Nathan Sundgren

The ideal time is the day before you were going to get a line infection from leaving it in. 7-10 days is a good range, but sooner if you can do without it. But in some ELBWs the ideal has to be thrown out the window. I am especially thinking of the 22-23 week or <500g babies where feeds cannot be advanced so fast and peripheral sites for PICC replacements are minimal to none. What then? 21 days if you must or longer if you need the central access and no other alternative.

This is such a great blog started and I'm late to the discussion. My journey/ my hospital's journey to offering resuscitation at 22 weeks has been a roller coaster as many new endeavors are. I'll just share some of my thoughts. As more and more data became available that 22 wk GA could survive, I grew tired of going to prenatal consults where I would say something like, "I'm sorry, but at this GA (22 weeks) your baby cannot survive." It was a lie. But it was also true that our system was not prepared to take care of them and without a concerted system-wide effort, resuscitations here and there would likely not go well. So we made the case to our faculty and our OBs and got the buy in needed to proceed. We developed guide lines as best we could based on the published ones available and that fit best with our system and culture. We implemented these guidelines and started in the beginning of 2023. One choice was to use high frequency jet ventilation as our first intention primary ventilation mode for all GAs 22-23 wks. We are a CPAP first center on all babies >/=24 wks and this was a bit of a culture shift. We initially thought we would expect them on the jet for 2-3 weeks and then extubate. But the reality has been much longer averaging somewhere around 6-7 weeks before first extubation attempt. We have learned to be more patient with them rather than pushing to extubate. We did join the Tiny Baby collaborative and are working to share data to all learn from each other. But we are also keeping a close eye on our single center data. In our first year of system wide approach, we had 13 babies born at 22 weeks GA. 7 survived. Our IVH rates are reasonable and while we have essentially 100% BPD, the rates of going home on respiratory support are very low. You asked right and wrong strategies, here are a few of my thoughts on that: 1. Intubate, surfactant and high frequency vent. I am aware the German NRN uses non-invasive but think for most this will not work 2. Delayed cord clamping - it can still be done. 3. Right equipment. Right information. We have had to get smaller umbilical lines and get 2.0 ETT. We pushed our pharmacists to know what meds are truly compatible or not with TPN to save extra fluids and line access. 4. Skin care - I don't know what is right for this, but I know it is the single biggest problem caring for 22 weekers that you never had to think about before. We wean humidity earlier in hopes of earlier keratinization of skin. But it affects many things like the type of ecg leads you use and tape. So my experience is simply to say that it can be done. And I agree with Dr. Seuss who said "A person's a person, no matter how small" (Horton Hears a Who). This made my day. Thank you Dr. Ohnstad.

Impressive size! Any cause identified for this pneumopericardium? I think I understand spontaneous pneumothorax causes, but spontaneous pneumopericardium???

Agree with @Stefan Johansson. First priority is - is it a problem? If emergent then you might just have to go in blindly. In my one near emergency, I was able to get cardiology to use echo guided needle pericardiocentesis.

I updated the 3 video series of neonatal resuscitation videos. Now in 4K resolution. Updated for changes in 8th edition NRP. Check them out and let me know what you think. Consider using them in education for learners taking your neonatal resuscitation course.

This is the guidelines I developed for the situation you are describing. It will be our standard approach at my institution

Not adding much here, but EXIT would seem to be the only realistic option at delivery if the parents are choosing trial of intervention. Comfort care would be the other option. Undiagnosed tracheal atresia is one of those nightmare forming scenarios in the delivery room for me. At least being diagnosed a plan can be made.

Happy to help. Done.

I feel like we more often see migration IN. We do suture in and even suture to the cord but still see the migration. I would at least look at the “LifeBubble” product at Novonate.com. It has some evidence by abstracts of reducing migration problems. We haven’t purchased but have thought about it. https://www.novonate.com

Do you use premedication for LISA/ MIST procedure? What combination do you use? We have started our LISA procedures successfully, but a lot of concerns from our faculty that we should be using premedication as we do for intubations. Any advice much appreciated.

I'm not sure I have much advice to offer. Our nursing has worked hard to maintain CPAP. We are very fortunate to get 1:1 nursing staffing even for CPAP in the first 3 days for our small babies and we get 1:1 nursing for extubations to CPAP or NIPPV.

1. C 2. No 3. A. mask. I am starting to use an (C) LMA in special circumstances as first line for ventilation.