rehman_naveed

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 Stefan. Exactly what I mean that. The same is true here as well but the problem is too many people write in their own style and don't update it daily which result in unnecessary details or old stuff carried forward. we do also have cut and paste facility which we use by copying the previous day note and paste it in new date and modify /update it. I need to ask few question 1. How do you avoid or make sure previous note is not carried forward without being updated? 2. Do you write week end summary note in the system or outside the system ( i mean where daily progress notes are auto populated or a separate folder. 3. Do you write with problem based approach or system based approach? 4. How do you approach with problems which are resolved , whether you remove them from notes or put them under separate headings in same note? 5. What about daily stuff like PEEP increased /decreased, urine out put, Ins and Output charting, examination findings What I want that everyone in unit should follow the same format and for this I want to form a uniform template acceptable to all, which is easy to follow, assist in discharge summary etc Would love to see a typical progress note template you use, if possible can you please share ( of course by removing patient informations) or inbox me and also weekly summary format and discharge summary. Thanks in advance for your help Naveed

Hi Everyone Our unit has recently changed to electronic documentation of daily progress notes but we find it very difficult to unite everyone on one uniform progress notes so that everyone in the unit write on same format. this will ultimately help to shorten the discharge summary at the end of newborn NICU course and easy to dictate plus also it will help to familiarize any one to get an impression of what is going on with he patient currently and what has happened in the past without going through each and every note. I was wondering those who have electronic charting in their unit, how they cope with it. is there a fixed check mark notes template or you create your own note, if yes what would you include in your notes especially main headings and how you daily update your note. Any help /feedback will be highly appreciated. Naveed

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

Hi there i would suggest that children and maternity hospital should be build in same tower. L&D and OR must be designed in such a way that both open in one room where newborn must be stabilized before transferring to NICU which ever floor it may be. isolation rooms not more than 4-5 as most of newborn infections are not usually need isolation unless you are planning to admit newborn from outside hospital in which case you might need more isolation room during RSV seasons. usually a block of 10 beds with direct assess from nursing station is must. most important is physician rooms, their lockers etc must be in same level. parents lobby, quite rooms for family meeting and also enough room for handover , eating rooms etc are all important . i don't know where this tower will be as it also depends on local NICU guidelines may vary also. regards naveed

Thanks for update. 3mm PDA will never close by medication. Good that surgical closure decision was taken early. but make sure to have ENT to have look on vocal cords before discharge to rule out VC paresis even if everything goes well. regards naveed

What is the Day of life now?how is the XR looks like ? I would treat with indomethacin before it is too late and we are left only with surgical closure .

Use vancomycin if line sepsis is suspected and only if cs grow s epidermidis that is resistant to clox otherwise for LOS clox and tobramycin coverage is enough. Also don't use too frequent cefotaxime , it will create much problem in terms of resistant bugs. Use only when meningitis is strongly suspected and u can't do LP due to sick baby etc. we use meropenem rarely.

Hi ayemen there is no universal rule . But to use meropenem as 2nd line is not at all allowed. but it all depends on baby condition. In case of septic shock , yes you can use big guns but for routine rule out sepsis ( most of NICU admission) don't change antibiotics unless blood cs comes positive and narrow down the antibiotics. it is very rare to grow gram negatives after 24 hrs of culture with modern techniques , so gram negatives should be discontinued after 24 hrs provided clinical and lab evidence are normal and then also DC gram positive later at 48 hrs. i hope it helps and answer your question naveed

Great news

Do basic things like prevent hypothermia, hypoglycaemia, give oxygen, cover antibiotics, and above all strict hand hygiene. Don't be disheartened by high tech equipment of developed countries. Neonates also die here as well with severe PPHN, NEC etc Basic steps of resuscitation and proper ambu bag technique is all that necessary and then CPAP. Very rarely kids need intubation. Hope I answer your question

Seems like pneumomediastinum

Can you plz tell are these sugars prefeed or post. Did you simultaneously checked bedside PCX and lab value. Since on trophic feeds, what is GIR, what fluids baby is receiving with dextrose load? Sample is taken from ??

I dont know exact reason but seems like albumin moves lot of fluids from 3rd space to intavascular compartment endagering cardiac failure and pulmonary edema. While plasma does the same but to lesser extent

The scenario you describe is usually achieved by giving albumin rather than plasma. And also this is done in severe anasarca with oliguria to get rid of extra fluids but this is usually transient to help baby respiratory status improved. Having said that in capillary leak cases secondary to sepsis no role of albumin only plasma will help and stay longer intravascularly.

Now its a different scenario. Ascities with liver disease, you need to check for albumin and in case you need to give plasma , donot give lasix. But it all depends what you want to achive, do you want to raise plasma oncotic presure so as to diurese the baby as baby having oliguria, in such a case i will go ahead with albumin rather than plasma and yes this with lasix. If it is just to replace clotting factors then no with lasix only plasma alone. I hope this will help.

No need for lasix routinely unless baby is having cardiac failure with volume overload condition

I think first you need a good nursing care. You need to recruit experienced nicu nurses, then needs for sterilization, hand hygiene, infection control stretegies and fundings. These are few grass root things on which good nicu care depends.

Can u tell more about x ray findings, based on what findings NEC was diagnosed. Free study of gastrografin means what? Continous feeds may help. Donot check aspirates untill baby is nauseating.

Adding to thread can someone tells me how much maximum pressure we can use on cpap

Why are you treating PDA at all cost irrespective of even contraindication and even in dying baby , As already mentioned not all PDA needs treatment and even current evidence is going away from treating any PDA. There is nothing Prophylactic ibuprofen in literature about treating PDA, I donot know from where you quote this term? do you have any evidence????? So in short answer to your question is " NO"

Experts debate the role of surfactant in the pathogenesis of pulmonary hemorrhage. It is postulated that surfactant decreases pulmonary vascular resistance, thereby increasing the left-to-right shunt across the PDA. This results in increased left ventricular pressure, which can increase pulmonary capillary pressure and result in pulmonary hemorrhage. Studies have shown a strong association between pulmonary hemorrhage and high pulmonary blood flow, due in most cases to ductal shunting. The symptoms of RDS usually peak by the third postnatal day, and they may resolve quickly when diuresis starts. Because infants who have RDS usually develop hypoxia, the ductus arteriosus may remain patent. Early in the disease, shunting is from right to left. The clinical improvement seen in this patient was accompanied by a rapid fall in pulmonary vascular resistance and rise in systemic arterial pressure, which led to the development of a large left-to-right shunt through a PDA. Therefore, the patient's recovery was interrupted by the development of congestive heart failure and pulmonary edema and, finally, pulmonary hemorrhage. When the granular pattern of RDS changes to a homogenously opaque appearance, pulmonary edema due to PDA or early chronic pulmonary changes should be suspected.

If baby is dying, donot bother about treating PDA with Ibuprofen, at that stage it is contraindicated. At that stage maintain BP, give inotrpes, blood products etc. Other causes beside PDA of pulmonary haemorrhage in EBW babies is immarurity and fragility of pulmonary vasculature, DIC etc

The answer is "No" echo to be done before ibuprofen, atleast for the first time. This is due to fact that even there is no structural heart disease, not all PDA needs treatment, only pulsatile type PDA needs to be treated if clinically condition permit and there is no contraindication. Pulmonary hypertension type do not need treatment with brufen to close rather it is contraindicated.