Justinas

In the UK we have national, societies' (BAPM), network and local hospital guidelines. They are fairly well aligned and agree to the TOBY criteria. Infants ≥36+0 weeks’ gestation are eligible for therapeutic hypothermia Treatment must start within 6 hours of birth (BAPM suggest case-by-case decision up to 24 hours) Apgar score ≤5 at 10 minutes, ongoing need for resuscitation at 10 minutes, cord or first-hour blood gas with pH ≤7.0, or base deficit ≥16 mmol/L. Evidence of moderate-severe encephalopathy (Sarnat or Thompson score, or 'clinical assessment' - this does not align clearly) aEEG showing abnormal background or seizures is strongly encouraged where available but should not delay cooling if clinical criteria are met. Cooling is not recommended for mild encephalopathy or for infants <36 weeks’ gestation outside clinical trials. Please find attached three levels of guidelines (I don't include a local one as usually they are not publicly available) NICE therapeutic-hypothermia-with-intracorporeal-temperature-monitoring-for-hypoxic-perinatal-brain-injury-pdf-1809589753436101.pdf NWLPODN-HIE-cooling-Guideline-V1.5-final.pdf BAPM THNE_Framework_2025.pdf

Hi, sorry to hear you are struggling with the extreme premature respiratory management. What do you mean by 'initial management was ok'? I think the devil is in the details of initial respiratory management. Here are my thoughts below. Some European practices have moved away from using non-invasive respiratory support as a first-line for these gestations as studies such as Epicure, SUPPORT and NRN subgroup analysis showed high NIV failure rates and worse outcomes for such babies. Therefore, services are moving back towards elective intubation at the time of delivery and giving very early surfactant (to prevent potential atelectasis-induced injury with CPAP/BiPAP/NIPPV). Volume-targeted ventilation has also become an initial starting ventilation mode to prevent volume-related lung damage (European RDS consensus, Cochrane review 2017) British association of perinatal medicine also included early hydrocortisone as an option for babies who are likely to have severe chronic lung disease due to emerging evidence https://www.bapm.org/resources/195-extreme-preterm-birth-a-framework-for-practice-2023 Early hydrocortisone should not be used with indomethacin due to significant increased risk of spontaneous gut perforation and there is a lack of long-term follow-up studies to assess its effect on neurodevelopment. I would be interested to know what is your usual initial respiratory management strategy for 22-24 weeks gestations.

I contacted the UCL education centre, they responded ‘The course directors asked us to close registrations last week as we have nearly 300 people registered to attend.’

Peripheral cannulae we fix only with steri-strips, UVC/UAC by single suture. Long lines come in only when skin has matured somewhat, at 4-5 days age (we use tegaderm for them).

I recomment to check out this webpage, which has also a documentary movie describing features of this NICU in the USA. http://www.chrichmond.org/Services/Neonatal-Medicine.htm