Nathan Sundgren

We talk about it. I want to get there, but one not so great experience makes me hesitant. If we are doing INSURE in our delivery room, I don't think it is practical enough and leans more to emergent in those cases. But if we are admitted in our unit, then I think it is the best. I'm convinced its better for babies getting intubated in general, but not consistent in my practice yet. FYI, we don't routinely use muscle relaxant and our standard is atropine and fentanyl.

I am not aware of any research on this specific subset receiving DCC. I think the problem is well put by Alex Scrivens above. If the placenta is detached from the uterus and oxygen supply is gone, we cannot leave an asphyxiated baby for 60 seconds with no resuscitation effort. Might they still benefit from the volume transfusion from the placenta? Maybe, but then our only option is to be scrubbed in with the OBs and resuscitate on the intact/ open cord. The data for this is intriguing, but I am not sure it is ready for wide spread adoption. The other situation is where there was an abruption scare but the baby comes out and looks vigorous. I try to do DCC in these cases, but often everyone was so convinced the baby would be depressed that old habits kick in and the cord gets clamped quickly and the baby passed off to our neo team. It is a work in progress here. Anecdotally, I had a baby once getting DCC that was very vigorous and doing well. As the OB clamped the cord after 60 seconds the placenta was delivered. We must have beecome detached at some point during the DCC, but the baby did great.

This is an interesting dialogue. I just had a long disuccussion about fluid management from the delivery room with our neonatal response team nurses. They see quite a bit of variability from our physicians. When we talk about fluids on the first day, we are usually thinking of so much more than just the dextrose/ nutrition containing fluids. We have to consider the "to keep open" fluids running in additional lumens of our UVC and UAC lines. Premature babies are often on antibiotics the first 2 days. Some get saline boluses or blood products. It is very easy to give 20-40mL/kg/d of fluid above the baseline nutrition containing fluid before you even realize it. The 2014 cochrane review of fluid restriction in preterm infants (https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD000503.pub3/full) includes only 5 trials done in 1980-2000. The fluid restricted arm in the individual studies ranged from 50mL/kg/d to 120mL/kg/d. "Fluid restriction" had more PDAs close and less NEC. The incidence of BPD, IVH, and death were in the right direction (favoring fluid restriction) but not significant. Trying to tie all these factors together and deliver an adequate GIR, I start with D10 fluid at 65mL/kg/d. I presume that flushes and medications will add an additional volume that will quickly put my total fluids in the range of 80 - 110 mL/kg/d, which I think is acceptable on the first day. If I have a low glucose, I first increase GIR by going up on the D10 to 80mL/kg/d, but thereafter I try to concentrate the dextrose containing fluids to deliver more GIR over increaseing the rate of administration. In subsequent days I use weight and sodium values to guide increasing total fluid targets. For almost all circumstances i use birthweight for calculations and continue to use it until the baby is back above birthweight. If the baby has edema and is above birthweight in the first week I stick with birthweight until the edema is resolved. I'm interested in others initial fluid strategies when leaving the delivery room. Where do you start - 60, 80, or more? Do you use D10 or D5 or something else? Thanks in advance for the replies.

We also start on AC-VG. We bring the ventilator into the delivery room and once intubated, get them on to volume ventilation and avoid as much t-piece or bag ventilation as possible. Initial settings are PEEP 5-6, 4-5mL/kg tidal volume, back up rate of 40, and iTime 0.3. We set PIP max at 3-5 cm H2O above the working PIP on the ventilator for the set tidal volume. If PIP to achieve these volumes is going above 28 or we are unable to make our target CO2 (50-70), we switch to HFOV. We are probably pretty quick to go to ECMO if needed, but we also have a fetal center doing fetal endoscopic tracheal occlusion (FETO) on severe cases and probably get a more severe population as a whole. Texas Childrens, Houston, Texas, U.S.

DCC has several advantages for our preterm babies. Probably most important is that DCC allows the heart to fill and maintain preload from the placental circulation while the lung vascular system is opening and being filled. Animal studies show a compelling improved stability on cerebral blood flow and pressures. Blood transfusion from the placenta to the baby increasing blood volume or hematocrit may actually be the less important effect of DCC in our preterm babies. The greatest advantage appears to be if DCC is delayed until after the baby starts breathing and the lung vasculature opens up. Cord milking in animal studies can produce a highly unstable cerebral blood flow pattern with alternating high and low blood flow with each "milk". It concerns me that this is a set up for IVH. But, the human study from Dr. Katheria showed no harm from cord milking compared to DCC and the neurodevelopmental follow up actually looked somewhat better for cord milking. So perhaps cord milking can be used, especially on babies that waiting 60 seconds for DCC is deemed unsafe. As for resuscitation on an open cord - where resuscitation is done while the cord is unclamped, Dr. Katheria has helped us there, too. He randomized babies to receive resuscitation vs only drying and stimulation while DCC was performed for 60 seconds. No difference. Most amazing from this study was that even in a high risk preterm population, 92% of the baies breathed spontaneously before the cord was clamped. This seems to have greatly negated the need for PPV for many of these babies and CPAP can be applied instead. I think this is a very exciting area. We are working with our OB colleagus to more frequently use DCC. I am still discouraging cord milking because I believe more research needs to be done to assess safety. Right now I don't see the advantage to the resuscitation trolley. If the placental-baby circulation is intact and uncompromised, the delay of 60 seconds to start resuscitation efforts appears safe to wait on resuscitation efforts and perhaps as 90%+ will start breathing in this time, we may find we do less interventions.

Minimal experience using LMAs in live babies. I have used it on 2 patients. I am at a level IV NICU and we follow NRP teaching to use it in circumstances of "can't ventilate and can't intubate." We teach LMA use and placement in simulation. Its usefulness with surfactant administration in my mind is limited since it can't be used on teh smallest babies where surfactant is most beneficial. In babies >1500g it has been shown to improve short term outcomes of resuscitation compared to mask ventilation in a recent cochrane review https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD003314.pub3/full?highlightAbstract=lma&highlightAbstract=neonat&highlightAbstract=neonates I think there probably is a population of preterm and term babies >1500g at a high risk for needing PPV that might benefit from LMA use before mask to avoid intubation and further resuscitation measures.