bimalc

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.

I have never practiced with a group that did INSURE, but I've often wondered about premedication, especially after the study from Albany with an astonishingly high failure rate when using morphine as the premedication. Helpfully, that same group now provides data on use of remifentanyl instead: https://www.ncbi.nlm.nih.gov/m/pubmed/29789465/ Personally, the biggest change for me once we go to INSURE (assuming we don't just skip to MIST/LISA) is that I've routinely muscle relaxed for intubation for a number of years.

I also have an exceedingly low success rate in SUA cases (I am credentialing at a new facility and reviewed 3 years of my umbilical lines and I had only one successful UAC in SUA listed over a 3 year period)

The approach these authors suggest is really only implementable for moderate to late preterm infants. The overall approach is tempting to extend to more extreme premature infants, but I'm not aware of anyone pulling together the data to do this (Presumably the NRN in the US has the underlying data and VON may as well, though both are limited datasets in terms of post-discharge data. CHNC has a much higher risk and outworn population but does have a validated PHIS linkage as well as (theoretically) neonatal follow-up data). Stefan - when you say individual fortification, are you looking solely at patient characteristics or are you assessing (for milk fed babies) the caloric density and relative macronutrient composition of the milk (mother's own or donor) in order to guide degree of fortification? At the Pediatric Academic Society Meeting in the US this year there was a Swedish vendor (https://www.mirissolutions.com) selling an FDA-approved solution for human milk analysis: Do you have experience with this device?

I would object to the interpretation that the CIs crossing 1 for several secondary outcomes suggests that these results are likely due to chance. On the contrary, the available evidence suggests that it is more likely these are real associations (though potentially with small effect sizes particularly for non-motor outcomes). First, all of the presumably mechanistically related outcomes have the same qualitative effect (ie CPR has the worse outcome) whereas if these were truly random, we might see some outcomes favor the CPR group. Second, for the outcomes where the CI does cross 1, most of the 'mass' of the CI still favors the no-CPR group. Third, the one contrary study you cited aside, the prevalence of pre-existing evidence favored the no-CPR before this study was even done (ie the prior was not non-informative).

I've never seen this, but my first instinct would be to work the child up for diabetes (assuming this isn't sepsis or iatrogenic). If a biochemical diagnosis was not immediately obvious and you are in the UK, I would see if the genomic medicine service in Cambridge would accept your patient for neonatal whole genome sequencing. In terms of actually lowering the blood glucose, you could try increasing protein intake (if calories are adequate already, you could even reduce carbohydrate calories). Branched chain AAs are a key signal for energy balance and can stimulate a more robust insulin.

I have never found the need to use the quantitative ratio of insulin and glucose concentrations (and I assure you, your lab is measuring an insulin concentration in the samples you provide. If you are getting reports of insulin levels that are not concentrations you need to call your lab director). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4141553/ is a review that discusses one demonstration of a modified ratio as well as its limitations, though not in neonatal data.