STABLE Course – Flashcards
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STABLE stands for:
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Sugar and Safe care Temperature Airway Blood pressure Labs Emotion
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Fetal/infant hypoxemia and hypotension can result in...
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Reduced intestinal blood flow, and ischemic injury --> withhold enteral feeds in sick infants!!
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Causes of Bowel Obstruction
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Congenital: Stenosis/Atresia, Malrotation + volvulus, imperforate anus Functional: Hirschprung's, meconium plug (?CF), meconium ileus, hypothyroidism Acquired: NEC, peritoneal adhesions (congenital = bands) ** Note: consider obstruction if polyhydramnios is present **
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Name of surgery for malrotation?
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Ladd's procedure - cutting obstructing bands, widening mesentery, to prevent volvulus
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Bilious emesis
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= bowel obstruction - work up: bloods, PFA, UGI series
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Where is best site for IV in infants?
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Hand, Foot, Scalp veins Umbilical vein --> IV fluids, meds; can be cannulated for up to 1 week after birth 24 gauge IV cath or 23/25 gauge butterfly, usually Insertion aided by transillumination under hand/foot
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Maternal meds affecting neonatal glucose metabolism
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1. Beta-sympathomimetics (terbutaline) - maternal hyperglycaemia --> fetal hyperinsulinemia - crosses placenta, breaks down glycogen stores 2. Sulfonylureas - maternal hypergly, fetal hyperinsulin - crosses placenta, promotes insulin secretion 3. Beta blockers - blocks fetal adrenergic receptors, prevent stimulation of glycogenolysis (persists after birth) 4. Thiazide diuretics, TCA - maternal hypergly... 5. Maternal IV Dextrose during labour - increased fetal insulin secretion
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High risk groups for inadequate glycogen stores
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1. Preterm infants 2. Late preterm (34 - 36+6) 3. SGA - chronically stressed fetus may use all placental insulin --> not creating enough glycogen stores
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High risk groups for hyperinsulinemia
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1. Infant of diabetic mother - can takes days or longer for insulin levels to down regulate --> regular feeding, +/- IV dextrose 2. LGA 3. IEM, hypopituitarism, hypothyroidism
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High risk groups for increased utilization of glucose
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1. Sick - including preterm, SGA 2. Also infection, shock, resp and cardiac disease, hypothermia, hypoxia
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Late preterms are at risk of
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- hypoglycaemia - feeding problems - temperature instability - respiratory distress - apnea - hyperbilirubinemia - higher hospital readmission rates - 3-fold higher mortality rates than term
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Monitoring hypoglycaemia post-delivery
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1. Check blood glucose within 1-2 hours after birth, then every 1-3 hours based on glucose/interventions/health status. Evaluate prior to feeding. 2. If glucose shows pattern of stability and remains in 50-110 range, slow and then stop monitoring. Can require monitoring 24-72+ hours
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How to check blood glucose
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- Plasma glucose is gold standard - Bedside is faster, but if low can confirm with a plasma test - but don't delay tx
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Signs/Symptoms of Hypoglycemia
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General: - weak, high pitched cry - poor feeding, poor suck coordination - hypothermia - diaphoresis Neuro: - tremors - irritability - hypotonia - lethargy - seizures Cardioresp: - tachypnea - apnea - cyanosis
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Sugar level that defines hypoglycemia? Goal of tx?
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In a sick infant --> <25-30, need IV dextrose Aim: 50-110 mg/dL
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Fluid/glucose management for the sick infant
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IV 10% Dextrose (D10W) if: a) ; 50 and symptomatic b) ;25-30 and asymptomatic 1. Confirm with plasma glucose, but proceed with tx 2. Bolus: 2 mL/kg D10 at rate of 1 mL/minute 3. Infusion: 80 mL/kg/day (divide by 24 for hourly rate; round up) 4. Recheck bedside glucose 15-30 minutes after completion of bolus or any increase in infusion rate 5. If still 25-30 mg/dL --> enteral feed ** if due to hyperinsulinemia, may need higher concentration of dextrose --> must be given through central venous line ** ** without electrolytes, unless infant is > 24 hours old **
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If fluids are given via umbilical venous or artery cath, add...
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0.1 - 1 unit heparin per mL of fluid e.g. 250 mL bag of D10, heparin concentration 1000 units/mL --> draw up 0.25 mL of heparin solution (=250 units), add to 250 mL bag
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Umbilical Vein Catheter (UVC)
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Indications: - rapid IV access needed - based on health status, if no time for trying peripheral access - more than 1 line is needed - need to give fluids with ; 12.5% dextrose - exchange transfusion C/I: - omphalitis, peritonitis, omphalocele, NEC Position: - at IVC/RA junction; confirm on AP CXR - in emergency, if no time to confirm location --> then just insert it 2-4 cm until there is blood return - malposition --> arrhythmias, thrombus, myocardial perf, cardiac tamponade/effusion, endocarditis, pulmonary hemorrhage/infarction - if malpositioned into liver --> hepatic necrosis, portal htn, intestinal ischemia, hepatic vessel perf... Meds: - can give all meds including vasopressors (if properly positioned)
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Umbilical Artery Catheter (UAC)
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Indications: - continuous arterial BP monitoring - frequent ABG necessary C/I: - omphalitis, peritonitis, omphalocele, NEC, vascular compromise in the lower limbs or buttocks Position: - High: between T6 and T9 on AP CXR - to avoid ischemic injury to organs and tissues supplied by celiac (T11) and SMA (T11-12) arteries - Low: in lower abdominal aorta between L3 and L4, and above bifurcation of iliac arteries (L4/5) - to avoid injury to renal (L1) and IMA (L2) Meds: - for fluids mainly ** NOT recommended for meds or blood products; do NOT give vasopressors or calcium ** monitor temp and colour of toes, legs, groin, abdomen --> signs of arterial spasm, clot/emboli
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Intraosseous Access
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- 18 gauge IO needle, or 18/20 gauge short spinal needle - medial aspect of tibial bone, below tibial tuberosity - can give meds, fluids, blood products
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If the UAC/UVC is malpositioned and needs to be advanced...
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DO NOT DO IT if you already took down sterile field! Can pull out but cannot advance in unless sterile!!
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Calculating Umbilical Catheter Depth
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1. High UAC (cm) = {3 x BW (kg)} + 9 + length of umbilical stump (cm) --> between T6 and T9 (above diaphragm, below aortic valve) 2. Low UAC (cm) = BW (kg) + 7 + length of umbilical stump (cm) --> between L3 and L4 (above bifurcation) 3. UVC (cm) = {0.5 X high line UAC length (cm)} + 1 + length of stump (cm) --> at jcn of IVC and RA (above diaphragm)
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Normal core temperature
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36.5 to 37.5 (97.7 - 99.5)
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Hypothermia levels
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Mild: 36 - 36.4 (96.8 - 97.6) Moderate: 32 - 35.9 (89.6 - 96.6) Severe: 37C, check temperature every 15-30 minutes
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Physiologic response to cold stress
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Action of norepinephrine (release mediated by hypothalamus) - peripheral vasoconstriction --> risk of anaerobic metabolism and lactic acidosis causing tissue damage - pulmonary vasoconstriction --> increased pulmonary vascular resistance, leads to R-to-L shunting thru ductus arteriosus or PFO --> hypoxemia because lungs bypassed --> worsens shunting (not really in preterm infants) - metabolism of brown fat --> "non-shivering thermogenesis"; however requires O2 and glucose so hypoglycaemic, low glycogen stores, and hypoxic infants will not be able to metabolize brown fat - increased muscle flexion and activity --> generates heat, reduces surface area for heat loss; hypotonia is worse for infants
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Why are premies at higher risk of hypothermia?
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- larger surface area to body mass ratio - weak muscle tone/poor flexion - thinner skin - increased evaporative water loss - poor ability to vasoconstrict - decreased amounts of insulating fat - reduced amounts or no brown fat
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Physiological effects of low temperature
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- outside of normal range, O2 consumption, glucose consumption, metabolic rate increase --> hypoxemia, hypoxia, hypoglycemia - progressive hypothermia (34-35 or lower) --> reduced consciousness, hypoventilation, bradycardia, hypotension - impaired coagulation (intraventricular or pulmonary hemorrhage), patent ductus arteriosus, increased risk of infection, AKI ** hypothermia can also impair surfactant production, worsening RDS in premies **
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Thermal neutral temperature/zone
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The temperature that permits the infant to expend the least amount of energy to maintain a normal body temperature.
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Mechanisms of heat loss
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1. Conduction: between 2 solid touching objects - prewarm objects before they come in contact with infant - insulation between body and cooler surface - clothing, hats - chemical thermal mattress 2. Convection: air currents - increased delivery room temp if premie - cover with food grade plastic (if ;1.5 kg) - closed, warmed incubator for transport - heated humidified O2 3. Evaporation: moisture on skin - quickly dry infant after delivery, after bathing with prewarmed blankets and immediately remove damp linens - hat - cover VLBW with plastic - increase room temp - minimize air turbulence - heated humidified O2 4.Radiation: between solid surfaces not in contact - move infant away from cold windows/walls - thermal shades over windows
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Reducing risk of hyperthermia, burns
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- do not overheat surfaces hotter than the infant's skin temperatures (except for specific warming mattresses which are at 40C) - never place hot water bottles next to infant - use temperature controlled blanket warmer, not microwave - do not apply heat directly to extremities that are poorly perfused
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Radiant Heat Gain
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- when surrounding surfaces are warmer than infant's skin temp --> e.g. using radiant warmer Reducing unwanted radiant heat gain: - when using radiant warming bed, ensure its on "sevo-control" not manual control - place temperature sensor probe over RUQ; ensure it is well secured otherwise can incorrectly heat infant - prevent direct sunlight on infant
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Hypoxic-Ischemic Encephalopathy
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- [birth] asphyxia (impaired gas exchange; a known perinatal sentinel event) leads to hypoxemia, hypercarbia - anaerobic glycolysis, lactic acidosis, metabolic acidosis - drop in pH, base deficit increases --> end organ damage - in developed world, incidence 3-5/1000 live births - impact: CP, cognitive and motor deficits, epilepsy, deafness, learning problems - during resuscitation, prevent hyperthermia (>37.5), reduce fever if it occurs, monitor for hypoglycemia
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Neonatal encephalopathy
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- due to HIE, brain hemorrhage, cerebral infarction - in USA, incidence 2-3/1000
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Therapeutic/Neuroprotective Hypothermia
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- reduces mortality rate and decreases chance of major disability in infants with ischemic insult to brain (late decels, cord prolapse, uterine rupture, maternal hemorrhage, placental abruption, maternal trauma) - candidates: `must be started within 6 hours of birth `greater than or equal to 36 weeks gestation `greater than or equal to 1800 g `with abnormal neurological exam `must fill 3 domains of: seizures, consciousness level, posture, tone, primitive reflexes, autonomic symptoms (pupils, HR, respirations) - passive cooling prior to transport might be needed --> turning off radiant warmer, monitoring temp so it does not drop too low (below 33.5C) - rewarming: aim for 0.5C per hour, to avoid sudden vasodilation and hypotension
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Rewarming a hypothermic infant
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- closely monitor vitals (HR and rhythm, pulses, BP, perfusion, resp effort and rate, O2 sats), level of consciousness, acid-base status, glucose level - in term infants, rectal temp is better measure; avoid in premies, use axillary temp; once normothermic, just use axillary - do not rewarm too rapidly - incubator or radiant warmer can be used; set incubator temp to 1-1.5 C above infant's core temp, and infant temp reaches the set temp, increase the set temp again by 1-1.5C - use humidified mist, cover with plastic sheet - signs of deterioration when rewarming: `tachycardia `hypotension `cardiac arrhythmia ` desating, cyanosis, worsening resp distress `worsening acidosis - be prepared for full CPR measures while rewarming
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Severity of Respiratory Distress
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1. Mild - rapid resp rate with or without need for supplemental O2, and with or without signs of distress (e.g. nasal flaring) 2. Moderate - cyanotic on room air - signs of resp distress (e.g. grunting, retractions) 3. Severe - infant is struggling to breathe, increasing difficulty maintaining acceptable O2 say despite supplemental O2 - ABG shows respiratory failure - exhaustion, worsening hypoxia, altered mental status (p/w hypotonia, poor/no response to stimulation)
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Normal Respiratory Rate
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30 - 60 breaths per minute Minute ventilation = Tidal Volume x Resp Rate
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Causes of Bradypnea
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- exhaustion - decrease central resp drive due to HIE, hemorrhage, cerebral edema - metabolic disorders - meds: e.g. maternal opioids - neuromuscular disease - severe shock (may be initially high to compensate for metabolic acidosis)
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Gasping
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** A sign of impending cardio-respiratory arrest!! ** - immediate PPV via a bag and mask - if HR low, may need LMA or ET tube - then continue PPV
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Signs of Increased Work of Breathing
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1. Nasal Flaring: sign of air hunger 2. Grunting: to increase FRC when there is collapse of alveoli, to improve oxygenation and ventilation --> NOTE: some late preterm and term infants grunt 30 min after birth and stop by 2 hours; eval for other signs of resp distress 3. Retractions: with inspiration, attempts to increase tidal volume - intercostal alone, usually mild resp distress - when severe, assess for airway obstruction, pneumothorax, displaced or plugged ET tube, worsening atelectasis - can be: suprasternal, subcostal, substernal, intercostal
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Normal O2 Sats
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By 24 hours of life, for healthy late preterm and term infants, SpO2 on RA ranges between 95.6 and 98.8%
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Pre- and Post-Ductal Sats
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Pre-ductal: RIGHT hand; ABG from right radial art Post-ductal: any FOOT; ABG from UA or post tibialis art - if there is a > 10% difference in saturation between the two, caution! a) R-L shunt at ductus arteriosus: pre-ductal higher than post-; due to persistent pulm HTN, L sided heart obstructive lesions (tricuspid or pulmonary atresia) b) R-L shunt at foramen ovale, +/- shunt at DA: pre- and post- are nearly equal, but both are lower than normal c) Transposition of great arteries + wide open DA: pre- lower than post-
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Universal Pulse Ox Screening
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- Can detect: hypoplastic L heart, coarctation of aorta, pulmonary atresia, ToF, TAPVR, transposition, tricuspid atresia, truncus arteriosus - Wait until after 24 hours of age to perform screening (after foramen ovale/ductus close) - report any difference of >3% between pre- and post-, any sat < 90%
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Cyanosis
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- it takes 3-5 g/dL of reduced Hb for cyanosis to be evident --> implications for infants with low and high Hb levels (e.g. anemic infant will be more severely hypoxemic and desaturated than an infant with normal or elevated Hb level)
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What to do with a cyanotic infant
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- Evaluate O2 sats - Supplemental oxygen, using O2/air blender when possible - Start with 21% oxygen, slowly increase amount of inspired oxygen until sat remains at 90% - If you need to give 100% O2 and the sats are still not rising to 90%, consider cyanotic CHD or PPHN
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Retinopathy of Prematurity
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- the more preterm, the higher risk - avoid excessive O2 administration - aim for sats 91-95%
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Rapidly increasing oxygen requirement with or without respiratory distress worsening...
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... may be a sign of impending respiratory or cardiac failure
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Conditions that can lead to hypoxia
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- lung disease - intracardiac mixing of blood - cardiac failure (poor pumping) - increased metabolic demand (e.g. sepsis) - anemia, or abnormal Hb
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Arterial Blood Gas in young infants
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pH 7.35 - 7.45 PCO2 35-45 mmHg PO2 60-80 mmHg HCO3 19-26 mEq/L Base Excess -4 to + 4 capillary not useful for assessing oxygenation
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Metabolic Acidosis
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Causes: - anaerobic metabolism, secondary to: `shock, poor tissue perfusion `hypothermia `hypoglycemia `severe CHD - sepsis - IEM Treatment: - hypoxia: improve oxygenation and ventilation - do not use hyperventilation (only a temp fix) - tx hypotension and shock with fluids, pressers, correction of anemia - tx heart failure/cause - tx IEM
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Respiratory Acidosis
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Causes: - loss of tidal volume: `lung disease (pneumonia, surfactant deficiency) `pneumothorax `airway obstruction - loss of respiratory drive `poor respiratory effort (most premies or very sick infants) `neurological injury (e.g. HIE, stroke) `apnea Treatment: - renal compensation is slow - CPAP, PPV by bag mask, Intubation - Tx cause
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CPAP
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Candidates: - has adequate respiratory effort - infant doesn't meet criteria for PPV/ET: `increased WOB/O2 req `mild CO2 retention and mild acidosis `PCO2 ; 55-60 and infant req 60-70% is needed, raises concern ET may be required - increased frequency or severity of apnea - atelectasis on CXR - tracheobronchomalacia NOT Candidates: - rapidly progressing respiratory failure - severe apnea with cyanosis, and/or bradycardia - gasping - infants w/: poor resp drive, CDH, TOF, choanal atresia, cleft palate, CV instability, poor heart fcn ** Use with caution in infant with Pneumothorax **
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PPV with Bag and Mask/T-piece resuscitator
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Indications: - apnea - inadequate breathing effort - bradycardia - hypoxemia not responsive to supplemental O2 - GASPING: if infant's HR is low and not rising despite effective ventilation, insert LMA/ET. PPV should be continued until HR maintained over 100
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Troubleshooting Respiratory Distress in the Intubated Infant
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DOPE - Displaced - Obstructed - Pneumothorax - Equipment failure
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Respiratory failure warning signs
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Consider PPV via LMA or ET when: - gasping (**PPV ASAP**) - periods of severe apnea and bradycardia - persistent bradycardia despite effective PPV - labored resp effort: mod-severe retractions, grunting, nasal flaring - hypercarbic with mod-severe resp acidosis - unable to ventilate/oxygenate adequately with PPV - rapidly increasing O2 concentration to maintain O2 sats > 90% - unable to maintain acceptable sats for the infant's suspected disease process - CDH
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Endotracheal Intubation
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Equipment: - Laryngoscope - Blades: `No. 1 - term infant `No. 0 - preterm infant `No. 00 - very low birth weight infant - McGill forceps (for nasotracheal intubation) - Uncuffed ET tube - CO2 detector - Suction ...
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ET Tube Size and Insertion Depth
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Tube insertion depth at lip (cm) using Lip-to-Tip Rule (add 6 to infant's weight in kg - use kg of upper limit) < 750 g: 6 3 kg: 10
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Correct ET tube location
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- in the mid trachea - halfway between the clavicles and carina - confirm on CXR, with neutral head position
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What do you do after intubation?
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Insert OG or NG, to decompress the stomach. Then confirm ET position on CXR.
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Suggested initial ventilator support
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1. VLBW ( 2.5 kg) Rate (/min): 20-40 Inspiratory Time (s): 0.35-0.4 PIP (cmH2O): 20-28 PEEP (cmH2O): 4-7
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Transient Tachypnea of the Newborn
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- affects term or late preterm - one of most common causes of respiratory distress - resp distress onset within 1-2 hours after birth, due to failure to adequately absorb fetal lung fluid into circulation/lymphatics - RF: C-section, precipitous delivery, preterm delivery - usually mild/mod distress, O2 req < 40% - resolves in 2-3 days, sometimes within 24 hrs - CXR: fluid in fissures, perihilar markings/opacity, lung overinflation, +/or pleural effusion - DDx: pneumonia, sepsis, RDS, aspiration, pulmonary edema due to cardiac cause
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RDS
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- seen in preterm infants, including late preterm - immature lung anatomy/physiology, surfactant insufficiency - increased risk in infants of diabetic mothers - onset of resp distress at birth or shortly after - CXR: uniform, diffuse granular appearance, air bronchograms, low lung volumes
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Pneumonia
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- term or preterm - onset of resp distress at birth or with onset of infection - CXR: variable, may show diffuse or focal infiltrates, hazy/opaque lung fields, lobar consolidation
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Aspiration
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- of amniotic fluid, blood, or gastric contents - affects term, preterm - onset of resp distress at birth or at time of aspiration - CXR: variable, may show patchy infiltrates, areas of atelectasis, hyperinflation
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Meconium Aspiration Syndrome
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- term and post-term - common cause of hypoxemic respiratory failure - a/w increased risk of sepsis - issue starts in utero: poor placental blood flow/oxygenation causes fetus to pass meconium, aspirate, after birth obstruction of airways leads to both atelectasis and hyperinflation; increases risk of pneumothorax, impaired ventilation/oxygenation, surfactant inactivation, pulm htn - intrauterine infection might be a RF - CXR: coarse, nodular opacities, atelectasis, overinflation
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Pulmonary Hemorrhage
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- term or preterm - onset of cardioresp distress is sudden, accompanied by blood in trachea - blood fills alveoli, inactivate surfactant - etiology: pulm edema, L-R ductal shunting through PDA, sepsis, LV failure, bleeding disorders
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Tracheoesophageal Fistula/Esophageal Atresia
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- term or preterm - 85% of time are concurrent - onset of resp distress usually soon after birth - excessive salivation (if EA), choking, coughing, and cyanosis with feeding, abdominal distension - a/w hx of polyhydramnios (think TEF or obstruction) - a/w VACTERL: vertebral defects, anal atresia, cardiac defects, TEF with EA, renal dysplasia, limb anomalies - management: make NPO, IV access, assess oxygenation and ventilation, insert low continuous suction catheter into esophageal pouch, position prone/elevate head of bed
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CDH
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- term or preterm - onset is at birth or shortly after - cyanotic, decreased breath sounds on side of hernia (usually left), scaphoid abdomen, barrel shaped chest - need to stop giving bag/mask, and need to intubate - otherwise you inflate the stomach which compresses mediastinal structures - hypoplastic lungs make oxygenation and ventilation difficult - commonly a/w PPHN; get pre-/post-ductal sats - watch for pneumothorax - insert NG or OG tube and frequently remove air from stomach to prevent air entering the bowel as this will further compromised lung expansion; leave tube open to air
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Airway Obstruction
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1. Choanal Atresia - term or preterm, F>M - in >50% of cases there is other congenital abnormality, including incidence of CHD - can have one or both posterior nasal passages blocked by bony septum or soft tissue membrane - cyanotic at rest, but pinks up with crying - if bilateral, can be severely cyanotic at rest, even severe asphyxia --> need an oral airway - dx: inability to pass 6-French feeding tube through nares 2. Pierre Robin Syndrome - term or preterm - small jaw with normal sized tongue that obstructs airway; half can have cleft palate - to relieve obstruction, turn infant prone - if still obstructed, insert NP tube; if that doesn't work, then LMA (ET intubation may be difficult)
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How to insert a NP tube
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- coat tip of 2.5 mm ET tube with water soluble gel - pass through one nostril until located at end of nasal passage - secure with tape - support breathing by attaching tube to device that provides CPAP at appx 6 cm H2O, or place infant into humidified O2 hood with supp O2
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Persistent Pulmonary Htn of the Newborn
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- affects term predominantly - elevated pulm vasc resistance causes R-L shunting of blood across PDA or foramen ovale, leading to hypoxemia - resp distress and cyanosis usually apparent within hours of birth - may be a/w: MAS, pneumonia, RDS, CDH, pulmonary hypoplasia, CHD, HF (secondary to infection, asphyxia), sepsis, hypothermia, idiopathic - ask if mom took NSAIDs during pregnancy - these are PG synthetase inhibitors, may cause constriction of ductus arteriosus and structural changes in pulm vasculature causing PPHN
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Pneumothorax
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- preterm or term - can occur spontaneously in non-intubated infants, or as complication of PPV - symptoms: increased resp distress, acute onset of brady or tachycardia, irritability, hypotension, resp and/or metabolic acidosis - signs: positive transillumination, chest asymmetry, asymmetric breath sounds, shift in point of maximum impulse, mottled appearance, poor peripheral pulses, hypotension, flattened or decreased QRS on ECG - CXR gives definitive diagnosis, if there's time... don't delay tx if infant severely compromised and transillumination is positive
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Transillumination of the chest
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- False positives: chest wall edema (hydrops), subcutaneous emphysema, pneumomediastinum, very preterm infants, light source not held perpendicular - False negatives: thick chest wall, darkly pigmented skin
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Pneumopericardium
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- almost always because of mechanical ventilation - signs: sudden onset of severe cyanosis, muffled heart sounds, flattened or decreased QRS, initial tachycardia followed by bradycardia, poor or absent peripheral pulses, poor perfusion, narrow pulse pressure
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Pain Control with Analgesics
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1. Non-pharmacologic comforting measures - non-nutritive sucking, swaddling, facilitated tucking, kangaroo care, music therapy 2. Oral sucrose - for minor procedures like heel stick or venepuncture 3. Opioids - block pain sensation at the level of CNS - indicated for painful procedures like intubation, chest tube insertion, surgery; infants mechanically ventilated and who become cyanotic with minimum stimulation may benefit - need to monitor for hypotension, tachy or bradycardia, resp status/apnea
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Morphine
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0.05 mg/kg per dose every 4-8 hours (IV, IM, SC) - dilute, give slowly over at least 15 min - onset of action should be in 15-30 min - causes resp depression, may lead to apnea --> be prepared to assist ventilation - s/e reversible with Naloxone
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Fentanyl
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1-2 mcg/kg per dose IV - dilute to a 2-3 mL volume, and give slowly over at least 15 min - onset of action within minutes - causes apnea, be prepped to assist ventilation
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Sucrose
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24% solution Full term - 0.5-2 mL Preterm - 0.1-0.4 mL Place a few drops on anterior portion of tongue or into buccal pocket 2 min before painful stimulus. Duration of effect 3-5 minutes. - sucking may be synergistic with sucrose in pain relief - pacifier can be dipped in sucrose solution - no point in giving via a gastric tube, no relief this way - best to give only to infants who are able to protect their airway; ensure an intact sucking reflex prior to administration
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Causes of Tachypnea
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1. With LOW PCO2 --> non-pulmonary - metabolic acidosis (shock, CHD/hypoxemia) - brain disorders (hemorrhage, meningitis, cerebral edema) 2. With HIGH PCO2 --> pulmonary - transient tachypnea of newborn - RDS - pneumonia, aspiration - pulmonary hemorrhage - TEF/EA - CDH - obstruction - pneumothorax
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Effects of Shock
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- oxygen debt, anaeorbic glycolysis, lactic (metabolic) acidosis - cardiac output drops - when hypotension develops, shock now Uncompensated (it's a late sign of cardiac decompensation)
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Tachycardia
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- if >220, consider SVT - may indicate poor CO and/or CHF - causes include pain, fever, hypoxia, meds
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Shock + heart murmur?
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TR most commonly. Rule out structural disease.
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Urine output with shock?
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< 1 mL/kg/hour or declining
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CRT
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- be consistent with testing - hold for 5 seconds - compare upper and lower body, if >3 second discrepancy, alert staff
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Pulse Pressure
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1. Normal - term: 25-30 - preterm: 15-25 2. Narrow - peripheral vasoconstriction - HF - compression on heart (pneumopericardium, effusion, tension pneumo) - severe aortic stenosis 3. Wide - large aortic diastolic run off lesion (PDA, AVM, truncus arteriosus, AR) - sepsis with vasodilated (warm) shock
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Hypovolemic Shock
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1. Causes - acute blood loss intrapartum `placental abruption or previa `umbilical cord injury `organ laceration (spleen or liver) `fetal-to-maternal hemorrhage `TTTS - postnatal hemorrhage `brain, lung, adrenal, scalp - obstructive `tension pneumothorax `pneumopericardium - non-hemorrhagic `umbilical cord accident (prolapse, knot, vasa previa) `severe capillary leake secondary to infection `dehydration 2. S/S - tachycardia - weak pulses - prolonged CRT - mottling - cyanosis
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Cardiogenic Shock
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1. Causes - intrapartum or postpartum asphyxia - hypoxia and/or metabolic acidosis - bacterial or viral infection - severe resp distress requiring ventilation - severe hypoglycemia - severe metabolic/electrolyte disturbance -arrhythmias - CHD
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Septic/Distributive Shock
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- hypotension that responds POORLY to fluid resuscitation - loss of vascular integrity, fluid leaks out of vessels into tissues - infants often need BP meds to treat severe hypertension
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Labs for Shock
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1. Blood Gas 2. Blood lactate 3. CBC + differential 4. Cultures 5. LFTs 6. Coag studies 7. Glucose - in response to stress/catecholamines, may be initially hyperglycemic; glucose utilization can be markedly increased which raises risk for hypoglycemia 8. Electrolytes - hypo- or hypernatremia, hypo- or hyperkalemia 9. Ionized Calcium - calcium needed for myocardial contractility, if it is low other inotropes will be significantly less effective 10. Renal Function tests 11. Cardiac enzymes - BNP, Troponin, CPK-MB to look for myocardial tissue injury 12 .Others: - ECHO, ECG - Evaluate urine output for oliguria or anuria
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Anion Gap
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Na - (Cl + HCO3) Normal for neonates is 5-15 1. High: - lactic acidosis - ketoacidosis - renal failure - late metabolic acidosis - toxins 2. Normal - loss of bicarb, usually GI or renal losses - excessive Cl in fluids - aldosterone deficiency - hyperchloremia is a compensatory mechanism 3. Low - caused by hypoalbuminemia
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Ionized Calcium
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- the best indicator of physiologic blood calcium activity - hypocalcemia: < 4.4 mg/dL (1.1 mmol/L) - if there is insufficient Ca available for myocardial contraction, other inotropes will be significantly less effective
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Cardiac Enzymes
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BNP - raised in: - CHF - Pulmonary Htn - CHD - Septic shock Troponin - newborns have slightly higher levels than adults - increased levels when asphyxiated
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Treating Shock, general principles
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1. Identify cause, start treating e.g. antibiotics for septic shock 2. ID can correct any related or underlying problems that may impair heart function (e.g. poor cardiac filling b/c of hypovolemia, tamponace, hypoglycemia, arrhythmias, hypoxemia) - volume infusions, +/- inotropic medications 3. Support ventilation and oxygenation
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Treatment of Hypovolemic Shock
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1. No acute blood loss - NS 0.9% 10 mL/kg/dose IV/UVC/IO over 15-30 minutes - may need 2 or 3 more boluses if severe - monitor response (HR, perfusion, BP) following each bolus 2. Acute blood loss - give NS while awaiting pRBC or whole blood - Type O- or cross matched - 10 mL/kg/dose IV/UVC/IO over 30 min to 2 hours - get newborn screen before any blood transfusion, but don't delay tx ** if there is a hx of chronic blood loss, some infants in severe shock may not tolerate volume boluses - VLBW infants would benefit from: a) Leukoreduction of cellular products (pRBC or platelets) for CMV safety +/- b) Irradiation of cellular products to reduce risk of transfusion-associated graft-versus-host disease - all babies who receive a blood transfusion must receive filtered cellular products
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Treatment of Cardiogenic Shock
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- correct underlying problems that may negatively affect heart function: `hypoxia `hypoglycemia `hypothermia `hypotension `acidosis `arrythmias `infection `electrolyte imbalance
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Treatment of Septic Shock
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- may require more fluid boluses - may need continuous dopamine infusion to help hypotension - optimize ventilation and oxygenation
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Other medications used for Shock
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1. Sodium bicarbonate 4.2% solution - tx severe acidosis (pH ; 7.15) - dose: 1-2 mEq/kg/dose (2-4 mL/kg/dose) IV over 30-60 minutes - too rapid administration can cause IVH in premies - infant must be adequately ventilated when administered or acidosis will worsen b/c of increase in CO2 as bicarb is metabolized 2. Dopamine Hydrochloride - for poor cardiac contractility; alpha receptors activated, vasoconstriction, increased systolic and diastolic BP; but after trial of fluid bolus - dose: 5-20 mcg/kg/min IV continuous pump ** do NOT give via arterial route or through an ET tube - mixed in D5W, so monitor blood glucose - monitor BP and HR every 1-2 minutes for 15 min then every 2-5 depending on response to medication - if fails to respond to 20mcg/kg/min, then increasing dose further is NOT recommended ** do NOT flush lines containing dopamine! - recommended to give via central line b/c extravasation can cause tissue necrosis - if in a peripheral IV and get extravasation - inject saline solution containing phentolamine mesylate
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Caput Succedaneum
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- molding of head during labour, causing superficial edema - in subcutaneous tissues of scalp; can cross suture lines - shifts with position - soft and spongy, pits on pressure - resolves in 48-72 hours
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Cephalohematoma
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- hemorrhage under the periosteum - does not cross suture lines - usually over parietal or occipital bones; may be bilateral - initially firm, more fluctuant after 48 hours - x-ray skull if fracture is suspected - resolves in 2 weeks - 3 months - blood loss rarely severe
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Subgaleal hemorrhage
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- rupture of emissary veins, which bring blood from scalp to dural sinuses, bleeding into subaponeurotic space, above periosteum - can occur in vacuum deliveries due to traction applied, or as a consequence of pop-offs during vacuum assisted delivery - can cross suture lines; may extend from eyes to nape of neck; swelling can extend to ears, eyes - firm, fluctuant, boggy - may lead to severe anemia and hypovolemic shock - resolves in 2-3 weeks - can be tx: tx anemia, stop bleeding, restore BP --> pRBCs, FFP, platelets, cryoprecipitate, NS volume infusions, dopamine - RF for SGH after VAD: `nulliparous mothers `failed vacuum extraction `pop-offs `sequential use of vacuum and forceps `APGAR <8 at 5 minutes `paramedian or deflexing cup application
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Risk Factors for Neonatal Infection
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- PPROM - Premature onset of labour - Rupture of membranes ; 18 hours - Chorioamnionitis (maternal signs!) - Recent maternal illness/infection - Maternal fever in peripartum period - Maternal GU infection - Perinatal asphyxia - CVS, amniocentesis - Fetal scalp electrode, vacuum - IV lines, invasive procedures
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Neonatal sepsis
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- early onset (first 72 hours) vs late - GBS and E. coli commonest - viruses: HSV, HIV, Hep, CMV, Parvovirus, Rubella
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HSV
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- infants who are exposed at birth may not have symptoms for 3-7 days - can p/w vesicles as well as: poor feeding, lethargy, fever, shock - Tx: aciclovir, while awaiting confirmatory culture/PCR
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4 B's of labs for ?infection prior to transfer
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1. Blood count (CBC) 2. Blood culture - at least 1 mL/culture bottle (if not enough blood, take aerobic before anaerobic) 3. Blood glucose 4. Blood gas
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Labs for after transfer
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1. CRP - normal: < 1.6 in first 2 days of life, < 1 mg/dL after - does not cross placenta - higher levels with: infection, resp illness, after surgery, after vacuum or forceps, immunizations, bruising, vaginal birth (rel to c-section) - does not rise immediately but within 4-8 hours - not always positive with sepsis 2. CSF - for meningitis - gram stain and culture, cell count, glucose and protein conc 3. Electrolytes, Ionized calcium, Mg - Mg if the mother was given MgSO4 during labour 4. Renal function tests 5. LFTs, including coag
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In an ILL neonate with normal CBC and CRP?
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NEVER withhold antibiotic treatment because of these normal results. There is a 4-6 lag for CBC and 8-12 hour lag for CRP.
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Left shift
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The presence of immature neutrophils in the blood
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Immature to Total Ratio (I/T)
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I/T = {band + metamyelocytes %}/{band + metamyelocytes + segs} - proportion of immature (band + metamyelocytes) to mature (segmented) neutrophils - most sensitive for estimating risk that infection may be present ** when > 20-25%, suspect bacterial infection **
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Absolute Neutrophil Count (ANC)
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ANC = {segmented neutrophil + band neutrophils + metamyelocytes} (count, %) * WCC (# cells) - normally, the WBC and neutrophil counts rise for the first day after birth; in term infants, neuts peak at 8 hours ** Therefore, a DECLINING neutrophil count (rather than the expected physiologic rise) should raise concern that the infant may be infected ** - low ANC means depleted neutrophil reserves, which means high risk of dying from sepsis - infants born to hypertensive mothers might have low ANC compared to others; also with trisomies - ANC increases with increasing gestational age - use ANC charts which considers hours from birth for different gestational ages
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Thrombocytopenia
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1. Causes - infectious - maternal conditions (PIH) - maternal auto- or isoimmunization (SLE, ITP) - genetic (familial thrombocytopenia, trisomies) - NEC, hyperviscosity, DIC following perinatal asphyxia, metabolic 2. Levels - mild: 100-149 - mod: 50-100 - severe: < 50k ** levels increase with gestational age 3. Evaluate - for signs of bleeding - e.g. from mucosal sites, lines, petechiae, bruising
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Ampicillin
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Dose: 50 mg/kg/dose < 29 weeks: 30-36 weeks: 37-44 weeks: - every 12 hours - IV slow push over 3-5 minutes, not faster than 100 mg/min S/E: - prolongs bleeding time because impacts platelet function; use with caution
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Gentamicin
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- different dosing recommendations based on gestational age - generally dose 4-5 mg/kg every 24-36-48 hours - IV over 30 minutes - can also be given IM Levels: - peak therapeutic range 6-12 mcg/mL - trough therapeutic range 0.5-1 mcg/mL - if worries about renal function, trough can be obtained before second dose - when given for 5-7 days, do levels *Traditional dosing: 2.5 mg/kg/dose, q12-18-24 hours IV - trough 0.5-2 mcg/mL, peak 5-10 - check trough before 3rd dose, then peak after (if given for > 3 days)
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When to do an LP?
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Indicated in any infant with a positive blood culture or in whom sepsis is highly suspected based on clinical signs, response to tx, and §lab results.
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Evaluating Asymptomatic Infants with RF for Sepsis
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RF: chorioamnionitis, PROM > 18 hours, IAP indicated but not adequate --> blood culture at birth, WBC/diff +/- CRP at age 6-12 hours --> if: a) cultures +: continue Abx b) cultures -, infant well, labs abnormal: continue Abx if mother received Abx during L&D c) all neg/normal: discontinue Abx ** note in term with no chorioamnionitis but PROM > 18 hours, do not empirically tx with Abx, if labs abnormal check culture
