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HickOnACrick

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Everything posted by HickOnACrick

  1. As of yesterday, baby has continued to wean slowly on HFNC. FiO2 needs are mostly <40% on 3 LPM. Most importantly, baby has started bottle-feeding. We were very concerned about oral aversion. Baby remains on caffeine, multivitamin with iron, and Pulmicort NEB BID. Baby is gaining weight on a mixture of EBM and Neosure. When we have a baby that seems to be failing on HFNC, we generally move them over to NBCPAP or NIPPV, but we have used increased LPM flows (>5 LPM) on occasion. I have colleagues in other NICUs that prefer using HFNC at 6-8 LPM vs NBCPAP.
  2. I use NaCl or NaAcetate in TPN. I can't remember the last time I used NaPO4. It is an option, but we do not use it often. We do not routinely check electrolytes until day 2-3, nor do we routinely add any supplements other than Ca and protein the first 2 days. What is happening with the weight of your babies that experience this hypernatremia? What about the urine output? A low UOP and substantial weight drop could imply lack if intravascular free water.
  3. Here is our initial fluid management strategy: <750 grams = 120 mL/kg/day 750 - 1000 grams - 110 mL/kg/day 1001 - 1500 grams = 100 mL/kg/day We use 0.25 or 0.5 Normal saline in our UAC lines, running at 0.5-1 mL/hr. We do not routinely see hypernatremia in the first week, transient hyponatremia from immature renal function seems more common to us. Outside of the UAC fluids, our babies do not see Na in their maintenance fluids until 2-3 days of life. Hope this helps
  4. We have had 4 confirmed subgaleal hemorrhages (SH) in the past couple of months. We have long suspected that many caputs have an element of SH, but avoid CT imaging due to the radiation and that identifying a SH will not change our management in most cases, if the baby is otherwise doing well. Of the 4 recent cases of SH, 2 have had more severe intracranial bleeding (intraventricular and subdural hemorrhages) and skull fractures - one of which was depressed. One of the cases was clearly in need of further head imaging on admission, due to the clinical picture, but the other was muc
  5. Going off service for a week, so an update. Baby has continued to slowly improve. Baby is now on HFNC 4LPM with oxygen needs around 30%, remains on full enteral feeds, fortified, and is gaining weight again. We may need to prolong the steroid course. As the course has weaned, baby's FiO2 needs have increased slightly (we have had the baby as low as 25% FiO2). The most recent chest radiograph shows improved expansion and aeration. Fibrosis and chronic changes are not the worst we have seen. We would not define the most recent CXR as being consistent with c
  6. I have found a few case reports about NICU graduates with BPD being admitted to PICUs with Covid-19. However, I have yet to find a case report of a former ELBW infant, who is still in the NICU, acquiring SARS-CoV-2, and deteriorating as a consequence. With regards to publishing, well, that is in part why I started this thread. It seemed like I was observing a novel effect of a novel virus, but wanted to see if others were seeing it as well. I reached out to my local University NICU's Medical Director, and they have not seen it in their NICUs. I have a couple other calls in to othe
  7. We also use: (weight in kg x 3) + 9 + length of cord This gives us an approximation of UAC depth. Half of UAC length approximates UVC depth. We use an AP radiograph to confirm placement. There is a method by which one can use the cardiorespiratory monitor to determine position of the UVC. Essentially you set the monitor to give an auditory beep with each heart beat. Advance the UVC until the frequency of beeps decreases (this implies the tip of the UVC is at the SA node), then pull the UVC back about 1/2 cm and it should be in a pretty good position. However, those I h
  8. Most I have worked with, including myself, will begin TPN as soon as possible in VLBW and ELBW babies, even with babies that have evidence of metabolic acidosis. In the larger babies, we are more likely to start a "clear" solution of trophamine, dextrose and calcium, or even just a straight dextrose solution - initially. To control blood glucose levels, mostly we can get by with just adjusting the IV rate until we can order a new bag of TPN (once daily). If adjusting the rate is not working (or we have reached a rate we are not comfortable with), we will "Y-in" an appropriate dext
  9. Former 27 weeker, 895 gram male (now 1700+ and 36 and 6/7). STAT C-section for abruption, Apgars 1/3/5. Suspected antepartum anoxia/hypoxemia based on blood gases. Developed renal failure, elevated transaminases, etc. Very difficult respiratory mgmt, at 2 months of life, still on 5LPM HFNC and 50% FiO2 which is far outside the norm for us. This weekend, increased frequency and severity of apnea prompted a septic workup, including viral respiratory panel by RT-PCR. Negative for all the common resp viruses (including RSV, metapneumo, and flu), negative blood culture (now day 3), but
  10. Sad day. In spite of our best efforts, we have been unable to get this baby to ventilate and oxygenate. This morning, on a MAP of 10.5, this was the CXR: Last night we tried a mixture of milrinone and dobutamine to increase cardiac output and open the pulmonary vascular bed, but this made our oxygenation and ventilation worse. We stopped those meds and the baby did fairly well overnight with respect to his blood gases, and we were able to wean the amplitude somewhat. The echo yesterday showed a small PFO shunting left to right, but otherwise, no significant pathology. Throughou
  11. Here is the CXR when the baby's MAP was 12: Here is the CXR when the MAP was 8: Clearly the hyperexpansion and air trapping are much worse on the second CXR with a lower MAP. Per @Miguel Pantoja we increased the MAP from 8 to 10 and have now weaned to 80% with SpO2 in the low 90s. We will continue to wean FiO2 until we reach a nadir, then slowly increase the MAP to a maximum of 12, while trying to wean the amplitude, then we will try and be patient and let the lungs heal if oxygenating and ventilating reasonably well. Ideally, I would like to get the amplitude
  12. We started steroids 5 days ago, albeit the low-dose DART protocol of dexamethasone. I am about to start Milrinone and dobutamine to improve cardiac function. Thanks for your input.
  13. We got the Hz down to 6, but our first attempt to wean the amplitude resulted in a pretty significant respiratory acidosis. What is really strange is that in spite of weaning the MAP from its original 14 to now 8, the hyperexapnsion by CXR is getting worse. I speculate that the air leak is not healing at all, and we essentially have thousands of little tension pneumothoraces surrounding what little areas of gas exchange the baby has; I wouldn't really call them alveoli at 24 weeks. Awaiting an echo now to assess shunting and see if an argument can be made to increase contractility w
  14. You may already be doing all of the following, but these are some of the things we do to prevent CLABSI: 1. TPN changes are performed as a sterile procedure; nobody is allowed within 10 feet of the bedspace without hat and mask. The RN doing the change is gowned up, hat, mask and sterile gloves. Of course, new tubing with every change of TPN 2. Standardized feeding guidelines to prevent days with a CVL in place 3. Minimizing breaks into the line for medications. Medications such as caffeine are changed to po as soon as baby demonstrates ability to tolerate po feeds (at about 60
  15. Thank you everyone for your input. In spite of continuing to lower the MAP, the CXR remains hyperexpanded. Base deficit slowly worsened throughout the day, although BP remained acceptable. The Hct is stable at 45%. I gave 20/kg of isotonic bicarbonate last night for a base deficit of -10, and the pH and base deficit improved. Awaiting another CXR this morning, if it still looks hyperexpanded, I will focus more on decreasing Hz. There seems to be some disagreement in what limited literature I can find (mostly opinions) as to whether a Hz of 12-15 or Hz of 6-9 is more beneficial. Anecdotal
  16. Over the past 3 hours, I have slowly weaned the MAP from 11 to 9. FiO2 has remained 80-90% while SpO2 has been 88 - 91%. Blood gas prior to weaning was 7.31/42/41/21/-5 and the CXR still looked hyperexpanded at a MAP of 11. Most recent gas on MAP 9, Amplitude of 38 and Hz of 9.5 was 7.13/69.6/45/23/-6, 90% FiO2 and 90% SpO2. I dropped the Hz by 0.5 but left all other parameters as they were. Although the base deficit is slowly worsening, he has brisk capillary refill, is urinating briskly, and is maintaining MBPs >32 mmHg without vasopressors or inotropes, thus his delivery of oxygen h
  17. I took over the care of a 24 weeker who developed PIE at about 5 days of life. Baby was doing well on conventional vent (volume-targeted ventilation), when at day 3 their oxygenation and ventilation began worsening. By day 5, PiPs were in the high 20s/low 30s. By day 6, the decision was made to change to HFOV. Our attempts to wean MAP while keeping SpO2 >88% were unsuccessful. We were able to get the MAP from 18 down to 14, but attempts to wean lower resulted in worsening oxygenation. At DOL 7, I made the decision that unless we could get the PIE to resolve, we were likely going
  18. We use a calculation of Total Fluid per day (on day zero) based on birthweight. <750 gram = 120 mL/kg/day 750 - 1000 grams = 100 mL/kg/day 1000 - 2000 grams = 80 mL/kg/day >2000 grams = 60 mL/kg/day For us, total fluids DOES NOT include medications, flushes and boluses/transfusions, rather we have guidelines in place to minimize extra fluid in medications and flushes, and we are very judicious with respect to boluses/transfusions. We increase total fluid by 20 mL/kg/day, assuming no edema. Whenever possible, we convert IV medications to po to avoid excess flushe
  19. Was there a transient improvement in SaO2 and FiO2 after surfactant administration, say for 2-4 hours? If so, I would consider a surfactant protein mutation such as heterogenous SPB mutation or homogenous/heterogenous ABCA3 mutation. Also SPC mutations are highly variable in their presentation(s). Homogenous SPB mutations may have a brief response to surfactant, but will inevitably return to a severe RDS clinical picture. Heterogeneous SPB mutations may be survivable if the baby is full term. Heterogeneous ABCA3 mutations are survivable if not premature while homogenous ABCA3 mutations a
  20. Who needs an electronic nose when dogs and/or pigs could be trained to detect the same differences in VOCs? That is some point of care testing, although I suspect it would not be bedside. I am being a bit facetious, we have cut our NEC rate to nearly zero with a standardized feeding protocol including the addition of Prolacta. We are currently assessing whether the cost of Prolacta warrants its continued use, but from the 45,000 foot view, I suspect it will show a cost benefit. Thanks for the interesting article(s).
  21. I queried one of my RTs this week, asking, "why are they not using HFOV as a lung protective strategy?" Essentially the answer was that HFOV is considered a rescue ventilator mode, and once they are on HFOV, they are calling for ECMO. The adult ICUs are using Vt of ~5mL/kg, but the PEEPs and PiPs to achieve that Vt is astonishing. Done properly, HFOV need not be a rescue therapy. With the increased focus on really good neonatal ventilators, especially those that can reliably provide volume-targeted support for babies < 1000g, I find myself using HFOV less and less. However, if my opti
  22. To answer my own question (5) https://www.frontiersin.org/articles/10.3389/fped.2020.00206/full#B16 It is mostly speculation by the authors, but very interesting nonetheless
  23. During Covid-19, I have spent more time researching Adult pulmonary critical care than Neonatal pulmonary critical care. Based on this blog: https://emcrit.org/category/pulmcrit/ I am both fascinated and disgusted by the approach to respiratory support for Covid-19 patients. For those that have been following adult pulmonary critical care: 1. Are you appalled by the PEEP and PiPs? 2. Are you appalled by the FiO2s? 3. Do you feel like this is Neonatology circa 1990? 4. Do you think HFOV and/or NBCPAP are tools that should be applied earlier, not later for Covid-19 pati
  24. Unfortunately, the very few N95 masks we have available are limited to the adult side of the hospital. 30 miles away, they are using N95 masks in the NICU.
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