cB23

Have a case: Stat CS for maternal abruption and decels Term baby. Poor tone and resp effort. Suspected blood aspiration. Needed PPV and 100% FiO2 for hypoxia. Intubated in DR. Cord gases pH 7.22 BE -8 Baby H/H: 18/50 Baby gas 7.18 / -8 at ~50 min of life Started having clinical seizures at 12 HOL. Electrical seizures on EEG. Normal HUS. Would you start late therapeutic hypothermia? Did not meet mod/severe sarnat encephalopathy on exam but was hypotonic, was intubated, and required prolonged resuscitation. TH is often fairly well tolerated and there's not much else to do. 2017 Laptook paper suggests potential benefit with late cooling. The baby had a perinatal event and clinical signs of possible HIE but no acidosis. Could be stroke or other. Some papers looking retrospectively at cooled infants who went on to have perinatal stroke had seizure reduction with TH. So far has received phenobarb, keppra, fospheny for refractory seizures.

What premedication are you using for INSURE or even for routine intubation in ELBW / VLBW? Is there a gestational age below which you would NOT use morphine? Have seen some babies < 28 wks GA receive morphine and have prolonged hypotension, anuria / oliguria, rise in Cr. Seems like these babies should receive fentanyl instead?

How do you manage fluids in the ELBW - 500g infant? We start at 100 ml/kg/d and increase by ~20 ml/kg daily. Despite plastic wrap in DR, humidified incubators, etc we often have significant hypernatremia usually by 24 hours, sometimes > 150, sometimes > 160. Is this a sodium problem or a water problem or (probably) both? These little guys have lots of transepidermal water loss especially in the first 2 days. They also get Na Acetate via UAC giving sometimes 1.5-2 mEq/kg/d of Na in that first day when the kidneys (from what I read) can excrete free water but cannot filter an excess sodium load well. And some lit suggests retention of birth weight (or not having the physiologic 10-15% wt loss in ELBW) is associated with BPD, PDA, etc. When would you give normal saline bolus for hypernatremia considering that the kidneys may not be able to excrete excess Na load? Or would you just continue to increase free water via non-Na fluids to replace the insensible losses and restore intravascular volume. How high would you go with total fluids? 180-200 ml/kg/d in the first 2-3 days of life? Higher? Any experience with sterile water drip via orogastric tube for ELBW with hypernatremia?

There is confusion here about set Vt and dead space volume. Do babies on 4-5 ml/kg Vt need an additional 0.8 ml added to that value to account for the flow sensor? Or do the varying Vt targets for different underlying pathologies already include the fixed dead space (ex flow sensor dead space of ~0.8 ml on Draeger babylog relatively more impact on ELBW babies, thus target 5-6 ml/kg)? Or is there a weight-based dead space calculation? or Which of these would be right for a 400g baby? 0.5 kg x 6 ml/kg = Vt 3 ml or (0.5 kg x 6 ml/kg) + 0.8 ml = Vt 3.8 ml or something else? 0.5 kg x (6 ml/kg + 0.5 ml/kg) = Vt 3.25 ml