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bimalc

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bimalc last won the day on May 2 2022

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About bimalc

  • Birthday 10/09/1982

Profile Information

  • First name
    Bimal
  • Last name
    Chaudhari
  • Gender
    Male
  • Occupation
    Physician-Scientist
  • Affiliation
    Nationwide Children's Hospital
  • Location
    Columbus, OH
  • Interests
    Genetics, Informatics

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  1. We no longer routinely provide abx prophylaxis in uncomplicated gastroschesis (your question is not really in my area of expertise, but this protocol was just reviewed so it is on the top of my mind)
  2. Given that this has lasted a month, if infectious causes and basic metabolic screens are unrevealing, monogenic causes of cholestasis are likely, more so if there is consanguinity in this family.
  3. If you're actually worried about extubation failure, there are evidence based things you can do to improve chances of successful extubation such as extubating to NIPPV and having the non-invasive interface setup (or even part way on the baby) at time of extubation to minimize loss of FRC. There is no evidence that I am aware of to support re-loading caffeine.
  4. I have done this in our medical NICU patients who have become de-recruited for any number of reasons, but not routinely on preemies (I mostly work in an outborn NICU that, in many ways, sees pathology closer to a pediatric ICU just in neonates who may incidentally be premature and are often coming to us at or new term corrected or later). No protocol, just recognition that this is an issue and taking the fellow and RRT to bedside and performing a series of recruitment maneuvers either with vent or by hand bagging.
  5. So I think there are two issues here: 1) Why do you think the child is anuric and what mode of kidney support therapy are you proposing to address the issue? (as an ancillary - what is the end point?) 2) Given the size, is your proposed plan even technically feasible? Assuming you mean PD and not CRRT/iHD, https://bmcnephrol.biomedcentral.com/articles/10.1186/s12882-020-02092-1 provides some experience and suggests that it may at least be technically feasible. Beyond that, I think you'd need to provide more details on the actual circumstances that led you to want to pursue PD for anyone to sensibly answer your question.
  6. We have a pharmacist enforced hard stop at 24h on all antibiotics and stewardship review of anything longer than 48h
  7. 'Use' in what sense? We record all of that data and I am sure it goes into our research databases, but we've not made any major changes in our threshold for consulting our BPD service since the paper came out (basically anyone still on CPAP at 36 weeks gets a BPD consult, some neonatologist variability on when to call for the kid on a low flow NC who is marginal).
  8. I will assume for a moment that you refer to 22/23 week neonates weighing <500g as I would argue that a 28 weeker can easily be secured with either a Miller 0 or a 00 blade which have been available as long as I have been in practice. More recently our hospital began demo-ing a variety of new laryngoscope blades and I got to try out a miller 000 blade from intubrite that, to me, looked comically small, but was surprisingly effective in our micro preemie manakin. Which is to say I'm not sure there's much of a shortage of equipment for DL. I have NOT seen good VL equipment for the 22/23 week population. On this I would agree and would welcome input from anyone who is aware of VL equipment for this size patient.
  9. The point about the VL is an important one. If intubation becomes a high risk/low frequency event, we should take a safety perspective and engineer our systems for safety, not widespread procedural competency with direct laryngoscopy. I am a physician-scientist who primary covers a level IV NICU without a delivery service. The over all number of intubations is relatively low and in most emergency circumstances there is a front line provider (typically NNP), a (very) experienced charge NNP, and a neonatal fellow available for managing the airway while I run the code. I can now count on one hand the number of times per year I even pick up a laryngoscope outside of a simulation (and as often as not, given that several experienced providers have tried to intubate before me, I'm busy re-engineering the situation to improve success or avoid need for intubation rather than somehow getting the tube in when others could not). I am confident that I've probably reached the point where I am significantly safer/better with VL than DL. This isn't just about trainees any more.
  10. Same as you, for the most part. Keys in my view are: 1) Anticipation of risk factors (length of intubation, cuffed tube, lack of leak, parenchymal lung disease which may make the child more prone to struggle with even transient upper airway narrowing, etc) 2) Early recognition/treatment with nebulized Epi and Steroids as well as consideration of heliox as a further temporizing measure until steroids can kick in 3) Shared mental model with frontline staff that re-intubation may be more challenging and/or need to happen fairly expeditiously if the airway cannot be preserved non-invasively
  11. In my units, provider preference, though as far as I am aware we all invite families to remain with the baby. Assuming it is a controlled intubation, I do warn parents that they cannot get in the way of staff and so should remain off to the side, preferably seated, just in case they become faint or ill watching the intubation and I emphasize to them that all our attention will be on the baby and if they think they will become a distraction to the team that they may want to go for a walk or sit in the waiting room instead. I would say 75-80% of families say they'll step out and wait for us to get them, the rest choose to stay. It has never particularly bothered me, but I've had parents watch me perform intubation since I was an intern so it is all I've ever known.
  12. Honestly, I do so little service at our delivery hospital now that I cannot recall the last positive I cared for. If you are interested, email Pablo.sanchez@nationwidechildrens.org as he is very active in CMV research.
  13. As @rehman_naveedsaid, this is NOT excess sodium provision. The baby is total body water depleted from all the ways an ELBW can lose free water (mostly skin and urine). You minimize insensible water losses (plastic bag, double wall isolate if available, etc) and, if these measure are not sufficient, provide more free water by increasing your total fluids. Without knowing the details of your fluid management, it is difficult to say more, but from your question, this is almost certainly the problem. What day of life are you seeing this issue? How much weight loss are you seeing (a marker of water losses early in life)? What is your current fluid management?
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