NICU Flashcards
Prenatal Screening
Umbilical Cord Management
Relative Contraindications: risk factors for significant hyperbili (polycythemia, severe IUGR, pre-gestational DM), maternal antibody titres high - clamp immediately in term, 30s in preterm
Iron supplementation in prem
- BF = 2-3mg/kg/day for first year
- Formula = high Fe formula
Risks and Benefits of DCC
- decreased IVH, NEC, blood transfusions and inotropes
- higher MAP
- higher hematocrit, higher bilirubin and polycythemia
Discharge Requirements for Preterm Infants
-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
Types of nerve injury in NBPP
- 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
Classification of NBPP
Risk factors for NBPP
- shoulder dystocia (strongest modifiable RF)
- pre-existing diabetes
- forceps/vacuum
- episiotomy
- fetal/birth asphyxia
- macrosomia
- LGA
When should you refer NBPP?
- if no signs of recovery by 1 month of age
Steroids to treat or prevent BPD
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
Imaging guidelines for preterm neonatal brain
Grading of Neonatal Brain Bleeds
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)
Risk Factors for IVH
- 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)
Definition of hypoglycemia
- < 2.6 in first 72 hours
- < 3.3 after 72 hours
Infants at risk of hypoglycemia
Management of Hypoglycemia
GIR
IV fluid rate x Dextrose concentration / 144
Neuro-protection Measures
- 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)
Discharge of Term Infant
Who should get therapeutic hypothermia?
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
Criteria for encephalopathy in HIE
Contraindications to cooling
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)
Side effects of cooling
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
When do you image in HIE?
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
What is the prognosis of HIE?
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
Indications to stop cooling in HIE
- uncontrolled bleeding
- uncontrolled PPHTN
- 72 hours! (re-cool x24 hours if seizure during re-warming)
Survival rates for extremely preterm birth
< 22 weeks = palliated
< 23 weeks ~20%
< 24 weeks ~ 40%
< 25 weeks ~ 60%
< 26 weeks ~ 80% (must resuscitate)
*GA is the strongest impact on prognosis
Kangaroo Care benefits
- 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
RBC Transfusion Thresholds in Neonates
Definitions of Hyperbili
- 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
RF on Bili nomogram
- preterm
- DAT +ve
- G6PD
- asphyxia
- sepsis
- acidosis
- resp distress
- temp instability
Bili thersholds
- birth - 60/90/120
- 24 hrs - 140/170/200
- 48 hrs - 200/230/260
- 72 hrs - 240/270/300
- 5 days - 250/300/350
Threshold for exchange transfusion
0: 200/240/280
24: 250/290/330
48: 290/330/370
72: 310/360/410
5d: 320/370/420
Effects of in utero exposure to opioids
- prematurity
- LBW
- increased risk of spontaneous abortion
- SIDS
- infant neurobehavioural symptoms
NAS Symptoms
Needs 8x3 or 12x2
Management of NAS
- 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
How do you fail a newborn CCHD screen?
- saturation < 90% in right hand or foot
- borderline (90-94% or > 3% difference between hand and foot) x3
- > 95% in both is a pass!
Retinopathy of Prematurity Screening
< 31 weeks or < 1250g
Screen at 4 weeks of age or 31 weeks CGA - whichever is later!
Classification of ROP
Treatment of ROP
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
Follow-up of ROP
Biophysical Profile
Fetal Heart Rate Monitoring
Impact of Maternal Cigarette Smoking
- Growth restriction
- preterm labour/delivery
- pROM
- placental abruption
- SIDS
Prenatal Exposures
Phenobarb = CLP, cardiac anomalies, hemorrhagic disease of newborn
Impact of Maternal Conditions on fetus
PDA Treatment
APGARS
Spinal Dimple Imaging
Giant congenital nevi on spine or head?
MRI due to risk of leptomeningeal melanocytosis
