User:Vpardeshi/sandbox

Presentations on Team Rounds
• Be succinct without extensive editorializing  • “Organ System” approach is suggested to help with organizing patient data: - FEN/GI - Respiratory -Heme - Cardiovascular - CNS/Metabolic - ID - Social/Discharge Planning  • Think about and make an assessment & plan on each problem before rounds.  o A good deal of the learning will be by discussions during rounds. Please ask questions, add your knowledge, and disagree as you see fit 

Charting
• Daily Notes – preprinted progress note templates will be provided by the attending usually the previous day or at least before morning rounds. You are expected to fill out as much of the note as possible before presenting the patient on rounds. An initial assessment and plan should be included. The attending will amend the notes as required • Procedure Notes - for lines, chest tubes, intubations, transfusions, etc. – even if unsuccessful. Make sure to include/document that “Time Out” was performed  • Progress Notes Æ IMPORTANT- document in the progress notes any changes to patient’s condition, medical plan, or family conferences at the time of the occurrence • On-going transfer/discharge summary – update on the computer a couple times a week  <ol>• Time and date ALL NOTES</ol>

Parental Contact
<ol>• Speak with the patient’s parents at least twice a week. Contact them with any important changes in the patient’s condition such as intubation, sepsis evaluations, transfusions </ol> <ol>• Inform parents were their child is transferred to level II. They are very scared when they call to check on their child and are told that the baby is gone!!!</ol>

In the Delivery Room
1. For the VLBW infant in the stabilization room, remember thermal control is a major issue! • Raise the air temperature of the stabilization room to a maximum and raise the temperature of the scrub room to 72-74°F • As soon as possible after drying the infant, cover with plastic wrap • Keep the stabilization unit doors closed 2. Prior to the birth, have all equipment at the bedside and verify that it is functioning properly. It is VITAL to check your equipment and have the appropriate sizes handy! • Neopuff with appropriate settings preset and O2 on • Laryngoscope with functioning bulb & correct size blade • ETTs • Suction • CO2 detector • Fully stabilize and provide initial support in the stab room prior to transfer to the nursery • Remember to assign APGAR scores, sign orders, and document the resuscitation on the infant birth record sheet • Notes and orders should be complete

General Principles
Drying, Warming, Positioning, Suctioning, Tactile Stimulation

Oxygen Bag-Mask Ventilation Chest Compressions Intubation Meds

Thermoregulation
• Infants <30 weeks are admitted to a “maximally humidified” incubator (80% humidity) with patient temperature servo control • Infants >30 weeks and <34 weeks are admitted to a 40% humidity incubator with patient temperature servo control • Infants >34 weeks are admitted to a radiant warmer that also has patient control of the temperature

Temperature
• Normal axillary temperature range: 36.5 - 37°C (97.9 - 98.3°F) Hypo/hyperthermia:  environmental factors  sepsis  prematurity  postasphyxial insult

Heart Rate
• Normal range 80-160 bpm; rate is lower during sleep & more rapid during crying

Persistent bradycardia (HR <80) = abnormal
 congenital heart block  sepsis  asphyxia  hypoxemia

Persistent tachycardia (HR >180) = abnormal
 anemia  hypoxemia  hypovolemia  sepsis  hyperthermia

Heart Sounds:
<ul>o S1 (“lub”): closure of tricuspid/mitral valves after atrial ejection of blood </ul> <ul>o S2 split (“dub”): closure of aortic/pulmonary valves after ventricular ejection of blood  slight separation of valve sounds is evident after 24-48 hours of age resulting in normal split sound  single S2 with click and SBP differential of >20mmHg between upper & lower extremities may indicate coarctation</ul> <ul>o S3: produced by vibration during ventricular filling Æ can be normal in newborn</ul> <ul>o S4: gallop rhythm is always abnormal</ul>

Respiratory Rate
• Normal range 30-60 breaths/min o Apnea = cessation of breathing for >15 seconds  prematurity  CNS injury  sepsis  metabolic abnormalities (hypoglycemia, hypocalcemia, hypermagnesemia)  anemia o Tachypnea = RR >60 breaths/min  pulmonary, cardiovascular, metabolic disease

Blood Pressure
• Neonatal blood pressure is affected by gestational age, birth weight, and day of life • In the first few days of life, we follow Mean Arterial Pressure to assess for hypotension o a general starting rule is that the MAP should be ≥ the gestational age. o this rule can be changed depending on the cardiac function and whether pulmonary hypertension is present • A widened pulse pressure can be a sign of a patent ductus arteriosus o widened pulse pressure is (systolic BP – diastolic BP) > ½ of systolic BP

Hypertension in Neonates
• For All Infants Æ Verify that the correct size cuff is used and that the infant is quiet during the assessment. May need to look at trends over a few days. • For Term Newborns: Age Group                     Significant Hypertension                             Severe Hypertension Newborn - 7 days          systolic BP>96                                            systolic BP>106 8 - 30 days                    systolic BP>104                                          systolic BP>110 Published by Second Task Force on Blood Pressure in Pediatrics 79(1) 1987 • For Preterm Neonates The following graph published by Zubrow et al in Journal of Perinatology vol. 15 1995 demonstrates the normal range of blood pressure for postconceptional age (gestational age). Measurements above the 95% confidence limit are considered hypertension.

Admission
• In the stabilization unit, every newborn is placed under a warm radiant warmer with patient temperature control. Infant is dried and hat is placed • VLBW infants are covered with plastic wrap or placed in plastic bag • Infants <30 weeks are admitted to a “maximally humidified” incubator (80% humidity) with patient temperature servo control o Patient temperature servo control means that a temperature probe on the infant’s skin controls the changes in temperature of the incubator o I.e. if the infant starts to get cool, the incubator will heat up • Infants >30 weeks and <34 weeks are admitted to a 40% humidity incubator with patient temperature servo control • Infants >34 weeks are admitted to a radiant warmer that also has patient control of the temperature

Management during Delivery
Gastroschisis : Usually cesarean recommended for decreased chances of infection and low chances of injury to mesentry and abdominal organs, however controversial On delivery, the infant's trunk and lower extremities should be placed in a sterile plastic "bowel bag." Sterile, moist gauze dressings, covered by a transparent plastic film have also been used to cover the exposed tissue. The use of moistened gauze dressings is associated with several problems including hypothermia caused by increased insensible water loss and radiant heat loss from the larger surface area of the exposed bowel, tissue trauma, and infection. Ensure patent airway and nasogastric tube to prevent gastric distension Infant placed under preheated warmer to decrease heat loss intubation indicated if the child is in distress this newborn is at increased risk for fluid loss, and hence shock fluid resuscitation keeping in mind glucose load Nasogastric or orgastric tube inserted and placed to intermittent suction to ensure decompression, important to prevent partial or total obstruction of blood flow Position infant right lateral decubitus to enhance venous blood return to the gut Antibiotics like ampicillin and gentamycin are started to decrease risk of infection from exposed bowel

Diaphragmatic Hernia [: There is usually pulmonary hypoplasia associated with diaphragmatic hernia. Bag and mask ventilation is avoided pass nasogastirc tube for immediate gastric decompression Continuous cardiac monitoring, ABG and systemic pressure measurements, urinary catheterization to monitor fluid resuscitation Both preductal (radial artery) and postductal (umbilical artery) oximetry Pressure limited ventilation to be used with PIP below 30 cm H2O High frequency oscillatory ventilation /ECMO or iNO used if stabilization difficult Surfactant rescue or prophylactic therapy helps in improvement in oxygenation. Efficacy of iNO improves after surfactant therapy

Meconium aspiration [: Intubation and tracheal suctioning is required Attach meconium aspirator to the suction device Intubation and suction should be repeated until the aspirated material is cleared or the newborn’s heart rate falls below 100 beats/min.

Shoulder Dystocia [: Usually fractured clavicle associated Upper arm muscles involved with c5, c6 involvement of brachial plexus May involve humeral fracture: heals spontaneously Most feared complication is fetal asphyxia

Perinatal asphyxia : It is the major contributor of morbidity and mortality 1) gentle cleaning of the airways 2) Breathing: maintain a good ventilation. Oxygen is toxic not only to preterms but also term babies 3) Cardiac activity: Maintain a good BP 4) Drugs: Beta mimetics, NaHCO3, surfactants should be used carefully