bimalc

Surgical or medical management? I am not a pediatric surgeon, but I am sure there is a literature on timing of closure. I think of several medical management issues when there is a baby with this problem in my ICU: - Delivery room: sterile bowel bag is a must. Avoid umbilical catheterization if possible. We obtain cultures and start antibiotics for all gastroschesis because of the exposed bowel and risk of contamination despite best efforts at sterility. - Fluids: surgeons may be worried excessive fluids will cause edematous bowel and make closure more difficult, but even with a silo there are lots of insensible losses and fluid needs will be great. Track urine output and heart rate closely as well as electrolytes. - Pain control/sedation/meds both for the abdomen and the fact that patient is likely to be intubated but also you may need to provide anesthesia for bedside closure. We use high dose fentanyl and rocuronium +/- benzodiazepine. Need to have code medications & fluid drawn up and nurse dedicated to administering medication. - Having enough access - you can try to use a PICC, but many of these patients will need longer term access anyway, so surgeons may place tunneled line for you. - Biggest issue with success in my experience is not the surgery itself, but re-establishing feeding afterwards. It pays to be patient and accept slower advancement if it ultimately means less time on TPN and less central line days. Are there specific issues/questions you have for your practice setting?

I must agree wholeheartedly with Francesco! Increasingly we must consider sedation/analgesia for 1) procedures 2) bedside OR and 3) chronic respiratory failure requiring long term intubation/tracheostomy Ultrasound in the form of targeted neonatal echo as well as for vascular access. I suspect an adjunctive workshop on US guided access and/or targeted echo would be well attended Genetic testing is changing rapidly, but at different paces in different economies. It would be helpful to discuss what the actual evidence base for different testing is as well as having a frank discussion about the costs involved As a US-based practitioner, I would also appreciate the most up to date information on LISA (especially if there was time on a simulator to become comfortable with procedure). Catheter based surfactant is not widely used in the USA, but surely that will change in the near future.

We do not have set national guidelines in the US due to the way our health services are organized, but in the NICUs I cover (one in-born one out-born, both with cooling) we do treat electrographic seizures though our tolerance for isolated seizures will increase as time goes on if it becomes established that seizures are persisting and there is the need to balance the benefits of extinguishing seizure against the side effects of AEDs. Regarding aEEG/CFM vs. EEG, because there is an active neurocritical care service available, we tend to reserve aEEG for urgent/emergent neurodevelopment-monitoring as it can be done by NICU nursing staff and interpreted by neonatologists as opposed to EEG which requires staff from neurology to set up and interpret. Once a patient is clearly on a pathway where we may plan and anticipate their monitoring needs, we use EEG and/or vEEG per the preference/recommendation of our neurocritical care service.

My interpretation of the GRADE review is to ignore the pooled estimates for the observational studies for sure because of the poor quality. The issue is, as Stefan highlights, confounding by indication. The available RCT data do not support transfusion as increasing risk of NEC. I think the most elegant study to try and better understand what is going on and by-pass the confounding by indication study is the JAMA https://www.ncbi.nlm.nih.gov/pubmed/?term=26934258 where they are able to parse out anemia from transfusion. I am still only a fellow, but I base my transfusion practice vis a vis NEC risk on the RCT data from the GRADE review and this paper highlighting the anemia as the key feature. This conclusion is consistent with the finding in the RCTs of less NEC in the liberal transfusion group because the liberal transfusion group would presumably have less (and likely less severe) anemia.

There are two issues. Can you? Yes. This is quite normal in inborn errors of metabolism for example. Are there improved outcomes? I am not aware of data for the general nicu population however I have seen that carnitine levels rapidly become low if baby is npo. For many babies who are not so sick and will start enteral feeds soon it probably does not matter, but I wonder if there is benefit in prolonged npo especially if baby is critically ill or with cardiac dysfunction