tangible that may bear their name or at least something they can look at and say “I bought that”. This is quite tough when it comes to a parking stall and as such I am still looking for that elusive donor. Having said that, is there any basis to believe that free parking is the solution that will deliver us from minimal visitation by some parents? A Study May Help Answer The Question Northrup TF et al published an article that was sent my way and to be honest I couldn’t wait to read it. A free parking trial to increase visitation and improve extremely low birth weight infant outcomes. This is like the holy grail of studies. A study that gets right to the point and attempts to answer the exact question I and others have been asking for some time. The study took place in Houston, Texas and was set up as an RCT in which families were randomized into two groups. Inclusion criteria were birth weight ⩽1000 g, age 7 to 14 days and deemed likely to survive. Seventy two patients were enrolled in the free parking group while 66 were placed in the usual care. Interestingly the power calculation determined that they would need 140 to show a difference so while 138 is close it wasn’t enough to truly show a difference but let’s see what they found. The Results Free parking made absolutely no difference for the whole group. Specifically there was no difference in the primary outcome of length of stay or hours spent per visit. Some interesting information though that may not be that surprising was found to be of importance in the table below. It may not seem like a surprise but the patients who were more affluent and those who had less children tended to visit more. The latter makes a lot of sense as what are many people to do when they have one or more other children to care for at home especially in the face of little support? Would free parking make one iota of difference if the barrier has nothing to do with the out of pocket cost? The conclusion was that the strategy didn’t work that well but as you may have picked up I think the study was flawed. By applying the strategy to all they were perhaps affected by choosing the wrong inclusion criteria. Taken to an extreme, would a 50 million dollar Powerball winner care one bit about parking vouchers? It wouldn’t make any difference to whether they were going to come or not. Similarly a single mother with 5 other kids who lives below the poverty line and has little support is not going to come more frequently whether they have a voucher or not. What if the study were redone? I see a need to redo this study again but with different parameters. What if you randomized people with a car or access to one who lived below a certain income level and had a committed support person who could assure that team that they could care for any other children the family had when called upon? Or one could look at families with no other children and see if offering free parking led to more frequent visitation and then from there higher rates of Kangaroo Care and breastfeeding. I for one haven’t given up on the idea and while I was truly excited to be sent this article and sadly initially dismayed on first read, I am hopeful that this story has not seen it’s end. It is intuitive to me that for some parents parking is a barrier to visiting. Finding the right population to prove this though is the key to providing the evidence to arm our teams with evidence to gain support from hospital administrations. Without it we truly face an uphill battle to get this type of support for families. Stay tuned…
  6. To many of you the answer is a resounding yes in that it reduces stress. Why is that though? Is it because you have had a personal experience that has been favourable, it is the practice in your unit or it just seems to make sense? It might come as a surprise to you who have followed this blog for some time that I would even ask the question but a social media friend of mine Stefan Johansson who runs 99NICU sent an article my way on this topic. Having participated in the FiCare study I realised that I have a bias in this area but was intrigued by the title of the paper. The study is Parental presence on neonatal intensive care unit clinical bedside rounds: randomised trial and focus group discussion by Abdel-Latif ME et al from New Zealand and was performed due to the lack of any RCTs on the subject specifically in the NICU. Before I go on though I have to disclose a few biases. I love parents being on rounds so I can speak with them directly and have them ask me any questions they may have after hearing about their infants condition. Our unit encourages the practice. We are rolling out the principals of FiCare after being part of the study which encourages parental presence at the bedside for far more than just rounds.For information on implementing FiCare click here While this study is the only reported RCT on the subject in the NICU, the FiCare results will be published before long. What is the problem with having families on rounds? The detractors would say that sensitive information may be more difficult to discuss out in the open for fear that the family will take offence or be hurt. Another concern may be that teaching will be affected as the attending may not want to discuss certain aspects of care in order to prevent creating fear in the parents or awkwardness in the event that the management overnight was not what they would have done. Lastly, when patient volumes and acuity are high, having parents ask questions on rounds may lead to excessive duration of this process and lead to fatigue and frustration by all members of the team. So what does this study add? This particular study enrolled 72 families of which 63 completed the study. The study required 60 families to have enough power to detect the difference in having parents on rounds or not.The design was interesting in that the randomisation was a cross over design in which the following applied. One arm was having parents on rounds and the other without. The unit standard at the time was to not have parents on rounds. ≤30 weeks 1 week in one arm, one week washout period then one week in the other arm >30 weeks 3 days in one arm, three day washout and then three days in the other arm The primary outcome was to see if there would be a significant difference in the Parental Stressor Scale. Surprisingly there was no difference across any domains of measuring parental stress. When we look at questions though pertaining to communication in the NICU we see some striking differences. The families see many benefits to the model of being on rounds. They appear to have received more information, more contact with the team, contributed more to the planning of the course of their babies care and been able to ask more questions. All of these things would seem to achieve the goals of having parents on rounds. So why aren’t parents less stressed? This to me is the most interesting part of this post. The short answer is I am not sure but I have a few ideas. The study could not be blinded. If the standard of care in the unit was to not have parents on rounds, what kind of conversations happened after rounds? Were staff supportive of the families or were they using language that had a glass is half empty feel to it? Much like I am biased towards having parents on rounds and thanking them for their participation were there any negative comments that may have been unintentional thrown the families way. Is a little knowledge a dangerous thing? Perhaps as families learn more details about the care of their baby it gives them more things to worry about. Could the increase in knowledge while in some ways being pleasing to the family be offset by the concern that new questions raise. Was the intervention simply too short to detect a difference? This may have been a very important contributor. This short period of either a week or two leaves the study open to a significant risk that an event in either week could acutely increase stress levels. What if the infant had to go back on a ventilator after failing CPAP, needed to be reloaded with caffeine or developed NEC? With such short intervals one cannot say that while communication was better the parents were not stressed due to something unrelated to communication. In an RCT these should balance out but in such a small study I see this as a significant risk. So where do we go from here? I applaud the authors for trying to objectively determine the effect of parental presence on rounds in the NICU. Although I think they did an admirable job I believe the longer time frame of the FiCare study and the cluster randomised strategy using many Canadian centres will prove to be the better model to determine effectiveness. What the study does highlight though in a very positive way is that communication is enhanced by having parents on rounds and to me that is a goal that is well worth the extra time that it may take to get through rounds. Looking at it another way, we as the Neonatologists may need to spend less time discussing matters after rounds as we have taken care of it already. In the end it may be the most efficient model around!
  7. When you mention electronic medical records to some physicians you get mixed responses. Some love them and some…well not so much. These tech heavy platforms promise to streamline workflows and reduce error with drop down menus, some degree of artificial intelligence in providing warnings when you stray too far from acceptable practice but for some who are not so tech savvy they are more of a pain. I have to admit I am in the camp of believing they are a good thing for patient care as I work in one centre with expanded EMR services and one without and I do find a number of benefits to working with a more robust EMR platform but I respect that not all do. The cell phone on the other hand is everywhere and even the most tech fearful often carry one including most of the parents we care for. What caught my eye this month was the article by Globus O The use of short message services (SMS) to provide medical updating to parents in the NICU in which an EMR system is described that sends parents a text message at a pre-specified time regarding their infants condition. I had a visceral reaction at first thought thinking “would I want my cell phone number sent to families?”, “how much time out of the day would all of this take?” and to be a little old fashioned “can’t we just talk on the phone?”. I am sure there are many other questions that others would have as well. Having said that as I read through the paper I warmed to the concept and by the end questioned whether we could do the same! The Intervention It turns out the SMS message comes from the EMR and not the personal cell phone of the bedside nurse and is sent out at 9 AM each day. Each nurse requires only 30 seconds of their day to populate a few questions during the night shift and then the information goes out to the parents. “The text message includes one-sentence prefaces and conclusions and provides updated information that includes the location of the infant’s crib (room and position), the infant’s current weight and whether medical procedures, such as head ultrasound, cardiac echocardiogram or eye examination, were performed. Information regarding acute events or deterioration of the infant’s medical condition are not included in the SMS, but are delivered personally to the parents in real time.” This last sentence is important. The SMS service will not notify the family that their infant is receiving chest compressions but is there to give them “updates”. The sceptics out there will likely comment that this should be the job of both nursing and medicine to regularly update the families but thinking about it, how many parents are not there everyday and when they are out of sight how many physicians regularly call them to provide them updates? No doubt there are some but I would think they are not in the majority. But is it effective? The measurement in this case was through surveys of nursing and families both pre-implementation and afterwards. Provided in the table below are the scores (means +/- SD) in the pre and post implementation phases of the program. Statement Pre-SMSi N=91 Post SMSi N=87 P-value The physician was available when needed 4.1+/-0.9 4.4+/-0.7 0.002 The physician was patient in answering my questions 4.6+/-0.7 4.9 +/-0.4 0.002 I felt comfortable approaching the physicians 4.3+/-1.0 4.7+/-0.6 0.001 I felt comfortable approaching the nurses 4.4+/-0.8 4.6+/-0.6 0.02 I regularly received information from the physicians regarding my infant’s medical status 3.7+/-1.3 4.1+/-1.1 0.03 These are some pretty powerful outcomes. The use of what many consider an impersonal form of communication (how many times have I looked at people texting furiously and thought JUST PICK UP THE PHONE!) actually appears to have improved the approachability of the staff in the unit and facilitated information transfer more easily. One other important finding was that when surveyed pre-intervention staff were somewhat sceptical that this would help and moreover were concerned that it would interfere too much with work flow in the day. Evaluations afterwards did not support these fears and many felt it was an improvement. In the end the total time spent on this by nursing was estimated to be no more than 30 seconds of each day! From the parent’s standpoint they certainly saw this as an improvement. The Future At least in our centre we are moving slowly but steadily towards a fully functioning EMR. Will we have this capability in the software that we use? After reading this I hope so. I can see how receiving a daily morning message would prime the family to interact with staff on rounds. The added benefit is that by knowing that the information would be ready at 9 AM, families could be present with questions already formulated in their minds. How often do we encourage families to be on rounds and have them listen to a tremendous amount of information and then turn to them with the standard “any questions?”. While I am sure many of us try and explain matters in lay terms, giving parents a change to mull over the issues first could well enhance the interaction they have with our team in a meaningful way. Time to look into whether this is possible…
  8. In the followup of nicu babies , neurodevelopemental assessment and early intervention have a great role to play in helping the baby. A structured concise and deligent record makes the baby to be indentified early and intervened, KIMS and CDC trivandrum have a produced a blue book as a prototype. i have attached few screenshots to show the contents of the book. You can use the book , or edit and change as per your institutions requirement. You can send a mail to me : selvanr4@yahoo.com i will send the pdf by e mail dr.r.selvan
  9. A one day study day covering hot topics in Neonatal ventilation Organised by the Evelina London Children's Hospital and King's College London Details: http://www.guysandstthomasevents.co.uk/paediatrics-training/neonatal-ventilation-updates-hot-topics-and-workshops/ A4 flyer - Neonatal Ventilation 2014 - low res.pdf
  10. Every NICU faces challenges. It just comes with the territory. After doing some research I feel like the following three challenges are pretty universal. Can anyone tell me how important these three issues are in your NICU? What solutions has your unit found to address them? Medication Errors Infection Control Tubing Misconnections Thanks!
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