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STABLE Course Notes
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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
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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
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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
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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
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↓ 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
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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
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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
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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
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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
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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
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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
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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
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IVC & SVC
AORTA
PA
PDA
PFO
RT Subclavian
(pre-ductal)