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Schumz

therapeutic hypothermia - do you ventilate just for cooling?

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Guys do you ventilate, SVIA (self ventilating in air) babies just for cooling? If not what strategies do u use for making them comfortable? 

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There should be no reason to intentionally ventilate babies while cooling. How can ventilation cause comforts?

we use low dose morphine infusion to keep them calm

Naveed

 

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@Schumz we also cool infants without keeping them intubated (for the sake if it), and we have good experience (PO2- and PCO2-wise ) that infants can do just fine even without CPAP, despite cooling and relatively large doses of analgesia / sedation. But of course, one needs to think both once and twice, especially not to be keep infants "breathing" but not giving sufficient analgesia and sedation. Also, if we do use mechanical ventilation, we do not extubate during cooling even if spont breathing is restored.

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I must agree with the others that therapeutic hypothermia is not, in and of itself, an indication for intubation.  However, given the known natural history of HIE, even in the era of cooling, I certainly have a lower threshold to intubate when the respiratory status is marginal.  Also, must agree with @Stefan Johansson once the ET tube goes in, it does not come out (In our case, not until we get the MRI).

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23 hours ago, ashok said:

@bimalc ,when r u taking mri after cooling 

24-72 hours after cooling.  I try to use spontaneous breathing modes in this setting whenever I can to try and get more information to guide counseling if I am concerned there will be an extubation failure.  For example, the draeger VN500 has mandatory minute ventilation mode and has some lovely graphics that you can show a parent so they can see their child go apneic or hypopneic (CPAP/PS can be used to a similar but not identical end)

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Concerning the need for intubation and Mech. vent. I concord with @bimalc, @Stefan Johansson and @rehman_naveed and once in during cooling it will remain in until the end of cooling or until an MRI is taken at 4~5 days of life.

As for comfort, we do as @rehman_naveed, we give low dose morphine infusion 5 mcg/kg/h not exceeding 10 mcg/kg/h or fentanyl 0.5 mcg/kg/h not exceeding 1 mcg/kg/h (fentanyl preferable for hemodynamic compromised infants).

Coming to the timing of MRI, it may vary according to each hospital`s protocol. In addition, it really depends on what you want to see, diffusion and metabolic changes preferably 4~5 days of life, and that concord with  24 to 72 hrs after cooling as @bimalc. Brain injury changes continue to develop as late as the 2nd week of life. That is why you find some units do the MRI at day 4~5 or day 7 or end of 2nd week of life.

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Thank you all for your comments. I agree @Stefan Johansson regarding babies who have been ventilated we don not extubate either. @ashok we get an MRI in the first week, usually after rewarming is completed. 

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i agree, would not necessarily ventilate a baby just for cooling - unless maybe they were particularly agitated, had PPHN or other problem

Controversially, I don't see a problem with extubating during cooling, particularly if baby breathing spontaneously or struggling with overventilation. 

Anyone fancy pooling some data and comparing practices in different places?

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On 11/5/2018 at 8:06 AM, AlexScrivens said:

i agree, would not necessarily ventilate a baby just for cooling - unless maybe they were particularly agitated, had PPHN or other problem

Controversially, I don't see a problem with extubating during cooling, particularly if baby breathing spontaneously or struggling with overventilation. 

Anyone fancy pooling some data and comparing practices in different places?

To be fair over ventilation/hypocapneia would be a very strong indication for extubation (the whole point of cooling is to save the brain, after all) however, in my experience this is exceedingly uncommon

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