NICU Flashcards
when are antenatal steroids recommended and what is the purpose
Antenatal steroids <34 +6 weeks
• lung development, IVH, NEC, mortality
when is magnesium sulphate recommended and for what purpose?
Antenatal magnesium sulphate <33+6 weeks
• neuroprotection (cerebral palsy)
maternal condition and effect on baby
diabetes
Diabetes:
Hypoglycemia, macrosomia, jaundice, polycythemia, small, left colon syndrome, cardiomyopathy, RDS, hypocalcemia
maternal condition and effect on baby graves disease hyperparathyroid obesity vitamin d deficient
Graves disease Hyperthyroidism, IUGR, prematurity
Hyperparathyroid Hypocalcemia, hypoparathyroidism
Obesity Macrosomia, birth trauma, hypoglycemia
Vitamin D deficit Neonatal hypocalcemia, rickets
maternal condition and effect on baby PIH ITP Rh/ABO SLE PKU
PIH: IUGR, thrombocytopenia, neutropenia, fetal demise
ITP: Thrombocytopenia, CNS hemorrhage
Rh / ABO: Jaundice, anemia, hydrops fetalis
SLE: IUD, heart block, neonatal lupus, decr Hb, plt, Nx
PKU: Microcephaly, MR
Risk factors for preterm delivery
SES status
– <20 or >40 years
– Very low SES, Low BMI
• Past Gyne/OB
- Pyelonephritis
- Uterine / cervical anomalies
- Multiple abortions
- Preterm delivery
• Lifestyle
– >10 cigarettes/day
– Heavy work
• Pregnancy
– Multiples
Risk factors for IUGR (maternal/fetal)
Maternal – Hypertensive, preeclampsia – Renal disease – Diabetes – Antiphospholipid syndrome – Severe nutrition deficiency – Smoking / substances – Maternal hypoxia (CHD, lung)
• Fetal – Multiple gestation – Placental abnormalities – Infection (viral) – Congenital anomaly, chromosomes
What is early vitamin K deficiency bleeding (VKDB)
Early vitamin K deficiency bleeding (VKDB)
– 1st 24 hours, due to maternal medication
What is classic VKDB
Classic VKDB – preventable by Vit K prophylaxis
– 1:400, bleeding 1st wk of life
what is late VKDB
what are risk factors? (3)
Late VKDB
– 1-7:100 000, bleeding 2nd-12th wk of life up to 6 months
– Exclusive breastfeeding, no Vit K (or only 1 oral dose!), fat
malabsorption (ex CF)
Treatment of VKDB
Treatment of VKDB: Vitamin K, FFP
Vitamin K prophylaxis
Vitamin K prophylaxis
– 0.5mg (<1500g) 1mg (>1500g) IM in first 6 hours of life
– Oral alternative if parents refuse (less optimal):
• 2mg at 1st feed, repeat at 2-4 weeks and 6-8 weeks
What are these shunts between:
1. Ductus Venosus
- Foramen Ovale
- Ductus Arteriosus
Shunts: 1. Ductus Venosus Umbilical Vein -> inferior vena cava 2. Foramen Ovale Right atrium -> Left atrium 3. Ductus Arteriosus Pulmonary artery -> Aorta
HC grows how much in 1st 2 months? until 6 mo?
HC: grows 0.5cm/week for 1st 2mos
• Then ~1cm/month from 2-6mos
most babies pass urine and meconium within what time frame?
24 hours
how much weight gain per day for a baby?
Weight gain: “1 oz/day except on Sunday”
Ddx for failure to pass meconium
Meconium plug Hirschprung’s meconium ileus (CF) imperforate anus small left colon (IDM)
Which of the following is least likely to be
picked up using pulse oximetry screening?
1. Pulmonary atresia with intact septum
2. Total anomalous pulmonary venous return
3. Truncus arteriosus
4. Unbalanced atrioventricular septal defect
Unbalanced atrioventricular septal defect
what screening is done for a newborn
- Universal hearing screen (Oto-acoustic emissions)
- Blood spot at >24 hours of age
- Bilirubin at 24 hours (see later) & 48 hours (late preterm)
- O2 saturation: screening for congenital heart disease
What is the most important part of NRP?
The most important part of NRP is ventilation of the baby’s lungs
what are the 3 questions to ask for neonatal resuscitation?
3 questions: TERMgestation? TONE, BREATHING/CRYING?
• If answer to questions is no → NRP
Tube size: >35 weeks;
Preterm > 1kg
<1kg 2.5
Tube size: >35 weeks 3.5-4.0;
Preterm > 1kg 3.0; <1kg 2.5
how do you confirm ETT placement
Confirm placement: • Visualize through cords • Chest movement • Bilateral air entry • Heart rate improves!
equation for depth of ETT
Depth: weight + 6cm (oral)
Oxygen percentage at Term?
preterm?
when do you increase to 100%?
Start in room air TERM
21-30% PRETERM
Preterm end-target: 88-94%
Increase to 100% when starting compressions
what is the preferred route for epinephrine administration for NRP?
IV
dose 0.01mg/kg
is Naloxone recommended?
No!
when is a plastic bag recommended at delivery?
<32 weeks
respiratory disease in the newborn clues:
– Prematurity, uncontrolled diabetes
– Term, elective C-section
– History oligohydramnios
– History polyhydramnios or ++ secretions
– Infection risk factors (GBS positive, chlamydia); ‘well’ then onset of resp symptoms
– Acute, asymmetric features, systemic sx
– sounds like cardiac symptoms
– Prematurity, uncontrolled diabetes: RDS
– Term, elective C-section: TTN
– History oligohydramnios: pulmonary hypoplasia
– History polyhydramnios or ++ secretions: TEF
– Infection risk factors (GBS positive, chlamydia); ‘well’ then onset of resp symptoms: pneumonia
– Acute, asymmetric features, systemic sx: pneumothorax
– sounds like cardiac symptoms: PPHN
what does increasing your rate do?
decreases CO2
when is rhogam(anti-D globulin) given?
28 weeks
How many kcal are in one ounce of formula? How many mLs are in an ounce?
Breastmilk/formula= 20kcal/oz 1oz= 30 mL
What is required to pass CCHD screen
sat >95% and <3% difference between right hand and foot
what is a borderline CCHD screen
90-94% OR >3% diff between right hand and foot
should be repeated in 1 hour (x2)- if remains abnormal call health care provider
what is considered a fail on CCHD screen
sat <90%
Who should get CCHD screen and when?
> 34 weeks
>24-36h of life
What does MRSOPA stand for
Mask re-adjustment Reposition Suction Open mouth Pressure increase Alternate airway
what color should your end CO2 detector turn after successful intubation
Gold is good
- yellow
when would you consider stopping chest compressions if there is no detectable heart rate
after 10 minutes
what is the survival to discharge for the following <22+6 weeks 23 weeks 24 weeks 25 weeks
≤ 22+6 weeks: 18%
23 weeks: 40%
24 weeks: 70%
25 weeks: 80%
what are the major morbidities associated with prematurity (4)
cerebral palsy
blindness
deafness
cognitive
what are 3 consequences of hypothermia (temp <35)
associated with increased mortality in infants
- decreased surfactant production
- hypoglycemia
- increased oxygen consumption
what is the most common neurodevelopment outcome for premature babies?
most have no or mild neurodevelopment disability 22- 57% 23- 60% 24- 72% 25- 76%
what is the treatment for PPHN
iNO
what is the dose for iNO
20ppm
what does iNO do
decreased mortality and need for ECMO>35 weeks
when would you start iNO
OI >20-25
what is OI
FiO2 xMAP/PaO2
what are two examples of pulmonary vasodilators
oxygen
nitric oxide
what is the treatment for a baby just born with TEF
NPO
Nasal esophageal tube to suction
Consult surgery
look for associated anomalies- VACTERL
does surfactant reduce the incidence of chronic lung disease?
NO!
what would you see on CXR for RDS (2)
ground glass
air bronchograms
what are some risk factors for RDS (3)
prematurity
IDM
asphyxia
- they have high resistance and low compliance
what is the treatment for a baby with RDS
transfer to a tertiary center
antenatal steroids- <34 weeks (decreases severity of RDS, IVH and mortality
surfactant- decreases pneumothorax, PIE, length of stay, duration of vent support
CPAP/ventilation
when should you give surfactant? max number of doses?
earlier is better
as early as 2h, avg 4-6h
no more than 3 doses
when can you give a repeat dose of surfactant
within the first 72 hours
if FiO2 >30%
what are 3 risks associated with giving surfactant
blocked tube
pneumothorax
bradycardia
what are 4 indications for surfactant therapy
intubated preterm with RDS meconium aspiration syndrome, FiO2 >50% Consider in sick baby with pneumonia or pulmonary hemorrhage, when OI >15 <29 weeks prior to transport
what change would you make on the ventilator to improve oxygenation
increase PEEP
what are some complications of mechanical ventilation
pneumothorax
pneumonia
subglottic stenosis
BPD
what is the definition of bronchopulmonary dysplasia
oxygen dependence beyond 28 days or at 36 weeks post gestational age
incidence: 25% <1500g
are corticosteroids recommended in the first week of life for prevention of bronchopulmonary dysplasia?
no!
routine use of inhaled corticosteroids is also not recommended
could consider later use: for ventilator–dependent, severe
CLD, low-dose with tapering short course (7-10 days)
LBW
VLBW
ELBW
LBW < 2500g
VLBW < 1500g
ELBW <1000g
what are some complications of prematurity
Apnea of prematurity Respiratory distress syndrome Chronic lung disease Patent Ductus Arteriosus Intraventricular hemorrhage Anemia requiring transfusions Sepsis, Necrotizing enterocolitis Retinopathy of prematurity Neurodevelopment: • CP, cognitive, hearing, blindness, learning disability, behaviour
what are some complications of late preterm (34-36 weeks)
respiratory distress, temperature instability, hypoglycemia,
kernicterus, apnea, seizures, and feeding problems, as well as higher rates of rehospitalisation
what is mortality rate at 24 weeks, 25 weeks, 30 weeks
40-50% 24 weeks
25% 25 weeks
<1% > 30 weeks
what is the definition of apnea
cessation of breathing 20 seconds OR
10-20s with bradycardia (<80)
how long can apnea of prematurity persist for VLBW
up to 44 weeks corrected
how many apnea free days are required prior to discharge for a late preterm
8 days apnea free prior to discharge
what are two treatment option for ductus arteriosus
fluid management (furosemide, transfusion) indomethacin (contraindications renal insufficiency or thrombocytopenia) surgical ligation
how do most babies with IVH behave?
most are asymptomatic
who should we screen for IVH
<32 or <1500g
head ultrasound
who should we screen for ROP
<31 weeks
<1250g
at 4 weeks of age or 31 weeks
what are two treatment options for ROP
- laser therapy
2. anti VEGF (Antivascular endothelial growth factor)
who needs treatment for ROP
ZONE 1- any stage ROP with plus disease, stage 3 ROP without plus disease
ZONE 2- Stage 2 or 3 with plus disease
what are 4 risk factors for ROP
Hypotension
Prolonged ventilation
Oxygen therapy
Slow postnatal growth
what is seen on abdominal xray for NEC (3)
- pneumatosis
- portal venous air (black lines over liver)
- Pneumoperitoneum
what are maternal risk factors for early onset sepsis? (3)
GBS
PROM >18h
temp >38
what is the treatment for maternal GBS infection
no allergy: IV Penicillin G, ampicillin >4 hours
mild allergy: cefazolin >4 hours
severe allergy: clindamycin or vancomycin *not considered adequate prophylaxis
what is the treatment for suspected early onset sepsis
amp+ gent
what is the most common cause of late onset sepsis in a baby (1 month)
CONS
Coagulase-negative staphylococci
Which of the following is NOT an association or
complication of LGA?
A. Birth trauma (dystocia, fractures, ICH, hip)
B. Asphyxia / HIE
C. Anemia
D. Hypoglycemia
anemia
* LGA are polycythemic
sarnat 1
hyperalert hyperreflexic normal tone mydriasis tachycardia no seizures minimal resp secretions
sarnat 2
obtunded hypotonic hyperreflexic miosis bradycardia GI motility increased seizures lots of resp secretions
sarnat 3
stuporous
flaccid/ decerebrate
absent reflexes
what are the criteria for HIE
Indications: (≥35-36 weeks) Criteria A or B AND C A. Cord pH ≤ 7 or BD ≥ -16 or B. pH 7.01 – 7.15 of -10 to -16 (cord or 1 hour gas) AND Hx of acute perinatal event AND APGAR ≤ 5 at 10m or at least 10m of PPV C. Signs of moderate to severe encephalopathy
what imaging should be done after reawarming?
MRI after rewarming • Basal ganglia / thalamus / PLIC = motor + cognitive (basal ganglia has 2 words) • Watershed areas = more cognitive than motor – If unclear: repeat at 10-14 days
what is the treatment for HIE >35 weeks
Temperature: 33-34C x 72h – Passive cooling (community) – Active cooling (total body or selective head) start ASAP, 1st 6 hours
what are 5 complications of cooling
hypotension bradycardia, coagulopathy PPHN Fat necrosis
All of the following are recognized causes of ‘floppy baby’ except: A. Trisomy 21 B. Zellweger syndrome C. Becker muscular dystrophy D. Spinal muscular atropy E. Prader Willi syndrome
Becker muscular dystrophy
Erb’s palsy
C5, 6, 7
watch for phrenic nerve (resp distress)
Klumpke
C7, 8, T1
Flail arm
Complete C5-T1 Flail arm
Often associated with Horner’s syndrome, less favorable
What is the prognosis for brachial plexus palsy
75% recover completely in first month
25% permanent impairment – refer at 1 month to brachial plexus team
what is glucose infusion rate
Glucose Infusion Rate= IV rate (ml/kg/day) x % of dextrose
(mg/kg/min) divided by 144
who should be screened for hypoglycemia
SGA LGA IDM asphyxia preterm <37 weeks
when do you stop doing glucose checks for SGA? LGA
SGA- after 24 hours
LGA- after 12 hours
what is your glucose target after treatment of hypoglycemia
> 2.8 initially
>3.3 after transition period
how do you treat asymptomatic infants with blood glucose levels of 1.8 - 2.5 mmol/L
feed 5ml/kg and breastfeed
or 40% dextrose gel and breastfeed
recheck blood glucose after 30 minutes
what should be done for refractory hypoglycemia
glucagon
what is the treatment for symptomatic hypoglycemia
IV bolus 2mL/kg D10 over 15 min then D10 at TFI 80ml/kg/d
check blood glucose after 30 minutes
red flags for jaundice (6)
Onset before 24 hours Hemolysis is a predictor of severity Pallor, Unwell Hepatosplenomegaly Pale stools, dark urine Conjugated hyperbilirubinemia
what is the treatment for clinical signs of acute bilirubin encephalopathy?
Clinical signs of acute bilirubin encephalopathy
→ immediate EXCHANGE transfusion
Severe TSB level=
Critical TSB level=
Severe: TSB > 340 umol/L in 1st 28d
• Critical: TSB > 425 umol/L in 1st 28d
No respiratory support Postnatal age: Week 1 Week 2 Week 3
No respiratory support
1- 100
2- 85
3- 75
what is hydrops fetalis
fluid in 2 or more fetal compartments
Which statement is correct regarding Neonatal
Alloimmune Thrombocytopenia?
A. Mother is often also thrombocytopenic
B. Risk of intracranial hemorrhage highest
during first 96 hours
C. IVIG is not an effective treatment
D. Expect a higher platelet count than in
autoimmune thrombocytopenia
Risk of intracranial hemorrhage highest
during first 96 hours
causes of neonatal thrombocytopenia
Infection: bacterial, TORCH
– Neonatal alloimmune thrombocytopenia
– Other maternal causes
• toxemia, ITP, SLE, Drugs (hydralazine, thiazides)
– Consumption: DIC, Kassabach-Merrit (hemangioma)
– Syndromes: IUGR, TAR, Fanconi’s
– Bone marrow suppression: pancytopenia, leukemia
You are caring for twins with an antenatal history of
moderate (stage III) twin-twin transfusion syndrome.
Twin A had a hematocrit of .75, Twin B had a Hct .30.
Which of the following is true?
A. Twin A had a history of oligohydramnios
B. Twin A is at increased risk of congenital heart disease
C. Twin B’s bladder was visualized antenatally
D. Twin B will require an partial exchange transfusion
with saline
Twin A is at increased risk of congenital heart disease
Indications for treatment of apnea of prematurity? when do you stop methylxanthine? when do you stop monitoring?
> 4 episodes in 8 hours
Episodes do not resolve with gentile tactile stimulation
Methylxanthine:
Apnea free period of 4-8 weeks
44 weeks postconceptual (milestone for maturity of the respiratory system)
Cardiac Monitors:
4-8 weeks after discontinuing caffeine if no recurrence of symptomatic apnea
who is at increased risk for polycythemia? (5)
small for gestational age, post-term infants, infants of diabetic mothers, infants with twin to twin transfusion, infants with chromosomal abnormalities (Down syndrome, trisomy 13 and 18)
what are 3 benefits of surfactant
decreases mortality
decreases pneumothorax
decreases PIE
- Newborn with axillary temperature of 37.8 degrees, well and normal exam. What do you do?
A. Full septic work up and antibiotics
B. Rectal temperature
C. Take off all clothes for 20 minutes and recheck temperature
D. CBC and diff
Do a rectal temperature!
Polycythemic newborn. Hb 240, Hct 0.75. Wt 2000g. Child requires a partial exchange transfusion. What fluid do you use as the diluent? How much blood do you replace to decrease the Hct to 0.5?
Total blood volume (weight x 80mL/kg) x [ patient’s hematocrit- desired hematocrit/ patient’s hematocrit]
Most likely cause of late hemorrhagic disease of the newborn? phenytoin use in mom baby did not get Vit K prophylaxis oral antibiotics cystic fibrosis
cystic fibrosis
Which of the following is associated with polyhydramnios IUGR Hirschsprung’s disease esophageal atresia renal agenesis
esophageal atresia
CPS statement - Risk factors for developing severe hyperbili:
visible jaundice at younger than 24 hours, visible jaundice before discharge at any age, shorter gestation (<38 weeks), previous sibling with hyperbili, visible bruising, cephalohematoma, male sex, maternal age > 25 years, Asian or European background, dehydration, exclusive and partial breastfeeding
Abstinence from methadone? Neonatal sx? Hyporeflexia Constipation Sneezing Lethargy
sneezing
7 day old being resuscitated. Rate of compressions to ventillations. Patient is intubated. (2008 Toronto)
a. 3:1
b. 5:1
c. 15:2
d. 100:1
3:1
90 compressions: 30 breaths
ELBW infant. What causes CLD?
a. PPV
b. oxygen use
c. barotrauma
d. surfactant deficiency
barotrauma
Infant with R arm sat of 90% and L leg sat of 70%. Pt tachypneic, RR 70, no distress. Dx?
a. CoA
b. truncus
c. TGA
d. TOF
coA
What is the most common complication after gastroschisis repair?
Bowel obstruction
Abdominal compartment syndrome
abdominal compartment syndrome
An ex-25 week premature infant is now 18 months old. She has bilateral increased reflexes in the lower limbs. At what age can you make the definitive diagnosis? 18m 24m 36m 40m
24 months
Kleihauer-Betke Test—how does it work.
test baby for mom’s blood
test mom for baby’s blood
test cord blood
test mom for baby’s blood
Neonate with dehydration and mom was IDDM. Baby develops hematuria. What’s the dx:
renal vein thrombosis
Renal vein thrombosis is the most common spontaneous VTE in neonates. Affected infants may present with hematuria, an abdominal mass, and thrombocytopenia. Infants of diabetic mothers are at increased risk for renal vein thrombosis, although the mechanism for the increased risk is unknown. Approximately 25% of cases are bilateral.
Infant in NICU admission with stone in kidney. What medication was used?
lasix
Disability for 23, 24 and 25 weeks
Disability
23: 30 - 60%
24: 20 - 40%
25: 10 - 20 %
Which of the following is the best predictor of risk of Rh autoimmune hemolytic disease at the time of delivery? Bili in the cord Hb in the cord Mom’s Ant-Rh titres Gestional age
bili in the cord
A newborn with omphalocele had hypoglycemia. What is this child at risk for?
a) Neuroblastoma
b) Wilm’s tumour
c) Leukemia
d) Duodenal atresia
wilm’s tumor
- think Beckwith-Wiedemann
what are 4 risk factors for severe hyperbili
jaundice <24h male sex gestational age <38 weeks sibling with a history of severe hyperbilirubinemia cephalohematoma maternal age >25
Baby born at 41 wks. Meconium staining. Flat babe requiring resucc. Apgars 2 at 1 min 3 at 5 min and 6 at 7 min. what 5 things may you expect with this baby in the near future. What 2 tests at discharge, if normal would suggest a good neurological outcome for this child
- decreased LOC
- decreased tone
- decreased activity
- bradycardia
- irregular resps/ apnea
- weak suck reflex
- EEG
- MRI
Mother of 2 hour newborn who has a mass of scalp that crosses suture lines. The mother took phenytoin during pregnancy and the child was delivered via vacuum delivery. Give two reasons why the child has this lesion.
- vacuum delivery
2. early vitamin k deficiency bleeding due to maternal phenytoin use
