rehman_naveed

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

Thanks so much. This is what I want, share and spread the knowledge. These mcq's are great asset for fellows in training. Naveed

Hi all, we have published the fifth edition of our e-book “NEOQUESTIONS 1to1” . Please feel free to distribute among your other colleagues to help them gain the knowledge of neonatology. https://docs.wixstatic.com/ugd/92a170_54197b618fb34a39a7702b7679a085ec.pdf With Best Regards NAVEED

For infants with sepsis/ septic shock due to their third spacing secondary to capillary leaks plus they require multiple fluids blouses/ colloids etc, we use weight prior to sepsis call it as dry weight till he or she is back to dry weight. If the kid is still puffy for few wks or month, we take 25th percentile for that age and calculate all fluids based on it. I hope it helps Naveed

This is what we do here in Canada as mentioned above by nashwa. There are no fixed numbers in short. naveed

Thanks terek for reference. What is not mentioned in study how they excluded feto maternal hemorrhage. May be that is contributing to KB positive test. It is highly unlikely that abruptio fetal blood is lost. Fetus either die or present with severe shock/acidosis secondary impaired exchange of nutrition and acids across placenta but anemia is not likely unless it is feto maternal hemorrhage. Naveed

Thanks Stefan and tarek let me frame this question in a different way. In abruptio placenta the blood lost is fetal blood or maternal blood? Thanks Naveed

Hi Everybody, Greetings from Canada I have a quick question, in case of mom presented with severe abruption placenta, can the baby present with severe anemia? will you arrange O-ve blood ahead before delivery or standby? Thnaks

There should be no reason to intentionally ventilate babies while cooling. How can ventilation cause comforts? we use low dose morphine infusion to keep them calm 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

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

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.