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@tarek and @Zsofia Dombi You are very much welcome, I hope I could be of any help. Concerning@tarek questions: Yes, this our policy for ELGANs, and majority of cases follow through the policy smoothly. However, as you know you could have the preterm on conventional ventilation (CMV) (A/C or SIMV) within the first 3days, and due to uncontrolled high PC02 in blood gas on CMV the mode is changed to HFO, without really making enough effort for troubleshooting and adjuesting the settings on CMV. I think that majority of preterms could be ventilated with A/C if you are comfortable with changing in the different components of the ventilator`s settings. This policy was implemented due a group of weak evidence: 1- The peak for IVH development is within the first 3 days of life. + 2- HFO has a slightly higher risk of IVH, and severe IVH. ==> Thus we try to avoid HFO during the first 3 days of life. On the other hand, CMV has a slightly higher risk of BPD, ROP and CLD/death at 36wks corrected age. Thus we shift to HFO after the first 3 days of life. Another opinion can state, that really all the evidence of increased risks on both arms are so low ranging from 0.02 to 0.05, and thus it doesn't really make a major difference to switch from one mode to another. Well may answer would be, It really depends on which mode you and your colleagues in the unit are comfortable with. This is true so long as your preterm has a homogeneous lung, but once it has a significantly heterogeneous lung eg PIEs or has a lot of secretions due to infection you will have to contemplate which ventilator and which mode is best for your patient. eg: in PIEs: HFO low frequency and low MAP with accepting higher FIO2. Or if a lot of secretions the Jet-HFV could be the best choice. @Zsofia Dombi Concerning CPAP, it would be always nice to mention how high was the PEEP. There are many reasons for CPAP failure, setting a low PEEP or unable to reach the desired PEEP (eg: try closing the baby`s moth with a pacifier), poor nursing care of CPAP, unfit nasal prong (try nasal mask), evolving BPD, PDA, increased apnea, and sepsis. Your departments dexamethason course sounds like a modified DART protocol for extubating babies who are stuck on ventilators for more than 7 to 21 days, if I follow you correctly your unit is using a total dose of dexamethason of 0.53 mg/kg over 10 days. It is smaller than what is used in some units in Canada which is a total dose of 0.89 mg/kg over 10 days. Best of luck.

Considering a contemporary definition of BPD that correlates with respiratory morbidity in childhood.

Thanks for sharing your 24wk`s case. To truly be able to give advice, its better to share the current setting which the baby is on her Sats and transCO2. From your question, she is now on conventional ventilation (AC or SIMV) without VG. You have several ventilation maneuvers you can follow: 1- If the ventilator you are using does not have VG, use PIPs which give you volumes of 4~5.5 ml/kg, however, if you have a big leak around the ET tube, it will be hard to follow volumes and you will depend then on your blood gas CO2 or transcu. Co2 or end tidal CO2 and saturation to give a sufficient PIP. 2- if the ventilator has VG, adjust your volumes as above at 4~5.5 /kg the ventilator will provide PIPs to give your selected volumes. Again if the ET tube has a big leak, VG will not work and then you better switch the VG off and do as in # 1 , Or you can change the ET tube with a wider one. 3- In our unit we keep these ELGANs during the first 3 days of life on A/C (after giving surfactant and if intubated) to lower the risk of IVH, then we switch to HFO for several days using gentle ventilation settings until the MAP drops to 10 or 9 in room air, then we consider switching to A/C again or just go down on the MAP and extubate from HFO. Lastly, you mentioned hypoxic episodes, to decrease that start Caffeine and if you are using SIMV switch to AC. Good luck.

Does anyone have a more recent article on acetate for acidosis in preterm neonates than the one by Olufunmi Peters and Steven Ryan 1997 (link below)? https://www.ncbi.nlm.nih.gov/pubmed/?term=acetate+for+acidosis+of+preterm+neonates Thanks

A very nice article, thanks @Stefan Johansson

Good work @spartacus007, would you be kind enough to share with us the X-ray finding before surgery? Was the hypoplastic lung apical? or hilar or you couldn't identify it? Would you share the current BP and ECHO results? Failure or difficult weaning of inhaled NO for treating pulmonary hypertension in hypoplastic lungs in CDH and preterms is not uncommon . Concerning your presented case, In our NICU settings we would prefer using HFO using MAPs 2~3 higher than your MAP on conventional (Go slowly on the increase in MAP increase by 1). We would prefer the HFO not to injure the hyoplastic lung and to recruit the lung volume to improve oxygenation and ventilation. Continue to increase your MAP to lower the FIO2 to below or =30%, but be careful not to over inflate the lungs which would be seen by rebound increase of FIO2 needs during your gradual increase in MAP or by X-ray seeing the size of the heart and level of the diaphragm. In addition, in our NICUs setting for PPHN due to CDH we would start Dopamine (1st increase SVR ) and according to the ECHO findings on TR and direction of flow through the PDA we would start NO at 20 mpp (2nd) if TR is still persist. BPs, follow up ECHO heart to see the effect on TR + FIO2 needs would be our guides. If still PH persist, we would add Milrinone (3rd). Sildenafil is used in our setting to wean off NO or if the above 3 medications were not controlling the PH. In your current setting, still FIO2 is 50% , Still needs to go down on the FIO2 before withdrawing your NO. I would work on recurring the lungs first before weaning NO totally ( as presented above). Hoping our settings could help you with your patient. Good luck.

Hi @Andrej Vitushka This is interesting, we usually avoid using CPAP in CDHto avoid dilatation of guts loops and further herniation with cardiovascular compromisation, however, this case seems to only have it`s liver herniation in the chest. I see the OG tube is somewhat in a high position in the lower 1/3 of the esophagus. Concerning feeding, in our setting, we start feeding after surgical repair of CDH and not before. However, this case`s X-ray seems like lt. sided diaphragmatic paralysis or paresis and is already on CPAP, thus I would start feeding if surgery is not expected within a few days

@rehman_naveed Thanks for sharing the experience from your unit. Have you came along another RCT for the use of acetate for metabolic acidosis in preterms beside the one from Liverpool 1997: Randomised controlled trial of acetate in preterm neonates receiving parenteral nutrition. Arch Dis Child Fetal Neonatal Ed. 1997 Jul;77 I agree with you concerning the use of albumen for giving volumes in preterms with or without low serum albumen, there is a limited number of studies to answer whether giving albumin helps babies in the short or long-term or to show any benefit above crystalloids.

@rehman_naveed Thanks for opening up a practical discussion. I am not sure if forgot to mention the GA and DOL in your example or you meant same as the above case. By the numbers, you have given this is not fitting a DOL0. I am not sure why in this example case the incubator`s humidity is only 80%? Usually, we start at 100% for ELGANs and go down slowly. If we consider this was a whatever DOL premature, with a high Na level, urine output is at a high level as you explained 6 ml/kg/h, normal Cr, high Urea most probably due to catabolic state (consider adjusting amino acids in TPN), Your answer in the clinical practice in Japan would be: Need to know: 1-The K level, because if you need to add acetate for acidosis you can put it in as K-acetate and not Na-acetate. 2- The blood pressures. Although is expected to be ok, due to your good urine output, unless your case is also hyperglycemic and thus polyuric. In that scenario you would consider the level of BS and if you would give insulin or not. 3- IVC diameter, SVC flow, a 4 chamber view to the cardiac filling, cardiac contractility (part of targeted ECHO done by neonates MDs and fellows). To estimate your circulatory volume. From the data collected above: * If circulatory volume (by ECHO) and BP is low (for example), increase the TFI with an additional 20 ml/kg , by Y in D5 and/or IVIG if the baby`s immunoglobulins level is below 100, to compensate for your additional 20 ml/kg/d increase TFI. If Na was not high could also give albumen. Restrict the Na given to lower limits of daily needs 2 mmol/kg/d, replace Na-acetate with K-acetate. *If volumes are good (detected as above by targeted ECHO), but BP is low: start an inotrope according to what your ECHO showed to select, ie Dopamine 5 microgram/kg/min, no need to increase the TFI as much as the case above. * Electrolytes are usually taken from of the bl gas which, if the Na was higher than 160, would then consider sending to hospital`s lab a sample to confirm. Another blood gas in 12hrs if ventilated, if not then with AM sampling Your answer in practice in NICU Canada or Egypt: Good urine output, increase TFI to 80 ml/kg/d by Y in D5%, restrict the Na given to lower limits 2 mmol/kg/d, replace the additional Na-acetate with K-acetate. Check BS and as above for hyperglycemia. If blood pressures are low, elevated Lac and prolonged CRT, give a bolus of 1/2 saline to D5% and Y in D5% to the TPN used to increase TFI by 10 ~20 ml/kg. Adjust TPN Na content at AM to 2 mmol/kg/d. BS as above. If still blood pressures are low considered starting dopamine. As for electrolytes chicking as above almost no difference, except in some units, you have to order the electrolytes results off the gas to get them, and can only use it to direct you to withdraw a sample to the hospital lab or not. I think in both ways of practice, the management could be somewhat similar in case of increase TFI, but what comes in different is that targeted ECHO here comes in as a decision-making tool for tailoring whether to start inotropes or give higher TFI volumes.

@bimalc and @tarek Thank you both for your comments and sharing your experiences. I do understand your points and concerns. Our standard starting point for TFII is 50 ml/kg/d on day 0 for micro preemies, but we tailor the TFI for each case depending on mean arterial blood pressure, cardiac size on chest X-ray, ECHO heart findings, and urine output. Thus one preem may be receiving a TFI of 50 ml/kg/day on day 0 and another preem with the same GA and BW receiving a TFI of 80 ml/kg/d. Each case is different. In addition, our rate of increase is 10 ml/kg/d as a basic standard, but still, it could be higher depending on how the same factors mentioned above go In an NICU in Canada, the TFI was 60~80 ml/kg/d for micro preemies < 26 weeks GA, and 100 ml/kg/d for < 24 weeks GA, as a standard, and when these fluid volumes were not enough to maintain the BPs and there was poor peripheral perfusion indicated by high Lac and prolonged CRT, saline boluses were given and inotropes were considered. The daily rate of increase was as a standard 20 ml/kg, unless the prem was puffy or chest X-ray showed increased lung fluids, then daily increase in TFIs was decreased or skipped. I do not imply that one strategy is better than the other, however, tailoring the fluids and inotropes given per each preem`s condition for me sounds practical. We have a special session on tailoring IV fluids and inotropes for preterms next month in the 62nd annual conference of the Japanese society of neonatal health and development http://jsnhd62.umin.jp/en/abstract.html . This could be an important topic to be also discussed in next 99NICU meeting @Stefan Johansson

@Stefan Johansson Thanks a lot, no I wasn't aware of this recent Cochrane review. Thanks a lot. I will share it with my coworkers and colleagues.

Pain control in preterms. Umbilical cord milking. Management of seizures during cooling and rewarming. Targeted ECHO and Ultrasound for neonatologists. Decision making in case of ELGAN ( how to help parents decide their baby`s management pathway). Methods for breaking hard news to parents about their baby or in an antenatal consultation. Including families in NICU rounds and care of their infant. Latest updates on modes of ventilation. Effective with time and effort efficient policy for daily rounds (How to make it successful for the patients, their parents, and medical staff).

Hi Tarek, Your experience with this 600 g ELBW is not uncommon. It is important to mention the gestational age in your description of the case. It can help the reader give you a more practical answer. I am assuming this was a 24 ~ 25 weeker infant unless it was also an IUGR. To minimize IVH you have special concerns to cover: A- Before birth giving mom Antenatal steroids. B- Delivery: 1-With minimal handling as possible. 2- Cord milking and delay cord clamping C- After delivery: 1- Positioning the head and body in same line ie not tilting the head to one direction lt or rt which will kink the neck (Jugular) veins and cause congestion of the bain of that side. 3-Prophylactic indomethacin (indicated in Japan if BW less than 1000 g + GA below 28 wks/ and in some NICUs in Canada if GA is less than 26+0 wks whatever the body weight is). 4- Correcting acidosis. 5- Maintain a good circulatory volume and start low IV fluids with a TFI at 50 ml/kg/d on DOL 0 and increase fluids by 10 ml/kg/day, unless the circulatory volume is low then you have to balance it. 6- Minimal handling. First 3 days are the highest risk time for IVH development. As for your concerns about intubation especially when there is no experienced medical team member (physician or RT), that depends on your unit`s policy for staff coverage. However, I recommend you not to jump quickly to intubation, a lot of 23, 24 and 25 weekers manage to escape from being intubated using CPAP and NIPPV.

Hi Bimlac and thanks for asking, Midazolam infusion is one of the 2nd line AEDs in Japan, and the most commonly used one when the infant is intubated. I myself prefer Keppra over both Midazolam and fosphenytoin. Especially, during cooling. Midazolam causes hypotension and fosphenytoin has several side effects as well as, it's hard to reach and maintain a therapeutic level using fosphenytoin. In Japan Keppra is not yet accepted for use in children under 4 years of age unless the treating doctor submits a special request to use it. According to my practice, Keppra showed almost no side effects during using as a 2nd AED in infants with and without cooling. If the infant is not intubated, fosphenytoin takes place as the most commonly used 2nd AED.

I agree with treating recurrent electrical seizures, however, what frequency of seizures and how long is each seizure until we would tolerate until starting AED or adding a 2nd one that is a concern which needs to be clarified. So long that it is not yet clearly outlined, I would go with what Stefan mentioned using a trigger for AEDs use, increase or addition of another line if > 2 seizure episodes. However, yet it is not clear is the > 2 episodes time-related? i.e. > 2 episodes in 3~6 hrs or in 12 ~ 24 hrs.

@chandas Thanks a lot for sharing the article Keszler M, et al. Multicenter controlled trial comparing high-frequency jet ventilation and conventional mechanical ventilation in newborn infants with pulmonary interstitial emphysema. J Pediatr 1991;119:85-93. It's a very conclusive article. The study used low PEEPs ( > 5 cm H2O), high resp. rates 60~100 BPM, low Tis 0.2 ~ 0.35 sec, and PIP guided by adequate chest wall movement and gas exchange. Lower pressures were targeted even at the cost of higher FIO2. It's clear, however, unfortunately, the authors didn't show how low did they go on the PEEPs and what was/were the indicator/s for how low they can go on PEEPs. Did they use PEEPs of 1 or 2 cm H2O and would that make any difference? We had a discussion in the NICU and it is hard to convince the team with PEEPs below 4 cm H2O. @mosarrat & @Stefan Johansson Thank you for your comments, really appreciated. I am attaching the article Keszler M, et al. Multicenter controlled trial comparing high-frequency jet ventilation and conventional mechanical ventilation in newborn infants with pulmonary interstitial emphysema. J Pediatr 1991;119:85-93. I marked the site of CMV ventilatory settings. If you have an article which supports higher PEEPs in PIEs, I would really appreciate if you could share it with me, as both high PEEP and low PEEP were challenged in our unit`s discussion. Lower PEEP in CMV for PIE.pdf

According to my knowledge, if I have a case with PIE and I would like to use a conventional ventilator, I would use a low PEEP. Does anyone have an article which mentions that? In addition, can anyone let me know the settings they use on conventional ventilation for PIEs, using both with volume guaranteed and without? Thanks

We actually usually use HFNC as a step down from CPAP. However, sometimes we give it a try from the start after extubation in preterms who are doing well and have a good compliance " static compliance" on Resp. function test before extubation. Our starting flow is about 3~5 L/Kg. We weaning we go at a rate of 0.5 L q 12 hrs.

Hi Stefan, I am not sure if I understand your answer. Do you mean that you check the aEEG on daily basis i.e. every 12 or 24 hrs and see if seizures are increasing or decreasing to consider treating? According to my practice, once the aEEG shows a seizure or the baby shows a clinical seizure we start phenobarbital (PB). Later on during cooling, if the aEEG shows seizures in spite that the PB level in the blood is within the therapeutic range we add another (2nd) antiepileptic drug (AD) for example Midazolam. We continue to increase the 2nd AD if the seizure activity is still present until it stops or we reach the maximum dose of Midazolam. I mean by "seizure activity" here if even there is an aEEG seizure activity every six or 12 hrs. We actually don't wait to count them. Once there is a seizure we proceed further. In addition, when the baby receives PB we depend mainly on the aEEG because it causes uncoupling. Could you please make it clearer for me?

Is Recooling for Rebound Seizures After Rewarming in Neonatal Encephalopathy a common practice in your NICU? I could only find a case report to support this practice "Recooling for Rebound Seizures After Rewarming in Neonatal EncephalopathyPediatrics. 2012 Aug;130(2):e451-5". However, I know it is widely used in Canada and is stated in the CPS guideline posted in 2012 and reaffirmed in 2017.

We actually depend on aEEG finding to treat seizures. Especially, if the infant is already on PB considering the phenomenon of uncoupling.