1 pointNot routinely, but for high risk extubations we often coordinate with ENT and make plans for things like race epi at extubation to Heliox. I've also used it many times as rescue therapy when there is post-extubation stridor and I am trying to buy time for airway steroids to kick in.
1 pointThis is not an uncommon dilemma. We have developed a one paged trigger/ assessment tool for babies who meet criteria for monitoring for moderate or severe encephalopathy. It seems to work most times and one of our fellows is conducting an audit to see if we miss any babies with this tool. Based on this case, it sounds like the baby would have met criteria for clinical monitoring for moderate or severe HIE i.e. prolonged resuscitation and possibly Apgar scores? but not pH or BE related values and we would have then assessed this baby hourly for the first 6 hours of life for clinical signs of moderate or severe encephalopathy. TH would have been started as per the trigger tool thresholds. The problem comes when these babies don't meet clinical criteria for moderate or severe HIE and clinical monitoring is ceased and then go on to have seizures some time later - as is seen in this case. The current trend in our unit would be to not cool them at the 12hr mark but I have personally cooled a baby who did not meet criteria for moderate or severe encephalopathy in the 1st 6hrs but then went on to have seizures at ~8hrs of life. We would just optimise other medical intervention and use anti-convulsants (levetiracetam, topiramate and midazolam or lignocaine) to treat seizure burden. I'm not sure if that helps! Cheers Richard HIE trigger tool.pdf
1 pointJust for the purpose of recall.(Cochrane 2013, Jacobs) Evidence of peripartum asphyxia, with each enrolled infant satisfying at least one of the following criteria: i) Apgar score of 5 or less at 10 minutes; ii) mechanical ventilation or resuscitation at 10 minutes; iii) cord pH < 7.1, or an arterial pH < 7.1 or base deficit of 12 or more within 60 minutes of birth. AND Evidence of encephalopathy according to Sarnat staging (Sarnat 1976; Finer 1981): i) Stage 1 (mild): hyperalertness, hyper-reflexia, dilated pupils, tachycardia, absence of seizures; ii) Stage 2 (moderate): lethargy, hyper-reflexia, miosis, bradycardia, seizures, hypotonia with weak suck and Moro; iii) Stage 3 (severe): stupor, flaccidity, small to mid position pupils that react poorly to light, decreased stretch reflexes, hypothermia and absent Moro. AND abnormal standard EEG or aEEG findings(this in addition to above as in NeoNeuro Network RCT by Simburner, Germany). Evidence Laptook etal. Effect of therapeutic hypothermia initiated after 6hours of age on death or disability among newborns with Hypoxic-ischemic encephalopathy, Jama 2017 October 24;318(16): 1550-1560. •Randomized clinical trial •April 2008 –june 2016 •Moderate or severe HIE enrolled at 6-24 hours after birth. •Twenty one US neonatal research network centers •There were 168 participants and 83 were randomly assigned to hypothermia and 85 to noncooling. Results 76% probability of any reduction in death or disability.(Biasian Statistics and analysis) 64% probability of at least 2% less death or disability at 18 to 22 months. Hypothermia initiated at 6 to 24 hours after birth may have benefit but there is uncertainty in its effectiveness. Gist: TH can be tried for its benefit though not greater than that of starting early but with due consideration of parents participation and Consultant in decision making.
1 pointOh well, so many thoughts after reading this article! Thanks for sharing! Although I agree with every word she says, I think that we should keep in mind that she describes the American reality, which in many ways may be different from European experiences. In many (most?) countries in Europe, we are privileged to have a generous parental leave and (rather) well-coordinated healthcare system. It doesn't change the fact that becoming a parent in the context of the Neonatal Intensive Care Unit must be extremely challenging- and we need to recognize the need to support NICU parents not only during hospitalization but also after the discharge. What really makes me grind my teeth is the fragment about guilt related to insufficient pumping. There is a beautiful (truly) article written by my colleague Sarah Holdren, in which she argues that many NICU mums feel that pumping is actually the only way they can contribute to their infant wellbeing because other ways to engage parents and promote closeness may not be available. I wholeheartedly recommend you reading that comparison of practices in Finland and the USA, the whole article is available here in Open Access. https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/s12884-019-2505-2
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