The all children's philosophy is that if you start your NG feeds in babies prior to their ability to take oral feeds because of respiratory trouble, that they will lose the. Developmental connection of oral feeding leads to a full belly, and so they don't feed them until they can feed by mouth.
The new protocol is we try to repair all ECMO kids within the 1st 12 to 24 hours of going on ECMO. And all the non-ECMO kids we repair somewhere between day 4 and 8, provided they are stable, which is the vast majority of the kids.
If they were off ECMO, we would do the surgical repair when their echo demonstrated that their pulmonary hypertension was improved. And this could be anywhere from a few days to the most delayed repair I've ever had was 56 days.
In addition to the drop in sedation. Is a drop on time on mechanical ventilation from a median of 19 days to a median of 9 days, so almost a 50% decline in the time on ventilation.
If parents want aggressive care, full respiratory support should be provided for at least the first 3 to 4 days, as many infants requiring high levels of support (including oscillator or pulmonary vasodilators) will begin to improve after this period.
Many infants who are pulmonary survivors have reduced reserve lung function, similar to reduced reserve renal function, and can rapidly transition from pulmonary survivor to non-survivor if injured.
Managing Advanced Chronic Kidney Disease: Cincinnati Fetal Center
▶Ep 1 · 1:33
quoteyeah, but all that's important, but it doesn't matter if the patient is not a pulmonary survivor.↗
▶Ep 1 · 2:42
clinicalIf amniotic fluid levels are restored to normal through shunting or amnioinfusion, the likelihood of pulmonary survival increases to approximately 80%.↗
▶Ep 1 · 3:08
clinicalIf amniotic fluid levels are not returned to normal, the pulmonary outcome is poor.↗
▶Ep 1 · 5:28
quotejust because you are a pulmonary survivor. That does not mean that you're normal from a respiratory standpoint.↗
▶Ep 1 · 5:33
clinicalMany infants who are pulmonary survivors have reduced reserve lung function, similar to reduced reserve renal function, and can rapidly transition from pulmonary survivor to non-survivor if injured.↗
▶Ep 1 · 6:00
clinicalBabies with renal problems who had normal amniotic fluid after replacement have developed chronic lung disease after delivery, demonstrating they are not normal from a respiratory standpoint.↗
▶Ep 1 · 27:46
clinicalIf parents want aggressive care, full respiratory support should be provided for at least the first 3 to 4 days, as many infants requiring high levels of support (including oscillator or pulmonary vasodilators) will begin to improve after this period.↗
▶Ep 1 · 28:15
clinicalIf the baby is not showing signs of stabilizing and improving after the first 3 to 4 days, the reality that the infant is likely not a pulmonary survivor must be discussed with parents.↗
▶Ep 1 · 28:44
clinicalThe question of pulmonary survival must be readdressed anytime there is an episode of lung injury, such as from sepsis.↗
Paul's statements about Congenital Diaphragmatic Hernia52 statements
quoteCDH is relatively rare in 1 in 3,000-ish births when you're at referral centers. You tend to see a few more. We tend to see 20 to 30 babies a year that have CDH.↗
▶Ep 38 · 0:21
epidemiologicalCDH occurs in approximately 1 in 3,000 births↗
▶Ep 38 · 0:40
epidemiologicalReferral centers tend to see 20 to 30 CDH babies per year↗
▶Ep 38 · 0:50
clinicalCDH anatomy is variable, and variability greatly impacts patient survival↗
▶Ep 38 · 1:00
clinicalInitial ultrasound at roughly 20 weeks of pregnancy often identifies CDH and potentially other anomalies that can greatly impact outcome↗
▶Ep 38 · 1:30
quoteDespite intensive efforts to improve the care of these infants, overall survival for infants born with CDH remains static at about 70% over the past two decades.↗
▶Ep 38 · 1:30
epidemiologicalOverall survival for infants born with CDH remains static at about 70% over the past two decades despite intensive efforts to improve care↗
▶Ep 38 · 1:50
clinicalImaging findings such as fetal lung volumes, liver herniation, and lung to head ratio contribute to prognosis↗
▶Ep 38 · 2:30
clinicalCincinnati Children's has an MRI in their NICU which allows easy postnatal imaging for CDH babies both before and after repair↗
▶Ep 38 · 3:10
clinicalUltra-short echo T MRI technique allows determination of lung volumes, lung density, and lung mass postnatally↗
▶Ep 38 · 3:30
clinicalIn a cohort of 13 babies at Cincinnati Children's with postnatal imaging compared to fetal MRI, the lungs do grow postnatally with increases in total lung volume, right lung volume, and left lung volume↗
▶Ep 38 · 3:55
clinicalThe non-CDH or good lung (right lung) grew better than the left side lung↗
▶Ep 38 · 4:05
quoteWas growing at about 2 mils per week slower than the right lung.↗
▶Ep 38 · 4:05
clinicalThe left lung was growing at about 2 mL per week slower than the right lung↗
▶Ep 38 · 4:15
clinicalThe relative growth of the left lung increased in babies that had better weight gain↗
▶Ep 38 · 4:25
quoteAnd this made it clear how important nutrition is for this population, maximizing calories, maximizing protein intake, and so forth.↗
▶Ep 38 · 4:25
clinicalMaximizing calories and protein intake is important for CDH patients to maximize growth, as growth is associated with better growth of the more severely hypoplastic lung↗
▶Ep 38 · 4:40
clinicalBabies who gained weight better had more growth of their left lung mass but did not impact the mass of the right lung↗
▶Ep 38 · 4:50
clinical2D time-of-flight MRI sequence can detect blood vessels in the lungs down to a size of 0.7 millimeters↗
▶Ep 38 · 5:00
clinicalVascular density is calculated by dividing the volume of blood vessels by the volume of the lungs↗
▶Ep 38 · 5:10
clinicalCDH pulmonary vascular density correlated very strongly with outcomes in babies with CDH↗
▶Ep 38 · 5:20
clinicalLower vascular density correlates with longer time spent on the ventilator↗
▶Ep 38 · 5:30
clinicalBabies discharged on room air had significantly higher vascular density than those discharged on oxygen or mechanical ventilation↗
Improving Outcomes for Congenital Diaphragmatic Hernia (CDH): Protocol Changes at Cincinnati Children's
▶Ep 39 · 0:27
clinicalInitial protocol focus was on delivery room, ECMO utilization, and ventilator management, then progressed system by system through GI, cardiac, and neuro↗
▶Ep 39 · 0:27
quoteInitially we focused on the delivery room and ECMO utilization and then ventilator management. We went through system by system EEN, cardiac, neuro to change each system.↗
▶Ep 39 · 0:46
quoteIf they were off ECMO, we would do the surgical repair when their echo demonstrated that their pulmonary hypertension was improved. And this could be anywhere from a few days to the most delayed repair I've ever had was 56 days.↗
▶Ep 39 · 0:46
clinicalPreviously, for non-ECMO patients, surgical repair was performed when echocardiography demonstrated improved pulmonary hypertension, ranging from a few days to as late as 56 days↗
▶Ep 39 · 1:09
quoteThe new protocol is we try to repair all ECMO kids within the 1st 12 to 24 hours of going on ECMO. And all the non-ECMO kids we repair somewhere between day 4 and 8, provided they are stable, which is the vast majority of the kids.↗
▶Ep 39 · 1:09
clinicalUnder the new protocol, all ECMO patients are repaired within the first 12 to 24 hours of ECMO cannulation↗
▶Ep 39 · 1:16
clinicalAll non-ECMO patients are repaired between day 4 and 8, provided they are stable, which applies to the vast majority↗
▶Ep 39 · 1:35
opinionThe clinical philosophy is that if you protect the lungs, all the rest will fall in line and improve↗
▶Ep 39 · 1:35
quoteIf you protect the lungs, all the rest will fall in line and improve. And never go above a peak pressure of 22.↗
▶Ep 39 · 1:39
clinicalThe new protocol never exceeds a peak pressure of 22 cmH2O↗
▶Ep 39 · 1:42
clinicalA standardized escalation and weaning protocol is followed approximately 100% of the time↗
▶Ep 39 · 1:51
clinicalEvery baby now gets started on hydrocortisone for blood pressure support↗
▶Ep 39 · 2:01
clinicalThere is a standardized protocol for which pressors are used↗
▶Ep 39 · 2:05
clinicalInhaled nitric oxide is only started if there is evidence of a need↗
▶Ep 39 · 2:20
quoteThe all children's philosophy is that if you start your NG feeds in babies prior to their ability to take oral feeds because of respiratory trouble, that they will lose the. Developmental connection of oral feeding leads to a full belly, and so they don't feed them until they can feed by mouth.↗
▶Ep 39 · 2:20
opinionThe All Children's philosophy is that starting NG feeds before oral feeding capability causes babies to lose the developmental connection between oral feeding and satiety↗
▶Ep 39 · 2:33
clinicalBabies are not fed enterally until they can feed by mouth; prior to that they receive TPN↗
▶Ep 39 · 2:47
clinicalEvery baby now gets started automatically on a continuous sedation drip↗
▶Ep 39 · 2:56
quoteEven though we're starting at a higher level of sedation than what we did before and that we're starting automatically on a drip versus a PRN, our overall use of sedation has plummeted since we've started doing this.↗
▶Ep 39 · 2:56
clinicalOverall use of sedation has plummeted since starting universal continuous drips despite starting at a higher baseline level↗
▶Ep 39 · 3:18
epidemiologicalAfter protocol implementation, the patient population appears to be skewed to the extremes with slightly more severe and slightly more mild cases↗
▶Ep 39 · 3:41
quoteThe most important thing, we have seen a bump up in survival from around that 70% mark to around 80% when we started implementing these changes.↗
▶Ep 39 · 3:41
epidemiologicalSurvival increased from around 70% to around 80% after implementing protocol changes↗
▶Ep 39 · 3:53
quoteIn addition to the drop in sedation. Is a drop on time on mechanical ventilation from a median of 19 days to a median of 9 days, so almost a 50% decline in the time on ventilation.↗
▶Ep 39 · 3:55
epidemiologicalMedian time on mechanical ventilation dropped from 19 days to 9 days, almost a 50% decline↗
▶Ep 39 · 4:19
quoteInterestingly, even though we're saying Trying to get them on ECMO sooner if they need it. That philosophy hasn't really caused an increase in the number of ECMO babies.↗
▶Ep 39 · 4:19
epidemiologicalThe philosophy of getting babies on ECMO sooner has not caused an increase in the number of ECMO babies↗
▶Ep 39 · 4:40
quoteOne important thing to realize is there's lots of problems that CDH babies have that we need to improve beyond survival.↗
▶Ep 39 · 4:40
opinionThere are many problems that CDH babies have beyond survival that need improvement↗
Paul's statements about Congenital Diaphragmatic Hernia29 statements
Improving Outcomes for Congenital Diaphragmatic Hernia (CDH): Protocol Changes at Cincinnati Children's
▶Ep 16 · 0:27
clinicalInitial protocol focus was on delivery room, ECMO utilization, and ventilator management, then progressed system by system through GI, cardiac, and neuro↗
▶Ep 16 · 0:27
quoteInitially we focused on the delivery room and ECMO utilization and then ventilator management. We went through system by system EEN, cardiac, neuro to change each system.↗
▶Ep 16 · 0:46
quoteIf they were off ECMO, we would do the surgical repair when their echo demonstrated that their pulmonary hypertension was improved. And this could be anywhere from a few days to the most delayed repair I've ever had was 56 days.↗
▶Ep 16 · 0:46
clinicalPreviously, for non-ECMO patients, surgical repair was performed when echocardiography demonstrated improved pulmonary hypertension, ranging from a few days to as late as 56 days↗
▶Ep 16 · 1:09
clinicalUnder the new protocol, all ECMO patients are repaired within the first 12 to 24 hours of ECMO cannulation↗
▶Ep 16 · 1:09
quoteThe new protocol is we try to repair all ECMO kids within the 1st 12 to 24 hours of going on ECMO. And all the non-ECMO kids we repair somewhere between day 4 and 8, provided they are stable, which is the vast majority of the kids.↗
▶Ep 16 · 1:16
clinicalAll non-ECMO patients are repaired between day 4 and 8, provided they are stable, which applies to the vast majority↗
▶Ep 16 · 1:35
opinionThe clinical philosophy is that if you protect the lungs, all the rest will fall in line and improve↗
▶Ep 16 · 1:35
quoteIf you protect the lungs, all the rest will fall in line and improve. And never go above a peak pressure of 22.↗
▶Ep 16 · 1:39
clinicalThe new protocol never exceeds a peak pressure of 22 cmH2O↗
▶Ep 16 · 1:42
clinicalA standardized escalation and weaning protocol is followed approximately 100% of the time↗
▶Ep 16 · 1:51
clinicalEvery baby now gets started on hydrocortisone for blood pressure support↗
▶Ep 16 · 2:01
clinicalThere is a standardized protocol for which pressors are used↗
▶Ep 16 · 2:05
clinicalInhaled nitric oxide is only started if there is evidence of a need↗
▶Ep 16 · 2:20
opinionThe All Children's philosophy is that starting NG feeds before oral feeding capability causes babies to lose the developmental connection between oral feeding and satiety↗
▶Ep 16 · 2:20
quoteThe all children's philosophy is that if you start your NG feeds in babies prior to their ability to take oral feeds because of respiratory trouble, that they will lose the. Developmental connection of oral feeding leads to a full belly, and so they don't feed them until they can feed by mouth.↗
▶Ep 16 · 2:33
clinicalBabies are not fed enterally until they can feed by mouth; prior to that they receive TPN↗
▶Ep 16 · 2:47
clinicalEvery baby now gets started automatically on a continuous sedation drip↗
▶Ep 16 · 2:56
clinicalOverall use of sedation has plummeted since starting universal continuous drips despite starting at a higher baseline level↗
▶Ep 16 · 2:56
quoteEven though we're starting at a higher level of sedation than what we did before and that we're starting automatically on a drip versus a PRN, our overall use of sedation has plummeted since we've started doing this.↗
▶Ep 16 · 3:18
epidemiologicalAfter protocol implementation, the patient population appears to be skewed to the extremes with slightly more severe and slightly more mild cases↗
▶Ep 16 · 3:41
epidemiologicalSurvival increased from around 70% to around 80% after implementing protocol changes↗
▶Ep 16 · 3:41
quoteThe most important thing, we have seen a bump up in survival from around that 70% mark to around 80% when we started implementing these changes.↗
▶Ep 16 · 3:53
quoteIn addition to the drop in sedation. Is a drop on time on mechanical ventilation from a median of 19 days to a median of 9 days, so almost a 50% decline in the time on ventilation.↗
▶Ep 16 · 3:55
epidemiologicalMedian time on mechanical ventilation dropped from 19 days to 9 days, almost a 50% decline↗
▶Ep 16 · 4:19
epidemiologicalThe philosophy of getting babies on ECMO sooner has not caused an increase in the number of ECMO babies↗
▶Ep 16 · 4:19
quoteInterestingly, even though we're saying Trying to get them on ECMO sooner if they need it. That philosophy hasn't really caused an increase in the number of ECMO babies.↗
▶Ep 16 · 4:40
opinionThere are many problems that CDH babies have beyond survival that need improvement↗
▶Ep 16 · 4:40
quoteOne important thing to realize is there's lots of problems that CDH babies have that we need to improve beyond survival.↗
Paul's statements about Oligohydramnios9 statements
Managing Advanced Chronic Kidney Disease: Cincinnati Fetal Center
▶Ep 1 · 1:33
quoteyeah, but all that's important, but it doesn't matter if the patient is not a pulmonary survivor.↗
▶Ep 1 · 2:42
clinicalIf amniotic fluid levels are restored to normal through shunting or amnioinfusion, the likelihood of pulmonary survival increases to approximately 80%.↗
▶Ep 1 · 3:08
clinicalIf amniotic fluid levels are not returned to normal, the pulmonary outcome is poor.↗
▶Ep 1 · 5:28
quotejust because you are a pulmonary survivor. That does not mean that you're normal from a respiratory standpoint.↗
▶Ep 1 · 5:33
clinicalMany infants who are pulmonary survivors have reduced reserve lung function, similar to reduced reserve renal function, and can rapidly transition from pulmonary survivor to non-survivor if injured.↗
▶Ep 1 · 6:00
clinicalBabies with renal problems who had normal amniotic fluid after replacement have developed chronic lung disease after delivery, demonstrating they are not normal from a respiratory standpoint.↗
▶Ep 1 · 27:46
clinicalIf parents want aggressive care, full respiratory support should be provided for at least the first 3 to 4 days, as many infants requiring high levels of support (including oscillator or pulmonary vasodilators) will begin to improve after this period.↗
▶Ep 1 · 28:15
clinicalIf the baby is not showing signs of stabilizing and improving after the first 3 to 4 days, the reality that the infant is likely not a pulmonary survivor must be discussed with parents.↗
▶Ep 1 · 28:44
clinicalThe question of pulmonary survival must be readdressed anytime there is an episode of lung injury, such as from sepsis.↗
Paul's statements about Peritoneal Dialysis Access18 statements
Managing Advanced Chronic Kidney Disease: Cincinnati Fetal Center
▶Ep 1 · 1:33
quoteyeah, but all that's important, but it doesn't matter if the patient is not a pulmonary survivor.↗
▶Ep 1 · 1:33
quoteyeah, but all that's important, but it doesn't matter if the patient is not a pulmonary survivor.↗
▶Ep 1 · 2:42
clinicalIf amniotic fluid levels are restored to normal through shunting or amnioinfusion, the likelihood of pulmonary survival increases to approximately 80%.↗
▶Ep 1 · 2:42
clinicalIf amniotic fluid levels are restored to normal through shunting or amnioinfusion, the likelihood of pulmonary survival increases to approximately 80%.↗
▶Ep 1 · 3:08
clinicalIf amniotic fluid levels are not returned to normal, the pulmonary outcome is poor.↗
▶Ep 1 · 3:08
clinicalIf amniotic fluid levels are not returned to normal, the pulmonary outcome is poor.↗
▶Ep 1 · 5:28
quotejust because you are a pulmonary survivor. That does not mean that you're normal from a respiratory standpoint.↗
▶Ep 1 · 5:28
quotejust because you are a pulmonary survivor. That does not mean that you're normal from a respiratory standpoint.↗
▶Ep 1 · 5:33
clinicalMany infants who are pulmonary survivors have reduced reserve lung function, similar to reduced reserve renal function, and can rapidly transition from pulmonary survivor to non-survivor if injured.↗
▶Ep 1 · 5:33
clinicalMany infants who are pulmonary survivors have reduced reserve lung function, similar to reduced reserve renal function, and can rapidly transition from pulmonary survivor to non-survivor if injured.↗
▶Ep 1 · 6:00
clinicalBabies with renal problems who had normal amniotic fluid after replacement have developed chronic lung disease after delivery, demonstrating they are not normal from a respiratory standpoint.↗
▶Ep 1 · 6:00
clinicalBabies with renal problems who had normal amniotic fluid after replacement have developed chronic lung disease after delivery, demonstrating they are not normal from a respiratory standpoint.↗
▶Ep 1 · 27:46
clinicalIf parents want aggressive care, full respiratory support should be provided for at least the first 3 to 4 days, as many infants requiring high levels of support (including oscillator or pulmonary vasodilators) will begin to improve after this period.↗
▶Ep 1 · 27:46
clinicalIf parents want aggressive care, full respiratory support should be provided for at least the first 3 to 4 days, as many infants requiring high levels of support (including oscillator or pulmonary vasodilators) will begin to improve after this period.↗
▶Ep 1 · 28:15
clinicalIf the baby is not showing signs of stabilizing and improving after the first 3 to 4 days, the reality that the infant is likely not a pulmonary survivor must be discussed with parents.↗
▶Ep 1 · 28:15
clinicalIf the baby is not showing signs of stabilizing and improving after the first 3 to 4 days, the reality that the infant is likely not a pulmonary survivor must be discussed with parents.↗
▶Ep 1 · 28:44
clinicalThe question of pulmonary survival must be readdressed anytime there is an episode of lung injury, such as from sepsis.↗
▶Ep 1 · 28:44
clinicalThe question of pulmonary survival must be readdressed anytime there is an episode of lung injury, such as from sepsis.↗
