rehman_naveed

Hi Colleagues May I ask a question, What does free water deficit means for Hypernatremia? I know the definition but what does it actually means when treating hypernatermia with crystolloids solution. For example if serum Na is 190, free water content of 0.9% NaCl is 19%, 0.45% Saline is 59% and 0.2% Saline is 81%. How this will help in giving free water to a baby weight 4Kg with Na 190 mmol/L, who require approximately 576ml of Free water in 4 days to drop Na slowly to 142 mmol/L. Many Thanks in advance.

So what is the question? 0.45% saline is the least you can give Hypernatremia in ELGA babies is likely not due to excessive Na intake

We usually don’t intentionally give unless they are already on. We discontinue as well early no matter chest drain is out or in.

Yes there is no VG, instead use PRVC for volume control ventilation

Hi only difference is PEEP is added to PIP while in others PEEP is separate. Meaning the PIP which baby get includes PEEP. Rest of concepts are same.

For #1, you answered yourself dark lung fields, so no RDS, hence no surfactant, looks like vascular phenomena rather than parenchymal as your scenario. Treatment lung protective strategy, and pulmonary vasodilation. for #2, adequate coverage, can be discharge with follow up

Yes our anesthesiologists routinely use cuffed tubes for any procedures not restricted to CDH We didn’t find any severe adverse events though sometimes mild post extubation stridor, also cultural acceptance in NICU community is an issue. Naveed

We usually do the same as what you mentioned, increase 20% fluids ad check Na frequently say Q6hrly. Once Normalize reduce TFI. Yes we replace free water with Na free solution but give maintenance Na which Baby any ways get from UAC heparin Saline ( 0.45% saline) and put 2mmol/Kg in TPN as acetate to tackle acidosis. We can go up as much as 200ml/kg/day and maximum Humidity to 95%. Never give saline bolus and NG drip with sterile water. I hope it helps

We use nasal intubation to have stability, fixation is usual with tape

The reason we use gel in term babies is to avoid admissions and transiently support feeds. On the other hand preterm <35wks is by default admitted to nicu so it doesn't make any sense to use gel in them plus you have to start IV D10w or formula NG feeds so gel has no role. Moreover gel is not 100% effective in preventing hypoglycemia same as vaccines are not 100% guaranteed. Having said that we use gels in terms because they have more glycogen reserves as compared to preterm and sustainability is more attainable in terms as compared to preterm.

Hi Dr. Vira Thanks for the comments and I am glad that you like our book useful. The Frequency is not appropriate for this 630gm baby, change in frequency affect your tidal volume and hence CO2. Hz of 10 is too low for this baby and hence the first thing to change since PCo2 is too low, we need to act aggressively on it since the change in frequency affect PCO2 more than amplitude. Also as mentioned in the text, amplitude should never be changed by this number i.e by 6 but slowly in increments of 2. Regards Naveed

Thanks @drnono for such a nice detailed answer, if u see the ECG in the question it is wide complex tachycardia, HR around 175, so not at all SVT by any means or even by definition. We can debate about lidocaine vs adenosine but I think from exam perspective I still stand that lidocaine is the answer and correct in book but @tarekhas a point and reference we can't ignore especially when there is VT and SVT aberency. Thanks for your comments. Don't know is there any pediatric cardiologist in this group who can comment to guide all folks.

Thanks Tarek, will take a note of this and will amend it.

Hi Tarek Thank you so much for the e mail and comments about Q2 of Cardiology. To my knowledge Adenosine has no role in Ventricular tachycardia. Here patient is stable with pulse and BP, so stable V Tach is treated with IV Lidocaine and pulseless V tach with defibrillation and not with synchronized cardio version. I am attaching a reference review article for our discussion.Unfortunately our site didn't upload >1.95MB files so as such I am sending DOI, it is free. Please see page 349. Please let me know what you think. Contrary what you said is what we do in Supraventricular tachycardia, IV adenosine when stable and synchronized DC shock when unstable. Thanks DOI: https://doi.org/10.3345/kjp.2017.60.11.344