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Everything posted by bimalc

  1. The data is fairly clear that routine checking of gastric residuals is neither sensitive nor specific for serious pathology (aside from possibly enteric tube placement). The practice is associated prolonged time to full enteral feeds which itself is associated with a number of downstream consequences (increased central line days, extrauterine growth failure, LOS, etc.). While the Cochrane reviews indicate these secondary effects are uncertain, the preponderance of evidence favors either no difference or favors not checking.
  2. Is there an error in the patient age or diagnosis? I can count on one hand the number of 3 year olds I have cared for in a NICU and collodion babies shed their initial dermatological findings in 1-3 weeks depending on etiology (at which time fluid management is much easier).
  3. My current units do not admit babies who have been home for exactly the reason @Stefan Johansson said. However, I trained at two children's hospitals that did admit such babies. The mainstay of therapy is supportive care: positive pressure as needed, vigorous airway suction, recognition that apnea is common in RSV with neonates and that intubation can be more challenging than 'typical' neonatal intubation because these patients are often much larger than what we are used to (and thus good access and premedication for intubation under controlled conditions is VERY beneficial). Of the listed inhalation therapies hypertonic saline can perhaps shorten length of stay by <1 day. When the diagnosis is known (and assuming this is a previously healthy term baby) there is little indication for albuterol/atrovent (except maybe albuterol for bronchospasm after hypertonic saline). Sorry, not a lot of data, just anecdote.
  4. No, but I feel the need to point out that (part of) the rationale for acetate in PN for premature infants is not for base infusion, per se, but rather to displace chloride and avoidance of iatrogenic hyperchloremic metabolic acidosis which is obviously a completely different problem than the bicarb infusions discussed in this thread. Contrary to the presented data that bicarb infusion is useless, there is a reasonable amount of data (though less for premature infants) that hyperchloremia is quite harmful. I'm not aware of any data arguing against acetate in parenteral nutrition for displacement of chloride. My experience is that it is almost never required and the handful of times I have done it I doubt that it is of any value. On the contrary, I have found that with appropriate fluid/volume management, aggressive use of acetate in parenteral nutrition to limit chloride infusion and good renal protection, metabolic acidosis is easily managed in all but the most extreme cases.
  5. I cannot access the full text from home, but it strikes me that intermittent hypoxia is, at best, a surrogate for the clinical indication I and my colleagues have done trials of post-pyloric feeding in this patient population. As you say, practices vary, so perhaps I'm an outlier, but I use post-pyloric feeding for the very specific subpopulation of BPD patients for whom I am trying to modulate the mode of support (eg wean the baby who is 'stuck' on a low level of CPAP or a HFNC from positive pressure to a low flow canula that can be weaned on an outpatient basis). These trials of post-pyloric feeding typically run ~1 - 2 weeks and the outcomes we follow are (in order from least to most important): intermittent hypoxemia, baseline FiO2 changes, changes in level of support. I agree that those who seldom or never resort to transpyloric feedings need not change their practice based on this study, but I'm not sure this trial addresses the way transpyloric feeding is used in my part of the world.
  6. Not routinely, but for high risk extubations we often coordinate with ENT and make plans for things like race epi at extubation to Heliox. I've also used it many times as rescue therapy when there is post-extubation stridor and I am trying to buy time for airway steroids to kick in.
  7. There are several articles describing its use for this purpose and I would agree that it has very desirable properties. Sadly, not stocked by pharmacy at the institutions I have worked at recently.
  8. I haven't used morphine for intubation in almost 10 years. The onset and duration of fentanyl are overall more desirable for purposes of intubation.
  9. Because they relied on nurse charting of changes in vital signs, there was almost certainly non-differential misclassification leading to significant bias of effects towards the null. Nurse charting of events like desaturations is notoriously uneven relative to continuously measured data from monitors (this is one of the rationales for using SpO2 histograms to drive management instead of 'event counts'). A trial with continuous VS capture would best resolve the issue.
  10. I would urge caution in assuming that tight glycemic control improves patient centered outcomes, though certainly, it would appear that if one were to test that hypothesis, it might be worthwhile to test it using such a closed loop system to give the intervention the best chance at success.
  11. I've come late to the conversation after being on vacation and of course the dx of pneumatosis is not in question. I am, however, interested in the recommendation for surgical consultation: What is everyone's threshold for consulting surgery in NEC? Frankly, if I did not need to worry about my relationship with the surgeons more generally, I would only call them if I thought ex-lap or a drain made sense. This was the practice at the last in-born ICU I worked in whereas as the outborn unit I last worked in every child with NEC got a surgical consult. The difficulty with this was that the surgeons would then insist on driving the decisions on abx and NPO
  12. I've used roughly the same thresholds as Hamed, fudging a little higher or lower based on symptoms. In addition to the collateral information Hamed recommended, the single biggest thing to figure out (in my experience) is whether this is iatrogenic or not. Often times, iatrogenic hypercalcemia even at high levels, can self-correct whereas if there is a real underlying cause, that too can suggest definitive therapy. Assuming it is not iatrogenic and the Family history is non-contributory, I would at least consider a diagnosis of William's Syndrome.
  13. I practice in two very different ICU environments, one delivery and one which is more of a med-surg ICU closer to a PICU than a NICU in many ways. I think the data are clear and many of the previous respondents concur that NaHCO3 in the delivery setting is at best useless. For the ELBW with anticipated renal losses NaHCO3 should almost never be needed because these losses can be anticipated and should be incorporated into nutrition to avoid the biochemical inevitabilities noted in the articles Stefan cited. I suppose I might use bicarb in the preemie population if I had metabolic acidosis and evidence it was effecting cardiac output and even then I probably would not correct past 7.2. However, in the case of the older child or the med-surg patient where some specific pathologic perturbation has led to rapid collapse and I suspect part of that mechanism is bicarb deficit, I would have no hesitation to rapid correct the pH. I have several times done this and watched the EKG improve in real time.
  14. When I was a fellow, I trained at a delivery hospital that used flow-inflating bags and it made this sort of failure very easy to recognize (if there was any defect in flow, the bag would not inflate). The downside to this is that without flow you can't give ANY respiratory support (after a critical incident of this kind where the flow inflating bag actually ripped in the middle of a resuscitation, we started stocking an emergency ambulance bag as back-up).
  15. 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?
  16. 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
  17. 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).
  18. 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.
  19. 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).
  20. 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.
  21. 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.
  22. 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.
  23. 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.
  24. 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.
  25. 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)
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