Can video laryngoscopes reduce risk of harm from intubation?

Can video laryngoscopes reduce risk of harm from intubation?









What does it mean?













Integrated Evaluation of Hemodynamics

Integrated Evaluation of Hemodynamics

Welcome to the home page for our Integrated Evaluation of Hemodynamics program at the University of Manitoba. This program began in Winnipeg, Manitoba, Canada in 2014 and has been growing ever since.

What is considered normal hemodynamics?

1. Intact or normal hemodynamics implies blood flow that provides adequate oxygen and nutrient delivery to the tissues.

2. Blood flow varies with vascular resistance and cardiac function; both may be reflected in blood pressure(2). Normal cardiovascular dynamics should be considered within the context of global hemodynamic function, with the aim of achieving normal oxygen delivery and end organ performance

3. The current routine assessment of hemodynamics in sick preterm and term infants is based on incomplete information. We have addressed this by adopting an approach utilizing objective techniques, namely integrating targeted neonatal echocardiography (TNE) with near-infrared spectroscopy (NIRS). Implementation of these techniques requires an individual with the requisite TNE training, preferably in an accredited program, who also has a good understanding of perinatal and neonatal cardiovascular, respiratory, and other specific end organ physiology.

Why are premature infants more susceptible to cardiovascular compromise?

Hemodynamic compromise in the early neonatal period is common and may lead to unfavorable neurodevelopmental outcome4. A thorough understanding of the physiology of the cardiovascular system in the preterm infants, influence of antenatal factors, and postnatal adaptation is essential for the management of these infants during the early critical phase5. The impact of the various ventilator modes, the presence of a patent ductus arteriosus (PDA), and systemic inflammation all may affect the hemodynamics6. The poor clinical indicators of systemic perfusion and the relative insensitivity of conventional echocardiographic techniques in assessing myocardial contractility mean that monitoring of the hemodynamics of the preterm infant remains a challenge7.
What is integrated hemodynamics in neonatal care?

Integrated hemodynamics focuses on how to interpret multiple tools of hemodynamics evaluation in sick infants (TNE, clinical details, NIRS, organ specific ultrasound) and the art of formulating a pathophysiologic relevant medical recommendation.
Main objectives of applying Targeted Neonatal Echocardiography and Evaluation of Neonatal hemodynamics

Optimise care of infants with hemodynamic compromise to prevent progression into late irreversible stages of shock (Hypoxia)
Decrease overall PDA related complications (Hypoxemia and hypoxia)
Optimize care of infants with hypoxemic respiratory failure (HRF)
Decrease the incidence of progression of infants with hypoxemic respiratory failure and shock to end organ dysfunction

Objective of the program

Orientation to the hemodynamics concepts and basics

Orientation to the 3 level of the pathophysiologic approach to hemodynamics:

Level one: Relying on blood pressure trends (systole, diastole, and pulse pressure) and waveforms with other clinical parameters (all NICU practitioners)

Level one plus (advanced monitoring): Relying on blood pressure trend and near infrared spectroscopy (NIRS) for assessment of hemodynamics and oxygen extraction (optional to NICU practitioners)

Level two (TNE approach): Relying on both clinical parameters and TNE for objective assessment of cardiac output, extra and intra cardiac shunts, systemic and pulmonary vascular resistance. (Neonatologist trained on TNE)

Level three (integrated evaluation of hemodynamics): integrating blood pressure trends, TNE and NIRS for assessment of oxygen delivery, specific end organ oxygen consumption and the degree of compensation (comprehensive hemodynamic approach)

Understanding the rationale for the measurements and the specific values for each disease, and recognize limitations of the 3 models

To see research that we have done in the area of Integrated Hemodynamics please see our publication list that can be found here.

To access our video series providing examples of TNE and presentations on the use of hemodynamics in clinical application please see our Youtube channel playlist “Integrated Neonatal Hemodynamics”


Wolff CB. Normal cardiac output, oxygen delivery and oxygen extraction. Adv Exp Med Biol. 2008;599:169-182. doi:10.1007/978-0-387-71764-7-23.
Azhan A, Wong FY. Challenges in understanding the impact of blood pressure management on cerebral oxygenation in the preterm brain. Front Physiol. 2012;3 DEC(December):1-8. doi:10.3389/fphys.2012.00471.
de Boode WP. Clinical monitoring of systemic hemodynamics in critically ill newborns. Early Hum Dev. 2010;86(3):137-141. doi:10.1016/j.earlhumdev.2010.01.031.
Sehgal A. Haemodynamically unstable preterm infant: an unresolved management conundrum. Eur J Pediatr. 2011;170(10):1237-1245. doi:10.1007/s00431-011-1435-4.
Vutskits L. Cerebral blood flow in the neonate. Paediatr Anaesth. 2014;24(2):22-29. doi:10.1111/pan.12307.
Noori S, Stavroudis T a, Seri I. Systemic and cerebral hemodynamics during the transitional period after premature birth. Clin Perinatol. 2009;36(4):723-36, v. doi:10.1016/j.clp.2009.07.015.
Elsayed YN, Amer R, Seshia MM. The impact of integrated evaluation of hemodynamics using targeted neonatal echocardiography with indices of tissue oxygenation: a new approach. J Perinatol. 2017. doi:10.1038/jp.2016.257.

Is paralysis for intubation really needed?

Is paralysis for intubation really needed?


Neonatal Intubation Registry




How did the groups compare?


How do we interpret the results?



Hospital or Home Based Therapy For Neonatal Abstinence?

Hospital or Home Based Therapy For Neonatal Abstinence?

This post is very timely as the CPS Fetus and Newborn committee has just released a new practice point:

Managing infants born to mothers who have used opioids during pregnancy

Have a look at discharge considerations as that section in the statement speaks to this topic as well!

As bed pressures mount seemingly everywhere and “patient flow” becomes the catch-word of the day, wouldn’t it be nice to manage NAS patients in their homes?  In many centres, such patients if hospitalized can take up to 3 weeks on average to discharge home off medications.  Although done sporadically in our own centre, the question remains is one approach better than the another?  Nothing is ever simple though and no doubt there are many factors to consider depending on where you live and what resources are available to you.  Do you have outpatient follow-up at your disposal with practitioners well versed in the symptoms of NAS and moreover know what to do about them?  Is there comfort in the first place with sending babies home on an opioid or phenobarbital with potential side effects of sedation and poor feeding?  Nonetheless, the temptation to shift therapy from an inpatient to outpatient approach is very tempting.

The Tennessee Experience

Maalouf Fl et al have published an interesting account of the experience with outpatient therapy in their paper Outpatient Pharmacotherapy for Neonatal Abstinence Syndrome.  The authors were able to take advantage of the Tennessee Medicaid program using administrative
and vital records data from 2009 to 2011 to capture a cohort of 736 patients who were treated for NAS.  Forty five percent or 242 patients were treated as outpatients vs 290 cared for in hospital for the duration of treatment.  It is worth mentioning at this point that when the authors say they were cared for as outpatients it really is a hybrid model as the duration of hospitalization for the inpatients was a median of 23 days (IQR 14-35) versus 11 days (IQR 7-18) for inpatients (P < .001).  This practice isn’t much different than my own in which I start therapy in hospital and then discharge home with a period of home therapy.

The strength of the study is the volume of patients and the ability to follow-up with these babies for the first 6 months of life to determine what happened to them after discharge.  In terms of duration of treatment, the differences are significant but perhaps not surprising. The median length of treatment for outpatients was 60 days (IQR 38-92) compared with 19 days (IQR 10-31) for inpatients (P < .001).  What was interesting as well is that 82% of babies were discharged home on phenobarbital and 9.1% on methadone and 7.4% with both.  A very small minority was discharged home on something else such as morphine or clonidine.  That there was a tripling of medication wean is not surprising as once the patients are out of the watchful eye of the medical team in hospital it is likely that practitioners would use a very slow wean out of hospital to minimize the risk of withdrawal.

An Unintended Consequence

This study found a statistically significant increase in risk for presenting to the emergency department for those patients treated as outpatients.

What this graph demonstrates is that there was no increase risk in the first month but there was for the first 6 months.  Despite the increased risk of presentation to the ED the rate of hospitalization was not different.  Drilling down the data further, the reason for coming to the ED was not for withdrawal which was 10% in the outpatient and 11% in the inpatient group.  The other major reason was The most common diagnoses were upper respiratory infections; 80% outpatient vs 71% inpatient.  So while there was a significant difference (which was not by much) my take on it is that it was most likely by chance as I can’t think of how infections in the first 6 months could be linked to choice of medication wean.

What about phenobarbital?

Phenobarbital has been used for many years in Neonatology for control of seizures, sedation (taking advantage of a side effect) and management of NAS.  The problem with a median use of phenobarbital for 2 months is its potential to affect development.

An animal study by Diaz in 1999 in which rat pups were given two weeks of phenobarbital starting on day 5 of life and then euthanized demonstrated the following weight reductions when high dose phenobarbital was utilized.  In human data, children with febrile seizures treated with phenobarbital in the paper Late cognitive effects of early treatment with phenobarbital. had decreased intelligence than those not exposed to phenobarbital.

The issue here for me is not necessarily whether babies can be treated successfully as outpatients for NAS.  The concern is at what cost if the choice of drug is phenobarbital.  The reason phenobarbital was chosen is likely due to compliance.  We know that the more frequently a drug is dose the less likely compliance will be achieved.  Phenobarbital being dosed either q12h or q24h is an ideal drug from a compliance point of view but the ramifications of this treatment deserve reconsideration.

I look forward to seeing further studies on this topic and hope that we see the results of an opioid outpatient treatment program.  I know these exist and would welcome any information you as the readers of this blog can offer.  Treating patients in the home makes great sense to me but we need to do it with the right drugs!