Random Questions Flashcards
Phenytoin (Dilantin) is often used to control neonatal seizures that are not controlled by Phenobarbital alone. What is the loading dose for Phenytoin in these cases?
10-20 mg/kg IV over 30 minutes
What is the recommended loading dose for Phenobarbital when treating neonatal seizures?
20 mg/kg IV push over 10-15 minutes
What is the typical maintenance dose of Phenobarbital in neonates?
3-4 mg/kg/day divided into two doses
What is an encephalocele and what genitourinary tract abnormality does it suggest?
A neural tube defect characterized by a sac-like protrusion of the brain and the membranes that cover it through an opening in the skull
- Polycystic kidneys, Meckel-Gruber and Walker-Warburg syndromes are commonly associated
What are the 5 components of a complete blood count (CBC)?
Red Blood Cells (RBCs): needed to carry oxygen
White Blood Cells (WBCs): fight infection
Hemoglobin: iron-containing protein
Hematocrit: % of red blood cells in total blood
Platelets: help with clotting
What does the “differential” of a CBC measure and what is it made up of?
The differential measures all WBC types (granulocytes - neutrophils, basophils, eosinophils; agranulocytes - lymphocytes, monocytes, macrophages)
How do you calculate the Immature/Total (I/T) Neutrophil Ratio? What is considered normal?
Add up all of the immature WBCs (bands + metas + myelos) and divide by total neutrophils
Normal: < 0.2
- Values between 0.2 and 0.25 suggest infection
- Values > 0.8 carry high risk of death
How do you calculate absolute neutrophil count (ANC)?
Multiply total WBC by all neutrophil percentages by 10
WBC x (segs + bands + metas) x 10 = ANC
What is a normal ANC?
> 1000
What is the normal neonatal platelet value?
150,000-450,000
What is C-Reactive Protein (CRP)?
CRP is an acute phase reactant that rises in response to sepsis
What is Rh Incompatibility?
The mother is Rh- and the fetus is Rh+
- Fetal blood enters maternal circulation
- Maternal immune system treats fetal Rh+ cells as foreign and makes antibodies against them
- Anti-Rh antibodies may cross the placenta and destroy the fetus’ circulating RBCs
- Leads to anemia, bilirubin release, and jaundice
What is the normal sodium level, what is its purpose, and what happens when values are off?
135-145 mEq/L
- Sodium helps conduct neuromuscular impulses, regulate acid-base balance, and maintain intravascular osmolality
- Abnormal values can cause seizures, CNS hemorrhage, venous vein thrombosis
What is the normal potassium level, what is its purpose, and what happens when values are off?
- 5-5 mEq/L
- Potassium is responsible for cardiac and skeletal muscle contraction and is needed for all cell functions to occur
- Abnormalities can cause weakness, arrhythmias, and death
What is the normal chloride level and what is its purpose?
95-110 mmoL/L
- Chloride works with sodium to maintain acid-base balance, transmit nerve signals, and regulate fluid in and out of cells
What is the normal phosphorus level, what is its purpose, and what happens when values are off?
5-7.8 mg/dL
- Phosphorus is needed for bone mineralization, erythrocyte function, cell metabolism, and the generation and storage of energy
What is the normal magnesium level, what is its purpose, and what happens when values are off?
- 6-2.8 mg/dL
- Magnesium is needed for energy production, cell membrane function, and protein synthesis
When are the symptoms of early onset GBS in neonates generally seen?
In the first 24 hours after birth
When are the symptoms of late onset GBS in neonates generally seen?
Late-onset GBS is seen between days 7-89 of life
What two vessels are connected by a PDA?
Aorta and pulmonary artery
Describe the direction of blood shunting across the PDA
Blood shunts from the aorta (left side of the heart) to the pulmonary artery (right side of the heart). This L–>R shunting increases pulmonary blood flow and volume to the left side of the body (and subsequently less blood flowing to the rest of the body)
What are 3 clinical signs of a PDA?
Murmur (only present in 50%)
Active precordium
Widened pulse pressure (difference between systolic and diastolic - diastolic is unreliable due to blood runoff through the PDA) and bounding peripheral pulses
What effect does blood shunting across a PDA have on the respiratory system?
Increased pulmonary blood flow Pulmonary edema Reduced lung compliance (stiff lungs) Increased WOB Higher vent settings
What are 3 non-medical treatments for PDA?
Fluid restriction
Maintenance of PEEP for alveolar distension
Time
What is the type of medication administered to close a PDA?
Prostaglandin Inhibitor (Indomethacin, Ibuprofen, Acetaminophen)
- Promote ductal closure
- May inhibit platelet function and reduce blood flow to the kidneys and bowel
What is Post-Ligation Syndrome and list some risks associated with PDA Ligation
The baby will be sicker in the first few days following the procedure (lower cardiac output, retracted and compressed lungs during surgery to access PDA)
Risks include atelectasis, pneumothorax, hemodynamic instability, phrenic injury, or vocal cord paralysis
What is synaptogenesis?
The formation of a synapse between neurons, which allows for electrical and chemical signaling between neurons
What is the site of neuronal cell proliferation?
Germinal Matrix
What is the Germinal Matrix?
A transient structure in the brain that disappears around 36-37 weeks gestation
- Made up of highly vascularized, thin-walled, fragile capillary beds
- With poor regulation of cerebral blood flow, risk of vascular injury and IVH increases (95% of IVH’s originate in the GM)
- IVH risk is inversely correlated with gestation
Describe Autoregulation in the preterm baby
The ability to maintain blood flow (and thus oxygen) to the brain
- In preterm infants, vasoactivity (ability to regulate - constrict and dilate - vessels) is immature and dependent on blood pressure, leading to a passive sort of blood flow
- Hypoxia and poor cerebral blood flow are risks for brain injury
What are the two most common types of brain injury?
Germinal Matrix Bleed/IVH and White Matter Injury
Describe the process of Organization when it comes to brain development and how does the NICU change this in preterm babies?
Organization refers to the process of neurons forming systems that communicate with each other and sort of fine-tune and organize input
- Occurs between 24-28 weeks
- Patterns of organization are altered when the baby is born early and this is happening outside of the womb
When are all major sensory structures formed and in place?
23-25 weeks
What is Sensory Processing Disorder?
Difficulties interpreting and using sensory information from the environment for behavioral regulation and motor performance
- Affects 39-52% of preterm infants
What is Sensory Modulating Disorder?
Difficulties regulating responses to sensory stimuli
- Affects daily functioning, ability to purposefully interact, and influences arousal and alertness
- Some people have a low threshold for sensory stimuli, others have a high threshold and are under-responsive to sensory stimuli, while others frequently seek out more stimulation
When does the stratum corneum begin to develop?
23-24 weeks
When does the germinal matrix disappear and why is it the most common site for IVH?
36 weeks - highly vascularized, thin-walled vapillaries
List 3 clinical sequelae of inadequate surfactant production
- Decreased lung compliance
- Decreased functional residual capacity (FRC)
- Reduced gas exchange
What is the target sPO2 immediately at birth and how do you calculate the goal with each subsequent minute of life?
60%
Add 5% per minute of life
- At 1 minute: 65%
- At 3 minutes: 75%
- At 5 minutes: 80-85%
- At 10 minutes: 85-95%
Should you suction the nose or mouth first?
Mouth
During resuscitation, when is PPV indicated?
Gasping or inadequate respirations, apnea, HR < 100 even if breathing, low sPO2 despite 100% fiO2 delivery via CPAP
During resuscitation, when is CPAP indicated?
Spontaneous breathing but insufficient respirations, HR > 100, labored respirations, inadequate oxygenation
During resuscitation, when are chest compressions indicated?
If the HR remains below 60 after 30 seconds of effective PPV
What do ABGs measure?
Acid-base balance; used to determine the extent of compensation by the buffer system
What is pH and what is the normal ABG level?
The concentration of Hydrogen ions; determines acidity or alkalinity of body fluids; 7.35-7.45
What is PaCO2 and what is the normal ABG level?
The partial pressure of carbon dioxide; shows adequacy of gas exchange; hypoventilation leads to CO2 buildup and acidosis results; 35-45
What is PaO2 and what is the normal ABG level?
Partial pressure of oxygen; indicates amount of oxygen able to bind with hemoglobin; low pH means less oxygen in hemoglobin; 75-100
What is HCO3 and what is the normal ABG level?
Bicarbonate; an alkaline substances; a deficit indicates metabolic acidosis; 22-26
What is the respiratory determinant in ABG analysis?
PaCO2; if low, suggests infant is hypoventilating and retaining CO2, leading to acidosis
What does a low or high base excess indicate?
A value of less than -2 is acidosis and a value of greater than +2 is alkalosis
Is the baby acidotic, normal, or alkalotic with a PaCO2 value of 17?
Alkalotic
How do the lungs control pH?
Vary the amount of CO2 that is excreted by hyper- or hypo-ventilating
How do the kidneys control pH?
By varying the rate of HCO3 excretion
What are two maternal screening tests available to help predict the probability of preterm birth?
- Cervical length: cervix shortens as gestation increases (if it is short early on, may predict PTL)
- Fetal fibronectin (FFN): an extracellular protein that holds the fetus inside the uterus and is absent or present in low levels after 22 weeks - elevated levels are associated with increased risk of PTL
How does maternal tobacco smoking affect the fetus in utero and what might we expect clinically in these neonates?
Carbon monoxide crosses the placenta and displaces oxygen from hemoglobin, leading to decreased oxygen delivery to the fetus
- Infants exposed to tobacco may be SGA, have congenital defects, and are more likely to be born early
What percentage of preterm births are due to multiple gestation?
10%
What is given to babies at birth to help prevent infection?
Erythromycin ointment
What is gestational hypertension?
Elevated blood pressure without proteinuria and normal lab tests after 20 weeks
What is preeclampsia and what are some risk factors and signs/symptoms?
Elevated blood pressure with proteinuria and/or end organ compromise after 20 weeks
- Pre-gestational diabetes, chronic hypertension, chronic renal disease
- Oliguria, pulmonary edema, epigastric pain
What is HELLP Syndrome?
A variant of preeclampsia that often occurs between 27-37 weeks but may develop 24 hours postpartum
- Hemolysis
- Elevated Liver enzymes
- Low Platelets
Why are infants of mothers with preeclampsia often small in size and what are these infants at risk of developing?
Long standing hypertension leads to utero-placental vascular insufficiency, which impairs the transfer of nutrients and oxygen to the fetus
- Thrombocytopenia
What perinatal medication may be given to provide fetal neuroprotection and what are some side effects of this drug in the neonate?
Magnesium Sulfate
- Hypotension, apnea, bradycardia, hypotonia, motor depression, decreased bowel motility
What are some clinical features of neonatal withdrawal?
Hyperirritability, wakefulness, diarrhea, loose stools, tachypnea, fever
Define placental abruption and what are some risk factors?
Sudden, premature placental separation (partial or complete detachment) from the uterine wall
- Risk factors include PROM, hypertension, cocaine and tobacco use, previous abruption, trauma, uterine anomalies
Define placenta previa and what are some risk factors?
Occurs when the placenta implants in the lower part of the uterus over the cervix
- Risk factors include advanced maternal age, increased parity, previous c/s, tobacco and cocaine use
- Infants tend to have poor growth, anemia, and increased risk of congenital anomalies
What is the most common cause of death in ELBW neonates between days 15-60?
NEC
What is the most common cause of death after day of life 60?
BPD
What two disorders affect motor function later in life for ELBW neonates?
Cerebral Palsy and Developmental Coordination Disorder (DCD)
- Often associated with clumsiness and difficulties with balance, coordination, manual dexterity, and hand-eye coordination
How do NICUs use quality improvement (QI) to reduce morbidities?
QI seeks to standardize processes and structure to reduce variation, achieve predictable results, and improve outcomes for patients
What 3 characteristics are vital to the makeup of a small baby unit?
- Core team (self-selected)
- Consistent strategy (shared mental model based on evidence and unit context)
- Separate location (developmentally appropriate)
What are the 5 stages that make up Swanson’s Theory of Caring?
- Maintaining Belief (philosophical attitudes towards people in general)
- Knowing (informed understanding of the clinical condition)
- Being With (messages are conveyed to the client)
- Doing For (therapeutic actions)
- Enabling (therapeutic actions)
What 4 psychological tasks does a mother experience throughout the process of being pregnant, giving birth, and transitioning to role as mother (maternal role attainment)?
- Ensuring safe passage
- Acceptance by others
- Binding in to child
- Learning to give of oneself
What 3 cognitive processes do women use to achieve the 4 psychological tasks of maternal role attainment?
- Replication and Mimicry
- Fantasy
- De-differentiation
What is “ensuring safe passage” related to maternal role attainment?
A “psychological task” of maternal role attainment related to seeking the means to assure a secure and healthy pregnancy and childbirth
- Hormones play a role in this
What is “acceptance by others” related to maternal role attainment?
A “psychological task” of maternal role attainment related to accepting herself as a mother, potentially identifying role models with respect to parenting
What is “binding-in to child” related to maternal role attainment?
A “psychological task” of maternal role attainment related to attachment and establishing a direct experience between mother and child (may happen when mom feels the baby move - quickening - which is around 20 weeks)
- Helps the baby go from an idea to a human
- Preterm births take away weeks and months of this binding-in and relationship forming between mother and fetus
What is “learning to give of oneself” related to maternal role attainment?
A “psychological task” of maternal role attainment related to psychological, physical, and social changes that are required to make for the benefit of the baby
What is “replication and mimicry” related to maternal role attainment?
A “cognitive process” of maternal role attainment where the mother internalizes signals that affirm or reject maternal behaviors
- Replication: search for maternal behaviors she wants to use herself
- Mimicry: imitating behaviors seen by other mothers
- Role-Play: an interactive method where mother sort of “tests out” behaviors
What is “fantasy” related to maternal role attainment?
A “cognitive process” of maternal role attainment involving an introspective way for a pregnant woman to deal with hopes and fears
- Sort of a safe place to test behaviors and determine what is acceptable and how she wants to mother
What is “de-differentiation” related to maternal role attainment?
A “cognitive process” of maternal role attainment where the mother determines congruence of fantasy and reality (where she is and where she hopes to be)
What are the 5 dysfunctions of a team?
- Absence of trust
- Fear of conflict
- Lack of commitment to a common course of action and end goal
- Avoidance of accountability
- Inattention to results
What are 4 types of information exchange between teams?
- Briefs (planning): like a huddle to ensure roles and responsibilities
- Debriefs (process improvement): space for feedback after something has happened
- Handoff (SBAR)
- Huddle (problem solving): discusses critical issues and emerging events, anticipates outcomes
What are some challenges to continuity of care?
- Blurred boundaries (“my baby”)
- Role clarity/overlap (speech & lactation)
- Emotional burden (compassion fatigue)
- Maintaining professionalism and balance (losing objectivity)
- Hero worship (poor or excellent continuity from certain staff and not others - parents may “worship” certain people)
List 3 respiratory benefits associated with prone and left lateral positioning
- Higher O2 saturations
- Increased tidal volume
- Decreased obstructive apnea
What are 2 classic signs of Symptom of Inappropriate Antidiuretic Hormone Secretion (SIADH)?
Excessive weight gain and low sodium levels
What are three classic signs associated with renal vein thrombosis?
Hematuria (blood in urine), hypertension, and a flank mass
What is the best lab to use in assessing kidney function?
Creatinine
Hearing loss is a rare side effect from what type of infection?
Viral
What condition refers to bronchospasms leading to airway obstruction?
Asthma
Which stage of ROP involves the presence of a demarcation line and where is it found?
Stage 1 - appears between the vascularized and avascular retina
What is the biggest risk factor for developing ROP?
Extreme prematurity
List the five stages of grief in the Kuebler-Ross model
Denial, anger, bargaining, depression, and acceptance
What is Anticipatory Grief?
Occurs when someone anticipates death or morbidity for themselves or someone else
What percentage difference must the oxygen saturation of the right hand and either foot be within in order to pass a CCHD screen?
3%
Which babies are required to pass a car seat fit and test?
Those born less than 37 weeks (regardless of corrected gestational age at discharge)
When is the MMR vaccine given to children?
12 months
How long should the newborn screen be delayed for and why?
At least 24 hours post birth since some conditions may not be picked up if drawn before
What is Crew Resource Management?
A model of using a team approach to assess for errors before they occur using elements such as situational awareness, communication, etc.
What type of communication occurs when one person verifies out loud what the other person is saying or asking them to do?
Closed-loop
When can infants focus on objects 8-12 inches away?
1 month
Around when can infants start to roll from tummy to back?
4 months
Define the ethical principle non-maleficence
Not doing harm
Which phase of the Plan-Do-Study-Act (PDSA) cycle involves evaluating if the intervention worked well or not?
Study
Describe the “act” phase of the PDSA cycle
Expanding the intervention or modifying it based on the “study” results
In which phase of the PDSA cycle are the root causes determined?
Plan
Define “benchmarking” in healthcare
When one compares individual data with an industry’s standard
What happens in the neonate when the cord is clamped in terms pulmonary vascular resistance?
Pulmonary vascular resistance decreases as the fluid is squeezed out of the alveoli and the infant begins to perfuse its lungs
What is delivery en caul?
Delivering the baby within the sac and not breaking it until the baby is born
What percentage of newborns require respiratory assistance of some form at birth?
10%
You are examining a new baby in the NICU and notice there is sparse lanugo, minimal vernix, and visible veins through the skin. What week gestation do you anticipate this baby is?
24-25 weeks
What percentage fiO2 is recommended to start with for resuscitation in infants <28 weeks?
Guidelines suggest using a blender and initially setting it at 0.30 for babies <28 weeks
What are some risks associated with use of CPAP?
Insufficient inflation of the lungs, gastric distension, or pneumothorax
What does “InSurE” stand for?
Intubate
Administer Surfactant
Extubate
What is Less Invasive Surfactant Therapy (LISA)?
When you give surfactant directly into the trachea via a small tube or catheter (baby must be spontaneously breathing for this to work)
What are some CPAP concerns for ELBW infants?
Difficult to fine adequate fit/seal without risk of skin injury, discomfort/irritability, intermittent hypoxia with apnea and desaturation, abdominal distension leading to feeding intolerance and interferes with lung expansion
During resuscitation, when do you stop compressions?
When HR is > 60 (continue PPV until HR is > 100 and baby breathes spontaneously)
What is the risk if volume expanders are administered too fast?
IVH
What is the recommended dose when using 0.9% NaCl as a volume expander in the delivery room?
10 mL/kg
When is it recommended to initiate parental nutrition and at what rate?
Within 30 minutes of delivery, generally started on total fluids of 80-100 ml/kg/day
Define “early preterm”
<34 weeks
Define “late preterm”
34 to 36+6
Define “early term”
37 to 38+6
Define “full term”
39 to 40+6
Define “late term”
41 to 41+6
Define “post term”
> 42 weeks
What is the half-life of caffeine?
5-7 days
Define steady state
A concentration of drug in the body whereby the rate of administration is equal to the rate of elimination
What disease process can hydrocortisone cause due to its effects on increased calcium excretion via the kidneys?
Osteopenia
What is the first line of treatment for hypotension in neonates?
Normal saline bolus
When given too quickly, what IV medication can lead to rigid chest syndrome?
IV Fentanyl
What is a side effect of indomethacin on the kidneys?
Oliguria due to kidney injury
What is a side effect of a long Gentamicin course?
Ototoxicity
Why is absorption of medication sometimes augmented in preterm neonates?
Gut motility organizes between 33-36 weeks, reduced intestinal surface area, variation in enteric blood flow, gastric pH is age-dependent and changes with frequency of enteral nutrition (this affects bioavailability)
List 3 situations in which rectal administration of medication may be indicated despite its erratic absorption
Nausea, vomiting, seizures
Define bioavailability
The amount of drug that reaches intended site of action
Define volume of distribution as it relates to pharmacokinetics
The amount of drug in the body relative to plasma concentrations (takes into account loading doses, half-lives, and drug clearances); tends to be higher in neonates for water-soluble drugs because they are ~85% water
How does the volume of distribution change based on adipose tissue?
Less adipose tissue leads to a lower volume of distribution and increased levels in the blood
What are 3 reasons hepatic metabolism is reduced in neonates and what can result?
- Decreased hepatic blood flow
- Decreased cellular uptake of drugs
- Decreased hepatic enzyme capacity
- These can lead to increased drug accumulation, higher risk of drug toxicity and elevated half-life
What is the primary site of elimination? List 3 less common sites
Kidneys (lungs, liver, salivary/sweat glands)
Where is the most common site of IVH and what is the associated grade if limited to this site?
Germinal Matrix - Grade I
What are the most common types of seizures seen in the NICU and what are some clinical signs?
Subtle seizures. Bicycle pedaling movements, eye deviation, lip smacking
What grade IVH is hemorrhage without dilation of the ventricles?
Grade II
List 6 strategies to decrease TEWL
- Plastic wrap
- Incubator rather than warmer
- Humidity
- Transparent adhesive dressings
- Emollients
- Supplemental conductive heat (heated mattress)
What is the suggested humidity guideline for the first week of life in ELBW neonates born 23-26 weeks gestation?
80-85%
What is the suggested humidity guideline for the first week of life in ELBW neonates born 27-30 weeks gestation?
70-75%
How does the stratum corneum differ among term, 28-weeks, and 23-weeks gestation?
Term: 10-20 layers
28-Weeks: 2-3 layers
23-Weeks: 3-5 cell layers of epidermis covered by thin SC
At what age are ELBW infants screened for Osteopenia of Prematurity and what are the labs?
4 weeks - alkaline phosphorus, calcium, phosphorus
Which is a sign of septic shock - metabolic alkalosis or acidosis - and why?
Metabolic acidosis; sepsis generally causes hypotension, which leads to tissues not receiving enough oxygen causing acidosis buildup
What I/T ratio is suggestive of possible infection?
Greater than 0.2 – An increased number of immature WBCs compared to mature WBCs indicates the mature WBCs may have died off fighting the infection and are being replaced with immature WBCs
What is the normal I/T ratio?
Less than 0.2
What are the two most useful labs in detecting late-onset sepsis?
Total neutrophil ratio (I/T Ratio) and C-reactive protein (CRP)
What is the I/T Ratio?
I: Immature
T: Total
I/T Ratio determines the percentage of immature to total white blood cells
- If the I/T ratio is > 0.2, there are more immature than mature neutrophils in the bloodstream, indicating an infection
List 10 risk factors for preterm birth
- Multiple gestation
- Extremes in maternal age
- History of preterm birth
- Genetics
- Stress/Anxiety
- Ethnicity
- Illicit Drug Use
- Infection
- Physical Injury
- IVF
What body systems tend to be most affected in neonates born by C/S versus vaginally?
Respiratory (no squeeze) and GI
What percentage of infants delivered 22-23 weeks survive to discharge?
78%
What percentage of infants delivered 24-25 weeks survive to discharge?
89%
What are 9 common neonatal morbidities?
- Severe IVH
- Chronic Lung Disease
- NEC
- Pneumothorax
- Early Infection
- Late Infection
- Intraventricular Leukomalacia
- BPD
- Growth Failure
What is the ultimate goal in Quality Improvement (QI) to reduce morbidities?
Reduction of practice variability
A one-week old former 27-weeker has a large PDA. What is the optimal fluid management for this infant?
A. Give less fluids than normal
B. Give more fluids than normal
C. Give normal amount of fluids
A. Give less fluids than normal - fluid restricting premature infants doesn’t close a PDA, but it may reduce the risk of it re-opening
A three day old 28-weeker is on a conventional vent and is ready to be extubated. A gas shows the following: pH 7.54 / pCO2 29 / PO2 75 / HCO3 26. What is this infant most at risk for given these results?
A. Hyperglycemia
B. IVH
C. PDA
B. IVH - low pCO2 cause cerebral vasoconstriction, which may cause IVH
Which of the following interventions is most useful when engaging with the vision sense?
A. Developmentally appropriate visual recording
B. High contrast colored mobiles
C. Parental gaze
C. Parental gaze - this is the most important way to engage with an infant’s sense of vision
A former 24-weeker is now 3 months old and requires CPAP. A recent ECHO reveals a small PDA with L-to-R shunting. Which is the best way to reduce the development of cor pulmonale?
A. Diuretic administration
B. PDA closure with medication
C. Prevent hypoxemia
C. Prevent hypoxemia - cor pulmonale is right ventricular heart failure, commonly caused by BPD and pulmonary hypertension. Preventing hypoxemia reduces hypertension
A two week old former 25-weeker develops NEC and shock. A cortisol level is drawn and found to be low. Hydrocortisone is started due to suspected what?
A. Adrenal insufficiency
B. Hyperpituitarism
C. Hypothyroidism
A. Adrenal insufficiency - preterm infants become adrenally insufficient when under stress
How do you calculate ANC?
(% neutrophils + % immature cells)) / (100)
Multiply that number by the number of WBCs
- If we have WBC: 4.2 (x1000), Segs: 21%, Bands: 7%, Myelo 3%, Promyelo 3%
- We take 21 + 7 + 3 + 3 = 34
- Divide 34 by 100 = 0.34
- Multiple 0.34 by total WBC (4200)
ANC = 0.34 x 4200 = 1428
ANC <1500 is concerning for sepsis
What is the primary site of drug elimination?
Kidneys
What type of infections do we use Gentamicin for and what are special considerations when used in neonates?
Gentamicin treats gram negative infections (usually caused by E. coli)
- Neonates require higher dosing to a high volume of distribution
- Eliminated 100% via kidneys (neonates have reduced renal clearance)
What type of infections does Vancomycin treat and what are some considerations when used with neonates?
Vancomycin treats gram positive infections (usually caused by Staph. aureus)
- Excreted in the urine (may cause nephrotoxicity)
- Aim for therapeutic level of 10-20 mg/L
What do NICUs use Methylxanthines for?
Treatment of apnea of prematurity
- Theophylline: narrow therapeutic index and requires levels to monitor
- Caffeine: longer half-life in neonates due to reduced hepatic clearance, daily dosing and no need for monitoring levels
What are the two indications for use of Phenobarbital in neonates?
To treat neonatal seizures and to assess biliary function
- Increased distribution into the brain with increased age
- Hydrophilic (higher volume of distribution)
- Long elimination half-life in neonates
What are some signs of Phenobarbital toxicity?
Over-sedation, miosis (pupil constriction), arrhythmia
What is Morphine used for in NICUs?
Sedation and analgesia
- Lower dosing in neonates
- Reduced renal clearance in neonates leads to increased accumulation of the drug
- Side effects include respiratory depression and decreased GI motility
What is the indication for use of Fentanyl in NICUs?
Sedation and analgesia
- Rapid onset and short duration of action
- 50-100 times more potent than morphine
- Highly lipophilic (small volume of distribution in neonates)
- Clearance via the liver is dependent on hepatic perfusion (reduced clearance leads to longer half-life)
According to what timeline are immunizations administered in the preterm neonate?
Every baby should get vaccines on the same schedule based on chronological age (not based on gestational age or weight at birth)
What is the Kleihauer Betke test used for?
The Kleihauser Betke test is utilized to determine if there is fetal blood in maternal circulation (assesses probability of fetomaternal hemorrhage)
- A Rh- mother will form anti-Rh antibodies if Rh+ fetal blood enters maternal circulation
- These anti-Rh antibodies will destroy fetal Rh+ and RBCs in future pregnancies
- Based on the results you can calculate appropriate dosing of anti-Rh globulin (RHOGAM))
What is Symmetric IUGR?
Primary or symmetric IUGR occurs when all parts of the body (including internal organs) are proportionately small in size
What is Asymmetric IUGR?
Secondary or asymmetric IUGR occurs when the baby’s head and brain are normal sized, but the abdominal area and rest of the body are abnormally small
What are the causes of IUGR?
IUGR is caused by an inadequate supply of nutrients and oxygen to the fetus (the leading cause is placental insufficiency)
- Other potential causes include substance use, maternal infection, maternal hypertension, and genetic anomalies
What is OFC and how do you measure it?
Occipital Frontal Circumference (head circumference)
- Measured over the most prominent part on the back of the head (occiput) and just above the eyebrows (supraorbital ridges)
What is the I/T ratio, how do you calculate it, and what is it used for?
Immature-to-Total Neutrophil Ratio
- Provides information about risk of early-onset sepsis
- Divide the total number of IMMATURE neutrophils (promyelocytes, myelocytes, metamyelocytes, bands) by the TOTAL number of neutrophils (immature + segmented neutrophils)
When is Early Onset Sepsis (EOS) diagnosed?
Within the first 72 hours of life
- Usually due to vertical transmission (from mother) from contaminated amniotic fluid or contact with bacteria in the lower genital tract
When is Late Onset Sepsis (LOS) diagnosed?
After the baby is at least 3 days old (usually the result of nosocomial infections)
What is the clinical presentation of sepsis by body system?
CNS (temperature instability, lethargy, irritability, hypertonic, hypotonia, seizures)
Respiratory (cyanosis, grunting, retracting, apnea, increased oxygen needs)
GI (poor feeding, emesis, distension, diarrhea)
CV (pallor, mottling, hypotension, decreased perfusion, edema)
Skin (rashes, erythema, edema)
Hematopoietic (jaundice, bleeding, thrombocytopenia)
Metabolic (glucose instability, metabolic acidosis)
What are the signs and symptoms of Meningitis?
Generalized signs/symptoms of sepsis, increased irritability, high-pitched cry, increased ICP (bulging fontanel, emesis, decreased tone), seizures
If we have a WBC of 15,000, 35% segmented neutrophils, 15% band neutrophils, 3% metamyelocytes, how do we calculate ANC?
- Add % of segs, bands, and metas (35 + 15 + 3 = 53)
- Multiply that number by the total WBC (53 x 15,000 = 795,000)
- Divide 795,000 by 100 = 7950
ANC = 7950
How is calculating the I’T ratio helpful in determining if an infection is present?
Most of the neutrophils should be mature (segmented) so an elevated level of immature neutrophils would raise suspicion that more immature cells are being released to help the mature neutrophils fight an infection
If we have a WBC of 15,000, 35% segmented neutrophils, 15% band neutrophils, 3% metamyelocytes, how do we calculate I/T Ratio?
- Add total immature cells (bands + metas = 15 + 3 = 18)
- Add the total number of neutriphils (bands + metas + segs = 15 + 3 + 35 = 53)
- 18 divided by 53 = 0.34 (I/T Ratio)
I/T Ratio of > 0.2 raises suspicion for infection
I/T Ratio of > 0.8 is correlated with higher risk of death from sepsis
What is CRP?
C-Reactive Protein: a non-specific marker for inflammation that is useful when trended
- CRP levels remain high as long as inflammation or tissue damage persists, then decrease rapidly
Which type of ROP involves dilated and tortuous vessels?
PLUS disease (diagnosed when tortuous vessels are seen in at least 2 quadrants
What is the red reflex and what does it signify?
The red reflex is a reflective phenomenon seen when light passes through the pupil and is reflected back off the retina creating a reddish-orange glow
- This test can reveal problems in the cornea, lens, vitreous, and retina
What does it mean for a drug to have a narrow therapeutic index?
A narrow therapeutic index means that small differences in dose or blood concentration may lead to therapeutic failures or adverse drug reactions
- The smaller the therapeutic index, the more dangerous the drug (watch for toxicity)
What is the difference between pathologic and physiologic jaundice?
Physiologic jaundice follows a typical pattern, peaking around DOL 3-4 and declining over the next week (sometimes results from dehydration/inadequate milk intake when breastfeeding)
- Jaundice becomes pathologic if it occurs in the first 24 hours of life and requires immediate intervention
- Causes of pathologic jaundice include sepsis, rubella, toxoplasmosis, occult hemorrhage
Why does jaundice occur?
Immature liver has trouble converting conjugated bilirubin to unconjugated bilirubin to be able to excrete it from the bloodstream
If a Jehovah’s Witness declines a blood transfusion, which other product can you use?
Normal Saline
What 4 things must be proven to make a malpractice case?
- Medical duty of care
- Breach of that duty
- Injury caused by that breach of duty
- Damages
What is the major difference in venous versus arterial blood gas samples?
Good correlation for most values except for PO2
- Arterial PO2 is typically greater than venous with significant variability
What is Blueberry Muffin Syndrome and what is it suggestive of?
Refers to a skin appearance with multiple raised, cutaneous, blue/purple lesions which may be suggestive of congenital infection (CMV, rubella), hematologic disease (ABO or Rh incompatibility), and malignant cancers
What is the Harlequin Sign?
A transient skin condition characterized by asymmetric/unilateral flushing/erythema
Through which vessel of the umbilical cord does unoxygenated blood from the fetus reach the mother?
Umbilical arteries (2)
Through which vessel of the umbilical cord does the mother pass oxygen-rich blood to the fetus?
Umbilical vein (1)
What are the major risk factors for neonatal sepsis?
Preterm birth, maternal GBS colonization, ruptured membranes > 18 hours, maternal symptoms of chorioamnionitis
- Other risk factors include recent maternal infection, any procedures or instrumentation used with delivery
How do you treat respiratory acidosis?
CPAP, PPV, Intubation (increase VT and/or rate)
What are the indirect and direct Coombs test looking for?
The indirect Coombs test screens women for antibodies that may cause hemolytic disease of the newborn (ABO or Rh incompatibility)
The direct Coombs looks for autoimmune hemolytic anemia
What are 4 classic signs of duodenal atresia?
Polyhydramnios during pregnancy, vomiting in the first 24 hours of life, abdominal distension, and absence of stool
What are 3 characteristics of pressure-support ventilation (PSV)?
Pressure-limited, constant in flow, and time-cycled
What size ET tube do you use in neonates below 1000g and <28 weeks?
2.5
What is the Lip-to-Tip Rule?
When determining how deep to insert an ET tube, add 6 to the infant’s weight in kg
How deep do you insert an ETT for an ELBW infannt?
Between 5.5-7cm
Where do you want to see the ETT on CXR?
Mid-trachea or halfway between the clavicles and the carina
What are the indications for placement of a UVC?
To provide emergency fluids and medications during resuscitation, if unable to start or maintain a PIV, to provide glucose greater than D12.5, when an exchange transfusion is necessary
What makes up a normal, 3-vessel umbilical cord?
1 vein and 2 arteries
Which direction (to or from baby) do the umbilical vessels travel?
1 vein goes from placenta —> baby
2 arteries go from baby —> placenta
