Neonatology Flashcards
Name some causes of IUGR
- Fetal conditions that reduce growth potential (chromosomal abnormalities, chromosomal abnormalities, congenital malformations)
- Reduced fetal production of insulin and insulin like growth factor
- Placental conditions
- Maternal conditions (preeclampsia, drugs/etoh, malnutrition)
Define erythema toxicum
Benign splotchy pattern of erythema and pustules filled with eosinophils
- usu found on face, trunk, extremities
- common, benign, will resolve on own
- must be distinguished from staphylococcal rash or herpes rash
Define IUGR. Name 5 things these babies are at increased risk for
=intrauterine growth restriction
- babies do not follow the expected growth pattern
- these babies have poor reserves and increased metabolic demands
At risk for:
- Problematic transition
- Poor feeding
- Hypothermia
- Hypoglycemia
- Hypovolemia
What 3 questions should be asked at every birth to decide need for resuscitation?
- Born at term?
- Breathing or crying?
- Good tone?
- if yes to all 3 -> baby ok to stay with mom
- if no to any 1 -> start initial resuscitation?
You begin the initial resuscitation of a baby. What should you do first? How long shoud it take?
- Provide warmth (place baby on table under warmer)
- Position head to open airway, clear as needed
- Dry skin, stimulate to breath, reposition head
-all should take less than 30 secs. If baby is not breathing (apnea or gasping) or has HR < 100 need further resuscitation
What 2 questions should you ask to assess baby at end of 30 seconds of initial warm, dry and stim?
- Is baby breathing?
2. Is HR over 100?
What do you do with a baby who after initial warm, dry, and stim is not breathing (apnea or gasping) or has a HR < 100?
30 seconds of positive pressure ventilation
-at end need to assess if ventilation is adequate (HR rising,etc) or if baby needs further resuscitation
You just gave a baby 30 seconds of positive pressure ventilation. However HR is 55. What do you do next?
HR < 60 start chest compressions.
Usually want to incubate first so easier to coordinate breathing and ventilation
Once HR > 60, stop chest compressions but continue PPV until baby breathing and HR > 100
You are giving chest compressions to an intubated newborn but HR still < 60. What do you do?
Give epinephrine
UVC: 0.1 to 0.3 ml/kg of 1:10,000 epi
ET tube: 0.5 to 1 ml/kg
What is the most important action in neonatal resuscitation?
Ventilate the lungs
If a baby is not breathing in response to stimulation what should you do?
If baby is apneic after warm, dry, stim, assume secondary apnea and provide PPV
State the targeted preductal O2 sat after birth?
1min: 60-65% 2 min: 65-70% 3 min: 70-75% 4 min: 75-80% 5 min: 80-85% 10 min: 85-90%
The newborn baby is covered in meconium but is vigorous. What do you do next?
Clear mouth and nose of secretions
Dry stimulate and reposition
How do you determine if a newborn is vigorous?
- Strong respiratory efforts
- Good muscle tone
- HR > 100
The newborn baby is covered in meconium and is limp and not breathing. What do you do?
Suction mouth AND trachea
Insert ET tube into trachea
Attach mec aspirator
Suction for several seconds continue until tube is slowly withdrawn.
Which should you bulb suction first?
Mouth then nose (m before n)
How should you stimulate to help a baby breath?
Slapping or flicking soles of feet
Gently rubbing back or trunk
What’s the easiest way to determine the HR of a newborn?
Feel pulse at base of umbilical cord
The newborn is breathing but HR is < 100 on initial assessment. What do you do?
Administer positive pressure ventilation
How do you assess for cyanosis in a newborn?
Look at skin color of trunk, lips, tongue
Pulse ox should be used to confirm not dx presence of cyanosis
Where should the pulse ox be placed on a newborn?
Right wrist (bc you want preductal sat)
The newborn is breathing but respirations are labored with grunting and retractions. What should you do?
CPAP. ( requires flow inflating bag)
How do you determine APGAR scores?
- Heart rate (0:absent, 1: 100)
- Respiratory effort (0: absent, 1: slow irregular, 2: good, regular crying)
- Muscle tone (0: limp, 1: some flexion, 2:active motion)
- Response to stimulation (0: no response, 1: grimace, 2:cough cry)
- Color (0: blue or pale, 1:pink with acrocyanosis, 2:completely pink)
What size ET tube should be used in babies greater than 38 weeks? How far should the tube be placed?
ET tube size: 3.5
Depth of insertion:9-10 cm
Rule for insertion: 6+ wt in kg
Name 5 risk factors for sepis in a neonate
- PROM > 18 hours
- Maternal peripartum fever (>38.0)
- Maternal infection (chorio, UTI, GBS colonization)
- Prematurity-most impt risk factor for sepsis
- LBW
- Meconium stained amniotic fluid
What are the maternal risk factors for chorioamnionitis and influence the risk of infection/sepsis in the neonate?
- Maternal fever > 38.0. (>38.5 should have sepsis work up regardless of other risk factors)
- Sustained fetal tachycardia > 160 bpm
- Maternal tachycardia >110
- Uterine tenderness
- Purulent amniotic fluid
- Prolonged rupture of membranes >18 hours
- Foul smelling fluid
You are going to do a rule out sepsis on a newborn. What do you need to do?
- CBC
- Blood cx
- CRP at 48 hours
- Amp/gent (for 48 hours, if CRP elevated then 7 days)
- Observe for at least 48 hours, 7 days if CRP > 10 to continue amp/gent
What are the clinical signs of sepis/infection in a newborn?
- Temp instability (ESP low temps)
- Feeding intolerance/poor feeding
- Poor perfusion
- Cyanosis (look at gums, lips)
- Mottling
- Petechiae
- Tachypnea, respiratory distress, apnea
What are the most common causes of early neonatal sepsis?
- GBS
- E. Coli
- Enterococcus
- Listeria
Probably acquired from mom in the birth process
What signs are suspicious for a subgaleal bleed?
Lesion is boggy, ballotable (can be bounced back and forth), crosses suture lines
Monitor HR, serial head circumference exams
What is a differential dx for tachypnea in a newborn? What should you evaluate?
Ddx: TTN, pneumonia, pneumothorax, paralyzed diaphragm, infection/sepsis, overheating
Evaluate: sat, WOB, comfort, temperature
What are some guidelines for getting a serum bili after TCB?
- infant < 36 hours and TCB > 9
- infant > 36 hours and TCB > 11
Name 7 risk factors for jaundice
- Premature
- SGA
- LGA/IDM
- ABO setup
- Polycythemic
- Cephalohematoma or subgaleal bleed
- Asian
What are the reference ranges for neonatal vital signs?
Temp: 36.8-37.2
HR: 120-160
RR: 30-60
MAP: GA + 10
How do you calculate the glucose infusion rate?
=(% dextrose x rate (ml/hr) x 0.167)/ wt (kg)
GIR = mg/kg/min
Like to keep at 6-8 initially
Define hypoglycemia in newborn
= plasma glucose < 45
Symptoms: irritability, jitteriness, lethargy, hypothermia, poor feeding, seizures
What are some risk factors for hypoglycemia in a newborn?
- IDM/ LGA (high insulin levels)
- SGA/IUGR (poor reserves)
- Sick (sepsis, asphyxia, Polycythemic)
- Hormonal abnormalities
How do you manage hypoglycemia?
- Confirm with stat central serum level
- If 45x 3
- Goal GIR between 6-8
- If BS not above 45, repeat bolus and increase glucose infusion rate
Define ABO incompatibility
MOC type O blood, infant is type A or B
Maternal antibodies can cross placenta and attack fetal cells
Risk of:
Hyperbilirubinemia
Hemolytic anemia
What are some good markers of hydration status in a newborn?
- Weight
- Urine output
- HCT
- Na levels (first few DOL esp in micropremies)
How do you assess for feeding intolerance?
- Gastric aspirate ( > 1/2 the feed or 3-5 ml/kg or any bilious aspirate)
- Abdominal circumference
- Heme occult stools
- Loops of bowel on PE
Define hyperglycemia. What is it caused by.
Term: >125, preterm: >150
Causes
- Too much in IV fluids
- Inability to mobilize glucose (sepsis, stress, severe encephalopathy)
- Meds (steroids, caffeine)
- Extreme prematurity
What is the goal MAP in infants < 30 weeks GA?
MAP should be at least the same number as the GA
The nurse calls you for a newborn that has a RR of 72. What is your work up?
- PE (O2 sat, signs of resp distress- retractions, nasal flaring, grunting, murmurs, cyanosis)
- If no respiratory distress consider pre and postductal O2 sats
- Consider CXR, ABG
- If in distress or hypoxemic, try giving supplemental O2 and see what response is
What are some things on the differential for respiratory distress?
Respiratory distress= tachypnea, nasal flaring, retractions, grunting)
- TTN
- PPHN
- Hyaline membrane disease, resp distress syndrome
- Meconium aspiration syndrome
- Air leak syndromes (pneumothorax, etc)
What are the characteristic CXR findings for TTN?
- Prominent perihilar streakiness
- Fluid in the fissure
Ddx: pneumonia, mec aspiration
Define bradycardia in newborn
HR < 100s
Define periodic breathing
3-10 sec period of respiratory pauses without associated bradycardia, cyanosis
Define chronic lung disease/BPD
= O2 requirement at 36 weeks post conceptional age
Causes:
Maldevelopment of immature lungs, ventilator related injury, oxygen toxicity, infection, inflammation, pulmonary edema, PDA
What is the classic CXR findings in chronic lung disease/BPD?
Diffuse haziness
What is the requirement to pass a room air challenge?
Keeping O2 sats > 80% for more than 40 mins
What is your goal PCO2 on the vent? What are some ways to adjust this with vent settings?
Goal PCO2: 45-55
If increase rate, tidal volume or the PiP you can decrease the PCO2
What is PEEP and what is its purpose?
PEEP= positive end expiratory pressure
Airway pressure maintained continuously between breaths to prevent atelectasis
Usually between 4-6
What measurement can you use to calculate the depth/length of insertion of UVC?
Measure the length of xiphoid to umbilicus and add 0.5-1 cm for umbilical stump
You know it’s in the right place when UVC at T8-T9 and tip at jxn IVC/RA, 1cm above diaphragm
Which types of FHR tracings are concerning?
- Absence of baseline variability
- Recurrent variable decels
- Bradycardia (baseline FHR < 110 bpm)
These are predictive of neonatal acidemia
Define a vigorous newborn in delivery room
Good cry and good respiratory effort
Good tone
HR>100
What size ET tube should be used in neonatal resuscitatin?
- <28 weeks
- 0 1000-2000g 28-34 weeks
- 2000-3000g 34-38 weeks
How do you confirm ET tube placement?
- Bilateral breath sounds
- Symmetric chest rise
- Color change on CO2 capnography
- Improving HR with PPV
A baby has a initial POCT glucose of 30 and is not feeding well. What do you do?
For BG <40 AND symptomatic
- Stat serun level
- IV D10 2 ml/kg bolus
- Place PIV and start D10 drip with initial GIR goal 6-8
- Repeat BG in 30 min
While a baby is on a D10 infusion for hypoglycemia. How often should glucoses be followed? When do you wean?
- Follow BG Q1-2 hours until >45 x 3, then space to Q3 hours
- Wean by 1 ml/hr D10 for every BG >60, 2 ml/hr for BG > 80
Why is CPAP helpful in preterm babies that are vigorous after birth and didn’t require intubation
Helps maintain lung volume and prevent de-recruitment
What should be considered pathologic A&Bs
- apnea in a term infant
- A&Bs in first 24 hours of life
- sudden onset of severe A&Bs
What’s on the DDX for A&Bs
- sepsis
- anemia
- hypoxemia
- IVH or stroke
- NEC
- Apnea of prematurity (dx of exclusion)
- Metabolic disturbances (hypoglycemia)
- drug withdrawl
- GERD (rarely)
What should you do to evaluate for A&Bs
- What are the vitals
- What do the events look like
- Is the baby acting sick?
- Are these related to feeds
- Are they positional or ET tube related?
When should you start caffeine for A&Bs?
- Prophylaxis in 10 A&Bs in 24 hrs
3. A&Bs requiring intervention
What are the side effects of caffeine?
- Long half life
- decreased LES tone -> reflux
- increased metabolic rate
When should caffeine be stopped?
- Usually at 34-35 weeks PCA
2. Once no events for 5-7 days or all are self-resolving
What are the general NICU discharge criteria?
- Nippling full volume feeds
- Maintain temp in open crib
- Gaining weight appropriately
- Meds discontinued (ie off caffeine 5-7 days)
- No acute illness
- Passed RA challenge
- SW issues resolved
What are the weight goals for newborns?
Preterm: 15-20 gm/kg/day
Term: 20-30 gm/day
When should an infant be started on iron?
At 14 days of age if on full feeds
When should you start checking a retic on a preterm infant?
At 4 weeks of age
Who needs an early HUS?
Any infant < 29 weeks GA at 7-10 days
Who needs a late HUS?
<33 weeks at 4-6 weeks of age
When do you start screening for ROP?
- If < 30 wk GA at birth or < 1500 g –at 4 weeks of age
Define BPD or chronic lung disease
=oxygen requirement at 36 weeks post menstrual age (PMA)
Define HIE
- Evidence of significant birth depression
- metabolic acidemia (pH 16) on cord or arterial gas from first hour of life
- low Apags (<5 at 10 minutes of life)
- continued resuscitation at 10 min of life - Evidence of encephalopathy (sz, lethargy, hypotonia, coma, irritability)
- Multi-organ dysfunction
When should you be concerned about reflux?
- Persistent regurgitation
- Poor weight gain
- aspiration
What can you do for reflux
- Upright position after feeds
- Thickened feeds
- Reglan
- Acid blockers
- Surgery (Nissen fundoplication)
What are the symptoms and signs of a PDA?
- murmur
- tachycardia
- Widened pulse pressure or low diastolic BPs (< 26)
- Calf or palmar pulses
- hyperactive precordium
- hepatomegaly
- CXR with increased heart size, pulm vascular engorgement, pulm edema
What are the clinical sx and signs for NEC?
- Abdominal distension, tenderness, or discoloration
- emesis
- Increased gastric residuals (can be bilious)
- Heme positive stools
- temp instability
- Increased A&Bs
- Decreased UOP
- Poor perfusion
- Hypotension
What should be your work-up for an infant with clinical concern for NEC?
- AXR
- CBC and CRP
- Make NPO
- Heme occult stool
- Consider need for blood cx, urine cx, LP
- Consider need for electrolytes
How do you manage NEC?
- Initial NPO/bowel rest
- Decide if need IVF boluses (follow UOP and BP)
- OG decompression
- Start TPN
- Blood cx and urine cx, consider LP
- Amp/Gent (usu can stop after BC neg x 48 hrs)
- Serial abdominal exams & AC
- Serial AXR (Q6-8 hours)
What can you use to estimate PTX level in a preterm (< 35 weeks GA infant?
- Take birthweight and divide by 2. That is your lightable level
