bimalc

This has been roughly my experience in3 different surgical NICUs in US

1) Our institutional practice (High volume, high acuity delivery service, 12k births/year) is to have a 'Chorio' nursery monitored and staffed by NICU RN and, covered by a pediatric hospitalist. Babies are admitted there for culture, antibiotics and screening CBC and CRP. Post-partum mothers are roomed on the same floor so they can more easily see their baby and feed. Assuming child is clinically well, antibiotics are stopped at 24-36h depending on biomarkers and the baby is transferred to the mother's room for remainder of stay. 2) We are studying the use of the Kaiser calculator, but there is lots of hesitancy about sending these babies directly to the normal nursery service as there is the perception (right or wrong) that a clinical decompensation in a baby would not be noticed by the normal nursery nurses in a timely manner. The other thing which is relevant for members of this forum is to understand that the Kaiser calculator is based on Likelihood ratios and knowledge of the background rate of neonatal sepsis in the population in question. While the calculator allows you to select a range of baseline risks, it is tuned (roughly) based on the US CDC baseline risk of 0.5/1000. If your local epidemiology is very different from the kaiser assumptions, the recommendations from the calculator may be wrong (disastrously so).

Next generation sequencing (NGS) can have a high diagnostic yield in the patients admitted to NICU with suspected genetic disorder. However, because of cost (and other reasons) this testing is not always available.

Any one with experience in the use of Methylene Blue for hypotension refractory to multiple pressors?

What are folks using as empiric antibiotics for NEC in your local units?

I will essentially agree with all your points (as I often do) but I think these two bear some comment. As for the first, depending on your institutional culture there may be good reasons to NOT involve surgery since most NEC is medical. 1 is transport if surgery is not actually an option in your unit and the other is if your surgeons like to dictate medical management. The antibiotic selection is very interesting as, yes, some variation probably reflects different susceptibility and pathogen patterns around the world, but I'm not aware of much data supporting any specific empiric regimen as 'superior'. In my units, most of our medical NEC gets covered with Amp and Gent (plus Flagyl if the surgeons are involved). Thus, I think the most interesting question now for us as a group is what our empiric abx selection is for NEC. I'll go start a new thread on that and I welcome your perspectives there.

This is one of my favorite topics but one which I have no academic time to pursue. 1) I think this has little to do with science and everything to do with the relative strengths, weakness and, frankly, interests of the NICU and PICU staff. Our NNPs are only credentialed to provide care upto 1 year of age, so a lot of the thinking at our institution is based around this. Also, I don't think it makes a lot of sense to send kids to PICU before they are term corrected unless there are VERY good institutional reasons. 2) At my out born unit the default from nursing and RT, etc. is always NRP so we've developed systems that focus on getting everyone onto PALS if that is deemed more appropriate. For certain cardiology patients who are in the NICU and not the CICU this becomes part of bedside hand off and the stated plan each day as well as signs at bedside (though I don't think we are very good at always doing the sign). For bigger/older kids, the code leader also always announces the algorithm they intend to follow and when they are changing algorithms and a charge RN will ask if an algorithm isn't stated in the first 30-60 seconds of arrival at a code. We've developed this culture because our group's consensus (if you can call it that) is that we should use the algorithm that makes sense for the reason for the code and these cannot always be anticipated. 3) We're all (residents, fellows, attending, APN) trained in both PALS and NRP 5) Agree that ILCOR should make a statement, but I'm not sure there is evidence to recommend anything other than 'use common sense' and 'more study needed'

Our nurses use NIPS

What is the cost of analyzing donor milk (or mother's milk) in this way?

I know our nurses are using many scales because of regulatory/payor requirements, but as a physicians rounding in the NICU I (and my physician colleagues) mostly use Sarnet staging for HIE, NAS scoring for withdrawal after in utero opiate exposure, WAT scoring for withdrawal after sedation. If dates are uncertain I will Ballard a baby a few times a year (usually more as a teaching exercise with trainees, but occasionally when some features seem discordant or the given GA by OB is very discordant with my impression and I want to document the basis for my disagreement). We are also discussing the Kaiser sepsis risk calculator but not using it routinely and some of the researchers in our group are looking at real time calculation of risk of decompensation based on vital sign monitors but this is research only right now.

I work in units with colorimetric verification and it is often exactly as you describe, particularly when a trainee performs the intubation and the HR is lingering, the colorimeter is not changing and then neonatologist has the trainee remove the ETT and the patient is reintubated. Earlier in my career I just assumed these were esophageal intubations by me (in the role of a junior trainee). Now, at the end of my fellowship, I have multiple experiences with this phenomenon where I have no doubt that I have seen the tube pass through the cords under a grade 1 view. We pull the tube, provide PPV (presumably further establishing FRC) and reintubate with more rapid CO2 detection on the second attempt.

I'm going to look at this from a different perspective than Hamed (who makes many good points, as usual): How sure are you that you are actually treating congenital pneumonia and not 'sick baby'?

It is a Quincke (assuming I was correct in my assessment that this is the same needle I've used my entire professional career).

We do not routinely provide analgesia in intubated preterm neonates, but when we do it almost exclusively an opiate (fentanyl). Many are extubated early in their course and there is concern that having an opiate onboard will complicate extubation and/or lead to reintubation for 'failure'. Our most common indication for opiate analgesia is actually to provide sedation in the event that this is felt to further the goals of mechanical ventilation. I don't have our unit's numbers on this handy, but my sense is that most of this is actually provided when babies are on HF jet vent and we need them to not over breath the jet.

I think the issue here (as evidenced by the several excellent articles Francesco posted) is what age to switch over from NRP to PALS (or maybe it doesn't matter). ie when is a baby in the NICU no longer a 'newborn' for purposes of this recommendation. I'm unsure what the practice is in other countries, but in the US it is increasingly common for quaternary level NICUs with complex surgical patients and severe BPD requiring chronic ventilation to have patients several months or even over a year old. The physiologic rational for synchronization seems less plausible the older/bigger the patient gets, but the exact timing or patient characteristics that define the optimal transition point remain unknown (to me at least)