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CPS statements > NICU > Flashcards

NICU Flashcards

1
Q

what is the recommended dose of vitamin K

A

0.5mg <1500g
1mg >1500g
give within 6 hours

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2
Q

what is the recommended dose of PO vitamin K

A

2mg at birth, 2-4 week and 6-8 weeks

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3
Q

what are 3 things you should tell parents if they opt for PO vitamin k

A

PO vitamin K is less effective than IM vitamin K for preventing VKDB
Making sure their infant receives all follow-up doses is important
Their infant remains at risk for developing late VKDB (potentially with intracranial hemorrhage) despite use of the parenteral form of vitamin K for PO administration

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4
Q

what are the two predominant patterns of brain injury seen with HIE

A

watershed (prolonged partial hypoxia-ischemia)

basal ganglia/thalamic (acute profound hypoxia)

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5
Q

When HIE is severe when does generalized brain edema peak?

A

72 hours (Can be seen on CT and MRI)

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6
Q

when should MRI be obtained in term newborns with NE

A

between 3 and 5 days of life to confirm diagnosis and determine the extent of hypoxic-ischemic injury (or after rewarming)

A repeat MRI at 10 to 14 days is a helpful adjunct when clinical examination or clinical evolution is not consistent with early MRI findings or when diagnostic ambiguity persists.

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7
Q

what is the neurodevelopment outcome for watershed injury

A

cognitive impairment

The watershed pattern of injury also appears to predict language outcomes

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8
Q

what is the neurodevelopment outcome for basal ganglia/thalamic

A

severe cognitive and motor disability

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9
Q

when CT is used for infants with HIE when should it be performed

A

as close to 72 hours of the suspected insult as possible, ideally within 72 ± 12 hours. A subsequent MRI is also recommended

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10
Q

what is the preferred imaging technique for examining the brain of term neonates who present with encephalopathy or a suspected brain injury or abnormality

A

MRI

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11
Q

what are 3 indications to stop cooling

A

Hypotension despite inotropes
Persistent pulm hypertension with hypoxemia, despite adequate support
Clinically significant coagulopathy, despite treatment

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12
Q

should you do whole body cooling or selective head cooling

A

whole body cooling

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13
Q

what temperature is recommended for whole body cooling

A

core Temp 33°C ± 0.5°C

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14
Q

when should whole body cooling be initiated

A

within 6 hours

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15
Q

how long should cooling persist? how should they rewarm?

A

72 hours

rewarm 0.5C ever 1-2 hours (so rewarm over 6-12 hours)

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16
Q

how old does a baby have to be to consider cooling

A

> 36 weeks!
consider for 35 weeks
increased mortality in preterm

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17
Q

what are some of the outcomes for HIE

A 
CP or severe disability
cognitive impairments
visual impairment or blindness
sensorineural hearing loss
behavioral difficulties (ADHD)
epilepsy
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18
Q

what is the criteria for cooling

A

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


History of acute perinatal event (such as but not limited to cord prolapse, placental abruption or uterine rupture) AND
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

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19
Q

what are the 6 criteria for defining mod-severe encephalopathy

A 
LSPTPA
L- level of consciousness
S- spontaneous activity
P- posture
T- tone
P- primitive relaxes
A- autonomic system (pupils, HR, respirations)
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20
Q

what are some side effects of cooling (5)

A 
hypotension
bradycardia,
coagulopathy
PPHN
Fat necrosis
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21
Q

when do we see max efficiency for antenatal steroids

A

within 7 days

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22
Q

how old should a baby be before you’d consider giving antenatal steroids

A

> 22 weeks

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23
Q 
survival to NICU discharge
>22+6
23
24
25
A

> 22+6: 20

23: 40
24: 70
25: 80

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24
Q 
Neurodevelopmental outcomes:
Most children have no or mild NDD:
22 weeks
23 weeks
24 weeks
25 weeks
A

Most children have no or mild NDD:

  • 57% at 22 weeks
  • 60% at 23 weeks
  • 72% at 24 weeks
  • 76% at 25 weeks
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25
Q

Extremely high likelihood of mortality or severe NDD, what care is recommended

A

palliative care

ex: born at 22 weeks or 24 weeks and <350g

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26
Q

Moderate-to-high likelihood of mortality or moderate-to-severe NDD

A

Intensive care or palliative care are both usual care options
ex: 23-24 weeks

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27
Q

Low likelihood of mortality or moderate-to-severe NDD

A

intensive care is recommended

>25 weeks without additional risk factors

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28
Q

what are the risk factors for early onset sepsis

A
  1. maternal fever >38
  2. GBS+
  3. GBS bacteriuria at any time during current pregnancy
  4. previous child with invasive GBS disease
  5. ROM >18 hours
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29
Q

chorioamionitis

A 
Maternal temperature >38 + two of:
uterine tenderness
maternal or fetal tachycardia
foul/purulent amniotic fluid
maternal leukocytosis
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30
Q

what is the empiric treatment for early onset sepsis in a neonate

A

amp+ gent

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31
Q

what is the treatment for mom prior to delivery for GBS

A

no allergy: penicillin
mild allergy: cefazolin
severe allergy: clindamycin or vancomycin

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32
Q

Does the Canadian Paediatric Society recommend routine car seat testing before discharge for preterm infants?

A

No!
Infants should only be placed in a car seat for travel in a moving vehicle and removed promptly once the destination is reached

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33
Q

is routine use of EPO recommended?

A

No!

Concern for more severe ROP

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34
Q

Does enteral iron supplementation reduce need for blood transfusions?

A

No evidence that using iron supplementation prevents or reduces the need for transfusions in the neonatal period

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35
Q

what volume of blood should be considered when transfusing a preterm baby

A

A higher volume of transfused blood (20 mL/kg) should be considered when transfusing a preterm baby, if the hemodynamic and respiratory status of the patient permits

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36
Q

is cord milking recommended?

A

the technique cannot be recommended as routine practice at the present time

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37
Q

how long is delayed cord clamping

A

30-180S

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38
Q

What dose of iron is recommended to prevent iron deficiency anemia is preterm babies

A

Elemental iron supplementation (2 mg/kg/day to 3 mg/kg/day once full oral feeds are achieved) is recommended to prevent later iron deficiency anemia

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39
Q

what are some risks of circumcision (7)

A 
pain
local infection
severe infection
minor bleeding
death from unrecognized bleeding
poor cosmetic result
most common late complication: meatal stenosis
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40
Q

what are some benefits of circumcision (5)

A 
prevention of phimosis
decreased UTI
decreased STI (HIV, HPV, HSV)- no effect on chlamydia/gonorrhoea
decreased cervical cancer
decreased penile cancer
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41
Q

what is the most common late complication of circumcision

A

meatal stenosis

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42
Q

what are two contraindications to circumcision

A

hypospadias

bleeding disorder

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43
Q

what is the transfusion volume for pRBCs for newborn

A

10-20ml/kg over 3-4 hours

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44
Q

what is the major risk of rapid and massive transfusion?

A

hyperkalemia

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45
Q

what are the two most frequent indications for blood transfusion in the newborn?

A

perinatal hemorrhagic shock

recurrent correction of anemia of prematurity.

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46
Q

how is the risk of CMV transmission from transfusion reduced

A

leukoreduction

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47
Q

what process prevents graft versus host disease

A

irradiation

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48
Q

what type of blood is used for emergency transfusion of newborns

A

O, rh negative

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49
Q

at what age is crossmatching of blood required

A

starting at 4 months of age

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50
Q

what are 4 risks associated with RBC transfusion

A
  1. infection
  2. leukocyte adverse effects (graft versus host, TRALI)
  3. volume and electrolyte disturbance
  4. blood group incompatibility
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51
Q

What hemoglobin level is recommended for the following weeks off of respiratory support
week 1
week 2
week 3

A

1- 100
2- 85
3- 75

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52
Q

What hemoglobin level is recommended for the following weeks on respiratory support
week 1
week 2
week 3

A

1- 115
2- 100
3- 85

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53
Q

what are 4 important competencies prior to discharge of a preterm infant

A
  1. Thermoregulation (temp >37)
  2. No apnea for 5-7d
  3. No oxygen required to maintain sats 90-95% for 1 week on RA
  4. Feeding and gaining weight (vit d and iron supplementation)

parents must feel confident and prepared

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54
Q

Preterm infants with a birthweight <2000 g who receive hepatitis B vaccine require how many doses??

A

Preterm infants with a birthweight <2000 g who receive hepatitis B vaccine require four doses.

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55
Q

Why is early Dex not recommended to prevent BPD?

A

associated with increased risk of CP

therefore early steroids are NOT recommended

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56
Q

when could you consider late dose Dex (>7 day)

A

low dose late dose Dex (0.15mg/kg/day)
has been shown to reduce duration of ventilator therapy
not recommended for everyone
can be used on case-by-case basis for infants at high risk of CLD who are ventilator dependent
0.15-0.2mg/kg/day, tapering course over 7-10 days

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57
Q

Is hydrocortisone recommended for treating CLD

A

No!

58
Q

Are inhaled corticosteroids recommended to prevent CLD?

A

No!

59
Q

Babies with late-trimester SSRI exposure should be observed for how long?

A

observed in hospital for neurobehavioural or respiratory symptoms for a minimum of 48 h.

60
Q

Is SSRI use a contraindication to breastfeeding?

A

Postpartum use of SSRIs is not a contraindication to breastfeeding, and women who choose to breastfeed should be supported

61
Q

Is there an increased risk of congenital malformations with SSRI use in pregnancy?

A

No!

Paroxetine use in mom- may have small increased risk of cardiac malformations but evidence is inconclusive

62
Q

what syndrome can be seen in a baby born to a mother taking an SSRI

A

SSRI neonatal behavioral syndrome
seen in 10-30% of infants exposed to SSRIs in late gestation
Symptoms within hours of birth, generally mild, and resolves in 2 weeks

63
Q

Signs of SSRI neonatal behavioral syndrome

A

tachypnea, cyanosis, jitteriness/tremors, increased muscle tone, and feeding disturbance

64
Q

what is the most concerning possible post-natal association with SSRI exposure?

A

PPHN

65
Q

what is the suggested protocol for premeditation intubation in a neonate

A

atropine 20mcg/kg (vagolytic)
fentanyl 3-5mcg/kg (analgesic)
succinylcholine 2mg/kg (muscle relaxant)

66
Q

Late preterm infants are particularly at risk for readmission with what? (6)

A

hyperbilirubinemia- Reassess for feeding, weight gain, and jaundice repeatedly in first 10 days, later peak (7 days)

feeding problems
apnea or acute life-threatening events
suspected sepsis
respiratory problems
hypothermia
67
Q

what is late preterm

A

34-36 weeks

68
Q

when should a late preterm infant that was discharged from hospital be seen in follow-up

A

within 72 hours

69
Q

what is the minimum body temp for a bath

A

36.5C

70
Q

what are some non pharmacological/pharmacological interventions for pain relief in a newborn (5)

A

oral sucrose
Kangaroo care
facilitated tuck, swaddle and developmental care
non-nutritive sucking
Topical anesthetics can be used to reduce pain associated with venipuncture, lumbar puncture and intravenous catheter

71
Q

what is the most common cause of brachial plexus palsy

A

birth trauma

72
Q

what are some risk factors for brachial plexus palsy (4)

A

LGA
instrumentation
IDM
shoulder dystocia

73
Q

what is the prognosis for brachial plexus injury

A

75% recover completely within the first month

25% with permanent impairment and disability

74
Q

when should you refer brachial plexus injury to a multidisciplinary team?

A

Refer to multidisciplinary brachial plexus team if ongoing deficit by 1 month

75
Q

what nerves are associated with Erbs palsy

A

C5, C6, C7

adducted, internally rotated shoulder, extended elbow

76
Q

what nerves are associated with Klumpke

A

C8, T1
extreme wrist extension
flexion at IP

77
Q

C5-T1

A

flail arm

often associated with horner’s syndrome

78
Q

what are 4 indications for surfactant

A

Intubated infants with RDS should receive surfactant therapy

Intubated babies with meconium aspiration syndrome and > 50% FiO2 need should receive surfactant

Sick newborns with pneumonia and oxygenation index >15 should receive surfactant

Intubated newborns with pulmonary hemorrhage and clinical deterioration should receive surfactant

Infants who deliver at less than 29 weeks gestation outside of a tertiary centre should be considered for immediate intubation followed by surfactant administration after stabilization

79
Q

what are 4 risks associated with giving surfactant

A

Bradycardia
hypoxia, or ETT blockage during instillation
Pulmonary hemorrhage
Over-distension and air leak

80
Q

should we use natural or synthetic surfactant?

A

Natural surfactants should be preferred over synthetic surfactants

81
Q

what is severe hyperbilirubinemia

A

> 340umol/L during the first 28 days of life

82
Q

what is critical hyperbilirubinemia

A

> 425umol/L during the first 28 days of life

83
Q

What are the risk factors for the development of severe hyperbilirubinemia (11)

A 
visible jaundice before 24h
visible jaundice before discharge at any age
shorter gestation
previous sibling with severe hyperbilirubinemia
visible bruising
cephalohematoma
male sex
maternal age >25
Asian or European background
Dehydration
Exclusive and partial breastfeeding
84
Q

what investigations should be performed in infants with early jaundice of mothers of blood group O (2)

A

Blood group and DAT

85
Q

when should bilirubin be checked

A

within the first 72 hours of life or prior to discharge

86
Q

Infants with a positive DAT who have predicted severe disease based on antenatal investigation or an elevated risk of progressing to exchange transfusion based on the postnatal progression of TSB concentration should receive?

A

IVIG 1g/kg

87
Q

what infants are at risk for G6PD

A 
Mediterranean 
Middle Eastern
African
South East Asian
all babies with severe hyperbilirubinemia
88
Q

What are some ways that health care professionals can support families through perinatal loss?

A 
compassionate communication
shared decision-making
creating meaningful memories
acknowledging grief
sibling care
family care
89
Q

cyanotic heart disease (8)

may be cyanotic

A 
T- Transposition of the great arteries
T- Tetralogy of Fallot
T- Tricuspid atresia
T- Total anomalous pulmonary venous connections
T- Truncus arteriosus
T- 'Tingle' ventricle (single ventricle)

A- pulmonary atresia
A- Ebstein’s anomaly

May be cyanotic:
Coarctation of the aorta
Double outlet right ventricle
Ebstein’s anomaly
Interrupted aortic arch
Defects with single ventricle physiology
90
Q

who should get pulse oximetry screening

A

all term and late term babies (>34 weeks)

91
Q

when should pulse oximetry screening be completed

A

ideally between 24-36 hours of age (after 24h but before 36h)
- although screening before 24 hours of age is better than no screening at all

92
Q

What is required to pass CCHD screen

A

sat >95% and <3% difference between right hand and foot

93
Q

what is a borderline CCHD screen

A

90-94% OR >3% diff between right hand and foot
should be repeated in 1 hour (x2)- if remains abnormal call health care provider

  • IF BORDERLINE ON 3 CHECKS THEN COMPLETE CLINICAL EVALUATION
94
Q

what is considered a fail on CCHD screen

A

sat <90%
should undergo a complete CLINICAL EVALUATION by the most responsible health care provider, which could include consultation with a paediatrician if the initial assessment did not involve one. If a cardiac diagnosis cannot be excluded, referral to a paediatric cardiologist for consultation and echocardiogram is advised.

95
Q

what limbs are used for CCHD screen

A

right and and either foot

96
Q

who needs ROP screening

A

infants <31 weeks

< 1250g

97
Q

when is ROP screening performed

A

4 weeks of age or minimum of 31 weeks

98
Q

when should treatment for type 1 ROP begin

A

within 72h of detection

99
Q

what is the difference between type 1 ROP and type 2 ROP

A

type 1- significant changes requiring treatment

type 2- significant changes not requiring treatment, close followup

100
Q

Who needs treatment for ROP?

A

Indications for treatment:
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

101
Q

when do you stop screening for ROP (3)

A

Vascularization in zone III without previous zone I or II ROP
Full retinal vascularization
Postmenstrual age of 50 weeks and no prethreshold or worse ROP
Regression of ROP

102
Q

what is type 1 ROP

A

zone 1- any stage ROP with plus disease
zone 1- stage 3 without plus disease
zone 2- stage 2, 3 with plus disease

103
Q

what is type 2 ROP

A

Zone I – stage 1 or 2 ROP without plus disease

Zone II – stage 3 ROP without plus disease

104
Q

what is plus disease

A

Increased vascular dilatation and tortuosity of posterior retinal vessels in at least two quadrants of the retina

105
Q

what are the two treatment options for ROP

A

laser therapy

anti-VEGF

106
Q

who needs followup for ROP in 1 week

A

type 2 ROP

immature vascularization, immature retina and aggressive posterior ROP

107
Q

who needs followup for ROP in 2 to 3 weeks

A

stage 1 or 2 ROP, no plus disease in zone 3
regressing ROP zone 3

easiest way is if it is zone 3 then followup in 2-3 weeks

108
Q

what are 4 benefits of kangaroo care

A 
Pain
Breastfeeding
Prevents nosocomial infections
Mother-baby bonding
Sleep
Neurodevelopmental outcomes
Decreased neonatal morbidity and mortality
109
Q

what is kangaroo care?

A

the practice of skin-to-skin contact between infant and parent (as young as 26 weeks)

110
Q

how does iNO work?

A

it causes pulmonary vasodilation

used to treat persistent pulmonary hypertension of the newborn

111
Q

who should get iNO

A

Infants ≥ 35 weeks GA with hypoxemic respiratory failure who fail to respond to appropriate respiratory management
* role in prems has not been established

iNO is usually started in infants with an OI > 20-25, or PaO2 < 100 despite ventilation with 100% oxygen

112
Q

what investigation should be done prior to starting iNO ideally

A

echo to rule out cyanotic heart disease

113
Q

what is the recommended starting dose of iNO in term infants? what is the expected response? how quick do you see a response?

A

20ppm (short half life 2-6s)
PaO2 increase ≥ 20mmHg, rapid response occurring within 30 min
If no response then the dose can be increased to 40ppm

dose 20-80ppm (>40ppm associated with increased toxicity)

114
Q

how should you wean iNO

A

by 50% every 4 hours (as long as OI<10) until down to 5ppm, then decrease by 1ppm every 4 hours
then stop as long as PaO2>50mmHg and FiO2<60%

if unable to wean by 7 days look for other causes (cardiac or pulmonary)

115
Q

what are 4 toxicities associated with iNO

A

methemoglobinemia (measure frequently, keep <2.5%)
Decreased platelet aggregation / bleeding
Surfactant dysfunction
NO2 production (pulmonary injury if >5ppm)

at doses 20-40ppm- associated with minimal toxicity

116
Q

what can happen with abrupt cessation of iNO

A

severe hypoxemia secondary to the downregulation of endogenous NO production and should be avoided

117
Q

is iNO use effective for most infants with congenital diaphragmatic hernia?

A

No! iNO use is not effective for most infants with congenital diaphragmatic hernia.

118
Q

what 2 drugs can be recommended for opioid-dependent pregnant women

A

methadone

buprenorphine

119
Q

what percentage of infants of mom’s on opioids during pregnancy will require treatment for symptoms of NAS

A

50-75%

120
Q

when do NAS symptoms present? how long do they last?

A

Symptoms usually present within 48-72 hours, up to 5-7 days, and can last up to 30 days, with mild symptoms up to 6 months

121
Q

when should NAS scoring be done? what is the minimum duration?

A

1-2 hours post delivery, then q3-4 hours for minimum of 72-102 hours.

122
Q

why is Naloxone not recommended for NAS

A

can cause seizures

123
Q

when would you consider treating a NAS baby with morphine?

A

NAS >8 x 3 or
>12 x 2
- short half life (9h)
- start at 0.32 mg/kg/day, divided every 4 h–6 h, orally
- If score persists ≥ 8 on 3 (or ≥ 12 on 2) consecutive evaluations, increase by 0.16 mg/kg/day every 4 h–6 h, to a maximum of 1.0 mg/kg/day.
Taper by 10% of total daily dose q48-72 hours when scores <8 for 48 hours

124
Q

what scoring system is used for NAS

A

modified Finnigan scoring system

125
Q

What medications can be used to treat NAS (5)

*table in CPS statement

A

morphine
methadone (long half life)
phenobarbitol- may be used in addition to morphine, especially with poly substance abuse cases
clonidine- requires gradual weaning (can cause rapid increase in BP and HR)
buprenorphine (30% alcohol)

126
Q

what are some nonpharmological treatments for NAS (8)

A 
Skin-to-skin
swaddling
gentle waking
quiet environment
minimal stimulation
low lighting
music and massage
breastfeeding
127
Q

what are some signs and symptoms of NAS

A 
high pitched cry
tremors
increased tone
sweating
fever
yawning
stuffiness
RR>60
excessive sucking
poor feeding
regurgitation
loose stools

(CNS, Resp, GI symptoms)

128
Q

what is the compression to ventilation ratio for NRP

A

3:1

129
Q

NRP: If HR is <100 what should you do?

A

PPV

130
Q

NRP: what percentage oxygen for <35 weeks

A

21-30%

131
Q

For infants <32 weeks how can you prevent hypothermia

A 
maintaining room temperature at 23°C
preheating the radiant warmer
use of a hat
placing a thermal mattress under the radiant warmer
use a polyethylene wrap
132
Q

NRP: when would you consider giving epi?

A

Administer epi if HR <60 despite effective ventilation and 60sec of chest compressions (0.01mg/kg IV or 0.1mg/kg ETT)

133
Q

For the term infant, resuscitation should start with ____ oxygen.

A

21%

134
Q

what is the preferred method for assessment of HR during chest compressions

A

ECG

135
Q

what technique is recommended for chest compressions

A

The two-thumb technique is recommended for chest compressions. The compressor should move to head of bed once airway is secured. Reassessment of heart rate should occur after 60 s of chest compressions.

136
Q

For vigorous term and preterm infants, delayed cord clamping for ______ is recommended

A

30-60s

137
Q

What percentage of kids will present with intracranial bleed with late HDN?

A

50%

138
Q

if metabolic screening is done before 24h of age when does it have to be repeated?

A

within the first week

139
Q

which medication has been shown to reduce the length of stay in hospital in symptomatic infants born to mothers on methadone

A

sublingual buphrenorphine has been shown to reduce length of stay in hospital by 42% in symptomatic infants born to mothers on methadone

  • sublingual
  • half life 24-60h
  • contains 30% alcohol
140
Q

is NAS scoring more or less severe in preterm infants?

A

less severe

CPS statements (24 decks)

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