rajnandyal

Sorry for my inadvertent delay in replying. I found this in my Spam folder, despite my habit of emptying spam folder without looking at them. It is indeed a very challenging, puzzling and potentially controversial question. I know every one suggested no exchange. Most of the answers recommended work up for cholestasis. I lean towards agreeing with Dr. Naveed. To start with, there is no good or even fair evidence to support any answer. There were case reports or anecdotal evidence to support exchange transfusion. During my fellowship, we had a 2 week old baby with klebsiella sepsis, status post- ECMO got treated with Exchange transfusion, but had mild neurodevelopmental deficits using Bayley II, at 2 years of age. What will I do? I will do (or delegate) moderately extensive literature search (including Legal/Law literature) and present the information to the parents (family), and then take a decision (I have worked only in US, and don't know how I would manage in other countries). I will also discuss with my hospital administration and ourNeonatal exchange transfusion (NET) – what is its current net value.htmlNeonatal exchange transfusion (NET) – what is its current net value.htmlNeonatal exchange transfusion (NET) – what is its current net value.htmlRisk Management. If I decide to do (no way out) double volume exchange transfusion, I will take all precautions. Short answer- most likely, I will not do Exchange transfusion, but definitely explain to the infant's parents/family. my reasons. The question of neurotoxicity of direct bili, despite the strong belief to the contrary, is still debatable in various clinical scenarios and presence of risk Neonatal exchange transfusion (NET) – what is its current net value.htmlfactors (gestational age, birth weight, chronological age, sepsis, medications, intracranial hemorrhage,

Very rarely, we send a baby home on home apnea/cardiorespiratory monitor, just for post-discharge monitoring for apnea. I don't think that, there is adequate evidence to support that practice on a routine basis (2016-AAP Guidelines). From our Level IV NICU, more than 90% of babies that go home on home apnea / CR monitors have O2 dependent chronic lung disease / BPD (That number is dwindling down). Remaining infants tend to belong to the following groups- a) babies that are otherwise ready to be sent home, but unable to be weaned off caffeine by 36 weeks PMA. We attempt weaning off caffeine by 32 to 34 weeks babies that had no "true apneic episodes" for a week (will stop caffeine if maintenance dose is 4 to 6 mg/kg/day, Or will decrease by 50% for 4 days, and stop it if remained asymptomatic, when the maintenance dose is 7 to 10 mg/kg/day, b) babies that are symptomatic at >36 weeks GA (apnea of infancy and other causes are ruled out), c) ALTE (apparent life threatening event- other cause are ruled out), and d) miscellaneous- babies that have very high potential upper airway obstruction, such as upper airway anomalies, severe GE reflux, CNS anomalies, central hypoventilation syndrome, s/p trach etc. Once on home apnea / CR monitor, we use the following criteria for discontinuing-- a) at 44 weeks (or more) corrected GA, and apnea free for 1 month, b) the reasons for using the monitors, have resolved, and c) off caffeine for 7 to 10 days, and remained asymptomatic. Yes, we have guidelines, but compliance is unsure. I guess, it tends to be individualized.

I also want to emphasize what previous discussants already mentioned, that the entire team should be on the same page. I am sure that all of you often heard this comment before- "baby failed HFJV". In most of those cases (with due credit to the clinicians), I feel that WE failed (not the baby) to choose the correct strategy, or manage the ventilation/oxygenation, or unable to wait for a strategy to work, based on our bias, bad habits or our past experience. I encourage our fellows to contact the HELP team of HFJV in difficult situations. Contacting that RT team is very productive and educational. Please let us know, if there is any such "on-call personnel" for other vendors. We all will benefit. Thanks.

Hello, I agree with Dr. SAS. To start with, I rarely use HFOV for ELBW babies (less than 1000 grams), either from the start or as a rescue mode. If I use HFOV, I start with frequency like 10 to 12 Hz. If I have to choose one of the high frequency vents, I usually prefer Jet ventilation (HFJV) over Oscillator (HFOV) for tiny babies. The reasons for that are, I want to have more control on PIP, PEEP (indirectly delta P), the rate, and to avoid/decrease the over distension of lungs (to decrease barotrauma and volutrauma). Nowadays in our unit, the number of babies who are still on ET ventilation is smaller beyond 2 days of age, when compared to those who are on non-invasive (nasal) ventilation (NIV). Our unit is big on early extubation within 24 to 48 hours (or even within 6 to 12 hours), after loading with caffeine, and use NIV. Some our neonatal fellows are admitting babies on HFJV for night admissions. They invariably end up on higher doses of medications like fentanyl, morphine or midazolam. One of the strong reasons for the heavy sedation is, night nurses' preference. Those babies tend to stay on ET HFJV for longer period. In day time, when the baby gets admitted on conventional ventilator, we load them with caffeine, give surfactant (only some babies get it), and extubate to NIV, all within a 4 to 6 hours. For ELBW babies, I personally use HFJV mainly as a rescue mode, when they require on conventional respirator MAPs of 10 to 12 (to maintain arterial PO2s 50 to 65 range and pCO2s in 45 to 55 range) either on PC/PS mode or PRVC mode, or if the chest X-rays show early s/o PIE. Based on the evidence (medical literature), and cumulative experience of 30 plus years, I strongly feel early extubation, tolerance to reasonable permissive hypercapnia, and the early use of NIV will decrease the incidence of BPD. Those are my two cents. Hopefully, this discussion is helpful,

If the repeat platelet count (by venipuncture) is still low, fungal sepsis is very likely, in view of several risk factors including use of multibroad spectrum antibiotics. I suggest investigating various foci/organs like renal, brain, liver etc, in addition to doing blood Cx, Urine Cx and CSF Cx. Obviously if any culture is positive, using two antifungal antibiotics is a good idea.