Would you extubate an ex premie?

[urge]

Let's say you do an ex 25 wga premie now 3 month old (~37week old now) for something short, not invasive. Would you attempt to extubate or not? Keep in mind there is high risk for apnea. Should the pt go to an icu, regardless of being extubated or not? I had one of this gork out on me recently.

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[Noyac]

Let's say you do an ex 25 wga premie now 3 month old (~37week old now) for something short, not invasive. Would you attempt to extubate or not? Keep in mind there is high risk for apnea. Should the pt go to an icu, regardless of being extubated or not? I had one of this gork out on me recently.

I would definitely extubate if criteria was met and I would definitely have the kido monitored for A's and B's for at least 24 hrs. ICU is not necessary as long as the A/B monitor is present at all times and the nursing is vigilant which at most facilities means ICU.

 

[militarymd]

tube out..

caffeine...

monitored setting..

 

[urge]

tube out..

caffeine...

monitored setting..

Caffeine in the OR?

Side topic: Are you aware of the cost of IV caffeine?

 

[militarymd]

Caffeine in the OR?

Side topic: Are you aware of the cost of IV caffeine?

it's a respiratory stimulant and there is data supporting its use in premie's undergoing GA.....circa 1990's....if there is newer data refuting its efficacy, then please post.

I don't know it's cost.

 

[bubalus]

How about IV mountain dew? Gives the caffeine and the dextrose at the same time. 50-75 cents for 375 ml. Probably cheaper than other IVF.

 

[Noyac]

Caffeine in the OR?

Side topic: Are you aware of the cost of IV caffeine?

I have used it in this scenario many times.

 

[urge]

Caffeine works well for apnea. We can agree on that. My point is that you have to give it during the case for it to work at extubation. I'm thinking about the best/safest way to approach this kids. Probably an icu bed for post op is the safest way. Caffeine will probably work too, but if the kid is in the icu already, it seems easier for me and the kid to go intubated and let the icu people deal with the extubation and caffeine. BTW, iv caffeine for 1 day is 110 dollars at my institution. That's a full years budget for Caramel Macchiatos

 

[Planktonmd]

How about IV mountain dew? Gives the caffeine and the dextrose at the same time. 50-75 cents for 375 ml. Probably cheaper than other IVF.

In florida we use cuban coffee.

 

[cchoukal]

last november, the NEJM published the long-term follow up of a study on caffiene and apnea of prematurity (used during the period of prematurity; that is, before 60 wks post-conceptual age). Caffiene was associated with reduced mortality and neurodevelopmental delay. Not exactly the question asked here, but doesn't seem unreasonable to use it. My experience here (U of Chicago) is that we don't routinely use caffiene intra- or post-op in these pts, but that they'd go to a monitored setting (unless they came to us from the ICU, which, at 37 wks PCA ex 28 wk premie, they probably would've)

 

[oldbearprofessor]

Let's say you do an ex 25 wga premie now 3 month old (~37week old now) for something short, not invasive. Would you attempt to extubate or not? Keep in mind there is high risk for apnea. Should the pt go to an icu, regardless of being extubated or not? I had one of this gork out on me recently.

I am glad to participate in this forum to provide a neonatologist's perspective on this issue. However, I do not want to intrude on an anesthesia question. We fully recognize that intra and immediate post-op management of these patients is yours, but it might be worthwhile to consider some thoughts from those who will take over care of the infant shortly after the case.

To give a complete answer, I would need to know all of the following, as they can affect how we would approach the infant post-op.

1. Is this in-patient or out-patient? Hernia repairs are common in this setting. Some babies have gone home first, others haven't.
2. If in-patient, is the infant on caffeine now? When was it stopped? If out-patient, is the infant monitored at home?
3. Does the baby have severe anemia, bronchopulmonary dysplasia, on-going apnea, IVH, steroid dependency?
4. What was the case and what pain medicines were used, etc? We are not anesthesia experts, but this information is helpful.

Given all of this, in general, we are glad when for short cases, the anesthesiologist returns the infant to a monitored NICU bed extubated. If the infant was not on caffeine prior to the surgery, we would generally not wish it to be started intra-operatively. This is because we may need 7 to 10 days to "de-caffeinate" the baby before discharge. Even low levels of serum caffeine affect apnea and if the baby is caffeinated in the OR, it can be difficult to discharge without a home monitor. If the baby has short apneas after the case, as is common with hernia repairs, we can decide if they are severe enough to need caffeine. There isn't much of a rush. Whether the baby will tolerate extubation depends on their BPD status and the anesthesia more than the caffeine. Alternately, you can extubate to nasal CPAP for a few hours while we see how the baby does. This is helpful in babies with BPD. If the baby is already on caffeine, then a bolus would be okay, but it is not usually helpful in this setting.

I hope these responses are helpful and would be glad to discuss this further here or via PM.

 

[Noyac]

I am glad to participate in this forum to provide a neonatologist's perspective on this issue. However, I do not want to intrude on an anesthesia question. We fully recognize that intra and immediate post-op management of these patients is yours, but it might be worthwhile to consider some thoughts from those who will take over care of the infant shortly after the case.

To give a complete answer, I would need to know all of the following, as they can affect how we would approach the infant post-op.

1. Is this in-patient or out-patient? Hernia repairs are common in this setting. Some babies have gone home first, others haven't.
2. If in-patient, is the infant on caffeine now? When was it stopped? If out-patient, is the infant monitored at home?
3. Does the baby have severe anemia, bronchopulmonary dysplasia, on-going apnea, IVH, steroid dependency?
4. What was the case and what pain medicines were used, etc? We are not anesthesia experts, but this information is helpful.

Given all of this, in general, we are glad when for short cases, the anesthesiologist returns the infant to a monitored NICU bed extubated. If the infant was not on caffeine prior to the surgery, we would generally not wish it to be started intra-operatively. This is because we may need 7 to 10 days to "de-caffeinate" the baby before discharge. Even low levels of serum caffeine affect apnea and if the baby is caffeinated in the OR, it can be difficult to discharge without a home monitor. If the baby has short apneas after the case, as is common with hernia repairs, we can decide if they are severe enough to need caffeine. There isn't much of a rush. Whether the baby will tolerate extubation depends on their BPD status and the anesthesia more than the caffeine. Alternately, you can extubate to nasal CPAP for a few hours while we see how the baby does. This is helpful in babies with BPD. If the baby is already on caffeine, then a bolus would be okay, but it is not usually helpful in this setting.

I hope these responses are helpful and would be glad to discuss this further here or via PM.

Thanks for the input, Oldbear. Its nice to get input from some of the other specialties, especially the ones that we (I) rarely work with.

 

[militarymd]

Thank you oldbear for your perspectives...

I'm asking questions as a non-peds guy..

So for outpatient surgery, it is better to just admit and observe for A&Bs without prophylaxis?

Is there a concensus statement on how to proceed with these ex premies's whose post conceptual age is < 50 weeks?

 

[urge]

Oldbearprofessor,
Thanks for your input.Your argument against intraop caffeine is very strong. My pt was an inpt, not on caffeine, no opioids were given. Sevoflurane was the only anesthetic used. Procedure was a g tube. Immediately upon extubation went apneic. Bag ventilation was difficult. Pt was reintubated and sent to icu. A cpap trial was attempted in the icu but the kid went apneic again.I'm leaning towards taking this kids intubated to the icu and extubating over there after a cpap trial.

 

[militarymd]

and I'm surprised at the cost of caffeine?

is this so for you also oldbear?

 

[militarymd]

Oldbearprofessor,
Thanks for your input.Your argument against intraop caffeine is very strong. My pt was an inpt, not on caffeine, no opioids were given. Sevoflurane was the only anesthetic used. Procedure was a g tube. Immediately upon extubation went apneic. Bag ventilation was difficult. Pt was reintubated and sent to icu. A cpap trial was attempted in the icu but the kid went apneic again.I'm leaning towards taking this kids intubated to the icu and extubating over there after a cpap trial.

A&B's occur in these patients whether you use naroctics or not....GA, sedation, & narcotics all cause A&B's....again I'm referring to old literature from the 1990's when I was a resident.

The only anesthetic which does not cause A&B's is a PURE spinal....ie no sedation .

 

[Noyac]

Thank you oldbear for your perspectives...

I'm asking questions as a non-peds guy..

So for outpatient surgery, it is better to just admit and observe for A&Bs without prophylaxis?

Is there a concensus statement on how to proceed with these ex premies's whose post conceptual age is < 50 weeks?

Mil, I think what Oldbear meant was whether the premie was inhouse b/4 the operation or coming from home. I don't think anyonw is going to send a 37 wk (28 wk) premie home after GA.
My practice is that any premie's <50 wks stay over night after GA and if they have h/o A/B's then they stay overnight until they are >60 wks. In general of course.

 

[urge]

Repost. Kind of hard to navigate with handheld. Sorry

 

[oldbearprofessor]

Thanks for the nice comments. I work in a very large NICU at a Children's Hospital and we have started having direct sign-out post-op of patients between attending/fellow anesthesia and attending/fellow neonatology. As always, these type of exchanges are extremely educational as well as helpful for patient care.

A g-tube is a bit of a special case due to the likelihood that the reason for the g-tube was some degree of neurological compromise that could include some central apnea. So, even a short case would be high-risk scenerio for post-op apnea and needs NICU monitoring.

I generally agree with Noyac that any premie coming from home who was less than about 32 weeks at birth who undergoes surgery at < about 50 weeks post-menstrual age (the new term we exclusively use in place of post-conceptional age), needs a monitor post-op overnight, often two nights. We really try to avoid having this situation happen. We try to get the surgeries done before the initial discharge as families hate the overnight post-op stay, but sometimes it happens that way. I am not aware of any consensus statement however.

IV caffeine is currently expensive as it is provided pre-made by a commercial source. It used to be compounded by our pharmacy, but those days are long gone. We really only use it IV in the initial care of the babies. Most of the time we can give it p.o. Even in babies having surgery, we'll give it the next day p.o. as the half-life is long and missing one dose usually doesn't matter.

With regard to spinal or other regional anesthesia, we love it. . The babies do really well with it. I know it can be a challenge technically and time-wise for anesthesia, but for some cases, especially in bigger babies and ones with a bit of BPD that we don't want to see intubated, it can be a tremendous approach.

Finally, I note that for bigger cases, sicker premies, and/or smaller babies, I entirely agree that there is often no reason to attempt post-op reversal and extubation. These babies often fail extubation and we currently like to use continuous narcotic infusions for 24+ hours post-op in the big abdominal cases (re-anastamosis, etc). So, send them back intubated, but don't be surprised if we take 24-48 hours to get them extubated.

Thanks for the chance to share ideas with you guys.

 

[Arch Guillotti]

Old Bear, your comments are very helpful and valuable. We appreciate them.

 

[jwk]

BTW, iv caffeine for 1 day is 110 dollars at my institution. That's a full years budget for Caramel Macchiatos

I'll bet that's the patient charge, not the hospital cost, which as we all know is two entirely different things. Morphine 10mg pre-fills costs our hospital a few pennies, yet the charge is probably $15 or so, which is the minimum charged for ANY medication.

 

[Carm]

Thanks for the post Old Bear.

It was interesting hearing your perspective on giving IV caffeine. I think my knee jerk response would have been similar to others, that I would have given IV caffeine in this patient.

I was not aware that a baby had to be "de-caffeinated" once given a bolus before discharge. Can you explain the reason for this.

This is a great discussion.

 

[oldbearprofessor]

Thanks for the post Old Bear.

It was interesting hearing your perspective on giving IV caffeine. I think my knee jerk response would have been similar to others, that I would have given IV caffeine in this patient.

I was not aware that a baby had to be "de-caffeinated" once given a bolus before discharge. Can you explain the reason for this.

This is a great discussion.

In brief (gotta go back to the NICU), we know that even a little bit of caffeine can prevent (or mask as it were...) a tendency towards central apnea. All premies have some abnormalities in their control of breathing leading to periodic breathing. Apnea is somewhat artificially defined actually. In any case, if you give a bolus of caffeine, you will raise the level above the threshhold for a caffeine effect for 5 days or even more.

There is a nice review of apnea of prematurity in uptodate. Here is a quote

"We continue caffeine until the postmenstrual age is 34 to 36 weeks and apnea has resolved for at least five days. Cardiorespiratory monitoring is continued until no apnea has been detected for five to seven days after it is estimated that the caffeine effect has worn off (which usually requires about one week after therapy is stopped)."

Now, if the baby is not already on a monitor at home, we have a problem. If we send the baby home in those 5 days, the caffeine may mask the tendency towards apnea and sometime during those 5 days, or shortly afterwards, as the caffeine level drops, the apnea would come back. This would not be good, especially since there is a slight increase in SIDS risk in preterm infants anyway.

Now in a baby who has gone home and come back, this may not be a realistic concern. But in the common case of a baby at 35-38 weeks post-menstrual age, we don't like to send a baby home until they have been off caffeine for "a while" if they aren't being monitored. "A while" is variable, but generally 5 to 7 days, sometimes longer.

So, since caffeine doesn't really usually affect the apnea post-surgery very much, we'd like to avoid it when possible if not already on caffeine unless a 5-7 day additional hospital stay is planned.