chigrl08

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Hi,

I will be starting on the NICU for my first rotation as an intern. Can I ask residents how they prepare for the rotation? Any good sources of reading material or cases that I can use to prepare? Any pearls of wisdom on how to handle certain situations from residents will be greatly appreciated! I'm very excited to start and want to perform the best I can :) I already have the Gomella book which is great resource, but was wondering what else there is out there?

Thanks!
chigrl08
 

oldbearprofessor

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http://forums.studentdoctor.net/showthread.php?t=286442

Bunch of info - not sure about the pearls part and some of it isn't from residents...

Feel free to add there or here. I'll bump up the annual "Where are you starting?" thread next month.

Good luck. Remember you'll always be able to tell folks you started in the NICU.
 

edmadison

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I wouldn't stress about it now. You need to be prepared to feel dumb. Really dumb. Dumber than you ever have before and that's OK. You will be overwhelmed at first. Give it time. Get down the basics: feeds, sepsis, basics of the vents. Ask questions when appropriate. Looking back three years later, you'll be amazed at how far you have come. Be patient. You will (and should) be uncomfortable with sick preemies for a long time. I was well into my third year before stuff started really clicking for me. I'm certainly no neo, but I felt I could stabilize a preemie if I had too -- at least until the transport team arrived. I recall a poster (med-student) a year or two ago fretting about the clinic saying that he'd rather be in the NICU because he felt comfortable with 24 week preemies. I replied that if you feel comfortable around 24 week preemies, you're missing something.

Ed
 
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DarthNeurology

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I recall a poster (med-student) a year or two ago fretting about the clinic saying that he'd rather be in the NICU because he felt comfortable with 24 week preemies. I replied that if you feel comfortable around 24 week preemies, you're missing something.

Ed
Wow! I am really amazed about how calm everyone is in the ICU who works there with 4 tiny premies all with sepsis and rds and under the lights lined up on just one wall, I felt nervous each time just walking in there. . . I doubt the student had any real responsibilities in the NICU, (well Dr. X the med student just ordered a head sono on Baby Jane) whereas in the clinic he has to see patients, get Hs and Ps and present (more work than NICU). . .
 

MedGoatTX

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I don't know if "comfortable" would necessarily be the right word, but I would prefer to be in the NICU over a GenPeds clinic any day of the week. And I did a Sub-I in our NICU last fall where I was the first one called with questions, etc. I'm sure the student experience varies from place to place though.
 

DarthNeurology

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I don't know if "comfortable" would necessarily be the right word, but I would prefer to be in the NICU over a GenPeds clinic any day of the week. And I did a Sub-I in our NICU last fall where I was the first one called with questions, etc. I'm sure the student experience varies from place to place though.
"Called with questions" by whom? Nurses? When I first started NICU I felt the nurses knew a lot more than me, why would they consult a student? Or do you mean pimping? The greatest autonomy I ever had was on an IM elective without residents so I worked with the attending more or less directly. I will probably do a NICU sub-I, other sub-Is I have done weren't that great as it took some arm-twisting the residents to see and do more and to slowly get more face time with attendings.
 

Perrotfish

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Bump. Does anyone know of a good resource for learning vents? A book or website or something? Also feeds and blood gases. I'm going to the NICU in 3 months and I've never had any ICU experience before.
 

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Stitch

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Bump. Does anyone know of a good resource for learning vents? A book or website or something? Also feeds and blood gases. I'm going to the NICU in 3 months and I've never had any ICU experience before.
"respiratory physiology" by Jon B. West. Not specific to neonates, but short, easy to read and contains concepts you must know.
 

BigRedBeta

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Bump. Does anyone know of a good resource for learning vents? A book or website or something? Also feeds and blood gases. I'm going to the NICU in 3 months and I've never had any ICU experience before.
Not specific to NICU per se, but the LearnICU.org site from the Society of Critical Care Medicine is a great resource and it has a PICU section here:

http://learnicu.org/Fundamentals/RICU/Pages/PICUModules.aspx

Some of the topics have audio, most dont, but it's a good place to start.


Overall, when I talk with medical students about vents, I take a very barebones approach.

First - ignore all the considerations of vent modes as the acronyms mean different things on different vents. But, understand that essentially all modes come down to either pressure control modes and volume control modes, and in their purest forms if you're in one of these modes than you've lost control of the other variable (ie, if you're in a pressure control mode, you can't set a tidal volume, and vice versa). All the fancy modes on a conventional ventilator are just riffs off of PC and VC.

Second - remember that the big reason for using vents (not necessarily in the NICU) is for ventilation - getting rid of CO2. We have a million different ways to improve oxygentaion, but if you can't get rid of CO2 properly, you need a machine to do the work for you.

Third - there are only so many settings you can control on a Vent. The basics are your PEEP (positive end expiratory pressure), PIP (peak inspiratory pressure), the FiO2, the tidal volume and your rate...tinkering with these basic settings will get you pretty far in most cases. The best way to think about these settings are simply, which will affect oxygenation, and which will affect ventilation. That dichotomy will help as you manage patients.

For getting rid of CO2, remember that minute ventilation is rate X tidal volume. If you've got too much CO2, you need alter these items. You're obviously going to be following your blood gases to find out your PaCO2

For oxygenation, obviously FiO2 is your first weapon, but O2 is harmful and toxic in many situations, and so avoiding 100% FiO2 is a wise idea. While you can use PaO2 on your blood gas to help guide your management, there are a limited number of situations where that's what's driving my decision making. Pulse oximetry is incredibly useful for that reason. But if you're maxed out on your FiO2 and the baby is still hanging out in the low 80's (and you know the child doesn't have a heart defect), you have to do something right? That's where PEEP becomes important. Without getting too far into the physiology, just know that increasing your PEEP is critical for "alveolar recruitment", the more alveoli that are open, the more surface area you have for gas exchange. Adjusting your PIP's can help with this (and in pressure control increases your tidal volume) but the overall effect is less because you spend much less time at that PIP.

That's the nitty gritty, and I think it's enough to at least allow you to make some decisions the first day.
 

elr1983

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Also keep in mind that many, many things in the NICU are not evidence based and depend a great deal on institution and individual attending preference. Be prepared for the plan and meds to change a great deal every week if you change attendings every week. I think the most valuable things you can learn as an intern in the NICU is NRP/delivery room resuscitation skills, vent management/physiology, and procedures, so I would focus on those things. For some of the other stuff, you'll probably be given a protocol/orientation book when you start in the NICU with your institution's consensus on feeding advances, antibiotics, etc, which is probably most helpful in the day to day NICU management. Good luck!
 

BigRedBeta

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Also keep in mind that many, many things in the NICU are not evidence based and depend a great deal on institution and individual attending preference.
Honestly, I'd argue the point that the NICU has WAY more evidence/research behind it than many areas of pediatrics. By that I mean there are far more high quality, large, multi-center trials in neonatology than any other subspecialty in pediatrics. So much of what happens elsewhere in peds is limited by small sample sizes, extrapolation from adult data and tradition. Certainly a great deal remains institutional dependent in the NICU, but overall, there are more "answers" there than any where else.
 
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oldbearprofessor

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There are a range of good reviews of this stuff, although I still think that for residents it's best to use a standard text and UpToDate.

One point I'd make here about vents and gasses is that it's important to distinguish between management of acute respiratory problems and chronic respiratory insufficiency. There are real differences in approach to vent management.

As far as variability in care, as with all medical fields, we have plenty in neo, although the use of standardized approaches has greatly decreased the intra-hospital variation in care in most of the larger institutions. Trials of feeding and ventilation of the neonate are fairly robust, although of course, imperfect especially when it get to fine details of management.
 

elr1983

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Honestly, I'd argue the point that the NICU has WAY more evidence/research behind it than many areas of pediatrics. By that I mean there are far more high quality, large, multi-center trials in neonatology than any other subspecialty in pediatrics. So much of what happens elsewhere in peds is limited by small sample sizes, extrapolation from adult data and tradition. Certainly a great deal remains institutional dependent in the NICU, but overall, there are more "answers" there than any where else.
Hmm, while I agree that there is a lack of evidence for many things we do in lots of areas of peds, I can't agree that there's MORE evidence in neonatology than anywhere else. I see waaay more attending to attending variability in neo than any where else I've rotated....which is fine, as long as the attendings are willing to explain their rationale and thought process so that residents can learn from it. Or to simply admit that a certain course of action is their preference, not a clear "right answer."
 

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The existence of evidence doesn't mean that practices are uniform. Those are different concepts.

Neonatology increasingly has a fairly solid set of controlled or at least partly controlled trials providing good information about best practices related to both respiratory and nutritional management of the very small preterm. More recently there has been increased clarity about management of PPHN and even prevention of late onset sepsis and BPD. We have the benefit or relative homogeneity of our patient population. More so in many ways than other critical care areas in pediatrics and adult medicine.

However, the range of outcomes is still broad, and national practices have not caught up entirely with the evidence base. This will happen and is happening through resources such as the Vermont Oxford Network (VON) and the Neonatal Network.

Neonatologists, like all physicians, are sometimes resistant to change, especially when it means given up cherished, but non-evidence based practices. However, the information base to guide management has advanced incredibly in the past 20 years and especially the last 5-8 years. Outcomes should improve to match this.

Residents are frustrated by being in a setting where there is no consistency of practice at all, and I'm not talking about trivial things like whether to advance feeds after 3 or 5 days of trophic feeds, but real issues like when to use iNO in PPHN. I believe this inconsistency nationally is improving and changing and will look very differently in 5 years than it does now.
 

Perrotfish

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Has anyone here read "workbook in practical neonatology" by Polin? . I'm definitely getting Lange for my Textbook, but honestly I tend to have an easier time learning from case files type books than I do with straight up textbooks and so far Polin is the only case files type book I can find. Reviews are welcome, as are other suggestions for case files type books or question books.
 

pediperson

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Same question about "workbook in practical neonatology" by Polin... seems like it could be good, but I don't want to drop $85 on it without a good recommendation.
 

oldbearprofessor

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Same question about "workbook in practical neonatology" by Polin... seems like it could be good, but I don't want to drop $85 on it without a good recommendation.
A quick on-line look shows the last edition as being 2007 (4th edition). Not sure if that is the latest out there, but if so, that's a bit out of date for texts on rapidly changing fields like neonatology. I have no specific comments about the text since I've never seen it.

I still don't think buying a textbook is the best way for a student or resident to go in learning neo, but if one insists on spending money on them, I'd stick to texts published in the last 3 years.
 
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