tarek

According to NRP textbook What are the limitations of a laryngeal mask? Laryngeal masks have several limitations to consider during neonatal resuscitation. •The device has not been studied for suctioning secretions from the airway. •If you need to use high ventilation pressures,air may leak through the seal between the pharynx and the mask, resulting in insufficient pressure to inflate the lungs. •Few reports describe the use of a laryngeal mask during chest compressions. However, if endotracheal intubation is unsuccessful, it is reasonable to attempt compressions with the device in place. •There is insufficient evidence to recommend using a laryngeal mask to administer intratracheal medications. Intratracheal medications may leak from the mask into the esophagus and not enter the lung. •Laryngeal masks can not be used in very small newborns. Currently, the smallest laryngeal mask is intended for use in babies who weigh more than approximately 2,000 g. Many reports describe its use in babies who weigh 1,500 to 2,000 g. Some reports have described using the size-1 laryngeal mask successfully in babies who weigh less than 1,500 g. This study by Prof Kary Roberts in USA Laryngeal Mask Airway for Surfactant Administration in Neonates:A Randomized,ControlledTrial

Its importance will come when you will face a baby when you can not hear His Heart sounds like Hydrops babies I wittnessed chest compression start to one hydrops baby as no hear beat detected by auscultation and after PPV I am with ECG leads and monitor to be available in perfect setup Using ECG leads accirding to NRP guidlines should be implemented from january 2017 Tell now we are trying to make it available in OR and LR How should you assess the baby’s heart rate response during compressions? Briefly pause compressions and, if necessary, pause ventilation. An electronic cardiac (ECG) monitor is the preferred method for assessing heart rate during chest compressions. You may assess the baby’s heart rate by listening with a stethoscope or using a pulse oximeter. There are limitations to each of these methods. •During resuscitation,auscultation can be difficult,prolonging the interruption in compressions and potentially giving inaccurate results. •If the baby’s perfusion is very poor,a pulse oximeter may not reliably detect the baby’s pulse. •An electroniccardiac(ECG) monitor displays the heart’s electrical activity and may shorten the interruption in compressions, but slow electrical activity may be present without the heart pumping blood (“pulseless electrical activity”). In the newborn, pulseless electrical activity is treated the same as an absent pulse (asystole). Copied from textbook of neonatal resusscitation 7th edition

Unfortunately We never have it in our hospital

We had it in our unit before but i never used it as i did not have any problem while intubating I think the technique is the most important thing In ELBW size 00 is it available for videolaryngscope( i don not think)

I enjoyed the discussion although we know that the benifit is less or even no benifit still many are using H2 blocker or proton pump inhibitor even some are using metoclopramide The first 5 days postop NGT or OGT is mandatory then gastrographin to be sure that there is no leak after that depend on GA and when we will start oral feeding

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