NICU Flashcards
What is an IT ratio
Immature to total neutrophil ratio
Ratio >= 0.2 is positive for sepsis
Early onset sepsis definition and risk factors
Neonatal sepsis in first 7 days of life
-maternal gbs status inadequately treated with antibiotics (history infant with severe gbs infection, gbs bacteriuria during pregnancy)
- chorioamnionitis
- ROM >18 hr
- preterm
-
Most common presenting sign/symptom of neonatal early onset sepsis
Respiratory distress
Most common organisms for early onset sepsis
- GBS (36%)
- E. coli (25%)
- viridans Strep (19%)
- listeria
Empiric antibiotics for early onset sepsis
Amp
Gent
NAS CPS Pearls
Treat if >/= 12 x 2 or >/= 8 x 3
first line: non pharm
first Rx: morphine or methadone
methadone typically onset of symptpoms later
moms who are HIV negative on buprenorphine or methadone should breast feed
NAS scoring duration
minimum 72 hr observation
(up to 120 hr if baby is exposed to long acting such as methadone)
scoring q3-4hr
for discharge, scores must be consistently <8 with stable treatment plan
what is the leading cause of neonatal brain injury, morbidity and mortality worldwide?
HIE
20-30% die
30-50% will have permanent neurodevelopmental sequelae
more significant morbidity if acidosis <6.7 or base deficit >25
best imaging in HIE
MRI done at 3-5 days of life
- loss of gray white differentiation
basal ganglia/thalamus is severe
US has little utilitiy for HIE unless trying to exclude hemorrhage but can be used to evaluate a preterm infant
therapeutic hypothermia
cool to 33.5 degrees within first 6 hours of life maintained for 72 hours
> /= 36 weeks (consider if 35-35+6)
whole body cooling preferred
adjuncts:
- low dose morphine infusion <10mcg/kg/h
- trophic feeds
- eppoietin (not recommended in CPS, mentioned in nelsons_
- phenobarb if seizures (target level 20-40)
complications
- coagulopathy
- subcutaneous fat necrosis +/- hypercalcemia
bradycardia and arrhythmia
brain death criteria after HIE
- coma unresponsive to pain/auditory/visual stim
- apnea with CO2 rising from 40 to >60 without ventilatory support
- absent brainstem reflexes (pupil, oculocephalic, oculovestibular, corneal, gag, suck)
*no universal agreement for clear definition or when to withrawal life support
criteria for therapeutic hypothermia
age >/= 36 weeks who are </= 6 hours old and meet crtiera A or B and C
A: cord pH </= 7 or base deficit >/= -16
B: pH 7.01-7.15 or base deficit -10 to -15 (cord or blood within 1 hr) AND history of perinatal event or apgar <5 at ten minutes or 10 mins PPV
C: evidence moderate to severe encephalopathy with presence of seizures OR at least one sign in three or more of the 6 categories (LOC, spontaneous activity, posture, tone, reflxes, autonomic)
indications to stop cooling
-hypotension despite inotropic support
- persistent pulmonary hypertension with hypoxemia, despite adequate treatment
- clinically significant coagulopathy, despite treatment.
SSRI counselling during pregnancy and breastfeeding
continue use - bad depression/anxiety is worse
risk of congenital malformations or PPHN is low
no clear increased risk of ADHD or ASD
encourage breast feeding
no specific monitoring required
Risk of PNAS - poor neonatal adaptation syndrome
- mild symptoms
- responds to supportive care measures
- resolves within days to 2 weeks
Blood transfusion hemoglobin cut offs for infants with anemia of prematurity
Hemoglobin (hematocrit)
Post natal Week 1
- respiratory support: 115 (35)
- no resp support: 100 (30)
Postnatal week 2
- respiratory support 100: (30)
- no resp support: 85 (25)
Postnatal week 3 and older
- respiratory support: 85 (25)
- no resp support: 75 (23)
*start at 115 (35)
* the no respiratory support is the same as the previous week with resp support
*the next step down is - 15 (-5) except for the last step down which is -10 (-2)
CPS ROP screening indications
≤ 30+6 weeks (regardless of weight)
≤ 1250 g
More mature infants thought to be at high risk for ROP
Start at 31 weeks OR at 4 weeks postnatal age, whichever is later
Maternal gonorrhea
mom should be treated with IM ceftriaxone or oral cefixime
Chlamydia: If baby is born and asymptomatic, don’t do anything and watch/wait.
Gonorrhea: treat empirically even if baby is asymptomatic
treatment for NAIT
HPA1a platelets preferred if bleeding or plt <30 (or <50 if unwell or sibling with NAIT)
- consider IVIG if giving unmatched or normal plt
HUS if plt <50
NAIT is similar to Rh incompatibility - can it occur in first pregnancy or only subsequent?
can occur in first whereas RH incompatibility only occurs in subsequent
xray findings in NEC
pneumoatosis (confirms diagnosis)
portal vein gas
pneumoperiotenum
sentinel loops (large bowel loops)
Bell staging criteria for NEC
Stage 1 = suspected NEC (sentinel loop)
*make NPO and start TPN, may not need to do abx immediately
Stage 2 = confirmed with radiographic findings (pneumatosis)
Stage 3 = shock, perforation, bleeding
A 3-day old term infant presents with irritability and poor feeding. The infant’s HR is 200, BP 90/60mmHg, and is very irritable with handling. Antenatal history is unremarkable except for long-standing maternal hypothyroidism on synthroid. Mom denies and any other medication or substance use in pregnancy. What is the most likely diagnosis?
neonatal thyrotoxicosis
Maternal Grave’s disease
adequate GBS prophylaxis
one dose of IV penicillin G (or amp or cefazolin) at least 4 hr before delivery
GBS + mom with inadequate prophylactic antibiotics
monitor infant in hospital for at least 24 hr with vitals q3-4hr
don’t need a CBC before discharge if well
condition with reversal of pre-post sats
TGA with PPHN
if mom has chorioamnionitis
consider CBC at 4 hr but not mandatory
Abnormal pulse ox testing
preductal is right limb
abnormal is
<90% in any limb
90-94$ is borderline
>3% difference between limbs is abnoral
95% or higher in any limb with 3% or less difference between limbs is normal
twin-twin transfusion syndrome
Recipient: Hypervolemia, polyuria, polyhydramnios, cardiac hypertrophy, cardiomegaly, cardiac dysfunction, R sided Heart failure, pulmonary venous HTN and hydrops
Donor: Hypovolemia and anemia, oliguria, and anhydramnios
antenatal steroids
<35 weeks
benefits of surfactant for RDS
Decr mortality, vent, and BPD/Death @28d
indications for surfactant
FiO2 > 50% or if needing to transfer to tertiary care center
LISA/MIST if not needing intubation
complication post surfactant
pneumothorax
corticosteroids for BPD
- risk of CP if given within first 7 days
- if needing it in first 48 hr of life, do low dose hydrocort (consider if <28 weeks and exposure to chorio)
- if >7 days, can use dex
dont give steroids
nitric oxide
selective pulmonary vasodilator
short half life (seconds)
inhaled only
hemodynamically significant PDA
Precordial murmur
And one or more of:
Hyperdynamic precordial impulse
Tachycardia
Bounding pulses
Wide PP
Worsening resp status
Typically >1.5mm
PDA management
conservative for 1-2 weeks
- do not aggressively fluid restrict but can use lasix if pulm
- PEEP
Meds
- ibuprofen if symptomatic PDA (high dose)
- second line: second course of ibuprofen ir indomethacin
- third line: enteral acetaminophen
- procedural if persistent after 2 courses pharmacotherapy
*PDA must be shunting L to R to consider treatment
IVH grading
Grade 1- just in GM
Grade 2- bleeding also inside ventricles but they are not enlarge
Grade 3 -ventricles are enlarged by accumulation of blood
Grade 4 - bleeding extends into the brain tissue around ventricles
gestational age at risk for IVH
under 32 weeks because the germinal matrix involutes
HUS screening is due for those <32 weeks (due 4-7 days post birth and repeat at 4-6 weeks)
HUS not routinely recommended for 32-36 weeks unless risk factors (ex. IUGR, septic, unwell)
common perinatal injuries resulting in CP
Spastic diplegia - PVL (associated with prematurity)
Spastic hemiplegia - MCA stroke or IVH
Spastic quadriplegia- Grade 4 IVH, PVL
Dyskenetic- kernicterus, asphyxia
Vitamin K in neonates
single IM vit K at birth (0.5 mg if <1500g, 1 mg if >1500 g)
within 6 hr of life
oral is less effective
if declines IM, then give 2mg PO at birth, repeat at 2-4 weeks and again at 6-8 weeks
giving mom vitamin K doesn’t help baby - poorly transferred across placenta
risk factors for early onset hemorrhagic disease newborn (within 24hr)
maternal oral anticoagulants, anticonvulsants, or anti TB meds
*presents with intracranial hemorrhage
Who should you not give soy formula to because of phytoestrogens?
congenital hypothyroidism on thyroixine (makes it hard to monitor levels)
apnea prematurity definition
<37 weeks
Apnea x 20 seconds
Apnea < 20 secs PLUS bradycardia (<80) or cyanosis (SpO2 <80)
what is complication of maternal magnesium sulphate
neonatal apnea
dosing caffeine for AoP
caffeine 10-20mg/kg IV loading dose then 5-10mg/kg/day
can trial off sometime between 32-37 weeks
if discharged home on caffeine, continue until 44 weeks CGA
ROP zones and stages
Zone 1 is worst, zone 3 is best
stages 0 is best, 5 is worst (total retinal detachment)
cut offs for severe and critical hyperbili
severe >340 anytime in first mo of life
critical > 425 in first mo of life
just remeber as 340 & 430
