DR Ramlawi

the first hour in the life of preterm infant is the most important hour in life if pretm delivery is anticipated, the following is the advisable proceedures /action in first hour 1- early antenatal discussion with parents regarding the expectation of the baby and the provisional decision regarding resuscitation 2- an experienced person in intubating those preterm babies to attend the delivery (a neonatologist may attend all deliveries less than 28 wks) 3-preheat the radiant warmer in the delivery room,aiming to avoid both hypothermia and hyperthermia 4-once the baby is born and less than 28 weeks he/she would be wrapped by glad rap or polyetheline bag 4-immediately after birth ;a baby is less than 28 weeks , he may be candidate for bhylactic surfactat( survanta) depends on the policy of the unit 5- immediately after birth ;a baby is 31-28weeks , he may be candidate for INSURE (Intubate, surfactant, extubatwe to CPAP) -depend upon the policy onf the unit 5- to apply pulse oximeter immediately after birth, AND to follow the expected saturation / age table by the AAP 2010 guidelines 6-if the baby is breathing to apply early CPAP of 5-6 cm H2O by T -peice" Neopuff " 7-if the baby is apneic or gasping ;to use the least required positive pressure ventilation just to push the heart rate above 100/min , with just noticable chest movement ,to use least fio2 as needed to reach sats/age as per the AAP guide line 8-in NICU keep the glad wrap until the lines are secured, Xrays are done and other intervention finished and the baby temperature in the needed range 9-Early insersion of double lumen UVC( in babaies<1 kg),and UAC, and early start of D/W10% 80-100ml/ in order to avoid hypoglycemia 10 - early X-ray to ensure good position of ETT and umbilical catheters 11- flat positioning of the bed and gentle handling all the time

No body should give intracardaic epinephrine any more as per the most recent AAP -NRP guidelines, , few heart beats will continue for 15-30 minutes even after the pupils are fixed dilated. So if heart rate is less than 60/ min after 10 min of resuscitation in the abscence of pneumothorax or malpositioned ETT i usually stop resuscitation because i dont wish the heart to come back after the brain gone ,

sildenafil is one of the major therapeutic lines for PPHN, usually it is a bridge to take the pt away from inhaled NO, and it can be used by itself as the primary therapy in moderate cases of PPHN in fact we have pts with severe PPHN which we treated with Sildenafil with good response, and with minimal side effectseven some newborn infants treated with it till age of 2 year. There is good article about it just published the journal of pediatrics Nov 2009

Usually babies with RDS are not ventilated electively by HFOV except if they fail while on Conventional ventilation after being given surfactant.Surfactant has to be given as early as possible in infants with RDS, Administering Surfactant early may times makes the baby ventilation very easy with conventional ventilators and avoid the needs for HFOV. If the baby clinical and radiological findings are consistent with RDS and baby is already on HFOV;then you should give surfactant "if available",to do this you take the infant off th HFOV and you give surfactant in quartiles under Ambu Bagging over 2-5 min ,once you finished giving surfactant and the endotracheal tube is clear from surfactant;then you can connect the infant back to the HFOV, you may need to increase the MAP temporary by 2cm for 2-5 min .After giving surfactant ;lungs dynamics will improve witin 5-15 min and you should wean on both the MAP if the fio2 dropped to less than 40%,and wean on Delta P if the chest wiggling started to be exagerated or blood gas that should be done within 30 min showed PCO2 less than 45 mmHg Good Luck

In the abscence of and no impending airleak, you add 2-4 cm H20 to the MAP of the failing conventional ventilator to start with as a MAP on the HFOV,then you can increase your MAP by 2cm if the needed fio2 is still higher than 40%, and you have to do a chest X-ray to the baby by 30-50 min from starting HFOV, your goal is to have the lungs well inflated ie the coupula of the right diaphragm about the 9th or 10th rib- counting posteriorly

High dose dopamine is known to cause vasoconstriction of the arteries all over the body including the gut vessels. once the baby is hemodynamic stable on low or moderate dose of dopamine ie not exceeding 10 microgram/kg/min i do start the baby on minimal enteral feeding ( trophic feeding that does not excced 20ml/kg/day ) but i will not upgrade the volume of the feeding until the baby is off dopamine or the dose is less than 5 microgram/kg/min -that is our policy of feeding sick preterm