Neonatal Assessment Flashcards
Neonate Definition
A newborn baby in the first 28 days of life
There may be some variability on the exact number of days but generally, it is the first 28/month
This does not take into consideration if the baby was a term baby or a preterm baby
Embryo Definition
Embryo: <10 weeks gestation
Fetus Definition
Fetus: 10 weeks till birth
Pre-Term Baby
Pre-Term Baby: Born between 20- 37 weeks gestation
Any baby that is born <23 weeks will tend to have a lot of issues and chances of survival are low
There are further divisions in the preterm classifications
Term Baby
Born within 38-42 weeks
Post Term Baby
Born after 42 weeks
Trimesters
1st < 12 weeks
2nd 13-28 weeks
3rd > 28 weeks
Gravidity
Number of pregnancies
If the mother gives birth to twins or multiple births it is still considered 1
An abortion will be considered a pregnancy under this definition
Parity
Number of pregnancies that where carried to viable gestation (>23 weeks)
Gravida/Para/Abortus
(charting shorthand is GPA)
G [# of pregnancies] P [# Carried to viable age] A {# of abortions]
If there are no abortions then we just drop the A
If a woman has had 2 pregnancies both that where live births it would be G2P2
KNOW this as it is a common question
Nullgravida
Never been pregnant
Nullpara
Never carried passed20 weeks
Primipariety
First pregnancy
Sources for Pt Information and Background
- Daily report
- Chart
- There may be a cardex which will give you the most recent and important information, then if you need more information you can look into the fully chart
- Bedside Nurse
- Family (Parents)
The Pt Information and Background should give you a feel for
- Patient and maternal history
- Prenatal and delivery history
- The prenatal history not always be available for us
- If mom is addicted to drugs or alcohol the baby may come out with respiratory depression
- Major clinical events
- Current clinical status
- Ex. In babies if they go apneic and have bradycardia at the same time it means that we have to improve their ventilation
- Current orders and PCP
What are the PPE Precaution in the Special Care Nursery and NICU
- Even before you start your shift you will begin with a 60 second hand wash
- It is required to take off everything below the elbows such as jewelry and watches and no long sleeves
- There will be a stethoscope that is at the bedside and specific for each patient
- Make sure to always keep hair up and everything pulled back and not hanging into the environment
- Make sure to wipe down your pager, ID, and everything external that you are bringing into the environment
- Absolutely no food or drink
- Wipe down all common surfaces
- Neatly trimmed and cleaned nails
- Stay home when you are sick
- Ex. The rhino virus is a common cold in adults but can be very severe in infants
Labor and Delivery Isolation Precautions
It is a clean procedure not a sterile procedure
However a C section in the OR is a sterile procedure
Vap Bundles Adults
HOB at 30 degrees
Inline suction
Limit circuit changes
VAP Bundle Neonates
- HOB at 15 degrees
- Preventing oral secretion from getting pass the tube and moving the gravity dependant condensation in the heated circuits downwards
- Inline suction
- Decreases circuit break
- You wont do open suction on a neonate
- Limit circuit breaks
- Only required when indicated or solid
- Single use nasal catheter
- Continuously assess for extubation
- Majority of the time we extubate to CPAP or BiPAP in order to help prevent VAP and allow lungs to develop normally
- Monitor sputum
Goals of Care
- Will be the same as with adults, but you will find that in neonatal they tend to make special consideration such as resuscitation on babies we know are not viable
- Resuscitation
- Medical care and interventions including resuscitation followed by admittance into the NICU
- Medical
- Medical care and interventions not including resuscitation
- Comfort
- Medical care interventions with the focus on comfort
Initial Impression
- Before you go in for your assessment make sure that you are coordinating your care with other disciplines and when they are doing their assessment in order to prevent unnecessary disruption to the baby as well opening and closing the isolette door may cause a draft and make the baby cold
- Utilize your visual evaluation of the patient and bedside monitors as much as possible to prevent disrupting the baby
- Perform the “inspection” of IPPA to gather an overall impression of the patient clinical status
- With NICU remember you can not always touch a baby so you have to rely a lot on the monitor
Many clinicians prefer to do the “monitoring” of the patient before the physical exam components. This allows collection of “baseline” data before disturbing the patient.
NOTE: The initial visual evaluation may reveal that in immediate intervention is required, however! (e.g. coughing/desaturation requiring suctioning).
Noise Controls
Noise can affect babies hearings
Even your normal speaking voice can be too loud
Set your pager to vibrate
Turn down vent alarms and monitors
Try to be as quiet as possible when closing the isolette door
In all NICU there will be a period of silence for 2 hours
Neutral Thermal Enviroment (NTE)
- We have to be very concerned about babies maintaining a normal temperature
- If they do not maintain a normal temperature it will affect oxygen demand
- Neonates are very susceptible to hypothermia due to their decreased surface area and body fat
- Premature babies will not have produced brown fat which would keep them warm
What are the Different Types of Heat Loss
Conduction
Evaporation
Radiation
Convection
Mechanism of Heat Loss-Conduction
What: Body heat loss to a cooler contact surface
Prevention: Avoid placing the baby on a cool surface
Devices: Use a warmed dry blanket, use preheated radiant warmers
Mechanism of Heat Loss-Evaporation
What: Removal of heat from a body that occurs as the liquid evaporates
Prevention: Increase room humidity, dry the baby, wrap the baby, bag the preemie, and humidify the inspiratory gases
Devices: Use warmed blankets to dry and wrap the baby and use humidifers
Mechanism of Heat Loss-Radiation
What: Heat loss to a cooler surface not in contact with the body
Prevention: Keep incubators heated or heat shielded, keep the room temperature high
Devices: Use a heated shielded incubator, use bonnets to cover the babies head
Mechanism of Heat Loss-Convection
What: Heat loss to cooler surrounding air
Prevention: Keep room temperature high, avoid drafts, and keep the baby covered
Devices: Use a radiant warmer or isolette
Radiant Warmer
- Used for overhead warming
- Body temperature can be maintained via servo mode, with a skin probe which is normally attached to the abdomen
- The giraffe isolette is the radiant warmer and does not have closed sides
- Used for older premature and term babies
Closed Isolette
Use for low birth weight infants with temperature instability (hypothermia)
Maintains a constant body temperature by using either a servo-controlled skin probe, air temperature control device, or air temperature probe
Should be double walled or heat shielded (will look almost cloudy which makes assessment more difficult)
What are the basic assessments and physical examination for CNS
PIPP
General Neurological State
Activity Level and Ability to Settle
Fontanel
Tone/Reflex
Head Circumference
Premature Infant Pain Profile (PIPP)
- As baby will not show pain in typical ways we use these scores (can desat with scores)
- Minimum score of zero and maximum score of 21
- The higher score correlates with the greater pain
- Lower gestational age will have a higher PIPP
- Done at admission to NICU (will determine how often done after), before and after procedures
Non Pharmacological Ways to Help Babies with Pain
- Rocking
- Re positioning
- Diaper change
- Decreasing environmental stimuli
- Skin to skin
- Prone positioning
- Breastfeeding
- Giving the baby sucrose (not available for intubated patients)
State of the Baby
- Undisturbed/Disturbed
- Crying
- Active awake
- Quiet alert-Not moving around a lot but still aware of you
- Drowsy-Touching them and they are slow to wake up it can be very similar to deep sleep which is why it is difficult to assess
- Active asleep-Moving around in their sleep
- Deep sleep
- Sedated
- Comatose-Babies may be comatose when they are very sedated (ex. Therapeutic hypothermia, massive head injury or brain bleeds)
Activity Level and Ability to Settle
Appropriate -Are they acting appropriately for their gestations age (term babies will have more tone and strength compared to preemies)
Jittery May indicate pain, repositioning, diaper change
Lethargic
Unresponsive
Paralyzed-It is rare that we will actually paralyze a baby
Intolerant of Handling
Fontanel
###
The fontanel is the non-ossified part of the skull and we will gently feel them for assessment
Soft & Flat
Depressed
Overriding Sutures-Will happen normally and will resolve quickly but if it is an early or late fusion it can lead to distorted skulls
Full/Bulging-Could mean we are giving them too much fluid or that there is a bleed
Tone and Reflex
- Appropriate
- Flaccid
- Hypertonic
- Bring in the extremities
- Baby in pain or cold
- Hypotonic
Check tone right away
Head Circumference
- Chest circumference ~ head circumference
- Term infant:
- Occipitofrontal circumference: around the front of the head above the brow and the occiput (occipital area)
- Above the ears
- Normally 32-37 cm at term
- Accessing development at birth & trending growth
- Head circumference, weight & length percentiles are recorded and trended
EEG
Used to assess seizure activity
CT Scan
Looks for bleeds or fluid in subdural or subarachnoid space
Assesses parenchyma
Skull #s
MRI
Myelination
Ischemic or hemorrhagic lesions
Agenesis of corpus callosum
AV malformations
Ultrasound
Performed at the bedside to check for intracranial and intraventricular hemorrhage
If there is a hemorrhage we can grade them based off of the CT scan (Grade 4 being the worse) and then take the baby to CT and MRI for more information
Most common is germinal matrix hemorrhage and is more common in the premature infants and they might be getting ultrasounds daily in order to assess for this
Can also be used to find hydrocephaly
Lumbar Punctures
Obtain CSF for diagnosis [meningitis, encephalitis, intracranial hemorrhage], check response of CNS infections to ABX, administer intrathecal meds
Specimen can be sent for: gram stain, C&S, glucose, protein, CBC & differential, or rapid testing for specific pathogens
Lumbar puncture will be inbetween the 4th and 5thlumbar vertebra in order to avoid the spinal cord which ends at about the L2 level
CNS Pharmacology-Sedation
Lorazepam- This is a benzo and an antianxiety medication
Phenobarbital- This is a barbiturate that is stronger than a benzo and is commonly used for seizures
We try to not over sedate in babies in order to avoid side effects (not as worried about delirium like we are worried about in adults)
CNS Pharmacology-Analgesia
Remeber that analgesic are used to help decrease the sensation of pain
Fentanyl-Less depressant effects than morphine
Morphine- Causes chest wall ridigity
Tylenol
Pain meds can be given intrathecal but as a last resort
CNS Pharmacology-Paralytics
Pancuronium
Vecuronium
Paralytics are not commonly used in neonates
A side effect of paralytics is the result of third spacing where we will them have to give them more volume to draw the fluid out of the 3rd space
Paralytics are commonly used with therapeutic hypothermia
Therapeutic Hypothermia Used For
Used to treat hypoxic-ischemic encephalopathy (HIE) at birth (perinatal asphyxia) in order to try and prevent/minimize the long term consequence of brain injury
Cerebral Palsy (CP), cognitive and visual impairments
If a baby is breach or has the vocal cord around their neck they may lose oxygenation
Therapeutic Hypothermia Mechanism of Action
- Reduces
- swelling, bleeding & infection
- edema, hemorrhage & neutrophil infiltration
- Excitatory neurotransmitters
- Free radical production
- protects cells from oxidative damage during reperfusion
- Cerebral tissue injury
- swelling, bleeding & infection
Infant undergoing hypothermia may exhibit
- Reduction of HR and Elevation of BP
-
Clotting Disorders
- Lower platlet counts and long prothrombin time
- Worsening Acidosis
-
Possible worsening oxygenation secondary to pulmonary hypertension
- When PPHN occurs with HIE we are compounding the problem
- Abnormal EEG
-
Skin Breakdown
- Secondary to decreased perfusion and lack of movement
-
Hyponatremia and Hypokalemia
- Will do blood work every 6 hours to check for this
Clinical Neurological Examination
All infants should undergo a brief neurological assessment (tone & reflexes) as part of the an initial examination
posture, movement, muscle tone, reflexes, cranial nerve and oromotor function, sensory responses, and behaviour
The normal full term infant will assess in a particular way
High risk infants require a more in-depth neurodevelopmental assessment
High Risk Infants
- Prematurity
- Intrauterine Growth Retardation (IUGR)
- We see this in moms who smoke which will make the baby hypoxic and have a growth retardation
- It can also occur if there is a placenta deficiency
- Asphyxia
- Very low APGAR score (0-3) for > 10 mins
- Associated with high mortality >50%
- If the baby survives only 25% will have a major handicap (Gomella)
- TORCH Infections
- Meningitis
- Tested through LP
- Hypoglycemia or Polycythemia
- Will be associated with neurological disability
- In utero exposure to drugs
TORCH Infections
Toxoplasmosis (Protozoan)-Cat Feces, raw meat
Other (syphilis)
Rubella
Cytomegalovirus
Herpes simple virus/hepatitis/HIV
CVS Basic Assessment and Physical Exam
Perfusion
Edema
Peripheral Temperature
Colour
Precordial
Heart Sounds
Perfusion (Central/Peripheral)
- Central (core)
- Peripheral (extremities)-Temp, blood volume, CO, BP, Acid-base balance
- Capillary refill will be done on stoach or foot
-
Newborns have a low systemic output and high vasoconstriction
- This is completely normal for the 1st 24 hours
Changes in Perfusion can Come From
Change in environmental temperature
Circulating catecholamines which contribute to vasoconstriction
Transcutaneous Monitoring
Transcutaneous monitoring probes are put on the stomach and are commonly used in neonates when they are peripherally shut down.
It is a little more complex and comes with more risk but sometimes it has to be done
Cause of Inability to Maintain a Stable Temperature
Skin Temperature (36-36.5)
- Prematurity
- Shock
- Will be more pronounced in neonates
- In shock you can get more vasoconstriction or dilation which can affect temperature
- Decreased perfusion
- Cardiac abnormalities
- They will either have persistent fetal circulation or are structurally abnormal
Why are all babies at risk for temperature instability and heat loss
All babies even term babies are at a risk for temperature instability it is just that pre mature babies are at more of a risk. Babies require entirely on the metabolism of brown fat which makes up 5%
They rely entirely on the metabolism of brown fat (easily metabolized fat that accumulates prior to birth to assist baby in keeping warm) and glycogen for heat production
Premature babies are more susceptible to temperature because if they are below 26 weeks they have no brown fat
When the baby is peripherally very cold and unable to warm up we can give vasodilators and fluid
When measured rectally core temperature should be 36.5-37.5
Low body weight and preterm babies have additional risks
- Little Sub q fat
- Preemies born prior to 26 weeks have no brown fat
- High body surface area to weight ratio
- Pediatrics have this too
- Reduced glycogen stores
To help promote normal temperature in babies
Keep room warm
Be quick with your assessment when you are opening isolette
Cold Stress
Cold Stress: Any environment where a newborn baby is not warm enough
In the presence of mild cold stress, the normal newborn will respond by peripheral vasoconstriction
This will increase the amount of norepinephrine and in turn metabolize brown fat
Norepinephrine will break down brown fat into fatty acids which hydrolyze into glycerol and nonesterified fatty acids which are oxidized to produce heat to increase body temperature
Non-Shivering Thermogenesis
- Glycogen will be converted to glucose to generate energy
- This requires increased metabolic and O2 demands that can be met through normal fat stores and feedings
- Which is why for a baby that is cold their sats may drop
- This requires increased metabolic and O2 demands that can be met through normal fat stores and feedings
- This means that is glycogen stores are low babies are unable to warm themselves
- Glycogen store may be low when they have an inability to feed (ex. Delayed sucking response) or a premature GI tract
- When the baby is cold they may start to use anerobic glycolysis will lead to metabolic acidosis
How to Prevent Cold Stress
- A bonnet for the head
- A closed environment with heat and humidity (isolette, heated circuit)
- Clothing or swaddling if more than a kilo
- If they are less than a kilo the skin is so delicate that they will not be wearing clothing besides a bonnet
- Temperature regulation devices like warmers, or an enclosure like a house or incubator
- Sufficient nutrition to meet metabolic demands
- A stable thermal environment
- All neonate will get heated circuits·
Hyperthermia
- Hyperthermia: Temp > 37.5 [normal core]
- Causes
- Environmental-Heating them up too much
- Infection {bacterial or viral}-Will mostly be bacterial
- Dehydration- Will occur from not getting enough breast milk
- This is a common cause
- Maternal fever in Labour: A common bacterial infection is GBS which can be very harmful to premature babies. So the mom may be put on antibiotics
- Drug Withdrawal:
- Increased metabolic rate & oxygen consumption [tachycardia, tachypnea, irritability, acidosis, brain damage & death]
Pink Color
Good perfusion, want to see pink warm and dry
Pale/Pallor Color
Baby washed out, anemia, birth asphyxiation, shock, infection, poor perfusion
Ruddy/Plethora Color
Polycythemia (this is common in babies until they transition to extrauterine life), hyperthermia infant
Dusky or Blue Color
Dusky is a common term for cyanosis and is a greyish blue tone,
Jaundiced
Normally wont see at birth and only occur after 24 from birth
We treat jaundice through UV light and phototherapy
Mottled
Sign of shock, hypovolemia
Looks like a marbling of the skin and it can be normal but it can be a sign of shock
Cyanosis
The baby can have peripheral (acroyanosis) or central cyanosis
Peripheral/Acrocyanosis is the extremities of the body and is more
Central cyanosis is determined from the lips/tongue and is an indication of low sats or a pulmonary problem or heart defect and will reflect desaturated hemoglobin of <5g/dcl
Cyanosis in Anemic Babies
these babes are pale and don’t look as hypoxic as they are – reflects the amount of Hgb
This can be difficult to detect by observation
Cyanosis in Babies with high Hematocrit Levels
these babes may look blue but are not hypoxic at all – reflects the amount of Hgb
Edema
- Caput succedaneum
- Edema on the scalp secondary to delivery; accompanied by bruising; it crosses the midline of the scalp and is outside the periosteum
- Face & eyes may be swollen & bruised
- Generalized edema may be indicative of fluid balance [renal] issues
Apex/Precordium
Apex: PMI/HR where is it?
Precordium: Active or not active
Heart Rate in Babies
- Term Infants
- HR: 120 to 170 beats/minute while awake
- HR: 80 or 90 beats/minute while asleep
- Transient tachycardia [>200 b/m] with stimulation or agitation
- Neonates older than 35 weeks of gestation have greater variability in heart rate than an infant born at 27 to 35 weeks of gestation
Blood Pressure in Neonates
- Systolic/Diastolic
- Adequate MBP = gestational age ( weeks ) + 5
- Pulse pressure: Difference between systolic & diastolic; widen may indicate a PDA in term infants
- Preemies
- To calculate an adequate MABP take gestations age and add 5
- 26 weeks should have a MABP of at least 31 mmHg
- Term Neonates
- 75/50 mmHg (~60 for MBP)
- 42 week MABP should be at least 47 mmHg
RR in Neonates
- Preemies
- 30-60
- Term Neonates
- 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
Heart Sounds [Murmurs]
Murmurs: “rushing” sound heard on auscultation
Most are normal and resolve with closure of patent ductus arteriosus (PDA)
Some murmurs are heard at specific spots on the chest wall & may be indicative of a heart defect/malformation
Weak Pulses
Low cardiac output states such as shock or hypoplastic left sided heart syndrome
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
UAC
UAC: 5 and 7 o’clock for arteries [2]
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
Echo/Functional Echo
Functional echocardiography- ductal and atrial shunting, pulmonary artery pressure, right and left ventricular output and superior vena cava flow as well as myocardial function
CO/ SVR Pharmacological Interventions
Dopamine [hypotension]
Dobutamine [hypotension]
Rate & Rhythm Pharmacological Interventions
Bradycardia -Atropine
Narrow complex SVT - Adenosine
Tachys: Na channel blockers, beta blockers [propranolol], K channel blockers [amiodarone], Ca channel blockers [verapamil]
Pulmonary vasodilators [PPHN] Pharmacology
- iNO
- Sildenafil (phosphodiesterase type inhibitor)—other name?
- Prostacyclins/prostaglandins:
- Iloprost
- Treprostinil
- Epoprostenol (flolan)•
Anti-thrombotics Pharmacology
Low molecular weight heparin [NP]
Unfractionated heparin [P]
The evidence supporting most recommendations for antithrombotic therapy in neonates and children remains weak. Studies addressing appropriate drug target ranges and monitoring requirements are urgently required in addition to site- and clinical situation-specific thrombosis management strategies
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
Other Pharmacological Interventions
Iron: needed for growth and development; anemia; breast milk or fortified formulas
Folate
Vitamin E
ECMO
Both the heart and lung supported
Blood taken from RA
CO2 removed, O2 added
Rewarmed to body temp & returned right common carotid artery
CVS Electrical Therapy
Circulatory collapse with a tachycardia whether broad or narrow complex requires cardioversion, which should be synchronised
PDA Closure
Indomethacin + ibuprofen
Ligation
Intravascular “coils”
IPPA of Neonates-Inspection
General appearance
Gestational age
Malformations
Colour
Tone
Chest excursion: Symmetrical or Asymmetrical
WOB: retractions, nasal flaring, grunting
Precordium – apical pulse
IPPA of Neonates-Palpation
Skin-perfusion, temperature, capillary refill
Compare central and peripheral pulses
Abdomen
Fontanels
IPPA of Neonates-Percussion
DONT DO IT
IPPA OF NEONATE-AUSCULTATION
Can be difficult due to the high level of transmission of breath sounds throughout the neonatal chest
Equality of breath sounds from side to side
Decreased breath sounds equally means under ventilation
Presence of adventitious breath sounds
Wheezes and crackles can both be heard with experience
Assessment of Artifical Airway
- Invasive
- Tube size
- Tube position
- ATG
- Off the carina
- Cuffed vs uncuffed
- Securing
- Tapes
ETT Size for <1000
Gestation Age <28
ETT 2.5
Suction 5/6
ETT Size for 1000-2000
Gestation Age 28-34
ETT 3.0
Suction 6 or 8
ETT Size for 2000-3000
Gestation Age 34-38
ETT 3.5
Suction 8
ETT Size for >3000
Gestation Age >38
ETT 3.5-4.0
Suction 8 or 10
Non-Invasive Ventilation
- NIV
- CPAP
- SiPAP
- Monitor: machines & pt
- Skin break down
- Changing from nasal mask to prongs
- Schedule
- Patient specific
- Nasal care & instillation
- Barrier creams/salves
- Changing from nasal mask to prongs
Bronchopulmonary Hygiene
- “Suctioning”; clearing airway of secretions
- In a spontaneous breathing patient
- Flexible catheter ~10F
- With 80-100mmHg
- Artificial Airway
- Flexible catheters for ETT size
- 80-100mmHg if open, 100-120 mmHg closed [AHS P&P2010])
- Rarely on a schedule
- Rarely after surfactant-Why not?
- Because it will suck out the surfactant
- Assess regularly via auscultation & vent wave forms [resistance] if intubated
Term (40 Weeks) ~24 Hours ABG
pH 7.35-7.45
PaCO2 35-45
PaO2 50-70
HCO3 18-22
SpO2 92-96%
28 Week-Term (40 Weeks) ABG
pH ≥ 7.25
PaCO2 45-55 (Permissive Hypercapnia)
PaO2 50-70
HCO3 18-20
SpO2 85-92%
< 28 Week Old ABG
pH ≥ 7.25
PaCO2 45-55 (Permissive Hypercapnia)
PaO2 45-65
HCO3 15-18
SpO2 85-92%
CBG Expected Values
pH 7.32-7.42
PaCO2 35-45
PaO2 30-40
HCO3 20-24
SpO2 85-88%
Quality Control
A systematic process used to monitor, document and regulate the accuracy and reliability of a procedure or a laboratory measurement
- Components of quality control are:
- Performance validation (testing new instrument)
- Preventative maintenance & function checks
- Automated calibration& verification
- Internal statistical quality control
- External quality control (proficiency testing)
- Remedial action (to correct errors)
- Record keeping (policies & procedures)
Non-Analytical Errors
- Pre:
- during sample draw [not removing air bubbles, venous admixture] handling or transport
- Wrong patient poked, or correct patient, but mislabeled sample [results to wrong chart]
- Status or therapy not recorded or assessed
- Post:
- Error in transcription phone report of critical values to someone not familiar with data, or a test run by someone who doesn’t know what the critical values are, so doesn’t report it
Analytical Error
Occurs during analysis, often equipment although improper mixing is the fault of the operator
Internal Quality Control
Scheduled analysis & recording of specific samples
Comparison between machines
Routine P&Ps to detect inconsistencies
An accreditation requirement
External Quality Control
- Labs compare results
- Sample sent to Calgary labs compared with labs elsewhere in province
- Independent agency
Supplemental Oxygenation
- Too much oxygen can be just as harmful in a newborn as too little oxygen, as free radial will form from hyperoxgenation leading to cell death in the brain and poor long term developmental outcomes
- Acceptable oxygenation saturation levels range from 87-95%
- When the neonate experiences a desaturation episode the following can be used to resolve the episode
- Observe the infant to see whether they self recover
- Stimulation
- Stable infants will oftn respond well to tactile stimulation
- Increase FiO2
- If you do need to increase FiO2 try to increase it in small 2-3% intervals
- Bag mask ventilation
- When we increase FiO2 it has been discovered that the cerebral oxygenation levels increased higher than what was needed and this could be harmful to the nwborn babies brain
- In adults there is a respiratory mechanicm that when cerebral oxygenation increase higher than what is needed there will be vasoconstriction, but this mechanism is not well developed in the newborn and will not occur leading to white matter damage
Chest X-Ray General
-
A/P View
- Heart appears larger
-
Inspiration
- Want to see 8 ribs
- The right side of the diaphram will be higher than the left and 60% of chest diameter
- Enlarged lung vessels
- Tracheal narrowing during E is normal
- Good film: chin neutral, centered
- Tubes and lines:
- ETT- halfway between the medial end of the clavicles and the carina (T2/T3/T4)
CHest X Ray-ETT with Flexion and Extension
When the neck is flexed the ETT will move down
When the neck is extended the ETT will move up
Position of the Carina
- The carina is situated higher than in adults
- neonate – level of third vertebrae
- 10 years of age – level of the fifth vertebrae
Chest X Ray Thymus Gland
- triangular shaped
- called the “sail sign” when identified on x-ray
- largest at about 2 years of age
- may be mistaken for
- heart border
- upper lobe atelectasis
Hyperaeration
Hyperaeration or hyperinflation is where the lung volume is abnormally increased, with increased filling of the alveoli. This results in an increased radiolucency on X-ray, a reduction in lung markings and depression of the diaphragm. … It causes one form of overexpansion of the lung.
Transient Tachypnea of the Newborn
Transient tachypnea of the newborn (TTN) is a parenchymal lung disorder characterized by pulmonary edema resulting from delayed resorption and clearance of fetal alveolar fluid .
Transient tachypnea of the newborn (TTN) CXR
- Common cause of respiratory distress in newborns
- Retention of fetal lung fluid
- Infiltrated in the hilar region
- Engorged veins and lymphatic vessels
- Hyperaeration
- Increased Raw due to fluid in the airway
- Clear 24-48 hours
Transient tachypnea of the newborn (TTN) Pulmonary Compliance
- The excess lung water in TTN results in decreased pulmonary compliance.
- Tachypnea develops to compensate for the increased work of breathing associated with reduced compliance.
- In addition, accumulation of fluid in the peribronchiolar lymphatics and interstitium promotes partial collapse of the bronchioles (increased resistance) with subsequent air trapping.
- Continued perfusion of poorly ventilated alveoli leads to hypoxemia, and alveolar edema reduces ventilation, sometimes resulting in hypercapnia.
Respiratory Distress Syndrome
- Most common lung disease in premature neonates
- To lessen the likelihood and/or severity of RDS, surfactant will be administered.
- Often an improvement in compliance post surfactant will be seen quite quickly with the infant requiring supportive measures (ventilation/oxygenation).
- What the baby ends up on is not just dependent on the administration of surfactant, as very premature babies will require respiratory support longer!
Respiratory Distress Syndrome CXR
- Reticulograndular “ground glass” appearance”
- Aerated alveoli are surrounded by areas of increased density
- Lack of aeration
- Causes a white out in the lung fields
- Increased opacification throughout the lung fields.
- Not likely to see pleural effusion as that would be more indicative of an infectious process
- Lungs will clear over a few days. Apices & periphery first, followed by more central and basal lung units.
Meconium Aspiration CXR
- In mild cases the CXR may seen normal
- In Severe cases you will see
- Bilateral infiltrates
- Air trapping
- Air leak syndrome
- Pulmoanry intersitial emphysema (PIE)
- Pneumomediastinum
- Pneumothorax
- Atelectasis
- Inflammation
- Chemical irritation from meconium
- Pleural effusion
Pneumonia CXR
Variable pattern difficult to distinguish
Diffused lung markings
Pleural fluid may be present
Looks like RDS
Pneumonia
Can occur just before, during, or after birth
Common source-Group B hemolytic streptococcus
Pneumothorax CXR
- The lung is displaced away from the chest wall by a dark band of air
- The dark air space will have no lung markings
- Border of the lung may be seen as a sharp white line
- Tension pneumothorax
- Depressed diaphragm on affected side
- Widening intercostal spaces
- Mediastinal shift to unaffected side
- Rapid deterioration of neonate
Congenital Diaphragmatic Hernia
- May occur in utero or at birth
- in utero will cause a hypoplastic lung
- usually ccurs on left side (80-85% of time)
- Stomach and bowel are present in the chest
- Mediastinal shift away from affected side
UAC
High UA - between thoracic vertebrae 6 and 8
Low UA - lumbar L3 and L4
Respiratory Pharmacology
- Inhaled meds
- Bronchodilators
- Steroids
- Systemic meds
- Dexamethasone
- Stimulants
- Caffeine
- Theophyline
- Specialty gases
- Nitric oxide
Transillumination
- The preferred diagnostic test for a pneumothorax would be a Chest X-Ray, but if there isn’t time you can use Transillumination of the chest to help with your diagnosis
- Place light source (otoscope, transilluminator) on infant’s chest. Ensure it isn’t hot.
- A normal chest will have a small glowing “Halo” around the light source. Usually it extends less than 1 cm from the light source and is symmetric.
- If the chest “lights up like a jack-o-lantern or ET’s chest” (large area of redness that is often asymmetric), then ptx should be HIGH on your DDx list..
- You should compare to the other side if you are unsure.
Respiratory Therapeutic Interventions
Chest Tubes
Emergent needling
Chest tubes
Heimlich valves
Respiratory Therapeutic Interventions
Vent Strategies
P & Ps/Algorithms
Normal targets
Lung protective
Persistent pulmonary hypertension newborn (PPHN)
Meconium aspiration syndrome (MAS)
Cyanotic heart defects (CHD)
Advanced Modes of ventilation [HFO, HFJV, ECMO-VV]
Weaning*
GI Assessment
- Weight (actual vs dosing)
- Abdominal girth/distension
- Necrotizing Enterocolitis
- NEC~10% of babies <1500 g
- More common in prems, but does occur in term infants
- 50% mortality rate in severe cases
- NEC~10% of babies <1500 g
- Necrotizing Enterocolitis
- Bowel sounds
- Not continuous
- Bowel movements
- Meconium
GI Monitors
-
BM frequency
- 99% of term infants within the first 24hrs
- 99% of preterm infants within the first 48hrs*
- *really premature infants are not fed because the colon is not developed
-
Weight trends
- ~10-15% of birth weight is lost during first week of life
- Weight gain begins in second week of life [~1-3% of body weight/day; Prems do not regain as quickly as term]
- FYI: Length ~0.75 cm/week term & almost 1 cm/week for preterm infants
GI Diagnostics
-
Residuals/Aspirates
- Gastric aspirates are performed before feeding to determine feeding tolerance and rate of digestion (avoid over or under feeding)
-
Calorimetry
- Resting Energy Expenditure (REE)
- Direct Measure: Heat produced and lost by the body. Requires specilized equitment and personale (expensive)
-
Indirect Measure: Measure O2 consumption and CO2 production
- Partial pressures inspired [control] vs exhaled [sample]
- Abdominal x-rays
GI Pharm and Interventions
-
Feeding
- Colostrum [antibodies and immunoglobulins]
- Breast
- Bottle [EBM & formulas]
- Tube [EBM & formulas]
- Total Parenteral Nutrition [TPN]
-
H2 blockers
- Decrease stomach acid production
- Ranitidine (Zantac®)
- Cimetidine (Tagament®)
- Decrease stomach acid production
-
Proton pump inhibitors (PPIs)
- Inactivates the pumps that produce stomach acid
- Pantoprazole (Pantaloc)
- 2012 FDA reviewing PPI use in <12 mos, as no benefit shown
- Inactivates the pumps that produce stomach acid
- Drains/colostomy
Colostrum
- Thick, yellowish milk
- Immunoglobulins
- Lipids
- Proteins
- Beta carotene
- Leukocytes
- 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
Renal Assessment
- Fluid balance
- 100% of all healthy infants (prems, terms & posts) void within 24 hrs
- Decreased urine output, no urine output or edema - “red flag”
- Diaper weight
Urine Output
- 1-3 mL/kg/hr in the newborn
- Normal newborn kidneys do not concentrate urine well
- Renal failure leads to volume overload, hyperkalemia, acidosis, hyperphosphatemia, and hypocalcemia
- ~25% of infants have some form of renal failure with 75% of those having pre-renal causes
- Prerenal causes are due to poor perfusion of the kidney:
- dehydration [poor feeding or environmental]
- perinatal asphyxia
- hypotensive states [septic shock, hemorrhagic shock, or cardiogenic shock secondary to congestive heart failure]
Urine Analysis
- Blood urea nitrogen [BUN]
- >15-20 mg/dL suggests dehydration
- Creatinine
- Levels drop from birth to < 0.6 mg/dL by 1 week of age
- Higher level suggest renal disease
Urine Cultures
Blood and Infections
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
Signs of abnormalities seen in 1st 24 hrs form Lab data
Sepsis
High or low RBC levels
RBC isoimmunization
Problems in glucose regulation
WBC are significantly higher in the neonate
Sepsis
Often diagnosed on clinical presentation and acted upon before lab results come back
Pale, mottled, floppy
Not feeding well
Irritable
Unresponsive (ominous)
Some Important lab values
- The presence of either of the below may occur with infection
- Leukopenia <3500/mm3
- Leukocytosis >25,000/mm3 … though not unusual in the “immediate” newborn period
- Compare immature granulocytes/total granulocytes [>0.2:1 implies infection]
- Low platelet levels <150,000/mm3 also implies infection or a clotting disorder
Lab Tests
Bilirubin
- Conjugated
- Unconjugated
Blood cultures/infection markers
Catheters and Lines
UVC [umbilical vein catheter]
PICC [peripherally inserted central catheter]
Peripheral IVs
Other Medications that can be given
Acetate
Tham
Bicarbonate
