bimalc

Does anyone have experience using a proximal flow sensor with an AVEA ventilator in Volume Guarantee mode? What is the smallest volume that can be reliably delivered?

I'm not sure whether the issue is equipment vs. us not really understanding what sorts of 'events' it is safe to have at home. The CHIMES study clearly shows that even well past term corrected many babies will have minor events that no one really ever notices because they aren't looking. There is reasonable evidence that you can ignore brief events without compromising safety (probably because many brief events reflect monitor limitations as opposed to actual biology) [see https://www.researchgate.net/publication/308756008_Clinically_significant_cardiopulmonary_events_and_the_effect_of_definition_standardization_on_apnea_of_prematurity_managementfor example]. My experience has been that the biggest issues are not, at their heart, technological but social and professional: We get parents who stare at the bedside monitor for weeks on end and are terrified to go home and we also get bedside nurses who either document every time the monitor alarms (often without enough context overnight for the team the next morning to figure out if the baby is actually any different) or nurses who document only the most severe episodes when a kid is getting ready to go home. One of my prior units started a program to standardize the approach of our nurses to these cases and, from a physician perspective, it Wass an unbelievably positive change

No, but we will give bolus surfactant (RDS dosing) after pulmonary hem. with hypoxia

Helsinki? Finland is the happiest country per the UN Happiness Report

2 weeks

Yes, we are in USA (3 different states I have practiced in)

We generally don't, for a combination of economic, physiologic and logistical reasons (in the USA). The reality is that our payers (private and even state insurance) will cover prolonged hospitalization for apnea so there is no financial pressure to discharge while apnea is a serious concern. Given this, we have a unit protocol that waits 5 days after any (unprovoked) clinically significant cardiopulmonary event (CSCPE) and 2 days after provoked events (usually feeding related). See https://www.ncbi.nlm.nih.gov/pubmed/27684421 for our standardized definition of CSCPE. There is weak evidence that there may be recurrent 'spells' even if a baby is spell free for 5 days (I can't find it at the moment, but there was a creative study from Virginia and Dartmouth a number of years ago that found recurrent spells unto 7-8 days after the previous event) but we've not seen this in practice. Finally, there are logistical barriers in our current environment: Our NICU clinic does not have staff/equipment/training to interrogate these devices. Our pulmonology colleagues do but they are very uncomfortable managing apnea of prematurity. The end result is that if we send babies on on such monitors and they go off the parents have no one to speak with who both understands the monitor and the underlying pathology and if they come to the ED no one will be able to interrogate the device in a timely manner. Furthermore, if the baby goes home on room air, there is no intervention the parents can offer if the monitor goes off except perhaps stimulation. Are they expected to stare at the monitor around the clock and swim the baby when it goes off? This way madness lies! When you combine these, I can recall sending ONE patient in 3 years home with such a device (not counting babies on home O2 who go home with a monitor for somewhat different reasons). It was at parents insistence and some deal brokered with the primary team that the covering weekend attending would discharge on a monitor. The baby was readmitted to our quaternary referral NICU for a blue spell at home within a week and it was a huge issue; I honestly cannot ever see myself sending a baby home on RA and with a monitor.

Yes; I'm familiar with its use in this context from a cardiac unit I used to work in and I know it has been used in PICU for refractory hypotension with at least case reports of success, but I have not seen any data for use in neonates. When I have proposed its use in extreme cases in my current NICU, everyone is concerned that the nitric oxide inhibition will precipitate pulmonary hypertensive crisis.

I suspect this is not a 'solved' problem in any of our units. I was recently on overnight with a similar baby and we were on Milrinone and Epi (maybe some dopa as well, can't remember details now); had a long conversation with our cardiac ICU about swapping out at least some of the Epi for Dobutamine one I had an ECHO with confirmed EF ~10-15% but this was very controversial (for reasons that were not very clear to me) and I was only on overnight, so I deferred to the primary team in the morning. Again, having just cared for such a case, when we have serial OB growth US and can see the weight trajectory prior to the fetus becoming hydropic, we estimate the non-edematous BW and make our initial dosing on that. Given that we subsequently follow urine output, weight and drug levels (where appropriate) I'm not sure that in practice we gain much from this exercise except that, perhaps, on the first day we are much tighter on fluids than we might otherwise have been.

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.