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Found 9 results

  1. A strange title perhaps but not when you consider that both are in much need of increasing muscle mass. Muscle takes protein to build and a global market exists in the adult world to achieve this goal. For the preterm infant human milk fortifiers provide added protein and when the amounts remain suboptimal there are either powdered or liquid protein fortifiers that can be added to the strategy to achieve growth. When it comes to the preterm infant we rely on nutritional science to guide us. How much is enough? The European Society For Pediatric Gastroenterology, Hepatology and Nutrition published recommendations in 2010 based on consensus and concluded: “We therefore recommend aiming at 4.0 to 4.5 g/kg/day protein intake for infants up to 1000 g, and 3.5 to 4.0 g/kg/day for infants from 1000 to 1800 g that will meet the needs of most preterm infants. Protein intake can be reduced towards discharge if the infant’s growth pattern allows for this. The recommended range of protein intake is therefore 3.5 to 4.5 g/kg/day.” These recommendations are from six years ago though and are based on evidence that preceded their working group so one would hope that the evidence still supports such practice. It may not be as concrete though as one would hope. Let’s Jump To 2012 Miller et al published an RCT on the subject entitled Effect of increasing protein content of human milk fortifier on growth in preterm infants born at <31 wk gestation: a randomized controlled trial. This trial is quite relevant in that it involved 92 infants (mean GA 27-28 weeks and about 1000g on average at the start), 43 of whom received a standard amount of protein 3.6 g/kg/day vs 4.2 g/kg/d in the high protein group. This was commenced once fortification was started and carried through till discharge with energy intakes and volume of feeds being the same in both groups. The authors used a milk analyzer to ensure consistency in the total content of nutrition given the known variability in human milk nutritional content. The results didn’t show much to write home about. There were no differences in weight gain or any measurements but the weight at discharge was a little higher in the high protein group. The length of stay trended towards a higher number of days in the high protein group so that may account for some of the difference. All in all though 3.6 or 4.2 g/kg/d of protein didn’t seem to do much to enhance growth. Now let’s jump to 2016 This past month Maas C et al published an interesting trial on protein supplementation entitled Effect of Increased Enteral Protein Intake on Growth in Human Milk-Fed Preterm Infants: A Randomized Clinical Trial. This modern day study had an interesting question to answer. How would growth compare if infants who were fed human milk were supplemented with one of three protein contents based on current recommendations. The first group of 30 infants all < 32 weeks received standard protein intake of 3.5 g/kg/d while the second group of 30 were given an average intake of 4.1 g/kg/d. The second group of 30 were divided though into an empiric group in which the protein content of maternal or donor milk was assumed to be a standard amount while the second 15 had their protein additive customized based on an analysis of the human milk being provided. Whether the higher intake group was estimated or customized resulted in no difference in protein intake on average although variability between infants in actual intake was reduced. Importantly, energy intake was no different between the high and low groups so if any difference in growth was found it would presumably be related to the added protein. Does it make a difference? The results of this study failed to show any benefit to head circumference, length or weight between the two groups. The authors in their discussion postulate that there is a ceiling effect when it comes to protein and I would tend to agree. There is no question that if one removes protein from the diet an infant cannot grow as they would begin to break down muscle to survive. At some point the minimum threshold is met and as one increases protein and energy intake desired growth rates ensue. What this study suggests though is that there comes a point where more protein does not equal more growth. It is possible to increase energy intakes further as well but then we run the risk of increasing adiposity in these patients. I suppose it would be a good time to express what I am not saying! Protein is needed for the growing preterm infant so I am not jumping on the bandwagon of suggesting that we should question the use of protein fortification. I believe though that the “ceiling” for protein use lies somewhere between 3.5 – 4 g/kg/d of protein intake. We don’t really know if it is at 3.5, 3.7, 3.8 or 3.9 but it likely is sitting somewhere in those numbers. It seems reasonable to me to aim for this range but follow urea (something outside of renal failure I have personally not paid much attention to). If the urea begins rising at a higher protein intake approaching 4 g/kg/d perhaps that is the bodies way of saying enough! Lastly this study also raises a question in my mind about the utility of milk analyzers. At least for protein content knowing precisely how much is in breastmilk may not be that important in the end. Then again that raises the whole question of the accuracy of such devices but I imagine that could be the source of a post for another day.
  2. It’s World Prematurity Day today and if you are a parent or are caring for a baby who has just entered this world before 37 weeks GA you are now part of a membership that counts 15 million new babies each year according to the WHO’s data. As I tell most new parents who have a baby admitted to our unit “It’s ok to take some time to adjust to this. You didn’t plan on being here”. That is true for most who go into spontaneous labour but of course those who are electively delivered due to maternal or fetal indications that have been followed closely often have time to prepare for the journey to the NICU. Many of these parents will have had the opportunity to visit the NICU or even connect with other parents before the anticipated birth of their child to at least get a glimpse into what life is like in the NICU. Much has been written about parental stress and methods to reduce it and I find that a piece that appeared in the Huffington Post offers some good pointers to helping parents manage the transition from pregnancy to NICU. The piece is entitled 5 Things Never To Say To Parents Of Preemies (And What To Say Instead). It is well worth a read but the one thing that stuck out in my mind is one very important thing to say. Congratulations on the birth of your baby There is no doubt that the family who gives birth to a preterm infant is experiencing stress. What may be lost in the first few days of surfactant, central lines and looking for sepsis among other things is that a new member of the 15 million strong has entered this world. They have a new child and just like anyone else should receive a congratulations. No one needs to tell them to be worried. They already are and likely view many of the possibilities more pessimistically than you do. Taking a moment to say congratulations though may go a long way to reminding them that amidst all this stress there is something to rejoice in and look to the future. If we aren’t supportive then I have no doubt the subconscious message is that they shouldn’t have hope either. I am not suggesting that we sugarcoat what is really going on but one can be honest about likely outcomes and still celebrate the arrival of a new baby. Much has also been written recently about a number of strategies to reduce stress in the NICU such as skin to skin care, integration of families more closely into the patient care team and forming parent support groups just to name a few. What else can be done to improve the quality of life for parents going through this journey? Enrol Your Baby In A Research Study I work in an academic centre and given the volume of research projects at any given time there is a need to approach families and sometimes quite soon after delivery. interestingly, I have heard from time to time that individuals have been hesitant to approach families due to a feeling that they are overwhelmed and won’t be receptive to being approached in this fragile state. I am guilty of the same thoughts from time to time but maybe it is time I reconsider. Nordheim T et al just published an interesting study on this topic entitled Quality of life in parents of preterm infants in a randomized nutritional intervention trial. This study was actually a study of parents within a study that called the PreNu trial that involved an intervention of a energy and protein supplemental strategy to enhance weight at discharge. The trial was an RCT and unfortunately although well intentioned was stopped when the intervention group was found to have an unexpected increase in sepsis rates. Although this study did not ultimately find a positive outcome there were additional analyses performed of quality of life and parental stress at two time points the first being during the hospital stay and the second at 3.5 years of age. The patients were all treated the same aside from the nutritional intake and in the end 30 intervention parents and 31 single parents not enrolled in a study (many in couples) participated in the study. In followup a little less than 70% completed the stress measures at 3.5 years. The results are found below. How Do We Interpret This The parents in this study who were part of the intervention group were about 3 years older so perhaps with more life experience may have developed some better coping strategies but during the hospital stay those who participated in research had better measures of quality of life and at three years better reports of sleep and energy levels. The study is quite small so we need to take all of this with a grain of salt with respect to the 3.5 year outcomes as there are so many variables that could happen along the way to explain this difference but I think it may be fair to acknowledge the quality of life measure during the stay. Why might parents report these findings? The finding of better quality of life is especially interesting given that more patients in this study had sepsis which one would think would make for a worse result. Here are a few thoughts. Involvement in research may have increased their knowledge base as they learned about nutrition and expected weight gain in the NICU. Frequent interaction with researchers may have given them more attention and with it more education. Some parents may have simply felt better about knowing they were helping others who would come after them. I have heard this comment myself many times and suspect that it would be attributable at least to a certain extent. A better understanding of the issues facing their infants through education may have reduced stress levels due to avoiding “fear of the unknown”. Regardless of the exact reason behind the findings what stands out in my mind is that participation in research likely provides comfort for parents who are in the midst of tremendous stress. Is it the altruistic desire to help others or being able to find something good in the face of a guarded outlook? I don’t know but I do believe that what this study tells us is that we shouldn’t be afraid to approach families. After first congratulating them give them a little time to absorb their new reality and then offer them the chance to improve the care for the next 15 million that will come this time next year for World Prematurity Day 2017.
  3. As with many things in Neonatology, changes in practice come and go. Such is the case with how best to manage an IV. During my career I have seen advocates for both continuous infusions and intermittent flushing. Sometimes with heparin and at other times none. The issue at hand is how best to preserve the precious IV. Based on opinion only I would have said that having a continuous flow through a plastic catheter should help avoid clot formation and prolong the life of an IV but what is the actual evidence to support one method or the other. Why might flushing be better? Clotting may not be the biggest issue to contend with. When I think about the IVs that are “lost” I am more commonly approached by nurses with concerns that the site is looking “red” and ultimately becomes indurated as the catheter extravasates. Far less common, is a concern that the catheter has simply obstructed or is reading high resistance these days. While we flush IVs with isotonic saline, infusions of dextrose are both hypotonic and acidic which may lead to endothelial damage. In theory then phlebitis should be lessened with intermittent flushes but could blockage due to clots still be an issue if there is no flow at the tip and lumen of the catheter? What does the evidence show? In 2012 Perez A et al looked at this in their paper Intermittent flushing improves cannula patency compared to continuous infusion for peripherally inserted venous catheters in newborns: results from a prospective observational study. As with the few recent papers out there on the subject, the study was small and performed over one year as an observational cohort. Out of 53 patients with 86 cannula insertions 25 had continuous dextrose infusions vs 28 who received at least one flush with NS per day. The findings in this study were that the mean cannula patency was 62.1 hr in the continuous group vs 92.8 hrs in the flushing group. Given the size of the study it might not be too surprising that practice did not change but that is where a more recent study may add some strength. A more recent paper by Stok and Wieringa adds to this discussion by looking exclusively at the use for durations of antibiotics (Continuous infusion versus intermittent flushing: maintaining peripheral intravenous access in newborn infants). As with the previous study this was an observational cohort in which a shift in practice occurred from use of continuous 5% dextrose infusions to flushing six times per day with NS through a 24 gauge IV. The primary outcome was duration of catheter patency but several other important outcomes were followed as well in particular the time required by nursing to deal with IV issues. A total of 115 newborns were recruited with 98 completing the analysis after excluding some patients. Of these newborns 71 fell into the continuous infusion vs 62 cannulas in the flushing cohort. Interestingly the main outcome was found to be no different between groups (55.42 hrs flushing vs 57.48 hrs continuous) regardless of placement site. Also interesting is that the median number of cannula placements were no different as well. With respect to complications the results indicate that this is more of an issue with continuous infusions and is shown in the table below. The differences in complication rates were significant between the two groups. Consistent with endothelial damage being more common from dextrose infusions, the incidence of phlebitis and infiltration were both higher in the continuous group. Arguably this was not a blinded study so the diagnosis of phlebitis could be subject to bias but infiltration should have been more objective. The amount of time nursing spent addressing IV related activities was significantly shorter with 8.8 minutes per shift vs 5.5 minutes in the continuous vs flushing groups respectively. Statistically significant but perhaps not that clinically relevant. Then again the extra three minutes of aggravation might be quite significant! Finally, it may be surprising that the length of IV patency was no different between the groups but the majority of the IVs were utilized for less than 48 hours so one can only speculate what would have happened if a different target population was looked at such as babies being treated with peripheral IVs for 7 days of antibiotics as an example. Given the differing rates of complications I would think that with longer use a difference in mean durations of patency would in fact present itself. What does the future hold? This is hard to say. Opinions run strong on this topic with most members of the medical team favouring continuous infusions as they “don’t want to lose the IV”. I suspect the way to truly look at this will not be through a randomized trial but rather a quality project in which a formal PDSA cycle is utilized to first collect our own numbers and then implement a formal change to using flushing only for those who only have an IV for antibiotics. Certainly something to discuss with our group and perhaps your own. If you have already done such a project and wish to share the results I would love to hear from you though!
  4. Choosing wisely is an initiative to “identify tests or procedures commonly used whose necessity should be questioned and discussed with patients. The goal of the campaign is to reduce waste in the health care system and avoid risks associated with unnecessary treatment.” The AAP Section on Perinatal Pediatrics puts the following forth as one of their recommendations. “Avoid routine use of anti-reflux medications for treatment of symptomatic gastroesophageal reflux disease (GERD) or for treatment of apnea and desaturation in preterm infants. Gastroesophageal reflux is normal in infants. There is minimal evidence that reflux causes apnea and desaturation. Similarly, there is little scientific support for the use of H2 antagonists, proton-pump inhibitors, and motility agents for the treatment of symptomatic reflux. Importantly, several studies show that their use may have adverse physiologic effects as well as an association with necrotizing enterocolitis, infection and, possibly, intraventricular hemorrhage and mortality.” How strong is the evidence? The evidence for risk with acid suppression is largely based on either retrospective or in the case of Terrin G et al a prospective observational cohort study Ranitidine is Associated With Infections, Necrotizing Enterocolitis, and Fatal Outcome in Newborns. In this study the authors compared a group of premature infants with birth weights between 401 – 1500g or 24 – 32 weeks gestation who received ranitidine for reflux symptoms to those who did not. All told 91 were exposed while 183 were not. The authors are to be commended for standardizing the feeding protocol in the study so that when comparing NEC between groups one could not blame differences in formula consumption or rate of feeding advancement. Additionally, bias was controlled by having those not involved in care collect outcome data without knowing the purpose of the study. Having said that, they may have been able to ascertain that ranitidine was used and have been influenced in their assessments. The patients in terms of risk factors for poor outcome including CRIB and apgar scores, PDA etc were no different to explain an increased risk for adverse outcome. From the above table, rates of infections were clearly higher in the ranitidine group but more concerning was the higher rate of mortality at 9.9% vs 1.6% P=0.003 and longer hospitalization median 52 vs 36 days P=0.001. Results of a Meta-Analysis Additional, evidence suggesting harm comes from a meta-analysis on the topic by More K, Association of Inhibitors of Gastric Acid Secretion and Higher Incidence of Necrotizing Enterocolitis in Preterm Very Low-Birth-Weight Infants. This analysis actually includes the study by Terrin and only one other retrospective database study of 11072 patients by Guillet et al. As the reviewers point out the study by Terrin while prospective did not employ the use of multiple regression to adjust for confounders while the larger study here did. In the end the risk of NEC with the use of acid suppression was 1.78 (1.4 – 2.27; p<0.00001). What do we do with such evidence? I can say this much. Although small in number, the studies that are available will make it very difficult to ever have a gold standard RCT done on this topic. This scant amount of evidence, backed by the biologic plausibility that raising the gastric pH will lead to bacterial overgrowth and potential aspiration of such contents provides the support for the Choosing Wisely position. Why do we continue to see use of such medications though? It is human nature I suspect that is the strongest motivator. We care for infants and want to do our best to help them through their journey in neonatal units. When we hear on rounds that the baby is “refluxing” which may be documented by gulping during a brady, visible spit ups during A&Bs or through auscultation hearing the contents in the pharynx we feel the need to do something. The question invariably will be asked whether at the bedside or by the parents “Isn’t there something we can do?”. My answer to this is yes. Wait for it to resolve on its own, especially when the premature infants are nowhere close to term. I am not sure that there is any strong evidence to suggest treatment of reflux episodes with gastric acid suppression helps any outcomes at all and as we see from the Terrin study length of stay may be prolonged. I am all in favour of positional changes to reduce such events but with respect to medications I would suggest we all sit on our hands and avoid writing the order for acid suppression. Failure to do so will likely result in our hands being very busy for some infants as we write orders to manage NEC, pneumonia and bouts of sepsis.
  5. It seems the expression "(insert a group) lives matter" is present everywhere these days so I thought I would join in after a moving experience I had today. For those of you who have been with the blog since the beginning you would have seen a number of posts that if you follow them in time, provide a glimpse into the transformation that Winnipeg has seen over the last year or so. Prior to that point, 24 weeks was a cutoff for resuscitation that had been in place for some time and after a great amount of deliberation and thought was changed to 23 weeks. This did not come without a great deal of angst and a tremendous amount of education and teamwork that our nurse educators and clinical leads were so instrumental in helping to role out. The experience was outlined in a couple of posts that you may find interesting if you didn't catch them the first time. The first was Winnipeg hospital now resuscitating all infants at 22 weeks! A media led case of broken telephone. and the second being Winnipeg Hospital About to Start Resuscitating Infants at 23 weeks! Since these two posts we have certainly had our fair share of experience as we have seen far more babies than anticipated but the region has met the challenge head on and although the numbers are small we appear to have not only more survivors than expected but all but one infant had gone home without O2 and all have been demand feeding at discharge. While we await the 18 month outcomes, the results thus far appear reassuring. A Special & Memorable Visit Then today, a visit occurred from the first of such infants who is now just over a year of age. He was bright eyed, smiling, interactive and by his parent's account, has normal tone and assessments thus far by physiotherapy. His presence in the NICU put smiles on faces and at least for myself made me think of the expression "Micropreemie Lives Matter". He was a baby that everyone predicted would not survive and then when he did, that he would be grossly developmentally impaired which he does not appear to be in the least. His presence in the unit no doubt gives everyone who doubted the merits of moving down this path reason to pause. Before you accuse me of wearing rose coloured glasses, make no mistake I know that he will not represent the outcome for everyone. In fact at one of our hospitals two of such infants have died while we await the 18 month outcomes for the other survivors. What his presence does though, is remind us or at least me that good outcomes are possible and in the case of our experience in Winnipeg may be more common that we thought they would be. Black Swans and Human Nature When I have spoken to audiences about the path forward when resuscitating such ELGANS I have often commented on the "Black Swan" effect. This was very nicely described by Nassim Taleb and described the human trait to react to unusual events with extreme reactions. An example is no one wanting to fly in the months after the world trade centre bombing when statistically this may have been the safest period in history to fly. Similarly, we as a team need to avoid the extreme reaction of saying that we should not be resuscitating such small infants when a bad outcome occurs. As I have told many people, we know these patients will not all survive, we know a significant number will have adverse development yet not all will and at least in our small sample thus far the babies would appear to be doing better overall than anticipated. If we know that bad outcomes will occur then why do we hear the questions come when they do such as "why are we doing this?", "maybe we should rethink our position on 23 week infants". It happens because we care and we hate seeing families and their babies go through such painful experiences. What we cannot do though for the sake of those such as our visitor today is react with a "Black Swan" reaction and steer the ship so to speak in the previous direction we were in. There are survivors and they may do well and that is why I say "Micropreemie Lives Matter". In the paper by Rysavy the overall finding at 23 weeks was that 1 out of 6 would survive without moderate or severe disability. What do we do as we increase our experience if the trend bears out that our outcomes are better? How will we counsel families? Will we continue to use the statistics from the paper or quote our own despite us being a medium sized centre? The Big Questions As our experience with such infants increases we will also no doubt see a change in our thoughts about infants at 24 weeks. I have seen this first hand already with a physician commenting today that 24 weeks is not such a big deal now! This brings me to the big question (which I will credit a nurse I work with for planting in my head in the last two weeks) which is for another time to answer as this post gets a little lengthy but is something to ponder. As our outcomes for 23 weeks improve and so do our results at 24 weeks (which is bound to happen with the more frequent team work in such situations) will our approach to infants at 24 weeks change. In our institution we generally follow the CPS guidelines for the management of infants at extremely low GA and offer the choice of resuscitation at 24 weeks. As outcomes improve at this GA will we continue to do so or will we reach a threshold where much like the case at 25 weeks we inform families that we will resuscitate their infant without providing the option of compassionate care? It is too early to answer these questions conclusively but they are very deserving of some thought. Lastly, I would like to thank the parent who came by today for inspiring me and to all those who will follow afterwards.
  6. It is hard to believe but All Things Neonatal is a year old. When I started this little concept I had no idea what was to come but am delighted with where it has gone. While the Blog site itself has about 200 followers, the Facebook page is home to nearly 4200 followers with twitter accounting for over 500 more. What began as a forum for me to get some thoughts off my chest about neonatal topics or articles of interest has morphed into a place to create change. As I look back over the last year I thought I would update the readers of this page and other social media platforms what the outcome has been for some of the ideas that I have brought forward. We have implemented some of these suggestions into our own unit practices, so without further ado here are the updates for some (but not all!) of the changes we have introduced. Expanding the Circle of Influence With Neonatal Telehealth March 4, 2015 Articles pertaining to use of Telehealth in all aspects of medicine are becoming commonplace. Locally we have seen expansion of rural sites that can connect with us and a strong desire by existing sites to connect via telehealth for a variety of reasons. While the thrust of the program was to deliver advice to rural practitioners and support our level I and II units we have found such support leading to possibilities we had not dreamed of. Initial discussions via telehealth and in person have occurred examining whether such treatments as CPAP stabilization and NG feedings could be done in these sites. Being able to provide such care will no doubt lead to more stable infants being transported to our site and moreover the possibility of moving the care for infants needing only gavage feeding back to their home communities. Who knows what the future will hold for us as we also look forward to the hiring of a telehealth coordinator for NICU! A Strategy to Minimize Blood Sampling in ventilated premature and term infants April 13, 2015 This has been one of my favourite topics to write about. The ability to sample CO2 from an area near the carina has been demonstrated to be accurate and to save pokes in the long run. Since writing this piece we have tried it on several babies by using a double lumen tube and found the results to be as accurate as described in the Israeli papers. In practice though, secretions have proved difficult to handle for longer periods of use as they can travel up the sampling lines and damage the filters in the analyzers. A costly issue to deal with that we are currently trying to solve. Being able to continuously sample CO2 and adjust ventilation without drawing frequent blood gases is somewhat of a dream for me and we will continue to see how we can go about making this an established practice but there is work to be done! Is it time to ban Cow's Milk Protein from the diet of our high risk NICU population? June 12, 2015 I think most people in Winnipeg would say the answer is yes. On this front two major positive changes have occurred in the last year in this regard. The first is that through a generous donation and the blessing of our health region we have been able to expand the use of donor breast milk from < 1250g for a two week period to < 1500g for a one month period. This wonderful change came about after much effort and was celebrated in December as we not only expanded the eligibility criteria but partnered with the NorthernStar Mother's Milk Bank to provide donor milk to Manitobans (Manitobans Now Able To Support Premature Infants Through Donor Milk Program!). The other change which the above post also spoke of was the potential to eliminate bovine milk altogether with the use of Prolacta (Human based human milk fortifier). While we don't have the approval to use the product as traditionally indicated, we have used it as a "rescue" for those patients who demonstrate a clear intolerance of bovine fortifier. Such patients would traditionally receive inadequate nutrition with no other option available but now several have received such rescue and we look forward to analyzing the results of such a strategy shortly! Winnipeg Hospital About to Start Resuscitating Infants at 23 weeks! September 25, 2015 Without question the most talked about change was the change in threshold for recommending resuscitation from 24 to 23 weeks. The change took almost a year to roll out and could not have been done without a massive educational rollout that so many people (a special thank you to our nurse educators!) took part in. Looking back on the year we have now seen several infants at 23 weeks who survived with a small minority dying in the newborn period. It is too early to look at long term outcomes but I think many of us have been surprised with just how well many of these children have done. Moreover I believe we may be seeing a "creep effect" at work as the outcomes of infants under 29 weeks have also improved as we developed new guidelines to provide the best care possible to these vulnerable infants. Antenatal steroid use is up, IVH down and at least from January to September of last year no infants died at HSC under 29 weeks! I look forward to seeing our results in the future and cannot tell you how impressed I am with how our entire team came together to make this all happen! What's Next? I wanted to share some of the initiatives that came forward or were chronicled on these pages over the last year to show you that this forum is not just a place for my mind to aimlessly wander. It is a place that can create change; some good, some great and no doubt some that won't take. It has also been a place where ideas are laid out that have come from afar. From readers anywhere in the world who ask a question on one of the social media sites that get me thinking! I have enjoyed the past year and expect I will continue to enjoy what may spring forth from these pages for some time to come. Thank you for your contributions and I hope you get a little something out of this as well!
  7. One of my very early posts on this blog pertained to my fascination with an Israeli strategy of monitoring end tidal CO2 in place of drawing blood gases. Please see A Strategy to Minimize Blood Sampling in ventilated premature and term infants. The gist of this strategy is that by sampling distal CO2 measurements near the carina you obtain a non diluted sample of CO2 as compared to the traditional proximal end tidal measurement. The authors have shown this to be highly accurate compared to comparable arterial samples during both conventional and high frequency oscilatory ventilation. This month the same group published a follow-up study that has me excited again about this technological approach. The paper is entitled Impact of Continuous Capnography in Ventilated Neonates: A Randomized, Multicenter Study. In this multicentre study 55 infants were ventilated through double lumen endotracheal tubes. The first group of 25 were randomized to an open group in which the continuous CO2 measurement was available to clinicians to base ventilator management on. The second group had these values recorded but the treating physicians were blind and based ventilatory changes on arterial blood gas sampling. The primary outcome was based on the percentage of time pCO2 was kept between 30 - 60 with the goal range for permissive hypercapnea being 45 - 55. The Results "Compared with infants in the masked group, those in the monitored group had significantly (P = .03) less time with an unsafe dETCO2 level (high: 3.8% vs 8.8% or low: 3.8% vs 8.9%). The prevalence of intraventricular hemorrhage or periventricular leukomalacia rate was lower in the monitored group (P = .02) and was significantly (P < .05) associated with the independent factors dETCO2 monitoring and gestational age." The same held true for the blood gas values with statistically significant benefits in terms of keeping CO2 within the predefined safe range. My Interpretation The findings make a great deal of sense. Sampling continuously and adjusting ventilation in real time (assuming a strong correlation between EtCO2 and blood gases) makes sense. Blood gases done even every four hours can not compare to having results available continuously. As such I tend to believe the findings of better accuracy. Although the incidence of IVH and PVL are part of the secondary outcomes there is significant biologic plausability to these findings. We know that cerebral blood flow is very sensitive to PCO2 with low values causing cerebral vasoconstriction and high values dilation of these same vessels. Furthermore having wide swings in CO2 could lead to periods of ischemia and then significant reperfusion with resultant injury. Finding that these two outcomes are increased with intermittent sampling therefore is plausible and deserving of further study. Challenges That Need to Be Addressed Since the publications by the same group showing the accuracy of this method of sampling CO2 we have tried this strategy for several infants. In short, it works and is very accurate. We have been able to avoid many blood gases along the way but there remains a significant challenge with avoiding blockage of the second port for sampling. Furthermore, secretions if getting past the end of the port and into the microstream sampling device can damage the analyzer such that we have only one left functioning in our units. As eager as I am to roll this out as a change in practice we need to address these technical issues but once accomplished this may truly have an impact as a cerebral protective strategy for the preterm infant and with time and further long term outcomes available offer a meaningful way of reducing disability in this population.
  8. Originally posted at: https://winnipegneonatal.wordpress.com/ Facebook Page: https://www.facebook.com/allthingsneonatal/ The journey from conception to the labour floor and then for some to the NICU is not a straight one. There are times of joy, interspersed with sadness, denial, anger and eventually acceptance, as initial news of being pregnant leads to complications in pregnancy and then eventual admission of an infant to the NICU. Much has been said in recent years about the building of partnerships with parents and in fact there is a new catchphrase attached to the concept "shared decision making" (SDM). There is no question that in the perfect world this is exactly the relationship that we should be striving for with all of our patients. The world however is not perfect and although this may not be the most popular opinion I have given, I question how applicable this really is in many situations. A Reality Check Take for instance the parents who present to the labour floor of their local hospital in advanced labour at 24 weeks. Proponents of this SDM model would suggest that a meeting take place and pertinent information be given to a family and together with the assistance of literature applicable to their situation (possibly a pamphlet) the health care providers and families come to a mutually agreeable decision as to what the best course of action is for them and their unborn infant. This all sounds wonderful but examining the real life situation a little more closely is it actually reasonable to assume we can obtain this? I have not been, nor will I ever be pregnant and certainly have never experienced contractions and felt the veil clouding my vision as the first dose of analgesia enters my veins to deal with the discomfort a woman experiences during labour. Not to mention there are people admitting this couple, taking histories, establishing IV access, scanning bellies and a whole host of other pokes and prods along the way. My Role Better Defined Then I come in. Among all this chaos I deliver the information, pass along a pamphlet and do the best job I can to inform said couple of the upcoming decision. The trouble of course is how do we come to this mutual decision in the 15 - 30 minutes I spend with them during this crisis? The answer sadly is we do our best but don't for a minute think that SDM has occurred. I don't believe this is possible unless the family has prior experience with a preterm birth or perhaps is a HCP working with newborns or children with disabilities themselves. In fact Boss RD et al in their own research on the subject identified that in hindsight religion, spirituality and hope are what motivated parents rather than what was said at the time. In essence their minds are already made up. It doesn't mean we shouldn't strive for the SDM but at least in my opinion, unless their contractions settle, a calmness ensues, they have time to digest the information being given and then meet again under less stressful circumstances, the SDM is a nice idea but for many not a reality. Shifting To The NICU I recall a significant moment in my training when I saw how the SDM model can actually cause more grief than help. Dr. Keith Barrington a fellow blogger (if you haven't discovered him, his work is fascinating over at Neonatal Research) published one of the most impactful pieces of research of the decade during my fellowship. The adverse neuro-developmental effects of postnatal steroids in the preterm infant: a systematic review of RCTs. Following this analysis there was a near moratorium on the use of post natal steroids. The issue this created was that to now receive them you had to be close to the end of the limits of care. At this point you either died (thereby concluding they are of no help) or you survived with disability that was due in part no doubt to how sick you had become (thereby concluding they are dangerous). The moment I am referring to was a conversation with a family in which the attending managing the unit presented the risks and benefits of postnatal steroids to the family when the FiO2 was at 40% one day. The language used was non directive and the parents asked for another day to decide. The next day and each of the following two days they were unable to choose between giving the steroids and the perceived risk of brain damage versus not and watching the FiO2 climb by about 10% per day. By the time the FiO2 several days later was at 80-90% they were distraught, teary and feeling helpless. What they needed was direction; someone to give them some advice or more simply an educated opinion. We can strive to share in the decision making but I continue to believe there is a time and place to help our families by taking a stance or side. We can equip them with as much information as we want but is there really any replacement for actually taking care of these infants, experiencing the ups and downs and hearing how they have done in follow-up? We simply can't expect the average parent to understand the true long term consequences of their decisions. I am not saying we go back to a paternalistic time in medicine but I am saying that one size does not fit all. We owe it to our families to pursue SDM when we can but we have an equal obligation to recognize when this ideal state is simply not possible. At this point we have to use the experiences and knowledge we have to provide them with the best advice we can. We have gone through medical training, and gone down these paths so many times. We can avoid biased opinion and rely on the facts as they are in our institutions but to not take a stand when it is needed at least for me is doing a disservice to those we are so eager to help.
  9. Originally posted at: https://winnipegneonatal.wordpress.com/ Facebook Page: https://www.facebook.com/allthingsneonatal/ As I read through the new NRP recommendations and began posting interesting points on my Facebook Page I came across a section which has left me a little uneasy. With respect to a newborn 36 weeks and above who is born asystolic and by ten minutes of age continues to remain so and has an apgar score of zero the recommendation that has been put forward is this: An Apgar score of 0 at 10 minutes is a strong predictor of mortality and morbidity in late-preterm and term infants. We suggest that, in babies with an Apgar score of 0 after 10 minutes of resuscitation, if the heart rate remains undetectable, it may be reasonable to stop resuscitation; however, the decision to continue or discontinue resuscitative efforts should be individualized. Variables to be considered may include whether the resuscitation was considered to be optimal, availability of advanced neonatal care, such as therapeutic hypothermia, specific circumstances before delivery (eg, known timing of the insult), and wishes expressed by the family (weak recommendation, very-low-quality evidence). There are some significant problems with this part of the statement. They claim that the apgar score at ten minutes is a strong predictor but when you look at the analysis of the evidence presented in the body of the paper it is weak at best. I am not clear how one declares the prediction is strong in the face of poor evidence but I will acknowledge intuitively that this makes some sense but do challenge them on the use of the word "strong". 2. They are correct in acknowledging that the introduction of hypothermia in such settings has changed the landscape in as much as I find it quite difficult to prognosticate unless a child is truly moribund after resuscitation. Given such uncertainty it is concerning to me that this recommendation may be committed to memory incorrectly in some places that do have access to cooling and may be used more rigidly as though shalt stop at 10 minutes. 3. In the middle of a resuscitation it is quite difficult to process all of the facts pertaining to a particular newborn while orders for chest compressions, emergency UVCs and epinephrine are being given. Can we really individualize within ten minutes accurately and take the families wishes truly into account? This just does not seem practical. 4. The families wishes are taken into account but inserted as a "weak recommendation". How can the wishes of the family in any family centred model of care be minimized in such a way even if we believe the situation to be dire? 5. Since the introduction of hypothermia there appears to be a near 50% survival rate in such newborns and as the authors state 27% of survivors who received cooling had no moderate or severe disability. Here in lies my greatest issue with this guideline and that is the hypocrisy this position takes when you compare populations at 23 and 24 weeks gestational age. Survival at these GA in the recent NEJM study of almost 5000 preterm infants under 27 weeks were 33 and 57 % respectively at 23 & 24 weeks with rates of survival without moderate or severe disability being 16 and 31% in the two groups. The fallout from this and other studies at the extremes of gestational age have been that we should be more aggressive as the outcomes are not as bad as one would predict. How can we argue this for the 23-24 week infants and for term infant with the same likelihood of outcomes we would unilaterally stop in many centres?! So Now What Do We Do? We are supposed to be practising family centred care and much like the argument at the edge of viability the same should apply here. The wishes of the family should never be minimized. Arguably it may be very difficult in such an unexpected scenario to appraise a family of the situation and have clarity around the issue but if a heart rate can be restored after a few more minutes do we not owe it to the family and the child to bring the infant back to the NICU and see what transpires especially if cooling is available? The million dollar question of course is where do we draw the line? No heart rate at 15, 20 minutes? Based on the evidence thus far it seems to me that a little longer than 10 minutes is reasonable especially in well equipped centres with access to cooling and modern ventilation and treatments for pulmonary hypertension. How long though must be individualized and should be determined in partnership with the team caring for the patient which must include the family.
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