1 | P a g e
STABLE Course Notes
1. Sugar & Safe Care
Aim for 2.8-6.0 mmol/L
Avoid enteral feeding – insert IVC or UVC
Risk...
2 | P a g e
 Seizures
Treatment
1. D10W @ 80ml/kg/day via infusion pump (approx 5.5mg/kg/min)
a. Central line for D15W an...
3 | P a g e
STABLE Course Notes
2. Temperature
Maintain whether patient well or unwell
1. EARLY Prem & SGA at ↑ risk of hy...
4 | P a g e
Physiological response to hypothermia (term infants)
Cold stress
Hypothalamus stimulated
Norepinephrine releas...
5 | P a g e
 ↓ resp rate
 ↑ sepsis risk
 DIC
 ARF
NB For re-warming, incubator is best choice. Set to air temperature ...
6 | P a g e
STABLE Course Notes
3. Airway
Arterial Blood Gases (CUMH)
pH 7.30-7.45 (7.26 acceptable)
pCO2 35-45mmHg (4.5-6...
7 | P a g e
pO2 blood > pO2 tissues
100mmHg > 23mmHg
↑ HCO3- = compensating respiratory acidosis
↓pCO2 = compensating meta...
8 | P a g e
PIP 14-22 18-24 20-28
PEEP 3-4 4-5 4-5
↑ PIP = ↑ TV = ↓ pCO2
↑ PEEP = ↓TV (unless ↑ PIP) = ↑pCO2
NB Adjust PEE...
9 | P a g e
 CXR
 Pre & post-ductal SpO2% - observe for PPHN. Greater than 10% difference = R-L shunting
 Vitals
 Volu...
10 | P a g e
STABLE Course Notes
4. Blood Pressure
Hypovolemic, cardiogenic & septic shock
HR x SV = CO
Fluids
10ml/kg/dos...
11 | P a g e
STABLE Course Notes
5. Lab Work
Blood count
Blood culture The 4 B’s
Blood glucose
Blood gas
Risk of infection...
12 | P a g e
Platelets
100-150k Abnormal
<100k Definitely abnormal, investigate for bleeding
<25k Dangerously low
VLBW (<1...
13 | P a g e
IVC & SVC
AORTA
PA
PDA
PFO
RT Subclavian
(pre-ductal)
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STABLE Course Notes

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Personal notes taken during STABLE course

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STABLE Course Notes

  1. 1. 1 | P a g e STABLE Course Notes 1. Sugar & Safe Care Aim for 2.8-6.0 mmol/L Avoid enteral feeding – insert IVC or UVC Risks for hypoglycaemia: 1. Prem (<37/40 gestation) 2. SGA 3. LGA 4. IDM 5. Stressed/sick 6. Some meds given to mother a. β -symps b. β -blockers c. Chlorpropamide d. Benzthiazides e. TCAs during 3rd trimester Foetal glucose is approx 70-80% of maternal value 3rd trimester = ↑ glycogen storage in liver Factors affecting BGL after birth: 1. ↓ glycogen stores 2. Hyperinsulinaemia 3. ↑ glucose utilisation Affecting: 1. Prem, SGA (@ term = 25% risk, prem SGA = ↑ risk) stressed/sick 2. IDM (insulin does not cross placenta. Foetus creates own insulin in response to mother glucose level. Cutting cord  glucose stopped. May result in ↑insulin  ↓ BGL), LGA (↑ insulin can be cause of LGA) 3. Prem, SGA, infection/shock/hypothermia/hypoxia (anaerobic metabolism; ↑ glucose consumption for ↓ ATP output)/cardiac or respiratory disease Screening: 15-30 min intervals until > 2.8mmol/L on at least 2 consecutive tests S&S of Hypoglycaemia:  ASYMPTOMATIC  Twitching  Jitteriness  Irritability  Hypotonia  Lethargy  High pitched cry  Tachypnoea  Cyanosis  Poor suck  Hypothermia  Apnoea/irregular resps Rate x conc x 0.167 = mg/kg/min Weight OR 100ml/kg/day = 10g/kg/day 10g / 1.44 = mg/kg/min
  2. 2. 2 | P a g e  Seizures Treatment 1. D10W @ 80ml/kg/day via infusion pump (approx 5.5mg/kg/min) a. Central line for D15W and above b. Weight x 80ml / 24 = ml/hr 2. Bolus of 2ml/kg of D10W @ 1ml/min 3. Rpt if no improvement 4. Repeat & increase to 100ml/120ml/kg/day (or increase glucose concentration if pt not candidate for ↑ fluids) NB prem may need ↑ fluids due to loss through thinner skin, radiant warmer, phototherapy lights etc. Watch for ↑ BGL due to immature endocrine sys (i.e. may need ↑ fluids but ↓ glucose concentration) UVC/UAC UVC  Rapid IV access  Difficulty gaining Peripheral IV  More than 1 IVC needed  CVC access for D12.5W+  Tip @ RA/IVC junction  Preterm never more than 5cm; term never more than 7cm. Emergency placement – 3cm you’re in! UAC  Continuous ABGs  ABP monitoring  NO MEDS – NaCl only to maintain patency  AP CXR – T6-T9 (high line - preferred); L3-L4 (low line)  Monitor for arterial spasm/emboli (discolouration of feet/abdo/buttocks/legs/groin) NB In life threatening emergency – IO access (tibial) 18G Heparin 0.5-1.0 unit/ml of fluid IV. CUMH – 0.5u/ml NB Comes in different concentrations! Check packaging first! Volvulus Green coloured emesis. Never assume to be normal! Rule out malrotation.  Pain  Bloody stool Ischaemia  Shock & metabolic acidosis Peripheral IVC 24G or 28G scalp needle
  3. 3. 3 | P a g e STABLE Course Notes 2. Temperature Maintain whether patient well or unwell 1. EARLY Prem & SGA at ↑ risk of hypothermia a. ↑ surface area v body mass b. Less insulating fat c. Thinner immature skin d. Little if any brown fat (5% of mass – back/spine/shoulder) 2. SMALL BW <1500g – problem accentuated 3. SICK Infants who require resuscitation or are acutely unwell a. Hypoxic b. Hypotonic (unable to flex/↓ activity  ↓ heat generation) NB Core temp = 36.5°C – 37.5°C Mild 36-36.4°C Moderate 32-35.9°C Grades of hypothermia Severe <32°C NB Hypothermia is an independent risk factor for mortality Normal response to cold stress Peripheral vasoconstriction, ↑ flexion & activity, metabolism of brown fat  ↑ metabolic rate  ↑ utilisation of O2 & glucose  Prem, SGA & hypoglycaemia are at increased risk of hypothermia Decreasing heat loss 1. Pre-warm objects before contact (mattress, hands, steth, XR plates, blankets) 2. Insulation between baby & surfaces 3. Clothing, hats (not always practical) 4. Chemical thermal mattress with cover 5. Pre-heat room to 25-28°C 6. Cover chin-to-feet with polyethylene covering (may not be useful >1500g BW) 7. Closed, pre-warmed incubator 8. Heat O2 & humidify 9. Radiant warmer – do not obstruct during resus 10. Quickly dry infant 11. Do not bathe unstable infants – PPHN 12. Minimise air turbulence 13. Warm any IV solutions 14. Thermal shades over windows 15. Move infant away from windows & walls 16. Radiant bed – SERVO-CONTROL MODE! a. Temp sensor on RUQ
  4. 4. 4 | P a g e Physiological response to hypothermia (term infants) Cold stress Hypothalamus stimulated Norepinephrine released Pulmonary vasoconstriction Brown fat metabolism ↑ activity, flexion R-L shunting (aerobic) ↑ O2 consumption ↑ glucose utilisation HYPOGLYCAEMIA HYPOXIA HYPOXAEMIA Physiological response to hypothermia (pre-term infants) Cold stress Hypothalamus stimulated Norepinephrine released Pulmonary vasoconstriction Brown fat metabolism ↑ activity & flexion ↑ O2 consumption Limited glucose stores HYPOGLYCAEMIA HYPOXIA Right – left shunting  hypoxemia Hypoxemia  Hypoxia  Anaerobic metabolism  ↑ lactic acid  ↓pH Hypothermia S&S of worsening Hypoglycaemia due to Hypothermia  Respiratory distress  ↓ LOC
  5. 5. 5 | P a g e  ↓ resp rate  ↑ sepsis risk  DIC  ARF NB For re-warming, incubator is best choice. Set to air temperature mode. Set 1-1.5°C above core temp. Closely monitor – avoid sudden vasodilation & hypotension  Core temperature  HR  ECG  BP Continuously monitor  Resp rate & effort  SpO2 > 90%  ABB  BGL NB Baby can lose 150ml/day in non-sensible, uncontrolled fluid loss through evaporative heat loss. 1ml of fluid loss = 4 cal energy loss Prolonged resus – turn off radiant warmer. Possible candidate for therapeutic hypothermia / passive cooling (33-34°C) Rewarming – ½°C/hour
  6. 6. 6 | P a g e STABLE Course Notes 3. Airway Arterial Blood Gases (CUMH) pH 7.30-7.45 (7.26 acceptable) pCO2 35-45mmHg (4.5-6 kPa) pO2 50-80mmHg (6.5-10 kPa) HCO3- 19-26 mEq/L (18-24) BE -4 to +4 (-6 to +6) NB Temperature when taken should be input in order to give accurate results! Respiratory Distress  Mild - ↑RR  Moderate - ↑RR, cyanosis, abnormal ABG  Severe – central cyanosis, struggling, abnormal ABG NB N = 30-60 r/min; < 30 = laboured; gasping = pre-arrest (BVM/tube/PPV) Tachypnoea & ↓ pCO2 (non-respiratory cause)  Congenital heart disease  Metabolic acidosis  Cerebral disorder (meningitis, oedema, haemorrhage) Tachypnoea & ↑ pCO2 (respiratory cause)  RDS (surfactant deficiency in immature infant)  Pneumonia (give ABx until proven otherwise!)  TTN (retained foetal lung fluid) (↑risk in pre-labour section)  Aspiration  Pulmonary haemorrhage  Airway obstruction  Chest mass, diaphragmatic hernia, pneumothorax (CXR for definitive Dx)  Penicillin is cheap, safe & effective – use it! Gas exchange Resp  Breathe in  pO2 in alveoli ↑  O2 diffuses into plasma  Diffuses into RBC  O2 binds to Hb  Hb saturated with O2  Heart  pumped to body  releases O2 to cells  O2 diffuses into cells  CO2 diffuses from cells into plasma  lungs  CO2 removed High  Low gradient
  7. 7. 7 | P a g e pO2 blood > pO2 tissues 100mmHg > 23mmHg ↑ HCO3- = compensating respiratory acidosis ↓pCO2 = compensating metabolic acidosis Metabolic Acidosis (lactic)  Shock  Poor perfusion  Anaerobic metabolism  Sepsis  Hypothermia  Congenital heart disease  TRAUMA – accidental & intentional Treatment of Metabolic Acidosis  Treat the cause!  ↑ O2 Respiratory Acidosis  Lung disease  Pneumothorax  Airway obstruction  ↓ resp effort  Neurological injury  Apnoea  Mechanical interference Treatment of Respiratory Acidosis  CPAP  PPV NB Deterioration with PPV in neonate – consider diaphragmatic hernia. Intubation Weight (in kg) + 6 = tube mark @ lips Ventilation  Time-cycled mode  Start low, work up VLBW LBW Term Rate 30-60 30-60 20-50 Insp time ≥0.25 Match GA < 0.45
  8. 8. 8 | P a g e PIP 14-22 18-24 20-28 PEEP 3-4 4-5 4-5 ↑ PIP = ↑ TV = ↓ pCO2 ↑ PEEP = ↓TV (unless ↑ PIP) = ↑pCO2 NB Adjust PEEP first, then PIP, then insp. time Analgesia Morphine – ref NEOPAIN study  0.05-0.1mg/kg per dose  IV/IM/SC  15-30 min admin time Fentanyl  1-2mg/kg per dose  IV  15-30 min admin time Sucrose  12-24% solution  Term – 0.5-2.0ml  Pre-term – 0.1-0.4ml NB Sedatives ≠ Analgesia Needle Aspiration of Pneumothorax 1. Turn 45°, pneumo side up 2. 4th /5th IC space 3. Mid-axillary or anterior axillary CDH  8/40 gestation – diaphragm develops. Mortality 40-60% with CDH  Recognition o Cyanosis o Resp distress o Scaphoid/sunken abdomen  Risk of pneumothorax with PPV NB DO NOT PPV if CDH – intubate! Stabilisation of CDH  Blow-by O2  10F OG tube
  9. 9. 9 | P a g e  CXR  Pre & post-ductal SpO2% - observe for PPHN. Greater than 10% difference = R-L shunting  Vitals  Volume boluses  Dopamine  Observe for pneumothorax  Analgesia PPHN PDA &/ FO remain open 3 main causes 1. ↑ muscularisation 2. Vasospasm – acidosis, hypoxia, hypothermia, sepsis 3. ↓ lung size – pulm hypoplasia, CDH CPAP Indications 1. Needs support but not intubation 2. ↑ severity/frequency of apnoea 3. ↑ work of breathing 4. ↑ O2 requirement 5. CO2 retention, acidosis (mild) 6. Atelectasis 7. Tracheobronchomalacia (flaccidity of tracheal cartilage) Contra-indications 1. Progressive respiratory failure 2. ↑pCO2 3. ↑ acidosis 4. Hypoxemia 5. CDH, TEF, choanal atresia, cleft palate, cardiovascular instability, ↓ resp drive
  10. 10. 10 | P a g e STABLE Course Notes 4. Blood Pressure Hypovolemic, cardiogenic & septic shock HR x SV = CO Fluids 10ml/kg/dose over 15-30 mins (NaCl or Ringers) Whole blood – over 30mins-2hrs Sodium Bicarbonate  4.2% solution  For tx of severe metabolic acidosis (pH < 7.15)  1-2mEq/kg/dose over 30-60 mins  IV Dopamine  5-20mcg/kg/min  IV Group B Strep – risk factors  Temp > 38.5°C  Labour > 18hrs  UTI / Previous delivery Double penicillin to treat meningitis. Ref HIP trial
  11. 11. 11 | P a g e STABLE Course Notes 5. Lab Work Blood count Blood culture The 4 B’s Blood glucose Blood gas Risk of infection  PROM  POL  Chorioamnionitis (inflammation of foetal membranes)  Increased risk of infection with o Maternal infection o Maternal fever o Maternal GU tract infection o ROM > 18hrs o Instrumentation use o Intubation/cannulation etc. Neutrophils Mature – Poly, Seg, Neut, PMNs Immature – Metas, Bands, Stabs  Immature-to-total (I/T) ratio is important  Absolute Neutrophil Count (ANC) in important (↓ ANC = ↑ RIP risk in presence of sepsis) NB ANC ≤ 1800 in term / pre-term is abnormal! ANC = Segs + Bands + Metas I/T > 0.25 (25%) – suspect that the infant is fighting infection. (Meta +band) Immature = I/T Ratio (Segs + meta + band) Total NB I/T > 0.8 = ↑ risk of death from sepsis
  12. 12. 12 | P a g e Platelets 100-150k Abnormal <100k Definitely abnormal, investigate for bleeding <25k Dangerously low VLBW (<1.5kg) 275k +/- 60k LBW (<2.5kg) 290k +/- 70k Normal platelet values Term 310k +/- 68k NB NEVER withhold antibiotic therapy on basis of N FBC! Time between onset of infection & FBC changes can be 4-12 hours! Antibiotics Ampicillin  100mg/kg/dose  Give over 3-5 mins  Every 12 hours Gentamicin  2.5mg/kg/dose  Give over 30 mins  Every 12-24 hours APGAR <3 critical 4-6 low 7-10 normal How Ready Is This Child? HR, RR, Irritability, Tone, Colour APGAR Appearance, Pulse, Grimace, Activity, Respiration
  13. 13. 13 | P a g e IVC & SVC AORTA PA PDA PFO RT Subclavian (pre-ductal)

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