bimalc

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.

This is one of my favorite topics but one which I have no academic time to pursue. 1) I think this has little to do with science and everything to do with the relative strengths, weakness and, frankly, interests of the NICU and PICU staff. Our NNPs are only credentialed to provide care upto 1 year of age, so a lot of the thinking at our institution is based around this. Also, I don't think it makes a lot of sense to send kids to PICU before they are term corrected unless there are VERY good institutional reasons. 2) At my out born unit the default from nursing and RT, etc. is always NRP so we've developed systems that focus on getting everyone onto PALS if that is deemed more appropriate. For certain cardiology patients who are in the NICU and not the CICU this becomes part of bedside hand off and the stated plan each day as well as signs at bedside (though I don't think we are very good at always doing the sign). For bigger/older kids, the code leader also always announces the algorithm they intend to follow and when they are changing algorithms and a charge RN will ask if an algorithm isn't stated in the first 30-60 seconds of arrival at a code. We've developed this culture because our group's consensus (if you can call it that) is that we should use the algorithm that makes sense for the reason for the code and these cannot always be anticipated. 3) We're all (residents, fellows, attending, APN) trained in both PALS and NRP 5) Agree that ILCOR should make a statement, but I'm not sure there is evidence to recommend anything other than 'use common sense' and 'more study needed'

Our nurses use NIPS

I know our nurses are using many scales because of regulatory/payor requirements, but as a physicians rounding in the NICU I (and my physician colleagues) mostly use Sarnet staging for HIE, NAS scoring for withdrawal after in utero opiate exposure, WAT scoring for withdrawal after sedation. If dates are uncertain I will Ballard a baby a few times a year (usually more as a teaching exercise with trainees, but occasionally when some features seem discordant or the given GA by OB is very discordant with my impression and I want to document the basis for my disagreement). We are also discussing the Kaiser sepsis risk calculator but not using it routinely and some of the researchers in our group are looking at real time calculation of risk of decompensation based on vital sign monitors but this is research only right now.

I'm going to look at this from a different perspective than Hamed (who makes many good points, as usual): How sure are you that you are actually treating congenital pneumonia and not 'sick baby'?

It is a Quincke (assuming I was correct in my assessment that this is the same needle I've used my entire professional career).

We do not routinely provide analgesia in intubated preterm neonates, but when we do it almost exclusively an opiate (fentanyl). Many are extubated early in their course and there is concern that having an opiate onboard will complicate extubation and/or lead to reintubation for 'failure'. Our most common indication for opiate analgesia is actually to provide sedation in the event that this is felt to further the goals of mechanical ventilation. I don't have our unit's numbers on this handy, but my sense is that most of this is actually provided when babies are on HF jet vent and we need them to not over breath the jet.

I think the issue here (as evidenced by the several excellent articles Francesco posted) is what age to switch over from NRP to PALS (or maybe it doesn't matter). ie when is a baby in the NICU no longer a 'newborn' for purposes of this recommendation. I'm unsure what the practice is in other countries, but in the US it is increasingly common for quaternary level NICUs with complex surgical patients and severe BPD requiring chronic ventilation to have patients several months or even over a year old. The physiologic rational for synchronization seems less plausible the older/bigger the patient gets, but the exact timing or patient characteristics that define the optimal transition point remain unknown (to me at least)

I think that context matters. In the DR, of course there is only NRP. However, depending on where you practice there may be good physiologic reasons to use PALS. You mention the ED where (I assume) you're being called for a neonate and the ED should probably be switching over to NRP (politically fraught suggestion, I know). Our local practice has been that if the ED is calling the NICU down for more than 'advice' (ie asking us to touch the patient, intubate, place lines etc), NICU takes over as code team leader. However, there are at least two scenarios where we switch to PALS (and for this reason, outside of the DR, one of the first things we try to establish after team leadership is what algorithm we are in). 1) Older kids in our Level 4 NICU who can be over a year old and 2) Cardiac ICU patients whom we co-manage with the CICU service and whom our fellows cover during the day.

Our abx come from central pharmacy in syringes. Our bedside RNs connect to tubing at bedside. I'm not on the specific committee, but there are periodic evidence reviews and pushes for specific practices to reduce CLABSI related to drug administration and I see the RNs doing things like 'scrubbing the hub' and using disinfecting 'Curos' caps (for which I do know there is reasonable evidence). I'm not aware of any evidence, but my experience suggests that probably the bigger gains in patient safety from moving to pharmacy dispensing are not in infection reduction but rather things like dose checking and interaction checking.

This is the crucial point. Very little of the care of the late preterm infant (particularly the older ones at 35-36 weeks) who does not have RDS is medical. These babies need good nursing care to maintain thermoregulation and euglycemia. In the US, many post-partum nursing units have one RN to 4-5 mothers AND their babies, making the staffing more like 10:1. It is in this context that I see many programs in the US move more and more of these babies into an ICU setting.

We use the same product Stefan posted

Interesting case. Sorry to come late to the discussion. Generally agree on seeking consultation (assuming it is available) from Heme/anti-coagulation on duration of LMWH and interval for imaging. Depending on the current size and status of the baby, the amount of blood for an anti-coag workup may be large and yield is low (also difficult to interpret early in life). In the absence of a clear family history, I would consider this a provoked thrombus and delay testing as long as possible, if not indefinitely.

The large delivery hospital we cover unfortunately does not have an intermediate level of care (at least not physically) so we admit many late preterm infants to our level III+ NICU. <36 weeks or <2000g is an automatic admission (had previously been <35 weeks or <1800g but so many were subsequently transferred to NICU that it was felt to be safer and more efficient to take these babies into NICU and then send them out to the nursery later.) The challenge is that for logistical and institutional/cultural reasons once these babies enter the NICU there is almost no hope of getting them back to mom prior to her discharge (particularly given the relatively short length of postpartum stay in the USA).

Need more details to give concrete advice: 1) What are your goals in conducting simulations? 2) Who are you targeting? (MDs, RNs, NNPs, RTs, all of the above?) 3) What resources do you have? (It would be stupid of me to tell you about fancy high fidelity simulators if you don't have that sort of infrastructure) The one universal I can endorse is that everyone needs to buy into the fact that these are done for the good of our patients and there can be no judgement. At our institution, that means the no information on individual performance ever gets reported outside the people at that specific mock code. It has to be 'ok' to fail in the mock code.

We plot BW on Fenton. In our med-surg unit which has many older kids, our dietitians switch to WHO at some point (timing appears to be a bit idiosyncratic)

I had not even heard of the practice until I saw your post. I have worked in 5 large academic NICUs around the US without encountering this.

I have done 80/kg in the past; I think we agree on the importance of uop,etc. and adjusting fluids based on weight, output and labs. 50/kg just seems unlikely to be sufficient in my experience, but if there is international experience suggesting otherwise, I might need to reassess my practice

@Hamed I am interested to hear your fluid management for micro preemies is quite different than practice in the US. I do not imply that one is superior to the other, but I must ask what difficulties (if any) you have in maintaining normal fluid electrolyte balance with only 50mL/kg/day of fluids in the smallest babies? In the two units I currently work in, such a baby would typically receive 100mL/kg/d on day 0 and increase 10-30mL/kg/d. My experience has been that even with humidified isolettes (or at least the ones I have used over the years) such babies can lose massive amounts of weight/water and become very hypernatremic if we are overly cautious with fluids early on.

I know it is not the question you asked, Hamed, but I just re-read one of your posts and was intrigued to see you identify a benzodiazepine as your second line agent. Is that common in your institutional or national practice? We reserve Midazolam infusion for seizure refractory to multiple AEDs and up-titrate to effect (usually patient needs to be intubated for airway protection if we are starting Midazolam infusion). I have used fosphenytoin and Keppra after phenobarbital (in discussion with colleagues in neurology) before starting benzodiazepines. I am now curious about other's experience/practice.

I'll make my comments inline and in bold so you can see: