Dose of antibiotics for infant with hydrops fetalis

[Andrej Vitushka]

Dear colleagues, 

Are there any differences with antibiotics' dosing for infants with hydrops fetalis. Today having a boy 37 weeks 4340 g weight with profoung edema of head, neck and upper part of the trunk. About 200 ml was evacuated from both sides of the thorax. What bodyweight should we use to calculate antibiotics' dose -- 4340 g or 4130 g (minus fluid from thorax) or something else? He is on HFOV. Blood pressure is stabilizing by 10 + 10 mcg/kg per minute of Dopamine and Dobutamine. Diuresis is good and no signs of impaired periferal perfusion. Many thanks.  

[Hamed]

It's not a big difference calculating the antibiotics 4.3 kg or 4.1 kg, especially you say that urine output is good.

Could you please let us know why Dobutamine is given?  

[Stefan Johansson]

Have discussed this principal question before IRL - generally we'd probably use the BW-adjusted doses and follow s-conc as usual (for aminoglyc or vanco), and dose-adjust accordingly. 

[Andrej Vitushka]

4 hours ago, Hamed said:

 

Could you please let us know why Dobutamine is given?  

Thanks for the answer, Hamed. Dobutamine was given because of relatively low cardiac contractivity. But frankly speaking, issues of cardiotonic/vasopressor support are still not well solved in our unit. 

[Hamed]

15 hours ago, Andrej Vitushka said:

Thanks for the answer, Hamed. Dobutamine was given because of relatively low cardiac contractivity. But frankly speaking, issues of cardiotonic/vasopressor support are still not well solved in our unit. 

1

Good luck with this case, 

Some points which are sometimes missed in our unit include a) following the daily rate of chest tubes drain ml/kg of BW to estimate severity and to follow the effect of therapy.  b) Measuring triglyceride in the drained fluid and at the same time in the infant's blood to determine the type of the fluid.    Best of luck

[bimalc]

On 6/27/2018 at 6:13 AM, Andrej Vitushka said:

But frankly speaking, issues of cardiotonic/vasopressor support are still not well solved in our unit. 

I suspect this is not a 'solved' problem in any of our units.  I was recently on overnight with a similar baby and we were on Milrinone and Epi (maybe some dopa as well, can't remember details now); had a long conversation with our cardiac ICU about swapping out at least some of the Epi for Dobutamine one I had an ECHO with confirmed EF ~10-15% but this was very controversial (for reasons that were not very clear to me) and I was only on overnight, so I deferred to the primary team in the morning.

On 6/27/2018 at 5:31 AM, Stefan Johansson said:

Have discussed this principal question before IRL - generally we'd probably use the BW-adjusted doses and follow s-conc as usual (for aminoglyc or vanco), and dose-adjust accordingly. 

Again, having just cared for such a case, when we have serial OB growth US and can see the weight trajectory prior to the fetus becoming hydropic, we estimate the non-edematous BW and make our initial dosing on that.  Given that we subsequently follow urine output, weight and drug levels (where appropriate) I'm not sure that in practice we gain much from this exercise except that, perhaps, on the first day we are much tighter on fluids than we might otherwise have been.

[Andrej Vitushka]

5 hours ago, bimalc said:

I suspect this is not a 'solved' problem in any of our units.

Keeping in mind that the patient had low contractility and mild pulmonary hypertension (sorry I don't remember numbers) what do you think would be the best option for this baby -- Dobutamine + Milrinon, Dopamine + Milrinon, Dobutamine + Dopamine or maybe some other? Many thanks.  

[Hamed]

7 hours ago, bimalc said:

I suspect this is not a 'solved' problem in any of our units.  I was recently on overnight with a similar baby and we were on Milrinone and Epi (maybe some dopa as well, can't remember details now); had a long conversation with our cardiac ICU about swapping out at least some of the Epi for Dobutamine one I had an ECHO with confirmed EF ~10-15% but this was very controversial (for reasons that were not very clear to me) and I was only on overnight, so I deferred to the primary team in the morning.

Again, having just cared for such a case, when we have serial OB growth US and can see the weight trajectory prior to the fetus becoming hydropic, we estimate the non-edematous BW and make our initial dosing on that.  Given that we subsequently follow urine output, weight and drug levels (where appropriate) I'm not sure that in practice we gain much from this exercise except that, perhaps, on the first day we are much tighter on fluids than we might otherwise have been.

That sounds really familiar hear in our unit,  the cardiology team and I don't prefer adding dobutamine unless the preload and cardiac filling are sufficient and evident weak cardiac contractility. Dobutamine has a hypotensive effect which makes us cautious about using.

Our first line inotrope as almost everywhere is Dopamine 5~10 mcg/kg/min, up to  15 ~20 mcg/kg/min, if still, systemic blood pressure is low we would add vasopressin (especially in cases of hydrops or CDH). Others add Epi instead of vasopressin and may reduce dopamine. In case the fluid identified in the hydrothorax as chyle, vasopressin is preferred. In case the chylothorax is severe (draining more than 50 ml/kg/day) for 3-4 days, during which NPO and on TPN, we start octreotide.

If systemic blood pressure is in our required target range and there are echo findings for pulmonary hypertension, then inhaled NO 20 PPM, followed by Milrinone if not controlled.

Would like to hear what others do and their preferences?

[Andrej Vitushka]

Thanks, Hamed. We use Dopamine plus Epi or Dobutamine (sometimes). Interestingly I didn't even thing about NO because we don't have it 😊. Pulmonary hypertension is treated by Milrinone and bicarbonate in our settings. As well we don't use vasopressin as well. 

[M C Fadous Khalife]

We use dopamine and donutamine . We use NO but no milrinone