Schumz

@ali We have recently started using LISA and we had a lot of disussion on what to use as premedication. ...the choices were propofol, fentanyl, morphine etc After much discussion we agreed on Fentanyl! I will have to double check if we give anything else along with it! We have developed a guideline ...which includes which baby, when and how! Only by consultants or under their supervision by senior trainees...Hope that helps.

@bimalc thanks for your reply. Yes we have the facility to do Echo in our unit but in a sick infant I was wonedring if it is of some use when monitoring continuously. I agree with you trend rather than spot check is required. The normal values for neonates only studied in 2 studies 1992 by Skinner and another one in 1980 which quote a range from 4-6 for healthy term infants. Most (49/62)babies studied by Skinner had a congenital heart disease and rest had RDS..it was an interesting read

Guys I need your expertise and knowledge about use of CVP monitoring in a sick neonate... The normal values range in between 4-6 in children (as per the literature...) How much do we rely on this measurement? Are there any normal values in preterm infants or non-immune hydrop babies?

@alexscriven I agree with pooling data ...would look into it !

Thank you all for your comments. I agree @Stefan Johansson regarding babies who have been ventilated we don not extubate either. @ashok we get an MRI in the first week, usually after rewarming is completed.

Thank you ...I thought so and did the right thing!

Guys do you ventilate, SVIA (self ventilating in air) babies just for cooling? If not what strategies do u use for making them comfortable?

Just to let you know baby's comgestion settled on its own ...waiting and watching was a good idea indeed.

Thank you for your comments. @Stefan Johansson and @Francesco Cardona yes he had a probable seizure but no further seizures. CFM for 48 hours all satisfactory. Baby is now extubated and we are normalising his care. I think waiting and watching worked.

Dear all A little bit of brainstorming is needed. We had a term baby deliver SVD. No risk factors for sepsis. Cord around the neck at delivery noted. Baby at birth did not require any resuscitation and was with mum in the postnatal ward. Had a 25 ml feed. Asked to review by the neonatal team due to facial congestion and low temp. Temp was normal on the review but grunting and facial congestion was noted straight away brought to nicu at 8 hours of age due to oxygen requirement. Soon needed ventilating and curosurf. Post ventilation oxygen requirements came down to air. Blood gases were satisfactory. PH>7.25 BE and Lactate WNL. Noted to have abnormal movements at 11 hrs loaded with phenobarbitone and CFM was commenced. No further clinical or subclinical seizures. However the baby's facial congestion is so bad that the face looks purple (as if strangulated) in comparison to the body (which is probably normal colour but looks pale if you look at the face) Bloods including platelets, coagulation and hematocrit are normal. I don't know... could be my perception, it seems that the facial congestion is getting worse. Head scan is normal. No obvious stroke (but limited study). Mild periventricular flare. Do I need to worry and investigate further???? but what ???? I'm thinking could there be a clot in the neck vessels? It might be just secondary to cord around the neck but wanted to share ...am I missing something! Your comments are appreciated.

All of the above as @hamid. Bowel loops very distended. There is no NG tube in this radiograph!

Thank you for your detailed comments. The baby did receive surfactant as part of the normal practice. Oxygen requirement was 26% when I got handed over the baby. As mentioned in the first instance ...I couldn't understand those settings at all and thought maybe I do not know the intricacy of HFOV this may be a strategy. But because I was uncomfortable, I read and found out, mostly what that you guys have mentioned above. This has given me so much clarity... cheers to all the gurus' (You all). Much appreciated.

Absolutely wonderful insight. Many thanks for your comments @Tanyah Very useful, read the article ...some important key take-home messages, many thanks Thank you

In our unit, the nursing staff prepare antibiotics and also attach IV to babies. Pharmacy check dosing, prescription and are responsible for preparing TPN.

Thank you very helpful discussion indeed. My personal practice and training have been as above, therefore, nothing made sense to me in the above case. I agree Conventional +VG is the only strategy that has shown to improve BPD or quick transition to NIV. But I would not disagree with @thx3 on the accepted use in preterms, but need to have a clear understanding before starting to do something new in this vulnerable population. He is right, the staff and everyone else should be on the same page.

Thank you for your comments. Very helpful. Thank you for the above explanation. I did read the Drager brochure and found that very helpful and that was when I got a bit confused. Because the baby in the unit was on a very low frequency, whereas, in Drager they recommend babies to be started on a frequency of 12-15 and on VG 10 Hz, hence I brought it up. I understand the lower frequency strategy for meconium babies etc but it was difficult to understand the lower frequency strategy in extremely preterm ELBW baby. I guess the aim was to increase VG but couldn't find a real explanation! Maybe frequency doesn't make any sense in VG as Dr SAS suggested so it was reasonable to go lower down in above case? I always thought it is the amplitude that you don't have to fiddle with when on VG mode, as the ventilator decides that. But overall I feel more in context with the use of VG in extremely preterm infants. I perhaps need more time and reading to try it one day.

Hi Guys, I would like an opinion on HFOV, HFOV+VG as a mode of ventilation for extremely preterm infants. Case: 24 weeks, 600g baby (day2-3) past honeymoon period, on 2x inotropes just maintaining borderline BP. Ventilation: HFOV+VG, Hertz 6, VG:3.3mls/kg. Blood gas was reasonable. The baby was put on this mode as there were apparently issues with CO2 clearance. My experience with this mode is (...use it when nothing works!) limited. I have used it comfortably in term or near-term infants but in an extremely preterm infant, I was a bit shaky. Anyhow, I thought gases are stable and the baby seems to be coping well... let's not rock the boat! Unfortunately, the VG started to play up as the ventilator kept beeping (...volume not being delivered) so I took off the VG... then didn't quite know whether to put the Hertz up (from 6 to ???? how much? or to just leave it) because now we were only HFOV minus VG. Repeat gas wasn't as good. In the middle of the night, the safest thing to do was to switch the baby over to conventional which I did and it worked for the baby. I couldn't comprehend the reasoning for the initial ventilator settings ...so started reading about strategies in preterm infants as I do not have enough experience with this mode in extremely preterm ELBW babies and thought I'll get some useful information. But I was totally confused and felt blank especially after reading what was available (not much, I have to say). Therefore I thought I shall bring my dilemma here ...for expert opinions and comments. I do not seem to find any standards or reasonable guidance on the following: 1. What should the starting frequency be (especially in babies <1000 g)? Should we be using this mode for these babies in the first place? 2. What about the VG mode? What kind of frequency do you use in your practice for extremely preterm ELBW babies? Is it ok to go down to 6hz in a baby ~600g on VG mode? Is there any evidence? Is it just experience-dependent? 3. Any useful literature or guidance on the strategies, safety, outcomes etc in this population to share, please? I would appreciate your input and comments.

This is awesome for training !!! simply great.

Great thanks for that... Ill email and find out more

Many thanks Naveed and Stefan... I definitely agree there are several different scopes of thought when handling nutrition. After prolonged periods of slow growth, when these premiees start to grow rapidly it feels a bit uncomfortable, whether to let them grow or do something about it. I also agree about "the role (no role)" of diuretics in BPD and discontinuing its use when its of no benefit but in other complicated scenarios this may be a point of discussion. What I did, while I awaited a response... I calculated her total volume for the most recent weight which came to be=165mls/kg/day while being on volume of 180mls/kg/day and I didn't optimise it according to her recent weight and left her on that volume (165mls/kg/day). She gained another 40g next day with this change. Diuretics have been stopped. I tried to run this program Stefan but it didn't seem to work ...may be doesn't like Mac!! Will try at work. It might be something we could use in our unit.

Hi Guys Is there anything called excessive weight gain in a premature (25+5 weeker) infant who is now 54 days old. Having gone through longterm MV, difficulties in getting extubated, use of steroids etc she is stable on CPAP currently and gaining weight 60-90 grams/day, at 180mls/kg/day of EBM and full strength fortifier. Her growth on chart going like mount everest...Bloods are normal...Creatinine is normal, urea is 8.9 which has crept up a bit. She is auto warning on her diuretics (0.8mg/kg) because of weight gain. Since she is gaining weight so fast, she appears oedematous to some nurses sometimes... but obviously she is not, its just fat as linear growth is yet to happen. My question actually is.... is there ever a logic in cutting back their feeds because there is too much weight gain? Having worked in different set ups I have seen clinicians cutting back on milk feeds from 200mls/kg/day to 180 or from 180 to 165 because the baby is gaining lots of weight.

Dear friends, I have never been able to undersatnd the fluid balance calculation in a neonate:confused:...When do we say positive balanve and when negative and what are the implications and what do we do to manage this. eg If a neonate is +/-ve 100mls but satble other wise with a urine output of >1ml/kg/hr I would appreciate any kind of input to explain this to me in detail thanks for your help.

Thank you very much ...That was very helpful! Things will make sense now.

Hi everyone, I am quite new to this forum but I really lik ehow the forum and site works. Although it seems quite silly but I need to understand the basics of pre and post ductal saturation what do they actually measure! Blood from the heart or to the heart? Thanks guys!