rehman_naveed

We never use laryngeal mask during resuscitation. All our fellows are well trained for intubation . Even in our level 2 we never use it

We don't use EKG, we struggle to get the signals from Sat probe , what to talk about EKG leads lifting off the chest. Although one can say that wipe off vernix from chest but even then leads can't stick. I think too much research on useless things is sad in evidence based medicine. Make things simple in neonatology and think babies are born not only in developed world but also in poor developing countries with no access to even stethoscopes, what to talk about EKG leads and monitor. At that time one rely only on cord palpating for heart rate.

Thanks for all the respectable members about great ideas and references. To summarize and close the loop, PALS vs NRP use depends on the type of ICU the child is, doesn't matter the chronological age or corrected age. It is all dependent on provider expertise and it makes sense as PICU, CICU are more trained in PALS while NICU providers are trained in NRP. BUT very important to mention is that at the start of CPR, the team leader has to mention ( especially when the code is in ER) that we will follow NRP or PALS guidelines and all members should follow it irrespective of the differences so that everyone is on the same pitch. Naveed

Thanks @gayle-omansky and @trish Interesting to know wide variation in practice across the globe on such issue. Evidence in NICU is not an evidence in ER when same patient arrive at different location. Do we know what is the logic behind this, " not to pause between compression and ventilation". when the ETT is not in, then may be tracheal compression with chest compression make it compulsory to pause for ventilation, but when ETT is in then no pause between two.

Yesterday I was conducting code in NICU and one fellow was assigned to chest compression and other was providing PPV via ETT. but they were not coordinating in 3:1 ratio. He argued that once ETT inserted then coordination is not required, which was new to me. He based his logic on PALS where coordination between chest compression and PPV is not required. Can someone further elaborate this point, what is your practice in your unit, do you do coordinating chest compression? and also when to switch to PALS in NICU at what gestational age. As far as I know, recent NRP 7th edition tells us chest compression to PPV via ETT ratio is 3:1. Thanks Naveed

No we don't stop feeds during PO ibuprofen. We don't use IV form as very expensive

Hi Judit Interesting case. in your case description, you mentioned last US showed mass even not attached to wall, it means thrombus is detached, in case it may obstruct the IVC flow, can you make it clear. Did you consult hematologist? What about thrombocytopenia? ( Yes/No), Coagulation profile, Anti Xa level monitoring, did you follow it to guide therapy of LMWH, Did you consult plastic surgeons? Did you screen for thrombosis workup, protein C, and S, factor V leiden deficiency There are no set guidelines to guide treatment for thrombosis in newborn, but here in canada we do treat with LMWH, follow serial anti Xa level, to guide therapy ,involve hematology/thrombosis team, and follow serial US with doppler . Length of treatment varies with size of thrombosis. Strange that in spite of thrombosis, patient went for surgery. was he on LMWH at that time? Keep us updated. Thanks Naveed

Great article shared by Stefan above, I will narrow my differential to Congenital Epulis. I published a similar case report few years back. see the link below https://www.researchgate.net/publication/221740407_Congenital_Epulis Needs imaging MRI to look for deep connection, as it could be encephalocele with CNS connection. Final treatment is surgical resection. Prognosis depends on underlying cause, if Epulis, Naveed

Excellent @tarek. I wish I can attend the meeting but due to working condition, didn't get time to attend as golden hour remained my favourite topic especially how to manage time in putting UAC and UVC in that 60minutes especially when you are training juniors , time consumed in x ray, medication arrival etc. these are the rate limiting steps to achieve golden hour success, do let us know what he comment on these issues. I am sharing the article you mentioned in above post for all reviewers. @Aymen Eshene your patient will have a somewhat similar outcome, so please make sure to have proper follow up and to start propranolol at proper time. Naveed e629.full.pdf

If baby is stable, just observe. Needs only CBC to rule out thrombocytopenia, Kasabach–Merritt syndrome. In a resource limited NICU like yours ,I would just keep the baby in followup, no investigation except CBC. If thrombocytopenia, will tell you what to do. till then routine care. Below is the link to have detail management of infantile hemangioma, not related to your case but overall review. https://www.dovepress.com/current-perspectives-on-the-optimal-management-of-infantile-hemangioma-peer-reviewed-fulltext-article-PHMT# keep posting, your cases are great learning case for all of us especially to guide someone in very limited resources Naveed

Hi Schumz i would suggest cut down the feed volume at which infant gain weight around 20-30g/kg/day, you can even cut down TFI to 130ml/kg/day but you need to titrate it gradually. First cut fluids to 150ml/kg/day and then 130 Any added fortifier needs also to be reduced. Keep this in mind that chubby babies are not healthy. Also diuretics have no evidence in BPD, so I would also discontinue them thanks naveed

@tarek thanks,

I would like to hear about "Evidence of evidence in NICU treatment and management" where are we heading, limited evidence for most of the NICU disease, all based on opinion based still in this century.

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. 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.

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