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.

The ultimate goal in personalized medicine. The big trials tell you if it works for a population or not. When you apply it to your n=1 patient, you decide if it works or not for that patient. Everyday in the NICU is n=1 research.

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.

Do you have a max weight? We tried on a larger baby over the weekend and encountered more difficulty probably for multiple reasons. Is there a weight you have found that is too big for this procedure (assuming they are truly surfactant deficient)?

@Florian I would love to use the catheters you are talking about, but they are not available in the United States. I specifically spoke to a Chiesi rep and they don't see making the effort to get FDA approval here anytime soon. @M C Fadous Khalife Glad you liked it.

Thanks for the feedback @dj 188 and @Tamimi . We do have clear guidelines on pressure settings and we are targeting above 30% FiO2 to make sure the surfactant is early rescue and not late. I have not wanted to necessarily limit weight or GA, but we recognize the biggest benefit is likely in the <1500 gram, and technically easiest in something larger than the sub 500g babies. I too wish we could get the surfcath. Drawing the line on the angiocath is my least favorite part of the whole thing.

So I've seen LISA done once, I've now done it once, next is to roll it out unit wide in our NICU. See one, do one, teach one, right? I'd like to hear from those of you that have been doing LISA/ MIST for a while now. What is the best tip you have? What do you know now that you wish you had known when you first did LISA? What barriers to implementation did you have when you started? Any feedback is welcome. Also, I made a video for our nurses and respiratory therapists to just introduce the idea. Not too in depth, but something to get our education rolling. See what you think.

Tough question, but something we see in various shades of similar. I would personally try the 2 rounds of steroids as in the scenario, but I would strongly hesitate for a third. I would probably tolerate a lower sat goal to keep the baby off 100% oxygen, fluid restrict more, and then wait. Grow, grow, grow. If I had to intubate (for whatever reason I "had to") I think I would focus on growth for several weeks before possibly trying the third round of steroids to extubate again. This is, of course, based on as little EBM as I can imagine, and faced with the actual circumstance I would probably actually do something completely different each time.

https://journals.lww.com/pidj/Abstract/9000/INTRAUTERINE_TRANSMISSION_OF_SARS_COV_2_INFECTION.96099.aspx A case report of likely vertical transmission as well.

Sorry. The link does not work for me.

Final video version now public on YouTube. Please share with interested colleagues.

@olamedmac what a privilege to have you respond to this thread. Thank you. I will definitely make some revisions based on your suggestions. I was nervous about the Aristotle quote, since his work is all Greek to me, but I thought I had it from a reputable source that it was true. Your suggested quote is many times better. I really thought I had the Erasmus - Charles Darwin connection correct, but I should have double checked my facts there, too. I will also fix this. As you said, deciding which articles to include does get tricky as I was really working hard to keep the video to 15-20 minutes long, and usually the shorter the better. I will look again at including some of your suggestions. As for the 60 second recommendation, I wholeheartedly agree with you about 3 minutes in term babies. Honestly, as a neonatologist, my mind is mostly thinking of the preterm babies. I do think right now that 60 seconds is probably the best compromise for preterm babies, especially since not many are resuscitating on the open cord. I need to make a better distinction in recommendations for preterm to term. I did try to express this by saying a few times in the video to consider longer for stable term babies. I think you are right that I can make a stronger statement for the term babies being 3 minutes. @Stefan Johansson the webinar idea sounds great and I'd love to give it a try. Thanks. Maybe we can DM on twitter for more discussion?