bimalc

The issue is that in most resuscitation (at least in my experience) you cannot be confident which is the case at the moment that you are handed a grey and lifeless baby. You are forced to proceed with full resuscitation and if you need volume and O- blood is available, given the alternatives, it seems reasonable to push some blood (of course, if you need volume and appropriate blood isn't available push saline as Stefan suggested - in the acute phase if you're in that much trouble you probably just need some preload while you try to get the heart going again)

in VLBW who is not edematous we use BW until 14d or until regain of BW, which ever is first. In the case of an edematous baby, our local practice is not uniform and I think you really need to tailor that to the clinical course (continued edema, or had some diuresis and now is gaining weight again but this time it is 'good weight' and not 'water weight', etc.)

I'm not sure we did anything particularly involved, iNO at 20ppm and assess if responder or not based on FiO2 requirement (although, in practice, I feel like no one ever turned the iNO off in non-responders, the kids just died eventually). We would try to get ECHO for indirect estimation of PH before starting (and to make sure this wasn't anomalous veins). My original comment still stands though: as this patient sounds like they have evolving CLD, I'd invest more of my time and effort in reviewing XRays and optimizing the vent for CLD. Also, if you haven't started, I'd have a very frank discussion about morbidity and mortality with the family. Have you considered re-posting/cross-posting to the virtual NICU if you are interested in discussing a specific patient? Bimal

I agree with Nathan about it being very easy to forget about the 'other' sources of fluid the baby is getting and that these are more significant the smaller the baby gets. One thing I will take exception to is TKO fluids for the second lumen of UVC. I would argue that if you care about volume of infusions in a specific baby, you should be writing your orders such that you don't need a TKO in the second lumen (either by running needed things in each lumen or by using a splitter to run one back through both lumens). Furthermore, if your baby is small enough/sick enough you need to be counting the UAC fluid into your total. When we write for fluids out of the DR, our practice is to specify the total fluid goal inclusive of all infusions. If the baby is small enough or edematous enough, we will also ask the pharmacy to maximally concentrate all medications and give us their best estimate of all drug volumes and flushes etc. The challenge then, becomes picking a number to target. The second table you posted best approximates our local practice, with the understanding that we're including almost everything, not just nutritional fluids in this volume. For the sickest/smallest we're then following urine output and serum sodiums as a guide to whether or not we're over- or under-shooting on total volume. As regards BP targeting, we are VERY permissive of low MAPs if there is no evidence of impaired end organ perfusion, especially in the first 6-12 hours or even 24 hours. Over the period of 24-72 hours we start to care more about MAP > 30mmHg even in the absence of evidence of organ dysfunction. Finally, as regards your hypothetical patient, I would pick some dry weight, probably birthweight unless born edematous.

Current local practice is neither. I think the evidence from PREMILOC is compelling and would prefer to either make it our routine or at least have a conversation with parents about this very early on, but I do not think I will be able to convince my group to do this as I am not part of our 'BPD team' and local culture is to view BPD as an acceptable outcome as long as the patient is discharged off O2 or with a low flow cannula only (and our current practices are very effective at this).

We used it in crisis during my fellowship with the goal, obviously, of transitioning to some combination of sildenafil, trepostinil, bosentan etc. Was there a specific aspect of therapy you had questions on? My experience with using iNO in this circumstance is that many, if not most of the 'bad BPD' we saw, the clinical manifestations of pulmonary hypertension were more helped by aggressive respiratory support as opposed to pulmonary vasodilator therapy. We would get many patients as transfers from level IIIs to our BPD program at the level IV ICU and these babies would be been on non-invasive support for very long periods of time and, in retrospect they had been retaining CO2 and were on far too much FiO2. These babies ended up in pulmonary hypertensive crisis around transport and needed iNO for a period, but it wasn't the iNO that 'fixed' things, it was choosing an appropriate ventilatory strategy with things like much higher PEEP, including possible use of peep titration during bronchoscopy, transitioning to a higher tidal volume and lower rate strategy (very different strategies designed to prevent BPD and much more like what our colleagues in PICU are used to doing). Steve Atman gave an excellent talk on this point at PAS a couple of years ago and has published quite a bit in this area.

I've only rarely used that particular term/code and then in the context Stefan mentioned. If a patient is truly encephelopathic without obvious antecedent asphyxial event, though, I will code neonatal encephalopathy P91.819. My one comment if you're trying to learn about this patient population is that, at least where I did my fellowship, maternal SSRI exposure seemed to be significantly over-represented in this population and I can recall cooling several babies who in retrospect probably had SSRI exposure not hypoxic insult.

To be fair over ventilation/hypocapneia would be a very strong indication for extubation (the whole point of cooling is to save the brain, after all) however, in my experience this is exceedingly uncommon

Are you relying solely on leak compensation from your vent or are you using cuffed tubes to manage the leak itself?

Many thanks. Where do you set your PIP alarms? More generally, how concerned are you about peak pressures and 'barotrauma'?

What approaches are in use around the world for the ventilation of CDH (especially pre-operative on or off ECMO)? Many guidelines continue to list PIP limits based on earlier studies of 'gentle ventilation' improving survival, but these studies were done before significant advances in microprocessors enabled accurate volume targeted ventilation. Given what we know about the importance of volume-trauma as opposed to baro-trauma, is anyone volume ventilating pre-operative CDH and permitting higher peak pressures?

24-72 hours after cooling. I try to use spontaneous breathing modes in this setting whenever I can to try and get more information to guide counseling if I am concerned there will be an extubation failure. For example, the draeger VN500 has mandatory minute ventilation mode and has some lovely graphics that you can show a parent so they can see their child go apneic or hypopneic (CPAP/PS can be used to a similar but not identical end)

I must agree with the others that therapeutic hypothermia is not, in and of itself, an indication for intubation. However, given the known natural history of HIE, even in the era of cooling, I certainly have a lower threshold to intubate when the respiratory status is marginal. Also, must agree with @Stefan Johansson once the ET tube goes in, it does not come out (In our case, not until we get the MRI).

We also use the PINT cut-offs. However, I want to call people's attention to the problem is knowing what device you are using to measure H/H If your institution has POC or on-unit Hgb/hct available (for example on an I-stat or similar device or on a blood gas analyzer in the ICU) you need to ask your lab what the accuracy of those devices is compared to a formal H/H in the main lab, particularly at the low end of the Hgb range where you will be making transfusion decisions. The chemistry for some of the POC devices is influenced by what else is in the sample. For example the I-Stat (the POC device I am most familiar with) only calculates a Hct, not a Hgb (it just divides the Hct by 3 and reports that number as the Hgb). The Hct it 'measures' is corrected for Na (but not other electrolytes which may affect conductivity - the method by which Hct is calculated/measured), there is no correction for leukocytosis and the machine does not adjust for low TP or hyperlipidemia (but there are published manual corrections you can use). There is also the problem that these devices are validated for their correlation with a gold standard over either a normal range or a 'clinically relevant' range. Unfortunately, accuracy is really not relevant over most of that range. What we, in the ICU, care about is accuracy specifically down at the transfusion threshold. I don't really care if my pt's Hgb is 14 or 14.5 but I might care a great deal if it is 7 vs 7.5. To my knowledge, there is no such data for the I-Stat (nor any other POC device that I know)

I've used an LMA for the specific indication of 'can't ventilate, can't intubate' in somewhat larger neonates (not for surfactant); we do have size 0.5 available now (I've never used them). The only time I've used them in a DR setting was once when called emergently to a non-birthing hospital for premature triplets and I wasn't confident everyone could be intubated if BMV wasn't working. Even in that case we ended up not giving surfactant until back in NICU and intubated. The single biggest use case I've used an LMA for was palliative where patient is DNR/I and we're waiting for family to come in because of a decompensation and the patient REALLY needs PPV, we've placed an LMA and hooked it up to a vent until family can get in. My experience is that families (and frankly staff) perceive this as less invasive/harmful than intubating and then pulling the ET tube when parents are there. How was I trained? Sim sessions in residency and fellowship and at PAS the past few years it seems there has been an airway skills workshop that I try to attend it there isn't a conflict.