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RC Review > NICU > Flashcards

NICU Flashcards

1
Q

Prenatal Screening

A
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2
Q

Umbilical Cord Management

A

Relative Contraindications: risk factors for significant hyperbili (polycythemia, severe IUGR, pre-gestational DM), maternal antibody titres high - clamp immediately in term, 30s in preterm

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3
Q

Iron supplementation in prem

A
  • BF = 2-3mg/kg/day for first year
  • Formula = high Fe formula
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4
Q

Risks and Benefits of DCC

A
  • decreased IVH, NEC, blood transfusions and inotropes
  • higher MAP
  • higher hematocrit, higher bilirubin and polycythemia
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5
Q

Discharge Requirements for Preterm Infants

A

-Thermoregulation
- breathing control (off caffeine for 5-7 days without apnea)
- no respiratory support (unless home O2, target 90-95%)
- feeding well
- discharge weight fits in a car seat
- euglycemia
- stable weight and bili
- follow-up bili in 24-48 hours (late prem)
- follow-up within 72 hours

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6
Q

Types of nerve injury in NBPP

A
  • neuropraxia = interruption of myelin sheath causing temporary conduction block, full recovery within weeks
  • axonotmesis = disruption of nerve fibres with some function return over months, but incomplete recovery
  • neurotmesis = nerve disruption and avulsion of nerve roots from spinal cord, no chance of recovery
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7
Q

Classification of NBPP

A
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8
Q

Risk factors for NBPP

A
  • shoulder dystocia (strongest modifiable RF)
  • pre-existing diabetes
  • forceps/vacuum
  • episiotomy
  • fetal/birth asphyxia
  • macrosomia
  • LGA
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9
Q

When should you refer NBPP?

A
  • if no signs of recovery by 1 month of age
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10
Q

Steroids to treat or prevent BPD

A

1st week of life - low dose hydrocortisone 1mg/kg/day x 7 days, 0.5mg/kg/day x 3 days) for those at highest risk
- no dex in 1st week of life

After 1st week of life - low dose dex 0.15mg/kg/day to 0.2mg/kg/day tapered) can be considered for those ventilated with increasing O2 needs and worsening lung disease
- no HC after 1st week of life

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11
Q

Imaging guidelines for preterm neonatal brain

A
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12
Q

Grading of Neonatal Brain Bleeds

A

Grade 1: IVH limited to germinal matrix (mild)
Grade 2: IVH involved blood in the ventricles (mild)
Grade 3: IVH has blood filling and distending ventricular system (severe)
Grade 4: parenchyma involvement with hemorrhage (severe)

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13
Q

Risk Factors for IVH

A
  • prematurity
  • LBW < 1000g
  • lack of prenatal steroids
  • birth outside tertiary care centre
  • chorio

RF for late and mod preterm:
- lower GA
- HC < 3rd %ile
- resuscitation at birth/difficult birth course (inotrope, ventilation 1st 24 hour post birth, complicated mono twin pregnancy, postnatal complications)

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14
Q

Definition of hypoglycemia

A
  • < 2.6 in first 72 hours
  • < 3.3 after 72 hours
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15
Q

Infants at risk of hypoglycemia

A
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16
Q

Management of Hypoglycemia

A
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17
Q

GIR

A

IV fluid rate x Dextrose concentration / 144

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18
Q

Neuro-protection Measures

A
  • chorio/PPROM - empiric antibiotics pending negative blood culture in baby
  • Antenatal steroids < 35 if at risk of delivery in next 7 days
  • MgSO4 if < 34 weeks and at risk of delivery in next 24 hours
  • DCC
  • plastic wrap
  • avoid inotropes unless delayed CR, decreased u/o or poor cardiac output
  • prophylactic PDA treatment only for high-risk, extreme prems
  • PCO2 45-55mmHg, volume ventilation for first 72 hours
  • neutral midline, HOB 30 degrees
  • deliver at tertiary care centre
  • nurturing environment (skin to skin, maternal voice, low noise, light cycling)
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19
Q

Discharge of Term Infant

A
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20
Q

Who should get therapeutic hypothermia?

A

Therapeutic hypothermia is effective in acute perinatal insults (e.g., placental abruption, cord prolapse), rather than for antenatal or chronic insults.
○ Term and late preterm infants ≥36 weeks GA with HIE who are ≤6 hours old and who meet either treatment criteria A or treatment criteria B, and also meet criteria C:
A. Cord pH ≤7.0 or base deficit ≥−16, OR
B. pH 7.01 to 7.15 or base deficit −10 to −15.9 on cord gas or
blood gas within 1 h AND
1. History of acute perinatal event (such as but not limited to cord prolapse, placental abruption or uterine rupture) AND
2. Apgar score ≤5 at 10 minutes or at least 10 minutes of
positive-pressure ventilation
C. Evidence of moderate-to-severe encephalopathy, demonstrated by the presence of seizures OR at least one sign in three or more of the six categories.

*aEEG for at least 20 minutes may be helpful (esp. for moderate). Can do 48 hours post birth for seizures/mild HIE. A normal aEEG does not predict a normal MRI or favorable acute outcome

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21
Q

Criteria for encephalopathy in HIE

A
22
Q

Contraindications to cooling

A

Who should not be cooled?
○ Major genetic/congenital anomalies with no further treatment planned
○ Severe IUGR
○ Clinically significant coagulopathy
○ Severe head trauma or intracranial bleeding (isolated IVH not an absolute contraindication)
○ Preterm infants < 35 weeks
○ Age > 6 hours (not an absolute contraindication, discussion risk vs. benefit needed)

23
Q

Side effects of cooling

A

What are the side effects?
○ Bradycardia
○ Hypotension
○ Mild thrombocytopenia
○ Persistent pulmonary hypertension with impaired oxygenation
○ Arrhythmias
○ Anemia
○ Leukopenia
○ Hypoglycemia
○ Hypokalemia
○ Urinary retention
○ Coagulopathy
○ Subcutaneous fat necrosis +/- hypercalcemia
Indications to stop treatment:
○ Hypotension despite inotropic support
○ Persistent pulmonary hypertension with hypoxemia despite treatment
○ Clinically significant coagulopathy despite treatment

24
Q

When do you image in HIE?

A

When should we image?
○ MRI preferred!
○ Ideally between days 2-4 (identifies lesions on DWI that are on T1/T2 at 10 days)
○ Essentially: get an MRI on day 4-5 after rewarming is done (hard to do when cool)
○ Repeat MRI at 10-14 days if imaging does not match clinical status or diagnosis unclear

25
Q

What is the prognosis of HIE?

A

What about follow-up?
○ Prognosis:
○ Cerebral palsy/severe disability: 30% of all (most common in severe)
○ Severe visual impairment or blindness: 25% of moderate to severe
§ Especially with hypoglycemia
○ SNHL: 18% of moderate without CP
○ Cognitive deficits: 30-50% of moderate
○ Behavioural difficulties should be considered
○ Childhood epilepsy: 13% of moderate to severe
○ Follow-up:
○ 18-24 months is standard of care
○ Should be followed closely through infancy and childhood
Multi-disciplinary recommend

26
Q

Indications to stop cooling in HIE

A
  • uncontrolled bleeding
  • uncontrolled PPHTN
  • 72 hours! (re-cool x24 hours if seizure during re-warming)
27
Q

Survival rates for extremely preterm birth

A

< 22 weeks = palliated
< 23 weeks ~20%
< 24 weeks ~ 40%
< 25 weeks ~ 60%
< 26 weeks ~ 80% (must resuscitate)

*GA is the strongest impact on prognosis

28
Q

Kangaroo Care benefits

A
  • reduce mortality, severe illness, infection, LOS in LBW (and attachment, stabilty, sleep, fussiness)

Delay if: < 27 weeks with high humidity needs, abdo wall/ NTD awaiting surgery, immediately post-op, HD unstable, prolonged recovery with handling

29
Q

RBC Transfusion Thresholds in Neonates

A
30
Q

Definitions of Hyperbili

A
  • severe hyperbili > 340
  • critical hyperbili > 425
  • acute bili encephalopathy: severe hyperbili, lethargy, hypotonia, poor suck, leading to seizure and coma
  • chronic bili encephalopathy: athetoid CP +/- sz, dev delay, hearing deficit, oculomotor disturbances, dental dysplasia
  • kernicterus: deep yellow staining of neurons and neuronal necrosis or basal ganglia na dbrainstem nuceli
31
Q

RF on Bili nomogram

A
  • preterm
  • DAT +ve
  • G6PD
  • asphyxia
  • sepsis
  • acidosis
  • resp distress
  • temp instability
32
Q

Bili thersholds

A
  • birth - 60/90/120
  • 24 hrs - 140/170/200
  • 48 hrs - 200/230/260
  • 72 hrs - 240/270/300
  • 5 days - 250/300/350
33
Q

Threshold for exchange transfusion

A

0: 200/240/280
24: 250/290/330
48: 290/330/370
72: 310/360/410
5d: 320/370/420

34
Q

Effects of in utero exposure to opioids

A
  • prematurity
  • LBW
  • increased risk of spontaneous abortion
  • SIDS
  • infant neurobehavioural symptoms
35
Q

NAS Symptoms

A

Needs 8x3 or 12x2

36
Q

Management of NAS

A
  • Morphine 0.32mg/kg/day div q4-6hr
  • methadone 0.05-0.1mg/kg/dose q6-12
  • phenobarb load 10mg/kg q12 x3, then 5mg/kg/day
  • clonidine 0.5mcg/kg q4-6 hours

Wean when scores < 8

Observe for 72-120 hours and d/c if no symptoms

37
Q

How do you fail a newborn CCHD screen?

A
  • saturation < 90% in right hand or foot
  • borderline (90-94% or > 3% difference between hand and foot) x3
  • > 95% in both is a pass!
38
Q

Retinopathy of Prematurity Screening

A

< 31 weeks or < 1250g
Screen at 4 weeks of age or 31 weeks CGA - whichever is later!

39
Q

Classification of ROP

A
40
Q

Treatment of ROP

A

Treatment for Retinopathy of Prematurity
Zone I – any stage ROP with plus disease
Zone I – stage 3 ROP without plus disease
Zone II – stage 2 or 3 ROP with plus disease
OR
threshold ROP: at least 5 continguous or 8 cumulative clock hours of stage 3 ROP in zone I and II with plus disease

41
Q

Follow-up of ROP

A
42
Q

Biophysical Profile

A
43
Q

Fetal Heart Rate Monitoring

A
44
Q

Impact of Maternal Cigarette Smoking

A
  • Growth restriction
  • preterm labour/delivery
  • pROM
  • placental abruption
  • SIDS
45
Q

Prenatal Exposures

A

Phenobarb = CLP, cardiac anomalies, hemorrhagic disease of newborn

46
Q

Impact of Maternal Conditions on fetus

A
47
Q

PDA Treatment

A
48
Q

APGARS

A
49
Q

Spinal Dimple Imaging

A
50
Q

Giant congenital nevi on spine or head?

A

MRI due to risk of leptomeningeal melanocytosis

RC Review (26 decks)

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