bimalc

I had not even heard of the practice until I saw your post. I have worked in 5 large academic NICUs around the US without encountering this.

I have done 80/kg in the past; I think we agree on the importance of uop,etc. and adjusting fluids based on weight, output and labs. 50/kg just seems unlikely to be sufficient in my experience, but if there is international experience suggesting otherwise, I might need to reassess my practice

@Hamed I am interested to hear your fluid management for micro preemies is quite different than practice in the US. I do not imply that one is superior to the other, but I must ask what difficulties (if any) you have in maintaining normal fluid electrolyte balance with only 50mL/kg/day of fluids in the smallest babies? In the two units I currently work in, such a baby would typically receive 100mL/kg/d on day 0 and increase 10-30mL/kg/d. My experience has been that even with humidified isolettes (or at least the ones I have used over the years) such babies can lose massive amounts of weight/water and become very hypernatremic if we are overly cautious with fluids early on.

I know it is not the question you asked, Hamed, but I just re-read one of your posts and was intrigued to see you identify a benzodiazepine as your second line agent. Is that common in your institutional or national practice? We reserve Midazolam infusion for seizure refractory to multiple AEDs and up-titrate to effect (usually patient needs to be intubated for airway protection if we are starting Midazolam infusion). I have used fosphenytoin and Keppra after phenobarbital (in discussion with colleagues in neurology) before starting benzodiazepines. I am now curious about other's experience/practice.

Surgical or medical management? I am not a pediatric surgeon, but I am sure there is a literature on timing of closure. I think of several medical management issues when there is a baby with this problem in my ICU: - Delivery room: sterile bowel bag is a must. Avoid umbilical catheterization if possible. We obtain cultures and start antibiotics for all gastroschesis because of the exposed bowel and risk of contamination despite best efforts at sterility. - Fluids: surgeons may be worried excessive fluids will cause edematous bowel and make closure more difficult, but even with a silo there are lots of insensible losses and fluid needs will be great. Track urine output and heart rate closely as well as electrolytes. - Pain control/sedation/meds both for the abdomen and the fact that patient is likely to be intubated but also you may need to provide anesthesia for bedside closure. We use high dose fentanyl and rocuronium +/- benzodiazepine. Need to have code medications & fluid drawn up and nurse dedicated to administering medication. - Having enough access - you can try to use a PICC, but many of these patients will need longer term access anyway, so surgeons may place tunneled line for you. - Biggest issue with success in my experience is not the surgery itself, but re-establishing feeding afterwards. It pays to be patient and accept slower advancement if it ultimately means less time on TPN and less central line days. Are there specific issues/questions you have for your practice setting?

I must agree wholeheartedly with Francesco! Increasingly we must consider sedation/analgesia for 1) procedures 2) bedside OR and 3) chronic respiratory failure requiring long term intubation/tracheostomy Ultrasound in the form of targeted neonatal echo as well as for vascular access. I suspect an adjunctive workshop on US guided access and/or targeted echo would be well attended Genetic testing is changing rapidly, but at different paces in different economies. It would be helpful to discuss what the actual evidence base for different testing is as well as having a frank discussion about the costs involved As a US-based practitioner, I would also appreciate the most up to date information on LISA (especially if there was time on a simulator to become comfortable with procedure). Catheter based surfactant is not widely used in the USA, but surely that will change in the near future.

I am a final year fellow at a US training program, so I am looking at jobs right now. I think both Stefan and Naveed have said many valid things; I will write from a US perspective as your profile indicates you are also US based. First, to take a step back, neonatology is a fellowship under pediatrics, so, as a 3rd year medical student you will need to plan on matching first to a pediatrics residency (preferably one with a large/high acuity NICU) and completing your training in general pediatrics before moving on to neonatology. I would urge you to look at programs with broad training pediatrics because you may decide in the intervening years that you enjoy other areas of pediatrics and this is OK. Assuming you proceed to neonatology fellowship, many (but not all) are front loaded, especially large academic programs like the one I train in. This means your first year will have very poor work-life balance. However, I have obtained a research grant to protect some of my time and I currently do ~12 weeks of service a year, 1 overnight call a week. Jobs: Broadly speaking there are 3 types of jobs based on how you are compensated and these may lead to a mix of research and patient care at either level III/IV (to use the AAP designations) or level II/III. Most level I jobs in the US are taken by general pediatricians, not neonatologists. Job type 1: Academic Clinical - You will probably do service for ~4-6 months a year in 2-3 weeks blocks depending on your other responsibilities to the university and department. Your service will likely be a mix of level II/III/IV (and possibly deliveries/consults if your consult or delivery services are busy enough to need a separate attending) and is based on what your institution needs and what you negotiate. Level II service will typically NOT require in house call and is often not very demanding. Level III/IV service can be exhausting and many people arrange their lives to have no obligations outside of work for those weeks. Call at these location is often in house overnight. Frequency of call is largely a function of how large the academic faculty is. Job type 2: Academic researcher - You will do ~1-3 months service/year, often at a level III/IV. The more you bring in in grants, the less service you do. I have many colleagues who do as little as 6 weeks service/year. Service, when you do it, is as above. The thing to remember about overnight call in most academic jobs is that 1) you probably were NOT providing patient care in the morning, just at your desk doing admin work or research and 2) You probably have fellows and/or residents taking most of the calls for you, so you really only pay attention to one of two kids, set them up for the night and then ask the fellow to wake you up if there are issues. Job type 3: Private practice - Mostly level II/III (although a colleague who graduated a couple of years ahead of me has a private practice level IV job in Seattle). The schedules for service and call here vary widely. I've heard of all sorts of things from being on for multiple days in a row a few days a month, to alternating weeks of days and nights, etc. The '10 24h calls' thing is misleading because it makes it sound like its you against the world for those 10 days and it isn't. You'll either have nurse practitioners doing most of the front line work or the volume will be quite low compared to fellowship, so I'd really think of it more like 10days I'm working and 10 days I'll either be a zombie because it was a bad night or (more likely) I can go to my kid's soccer game just fine. In the US the real trade off is in private practice you'll work more but get paid more. In academic jobs you'll get paid less and put up with academic bureaucracy, BUT you'll also have access to academic resources to help you pursue projects of interest which may not be financially lucrative. Also, one further option for providing neonatal care in the US is being a hospitalist which would allow you (in the right job) to work in a NICU without being a neonatologist. The pay is decent (not as good as a neonatologist but at least as good, if not better than a general pediatrician in the community), the hours are better than a neonatologist and you will always have a neonatologist to back you up on procedures, etc. Hope this helps Bimal

We do not have set national guidelines in the US due to the way our health services are organized, but in the NICUs I cover (one in-born one out-born, both with cooling) we do treat electrographic seizures though our tolerance for isolated seizures will increase as time goes on if it becomes established that seizures are persisting and there is the need to balance the benefits of extinguishing seizure against the side effects of AEDs. Regarding aEEG/CFM vs. EEG, because there is an active neurocritical care service available, we tend to reserve aEEG for urgent/emergent neurodevelopment-monitoring as it can be done by NICU nursing staff and interpreted by neonatologists as opposed to EEG which requires staff from neurology to set up and interpret. Once a patient is clearly on a pathway where we may plan and anticipate their monitoring needs, we use EEG and/or vEEG per the preference/recommendation of our neurocritical care service.

My interpretation of the GRADE review is to ignore the pooled estimates for the observational studies for sure because of the poor quality. The issue is, as Stefan highlights, confounding by indication. The available RCT data do not support transfusion as increasing risk of NEC. I think the most elegant study to try and better understand what is going on and by-pass the confounding by indication study is the JAMA https://www.ncbi.nlm.nih.gov/pubmed/?term=26934258 where they are able to parse out anemia from transfusion. I am still only a fellow, but I base my transfusion practice vis a vis NEC risk on the RCT data from the GRADE review and this paper highlighting the anemia as the key feature. This conclusion is consistent with the finding in the RCTs of less NEC in the liberal transfusion group because the liberal transfusion group would presumably have less (and likely less severe) anemia.

There are two issues. Can you? Yes. This is quite normal in inborn errors of metabolism for example. Are there improved outcomes? I am not aware of data for the general nicu population however I have seen that carnitine levels rapidly become low if baby is npo. For many babies who are not so sick and will start enteral feeds soon it probably does not matter, but I wonder if there is benefit in prolonged npo especially if baby is critically ill or with cardiac dysfunction