Hamed

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.

Hi Ayman, Thanks for sharing the X-ray. To answer your concern, to comment on an X-ray abdomen in neonates use this guide in your comment 1) Bowel loops distension: (larger than width of a vertebral body) 2) Bowel loop shape (Polyhedral or Rounded and Sausage shape) 3) Bowel wall thickening (Thin or Thick) 4) Gas distribution pattern (In all the abdomen or localized) Then look for 5) Pneumatosis intestinalis 6) Air in portal vein 7) Free air When you are suspecting a possibility of NEC take a cross-table lat view to better visualize free air and ascites. Now try it on the X-ray you sent.

@tarek yes you are correct the use of systemic prophylaxis anti-fungal therapy (IV fluconazole) varies from one unit to another, according to their experiences with unit`s fungal infection rate. A units with a fungal infection rate less than 5~10% would most probably preserve its use of systemic prophylaxis anti-fungal therapy for only suspected cases with possible risks of fungal infection, according to the AAP`s recommendations. https://www.ncbi.nlm.nih.gov/pubmed?otool=ijpsamulib&amp;term=26679628 In our unit in Japan for example, we wouldn't use systemic prophylaxis anti-fungal therapy in VLBWI . Meanwhile, in Canada we didn't use in ELBWI nor in VLBWI unless suspected cases with possible risk to avoid promoting resistant candida species within the unit. As for oral Nystatin, it is not well absorbed from the gut. In both of my experiences in Japan and Canada we didn't use as prophylaxis, but only as therapeutic for oral candidiasis. Although using for prophylaxis was shown to reduced the incidence of invasive fungal infection in VLBWI in a meta-analysis, in both units we found the cons to overweight the pros.

@danielirra Thank you for opening this topic, It would be nice to know what you reached in your unit`s updated protocol when it is completed.

Happy Anniversary!

Hi Ayman, Dividing your question to EOS and LOS EOS: -Concerning your first question please visit the Management of term infants at increased risk for early onset bacterial sepsishttps://www.cps.ca/en/documents/position/management-infant-sepsis -Concerning your second question: In our practice, we would NOT include tracheal aspirate to routine septic workup. - Antifungal for prophylaxis in ELBWI (in Japan 3 times/week) unless we have a positive culture or suspected skin rash we switch to a therapeutic regimen. - Antiviral eg HSV (acyclovir) given in the following scenarios: The CPS statement on prevention and management of HSV infection in this link: https://www.cps.ca/en/documents/position/prevention-management-neonatal-herpes-simplex-virus-infections 1- If symptomatic for signs and symptoms of neonatal HSV regardless and/or without knowing maternal history. (symptoms eg: vesicular skin lesion, seizures, DIC, unexplained thrombocytopenia, elevates liver enzymes with or without resp. distress) 2- If asymptomatic newborn plus (A) +ve maternal history WITH active genital herpes lesion and delivered by CS (in primary genital herpes) or CS/VD (in recurrent genital herpes) --> collect surface swabs within 24hrs of age for HSV PCR (eye, throat, umbilicus) if PCR results are +ve or neonate become unwell take CSF sample via lumbar puncture (LP) for HSV PCR and start acyclovir. (B) +ve maternal history of primary genital herpes WITH active genital herpes lesion and delivered by VD --> take swabs + LP + start acyclovir. (C) +ve maternal history primary or recurrent genital herpes WITHOUT active genital herpes lesion--> Observation If develops any symptoms of neonatal HSV as above --> take swabs + LP + start acyclovir. LOS: once clinical suspected we take cultures (Bl, urine and CSF) start antibiotics (the type of antibiotics depends on your units policy eg in Japan: mostly Gentamycine and ampicillin, in Canada: Vancomycin and tobramycin). Results in 48hr If cultures + , take another culture and switch antibiotics according to sensitivity if not sensitive to the initially given. Duration of treatment after obtaining a -ve culture depends on the organisms type and whether or not CSF sample was +ve. We use meningitic dose from the start if suspected meningitis (eg seizure). until CSF results. Antifungal if cultures are +ve for fungus. Rarely would we take a tracheal aspirate, however, if there is a lot of secretions in an intubated infant and received a septic workup and bl cultures are -ve after 48hrs and still secretions are a lot, then we may consider taking a tubal aspirate for culture.

In our unit, all medications including IV fluids, TPN, and antibiotics are prepared by nursing staff in a medication room, which has a direct connection to the NICU. Antibiotics and tubing are prepared under the hood during wearing gloves, masks, overheads and disposable gowns. I didn't come upon an RCT comparing site of medications preparation.

Hi Schmuz, thank you for sharing your case and bringing up the subject so we can all hear the different opinions and practices. A lot has been covered in the above opinions. Here are some points I only want underline. 1- Deterioration after day 2 or 3 “Honey moon period” in preterms with RDS. Although, we don't know if this preterm received surfactant or not. However, our practice is giving surfactant if the preterm is intubated and needing an FIO2 above 0.25 and climbing. Take a look on the Cochrane Rev. by Bahadue FL, Soll R. Early versus delayed selective surfactant treatment for neonatal respiratory distress syndrome. Cochrane Database Syst Rev. 2012. If such a preterm is not weaned promptly after surfactant and extubated to nCPAP within the first 2~3 days, VILI would develop. Usually within the first hour for such a preterm after given surfactant, ventilator settings are weaned significantly, reducing FIO2 until reaching below 0.3 and then reducing PIPs by following the expiratory volumes +/- CO2 levels if available, if using A/C or SIMV without VG. If VG is available we set volumes to 4~4.5 ml/kg and the PIPs will go down by its self when the compliance is improving, and you just wean off the FIO2. Give a loading caffeine and plan extubation. Failure to wean within an hour after surfactant means something is wrong and a follow-up X-ray and probably a 2nddose of surfactant to be given if still RDS signs are present and if no other evident findings which explains failure to wean. For giving surfactant during on HFO check it in HFOV Drager booklet by Jane Pillow 2016 its clearly explained. 2- The best mode of ventilation and safest is the mode your team masters and are fully experienced with. Typically in our unit we start on conventional ventilation A/C for 3 days (as it has a very slightly less risk than HFO in development of IVH) and then we shift to HFO if not extubated to nCPAP (as HFO has a very slightly less risk of BPD). However, due to the fact that only very slight less risks in both Cochrane statements, any mode a team is confortable with is better HFO or A/C or SIMV+PSV. 3- This preterm was on two inotropes, please be careful if Dobutamine is one of them. The problem of ventilation could be due to hypotensive effect of Dobutamine, check if both the systolic and diastolic blood pressures are acceptable with a preserved pulse pressure and not only the Mean BP. 4- Coming to your question on HFV +VG, - Typically on HFO without VG the setting would be: o SV (Δ P) to give Volumes of 2 (1.7~2.5) ml/kg, MAPs of (9~12) to have a FIO2 below 0.3 and a lung expansion with diaphragm reaching 8th~ 9th rib on X-ray. How to reach the suitable MAP is well explained in the HFOV Drager booklet by Jane Pillow 2016. o Frequency of 12~15 is gentle ventilation which is our usual used frequency in these small prterms unless otherwise indicated in such cases eg: development of PIEs, where we would use lower MAPs (eg 8~9) on the cost of higher FIO2s, lower end of volumes eg 1.5~1.7 cm/kg and then lower frequencies eg 9~7 Hz for controlling CO2 (keeping PCO2 40 ~ 60). - With adding the VG it will adjust the Amplitude to maintain your requested volumes, as explained by both @Tanyahand @Christian Heiring. - If using the VN500, check the table data (table 2) will include the DCO2 (ml2/sec) try to keep it above 40 up to 80 (adjusted by body weight for the ELBW infants) DCO2/BW2 Hopefully we can get a comment on that equation adjustment for ELBWIs from @Tanyah - Recommended reading for intial settings and weaning, chapter 23 Mechanical Ventilation: Disease-Specific Strategies, by Bradely Yoder in “6th ed. of Assisted Ventilation of the Newborn”

In our FMC we have three levels of newborn care, the 35wks+0d ~ 36wks+6d stay for one day (24hrs) in the level II (being with a BW of > or = to 2000 grams). During that time their vitals are being monitored (on a pulse oximeter: saturation and HR), blood sugar, levels bili. Next day if oral feeding and vitals show no issues, they are moved to mom. Moms are discharged 4thday after birth if NVD and 7th day if CS. All babies would receive a check up before discharge and would make reservations for their 1 month followup check. In Canada I was in a level III unit which had a section as a step down, only 35 weekrs were kept in the NICU for 6hrs under observation by the pediatrician (under Obs) in the step down section, if the newborn could control its temp. and showed no issues on feeding and bl. sugar levels, would be moved to mom. If any issue appears, the Pediatrician would consult the NICU for management or NICU admission. 36weekrs kept with mom from birth. I have the same concept as @tarekand @Stefan Johansson "Non-separation and non-medicalization" of this population, especially that we actually very rarely need to admit these babies to the NICU.

@tarek & @rehman_naveed Well, there is no clear national pre-screening guidelines for the use of propranolol. However, we do the following screening parameters: Full clinical examination, CBC, electrolytes, urea and creatinine, bl glucose, T3, T4 and TSH, Abdominal ultrasound (in case of multiple lesions), cranial U/S, ECG and ECHO. In addition to photos of the hemangiomas and their diameters. I believe every unit will follow their own screening guideline until we have a clear statement. Agree with both of you, the Golden hour and the expected magic bullets of the golden hour will be a really nice subject talk. Unfortunately, I am not able to join the meeting also. Looking forward to hearing your feedback and the recommendations coming out of the meeting.

Thanks for sharing your case Ayman. As @rehman_naveed clearly recommended concerning CBC. Reassure the infant`s family, the size may increase in the first few months and is expected to decrease later on. In similar cases in our unit we would consider propranolol after a normal cardiac examination and ECG, to be started in the NICU and if the infant tolerates it, will be D/C to home on oral propanolol and followed in outpatient. Good luck.

Hi, concerning morphine and fentanyl during cooling, smaller doses as potentially toxic serum concentrations of morphine may occur with hypothermia with doses above 10 mcg/kg/h. Start 5 mcg/kg/h and not exceed 10 mcg/kg/h. Another option is boluses 50 mcg/kg/4hrs. As for Fentanyl 0.5 mcg/kg/h max is 1 mcg/kg/h or boluses 0.5mcg/kg every 2 ~4 hs. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3552186/ I am not sure about the better action of morphine, but what I know that fentanyl shows a rebound increase in serum levels during rewarming. on the other hand, in cooling Morphine glucuronidation is inhibited in cooling and thus M3G (a product of morphine glucuronidation) is less produced which is a potent opiate receptor antagonist. http://neoreviews.aappublications.org/content/14/1/e22?sso=1&sso_redirect_count=1&nfstatus=401&nftoken=00000000-0000-0000-0000-000000000000&nfstatusdescription=ERROR%3a+No+local+token Although, fentanyl is 80 times more potent to morphine, we usually use fentanyl in our unit with doses less than 1 mcg/kg/h.

There is a lot of debate when it comes to marijuana and breastfeeding. Although, it has been reported that breastfeeding from mothers who smoke marijuana during lactation showed a delay in motor development at 1 year of age, It can be hard to draw any conclusions because mothers who smoke marijuana during lactation are much likely to have smoked during pregnancy, as well. This means we can’t always determine whether exposure in utero through smoking marijuana during pregnancy, or from exposure through breastfeeding causes changes in the baby’s development. One must weigh the pros and cons, On one hand, there are many benefits to breastfeeding babies, that is well established. On the other hand, the risks of using marijuana while breastfeeding are under debate. I would recommend, sharing the decision with the mom, explain to her the benefits of breastfeeding vs. formula and the debate on the risks of using marijuana while breastfeeding. Advocate for her baby by encouraging mom to wean-off the marijuana she is taking by 5 ~10 % during pregnancy and every 2 to 3 weeks after and to get professional help for her weaning-off.

I think the question can contemplate both meanings 1- The infant already has a PICC in place. 2- In some units the PICCs are being inserted with the infant inside a closed isolette (incubator) through the arm side windows, as our NICU in Japan. Thus the question of putting on a mask and overhead could be more questionable. I don't know a study which compared using /or not masks and overheads for inserting PICCs, but here we always put them on during PICCs insertion, but during sampling and handling we don't.

IV Caffeine early after birth (DOL0) for preterm newborns.