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  1. Let me start off by giving thanks to John Minski for this article and in fact for many others that have been reviewed on this blog. John is a registered respiratory therapist in Winnipeg with a passion for respiratory care like no other. John frequently sends articles my way to think about for our unit and this one was quite sensational to me. As readers of this blog I thought you might find it pretty interesting as well. Why Would A Mask Cause Apnea To begin with this seems counterintuitive as don’t we use masks when babies are apneic to help them breathe? While this is true an
  2. It’s Father’s Day so why not put out a post about a role for father’s in resuscitation. Given that we are talking about a parent being present for resuscitation after delivery and the mother will have just delivered, what follows is a discussion about having the other parent present at the ensuing resuscitation if needed. This will of course not always be a father as in female same sex parenting so what follows could apply to any situation in which there are two parents present and one has just delivered. Since I was a resident this question has been batted around. During a resuscitati
  3. How you people r keeping sterilised/disinfected ambu bag in ward /near patient? Hanging bags? Bin? Kept in a corner?each in warmer? What options are available if plastic bags are banned in your state?
  4. European Neonatal Ethics Conference 1st and 2nd May 2014 Venue: Chilworth Manor Hotel Southampton United Kingdom Simulation Neonatal Ethics & Difficult Situations Workshops 1st May 2014 The first day challenges participants to address challenging issues, ethical dilemmas, and difficult clinical circumstances in a safe simulated environment. Simulations cover decision making regarding difficult ethical scenarios, limits of viability, neonatal death, and serious medical errors. Workshop 1 Neonatal Ethics 15 places Workshop 2 Difficult Situations 15 places Conference 2nd M
  5. Just about all of our preterm infants born at <29 weeks start life out the same in terms of neurological injury. There are of course some infants who may have suffered ischemic injury in utero or an IVH but most are born with their story yet to be told. I think intuitively we have known for some time that the way we resuscitate matters. Establishing an FRC by inflating the lungs of these infants after delivery is a must but as the saying goes the devil is in the details. The Edmonton group led by Dr. Schmolzer has had several papers examined in these blogs and on this occasion I am
  6. We have all been there. After an uneventful pregnancy a mother presents to the labour floor in active labour. The families world is turned upside down and she goes on to deliver an infant at 27 weeks. If the infant is well and receives minimal resuscitation and is on CPAP we provide reassurance and have an optimistic tone. If however their infant is born apneic and bradycardic and goes on to receive chest compressions +/- epinephrine what do we tell them? This infant obviously is much sicker after delivery and when the family asks you “will my baby be ok?” what do you tell them? It is a
  7. Recent statements by the American Academy of Pediatric’s, NICHD, the American College of Obstetricians and Gynecologists (ACOG), the Society for Maternal-Fetal Medicine (SMFM), and recommend selective approaches to mothers presenting between 22 0/7 to 22 6/7 weeks. The decision to provide antenatal steroids is only recommended if delivery is expected after 23 weeks. Furthermore the decision to resuscitate is based on an examination of a number of factors including a shared decision with the family. In practice this leads to those centres believing this is mostly futile generally not resuscitat
  8. Much has been written on the topic of cord clamping. There is delayed cord clamping of course but institutions differ on the recommended duration. Thirty seconds, one minute or two or even sometimes three have been advocated for but in the end do we really know what is right? Then there is also the possibility of cord milking which has gained variable traction over the years. A recent review was published here. Take the Guessing Out of the Picture? Up until the time of birth there is very little pulmonary blood flow. Typically
  9. It has to be one of the most common questions you will hear uttered in the NICU. What were the cord gases? You have a sick infant in front of you and because we are human and like everything to fit into a nicely packaged box we feel a sense of relief when we are told the cord gases are indeed poor. The congruence fits with our expectation and that makes us feel as if we understand how this baby in front of us looks the way they do. Take the following case though and think about how you feel after reading it. A term infant is born after fetal distress (late deceleration to as low as
  10. One of the first things a student of any discipline caring for newborns is how to calculate the apgar score at birth. Over 60 years ago Virginia Apgar created this score as a means of giving care providers a consistent snapshot of what an infant was like in the first minute then fifth and if needed 10, 15 and so on if resuscitation was ongoing. For sure it has served a useful purpose as an apgar score of 0 and 0 gives one cause for real worry. What about a baby with an apgar of 3 and 7 or 4 and 8? There are certainly infants who have done very well who initially had low apgar scores and co
  11. It is hard to believe but it has been almost 3 years since I wrote a piece entitled A 200 year old invention that remains king of all tech in newborn resuscitation. In the post I shared a recent story of a situation in which the EKG leads told a different story that what our ears and fingers would want us to believe. The concept of the piece was that in the setting of pulseless electrical activity (where there is electrical conductance in the myocardium but lack of contraction leaves no blood flow to the body) one could pick up a signal from the EKG leads when there is in fact no pulse or perf
  12. For almost a decade now confirmation of intubation is to be done using detection of exhaled CO2. The 7th Edition of NRP has the following to say about confirmation of ETT placement “The primary methods of confirming endotracheal tube placement within the trachea are detecting exhaled CO2 and a rapidly rising heart rate.” They further acknowledge that there are two options for determining the presence of CO2 “There are 2 types of CO2 detectors available. Colorimetric devices change color in the presence of CO2. These are the most commonly used devices in the delivery room. Capnographs are elect
  13. until
    https://www.mcascientificevents.eu/intensive-care-newborn2018/ MAIN TOPICS Resuscitation Oxygen And Ventilation Infections High-Tech Monitoring Nursing Ventilation
  14. until
    If you are coming to Hot Topics 2017, dont forget to take part in this Satellite Symposium! Topics include: Intubation and Tracheal Suction for Meconium Stained Video Recording Neonatal Resuscitation Pros and Cons of EKG in the Delivery Room Upcoming/Ongoing Trials in Delivery Room Resuscitation, Wrap up
  15. Given that today is world prematurity day it seems fitting to talk about prematurity at the absolute extreme of it. It has been some time since as a regional program we came to accept that we would offer resuscitation to preterm infants born as early as 23 weeks gestational age. This is perhaps a little later in the game that other centers but it took time to digest the idea that the rate of intact survival was high enough to warrant a trial of resuscitation. This of course is not a unilateral decision but rather a decision arrived at after consultation with the family and interprof
  16. We can always learn and we can always do better. At least that is something that I believe in. In our approach to resuscitating newborns one simple rule is clear. Fluid must be replaced by air after birth and the way to oxygenate and remove CO2 is to establish a functional residual capacity. The functional residual capacity is the volume of air left in the lung after a tidal volume of air is expelled in a spontaneously breathing infant and is shown in the figure. Traditionally, to establish this volume in a newborn who is apneic, you begin PPV or in the spontaneously breathing baby with re
  17. I know how to bag a baby. At least I think I do. Providing PPV with a bag-valve mask is something that you are taught in NRP and is likely one of the first skills you learned in the NICU. We are told to squeeze the bag at a rate of 40-60 breaths a minute. According to the Laerdal website, the volume of the preterm silicone bag that we typically use is 240 mL. Imagine then that you are wanting to ventilate a baby who is 1 kg. How much should you compress the bag if you wish to delivery 5 mL/kg. Five ml out of a 240 mL bag is not a lot of squeeze is it? Think about that the next time you
  18. Look around you. Technology is increasingly becoming pervasive in our everyday lives both at home and at work. The promise of technology in the home is to make our lives easier. Automating tasks such as when the lights turn on or what music plays while you eat dinner (all scripted) are offered by several competitors. In the workplace, technology offers hopes of reducing medical error and thereby enhancing safety and accuracy of patient care. The electronic health record while being a nuisance to some does offer protection against incorrect order writing since the algorithms embedded in th
  19. I think my first training in resuscitation began with the principles outlined in the NRP 3rd edition program. As we have moved through subsequent editions with the current edition being number 7, I can’t help but think about how many changes have occurred over that time. One such change has been the approach to using medications as part of a resuscitation. Gone are such things as calcium gluconate, naloxone and sodium bicarbonate but something that has stood the test of time is epinephrine. The dosing and recommendations for administering epinephrine have changed over time as well with the
  20. I have written about respectful communication before in Kill them with kindness. The importance of collaborating in a respectful manner cannot be overemphasized, as a calm and well prepared team can handle just about anything thrown their way. This past week I finally had the opportunity to take the 7th ed NRP instructor course. What struck me most about the new version of the course was not the approach to the actual resuscitation but the preparation that was emphasized before you even start! It only takes 30 seconds to establish who is doing what in a resuscitation and while it w
  21. The other day I met with some colleagues from Obstetrics and other members from Neonatology to look at a new way of configuring our delivery suites. The question on the table was which deliveries which were always the domain of the high risk labour floor could be safely done in a lower acuity area. From a delivery standpoint they would have all the tools they need but issues might arise from a resuscitation point of view if more advanced resuscitation was needed. Would you have enough space for a full team, would all the equipment you need be available and overall what is in the best intere
  22. Ask almost anyone who has worked in the field of Neonatology for some time and they will tell you that babies are not as sick as they once were. We can give a lot of credit to better antenatal steroid use, maternal nutrition and general management during pregnancy. Additionally, after birth we now rush to place infants on CPAP and achieve adequate expansion of the lungs which in many cases staves off intubation. The downside to our success though is that the opportunities to provide positive pressure ventilation (PPV) and moreover intubation are becoming less and less. How then do we pe
  23. Every now and then I come across an instance when I discover that something that I have known for some time truly is not as well appreciated as I might think. Twice in my career I have come across the following situation which has been generalized to eliminate any specific details about a patient. In essence this is a fictional story but the conclusions are quite real. Case of the Flat Baby A mother arrives at the hospital with severe abdominal pain and in short order is diagnosed with a likely abruption at 26 weeks gestational age. Fetal monitors are attached and reveal a signi
  24. I switched hospital ~2 years ago and even if our resuscitation tables are equipped exactly the same as in the previous hospital, I have noticed that fellows here use laryngeal masks more often during resuscitation, instead of going directly from mask (+NeoPuff ventilation) to intubation. I must say that my experience has grown very positive, laryngeal masks can be applied with little training and gives good airway support. EBNEO has published a review here : https://ebneo.org/2015/09/airway-support-during-neonatal-resuscitation-how-effective-is-a-laryngeal-mask/ on a RCT on this specific quest
  25. We are back with the 99nicu Polls! Inspired by the EBNEO review on ventilation through a laryngeal masks during resuscitation, we started a poll here! Find the interesting review on the EBNEO website: https://ebneo.org/2015/09/airway-support-during-neonatal-resuscitation-how-effective-is-a-laryngeal-mask/ So now... visit go to our poll on http://99nicu.org/forums/topic/1878-laryngeal-masks-should-be-available-for-neonatal-resuscitation/ and share your comments on laryngeal mask ventilation!
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