Hamed

Only when showing post-extubation stridor agree with @bimalc Although, @Pototo I would like to know did you mean Racemic epinephrine (before or after extubation)?

@Lenks I do agree with @bimalc, as many of these cases are transient and seem to resolve spontaneously without any specific treatment. In case high Ca intake is suspected to be the cause of hypercalcemia, discontinuing powdered human milk fortifier or preterm formula to first stop this extra intake and closely monitor serum calcium levels without immediate further evaluation. Additionally consider temporarily discontinuing vitamin D supplementation if providing. In case spontaneous correction of serum Ca doesn't take place further invitations as mentioned above with adding renal ultrasound when hypercalciuria is present.

Routinely, we would confirm umbilical lines with a cross table lateral view additionally to the AP view. Although, in the X-ray kindly presented here I do agree with @bimalc the UVC is mal-positioned and no need for a later view. This UVC could be pulled back to be 2 cm below the level of the base of the umbilical stump = (2 cm + length of the umbilical stump) and be used as a low line = (as a peripheral line) /Or if still a central line is indicated a PICC could be placed. I would revise the need of a central line in this infant. In the scenario if this infant was just being resuscitated after delivery and this UVC was just placed in and still the area around the umbilicus is sterile, trying to replace this UVC with a new one, the new UVC will usually follow the track made by the first one. Another way is, if the opening of the umbilical vein could accommodate passing another UVC through without removing the first one, the new UVC could pass in the correct direction. A gentile pressure on the liver downwards and medialy would facilitate passing the UVC in the proper direction.

Same here in Japan, as well as in our unit in Canada, no special management for preterm infants of smoking mothers. Although we have a concern towards smoker parents when they visit their babies in the NICU, we do ask them not to smoke before coming to the NICU and to wear newly washed cloth which doesn't have smoking smell in them.

@Lenks Concerning hypercalcemia (total Calcium of 12 mg/dL is our cutoff for IV saline 10-20 ml/kg with 1 mg/kg lasix. A persistent hypercalcemia in-spite the lasix and total Calcium above 14 mg/dL we would consider glucocorticoids. No experience with bisphosphonates. Calcium intake should be thoroughly reviewed. Although day 7 is early for subcutaneous fat necrosis to cause hypercalcemia, but checking for sites of it could be advised, Further lab. data to know the etiology: ionized calcium, pH, albumin, phosphorus, alkaline phosphatase, PTH, urine sample for spot calcium/creatinine ratio, 25 OH Vit D and 1, 25 OH Vit D. Ask mother and father for Familial hypocalciuric hypercalcemia (autosomal dominant) or check their urine spot calcium/creatinine ratio.

@AntonioPCam thanks a lot, I think contactless monitoring would really be helpful in the NICU. Wishing you all the best.

Concerning the need for intubation and Mech. vent. I concord with @bimalc, @Stefan Johansson and @rehman_naveed and once in during cooling it will remain in until the end of cooling or until an MRI is taken at 4~5 days of life. As for comfort, we do as @rehman_naveed, we give low dose morphine infusion 5 mcg/kg/h not exceeding 10 mcg/kg/h or fentanyl 0.5 mcg/kg/h not exceeding 1 mcg/kg/h (fentanyl preferable for hemodynamic compromised infants). Coming to the timing of MRI, it may vary according to each hospital`s protocol. In addition, it really depends on what you want to see, diffusion and metabolic changes preferably 4~5 days of life, and that concord with 24 to 72 hrs after cooling as @bimalc. Brain injury changes continue to develop as late as the 2nd week of life. That is why you find some units do the MRI at day 4~5 or day 7 or end of 2nd week of life.

Hi @Andrej Vitushka thank you for your question and discussion, it opened up a lot of thoughts. Sorry for seeing your question so late, @Stefan Johansson kindly answered. Thanks Stefan.

Hi @Andrej Vitushka you can use both central or capillary. For cutoffs please check the PINT study. We use table 1 low threshold cutoffs for transfusion. https://www.ncbi.nlm.nih.gov/pubmed/16939737 PINT trial.pdf

Unfortunately, not using LMAs in our Perinatal-neonatal center.

@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