Final Flashcards
Pre Term Baby
Born between 20-37 weeks
Parity
How many times they have carried past 20 weeks
Trimesters
1st Trimester: First 12 weeks
2nd Trimester: 13-28 weeks
3rd Trimester: 28 weeks onwards
Radiation
Heat loss to a cooler surface not in contact with the body
keep incubators heated or heat shielded and keep room temp high
Use heated incubator ans use bonnets
Conduction
Body heta loss to a cooler contact surface
Prevent placing the baby on a cool surface
Use a warm dry blanket, use preheated radient warmers
Evaporation
Removal of heat from a body that occurs as the liquid evaporates
Increase room humidity, dry the baby, wrap the baby, bag the preemie, humidify gases
Use warm blankets to dry and wrap the baby
Convetion
Heat loss to cooler surronding air
keep room temp high, avoid draft, and keep baby covered
use radient warmer or isolette
Radient Warmer
Overhead warmer
Body temp maintained with servo mode and skin prode attached to baby
Ex. Giraffe isolette for older babies
Closed Isolette
Will be closed isolette
Used for preemies with temp instability
Maintain temperature via skin probe, air temp control device or probe
Premature Infant Pain Profile (PIPP)
Minimium score of zero and max score of 21
the higher the score the greater the pain
Lower gestational age the higher the score
Done at admission to NICU and the score will determine how often it is done after
Non-Pharmacological Ways to Help With Pain
Giving Sucrose- Can not give to intubated patient
Rocking and Skin to Skin
Repoistioning-Prone Positioning
Diaper Change and Feeding
Decrease Enviromental Stimuli
Activity Level and Ability to Settle
Appropriate-Think of how term babies will have more tone and strength
Jittery-Try non pharmacological way to soothe
Lethargic
Unresponsive
Paralyzed-Rare
Intolerant of Handling
Fontanel
Soft and Flat
Depressed
Overriding Sutures- Normal and resolve quickly, but if an early or late can lead to distortion of the skull
Full/Bulging-Fluid overload
Tone
Check tone right away
Appropriate
Flaccid
Hypertonic-Bring in extremities, baby in pain or cold
Hypotonic
Head Circumference
Chest Circumference ~ Head Circumference
In a term infant
- Occipitofrontal circumference above the ears is normally 32-37 cm at term
CT Scan
Looks for bleeds or fluid in subdural or subarachnoid space
Assess parenchyma and # of skull bones
Term Baby
38-42 weeks
Post Term Babies
>42 weeks
Primipartiety
First pregancy
VAP Prevention in Neonates
HOB 15 Degrees
Inline Suction and limit circuit breaks (only change when solid or indicated)
Single use nasal catheter
MRI
Myelination
Ischemic or hemorrhagic lesions
Agenesis of corpus callosum
AV malformations
CNS Pharmacology-Sedation
Lorazepam-Benzo and antianxiety medication
Phenobarbital-Stronger than a benzo and used for seizures
Try to avoid over sedation to avoid side effect (not as concerns with delirium as in adults)
CNS Pharmacology-Analgesia
Fentanyl-Less depressant effects than morphine
Morphine-Causes chest ridigity
Tylenol
As a last resort pain meds can be given intrathcal
Ultrasound
Looks for intracranial an intraventricular hemorrhage
Also used to assess hydrocephaly
Intracranial an Intraventricular Hemorrhage
Graded based on CT Scan
Grade 4 is the worse
After CT scan the baby will be taken to MRI for more information
Most common type of Hemorrhage Ultrasounds is looking for
Most common in premature infants is germinal matrix hemorrhage
Premature may be getting dialy ultrasounds in order to assess for this
Lumbar Punctures
Used to obtain cerebral spinal fluid to diagnose meningitis, encephalitis, and intracranial hemorrhage
Can be used to administer intrathecal medicine
Puncture will be done between 4th and 5th lumbar vertebra to avoid the spinal cord which ends at L2
CNS Pharmacology-Paralytics
Pancuronium
Vecronium
Not commonly used in neonates with the exception of use with therapeutic hypothermia
Side effect is third spacing
Therapeutic Hypothermia Used For
Treat hypoxic-ischemic encephalopathy (HIE) to minmize brain injury consequences
Cerebral palsy
Hypoxic-Ischemic Encephalopathy (HIE)
Can be caused at birth from perinatal asphxia which can occur when the baby is breech or has the vocal cord around the neck
Therpeutic Hypothermia Mechanism of Action
Will Reduce the Following
Swelling, bleeding and infection (neutrophil infiltration)
Excitatory neurotransmitters
Free radial production-Protect oxidative damage durign reperfusion
Cerebral tissue injury
Infants undergoing hypothermia may exhibit
Reduce HR
Elevate BP
Clotting Disorders- Lower platelet counts and long prothrombin time
Worsening Acidosis
Worsening oxygenation secondary to pulmonary hypertension
Abnormal EEG
Skin breakdown-Lack of perfusion and movement
Hypoatremia and Hypokalemia
Nullpara
Never carried past 20 weeks
High Risk Infants
Premature
Intrauterine Growth Retardation (IUGR)-Moms who do drugs or have a placenta deficiency
Asphyxia-Very low APGAR (0-3 for >10 min) which is associated with high mortality (>50%) and 25% mordity (Gomella)
TORCH Infections
Meningitis
Hypoglycemia and Polycythemia
TORCH Infection
Toxoplasmosis (Protozoan)-Cat feces
Other (syphilis)
Rubella
Cytomegalovirus
Herpes/Hepatitis/HIV
Perfusion
Cap refill can be done on stomach or foot
Newborns will have low systemic output and high vasoconstriction- This is completely normal for the 1st 24 hours
Changing in Perfusion
Enviromental temp
Circulating catecholamines which contribute to catecholamines
Nullgravida
Never been pregnant
Causes of Unstable Temp
Skin Temperature (36-36.5)
Premies
Shock-Will get more vasoconstriction or dilation
Decreased Perfusion
Cardiac Abnormalities
Why are Babies at a High Risk for Temperature Instability
Even term babies are at risk but preemies babies are more at risk
Preemies (<26 weeks) will have no brown fat and little sub q fat
There is a high body surface area to weight ration
Reduced glycogen stores
How do we treat a hypothermia (not therapeutic) baby
vasodilators and fluid
Rectal Core Temperature
36.5-37.5
Cold Stress
Cold Stress: Enviroment where baby is not warm enough
Mild Cold Stress: Normal newborn will pheriperally vasoconstrict. The amount of norepinephrine will increase and metabolize brown fat
Norepinephrine will break down brown fat to fatty acids which hydrolzye to glycerol and nonesterified fatty acids which are xoidized to produce heat to increase body temp
Non-Shivering Thermogenesis
Glycogen will be convered to glucose to generate energy
Will increase metabolic and O2 demands so if the baby is low on glycogen stores they are unable to warm themselves (sufficent nutrition important to maintain warmth)
When the baby is cold they may start to use anerobic glycolysis will lead to metabolic acidosis
Ruddy/ Plethora Color
Polycythemia (common in children as they transition to extrauterine life)
Hyperthermia
Dusky or Blue Color
Cyanosis
Hyperthermia
>37.5
Causes
- Enviroment
- Infection (most likley bacteria)
- Dehydration
- Maternal fever
- Drug withdrawal
Pale/Pallor Color
Wash Out
Anemia
Asphyxiation
Shock
Infection
Poro Perfusion
Mottled
Cardiac problem such as hypovolemia
Marbling of the skin
Cyanosis
Peripheral Cyanosis= Acroyanosis
Classically described as occurring if 5.0 g/dL of deoxyhemoglobin or greater is present.
Anemic Babies and Cyanosis
These babies are pale and do not look as hypoxic as they are
Cyanosis in Babies with High Hematocrit Levels
May look blue but are not cyanotic
Caput Succadaneneum
Edema on the scalp secondary to delivery
Accompanied by bruising
Edema may also be on the eyes and face
Generalized Edema
Indicative of fluid balance (renal) issue
Heart Rate in Babies
In term Infants
- HR: 120 to 170 beats/minute while awake
- HR: 80 or 90 beats/minute while asleep
Neonates older than 35 weeks of gestation have greater variability in heart rate than an infant born at 27 to 35 weeks of gestation
Transient Tachycardia
Transient tachycardia [>200 b/m] with stimulation or agitation
Mean Artieral Blood Pressure
Ideal Mean Arterial Blood Pressure = Gestational Age (weeks) +5
Mean Arterial Blood Pressure= Diastolic Pressure + 1/3 Systolic Pressure
RR in Neonates
Preemies = 30-60
Term= 40-60
Slow HR Benign Reasons
Pooping
Feeding
Barfing
Suctioning
Slow HR Pathological Reasons
Hypoxia
Seizures
Airway
Acidosis
Hypothermia
Drug
Fast HR Benign Reasons
Stress
Pain
Fast HR Pathological Reasons
Fever
Shock
Anemia
Sepsis
Cardiac Abnormalities
Drugs
Bounding Pulse
PDA
L to R Shunt
ECG Monitor
High incidence of arrhythmias in first few days
1-5% have some disturbance in HR or rhythm
Dropped beats (PAC); benign
Umbilical Artery Catheter
High [T6-T8/9] below ductus arteriosus & above celiac artery
Low [L3-L4] above the inferior mesenteric and below the renal artery aorta intersection
Pre/Post-Ductal SpO2
Pre: R arm will have a higher O2 saturation
Post: L arm & lower extremities will have a lower O2 saturation
CO/ SVR Pharmacological Interventions
Dopamine [hypotension]
Dobutamine [hypotension]
Rate & Rhythm Pharmacological Interventions
Bradycardia
Bradycardia -Atropine
Rate & Rhythm Pharmacological Interventions
Narrow Complex
Narrow complex SVT - Adenosine
Rate & Rhythm Pharmacological Interventions
Tachycardias
Na channel blockers
Beta blockers [propranolol]
K channel blockers [amiodarone]
Ca channel blockers [verapamil]
Pulmonary vasodilators [PPHN] Pharmacology
iNO
Sildenafil (phosphodiesterase type inhibitor)
Prostacyclins/prostaglandins:
- Iloprost
- Treprostinil
- Epoprostenol (flolan)•
Anti-Thrombotics Pharmacology
Heparin
The use of anti thrombotics in newborns will remain weak
Other Pharmacological Interventions
Iron: Needed for growth and development, used to help anemia
Folate:
Vit E:
Functional Echocardiography
Ductal and Arterial Shunting
Pulmonary Artery Pressure
R and L ventricular output
SVC flow
Myocardial function
PDA Closure
Indomethacin and Ibuprofen
Ligation
Intravacular Coils
Blood Products
Blood products [N blood volume 80mL/kg]
PRBC: O Rh neg; to get hematocrit to 50% [maintenance of 02 carrying capacity]
FFP [fresh frozen plasma]
Albumin
EPO
ETT Size for >3 000
Gestation Age >8
ETT 3.5-4
Suction 8 or 10
ETT Size for 2 000- 3 000
Gestation Age 34-38
ETT 3.5
Suction 8
ETT Size for 1 000-2 000
Gestation Age 28-32
ETT 3
Suction 6 or 8
ETT Size for <1 000
Gestation Age <28
ETT 2.5
Suction 5/6
Bronchopulmonary Hygiene
- In the spontaneous breath pt
- Flexible catheter with 80-100 mmHg (open)
- Artifical Airway
- Closed (100-120 mmHg)
- Rarely on a schedule b/c it willsuck out surfactant
Supplemental Oxygen
Free radicals will form from hyperoxygenation leading to cell death in the brain and poor long term development
Acceptable SaO2 87-95%
Increasing FiO2 can increase cerebral oxygenation above what is needed leading to whit ematter damage
When Neonate Desaturates
Observe the infant to see if they self recover
Stimulation -Tactile Stimulation
Increase FiO2 in small intervals
BMV
Chest X Ray
AP View: Heart appears larger
Inspiration: Want to see 8 ribs
Diaphram: Right side will be higher than left
Tracheal Narrowing during E
Chest X Ray
ETT
Halfway between medial end of calvicles and carina
T2-T4
When the neck is flexed the ETT will move down and when extended it will move up
Carina Position
Higher than in adults
Level of 3rd vertebrae in neonates
10 yrs level of 5th vertebrae
Thymus Gland on a Chest XRay
Triangular shaped and called the sail sign
Largest at 2 yr of age
Can be mistaken for heart border or upper lobe atelectasis
Hyperaeration
Hyperinflation
Increased radioluncency= Reduction in lung markings and depression
Transient Tachypnea CXR
Infiltration of hilar region- Engorged veins and lympathic vessels
Hyperaertation - Incaresed Raw
RDS Chest XRay
Reticulgrandular (ground glass) apperance
Lack of aeration (white out; increased opacification)
Lung may appear clear over a few days then apices and periphery first and then more centrally
Meconium Aspiration CXR
In mild cases may seem normal
In severe cases will see bilateral infiltrates, air trapping, air leak syndrome, atelectasis, inflmattion, pleural effusion
Pneumonia CXR
Diffused lung markings
pleural fluid may be present
Looks like RDS
Pneumothorax CXR
lung displaced from chest by a dark band of air which will have no lung markings
Border of the lung will be seen as a sharp white line
Tension Pneumothorax CXR
Depressed diaphram on affected side
Widening of intercostal space
Mediastinal shift to unaffected side
Respiratory Pharmacology
- Inhaled Medications
- Bronchodilators
- Steroids
- Systemic Meds
- Dexamethasone
- Stimulants
- Caffeine and theophyille
- Specialty gases
- Nitric oxide
Translumination
a normal chest will have a small glowing halo around the light source
If the chest lights up the it is a pneumothorax
Nectrotizing Enterocolitis
Occurs in 10% of babies <1500 g
More common in preemies but can occur in term babies
50% mortality
Bowel Movement Frequency
99% of term infants will poop in first 24 hr
99% of preterm infants will poop in first 48 hr
Very premature infants are not fed because the colon is not developed
Weight Trends
~10-15% of birth weight is lost during the first week
Weight gains will begin in second week of life. ~1-3% of body weight/day and preterms do not regain it as quickly
Residuals/Aspirates
Gastric aspirates performed before feeding to determine feeding tolerance and rate of digestion
Will help to avoid over or under feeding
Calorimetry
Resting Energy Expenditure (REE)
Direct Measure: Heat produced and lost by the body, requires specialized equitment and personal so it is expensive
Indirect Measure: Measure O2 consumption and CO2 production
H2 Blockers
Decrease stomach acid production
Ranitidine (Zantac)
Cimetidine (Tagament)
Proton Pump Inhibitors (PPIs)
Inactivates the pumps that produce stomach acid
Pantoprazole (Pantaloc)
Colostrum
Colostrum is the first form of milk produced by the mammary glands of mammals
Thick, yellowish milk
Coats the GI tract with a protective barrier to decrease permeability & prevent pathogens from adhering
Laxative effect-helps with the passing of meconium
Decreasing the amount of bilirubin and aid in jaundice prevention
Colostrum Composed Of
Immunoglobulins
Lipids
Proteins
Beta carotene
Leukocytes
Urine Output
1-3 mL/kg/hr
Normal newborn kidney will not concentrate urine well
Renal Failure Leads to
Volume overload
Hyperkalemia
Acidosis
Hyperphosphatemia
Hypocalcemia
Renal Failure and Prerenal Causes
~25% of newborn will have renal failure and 75% will be due to pre renal causes
Causes include: Dehydration, asphyxia, Hypotension
Urine Analysis
BUN >15-29 mg/dL suggests dehydration
Creatinine levels will drop to <0.6 mg/dL by 1 week and higher levels suggest renal disease
Diuretics
Chlorothiazide with spironolactone-chronic management
Furosemide {lasix}-potent and good for rapid diuresis
Side effects: ototoxicity, electrolyte abnormalities, interference with bilirubin-albumin binding
Foley (in/out)
Check to see if poor output secondary to obstruction
Collect adequate sample for labs, cultures
Sepsis
Often diagnosed on clinical presentation and acted upon before lab results come back
Pale, mottled, floppy
Not feeding well
Irritable
Unresponsive (ominous)
Leukopenia
<3500/mm3
Leukopcytosis
>25 000/ mm3
Not unusual in the immediate period
Immature Grnaulocytes/Total Granulocytes
>0.2:1 Implies infection
