IVH and ELBW

It is really a bad experience having a 600 gms baby with IVH grade 3 or 4

What is your best practice to minimize the risk of IVH?

Management of hypotension and risk of IVH

Intubation and IVH who should intubate it is not always the most expert will be there

Delayed cord clamping really we should not miss its benifits

Painful procedures and IVH is it helpful to give morphine before any painul and irritant procedure like suctioning

PDA and IVH should i give prophylactic endomethacin in first few hours of life

Hi Tarek, 

Your experience with this 600 g ELBW is not uncommon. It is important to mention the gestational age in your description of the case. It can help the reader give you a more practical answer. I am assuming this was a 24 ~ 25 weeker infant unless it was also an IUGR.

To minimize IVH you have special concerns to cover:

A- Before birth giving mom Antenatal steroids.

B- Delivery: 1-With minimal handling as possible. 2- Cord milking and delay cord clamping

C- After delivery: 1- Positioning the head and body in same line ie not tilting the head to one direction lt or rt which will kink the neck (Jugular) veins and cause congestion of the bain of that side. 3-Prophylactic indomethacin (indicated in Japan if BW less than 1000 g + GA below 28 wks/ and in some NICUs in Canada if GA is less than 26+0 wks whatever the body weight is). 4- Correcting acidosis. 5- Maintain a good circulatory volume and start low IV fluids with a TFI at 50 ml/kg/d on DOL 0 and increase fluids by 10 ml/kg/day, unless the circulatory volume is low then you have to balance it. 6- Minimal handling. First 3 days are the highest risk time for IVH development.

As for your concerns about intubation especially when there is no experienced medical team member (physician or RT), that depends on your unit`s policy for staff coverage. However, I recommend you not to jump quickly to intubation, a lot of 23, 24 and 25 weekers manage to escape from being intubated using CPAP and NIPPV.

 

@Hamed Thanks for sharing valuable info.

however, on head positioning, have you seen recent Cochrane review?

 

@Stefan Johansson Thanks a lot, no I wasn't aware of this recent Cochrane review. Thanks a lot. I will share it with my coworkers and colleagues.

Thanks a lot @Hamed really its great help

Thanks a lot @Stefan Johansson

@Hamed I am interested to hear your fluid management for micro preemies is quite different than practice in the US.  I do not imply that one is superior to the other, but I must ask what difficulties (if any) you have in maintaining normal fluid electrolyte balance with only 50mL/kg/day of fluids in the smallest babies?  In the two units I currently work in, such a baby would typically receive 100mL/kg/d on day 0 and increase 10-30mL/kg/d.  My experience has been that even with humidified isolettes (or at least the ones I have used over the years) such babies can lose massive amounts of weight/water and become very hypernatremic if we are overly cautious with fluids early on.

@bimalc

One of my friends in Minnesota i discussed this issue with her they are starting with 80 ml/kg and checking of sodium ,uop and adjust ivf accordingly so not all in US starting with 100 ml/kg

And i am in favour of restricted intake initially and adiustement according UOP ,Na and Urea

More fluids more IVH PDA and pulmonary hge

So the most important is follow up and adjust accordingly allowing for physiological wt loss in the first 5 days

I have done 80/kg in the past; I think we agree on the importance of uop,etc. and adjusting fluids based on weight, output and labs.  50/kg just seems unlikely to be sufficient in my experience, but if there is international experience suggesting otherwise, I might need to reassess my practice

@bimalc and @tarek Thank you both for your comments and sharing your experiences.

I do understand your points and concerns. Our standard starting point for TFII is 50 ml/kg/d on day 0 for micro preemies, but we tailor the TFI for each case depending on mean arterial blood pressure, cardiac size on chest X-ray, ECHO heart findings, and urine output. Thus one preem may be receiving a TFI of 50 ml/kg/day on day 0 and another preem with the same GA and BW receiving a TFI of 80 ml/kg/d. Each case is different. In addition, our rate of increase is 10 ml/kg/d as a basic standard, but still, it could be higher depending on how the same factors mentioned above go

In an NICU in Canada, the TFI was 60~80 ml/kg/d for micro preemies < 26 weeks GA, and 100 ml/kg/d for < 24 weeks GA, as a standard, and when these fluid volumes were not enough to maintain the BPs and there was poor peripheral perfusion indicated by high Lac and prolonged CRT, saline boluses were given and inotropes were considered. The daily rate of increase was as a standard 20 ml/kg, unless the prem was puffy or chest X-ray showed increased lung fluids, then daily increase in TFIs was decreased or skipped.

I do not imply that one strategy is better than the other, however, tailoring the fluids and inotropes given per each preem`s condition for me sounds practical.

We have a special session on tailoring IV fluids and inotropes for preterms next month in the 62nd annual conference of the Japanese society of neonatal health and development http://jsnhd62.umin.jp/en/abstract.html . This could be an important topic to be also discussed in next 99NICU meeting @Stefan Johansson 

 

 

@harnon are you referring to this paper: https://www.ncbi.nlm.nih.gov/pubmed/21166684