Neonates

Question 1

Describe the appropriate setting for a T piece device in neonatal resuscitation

Answer 1

PIP 30 cm H20
PIP 20 - 25 cm if <32 weeks
PEEP 5-8 cm H20

Question 2

Describe the rules for calculating ETT size and depth

Answer 2

Rough guide to size = gestation divided by 10
Depth at lips = weight + 5.5 - 6

Question 3

Describe the appropriate dosing of adrenaline during neonatal resuscitation

Answer 3

Intravenous: 0.1 - 0.3 mls/kg of 1/10,000 adrenaline
= 10 - 30 mcg / kg
If via ETT 0.5 - 1 ml /kg of 1/10,000
= 50 - 100 mcg/kg

Question 4

What is the formula for calculating tidal volume in a newborn infant?

Answer 4

4-6 ml/kg in a newborn

Question 5

In what scenarios might a pedicap remain yellow in both inspiration and expiration?

Answer 5

Contamination with adrenaline
Contamination with gastric juices
Contamination with surfactant
Exposure to high humidity

Question 6

An ex 27/40 infant at day 9 of life develops fresh blood PR, abdominal distension and bilious aspirates associated with temperature instability.

You suspect NEC

Using Bell Grading, what rating would you ascribe

Answer 6

Answer = 1B
See table attached

Essentially - suspected, proven, advanced
Fresh blood PR gets you from 1A to 1B
Pneumatosis/other radiological signs gets you to II
Ascites/mass/abdominal cellulitis gets you to 2B
Hypotension/bradycardia gets you to 3
Pneumoperitoneum gets you to 3B

Question 7

Which of the following factors is NOT associated with NEC?

a. absent or reversed end-diastolic flow on antenatal ultrasound
b. early introduction of enteral feeds
c. PDA
d. intestinal dysbiosis
e. assisted ventilation

Answer 7

Answer = B. Early introduction of enteral feeds not associated with NEC in trial discussed in Auckland Neonatal lecture 1

Question 8

Which of the following is a risk factor for short gut syndrome in neonates with surgically managed intestinal conditions?

a. pre-term at time of surgery
b. NEC as cause
c. Low plasma citrulline level
d. retained ileocaecal valve

Answer 8

answer = C (low plasma citrulline) - linear association with bowel retained
NEC protective vs congenital (likely to have had normal bowel at birth vs congenital)
Pre term protective - more growth potential
IC valve good - slows transit time

SB 258 cm +/- 40 cm at term

Question 9

What factor provides the greatest impetus for closure of the PDA

a. systemic O2 saturations
b. decreased prostaglandin
c. increased pulmonary blood flow
d. sympathetic stimulation

Answer 9

A = O2 saturations is correct

Question 10

Which of the following conditions does pre term administration of caffeine NOT protect against?

a. CLD
b. cerebral palsy
c. retinopathy of prematurity
d. NEC

Answer 10

Answer = D

Doesn’t protect against NEC

See image re CAP trial

Question 11

What is the most serious potential complication of oligohydramnios?

Answer 11

Pulmonary hypoplasia

Question 12

In a intubated and ventilated baby, what 2 factors will determine oxygenation?

Answer 12

Mean airway pressure and FiO2

Question 13

What are the 3 modifications it is possible to make to a ventilator to increase mean airway pressure?

Answer 13

1. Increase PEEP (higher baseline)
2. Increase PIP (higher peak)
3. Increase Ti (increased proportion spent at peak)

Rate does not increase total AUC

Question 14

What physiological factor determines CO2 clearance?

Answer 14

Minute ventilation
ie: tidal volume

Question 15

When using high frequency oscillatory ventilation, what setting will most influence ventilation (and therefore CO2)

Answer 15

Amplitude
AKA delta P or difference between PIP and PEEP
This is the equivalent of tidal volume and determines ventilation and is the setting you would alter if CO2 is too high or low

Question 16

When using high frequency oscillatory ventilation, what setting will most influence oxygenation?

Answer 16

Mean airway pressure (MAP)
Aim 7-9 ribs expanded
If less V/Q mismatch
If more volutrauma/decreased venous return

Question 17

What type of ventilation is described below?

When used alone provides only mandatory breaths (ie: spontaneous breaths above the set rate are not supported)

Answer 17

SIMV

Question 18

What type of ventilation is described below?

Mandatory breaths at a set rate (control breaths)
Supports spontaneous breaths above the set rate (assist breaths)
Breath limitation (ie: support) is the same regardless of whether it is a assist or control breath

Answer 18

PC-AC / SIPPV

Question 19

What is the ANZCOR recommendation regarding delayed cord clamping for infant born at less than 34 weeks?

Answer 19

From the ANZCOR guideline:

For infants born at less than 34 weeks’ gestational age who do not require immediate
resuscitation after birth, ANZCOR suggests deferring clamping the cord for at least 30 seconds.
42 [Weak recommendation, low certainty of evidence]

Question 20

What is the ANZCOR recommendation for delayed cord clamping in neonates born at 34 weeks gestation or later?

Answer 20

For term and late preterm infants born at ≥34 weeks’ gestation who are vigorous or deemed
not to require immediate resuscitation at birth, ANZCOR suggests later (delayed or deferred)
clamping of the cord at ≥ 60 seconds. 41 [Weak recommendation, very low certainty of evidence]

Question 21

Which of the following summaries regarding HFOV vs conventional ventilation are correct?

a. HFOV is associated with decreased air leak, but increased CLD
b. HFOV is associated with decreased CLD, but increased air leak
c. HFOV is associated in a reduction of both air leak and CLD
d. CMV is associated with a reduction in both air leak and CLD

Answer 21

Correct answer is B

Answer is very general
Cochrane review suggested that there may be decreased CLD, but that evidence across studies is inconsistent
Possibly offset by an increase in air leak

Question 22

Which of the following is NOT a potential adverse effect of iNO?

a. hypotension
b. methemoglobinaemia
c. impaired platelet function
d. airway irritation

Answer 22

A - hypotension should not occur

Question 23

What form of cerebral palsy is periventricular leukomalacia most commonly associated with?

Answer 23

Spastic diplegia

Question 24

What grade is this IVH?

Answer 24

1 - haemorrhage confined to the germinal matrix/subependymal area

Question 25

What grade IVH is shown?

Answer 25

2 - extension into the ventricle, does not cover >50% of the ventricle + is not associated with ventricular dilation

Grade 2 intraventricular hemorrhage (IVH). Head US examination in a 7-day-old boy born at 28 weeks of gestation. a US in the coronal plane shows echogenic clot within the right frontal horn (arrowhead). There is no prominent dilation of the ventricle. b US in the left parasagittal plane shows clot (arrowhead) in the dependent portion of the atrium of a not prominently dilated lateral ventricle

Question 26

what grade IVH is shown?

Answer 26

Left sided IVH with marked ventricular dilation = grade 3

Question 27

what grade IVH is shown?

Answer 27

Severe intraventricular hemorrhage (IVH). Coronal ultrasounds at postnatal age (a) 1 d and (b) 4 d from a 28-wk gestation neonate with IVH. In a, blood is seen in the germinal matrix and filling the right lateral ventricle; at postnatal d 4, the ventricular system is dilated, and blood is seen both filling and distending the right lateral ventricle as well as in the parenchyma of the right hemisphere, consistent with grade 4 IVH.

Question 28

What temperature range should be targeted in therapeutic cooling?

Answer 28

33-34 C