IVH

[tarek]

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

[Hamed]

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.

 

[Stefan Johansson]

@Hamed Thanks for sharing valuable info.

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

 

[Hamed]

@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.

[tarek]

Thanks a lot @Hamed really its great help

Thanks a lot @Stefan Johansson

[bimalc]

@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.

[tarek]

@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

[bimalc]

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

[Hamed]

@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]

Dear Drs,

Are you aware of studies done by Christensen et al connecting IVH to blood products transfusion after birth, recommending giving PRBC if needed slowly. We are now giving for symptomatic anemia (hypotension+HTC<35%) after birth only 10cc\kg of PRBC over 3 hours (not evidence based practice) 

[Stefan Johansson]

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

[rehman_naveed]

On 9/20/2017 at 11:17 PM, Hamed said:

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.

 

Excellent discussion. Yes here in Canada it is true what you said. It's unique that your unit start TFI at 50ml/kg but it depends on gestation and others factors. My question to you

1. how frequently you monitor electrolytes and suppose Na is 151, urea is 12 and Cr is 86, urine output is 6ml/kg/hr, there is metabolic acidosis and child is on 80 humidity,

2. how do you increase his fluids and which type of fluids you use to increase the TFI.

3. how much do you put Na in TPN considering you have to give acetate for acidosis.

4. Do you keep the TPN to run in at constant rate and Y in D5 to make up TFI?

I am curious to know your unit practice.

 Thanks 

naveed

[tarek]

Thanks too much Naveed

I was following what i will post now because this was very big dilemma and i find this helpful for me

If you kindly read it and give me your valuable comments

https://uichildrens.org/health-library/fluid-and-electrolyte-management-newborn

[Hamed]

@rehman_naveed

Thanks for opening up a practical discussion. I am not sure if forgot to mention the GA and DOL in your example or you meant same as the above case. By the numbers, you have given this is not fitting a DOL0.

I am not sure why in this example case the incubator`s humidity is only 80%? Usually, we start at 100% for ELGANs and go down slowly. 

If we consider this was a whatever DOL premature, with a high Na level, urine output is at a high level as you explained 6 ml/kg/h, normal Cr, high Urea most probably due to catabolic state (consider adjusting amino acids in TPN),

Your answer in the clinical practice in Japan would be:  

Need to know:

1-The K level, because if you need to add acetate for acidosis you can put it in as K-acetate and not Na-acetate.

2- The blood pressures.  Although is expected to be ok, due to your good urine output, unless your case is also hyperglycemic and thus polyuric. In that scenario you would consider the level of BS and if you would give insulin or not.

3- IVC diameter, SVC flow, a 4 chamber view to the cardiac filling, cardiac contractility (part of targeted ECHO done by neonates MDs and fellows). To estimate your circulatory volume.

From the data collected above:

* If circulatory volume (by ECHO) and BP is low  (for example),  increase the TFI with an additional 20 ml/kg , by  Y in D5 and/or IVIG if the baby`s immunoglobulins level is below 100, to compensate for your additional 20 ml/kg/d increase TFI. If Na was not high could also give albumen. Restrict the Na given to lower limits of daily needs 2 mmol/kg/d, replace Na-acetate with K-acetate.

*If volumes are good (detected as above by targeted ECHO), but BP is low: start an inotrope according to what your ECHO showed to select, ie Dopamine 5 microgram/kg/min, no need to increase the TFI as much as the case above.

* Electrolytes are usually taken from of the bl gas which, if the Na was higher than 160, would then consider sending to hospital`s lab a sample to confirm. Another blood gas in 12hrs if ventilated, if not then with AM sampling

Your answer in practice in NICU Canada or Egypt:

Good urine output, increase TFI to 80 ml/kg/d by Y in D5%,  restrict the Na given to lower limits 2 mmol/kg/d, replace the additional Na-acetate with K-acetate. Check BS and as above for hyperglycemia.

If blood pressures are low, elevated Lac and prolonged CRT, give a bolus of 1/2 saline to D5% and Y in D5% to the TPN used to increase TFI by 10 ~20 ml/kg. Adjust TPN Na content at AM to 2 mmol/kg/d. BS as above. If still blood pressures are low considered starting dopamine.

As for electrolytes chicking as above almost no difference, except in some units, you have to order the electrolytes results off the gas to get them, and can only use it to direct you to withdraw a sample to the hospital lab or not.

 

   I think in both ways of practice, the management could be somewhat similar in case of increase TFI, but what comes in different is that targeted ECHO here comes in as a decision-making tool for tailoring whether to start inotropes or give higher TFI volumes.

 

[rehman_naveed]

Hi Hamed

Thanks for the comments. Sorry I forgot to mention the gestation age but you assume it being 23 weeker, DOL 2-3 days.

1. We usually put 2mmol/kg Na in TPN and about 1mmol/kg baby get Na via UAC having heparin saline in 0.45% saline. we also give K as well in 1mmol/kg dose. so it is very challenging to split both Na and K between acetate and Phosphate as we have to give some phosphate to this preterm baby.

2. It is new to me that you in Japan give immunoglobulin's to newborn if their level is <100, and also you mentioned albumin which we never give in our setting here in Canada.

3. Also usual recomendations for humidity for <30wks  is 65-70% but we go upto 85% if Na is high but never above 85% as it get showers in incubator and it will then make overhead phototherapy ineffective and also chest electrodes will not stick to baby chest plus sepsis risks etc.

Yes I agree management is mostly similar between Canada, Egypt and Japan. we do also TnEcho at bedside occasionally.

 

 

On ‎10‎/‎3‎/‎2017 at 1:54 AM, tarek said:

Thanks too much Naveed

I was following what i will post now because this was very big dilemma and i find this helpful for me

If you kindly read it and give me your valuable comments

https://uichildrens.org/health-library/fluid-and-electrolyte-management-newborn

Hi Tarek

thanks for your comments. it is interesting to see the above mentioned guidelines. I think @hamed explained much detail on this topic. to summarize it in 2 lines, start at 80-100ml/kg, high humidity, frequently checking electrolytes, put as much acetate in TPN as you can, increase fluids in 20ml/kg as Y in D5, monitor sugar and tailor your TFI and dextrose.

[Hamed]

• @rehman_naveed   Thanks for sharing the experience from your unit. Have you came along another RCT for the use of acetate for metabolic acidosis in preterms beside the one from Liverpool 1997: Randomised controlled trial of acetate in preterm neonates receiving parenteral nutrition.  Arch Dis Child Fetal Neonatal Ed. 1997 Jul;77 
• I agree with you concerning the use of albumen for giving volumes in preterms with or without low serum albumen, there is a limited number of studies to answer whether giving albumin helps babies in the short or long-term or to show any benefit above crystalloids.