Hamed

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

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.