ITT Definitions & Treatments Flashcards
HIE criteria A and B and inclusion age
Age >35 for cooling within 6 hours of delivery
Criteria A:
-pH < 7.0 and BE -10
Criteria B:
-pH <7.01 - 7.15 and BE -10 to -16 within 1 hour PLUS APGAR <5 at 10 or 10 min of PPV and sentinel event, evidence of NE
HIE Treatments
- Therapeutic hypothermia for 72 hours at 33 (+/- 5) rectal temp
- Morphine for sedation/analgesia .1mg/kg loading then 20mcg/kg/h IV
- Neutral head alinement, allow for venous drainage
- 50ml/kg/d to decrease complications associated with dysfunctional autoregulation
- micro-repositioning (fat necrosis)
- watch for autonomic dysfunction and complications of cooling
Neonatal seizures
- Phenobarbital 20mg/kg IV over 20 minutes
- Phenobarbital 10mg/kg IV x 2 q 5 minutes
- consider phenobarbital 5mg/kg/d (check levels)
- Phenytoin 20mg/kg IV over 20 minutes
- Keppra 40-60 mg/kg IV
- Midazolam 0.15mg-0.2mg/kg IV loading
- Ativan 0.05-0.1mg/kg
IVH mgmt
- Neuroprotection (corticosteroids, mag for mom)
- normotension, normocapnia, normoxia, normal pH, appropriate TFI, correct coagulopathies
- seizure mgmt to reduced demand
- midline to allow venous drainage
Undifferentiated neonatal encephalopathy mgmt
Essentially treat like a undifferentiated head in for adults. Normal everything with ICP bundle. Consultation for risk/benefit of cooling
consider:
- HIE
- Perinatal stroke
- IVH
- Hypoglycemia
- Inborn errors of metabolism
- structural anomalies
- infection (GBS, TORCH)
- maternal toxins
Prematurity Mgmt
- Bag if <28 weeks n set incubator appropriately
- TFI
- Small baby care
Subgaleal Hemorrhage
- supportive care for hemorrhagic shock and coag profile
- monitor fontanelles
- investigate sodium, cbc/coags, head size
Undifferentiated congenital heart disease
- Pre/Post ductal saturations
- Hyperoxia test
- CXR
- Prostaglandin E1 0.05-0.1 mcg/kg/min
- consider the need for intubation
Hypoplastic left heart syndrome mgmt and goals of care
initial mgmt is aimed ensuring sufficient mixing of oxygenated and deoxygenated blood and optimizing ventricular function via PDA
- prostaglandin E1 0.01-0.05mcg/kg/min
- avoid supplemental oxygen if able
- Consider dobutamine/milirone to reduce SVR
- allow a mild resp acidosis and avoid supplemental oxygenation in order to allow SVR BF. Acidosis and hypoxia causes pulmonary vasoconstriction.
- the initial goal of therapy is to balance PVR and SVR as BF will always take the course of least resistance.
Tet Spell Mgmt
- legs to chest
(to increase SVR by occluding femoral artery) - supplemental oxygen (to reduced PVR)
- Morphine (to decrease PVR)
- vasopressors (to increase SVR) dopamine,phenlyphrine
Coracation of the aorta mgmt
- prostaglandin 0.01-0.05mcg/kg/min
2. balloon angioplasty
How to close a PDA
- PEEP to reduced BF across the duct
- alkalosis
- ibuprofen, indomethacin, Tylenol, surgical closure
How to keep a PDA open
Prostaglandin
- 01-0.05mcg/kg/min if its already open
- 1mcg/kg/min is large dose for those we need to re-open
PPHN mgmt
- HYPEROXIA - (decrease PVR). Initially FiO2 1 then target PREDUCTAL spo2 90-95%, PaO2 50-70
- NORMOCAPNIA - (decrease PVR) PCO2 40-45 since hypercarbia increases PVR
- SEDATION - (decrease PVR and vent synchrony)
- HD SUPPORT (Dobuatmine, milirone, or vasopressin)
- Correct pH
(acidosis increase PVR) - SURFACTANT (Should be considered in patients with associated parenchymal lung disease)
- iNO (decrease PVR - initiate if OI >25 initate at 20 PPM, wean to maintain SaO2 >90 then wean Ino when FiO2
SVT mgmt
- 20 sec ice on face
- .1mg/kg, .2mg/kg Adenosine
- electrical cardio version
High Flow mgmt in neonates
1) setting: flow 2LPM/kg. begin at 2
2) max capacity of the ANAPOD is 25LPM
3) temperature ideally 35-37 degrees
4) Prongs should be 50% of then are diameter
nCPAP mgmt in neonates
nCPAP generally 5-7cmH20 with Fio2
TTN mgmt
- neutral thermal environment
- consider high flow (1-2LPM/kg)
- nCPAP 5-7cmH20
- intubation if failing nCPAP
RDS mgmt
surfactant therapy is indicated for FiO2 > 30 and nCPAP >7cmH20, significant WOB, CXR consistent with RDS, BLES 2.5mg/kg x 2 doses
Congenital Diaphgramatic Hernia mgmt
- intubation (immediately to prevent dilation of abdominal content by increase ITP)
- NG tube placement (reduce pressures)
- fluid resus and inotropes
- surfactant prn
- echo
- surgical intervention
- iNO, sildenafil, prostaglandin, vasopressin, miliron, etc for PPHn
Hyperbilirubinema pathophysiology and treatments
Unconjugated bilirubin is a waste product of hemoglobin breakdown that is taken up by the liver, where its converted to conjugated bilirubin.
Conjugated bilirubin is water-soluble and is excreted into the bile to be cleared from the body.
Bilirubin is a product of heme catabolism. The enzyme heme oxygenase located in all nucleated cells, catalyze the breakdown of heme, resulting in the formation biliverdin. Biliverdin then rapidly converts to Hb.
primary concern would be BIND/karnectus.
- use the bilitool to gage treatment threshold
- phototherapy
- go up on TFI by 20%
- exchange transfusion, IVIG.
Hyperbilirubinema pathophysiology and treatments
Bilirubin is a product of heme catabolism. The enzyme heme oxygenase located in all nucleated cells, catalyze the breakdown of heme, resulting in the formation biliverdin. Biliverdin then rapidly converts to Hb.
primary concern would be BIND/karnectus.
- use the bilitool to gage treatment threshold
- phototherapy
- go up on TFI by 20%
- exchange transfusion, IVIG.
Hyponatremia treatment and goals of therapy
tx: hts 3% 3ml/kg
goals:
1. relieve hyponatremia symptoms
2. avoid rapid correction to prevent osmotic demylinationation
3. prevent further decline in sodium concentration
Approach to gestational HTN
- steroids if predicted risk of PTL
- deliver between 38 and 39+6 if otherwise uncomplicated
post-partrum HTN mgmt
PO/IV antihypertensives like non-pregnant patients
Gestational HTN and severe G.HTN definition
≥140/90, ≥160/110
Preeclampsia criteria dx
140/90 with proteinuria, end organ dysfunction markers, +? fetal effect
Preeclampsia Treatment package
- Acute BP <160/110 (~25% reduction 2 hours)
- reduce with:
a) Nifedipine 5-10mg q 30minutes (XL dose not appropriate for acute HTN)
b) Labetalol 200mg PO - Mag 4g/20 minutes then 1g/hr
- Betamethasone 12mg q 24 hours
- 80ml/hr of fluid maximum
Treatment of
eclampsia
Tx with
- a) 4-6G of Magnesium over 15-20 minutes
b) 1-2g/hr for 24 hours - Consider midaz if seizures >20 minutes
- Load of Phenytoin
- Manage HTN
a) Consider labetalol 20mg IV over 20 minutes followed by 1-2mg/min; Max dose 300mg
b) Hydralzine 5mg 1-2minutes followed by 5-10mg q 20minutes until target BP is hit
Phone assessment for maternal/LD patients
- cervix (dilation/effacement/length)
- contractions (frequency, duration and strength)
- membranes (intact, rupture)
- baby (FHR)
- Meds given - (abx, corticosteroids, tocolytics)
- maternal (GBS, PIH, GDM, GTPAL)
General approach to placental abruption
- maternal hemodynamic assessment
- fetal assess
- all acute abruptions ≥36 weeks should be delivered
Approach to placenta previa
- achieve maternal hemodynamics
- determine if emerg c-section is indicated
Preterm Labour mgmt:
- tocolytics
- steroids
- abx
- magnesium
Nifedipine dose
loading: 10mg PO q 30 until contractions stop (max 40mg/2hr) then 1 hour after loading dose 30mg q 12 hours x 48
Most common induction medications
oxytocin. synthetic oxytocin administration is the most common and proven method of labour induction.
Proper placement of a UVC
Through the ductus venous. The placement of a line through the portal veins could cause a hematoma. UVC should place confirmed on XRAY at T8-9
We provide oxygen in the setting of TET spell because
its a pulmonary vasodilator and systemic vasoconstrictor.
Complications of Prostaglandin administration
Apnea (inhibition of resp centers0
Hypotension
Also, the DA most responsive the earlier in life
Principles of single ventricle physiology manipulation regarding:
FiO2, CO2 reduction, pH Alkalosis, Afterload reduction, Inotropes.
Essentially, what do these things do
FiO2 increase = PVR decrease CO2 reduction = PVR decrease pH Alkalsosis = PVR decrease Afterload Reduction = decrease in SVR Inotrope = decrease CO
CDH mgmt pillars
- VENTILATION
- intubate immediately after birth
- NG tube to decompress the stomach
- avoid BVM/NIPPV
- preductal 85-95%
- gentle ventilation
- avoid sedation - HD Support
- cautious use of lfuids
- steroids
- inotropic support
- ECHO - Pulmonary HTN
- oxygen
- sedation
- iNO
- Sildenafil
- prostaglandin
- vasopressin
- milirinone
- ECMO
ABG goals in NICU
7.25-7.45 / 45-55/ 50-80/ 22-26 BE 0 to -2
SpO2 goals for >36 and <26
>36 = 90-95% <36 = 88-92%
Indications for high-flow oxygen
Oxygenation not met by low-flow N/C.
Any elevated WOB without signs of failure.
Respiratory secretions causing increased WOB.
How does high flow improve ventilation
§ Promotes airway patency
§ Creates nitrogen washout, which improves diffusion of CO2 washout and increases oxygenation diffusion.
§ CO2 elimination is improved with a higher PAO2 because of the displacement of CO2, increasing the gradient between PaCO2 and PACO2, improving diffusion and ultimately elimination. There is less of an effect on CO2 elimination compared to minute ventilation
Reduces sticky secretions/pugs
Vent circuit sizing for KG for each population neo peds adult
neo = <10kg peds = 10-20kg adults = >20kg
Normal iTIME for neonate
0.35-0.45
Normal iTIME for peds
0.8
The high pressure limit is set to detect, what?
large spikes in pressure (cough, plugs)
The white line, on the Hamilton t1, is always set to 10CMH20 below the high PIP limit, why?
because it is the max pressure that the vent will apply in (S)CMV+, which is PRVC
List how thermal regulation is maintained in an incubator in regards to: conduction convection radiation evaporation
○ Conduction – thermal pad matches infants temperature
○ Convection – barrier to air prevents conection loss
○ Radiation – incubator cover prevents sunlight penetration
Evaporation – prevention of heat loss environmental box
Indications and why to close a PDA
Moderate to large PDA’s
- PDA closure is recommended for patients with moderate to large PDAs associated with symptoms of left-right shunting, clinical evidence of volume overload or reversible pulmonary arterial hypertension.
-Closure results in resolution of symptoms and a decrease in the likelihood of severity of PAH and the development of irreversible pulmonary vascular disease (Esinmenger syndrome)
Management of placental abruption complicated by PTL <34 weeks
C-Section if unstable.
If stable mom and reassuring fetal status <34 weeks
- PTL = Tocolytics for 48 hours, betamathasone
When the fetus and mother are both stable and there is no evidence of major bleeding/coagulopathy, conservative mgmt with the aim of delivering a more mature fetus.
Placental Abruption mgmt of 34-36 weeks.
We deliver most patients with acute abruption at 34+0 to 36+6 GA since patient’s remains at risk of maternal or fetal compromise from progressive placental abruption and neonatal morbidity is relative low at this GA
Placental abruption at 36w to term mgmt
deliver all pregnancies with suspected acute abruptions
Eclampsia key principals of management revolve around
Prevention of maternal hypoxia and trauma
treatment of severe HTN if present
Prevention of reoccurring seizures
Evaluation of prompt delivery
Drug of choice for prevention of recurrent seizures in the setting of Eclampsia
Magnesium Sulfate is the anti seizure medication of choice.
Treatment is primarily directed at prevention of recurrent seizures rather than control of the initial seizure since the initial seizure is usually short duration and may occur in a setting where IV access or drugs are not readily available.
PPROM treatment
Antibiotics
- Ampicillin 2G IV q 6 for 48 hours
- Erythromycin 250mg IV q 6 for 48hrs
- Then Amoxicillin 250mg q 8 hours, erythromycin 333mg q 8 hours for 5 days
Betamethasone
-12mg q 24hr x 2
Approach to diastolic hypotension in neonates in the setting of vasodilation
Initial fluid resus of 10-20ml/kg to max of 60ml/kg followed by early pressor such as dopamine
Approach to diastolic hypotension in the setting of HD significant PDA
Diastolic hypotension is best managed by strategies to increase PVR and reduce L-R shunt
- maximum oxygen 88-92%
- Permissive Hypercapnia 50-60mmHg
- Optimize PEEP
Approach to diastolic hypotension in the setting of hypovolemia
15-20ml/kg of PRBCs over 10-30minutes for emergency administration
Approach to undifferentiated shock physiology in Neonates
Neonates who present with profound hypotension should be managed as severe warm septic shock with presumed associated LV dysfunction.
- Modest volume expansion followed by agents that increase SVR should be considered such as dopamine, levophed, vasopressin and early hydrocortisone.
Vitamin K in infant that weighs <1500g
.5mg IM
Vitamin K in infant >1500g
1mg IM
Neonatal seizure clock
Phenobarbital 20mg/kg over 20 minutes Phenobarbital 10mgkg q 5 minutes Phenobarbital 10mg/kg q 5 Phenytoin 20mg/kg over 20 minutes or forsphenytoin Keppra 40-60mg/kg IV loading dose Midazolam
Paediatric seizure clock
Midazolam .1mg/kg or Ativan Phenytoin 20mg/kg over 20 Phenobarbital 20mg/kg over 20 Keppra 40-60mg/kg IV loading Midazolam infusion Ketamine infusion Propofol infusion
Whats the definitive treatment for preeclampsia
delivery
What medication reduces the occurrence of preeclampsia
low dose ASA
Antihypertensive are used in preeclampsia to prevent and treat
Severe HTN. and reduce risk of CVA/Pulmonary edema
Magnesium can be used to decrease risk of _________ in preeclampsia
Seizures
What is the week limit for administration of indomethacin
28-32 weeks is the latest it can be used for tocolysis
Cerivcal dilation per hour
1.5 cm/hr
What is a world wide practice that is used to decrease PPH
Prophylactic administration of a uterotonic drug after birth is a routine practice worldwide to prevent atony
