rehman_naveed

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

Thanks for this excellent post, being in level III NICU with 50+bed capacity, it is not quite easy to cope with but with careful time distribution one can relax as well and give time to family. This is how I distribute my time. If you are frontline person ( meaning first respond to L & D calls, code pink) then you have to be little quick. usually in morning we distribute patients according to team, usually 7-8 patients per person will get. they are mix with sick and feeder and grower. try to quickly through the patient , ask bed side nurse any overnight issue, check ins and out, do relevant exam and write your note, preferably before rounds as you may be called any time for c section or any delivery. once your notes are done, present your cases in rounds, we usually present case on our turn and no need to stay in whole round of NICU. once your patient are done, your work is done, now you are free, if any discharge of your patient, just quickly dictate, check at the end of week about discharge summaries if needed any update. now you can chat, relax and enjoy your free time. give handover at 1700hrs and go home. similarly if you are on nights , organize yourself . usually 2-3 patients needs your attention in night, rest of them are usually routine cases like jaundice, increasing feeds, check ins and out etc. finish your night rounds with the team quickly focussing on particular patients and thats it. get time to rest, read or whatever time you want to devote to research etc. This is how I distribute my time. hope it will help Naveed

Hi Simon we have 46 bed level III NICU, and 15 bed level II.