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Because they relied on nurse charting of changes in vital signs, there was almost certainly non-differential misclassification leading to significant bias of effects towards the null. Nurse charting of events like desaturations is notoriously uneven relative to continuously measured data from monitors (this is one of the rationales for using SpO2 histograms to drive management instead of 'event counts'). A trial with continuous VS capture would best resolve the issue.

I would urge caution in assuming that tight glycemic control improves patient centered outcomes, though certainly, it would appear that if one were to test that hypothesis, it might be worthwhile to test it using such a closed loop system to give the intervention the best chance at success.

I've come late to the conversation after being on vacation and of course the dx of pneumatosis is not in question. I am, however, interested in the recommendation for surgical consultation: What is everyone's threshold for consulting surgery in NEC? Frankly, if I did not need to worry about my relationship with the surgeons more generally, I would only call them if I thought ex-lap or a drain made sense. This was the practice at the last in-born ICU I worked in whereas as the outborn unit I last worked in every child with NEC got a surgical consult. The difficulty with this was that the surgeons would then insist on driving the decisions on abx and NPO

I've used roughly the same thresholds as Hamed, fudging a little higher or lower based on symptoms. In addition to the collateral information Hamed recommended, the single biggest thing to figure out (in my experience) is whether this is iatrogenic or not. Often times, iatrogenic hypercalcemia even at high levels, can self-correct whereas if there is a real underlying cause, that too can suggest definitive therapy. Assuming it is not iatrogenic and the Family history is non-contributory, I would at least consider a diagnosis of William's Syndrome.

I practice in two very different ICU environments, one delivery and one which is more of a med-surg ICU closer to a PICU than a NICU in many ways. I think the data are clear and many of the previous respondents concur that NaHCO3 in the delivery setting is at best useless. For the ELBW with anticipated renal losses NaHCO3 should almost never be needed because these losses can be anticipated and should be incorporated into nutrition to avoid the biochemical inevitabilities noted in the articles Stefan cited. I suppose I might use bicarb in the preemie population if I had metabolic acidosis and evidence it was effecting cardiac output and even then I probably would not correct past 7.2. However, in the case of the older child or the med-surg patient where some specific pathologic perturbation has led to rapid collapse and I suspect part of that mechanism is bicarb deficit, I would have no hesitation to rapid correct the pH. I have several times done this and watched the EKG improve in real time.

When I was a fellow, I trained at a delivery hospital that used flow-inflating bags and it made this sort of failure very easy to recognize (if there was any defect in flow, the bag would not inflate). The downside to this is that without flow you can't give ANY respiratory support (after a critical incident of this kind where the flow inflating bag actually ripped in the middle of a resuscitation, we started stocking an emergency ambulance bag as back-up).

The UVC is clearly malpositioned. We could have an academic discussion of what vessel you've ended up in, but that thing is never going to get to the IVC/RA junction. It is also worth noting that the enteric tube appears coiled on itself also needs to be adjusted. Just curious, but was the indication for line placement?

In the top right corner of the site is a link to an English language version of the software, but I did not see extensive English language documentation

The problem with this population is seldom in the ICU setting (assuming people are not actually smoking in your ICU), however, from my experience as a house officer on a children's hospital pulmonary ward, certainly children with BPD will suffer from a home environment full of smoke (it certainly felt like many of the BPD 'frequent flyers' had parents who smoked while the pulmonary fellows would insist that their BPD clinics were not like this).

I fear I may have exposed myself poorly. My concern is less with a ceiling (which implies that I am opposed to escalating levels of care) as opposed to walls or boundaries. By this I mean, my concern is that we sometimes offer families options which have no realistic hope of helping the family achieve their goals of care all because we do not wish to be paternalistic.

This is an important topic, but also one where national/cultural norms will have a large influence on practice. Coming from the United States, where a stated standard of shared decision making often is felt to devolve into 'the customer is always right', I have found that the single most important thing I can communicate with the team (either the ICU team I am leading, or the one I am consulted on as a member of my hospital ethics committee) is to remind everyone that not only do we have no ethical obligation to offer/perform non-helpful interventions, to do so is often unethical, especially when those interventions are invasive and/or traumatic. In the US, we often have the problem of feeling like we must ask the parents about every decision we make when, in reality, if there is no actual choice to be made we ought not to offer a false choice (and then get mad at the family for choosing incorrectly).

Given that ELBWs get comprehensive follow-up (at least in most settings I know where you could even contemplate routine MRI at discharge), what possible value could MRI provide which would change care or outcomes? Would you stop following up ELBWs who you 'knew' by imagining criteria were not going to have CP? I doubt it, because you'd want to see them anyway for other developmental reasons. Do you have an intervention which can prevent CP after NICU discharge? I don't. The best you can say about a routine MRI protocol is that you could tell the parents on graduation the probability of their child developing CP. That prediction is only reasonably reliable for a 'normal' study and in either case isn't really much better with MRI than with US. Maybe this will change with research, but I'm pessimistic. Research will probably make imaging a better research tool and inform our understanding of brain development and injury, but the clinical utility of making predictions at NICU graduation, in the absence of some sort of specific post-discharge intervention, seems dubious at best.

I was unaware anyone was arguing that 0.5mcg/kg/dose reliably provided any clinically meaningful effect in the context of direct laryngoscopy. There are, however, doses of fentanyl between 0.5mcg/kg and 5mcg/kg which almost certainly offer some analgesic relief and (at least as importantly) provide a side effect of sedation which improve intubating conditions while not so suppressing respiratory drive that extubation becomes impossible.

The practical problem with this claim (which I think we all believe in in principle) is that, at the time the initial plan for the day is made, TPN must be ordered and a fluid goal set. In the setting of MEF, you have no sense of how much will be tolerated and absorbed, whose belly will blow up, etc. As a practical matter, one has to simply assume that volume does or does not 'count' and accept that you will be 'off' in one direction or another. It actually does not matter, as long as one is consistent within the unit and if there is ambiguity when sharing with other units, that you are clear on what your practice is. As long as all sides of a discussion understand the chosen convention, you can have an informed discussion about the specific needs of the patient and any needed changes in the plan over time. My experience in 5 NICUs over the years is that none has counted MEF towards calories or volume and instead relied upon TPN to meet all nutritional needs during this period. Again, for ease of computation (and thus safety) the practice in ICUs I've worked in (and a practice I subscribe to) is that once you are past MEF you are implying a belief in physiologic tolerance of the feeding volume (otherwise you would not be ordering feeds) and so you should count all the volume/calories.

I have no idea what the cost is, but intranasal fentanyl could be an option. I've only ever used it in a palliative setting, but all out babies who would be insure candidates are getting IV placed for fluids. Even with aggressive enteral nutrition we used a few days of fluid.