bimalc

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.

I actually think the potential benefit in the bigger preemies is a major selling point. In regionalized NICU systems, need for intubation is a common trigger for neonatal transport. I could see nebulizer surfactant being very attractive to level 2+ NICUs in the US wanting to keep such babies closer to mom.

I have only had access down to size 0 (as PICU bought the VL set up there was no urgency to get a 00 blade and many of my colleagues in NICU were of the attitude that they could intubate anything with a pulse so why budget for such an item). I will admit that with just a size 0 blade there were instances where you could get a decent view but simply ran out of real estate in a small oropharynx using the VL 0 blade and were unable to actually pass the ET tube. Even in those cases, though, the broader field of view made subsequent DL significantly easier.

I have used VL in our cardiac ICU (where we co-manage neonates with colleagues from PICU with cardiac training). I have been long impressed by its potential both for teaching (as in the previous study) and in reducing adverse intubation events (very difficult to do an esophageal intubation under VL).

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.