Lecture 16: Infant acute care/nicu

Question 1

ICU terminology

Question 2

Question 3

Level 1: Well baby nursery:
* Provide neonatal resuscitation at every delivery
* Evaluate and provide postnatal care to stable term newborn infants
* Stabilize and provide care
* 35-37 weeks’ gestation
* Physiologically stable
* Stabilize ill and < 35 weeks’ gestation until transfer to a higher level of care

Question 4

Level 2: special care nursery
* Level 1 capabilities plus:
* Care for >/32 weeks’ gestation and weighing >/ 1500g
* Physiological immaturity or moderately ill
* Problems expected to resolve rapidly
* Not anticipated to need subspecialty services on an urgent basis
* Care for infants after intensive care
* Mechanical ventilation for brief duration (<24 hours) or continuous positive airway pressure or both
* Stabilize born before 32 weeks’ gestation and weighing less than 1500 g until transfer to a neonatal intensive care

Question 5

Level 3: NICU
* Level 2 capabilities plus:
* Sustained life support
* Comprehensive care
* Born < 32 weeks gestation
* Weighing < 1500 g
* All gestation ages at birth weights with critical illness
* Prompt and readily available access to full range of pediatric medical subspecialists, pediatric surgical specialists, pediatric anesthesiologists, and pediatric ophthalmologists
* Full range of respiratory support
* Advancing imaging, with interpretation on an urgent basis
o CT
o MRI
o Echocardiography

Question 6

Level 4: Regional NICU - typically located in big cities
* Level 3 capabilities plus
* Located within an institution with capability to provide surgical repair of complex congenital or acquired conditions
* Maintain full range of pediatric medical subspecialists, pediatric surgical subspecialists, and pediatric anesthesiologists at the site
* Facilitate transport and provide outreach education

Question 7

at what age are they at level 1

Answer 7

< 35 wks

Question 8

level 2
* age and wt

Answer 8

> /32-35
/1500g

Question 9

level 3
* age and wt

Answer 9

< 32 wkes

wt < 1500

Question 10

KNOW: level 4 for can do those complex surgeries (main thing that dilinates it from lvl 3)

Question 11

Often hard to work in NICU as new grad, but can train as new grad

Question 12

Question 13

Role of PT in the NICU
* Screening and examination of infants to determine need for direct services
* Referral for consultation by other health care progessionals
* Design and implementation of individualized and developmetally appropraite interventions adapted to the infants physiologic, motor, neurologic and developmental needs
* Collaboration w/ other health care professionals
* Incorportate family members to best support developmental outcome

Question 14

Question 15

Question 16

developmental specialist = person who does everything in NICU
* we need as few people touching these babies as possible

Question 17

Question 18

other health professionals in the NICU
* Certified lactation consyltants
* social workers
* Discharge planners

Question 19

Question 20

Question 21

Question 22

Question 23

Question 24

So highly variable
Longer in NICU = higher chance of eating and sleeping problems
Higher postpartum depression in NICU (might be partly due to decreased sleep)

Question 25

Question 26

ICF model of care High-risk neonates frequently demonstrate impairments: * Muscle tone – start as hypertonic * ROM * Sensory organization – is just off * Postural reactions Impairments in body functions and structures may contribute to limitations in activities such as: * Difficulty in breathing * Feeding * Visual and auditory responsiveness * Motor activities such as head control and movements of hand to mouth The interaction between impairments and activity limitations may contribute to restrictions in parent-infant interaction (participation)

Question 27

Question 28

Clinical manifestations of respiratory distress syndrome * Grunting respirations * Retractions * Nasal flaring * Cyanosi * Increased O2 requirement post birth

Question 29

Treatment for respiratory distress syndrome * Oxygen supplementation * Assisted ventilation * Surfactant administration * Extracorporeal membrane oxygenation (ECMO) * Continuous positive airway pressure (CPAP) * Positive end-expiratory pressure (PEEP) * Mechanical ventilation

Question 30

Question 31

Question 32

Cardiac system – lots of babies are born early due to cardiac issues – these require surgery * Patent ductus arteriosus – hole in heart * Pulmonary atresia * Tetralogy of Fallot * Coarcation of the aorta

Question 33

Intraventricular Hemorrhage (IVH) and Periventricular hemorrhage IVH-about 45% of infants w/ birth weights between 500-750 g (so low birth weight leads tot his) About 20% of infants w/ birth weights < 1500 g **Most hemorrhages occur within the first 48 hours after birth** Diagnosis is based on routine or symptom-driven screening through **cranial ultrasound** Risk factors that can disturb cerebral blood flow include: * vaginal delivery * Low apgar score (remember this is to asses how they're doing right after birth) - does not affect long term anything - just saying if they need immediate medical care * Severe respiratory distress syndrome * Pneumothorax * Hypoxia * Hypercapnia * Seizures * Patent ductus arteriosus - heart w/ hole in it * Thrombocytopenia * Infection * Mechanical ventilation - increases risk for BF disruption

Question 34

Describe a grade 1 intraventricular dysfunction

Answer 34

Hemorrhage isolated to the germinal matrix * this is often reabosrbed and theres no s/s

Question 35

Describe a grade 2 intraventricular hemorrhage

Answer 35

Normal sized ventricles that occurs when hemorrhage in the subependymal germinal matrix ruptures through the epndyma into the lateral ventricles * so basically theres blood in the ventircles bust doesnt cause them to swell - that blood is not fully reabsorbed here

Question 36

Describe a grade 3 intraventircular hemorrhage

Answer 36

Acute ventricular dilation (so they're dialted)

Question 37

Describe a grade 4 intraventricular hemorrhage

Answer 37

hemorrhage that spreads into the periventricular white matter * so the ventricles arent just dilated but blood has actually bursted forth

Question 38

Signs of intraventricular hemorrhage Range from subtle and nonspecific to catastrophic Clinical signs: abnormalities in level of consciouness, movement, muscle tone,Stupor progressing to coma respiration, and eye movement * big thing we see is that they start floppy and end up w/ higher tone * typically the respiratoration is what gets caught Catstorphic deteriortation * Major acute hemorrhages * Stupor progressing to coma * resp distress progressing to apnea * Generalized tonic seizures * Decerebrate posturing quadriparesis

Question 39

Oremature infants with grade 1-2 IVH are at risk for neurosensory impairment, developmental delay, cerebral palsy, and deafness at 2-3 years of age More severe IVH, espeically grade 4, the risk for cerebral palsy can be present in up to 39% of infants, hydrcephalus in up to 37%

Question 40

IVH * Prenatal care aiming at reducing premature birth * Antenatal steriods to reduce severity and incidence of severe IVH - steirod injections they give to the mom * Indomethacin-used to close pactent ductus (hole in heart) arteriousus shown to prevent IVH - so if they close the heart theres less irsk of IVH (idk why) * Interventions following IVH * Close monitoring and amagement of ventricular dialtion * Physiologic support to maintain o2, perfusion, body temp, and blood glucose level * Management of ventricular dilation )ventriculoperitoneal shunting, temporary ventricular draining) * **physical handeling is minimized** - so not doing loads of therapy on a baby following a IVH

Question 41

Pain Since they're babies they cannot report on pain Express pain - so pain can make them do these things * Pain behaviors * Physiological change * Changes in cerebral BF * Cellular and molecular changes in pain processing pathways Adverse sequelae * Death - pain can cause death in babies * Poor neurologic outcomes * Abnormal somatization and repsonse to pain later in life

Question 42

Pain - in babies peripheral NS is capable of responding to stimuli by 20 weeks gestational age (age of viability ~22 weeks) - so need to be at age of viability to respond to sitmuli Number and types of peripheral receptors similar to adults by 20 to 24 weeks of gestation Increased densitry of receptors in newborn compared with adult Spinal cord and brain stem tracts not fully myelianted * messages don't go as quickly = delayed response Pain payhways, cortical and subcortical centers of pain perception, and neurochemical systems associateds w/ pain transmission functional in 20 to 24 weeks gestational age * so when a baby is born if they're viable they can feel pain * However, things that inhibit pain dont happen until 36 weeks * so pain modulation isnt in tact - meaning they're more sensitive to pain

Question 43

Pain: ** Pain modulatory tracts, which can inhibit pain through release of inhibitory neurotransmitters such as serotonin, dopamine, and norepinephrine, not developed until 36 to 40 weeks of gestation** - meaning babies cant inhibit pain until then Preterm infants more senstivie to pain than term or older infants painful stimuli from medical conditions and medical procedures (heel sticks, intubation, ventilation, and IV placement) can lead to porlonged structural and functional alterations in pain pathways that may persist into adult life May associate touch with painful input, which can interfere with bonding and attachment

Question 44

Physiological manigestations of pain - what makes us know babies have pain * increased HR * Heart rate variability - goes and down quickly * BP resoinse * Increased respirations * Decreased oxygentation - breathing a tone but bad O2 exchange * Skin color and character include pallor or flushing, diaphorssis, and palmar sweating * **Increased muscle tone** - think about when you;re hurting, you get tight * Dilated pupils * Laboratory evidence of metabolic or endocrine changes

Question 45

to pain

Question 46

non-nutritive sucking = passifre

Question 47

Pain my lead to poor nutritional intake, delayed wound healing, impaired mobility, sleep disturbances, withdrawal, irritability, and other developmental regression

Question 48

Gastroesophageal reflux (GER) - this is just basically spitting up - normal for babies very common - gastric sphincters not strong enough to hold it in - not acidic, not a big deal - typically spit up about till 6 months because they can sit up (can stop burping them here as well) * 2/3 healthy infants seek advice from health care providers for GER * Passage of gastric contents into esophagus * Normal physiological process that occurs several times a day in infants, children, and adults * Transient relaxations of lower esophageal sphincter independet of swallowing * Permits gastric content to enter esophagus * Typically after meals and causes few or no symptoms * May be assciated w/ reguritation, spitting up, and even vomitting * Content of reflux is generally nonacidic and improves malnutrition

Question 49

Gastroesophageal reflux disease (GERD) - not normal for babies to have - this is now painful (ger is not painful - babies cry when they eat) * GERD far less common than ger * Vomitting - different than spit up, has a lot more chunk to it - more projectile - spit up kind of dribbles out of mouth * Irritability * Poor wt gain * Dyphasgia, abdominal * Substernal pain * Esophagitits * Respiratory symptoms-Cough, laryngitits, and wheezing * dental erosions, pharyngitits, sinusitits, and recurrent otitis media can also be present as age * Incidence lower in breastfed infants compaed to formula-fed infant need medications or will destory esophagus (which will need surgery) higher risk: * neurlogical impairment * Certain gentic disorders * Esopheafeal atresia * Chronic lung disease - can look like Tb * Cystic fibrosis * Prematurity

Question 50

Dosage of medication needs to change w/ wt, so need to change dosage often or they will starting crying again

Question 51

Neonatal abstinence syndrome/neonatal withdrawal (NAS) - exposed to something they shouldnt have been - irritable because going through withdraws / lots of autonomic dysfunction / can't regulate body well Signs and neurobehaviors seen in newborn after abrupt termination of gestational exposure to substances taken by the mother during Common presentations * **High pitched cry** * Irritability * Sleep wake distrubances * Hyperactive primitive reflex * Transient tone alterations (tremors, hypertonicity) * Feeding difficulities * GI disturbances (vomiting and loose stools) * Autonomic dysfunction (mottling, tachypnea, sweating, sneezing, nasal stuffiness, fever, yawning) * Failure to thrive * Seizures **Symptoms of withdrawal usually occur within 72 hours after birth** - because thats when they start getting withdrawl symptoms * often need long term care

Question 52

Diagnosis of NAS * Based on maternal hx, maternal and infant toxicology lab tests, and clinical examination of the infant * NICU * Medications * Supportive measurs for infants ability to eat, sleep, and interact Supportive theapeutic modailities * Nonnutritive sucking * Positioning/swaddling * Gentle handling * Demand feeding * Minimal stimulation * Environmental modifications Difficulty with state organization

Question 53

So what do they need to maintain homeostasis

Question 54

What we test as PT's Neurologic function tested by looking at their reflexes TIMP = lookins at movement patterns. To see if they're jittery or figity

Question 55

Question 56

Kangaroo Mother Care (Skin to skin holding) * infant on the parent's / caregiver's bare chest * Shown to foster attachment, improve maternal confidence in caring for premature infant, and improve odds of breastfeeding at discharge * Reduce stress and depression * More mature neurobehavioral profiles * Motor development * Overwhelming data supporting the benefits and limited risks * Consciousus statement encourgging the international adoption of the standard use of kangaroo care in the care of all infants born preterm

Question 57

Question 58

Question 59

What stage of arousal is this. No movement of body or eyes. Optimal for growth and recovery

Answer 59

Deep sleep NOTE: we don't do PT when baby is asleep. Sleep is more important

Question 60

What stage of arousal is this. Body jerns and eye movements seen. Heart and respiratory rate responses to noise and lights noted on bedside monitors

Answer 60

Light sleep Going to have some response to things around them

Question 61

What stage of arousal is this. Transitional state between sleep and wakefulness. Eyes may open briefly. Little spontaneous movement. Behavioral signs of stress often present.

Answer 61

Drowsiness Where I always am. If they want to fall asleep they good. NOTE: if they've just woken up and they're moving toward quite alert were okay to treat them. However, if they're getting tired you wouldnt want to treat them here

Question 62

What stage of arousal is this. Eyes open and eye contact made. Relaxed face and facial expressions. Movements smooth. Ready for interaction

Answer 62

Quiet alertness **This is the stage we want to do treatment in**

Question 63

What stage of arousal is this. Eyes open or closed. Facial grimace or hyperalert appearance common. Large-ranged, constatnt movements of extremtities seen. Trunk extension often seen. Behavioral signs of stress present. Increased heart and resp rates.

Answer 63

Active alrertness Don't want to treat here. They're likely about to start crying. On the way from quite alert to crying. Giving you s/s that they arent super happy. Don't want to treat until calmed down

Question 64

What stage of arousal is this. Eyes closed, crying, stressed facial exoression. Extremity and trunk movements seen. increased heart and resp rates

Answer 64

Crying

Question 65

**What stage do you want to treat during?**

Answer 65

Quite alert

Question 66

dont have hd / neck contorl so they're susecptable to positioning shouldnt always be in one position However, we do want them in midline at least part of the time. We need them off their backs sometimes (need tummy time)

Question 67

Question 68

Question 69

Normal fetal BPM

Answer 69

120-160 so pulse rate is high (same as BPM I guess) know resp rate decreases w/ age O2 sat should still be 95-100% (Hb holding)