Hamed

@NICU RN 7 thanks, could you please clarify this sentence " clean skin with chlorhexidine 2% without" ?

Yes, please check my writings above @M C Fadous Khalife if you have further concerns, I would be happy to help out.

Copenhagen

That sounds really familiar hear in our unit, the cardiology team and I don't prefer adding dobutamine unless the preload and cardiac filling are sufficient and evident weak cardiac contractility. Dobutamine has a hypotensive effect which makes us cautious about using. Our first line inotrope as almost everywhere is Dopamine 5~10 mcg/kg/min, up to 15 ~20 mcg/kg/min, if still, systemic blood pressure is low we would add vasopressin (especially in cases of hydrops or CDH). Others add Epi instead of vasopressin and may reduce dopamine. In case the fluid identified in the hydrothorax as chyle, vasopressin is preferred. In case the chylothorax is severe (draining more than 50 ml/kg/day) for 3-4 days, during which NPO and on TPN, we start octreotide. If systemic blood pressure is in our required target range and there are echo findings for pulmonary hypertension, then inhaled NO 20 PPM, followed by Milrinone if not controlled. Would like to hear what others do and their preferences?

Good luck with this case, Some points which are sometimes missed in our unit include a) following the daily rate of chest tubes drain ml/kg of BW to estimate severity and to follow the effect of therapy. b) Measuring triglyceride in the drained fluid and at the same time in the infant's blood to determine the type of the fluid. Best of luck

No experience at all using it here, but I know its an old inhibitor of nitric oxide used in refractory vasoplegia.

It's not a big difference calculating the antibiotics 4.3 kg or 4.1 kg, especially you say that urine output is good. Could you please let us know why Dobutamine is given?

The OG tube in postoperative oesophageal atresia is placed by the pediatric surgeon and is kept as long as possible until oral feed. This is to avoid injury of the anastomosis site if the OG is replaced blindly.

Up to my knowledge from our unit`s practice and consulting a friend from another NICU in Tokyo. Concentration: using 1 vial of surfactant (120 mg) to 6 CC up to 10 CC of saline (ie, making a concentration of 12mg/ml ~ 20mg/ml) Administration: administered via a size 3 Fr OG tube, 2CC of the prepared surfactant concentration mentioned above is injected and pulled out using 2~ 5 CC syringe and repeated with another 2CC until the 6 ~10 CC is all used. Indications include: MAS requiring intubation and mech. vent. with high settings. Pulmonary Hemorrhage. RDS with evolving BPD, intubated and mech. vent. using high settings with X-ray showing a heterogeneous distribution of lung atelectasis. Concerning my experience: I can say it shows a beneficial effect in MAS and pulmonary hemorrhage, but less effective in RDS with evolving BPD. However, I don't think it shows more beneficial effect than surfactant administration as a practice used in all NICUs. Although that been said, an RCT is warranted to reach an evidence-based conclusion. Hoping to know if other countries have such a practice. We didn't use in Canada though.

Surfactant lavage, a therapeutic intervention used in Japan, although I have doubts about this intervention, it would be nice to know whether other NICUs out there use it. Do you use surfactant lavage in your unit? If “Yes” What are the possible indications? What surfactant/saline ratio do you use? Would you use in atelectatic changes in BPD cases suspecting thick secretions to be causing the atelectasis?

Over here, in Japan Famotidine (Gaster 10) for 2 weeks is almost a standard postoperative regimen after esophageal atresia advocated by Pediatric surgeons. However, almost all the cases continue on it for a month or more.

Empirically in both NICUs in Japan and Canada ampicillin and aminoglycoside: (Gentamycin in Japan & Tobramycin in Canada).

Our skin care team are in favor of not using chlorhexidine as @Stefan Johansson explained, which I personally go with, however, until date we are still using our current guideline as mentioned above. It could be a nice topic to do an RCT on.

Thanks @Stefan Johansson for sharing the difference in the practices, but I would like to clarify what you are contemplating. In Stockholm you wash with physiological sodium chloride infants <25 weeks, does this mean washing with physiological sodium chloride : After sterilizing skin with chlorhexidine 2% for UVC and UAC Or Not using chlorhexidine 2% at all and only wash with physiological sodium chloride? & For routine diaper care using wipes soaked in physiological sodium chloride?

Here is a bundle we use for skin care in ELGANs below 24 wks. I will not be able to provide supporting articles to most of what is done for this population and written here below. Hoping you can find it useful for your team and ELGANs. Resuscitation: · Receive baby in OR sheet (pre-warmed) and place in plastic bag from the OR sheet. Plastic bag an opening to deliver the head from the bag (pre-made) and an opening to over the umbilical stump to be made. Try to keep the bag closed as possible. https://www.ncbi.nlm.nih.gov/pubmed/24042134 · Incubator to be pre-wormed with humidity of 85~90% and temp around 37 ~ 38 C. · No ECG lead; use UAC to obtain vitals or Sa02 probe to get HR · If no UAC, BP frequency on case-by-case basis; change site every time, do not leave cuff on. · Once out of plastic bag, place baby on Biatain Alginate sheet(s) (change sheet every 1 week); avoid skin contact with baby blankets, use Huck towel or OR sheet underneath Biatain. · Use disposable saturation probe. · Semi-sterile conditions: sterile gloves, hat and mask for all resuscitation team members. · ETT to be handled with sterile gloves only. · UVC, UAC insertion using checklist; clean skin with chlorhexidine 2% without alcohol swabsticks and rinse with sterile water. · Plastic bag; hat; warming mattress. Keep plastic bag on until baby in isolette with temperature within normal limits (36.5-37.5 C measured at axillary or back) and humidity level is stable (2-4h). For 1st72 hrs of life · Humidity in isolette: 90 ~ 85%. · In case of skin breakdown: apply Adaptic (non-adherent) and Nu-Gel Hydrogel and cover with hydrofiber wound dressing. · No bath until 7 days. · Minimize use of tape. · Routine diaper care with disposable wipes soaked in sterile water. · Open diaper. · No ECG leads. · Score skin health with a skin care score. From 4 to 7 DOL · Humidity in isolette: 85%; wean by 5% daily after day 7 as temperature allows and based on skin condition. · In case of skin breakdown: apply Adaptic (non-adherent) and Nu-Gel Hydrogel and cover with hydrofiber wound dressing. · Delay bath until day 7. · Minimize use of tape. · Lay baby on Biotain Alginate sheet; change every 1 week until skin condition no longer requires. · Transition to PICC by day 7; If skin condition poor, keep UVC if in good position, until skin condition permits PICC (max 14 days). · Discontinue UAC by day 7. Good luck.