Neonatal intensive care involves specialized care for ill or premature newborns. Conditions requiring intensive care include prematurity, low birthweight, and medical issues. Intensive care aims to stabilize infants and address physiological immaturities in organ systems like respiratory, cardiovascular, and gastrointestinal systems. Intensive care involves continuous monitoring, respiratory support like CPAP or ventilation, thermoregulation, fluid management, and nutrition until infants can maintain homeostasis independently. Surgery for conditions like gastroschisis requires optimizing all body systems before, during and after the operation.
baby born before 37 weeks of gestation calculating from the first day of last menstural period is defined as preterm baby/ premature baby.
These babies are known as preemies
baby born before 37 weeks of gestation calculating from the first day of last menstural period is defined as preterm baby/ premature baby.
These babies are known as preemies
neonatal hypothermia is a very emergency condition. if we identify this in early stage we can save the life of neonate. all should know about the maintaining the temperature if the neonate is in our home.
Health Assessment of the Newborn
The newborn requires thorough skilled observation to ensure a satisfactory adjustment to extra uterine life.
Health assessment of newborn after delivery can be divided into:
1. Initial Assessment
2. Transitional Assessment
3. Assessment of gestational age
4. Behavioural asessment
5. Systemic physical examination
Initial Assessment:
Initial assessment is done by using the APGAR scoring system.
APGAR score: It is method use to assess the newborn’s immediate adjustment to extra uterine life.
• The score based on five signs
1. Appearance (colour)
2. Pulse (Heart rate)
3. Grimace (Reflex irritability )
4. Activity (Muscle tone)
5. Respiratory rate
• Each item is given a score 0, 1, or 2
• 0-3 severe distress
• 4-6 moderate difficulty
• 7-10 no difficulty adjusting to life
• Evaluations of all five categories are made on 1-5 min after birth.
APGAR score:
Sign 0 1 2
Appearance (colour) Blue or pale Body pink, Extrimities Blue Completely Pink
Pulse (Heart rate) Absent Slow (<100 /> 100/m
Grimace (Reflex irritability ) No response Grimace Cough Or Sneeze
Activity(Muscle tone Limp Some flexion Active movement
Respiratory rate Absent Slow, Irregular Good, Crying
Other initial assessment are-
• Stabilization
• Measuring weight.
Transitional Assessment during the period of reactivity
First period of reactivity (6- 8 hours after birth):
During the first 30 minutes the newborn is very alert, cries vigorously, may suck a first greedily, and appears very interested in the environment. Physiologically the respiratory rate can be as high as 80 breaths/ min, crackles may be heard, heart rate may reach 180 beats/min, bowel sound are active, mucus secretions are increased and temperature may decrease slightly.
Second period of reactivity:
Began when the newborn awake from the deep sleep, it lasts about 2-5 hours. The newborn is alert and responsive, heart and respiratory rate are increased, gastric and respiratory secretions are increased, and passage of meconium commonly occurs.
Following this stage is a period of stabilization of physiologic systems & vacillating patern of sleep & activity.
Phototherapy in neonatal jaundice: Introduction, definition, indication, purposes, rule of thumb, lights used in phototherapy mechanism of phototherapy, techniques of phototherapy, phototherapy units, nursing care in phototherapy, short term and long term complications, nursing diagnosis in phototherapy.
Antenatal exercises aim at improving the physical and psychological well-being of an expected mother for labor and preventing pregnancy-induced pathologies by various physical means. It generally includes low impact aerobic exercises and stretching exercises.
Hypothermia occurs when the newborn’s temperature drops below 36.3°C.
The smaller or more premature the newborn is, the greater the risk of heat loss. When heat loss exceeds the newborn’s ability to produce heat, its body temperature drops below the normal range and the newborn becomes hypothermic.
Early prevention measures are vital.
neonatal hypothermia is a very emergency condition. if we identify this in early stage we can save the life of neonate. all should know about the maintaining the temperature if the neonate is in our home.
Health Assessment of the Newborn
The newborn requires thorough skilled observation to ensure a satisfactory adjustment to extra uterine life.
Health assessment of newborn after delivery can be divided into:
1. Initial Assessment
2. Transitional Assessment
3. Assessment of gestational age
4. Behavioural asessment
5. Systemic physical examination
Initial Assessment:
Initial assessment is done by using the APGAR scoring system.
APGAR score: It is method use to assess the newborn’s immediate adjustment to extra uterine life.
• The score based on five signs
1. Appearance (colour)
2. Pulse (Heart rate)
3. Grimace (Reflex irritability )
4. Activity (Muscle tone)
5. Respiratory rate
• Each item is given a score 0, 1, or 2
• 0-3 severe distress
• 4-6 moderate difficulty
• 7-10 no difficulty adjusting to life
• Evaluations of all five categories are made on 1-5 min after birth.
APGAR score:
Sign 0 1 2
Appearance (colour) Blue or pale Body pink, Extrimities Blue Completely Pink
Pulse (Heart rate) Absent Slow (<100 /> 100/m
Grimace (Reflex irritability ) No response Grimace Cough Or Sneeze
Activity(Muscle tone Limp Some flexion Active movement
Respiratory rate Absent Slow, Irregular Good, Crying
Other initial assessment are-
• Stabilization
• Measuring weight.
Transitional Assessment during the period of reactivity
First period of reactivity (6- 8 hours after birth):
During the first 30 minutes the newborn is very alert, cries vigorously, may suck a first greedily, and appears very interested in the environment. Physiologically the respiratory rate can be as high as 80 breaths/ min, crackles may be heard, heart rate may reach 180 beats/min, bowel sound are active, mucus secretions are increased and temperature may decrease slightly.
Second period of reactivity:
Began when the newborn awake from the deep sleep, it lasts about 2-5 hours. The newborn is alert and responsive, heart and respiratory rate are increased, gastric and respiratory secretions are increased, and passage of meconium commonly occurs.
Following this stage is a period of stabilization of physiologic systems & vacillating patern of sleep & activity.
Phototherapy in neonatal jaundice: Introduction, definition, indication, purposes, rule of thumb, lights used in phototherapy mechanism of phototherapy, techniques of phototherapy, phototherapy units, nursing care in phototherapy, short term and long term complications, nursing diagnosis in phototherapy.
Antenatal exercises aim at improving the physical and psychological well-being of an expected mother for labor and preventing pregnancy-induced pathologies by various physical means. It generally includes low impact aerobic exercises and stretching exercises.
Hypothermia occurs when the newborn’s temperature drops below 36.3°C.
The smaller or more premature the newborn is, the greater the risk of heat loss. When heat loss exceeds the newborn’s ability to produce heat, its body temperature drops below the normal range and the newborn becomes hypothermic.
Early prevention measures are vital.
Definition of High-risk Neonate: Any baby exposed to any condition that make the survival rate of the neonate at danger.
Factors that contribute to have a High-risk Neonate:
A) High-risk pregnancies: e.g.: Toxemias
B) Medical illness of the mother: e.g.: Diabetes Mellitus
C) Complications of labor: e.g.: Premature Rupture Of Membrane (PROM), Obstructed labor, or Caesarian Section (C.S).D) Neonatal factors: e.g.: Neonatal asphyxia
At the end of the session, the students shall be able to
What are the various measurements in assessing the growth and maturity of the baby
Describe the purpose of neonatal screening
Identify at-risk infant
Define low birth weight. Enumerate the causes of LBW and discuss the prevention and treatment of LBW babies.
Unit IV new born.pptx in obstetrics and gynecologyDelphyVarghese
Make sure your bladder is empty, then sit or lie down.
Tighten your pelvic floor muscles. Hold tight and count 3 to 5 seconds.
Relax the muscles and count 3 to 5 seconds.
Repeat 10 times, 3 times a day (morning, afternoon, and night).
How to resuscitate, management in meconium aspirated baby, thin and thick meconium, ratio of ventilation and perfusion in new born, latest change in guidelines for resuscitation
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
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micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Ocular injury ppt Upendra pal optometrist upums saifai etawah
Intensive care in neonates
1. Intensive care in neonates
Presenter: Dr PASHI
Moderator: Dr Bvulani
22/09/16
2. Introduction
• Neonatal intensive care unit (NICU) - specialised care offered to ill or
premature newborn infants
• NICU and surgery have helped improve the survival of neonates with
various conditions
• These conditions include, but are not limited to, prematurity, low
birthweight, congenital anomalies, and other medical issues
3. Neonatal Classifications
• Neonate : Newborn baby in the first 4 weeks of life
• Gestational Age (GA)
Premature - < 37 weeks
Term – 37 to 42 weeks
Post term - > 42 weeks
• Weight Vs Gestational Age
Small for GA – weight lies below the 10th percentile for GA
Appropriate for GA – weight lies between 10th and 90th percentile
Large for GA – weight lies above 90th percentile for GA
4. Neonatal classification ctd
• Premature
Moderately low birth weight (82%) – 1501 to 2500g
Very low birth weight (12%) – 1001 to 1500g
Extremely low birth weight (6%) - < 1000g
• Intrauterine Growth Retardation (IUGR)
• Documented decrease in intrauterine growth noted by ultrasonography
1. Symmetric IUGR – normal body proportions
2. Assymetric IUGR – small abdominal circumference, decreased subcutaneous
and abdominal fat, reduced skeletal muscle mass, normal head circumference
6. Neonatal problems ctd
Assessment of gestational age can be done
Antenatally – Ultrasonography
First days after birth – Ballard score (assesses general and physical maturity)
Birth weight and GA – strong indicators of mortality
Preterm infants suffer physiologic handicaps
Functional immaturity
Anatomic immaturity
7. Resuscitation at birth
• Resuscitation at birth is a relatively frequent occurrence.
• Approximately 10% of newborns will require help to establish
breathing at birth, with 1% requiring more extensive resuscitation
• Two broad categories identified:
Those who have undergone a period of hypoxic stress in utero,
and
those who are prone to hypoxaemia in the immediate postnatal
period due to inadequate pulmonary development, airway
obstruction or congenital malformations.
8. Goals of Neonatal Intensive care
• Vary depending upon the status of the infant
• To return the infant to its normal state of health e.g extremely
premature infants
• To find the balance between undertreating and overtreating the
infant e.g. infants with defects or conditions where intensive care may
only increase suffering, prolong the act of dying, or result in survival
with significant burdens
9. NICU admission criteria
• Admission to NICU should be routine for the following babies:
• • Less than 34 weeks
• • Less than 1.7kg
• • Respiratory distress
• • Poor condition at birth requiring resuscitation (consider admission if the cord pH is less
than 7.0)
• • Congenital abnormalities likely to threaten immediate survival
• • Seizures
• • Cyanosis
• • Sepsis
• • Jaundice, requiring intensive phototherapy
• • Any other babies where there are substantial concerns
10. Monitoring
• Intensive care unit environment offers continuous monitoring
• Monitoring enables assessment of
• impact of intensive care unit intervention
• characterize the nature and significance of derangements
• Monitoring strategies are designed to follow individual organ function
and, to a lesser degree, the interaction between systems.
11. Parameters Monitored - NICU
• Available devices can analyze
• physical parameters (pressure, temperature, flow, volume),
• electrical function (EEG, ECG, train-of-four),
• gas dynamics (saturation, partial pressure),
• concentrations (hemoglobin), and
• chemistries (microdialysis).
• Monitors are limited in their ability to interrogate tissue health and
cellular function.
12. Monitoring - Interpretation of readings
• Measurements should be interpret carefully
• considering population norms,
• baseline patient capability,
• demands of the physiologic circumstance, and tolerance of
deviations from “optimal” or “normal” function
13. General principles of ICU management
Goals in surgical neonate
• Stabilisation
• Pre-operative assessment and management to determine ability to
cope with surgery.
• While the surgery may be relatively short, its success will depend
upon the calibre of both pre- and post-operative care.
14. Thermoregulation
Prevention of hypothermia
• This is well recognised and compensated for in NICU
• Transportation vehicles/operating theatres usually not well adapted
and the temperature will need adjustment.
• The baby’s core temperature should be maintained at 37°C with
peripheral temperature maintained at 36°C
• Thermoneutral temperature – T maintained with minimal metabolic
rate
• Critical Temperature – metabolic response to cold to replace lost heat
• Incubator T determined by Weight and Postnatal age
15. Thermoregulation - embryology
• 5-35 weeks gestation - Hypothalamic function matures
• Regulates T control
• Regulates pituitary gland hormones
• 20 wks onwards - Brown fat is formed
• 23-24wks GA – fetal lung can support gas exchange
• 26wks GA - developed keratinised stratum corneum with thin
epidermis
• 34 wks GA – epidermal development is complete
16. Thermoregulation-Heat production
• Term baby initiates thermal control at birth
• Thermogenesis is initiated by 3 different mechanisms:
1. cutaneous cooling
2. oxygenation
3. separation from the placenta
• Non shivering thermogenesis
• Brown fat metabolism – primary source of heat
• Hepatic glycogenolysis
17. Thermoregulation-Heat production ctd
• The mechanisms of non-shivering thermogenesis include
the metabolism of brown adipose tissue
the secretion of noradrenaline and
the release of thyroxin
18. Thermoregulation- inhibitors
• Brown fat thermogenesis is inactivated
• Vasopressors
• Anesthetic agents
• Nutritional depletion
• Infants undergoing laparotomy are at increased risk from heat loss
directly from exposed bowel.
• Aqueous rather than alcohol-based skin preparations - reduce
evaporative heat loss.
19. Thermoregulation – Heat loss
• Heat loss is by
Evaporation
Conduction
Convection
Radiation
20. Thermoregulation – Heat loss
• Surgically ill neonates lose heat by
• vomitus,
• tachypnoea
• when undergoing laparatomy
• evisceration at birth (gastroschisis or ruptured exomphalos)
21. Respiratory system - embryology
• Bhutani (2006), lung development can be divided into 7 stages
• 5 fetal stages, a neonatal period of approximately 2 months to full
lung development by approximately 8 years
• 1. The embryonic stage (0–7 weeks’ gestation)
• 2. The pseudoglandular stage (8–16 weeks’ gestation)
• 3. The canalicular stage (17–27 weeks’ gestation)
• 4. The saccular stage (28–35 weeks’ gestation)
• 5. The alveolar stage (>36 weeks’ gestation)
22. Respiratory system-Surfactant
• Produced by the alveolar type II cells
reduce the surface tension in the lungs aiding gaseous exchange
prevents the alveoli from collapsing completely (atelectasis) at the end of expiration
Helps to reduce the work of breathing for the infant
• Factors that stimulate synthesis
glucocorticoids
Catecholamines also increase surfactant
• Factors that inhibit synthesis
Insulin
Hypothermia
acidosis
23. Respiratory system at birth
• Stimulus of first breath:
• Clamping/obstructing the umbilical cord results in an ‘asphyxial’ event
• cooling – sudden drop from intra-uterine temperature
• physical discomfort from touching and drying
• Neonates : obligatory nasal breathers & obligatory diaphragmatic
breathers
• Alveoli in the neonatal lung < 10% of the adult quota
• new alveoli are continually added up to 8 years of age
24. Respiratory function
• Assessment of respiratory function is a prerequisite for all surgical
neonates as urgent intervention may be required.
• Anatomical abnormalities/increasing abdominal distension -
compromise ventilation.
• Surfactant deficiency or aspiration pneumonia may contribute
• The extent of respiratory support required depends upon clinical and
radiological findings and blood gas analysis
25. Respiratory support levels
• Infants with mild Respiratory Distress Syndrome (RDS)
• with good respiratory effort
• and effective ventilation
only require supplemental oxygen to manage their condition
O2 delivered through nasal cannula, via the incubator or a head box or hood
• Infants who display an increase in their work of breathing
• associated with hypercarbia
• and an increase in oxygen requirements will benefit from increased
• reasonable spontaneous respiratory effort with mild hypercarbia
Respiratory support in the form of CPAP
• Infants with decreased respiratory drive or apnoeas with a raised PaCO2
and reduced PaO2 will need to be intubated and ventilated
26. Respiratory support trauma
Ventilation in the neonatal period can result in lung injury
• increases risk of respiratory morbidity including air leak and chronic lung disease.
• Proposed mechanisms for ventilator induced lung injury (VILI):
• Volutrauma - alveoli are over-distended by the delivery of too much gas.
• Barotrauma - alveoli are subjected to high pressures causing alveolar disruption
• Biotrauma due to injurious effects of inflammation, infection and oxidative stress.
• Atelectotrauma - alveolar collapse at the end of expiration requiring re-
recruitment with every breath.
• Stretch trauma - rate of inflation of the alveoli is beyond their normal elastic
capability.
27. Respiratory support trauma ctd
• The modern trend in ventilating preterm newborns is to provide
the gentlest invasive ventilation possible for the shortest time
possible.
allowing permissive hypercarbia
and permissive hypoxaemia
28. Respiratory Support Target readings
• Acceptable blood gas results for infants requiring respiratory support
Parameter Normal Ventilated preterm infants Term targets
Targets with permissive
hypercarbia and permissive
hypoxia
pH 7.35–7.45 >7.25 7.3–7.4
PaCO2 4.5–6 kPa 6–7.5 kPa 4.5–6 kPa
Arterial PaO2 11–14 kPa 7–12 kPa >8 kPa
SaO2 100 per cent 90 per cent >95 per cent
29. Respiratory support Types
1 - Non-invasive – Continuous Positive Airways Pressure (CPAP)
• Deliver a predetermined continuous pressure and supplementary oxygen
to the airways of a spontaneously breathing infant (Jones and Deveau
1997)
• mechanically splinting the airways open
• Reduce upper airway occlusion and
• decreases upper airway resistance
• Improves ventilation
• recruiting collapsed alveoli
• increasing the surface area available for gas exchange
• Stabilises the chest wall and reduces the work of breathing.
30. Respiratory support Types ctd
CPAP delivery
• Nasal CPAP (nCPAP) prongs are the most commonly applied means of
delivering CPAP (Gomella 2004)
• Newborn infants are inherent nasal breathers
• nCPAP is easily facilitated and well tolerated
• Binasal (double) prongs are more widely used than single prongs
• Nasal prongs have been associated with erosion
• Need to be carefully sized before insertion into the infant’s nares
31. Respiratory support Types ctd
2. Invasive Ventilation
• Ventilatory support optimised by monitoring interaction between infant and
ventilator
• Allow infant-regulated breath-by breath changes in peak pressures, tidal
volumes, inspiration times and rate
• help reduce the ventilator induced lung injury (VILI)
• Types
• Continuous mandatory ventilation (CMV)
• Volume control (VC)
• Assist control ventilation (A/C)
• Synchronised intermittent mandatory ventilation (SIMV)
32. Gastric decompression
• Intestinal obstruction and/or sepsis predispose the infant to increased
gastric secretions
• Gastric decompression
avoid vomiting and aspiration pneumonia
reduce splinting of the diaphragm and aid ventilation.
• Correctly positioned naso-gastric tube large enough to prevent
blockage (8fg or greater)
• The tip of the tube should be in the stomach and left on continuous
open drainage with gentle intermittent aspiration
33. Fluid and electrolyte balance
• Surgery can exacerbate physiological imbalances in the newborn.
• Continuous assessment and monitoring is essential of
perfusion,
parenteral fluid and electrolyte requirements and
metabolic response to surgical trauma.
• Some infants will need fluid resuscitation pre-operatively – exposed
viscera in gastroschisis and examphalos.
• Losses via the naso-gastric tube should be measured and replaced
with normal saline with added potassium.
34. Fluid and electrolyte balance ctd
• The stimulus of surgery and intermittent positive-pressure ventilation
(IPPV) lead to increased aldosterone and antidiuretic (ADH) secretion
resulting in water and sodium retention.
• It may therefore be pertinent to restrict fluid and sodium post-
operatively
35. Acid Base Balance
• Alterations in acid base balance can be caused by several factors.
• Respiratory acidosis occurs with inadequate ventilation, for example, in
pulmonary hypoplasia secondary to congenital diaphragmatic hernia.
• Metabolic acidosis can occur when
bicarbonate losses are increased
poor tissue perfusion,
tissue necrosis, infection,
hypovolaemia
intestinal fistulas and necrotising enterocolitis (NEC).
• The commonest cause in the ‘surgical neonate’ is hypovolaemia which requires
fluid replacement for its correction.
• Correction with bicarbonate should be cautious, as it may cause hypocalcaemia
(Haycock 2003).
36. Nutrition
• Total parenteral nutrition allows delivery of nutritional substrates
directly into the circulation
During prolonged pre-operative stabilisation,
conditions predisposing paralytic ileus,
• It promotes anabolism and provides for normal growth and
development until gut function is restored.
37. Nutrition ctd
• Glycogen is a skeletal muscle and hepatic storage carbohydrate and is
metabolised when blood glucose falls outside the homeostatic range
(Kotoulas et al. 2006).
• Neonates have poor glycogen stores due to decreased availability of
substrate in utero, and therefore need a constant glucose intake.
• It is essential that dextrose should be administered and the blood
glucose monitored frequently, maintaining a level of 2.6–5.0mmol/L
(Nicholl 2003).
38. Cardiovascular System
• A neonate’s blood volume is approximately 80ml/Kg body weight.
• A 2kg infant has a circulating volume = average loss during minor adult sgy
• Foetal Circulation is associated with
(1) the ductus venosus
(2) the foramen ovale
(3) the ductus arteriosus and including
• high resistant pulmonary vascular system due to the collapsed lungs, and a
• low-resistance systemic circuit
39. Cardiovascular System ctd
• At birth, haemodynamic changes occur in the transition from fetal to
ex-utero circulation due to
• clamping of the placental blood flow and
• the expansion of the lung fields
• Cardiac abnormalities can be primary (congenital), maladaptive at
birth or acquired (secondary)
40. Haematological disorders
• Coagulation status should be assessed pre-operatively and treated
accordingly.
• Assessment should involve those with liver pathologies and suspected
heamoglobinopathies
• The neonate is deficient in vitamin K
• May be given either subcutaneously or intramuscularly
• In an emergency, it can may given intravenously but close observation will be
required for anaphylaxis (Beers et al. 2006)
41. Haematological disorders ctd
• Neonates with severe sepsis or NEC may develop disseminated
intravascular coagulation (DIC) with associated thrombocytopenia
(Puri and Sureed 1996; Stokowski 2006).
• Correcting underlying disease process triggering the condition is key
• Clotting factors should be replaced by transfusion with appropriate
blood products.
42. Haematological disorders ctd
• Concurrent treatments to control the haemorrhage/clotting cycle
include the administration of
• Cryoprecipitate increases Factor VIII and fibrinogen levels
• fresh frozen plasma (FFP), FFP can increase coagulation factors by 15–
20 per cent
• Platelet infusion of 10ml/kg can increase the platelet count by up to
100000/mm3 (Emery 1992; Kenner et al. 1993; Kuehl 1997).
• Exchange transfusions may be used to ‘wash out’ any toxins in the
infant’s blood and to replace clotting factors.
• Vitamin K may also be given.
43. Vascular access
• A central venous line is highly recommended for prolonged venous
access because
last longer
safely infuse fluids known to have a local irritation or sclerosing
effect.
• Peripheral cannulae for administration of medications and blood
product transfusion when necessary.
• Arterial access is also helpful to monitor haemodynamic, biochemical
and respiratory status.
44. Pharmacological support
• There is a risk of sepsis whenever surgery is performed, especially in
intra-uterine growth restriction (IUGR) and preterm babies with
immature immune systems.
• Untreated infection promotes deterioration of the respiratory and
cardiovascular systems and prophylactic antibiotic therapy can reduce
this risk.
• However, continual review of the course of treatment is essential to
minimise the eventual microbial resistance to antibiotic therapy over
time (Kolleff and Fraser 2001).
45. Pharmacological support ctd
• Inotropes are often necessary to improve cardiac function, thus
improving organ perfusion. Dopamine, dobutamine and adrenaline
are the most commonly used inotropes in hypotension in neonates.
• Pain relief is an important consideration both pre- and post-
operatively.
• Cellular damage, particularly in cases of NEC, release pain-producing
substances, augmenting the perception of pain (Brophy 2007).
46. Anaesthetic effects
• Neonates are sensitive to the respiratory depressant effects of opiates
hence require Intubation and ventilation
• Effective analgesia via an epidural catheter can be provided without
depressing respiration (Reynolds 2005)
• suitable for all surgical procedures below the umbilicus
inguinal herniotomy,
Lower limb surgery
genito-urinary surgery
47. Transportation
• The critically ill neonate can make several potentially hazardous
journeys
from the delivery room to NICU,
interhospital referral
to and from the operating theatre.
• Safe transportation demands collaboration between a doctor and
nurse experienced in neonatal intensive care, and a specialist
anaesthetist for the return journey from theatre.
• It is suggested that utilisation of specialist staff at this time reduces
‘disasters’ such as aspiration, hypothermia and airway obstruction
48. Post-operative considerations
• Management in the post-operative period mirrors the pre-operative
care in achieving and maintaining physiological stability, but in
addition the factors listed below need careful consideration.
• Do not leave the operating theatre until the baby is stable.
• Doctor and anaesthetist should be in attendance in return journey to NICU
• Before returning the baby to the incubator and ventilator, check the settings,
then reconnect fluids and monitor leads to static equipment
• Adjust maintenance and arterial line fluids. Commence NG replacement
losses if necessary. Titrate sedation and epidural infusions as appropriate.
Observe entry sites
• Attach naso-gastric tube to drainage bag
49. ctd
• As soon as possible record:
• core temperature then 4-hourly until stable
• blood sugar then 1–2-hourly until stable
• ventilator settings then 1-hourly until stable
• blood pressure continuous read-out, but record hourly
• heart/respiratory rate
• Attach peripheral temperature probe and maintain temperature above
34°C
• Organise a chest X-ray if the baby was intubated in theatre, there is a chest
drain in situ and following diaphragmatic hernia repair
• Check blood gas and repeat as necessary
50. ctd
• Record urinary output – attach urine bag or weigh nappies – expect 1ml/kg
per hour after the first 24 hours
• Check biochemical and haematological status
• Maintain adequate pain relief
• Carefully observe wounds, stomas, etc., recording any losses
• Tailor endotracheal suction to each individual’s needs – pre-oxygenating if
necessary
• Encourage parental involvement in care as appropriate
• minimal handling is essential to recovery
• passive movements and change of position every 4 hours – 6- to 8-hourly
care is adequate