tarek

Thanks @bimalc For your valuable comments For antibiotics choice it differ from full term to preterm babies NEC has not been shown to occur in germ-free animals. While bacterial and viral pathogens including Escherichia coli, Klebsiella spp, Clostridium spp, Staphylococcus epidermidis, rotavirus, and enterovirus have been implicated, no single organism has been consistently associated with NEC. Blood cultures are positive in only 20–30% of cases. While colonization by normal gut flora supports the intestinal mucosa through toll-like receptors, pathological bacteria induce inflammation and apoptosis by signaling pathways such as nuclear factor-κB. The growth of these noncommensal bacteria may also result in endotoxin release, leading to mucosal damage.(Gomella) This suggestion was mentioned in Gomella Antibiotic regimen should cover pathogens that can cause late-onset sepsis in premature infants. Add anaerobic coverage if bowel necrosis or perforation is suspected. Reasonable antibiotic regimens include a. Vancomycin, gentamicin, and clindamycin (or metronidazole). b. Vancomycin and piperacillin/tazobactam. c. Vancomycin, gentamicin, and piperacillin/tazobactam. d. Term infants may be treated with ampicillin, gentamicin, and clindamycin.

@AntoineBachy https://clinicaltrials.gov/ct2/show/results/NCT00947518

I can appreciate dilated bowel loops small and large intestine air up to rectum Wall looks thin but either thin or thick can be presentvin NEC No portal vein gas No evidence of pneumatosis intestinalis My suggestions: check previous x ray to rule out dilated fixed loops Check if the patient on CPAP how much flow and how much PEEP Is there is abdominal tenderness wall oedema dilated veins Any other signs of feeding intolerance how much milk he is recieving and EBM or artificial How much is platlets Any metabolic acidosis Next x ray do with lateral decubitus Ultrasound abdomen for diagnosis of NEC is more sensitive than x ray but need some one who is expert ( take the patient as full and not x ray only) If you going to start antibiotics i like tazocin +vancomycin Involve pediasurgery to make them aware

Really wonderful discussion. Thanks @AntoineBachy for raising this question @Hamed i am always waiting for your replies @Stefan Johansson a lot of thanks for such beautiful 99nicu Chapter 12 Clinical procedures_ABMU Neonatal Guideline v 2017 1.pdf

Thanks a lot @Aymen Eshene Really i appreciate your effort and your good questions but let me add another dilemma: if you started antibiotics for suspecting congenital pneumonia and blood culture result showed no growth after 72 hours what you will do ?? Regarding tracheal cs we are taking it if we are thinking in VAP( although i read one article that normally the ETT will colonize with gram positive bacteria after 6 hours from intubation and will colonize with gram _ve bacteria after 48 hours) The 3rd question @Hamed antifungal prophylaxis fluconazole( 3- 6 mg/kg) iv 72 hourly if less than 1 kg in nursuries with high rates of invasive candidiasis > 10 % for 6 weeks can i use it even the rate is not that much For babies 1 - 1.5 kg oral nystatin 100000 units 8 hourly is used( week recommendation)

One for all and all for one I feel that i have many wings all over the world

Thanks a lot Whould you please post your practice guidlines for TPN And what is the osmolarity that you are accepting if TPN is going through peripheral IV line And are you adding heparin as mandatory or optional if there is no contraindication for heparin

When i was practicing in Egypt we were using Down score for Respiratory distress this was 12 years ago We are using Sarnat staging for HIE In Pediatrics they are using GCS and modified GCS In USA some areas using sepsis calculator ( i went through it but we are not using)

Thanks @mahmoud very informative This is another article taking about Advances in Diagnosis and Management of Hemodynamic instability in Neonatal Shock https://files.acrobat.com/a/preview/1d78eae5-940a-407d-970a-7461f06d4629

@Dr Jubara Alallah She is my boss in Saudi NRP Welcome Dr Jubara in 99nicu

Nice topic neonatal pain policy.pdf

Happy anniversery I am proud to be a 99nicu member Thanks @Stefan Johansson

the other differential is vegetations and 6 weeks course of antibiotics should be instituted we have one case with thrombus in left atrium and after heparin started on aspirin by cardiology team

I am using this app and as we are following the NICE guidlines Really very helpful and easy to use

Thanks for all very nice discussion and very nice refrences