- Neonates have immature organ systems that require special consideration for anesthesia and surgery. Their respiratory, cardiovascular, and renal systems are underdeveloped and they have reduced liver function.
- Due to their high metabolic needs and limited reserve, neonates are prone to hypoxia, bradycardia, hypoglycemia, and fluid/electrolyte imbalances under anesthesia if not carefully monitored and supported.
- Regional or minimal sedation techniques may be preferable to general anesthesia in neonates to reduce risks of apnea, hypotension, hypothermia and other complications.
This document discusses neonatal physiology including:
1. Neonates have limited reserve capacity for temperature control, cardiovascular and respiratory functions due to physiological changes after birth.
2. Fluid requirements vary greatly between individual neonates due to immaturity of the liver and kidneys.
3. The document defines terms like newborn, neonate, preterm neonate and discusses differences in cardiac output and circulations between fetal and neonatal stages.
This document discusses fetal and neonatal physiology. It defines terms like newborn, neonate, preterm, and low birth weight. It describes the placenta's role in nutrient/waste transfer and hormone production. It discusses fetal circulation and the changes at birth as shunts close. Characteristics of the newborn circulation include higher cardiac output and lower blood pressure. The document also covers temperature regulation, immunity, liver function, jaundice, breathing onset, lung expansion, and respiratory distress syndrome in newborns.
The fetus grows rapidly in the third trimester, reaching weights of 3 pounds at 2 months before birth and 7 pounds at birth. While the major organ systems begin developing early in pregnancy, the nervous system, kidneys, and liver are not fully mature at birth. After birth, the newborn must adjust to breathing air and circulating blood independently of the mother. Important adjustments include opening the lungs and initiating breathing, closing the foramen ovale and ductus arteriosus, and ramping up cardiac output and blood pressure to support the systemic circulation. Premature infants face additional challenges with immature respiratory, digestive, and immune systems.
This document provides an overview of newborn resuscitation by Dr. Lokanath Reddy from the Department of Paediatrics at Kasturba Medical College in Manipal, India. It covers the history and principles of newborn resuscitation, initial steps, positive pressure ventilation, intubation, medications, special considerations for preterm babies, and ethics. Causes of neonatal compromise are discussed. Guidelines for newborn resuscitation from various medical organizations over time are summarized.
Growth of the fetus begins soon after fertilization, when the first cell division occurs.
Cell division, hypertrophy, and differentiation are highly coordinated events that result in the growth and development of specialized organ systems.
The fetus, fetal membranes, and placenta develop and function as a unit throughout pregnancy, and their development is interdependent or symbiotic.
The growth trajectory of fetal mass is relatively flat during the first trimester, increases linearly at the beginning of the second trimester, and rises rapidly during the third trimester.
Respiratory physiology & Respiratory Distress syndrome in a newborn.Sonali Paradhi Mhatre
Hi guys, This ppt shows the pathophysiology of pulmonary surfactant in newborn and respiratory distress syndrome. Main focus is towards management of RDS esp. exogenous surfactant administration. Your comments are welcome. Thank you.
Respiratory distress syndrome is a life-threatening lung disorder that affects newborns, especially preterm infants. It results from underdeveloped lungs and low surfactant levels. Signs include rapid breathing, grunting, and chest retractions within 6 hours of birth. Treatment involves oxygen therapy, ventilation support if needed, maintaining nutrition/hydration intravenously, and surfactant replacement. With appropriate care, survival rates are 60-80% for infants over 1000g, though complications can include brain/lung issues. Respiratory distress syndrome requires close monitoring and management of respiratory and metabolic acidosis in newborns.
The document discusses mechanical ventilation in neonates. It provides a brief history of mechanical ventilation and describes various modes of ventilation including positive pressure ventilation. Key aspects of intubation and ventilation such as indications, procedures, settings and complications are outlined. Lung physiology considerations specific to neonates such as compliance, resistance and time constant are also reviewed.
This document discusses neonatal physiology including:
1. Neonates have limited reserve capacity for temperature control, cardiovascular and respiratory functions due to physiological changes after birth.
2. Fluid requirements vary greatly between individual neonates due to immaturity of the liver and kidneys.
3. The document defines terms like newborn, neonate, preterm neonate and discusses differences in cardiac output and circulations between fetal and neonatal stages.
This document discusses fetal and neonatal physiology. It defines terms like newborn, neonate, preterm, and low birth weight. It describes the placenta's role in nutrient/waste transfer and hormone production. It discusses fetal circulation and the changes at birth as shunts close. Characteristics of the newborn circulation include higher cardiac output and lower blood pressure. The document also covers temperature regulation, immunity, liver function, jaundice, breathing onset, lung expansion, and respiratory distress syndrome in newborns.
The fetus grows rapidly in the third trimester, reaching weights of 3 pounds at 2 months before birth and 7 pounds at birth. While the major organ systems begin developing early in pregnancy, the nervous system, kidneys, and liver are not fully mature at birth. After birth, the newborn must adjust to breathing air and circulating blood independently of the mother. Important adjustments include opening the lungs and initiating breathing, closing the foramen ovale and ductus arteriosus, and ramping up cardiac output and blood pressure to support the systemic circulation. Premature infants face additional challenges with immature respiratory, digestive, and immune systems.
This document provides an overview of newborn resuscitation by Dr. Lokanath Reddy from the Department of Paediatrics at Kasturba Medical College in Manipal, India. It covers the history and principles of newborn resuscitation, initial steps, positive pressure ventilation, intubation, medications, special considerations for preterm babies, and ethics. Causes of neonatal compromise are discussed. Guidelines for newborn resuscitation from various medical organizations over time are summarized.
Growth of the fetus begins soon after fertilization, when the first cell division occurs.
Cell division, hypertrophy, and differentiation are highly coordinated events that result in the growth and development of specialized organ systems.
The fetus, fetal membranes, and placenta develop and function as a unit throughout pregnancy, and their development is interdependent or symbiotic.
The growth trajectory of fetal mass is relatively flat during the first trimester, increases linearly at the beginning of the second trimester, and rises rapidly during the third trimester.
Respiratory physiology & Respiratory Distress syndrome in a newborn.Sonali Paradhi Mhatre
Hi guys, This ppt shows the pathophysiology of pulmonary surfactant in newborn and respiratory distress syndrome. Main focus is towards management of RDS esp. exogenous surfactant administration. Your comments are welcome. Thank you.
Respiratory distress syndrome is a life-threatening lung disorder that affects newborns, especially preterm infants. It results from underdeveloped lungs and low surfactant levels. Signs include rapid breathing, grunting, and chest retractions within 6 hours of birth. Treatment involves oxygen therapy, ventilation support if needed, maintaining nutrition/hydration intravenously, and surfactant replacement. With appropriate care, survival rates are 60-80% for infants over 1000g, though complications can include brain/lung issues. Respiratory distress syndrome requires close monitoring and management of respiratory and metabolic acidosis in newborns.
The document discusses mechanical ventilation in neonates. It provides a brief history of mechanical ventilation and describes various modes of ventilation including positive pressure ventilation. Key aspects of intubation and ventilation such as indications, procedures, settings and complications are outlined. Lung physiology considerations specific to neonates such as compliance, resistance and time constant are also reviewed.
This document describes the case of a 10-day-old infant presenting with signs of shock including tachycardia, poor perfusion, and decreased urine output. Examinations revealed hepatomegaly and other signs suggestive of shock. Investigations showed metabolic acidosis and low blood sugar. The infant did not respond to initial fluid resuscitation and inotropic support. Echocardiogram revealed hypoplastic left heart syndrome. Prostaglandin E1 was started and the infant responded, confirming duct-dependent systemic circulation. The case highlights the importance of early recognition and management of neonatal shock.
This document discusses neonatal mechanical ventilation. It begins by introducing mechanical ventilation and its importance in improving neonatal survival since the 1960s. It then discusses the benefits of mechanical ventilation in improving gas exchange and decreasing work of breathing. Various indications for ventilation are provided. Common conditions requiring ventilation are also listed. The document goes on to describe different types of ventilators and modes, how to initiate a breath, and studies comparing different modes. It concludes by discussing parameters for conventional ventilation like PIP, PEEP, flow rates, and methods for controlling oxygenation and ventilation.
1) Neonatal shock is characterized by an imbalance between oxygen delivery and demand, leading to tissue hypoxia. Myocardial dysfunction, abnormal vasoregulation, and hypovolemia are common causes.
2) Pathophysiology includes an immature myocardium with fewer contractile elements and higher basal contractility, as well as complex vascular smooth muscle tone regulation. Relative adrenal insufficiency also contributes.
3) Clinical assessment of shock includes vital signs, perfusion markers like capillary refill time and lactate, and echocardiography to evaluate cardiac function and filling. Goal-directed management targets normalization of these parameters.
This presentation deals with the basic physics of human ventillation. I have made an effort to clarify most of the venti lingo , so as to make way for further discussions on ventilator use. Hope it turns out to be helpful for you. Thank you.
This document discusses persistent pulmonary hypertension of the newborn (PPHN) with a focus on management in resource-limited settings. It provides background on PPHN, including associated conditions, signs and symptoms, diagnostic testing, and supportive care strategies. Key interventions discussed include inhaled nitric oxide (iNO), high frequency ventilation (HFV), and sildenafil. While iNO and HFV are standard treatments, their high costs limit use in many resource-poor areas. The document explores using less expensive options like sildenafil and discusses how HFV could potentially be utilized more in Nepal with appropriate equipment, training, and support.
This document discusses enteral nutrition in preterm neonates. It notes that providing adequate nutrition to preterm infants is challenging due to immaturity of bowel function and inability to suck and swallow. While parenteral nutrition can provide nutrients, lack of enteral intake can impair gut development and function. The document reviews evidence from several Cochrane reviews on different approaches to enteral feeding in preterm infants, finding insufficient evidence to recommend one approach over others and calling for additional large randomized controlled trials to evaluate effects on important outcomes.
Neonatal fluid requirements and specials conditionsRakesh Verma
This document provides an overview of neonatal fluid and electrolyte requirements, including physiological changes affecting balance in fetuses and neonates. It discusses developmental changes in total body water, extracellular and intracellular fluid during gestation and after birth. Maturation of organs like the cardiovascular system and kidneys that regulate fluid compartments is also covered. Guidelines are provided for calculating total fluid needs as well as maintenance, deficit and ongoing loss replacement in both term and preterm infants of different weights. Electrolyte supplementation amounts and choices of IV fluids are also summarized.
Diabetes in pregnancy poses risks to both mother and baby. Good glycemic control through nutrition, lifestyle changes, and possibly medication can help reduce risks. Babies of diabetic mothers may be large with potential birth injuries, and face risks of low blood sugar, breathing issues, and heart and metabolic problems. Close monitoring and management throughout pregnancy aims to deliver healthy babies.
The document discusses neonatal hypoglycemia, including:
1. Hypoglycemia is common in newborns, especially sick ones, as they transition from receiving glucose from the placenta.
2. The brain relies heavily on steady glucose, so low blood sugar can impact brain development if not addressed.
3. At-risk newborns include preterms, SGA, LGA, those with infections or perinatal stressors.
4. Treatment involves monitoring blood sugar based on risk level and intervening with oral or IV glucose if levels dip below thresholds.
A single live preterm male infant was delivered via normal vaginal delivery at 30-32 weeks gestation with a birth weight of 1.2kg. He was admitted for preterm care and respiratory distress. He required surfactant therapy, ventilatory support for 48 hours, and phototherapy for hyperbilirubinemia. Chest x-ray showed signs of respiratory distress syndrome. He is being closely monitored and managed supportively for preterm complications.
Nutritional Management of Premature InfantsMCH-org-ua
International conference «Actual approaches to the extremely preterm babies: International experience and Ukrainian realities» (Kyiv, Ukraine, March 5-6, 2013)
CLINICAL TEACHING ON BUBBLE CPAP: Introduction, Definition, History of development, Physiology of Bubble CPAP, Principle, Patient interface, equipments for bubble CPAP, indication and contraindication for bubble CPAP, essential of CPAP, CPAP machine, bubble cpap machine application, setting pressure, FiO2, oxygen flow, Monitoring adequacy and complications of bubble CPAP, Monitoring infant condition, weaning for Bubble CPAP, CPAP Failure, complications related to CPAP, Preventing complications, Nursing Care.
This document discusses different types of blood components used in transfusion therapy. It describes fresh whole blood, packed red blood cells (PRBCs), platelet concentrates, plasma components like fresh frozen plasma and cryoprecipitate. It provides details on the preparation, storage conditions and indications for transfusion of these various components. Guidelines for PRBC transfusion thresholds in preterm neonates and children with chronic anemias are also summarized.
This document discusses the physiology of transition from fetal to newborn life. It outlines the major changes that occur at birth including the establishment of air breathing and changes in cardiovascular pressures and flows. The fetal circulation operates in parallel while the newborn circulation switches to series. At birth, the umbilical vessels and ducts close, the lungs aerate, and respiratory and cardiac functions are established. Abnormalities in the transition process can occur with preterm birth or C-section and may require assistance.
This document discusses shock in neonates. It defines shock and describes the unique pathophysiology of shock in newborns, including their immature cardiovascular systems. It outlines various types of shock seen in neonates such as cardiogenic, hypovolumic, obstructive, and distributive shock. Clinical scenarios that can cause neonatal shock are described. The use of echocardiography to evaluate shock is discussed. Parameters to assess shock are provided. Treatment approaches for different shock types are summarized, including fluid resuscitation, inotropic support, and other interventions.
Nutritional planning for growth & development of preterm neonatesArnab Nandy
This document discusses nutritional planning for pre-term neonates. It notes that pre-term neonates have unique nutritional needs due to higher rates of growth and metabolism. These include higher protein, energy, water, electrolyte and fatty acid requirements compared to term infants. The document outlines strategies for nutritional support including parenteral and enteral feeding, the importance of breastmilk and fortification, monitoring growth, and educating families. The overall aim is to ensure normal growth and neurodevelopmental outcomes for pre-term infants.
This document discusses feeding guidelines for low birth weight infants. It notes that LBW infants have physiological and biochemical handicaps that require special feeding considerations. Feeding should begin as soon as possible, using expressed breast milk. Initial feeding methods may include gavage, cup, or breast feeding depending on gestational age and abilities. Feedings should be given every 2-3 hours. Human milk fortifier may be needed if the infant is not gaining weight adequately. Growth should be closely monitored and supplements like iron may be required. Intolerance issues should be managed conservatively.
This document discusses neonatal hypoglycemia, including its definition, causes, screening, management, and long-term outcomes. Some key points:
- Hypoglycemia is common in newborns due to immature metabolic pathways and dependence on glucose. It can cause neurological damage if persistent.
- Definitions vary but typically include blood glucose levels below 45 mg/dL, or 36 mg/dL for asymptomatic babies with risk factors.
- Causes include decreased stores, increased utilization, and endocrine disorders like hyperinsulinemia.
- At-risk babies should be screened at birth and every few hours. Treatment involves glucose boluses and intravenous infusions to maintain safe blood glucose levels.
This document discusses fluid and electrolyte physiology in neonates. It covers developmental changes from intrauterine life through childhood and how this affects total body water, extracellular fluid, and intracellular fluid levels at different ages. It also discusses fluid shifts that occur during labor, delivery, and the postnatal period. Guidelines are provided for estimating insensible water loss and determining intravenous fluid and electrolyte requirements for term and preterm neonates of different gestational ages and weights.
This document describes the case of a 10-day-old infant presenting with signs of shock including tachycardia, poor perfusion, and decreased urine output. Examinations revealed hepatomegaly and other signs suggestive of shock. Investigations showed metabolic acidosis and low blood sugar. The infant did not respond to initial fluid resuscitation and inotropic support. Echocardiogram revealed hypoplastic left heart syndrome. Prostaglandin E1 was started and the infant responded, confirming duct-dependent systemic circulation. The case highlights the importance of early recognition and management of neonatal shock.
This document discusses neonatal mechanical ventilation. It begins by introducing mechanical ventilation and its importance in improving neonatal survival since the 1960s. It then discusses the benefits of mechanical ventilation in improving gas exchange and decreasing work of breathing. Various indications for ventilation are provided. Common conditions requiring ventilation are also listed. The document goes on to describe different types of ventilators and modes, how to initiate a breath, and studies comparing different modes. It concludes by discussing parameters for conventional ventilation like PIP, PEEP, flow rates, and methods for controlling oxygenation and ventilation.
1) Neonatal shock is characterized by an imbalance between oxygen delivery and demand, leading to tissue hypoxia. Myocardial dysfunction, abnormal vasoregulation, and hypovolemia are common causes.
2) Pathophysiology includes an immature myocardium with fewer contractile elements and higher basal contractility, as well as complex vascular smooth muscle tone regulation. Relative adrenal insufficiency also contributes.
3) Clinical assessment of shock includes vital signs, perfusion markers like capillary refill time and lactate, and echocardiography to evaluate cardiac function and filling. Goal-directed management targets normalization of these parameters.
This presentation deals with the basic physics of human ventillation. I have made an effort to clarify most of the venti lingo , so as to make way for further discussions on ventilator use. Hope it turns out to be helpful for you. Thank you.
This document discusses persistent pulmonary hypertension of the newborn (PPHN) with a focus on management in resource-limited settings. It provides background on PPHN, including associated conditions, signs and symptoms, diagnostic testing, and supportive care strategies. Key interventions discussed include inhaled nitric oxide (iNO), high frequency ventilation (HFV), and sildenafil. While iNO and HFV are standard treatments, their high costs limit use in many resource-poor areas. The document explores using less expensive options like sildenafil and discusses how HFV could potentially be utilized more in Nepal with appropriate equipment, training, and support.
This document discusses enteral nutrition in preterm neonates. It notes that providing adequate nutrition to preterm infants is challenging due to immaturity of bowel function and inability to suck and swallow. While parenteral nutrition can provide nutrients, lack of enteral intake can impair gut development and function. The document reviews evidence from several Cochrane reviews on different approaches to enteral feeding in preterm infants, finding insufficient evidence to recommend one approach over others and calling for additional large randomized controlled trials to evaluate effects on important outcomes.
Neonatal fluid requirements and specials conditionsRakesh Verma
This document provides an overview of neonatal fluid and electrolyte requirements, including physiological changes affecting balance in fetuses and neonates. It discusses developmental changes in total body water, extracellular and intracellular fluid during gestation and after birth. Maturation of organs like the cardiovascular system and kidneys that regulate fluid compartments is also covered. Guidelines are provided for calculating total fluid needs as well as maintenance, deficit and ongoing loss replacement in both term and preterm infants of different weights. Electrolyte supplementation amounts and choices of IV fluids are also summarized.
Diabetes in pregnancy poses risks to both mother and baby. Good glycemic control through nutrition, lifestyle changes, and possibly medication can help reduce risks. Babies of diabetic mothers may be large with potential birth injuries, and face risks of low blood sugar, breathing issues, and heart and metabolic problems. Close monitoring and management throughout pregnancy aims to deliver healthy babies.
The document discusses neonatal hypoglycemia, including:
1. Hypoglycemia is common in newborns, especially sick ones, as they transition from receiving glucose from the placenta.
2. The brain relies heavily on steady glucose, so low blood sugar can impact brain development if not addressed.
3. At-risk newborns include preterms, SGA, LGA, those with infections or perinatal stressors.
4. Treatment involves monitoring blood sugar based on risk level and intervening with oral or IV glucose if levels dip below thresholds.
A single live preterm male infant was delivered via normal vaginal delivery at 30-32 weeks gestation with a birth weight of 1.2kg. He was admitted for preterm care and respiratory distress. He required surfactant therapy, ventilatory support for 48 hours, and phototherapy for hyperbilirubinemia. Chest x-ray showed signs of respiratory distress syndrome. He is being closely monitored and managed supportively for preterm complications.
Nutritional Management of Premature InfantsMCH-org-ua
International conference «Actual approaches to the extremely preterm babies: International experience and Ukrainian realities» (Kyiv, Ukraine, March 5-6, 2013)
CLINICAL TEACHING ON BUBBLE CPAP: Introduction, Definition, History of development, Physiology of Bubble CPAP, Principle, Patient interface, equipments for bubble CPAP, indication and contraindication for bubble CPAP, essential of CPAP, CPAP machine, bubble cpap machine application, setting pressure, FiO2, oxygen flow, Monitoring adequacy and complications of bubble CPAP, Monitoring infant condition, weaning for Bubble CPAP, CPAP Failure, complications related to CPAP, Preventing complications, Nursing Care.
This document discusses different types of blood components used in transfusion therapy. It describes fresh whole blood, packed red blood cells (PRBCs), platelet concentrates, plasma components like fresh frozen plasma and cryoprecipitate. It provides details on the preparation, storage conditions and indications for transfusion of these various components. Guidelines for PRBC transfusion thresholds in preterm neonates and children with chronic anemias are also summarized.
This document discusses the physiology of transition from fetal to newborn life. It outlines the major changes that occur at birth including the establishment of air breathing and changes in cardiovascular pressures and flows. The fetal circulation operates in parallel while the newborn circulation switches to series. At birth, the umbilical vessels and ducts close, the lungs aerate, and respiratory and cardiac functions are established. Abnormalities in the transition process can occur with preterm birth or C-section and may require assistance.
This document discusses shock in neonates. It defines shock and describes the unique pathophysiology of shock in newborns, including their immature cardiovascular systems. It outlines various types of shock seen in neonates such as cardiogenic, hypovolumic, obstructive, and distributive shock. Clinical scenarios that can cause neonatal shock are described. The use of echocardiography to evaluate shock is discussed. Parameters to assess shock are provided. Treatment approaches for different shock types are summarized, including fluid resuscitation, inotropic support, and other interventions.
Nutritional planning for growth & development of preterm neonatesArnab Nandy
This document discusses nutritional planning for pre-term neonates. It notes that pre-term neonates have unique nutritional needs due to higher rates of growth and metabolism. These include higher protein, energy, water, electrolyte and fatty acid requirements compared to term infants. The document outlines strategies for nutritional support including parenteral and enteral feeding, the importance of breastmilk and fortification, monitoring growth, and educating families. The overall aim is to ensure normal growth and neurodevelopmental outcomes for pre-term infants.
This document discusses feeding guidelines for low birth weight infants. It notes that LBW infants have physiological and biochemical handicaps that require special feeding considerations. Feeding should begin as soon as possible, using expressed breast milk. Initial feeding methods may include gavage, cup, or breast feeding depending on gestational age and abilities. Feedings should be given every 2-3 hours. Human milk fortifier may be needed if the infant is not gaining weight adequately. Growth should be closely monitored and supplements like iron may be required. Intolerance issues should be managed conservatively.
This document discusses neonatal hypoglycemia, including its definition, causes, screening, management, and long-term outcomes. Some key points:
- Hypoglycemia is common in newborns due to immature metabolic pathways and dependence on glucose. It can cause neurological damage if persistent.
- Definitions vary but typically include blood glucose levels below 45 mg/dL, or 36 mg/dL for asymptomatic babies with risk factors.
- Causes include decreased stores, increased utilization, and endocrine disorders like hyperinsulinemia.
- At-risk babies should be screened at birth and every few hours. Treatment involves glucose boluses and intravenous infusions to maintain safe blood glucose levels.
This document discusses fluid and electrolyte physiology in neonates. It covers developmental changes from intrauterine life through childhood and how this affects total body water, extracellular fluid, and intracellular fluid levels at different ages. It also discusses fluid shifts that occur during labor, delivery, and the postnatal period. Guidelines are provided for estimating insensible water loss and determining intravenous fluid and electrolyte requirements for term and preterm neonates of different gestational ages and weights.
INTEGRETED MANAGEMENT OF NEONATAL & CHILDHOOD ILLNESSshivakumar chawan
The Integrated Management of Neonatal and Childhood Illness (IMNCI) was developed by WHO and UNICEF to reduce morbidity and mortality among children under five years old. It takes a curative, preventive, and promotive approach through improving family practices, ensuring access to essential medicines, strengthening health care workers' skills, and engaging communities. The IMNCI process involves assessing and classifying a child's illness, identifying and providing appropriate treatment, counseling the mother, and arranging follow-up care. Its overall goal is to improve growth, development, and survival of young children.
This document provides information on caring for distressed newborns in the pre-hospital setting. It discusses the normal transition from fetal to neonatal circulation and common complications such as respiratory distress, hypothermia, and congenital heart anomalies. It outlines the steps of newborn resuscitation which include establishing an airway, preventing heat loss, cutting the umbilical cord, assessing vital signs, providing oxygen or ventilation, and administering chest compressions or medications if needed. Specific situations like meconium aspiration, apnea, and prematurity are also addressed. The document emphasizes the importance of supporting the newborn's first breaths to prevent hypoxia and acidosis.
This document outlines the topics, schedule, faculty, and learning outcomes for the Adult Health Nursing I course at Southwest Tennessee Community College for the Spring 2012 semester. The course covers several units: Unit I on genitourinary and blood topics from January 12th-26th; Unit II on respiratory topics from January 31st-February 14th; and Unit III on cardiovascular topics from February 16th-23rd. The schedule includes class meetings, exams, and exam reviews. Learning outcomes cover assessing, diagnosing, treating, educating patients, and administering medications for conditions in each body system.
Dokumen tersebut membahas konsep asuhan neonatus dan balita yang mencakup:
1. Adaptasi bayi baru lahir terhadap kehidupan di luar rahim meliputi perubahan sistem pernapasan, sirkulasi, dan termoregulasi.
2. Transisi kehidupan luar rahim yang meliputi perubahan darah, sistem pencernaan, imun, dan ginjal.
3. Pencegahan infeksi melalui tindakan asepsis, cuci tangan, dan menjaga kebers
The document provides information about:
1) A graduate student's final examination for a Master's in Nursing with a focus on Maternal and Child Nursing.
2) The examination includes questions about the psychological and physiological changes of pregnancy, fetal development, and assessing fetal and maternal health during the first prenatal visit.
3) The student is asked to explain topics like nutrient exchange between mother and fetus, reasons for advising certain sleeping positions during pregnancy, and the importance of assessing oxygen administration to premature infants.
The document provides an introduction to using Twitter for professional development. It defines common Twitter terms like tweets, retweets, favorites, follows, hashtags, and mentions. It encourages attendees to follow 50 people from related fields, explore and explain 25 hashtags, and lists 10 Twitter commandments. The document also introduces several Twitter client applications and credits the photos used.
Self hosted server applications - Adam Horvathadamhorvath
How to get rid of configuration and deployment headaches; How to ease A-B testing, load balancing and testing new versions before rolling out to the public using a simple technique.
Architects started as makers of mass. Later, this idea evolved into the thought that the spaces carved out in buildings were the true art of architecture. As society evolved and mass transit provided the opportunity for many different classes, races and geographical groups would be in the same space, architecture began to embody utopian ideals of society.
Similarly, the “user experience” field began with the study of the interactions between people & computers. UX designers bridged the cognitive gap between people’s minds & the logical 1’s and 0’s of machines. As “user-centered” design & social media continue to grow, UX’ers realize they create frameworks in which brands build connections to customers, even facilitating interaction between those users: Interaction Design. A 2D space that gives people agency to participate in desired patterns. Social Choreography.
If there's anything to be borrowed from the practice of architecture to help UX, its the power of the diagram. The key to great UX is ensuring we meet both business and user goals by mating the mental models of the people interacting with the experiences we design.
The main idea of an action research project that seeks to prove that educational technology implemented on a 1:1 device to learner ration is effective in increasing passing rates on a state mandated reading test.
seminar NEW pediatric anatomy and physiology.pptxdhivyaramesh95
This document provides an overview of pediatric anatomy and physiology across different age groups from neonates to adolescents. It covers several body systems including airway and respiratory, cardiovascular, renal, hepatic, glucose metabolism, hematology, and musculoskeletal. Key points include that the pediatric airway is smaller and more prone to obstruction; cardiovascular function is rate dependent with lower cardiac output; renal function is immature; and thermoregulation, metabolism, and bone growth continue developing through childhood. Special considerations are discussed for preterm infants regarding respiratory drive, temperature regulation, and glucose levels.
This document discusses several key anatomical and physiological differences between pediatric patients and adults that are important for anesthesiologists to consider. It covers differences in the respiratory, cardiovascular, renal, hepatic, gastrointestinal, and thermoregulatory systems between infants/children and adults. It also discusses how these developmental differences can impact a child's response to medications and their pharmacokinetics. Special attention is needed for neonates due to their underdeveloped organ systems and immature metabolism. Careful preoperative evaluation of a child's medical history is important for anticipating potential anesthetic implications.
PAEDIATRIC PHYSIOLOGY & ITS IMPLICATION IN ANEASTHESIA - Muthu.pptxMubshiraTC1
This document discusses paediatric physiology and its implications for anaesthesia. Some key points:
- Children are not small adults and have significant physiological differences, especially neonates.
- Neonates have increased surface area, heat and fluid requirements compared to adults. Their cardiovascular and respiratory systems are also less developed.
- Fetal circulation changes at birth as lungs aerate and ductus arteriosus/foramen ovale close. Transitional circulation can occur if these remain patent.
- The paediatric airway has anatomical differences like a higher larynx that make intubation more challenging.
- Respiratory rate and oxygen needs are higher in children due to lower functional residual capacity and higher metabolic demands.
- Hyp
Applied anatomy and physiology of paediatric anaesthesiaKhairunnisa Azman
This document discusses the key anatomical and physiological differences between pediatric and adult patients that are important for anesthesia. It notes that infants have proportionally larger tongues, narrower airways that are more prone to obstruction, and an anterior larynx. Infant respiratory systems are also more compliant, with lower functional residual capacity. Their cardiovascular systems have higher heart rates and are more sensitive to bradycardias. Infant renal, hepatic and glucose metabolism are also immature. The document provides guidance on pre-operative evaluation, fluid management, and considerations for intubation and induction for pediatric anesthesia. It emphasizes being aware of potential unexpected responses due to the anatomical and physiological differences between pediatric and adult patients.
- Pediatric patients have unique anatomic and physiologic features compared to adults that impact surgical care. These include differences in the airway, respiratory, cardiovascular, gastrointestinal, and other body systems.
- Younger pediatric patients (neonates and infants) have particularly significant differences compared to older children and adults, such as an anatomically higher and smaller airway, immature organ systems, and distinct circulatory transitions at birth.
- Understanding these developmental variations is essential for perioperative management of pediatric surgical patients to optimize outcomes and minimize risks related to their smaller sizes and developing physiology.
ANATOMICAL AND PHYSIOLOGICAL DIFFERENCES IN PAEDIATRICS.pptxMercyHombe
This document discusses the numerous anatomical and physiological differences between paediatric patients and adults that are relevant to anaesthesia. It covers differences in the airway, respiratory system, cardiovascular system, central nervous system, hepatic and renal systems, thermoregulation, pharmacology, and psychological considerations. The key differences include proportionally larger heads, smaller airways, incomplete organ system development and immaturity of various physiological systems in paediatric patients compared to adults. These differences require special considerations for anaesthesia management in children.
This document discusses neonatal resuscitation and the physiologic changes that occur at birth. It covers topics like fetal circulation, oxygenation, the transition at delivery, signs of a compromised newborn, resuscitative steps including providing warmth, clearing the airway, stimulation and ventilation. Positive pressure ventilation techniques like bag-mask ventilation are described. The importance of anticipating resuscitation needs, preparing appropriately, and understanding the heart rate response to determine next steps is emphasized. Maintaining normal body temperature and oxygen saturation targets are also addressed.
This document discusses apnea of prematurity (AOP), which refers to cessation of breathing seen in premature infants due to immaturity of respiratory control systems. AOP is defined as absent breathing accompanied by bradycardia and desaturation. The risk is highest in infants born before 28 weeks gestation, with over 60% affected. Treatment involves identifying/treating underlying causes, caffeine therapy to increase breathing drive, and respiratory support like CPAP if needed. AOP generally resolves by 37 weeks but can persist longer in more premature infants. Prompt treatment is important to avoid hypoxia-related risks.
Birth asphyxia occurs when a baby fails to breathe at birth and can lead to neonatal mortality. It is caused by factors that obstruct breathing such as meconium aspiration or complications during delivery. Symptoms may include abnormal skin tone, lack of crying, and low heart rate. Diagnosis involves assessing signs, using the Apgar score, and determining acid-base balance. Treatment involves clearing the airways, stimulating breathing, warming the baby, and providing ventilation and oxygen as needed. Nursing care focuses on resuscitation and monitoring for complications like brain damage or developmental delays. While immediate effects include acidosis and respiratory issues, long-term effects of severe asphyxia can be cerebral palsy, intellectual disability, or
1) The document discusses the anatomical and physiological differences between pediatric and adult patients that are important for pharmacology. Key differences include higher water content, less developed organs, and immature metabolism in pediatric patients.
2) Absorption and distribution of drugs can be affected by factors like gastric pH, muscle blood flow, and protein binding, which continue developing in early life. Metabolism also matures over months, with phase I and II enzyme activity increasing with age.
3) These developmental factors mean pharmacokinetics and pharmacodynamics of drugs often differ substantially between pediatric and adult patients. Dosages may need to be modified and effects monitored carefully in children.
This document discusses the anaesthetic considerations for premature infants undergoing surgery. It outlines the physiological differences between premature and term infants that impact anaesthesia, including differences in the airway, respiratory, cardiovascular, renal and temperature regulation systems. It provides guidance on pre-operative assessment, appropriate intra-operative monitoring and management, including fluid management and blood product transfusion thresholds. Post-operative care involves close monitoring due to the risks of apnea and other complications in the first 48-72 hours after surgery.
This document provides guidance on newborn resuscitation and delivery room management. It discusses the normal transition from fetal to newborn circulation at birth and signs that can indicate in utero or perinatal compromise requiring resuscitation. It outlines the initial steps of resuscitation including maintaining temperature, positioning, clearing secretions if needed, drying, and stimulating the newborn. It emphasizes timely assessment of heart rate and oxygen need using pulse oximetry to guide ventilation and oxygen administration.
This document summarizes the physiology of transitional circulation from fetal to neonatal life. It discusses hematological adaptations like high erythropoietin and fetal hemoglobin in utero. It describes the ductus venosus shunt and its assessment by Doppler. After birth, there is a surge in catecholamines and other hormones to increase cardiac output to neonatal levels. The placenta develops from villi and contains the functional units of lobules and placentomes. Maternal and fetal circulation run in opposite directions to facilitate material exchange. Spiral artery defects may occur in preeclampsia. Doppler of uterine arteries can identify increased resistance associated with conditions like preeclampsia and IUGR.
This document discusses respiratory physiology in infants and children compared to adults. Some key points:
1) Infants have higher lung compliance and lower chest wall compliance than adults, making them more susceptible to reductions in functional residual capacity under anesthesia. Positive end-expiratory pressure is important to prevent atelectasis.
2) Ventilatory responses to hypoxemia and hypercapnia are blunted in infants compared to adults. General anesthesia can further depress these responses.
3) Infants rely more on active expiration mechanisms like laryngeal braking and diaphragmatic activity to maintain functional residual capacity versus passive mechanisms in adults.
4) Airway resistance is higher in infants due to smaller airway diameter
This document discusses newborn physiology across multiple body systems. It covers thermal regulation in newborns, cardiovascular physiology including ductus arteriosus closure and treatment of patent ductus arteriosus. It also discusses pulmonary development and surfactant, immunology, fluid management, nutrition and total parenteral nutrition. Other topics covered include blood volume, thermoregulation, pain management, and extracorporeal life support. The document provides detailed information on the anatomical and physiological differences between newborns and older children or adults.
The document discusses asphyxia neonatorum (birth asphyxia), including:
1) It defines asphyxia neonatorum as failure to establish sustained respiration within 1 minute of birth, which can lead to hypoxia and brain damage if not managed correctly.
2) Causes include prenatal hypoxia, umbilical cord compression during delivery, preterm birth, and maternal anesthesia.
3) Management involves resuscitation to establish respiration and circulation, including clearing the airway, ventilation with oxygen, cardiac massage if needed, and monitoring vital signs like temperature and blood glucose. The goal is to prevent complications like hypothermia.
This document provides guidelines for neonatal resuscitation. It defines neonatal resuscitation as intervention to help a newborn breathe and for its heart to beat after birth. Some key points include identifying infants at high risk for asphyxia, the goals of resuscitation being to minimize heat loss, establish breathing and circulation, and supporting cardiac output. Chest compressions are indicated for heart rates below 60 bpm. The initial assessment of a newborn involves asking if it is term gestation, if the amniotic fluid was clear, and if the newborn is breathing/crying and has good muscle tone.
Pharmacology for pediatric anaesthesia [autosaved]DeepakGupta825
This document discusses pharmacology considerations for pediatric anesthesia. It covers several key topics:
1) Developmental pharmacology - Drugs affect infants and children differently due to factors like body composition, organ maturity, and blood-brain barrier development. This impacts drug dosing, distribution, and elimination.
2) Inhalational agents - Sevoflurane and isoflurane are commonly used and have advantages like rapid induction/recovery, but sevoflurane can cause renal damage with prolonged use.
3) Intravenous agents - Propofol, ketamine, midazolam, fentanyl and other opioids are discussed. Propofol requires higher doses in children and should not be used for prolonged sedation in those under 12
The document discusses the history and techniques of assisted ventilation. It begins by describing early negative pressure devices like the Spirophore and Iron Lung. It then covers developments in positive pressure ventilation including early devices from the 1700s-1800s and discusses key aspects of applying ventilation support to neonates including: applied pulmonary mechanics regarding compliance and resistance, optimizing gas exchange through adjustments to factors like peak pressure, PEEP, and flow; ventilator management strategies; and practical hints for initial settings and weaning.
The document discusses various strategies to avoid ventilator-induced lung injury in infants, children, and adults with acute respiratory failure. It describes how using excessive pressure or tidal volume can overdistend and damage already open alveoli. Maintaining adequate PEEP and restricting tidal volume to below the upper inflection point on the pressure-volume curve can prevent injury. Techniques like high-frequency oscillatory ventilation, inhaled nitric oxide, extracorporeal membrane oxygenation, and partial/total liquid ventilation aim to minimize alveolar opening and closing while avoiding excessive pressures and volumes. Though experimental, these advanced strategies may help further improve outcomes by preventing ventilator-induced lung injury.
This document discusses guidelines and considerations for using high frequency oscillatory ventilation (HFOV) to treat large patients over 30 kg. While there is no strict upper weight limit, ventilation ability is constrained more by physiology than weight alone. Settings like mean airway pressure and amplitude are discussed. Early use within 72 hours of conventional ventilation is recommended to aid in CO2 elimination. An oxygenation index over 42 after 48 hours of HFOV indicates increased risk of non-survival. Patient preparation and monitoring are also outlined.
A peripherally inserted central catheter (PICC) line provides long-term venous access and is ideal for patients requiring prolonged intravenous therapy such as antibiotics, chemotherapy, or nutrition. It can remain in place for weeks or months at a time. A PICC line has multiple benefits including reduced infection risk compared to peripheral intravenous catheters since the insertion site is further from the heart. It also decreases the need for repeated punctures associated with blood draws by providing stable central access. Proper placement of the PICC tip within the central circulation must be confirmed with an x-ray to avoid potential complications from malpositioning.
This document discusses Percutaneous Endoscopic Gastrostomy (PEG) tubes, which are feeding tubes placed through the abdominal wall into the stomach endoscopically. It covers what a PEG tube is, how they are placed, types of feedings through PEG tubes, benefits of PEG feeding, management after insertion, routine PEG tube care, potential complications, and major complications. The overall purpose is to provide information on PEG tubes, their use, and nursing management of patients with PEG tubes.
Respiratory acidosis is a condition caused by a buildup of carbon dioxide in the body due to impaired lung function. This disrupts the body's acid-base balance, causing fluids like blood to become too acidic. Causes include lung diseases like asthma, obesity, and drugs that suppress breathing. Symptoms include confusion, fatigue, and shortness of breath. Treatment focuses on the underlying lung condition through medications, ventilation support, and oxygen if needed. The prognosis depends on the severity and cause of the respiratory acidosis.
Elevate Your Nonprofit's Online Presence_ A Guide to Effective SEO Strategies...TechSoup
Whether you're new to SEO or looking to refine your existing strategies, this webinar will provide you with actionable insights and practical tips to elevate your nonprofit's online presence.
Andreas Schleicher presents PISA 2022 Volume III - Creative Thinking - 18 Jun...EduSkills OECD
Andreas Schleicher, Director of Education and Skills at the OECD presents at the launch of PISA 2022 Volume III - Creative Minds, Creative Schools on 18 June 2024.
How Barcodes Can Be Leveraged Within Odoo 17Celine George
In this presentation, we will explore how barcodes can be leveraged within Odoo 17 to streamline our manufacturing processes. We will cover the configuration steps, how to utilize barcodes in different manufacturing scenarios, and the overall benefits of implementing this technology.
THE SACRIFICE HOW PRO-PALESTINE PROTESTS STUDENTS ARE SACRIFICING TO CHANGE T...indexPub
The recent surge in pro-Palestine student activism has prompted significant responses from universities, ranging from negotiations and divestment commitments to increased transparency about investments in companies supporting the war on Gaza. This activism has led to the cessation of student encampments but also highlighted the substantial sacrifices made by students, including academic disruptions and personal risks. The primary drivers of these protests are poor university administration, lack of transparency, and inadequate communication between officials and students. This study examines the profound emotional, psychological, and professional impacts on students engaged in pro-Palestine protests, focusing on Generation Z's (Gen-Z) activism dynamics. This paper explores the significant sacrifices made by these students and even the professors supporting the pro-Palestine movement, with a focus on recent global movements. Through an in-depth analysis of printed and electronic media, the study examines the impacts of these sacrifices on the academic and personal lives of those involved. The paper highlights examples from various universities, demonstrating student activism's long-term and short-term effects, including disciplinary actions, social backlash, and career implications. The researchers also explore the broader implications of student sacrifices. The findings reveal that these sacrifices are driven by a profound commitment to justice and human rights, and are influenced by the increasing availability of information, peer interactions, and personal convictions. The study also discusses the broader implications of this activism, comparing it to historical precedents and assessing its potential to influence policy and public opinion. The emotional and psychological toll on student activists is significant, but their sense of purpose and community support mitigates some of these challenges. However, the researchers call for acknowledging the broader Impact of these sacrifices on the future global movement of FreePalestine.
🔥🔥🔥🔥🔥🔥🔥🔥🔥
إضغ بين إيديكم من أقوى الملازم التي صممتها
ملزمة تشريح الجهاز الهيكلي (نظري 3)
💀💀💀💀💀💀💀💀💀💀
تتميز هذهِ الملزمة بعِدة مُميزات :
1- مُترجمة ترجمة تُناسب جميع المستويات
2- تحتوي على 78 رسم توضيحي لكل كلمة موجودة بالملزمة (لكل كلمة !!!!)
#فهم_ماكو_درخ
3- دقة الكتابة والصور عالية جداً جداً جداً
4- هُنالك بعض المعلومات تم توضيحها بشكل تفصيلي جداً (تُعتبر لدى الطالب أو الطالبة بإنها معلومات مُبهمة ومع ذلك تم توضيح هذهِ المعلومات المُبهمة بشكل تفصيلي جداً
5- الملزمة تشرح نفسها ب نفسها بس تكلك تعال اقراني
6- تحتوي الملزمة في اول سلايد على خارطة تتضمن جميع تفرُعات معلومات الجهاز الهيكلي المذكورة في هذهِ الملزمة
واخيراً هذهِ الملزمة حلالٌ عليكم وإتمنى منكم إن تدعولي بالخير والصحة والعافية فقط
كل التوفيق زملائي وزميلاتي ، زميلكم محمد الذهبي 💊💊
🔥🔥🔥🔥🔥🔥🔥🔥🔥
A Visual Guide to 1 Samuel | A Tale of Two HeartsSteve Thomason
These slides walk through the story of 1 Samuel. Samuel is the last judge of Israel. The people reject God and want a king. Saul is anointed as the first king, but he is not a good king. David, the shepherd boy is anointed and Saul is envious of him. David shows honor while Saul continues to self destruct.
This document provides an overview of wound healing, its functions, stages, mechanisms, factors affecting it, and complications.
A wound is a break in the integrity of the skin or tissues, which may be associated with disruption of the structure and function.
Healing is the body’s response to injury in an attempt to restore normal structure and functions.
Healing can occur in two ways: Regeneration and Repair
There are 4 phases of wound healing: hemostasis, inflammation, proliferation, and remodeling. This document also describes the mechanism of wound healing. Factors that affect healing include infection, uncontrolled diabetes, poor nutrition, age, anemia, the presence of foreign bodies, etc.
Complications of wound healing like infection, hyperpigmentation of scar, contractures, and keloid formation.
This presentation was provided by Racquel Jemison, Ph.D., Christina MacLaughlin, Ph.D., and Paulomi Majumder. Ph.D., all of the American Chemical Society, for the second session of NISO's 2024 Training Series "DEIA in the Scholarly Landscape." Session Two: 'Expanding Pathways to Publishing Careers,' was held June 13, 2024.
Philippine Edukasyong Pantahanan at Pangkabuhayan (EPP) CurriculumMJDuyan
(𝐓𝐋𝐄 𝟏𝟎𝟎) (𝐋𝐞𝐬𝐬𝐨𝐧 𝟏)-𝐏𝐫𝐞𝐥𝐢𝐦𝐬
𝐃𝐢𝐬𝐜𝐮𝐬𝐬 𝐭𝐡𝐞 𝐄𝐏𝐏 𝐂𝐮𝐫𝐫𝐢𝐜𝐮𝐥𝐮𝐦 𝐢𝐧 𝐭𝐡𝐞 𝐏𝐡𝐢𝐥𝐢𝐩𝐩𝐢𝐧𝐞𝐬:
- Understand the goals and objectives of the Edukasyong Pantahanan at Pangkabuhayan (EPP) curriculum, recognizing its importance in fostering practical life skills and values among students. Students will also be able to identify the key components and subjects covered, such as agriculture, home economics, industrial arts, and information and communication technology.
𝐄𝐱𝐩𝐥𝐚𝐢𝐧 𝐭𝐡𝐞 𝐍𝐚𝐭𝐮𝐫𝐞 𝐚𝐧𝐝 𝐒𝐜𝐨𝐩𝐞 𝐨𝐟 𝐚𝐧 𝐄𝐧𝐭𝐫𝐞𝐩𝐫𝐞𝐧𝐞𝐮𝐫:
-Define entrepreneurship, distinguishing it from general business activities by emphasizing its focus on innovation, risk-taking, and value creation. Students will describe the characteristics and traits of successful entrepreneurs, including their roles and responsibilities, and discuss the broader economic and social impacts of entrepreneurial activities on both local and global scales.
Chapter wise All Notes of First year Basic Civil Engineering.pptxDenish Jangid
Chapter wise All Notes of First year Basic Civil Engineering
Syllabus
Chapter-1
Introduction to objective, scope and outcome the subject
Chapter 2
Introduction: Scope and Specialization of Civil Engineering, Role of civil Engineer in Society, Impact of infrastructural development on economy of country.
Chapter 3
Surveying: Object Principles & Types of Surveying; Site Plans, Plans & Maps; Scales & Unit of different Measurements.
Linear Measurements: Instruments used. Linear Measurement by Tape, Ranging out Survey Lines and overcoming Obstructions; Measurements on sloping ground; Tape corrections, conventional symbols. Angular Measurements: Instruments used; Introduction to Compass Surveying, Bearings and Longitude & Latitude of a Line, Introduction to total station.
Levelling: Instrument used Object of levelling, Methods of levelling in brief, and Contour maps.
Chapter 4
Buildings: Selection of site for Buildings, Layout of Building Plan, Types of buildings, Plinth area, carpet area, floor space index, Introduction to building byelaws, concept of sun light & ventilation. Components of Buildings & their functions, Basic concept of R.C.C., Introduction to types of foundation
Chapter 5
Transportation: Introduction to Transportation Engineering; Traffic and Road Safety: Types and Characteristics of Various Modes of Transportation; Various Road Traffic Signs, Causes of Accidents and Road Safety Measures.
Chapter 6
Environmental Engineering: Environmental Pollution, Environmental Acts and Regulations, Functional Concepts of Ecology, Basics of Species, Biodiversity, Ecosystem, Hydrological Cycle; Chemical Cycles: Carbon, Nitrogen & Phosphorus; Energy Flow in Ecosystems.
Water Pollution: Water Quality standards, Introduction to Treatment & Disposal of Waste Water. Reuse and Saving of Water, Rain Water Harvesting. Solid Waste Management: Classification of Solid Waste, Collection, Transportation and Disposal of Solid. Recycling of Solid Waste: Energy Recovery, Sanitary Landfill, On-Site Sanitation. Air & Noise Pollution: Primary and Secondary air pollutants, Harmful effects of Air Pollution, Control of Air Pollution. . Noise Pollution Harmful Effects of noise pollution, control of noise pollution, Global warming & Climate Change, Ozone depletion, Greenhouse effect
Text Books:
1. Palancharmy, Basic Civil Engineering, McGraw Hill publishers.
2. Satheesh Gopi, Basic Civil Engineering, Pearson Publishers.
3. Ketki Rangwala Dalal, Essentials of Civil Engineering, Charotar Publishing House.
4. BCP, Surveying volume 1
Chapter wise All Notes of First year Basic Civil Engineering.pptx
Neonatal physiology
1. You are in Home >> Resources >> Clinical anaesthesia >> ATOTW archiveNeonatal PhysiologyCreated: 14/8/2007Email this pageAdd this article to my examination home page Print friendly page Neonatal Anaesthesia 1: physiologyIsabeau Walker Consultant Anaesthetist, Great Ormond Street Hospital Karen Wouters Anaesthetic SpR , Great Ormond Street Hospital Address for correspondence: isabeau@isabeau.demon.co.uk Self assessmentPlease answer the following questions prior to reading the tutorial 1. Explain why atropine is useful for premedication or on induction in neonates. 2. What are the normal values for heart rate, respiratory rate and blood pressure in a neonate? 3. What are the consequences of a patent arterial duct? (PDA); is a PDA always a bad thing? 3. Explain why you should support the ventilation in a neonate? 4. When is it safe to discharge a baby home on the day of surgery? 6. What happens if babies get cold? 7. What are the principles of fluid administration in neonates? Introduction Age is an important risk factor in anaesthesia. The risks of anaesthesia are greater in neonates and infants, even in expert hands. In order to reduce these risks, surgeons and anaesthetists should only undertake work that they have been trained to do and that they have continuing experience of. The full range of facilities for the perioperative care of children should be available. This article will consider the physiology of the neonate and the premature infant and the implications for clinical practice. Physiology of the neonate Definitions • Infant: child less than 1 year of age • Full term neonate: born between 37-40 weeks and aged less than 1 month • Premature neonate: child born before 37 weeks gestation • Extreme preterm neonate: child born less than 28 weeks gestation • Postconceptional age: gestational age + postnatal age. Respiratory function • Development of the lung starts early in embryonic life, pulmonary surfactant is produced at 24-26 weeks; alveolar development begins at 32 weeks and is complete by 18 months of age. Extreme prems require pulmonary surfactant and CPAP or IPPV after delivery for survival and are susceptible to bronchopulmonary dysplasia and later chronic lung disease. • The newborn lung is small in relation to body size, tidal volumes small in absolute terms (7 ml/kg), the respiratory rate is high (30-40 breaths per minute) and there is little respiratory reserve. The deadspace and resistance of the breathing circuit should be kept to a minimum in infants who are breathing spontaneously, to minimise the work of breathing. • The tongue is relatively large, the occiput prominent so the head tips forward and the airway is easily obstructed. Airway patency is best maintained by chin lift, avoiding compression of the floor of the mouth, possibly with the use of an oropharyngeal airway. • The epiglottis is long and straight and tends to flop back over the laryngeal inlet which is high and anterior; intubation in is best achieved with a straight blade laryngoscope. • The larynx is conical in shape, the narrowest portion at the level of the cricoid cartilage. Uncuffed tracheal tubes are commonly used in neonates to avoid airway oedema, also later subglottic stenosis. • The trachea is short and endobronchial intubation is not uncommon. The position of the tracheal tube should always be checked by auscultation. • The airways are narrow and are easily blocked by oedema or secretions. A clear nasal airway is important in a small infant postoperatively as they breathe predominantly through their noses whilst feeding. • Lung compliance is high and the ribs soft and elastic; chest wall compliance is higher compared with adults. Chest wall stability increases by about 1 year of life. The distending pressures on the lung are low and the newborn infant is prone to lung collapse, especially under general anaesthesia. The diaphragm is the predominant respiratory muscle in neonates but is more easily fatigable than in adults. Ventilation under anaesthesia should be at least assisted and infants should not be left to breathe spontaneously through a tracheal tube. CPAP or PEEP should be employed to avoid atelectasis. • Gastric distension is common after facemask ventilation and will splint the diaphragm, compromise respiration and increase the possibility of aspiration. A nasogastric tube should be passed to relieve gastric distension. • Anaesthetic agents depress the pharyngeal dilator muscles leading to upper airway obstruction. Neonates should be intubated for all except the briefest of procedures and positive pressure ventilation should be used. Oxygen transport • Neonates have a high metabolic requirement for oxygen (6-8 ml/kg/min vs 4-6 ml/kg/min in adults). • Tissue oxygen delivery is achieved by a relatively high cardiac output (300ml/kg/min vs 60-80 ml/kg/min in adults), high heart rate (120-180 beats per min) and respiratory rate (30-40 breaths per min); neonates do not tolerate bradycardia or interruption in ventilation for any length of time and become hypoxic very readily. Hypoxia may lead to profound bradycardia. • Oxygen transport by haemoglobin shows developmental changes with time and is characterised by changes in the oxygen dissociation curve, described by the P50, the partial pressure of oxygen at which haemoglobin is 50% saturated. • At birth, foetal haemoglobin (HbF) forms 70-80% of total haemoglobin. Foetal haemoglobin delivers oxygen effectively to the tissues in the hypoxic conditions found during foetal life but tends to ‘hold on’ to oxygen in normal conditions after birth (the oxygen dissociation curve for foetal haemoglobin is shifted to the left). This is compensated for by a relatively high haemoglobin concentration at birth, from 13-20 g/dl, depending on the degree of placental transfusion, increasing the availability of oxygen to be delivered to the tissues. • Adult haemoglobin, HbA2 increases from birth, being the dominant haemoglobin by the first few months of life. It is very efficient at delivering oxygen to the tissues, even more so during infancy than adult life (the oxygen dissociation curve is shifted to the right during infancy). This is because there are higher levels of 2,3 diphosphoglycerate (2,3 DPG) during infancy which helps ‘offload’ oxygen to the tissues. • Coupled with a relatively high cardiac output, tissue oxygen delivery is extremely efficient in infants compared to adults. These factors affect the triggers for transfusion or the haemoglobin level at which a child should be considered significantly anaemic. Equivalent haemoglobin concentrations for the same tissue oxygen delivery are 8g/dl, 6.5g/dl and 12g/dl for an adult, infant and neonate respectively. An infant tolerates anaemia fairly well, a neonate does not. • If a child does require transfusion, they should be transfused if possible from one donor unit. A useful formula for transfusion is: 4 ml/kg packed cells raises the Hb by 1g/dl 8ml/kg whole blood raises the Hb by 1 g/dl Control of ventilation The control of ventilation is immature at birth and neonates are at risk from postoperative apnoeas, especially if born prematurely, anaemic or exposed to opiates. • The ventilatory response to hypercapnia is blunted in the first few weeks of life. • Neonates respond to hypoxia by a brief increase in ventilation followed by apnoea. The apnoeic response to hypoxia is probably due to respiratory muscle fatigue or upper airway obstruction. • Control of respiration matures by three weeks of age in the term baby. • Anaesthetic agents depress ventilation in a dose dependent manner. • Term neonates are probably not at risk of postoperative apnoea after routine minor surgery (avoiding opiates) from 1 month of age (i.e. 44 weeks PCA) • Premature neonates are at low risk of postoperative apnoeas after 60 weeks post conception. • Regional anaesthesia, without sedation (e.g. spinal anaesthesia for hernia repair) may reduce the risk of postoperative apnoeas. Cardiovascular function • The cardiac muscle is immature at birth. • Heart rate is an important determinant of cardiac output and the heart rate should be maintained in the normal range (120-180 bpm, term neonate). • The Frank-Starling relationship regulates cardiac output as in adults but is limited; neonates increase cardiac output with careful volume loading (fluid bolus 5-10ml/kg), but they do not tolerate fluid overload. • Contractility in neonates is high due to high sympathetic tone, especially around the time of birth, and this also explains the high resting heart rate of neonates. • Cholinergic innervation is well developed at birth and vagally mediated cardiac reflexes are obvious, even in premature infants. Hypoxia and laryngoscopy lead to profound bradycardia. • Afterload is also a major determinant of cardiac output. The neonatal heart is exquisitely sensitive to increases in systemic or pulmonary vascular resistance which will reduce the cardiac output. • The myocardium is dependent on extracellular calcium for contraction and ionised hypocalcaemia is poorly tolerated. Hypocalcaemia may occur after large volume blood or blood product transfusion or in a child who is septic. • Neonates are more sensitive to the negative inotropic effects of anaesthetic agents than older children; the effect is more marked with halothane than isoflurane or sevoflurane. Avoid deep anaesthesia, especially ventilation with high concentrations of volatile agents • Atropine may counteract the reduction in cardiac output seen with volatile agents and will protect against vagally mediated reflexes, especially those associated with laryngoscopy and intubation. It is useful as premedication, although no longer routinely used, but should always be drawn up ready. Transitional circulation • Cardiorespiratory adaptation at birth results in an increase in pulmonary blood flow and closure of the foetal shunts which allow the blood to bypass the lungs – the foramen ovale and ductus arteriosus. • In utero the right and left hearts pump in parallel. There is a connection between the systemic and pulmonary circulation via the ductus arteriosus (pulmonary artery to the aorta) and the foramen ovale (right to left atrium). The pulmonary circulation has a high resistance and the right and left ventricular pressures are equal, even though the right ventricle ejects 66% of the combined ventricular output. • When the umbilical cord is clamped and the low resistance placental circulation is lost, there is a sudden rise in systemic vascular resistance • With the first breath and expansion of the lungs there is an increase in pH and increased oxygenation, the pulmonary vascular resistance decreases and pulmonary blood flow increases. The increased pulmonary venous return to the left atrium raises the left atrial pressure above the right and as a result the flap valve of the foramen ovale closes. • The increase in left sided pressures and the fall in right pressures results in a decrease or reverse flow through the ductus arteriosus • The duct closes in response to oxygen, prostaglandins, bradykinin and acetylcholine. Anatomical closure by constriction occurs at 6hrs, complete occlusion usually occurs at 6 weeks of age. • The pulmonary vascular resistance may increase in response to hypoxia, hypercarbia or acidosis. Severe pulmonary hypertension may ensue, with reopening of the foetal shunts, causing profound hypoxia and cardiovascular compromise. • Persistent Pulmonary Hypertension of the Newborn (PPHN) is associated with congenital diaphragmatic hernia, meconium aspiration, asphyxia, hypoxia and sepsis. Management includes optimising oxygenation and ventilation, sedation, inotropic support, inhaled nitric oxide and high frequency oscillatory ventilation (HFOV) and extracorporeal membrane oxygenation (ECMO) if available. • Patent arterial duct (PDA) is seen in 50% of extreme premature infants. Shunting from the aorta to the pulmonary artery results in respiratory distress syndrome and is a risk factor for intraventricular haemorrhage and necrotising enterocolitis. • Some congenital cardiac abnormalities may be dependent on a patent arterial duct. Collapse of the neonate will occur with closure of the duct, typically at one week of age. For example, duct dependent pulmonary circulation (pulmonary atresia) and duct dependent systemic circulation (critical coarctation of the aorta); prostaglandin infusion is required until definitive treatment is possible. The differential diagnosis of collapse in a neonate is sepsis. Hepatic function and drug handling. • The liver in the newborn contains 20% of the hepatocytes found in adults and continues to grow until early adulthood. • The liver is the principle site of drug metabolism, some evidence of which can be found in foetal life, albeit at low levels. • Phase I processes (metabolic, e.g. the cytochrome P450 system) are significantly reduced at birth whilst phase II processes (conjugation) may be well developed (sulfation) or limited (glucuronidation). Paracetamol is useful in neonates as it is excreted by sulfation (rather than glucuronidation as in adults). • In general, drug effects are prolonged in neonates and drugs should be titrated to effect, given by bolus rather than infusion, or plasma levels monitored as appropriate. • Maturation of enzymatic processes increases over the first few weeks of life and the half-life of drugs such as morphine reaches adult levels at 2 months of life. Neonates require significantly less morphine than older children, especially in the first week of life. Morphine should be given as a bolus dose of 10 mcg/kg; beware, the half-life may be up to 8 hours (double that of older children). • Plasma protein binding is reduced in neonates (low levels of α1-acid glycoprotein) and drugs that are plasma protein bound (such as local anaesthetics) may demonstrate increased toxicity in infants. • Neonates have reduced hepatic stores of glycogen and immature gluconeogenic enzyme systems. Coupled with a high metabolic rate, this makes them susceptible to hypoglycaemia following starvation. Neonates should not be starved excessively (breast milk feed 4 hours preoperatively, clear fluids 2 hours preoperatively), and if possible, blood sugar should be measured during surgery. Glucose should be added to the intraoperative fluids, for instance, add 25ml of 50% dextrose to 500ml of Ringers Lactate to give a solution of 2.5% dextrose in Ringers Lactate. Renal function • Nephrogenesis is completed at 36 weeks gestation and no further nephrons are produced (impaired nephrogenesis in premature infants has been related to hypertension in adult life). Further increase in renal mass is due to the growth of tubules. • The glomerular filtration rate at term is low and reaches adult indexed values only at 2 years of age. Creatinine at birth reflects the mother’s creatinine and falls to reflect renal function of the baby by 1 week of age. • Tubular function matures over the first few months of life; infants usually produce urine that is isotonic to plasma, but if required, can concentrate their urine to achieve an osmolality of 500-700 mOsmol/kg H2O. Adult values (urinary osmolality typically 1200-1400 mOsmol/kg H2O) are reached by a year of age. Infants tolerate fluid restriction poorly and become dehydrated quickly. • The neonate’s limited renal function is appropriate to the period of rapid growth after birth – growth has been termed the ‘third kidney’. However, in the postoperative (catabolic) infant, renal insufficiency may become apparent and the neonate does not handle fluid or sodium overload. Fluid and electrolyte balance • The extracellular fluid compartment is expanded in neonates, with total body water representing 85% of body weight in premature babies, 75% of body weight in term babies, compared to 60% body weight in adults. • The expanded extracellular fluid compartment results in an increased volume of distribution of commonly used drugs and increased dose requirements, despite increased sensitivity (muscle relaxants, intravenous induction agents). • Contraction of the extracellular fluid compartment and weight loss in the first few days after birth is a normal physiological process, due in part to a diuresis induced by atrial naturetic peptide (ANP) secondary to increased pulmonary blood flow and stretch of left atrial receptors. After this period of negative water and sodium balance, water and sodium requirements increase to match those of the growing infant. • Fluids should therefore be restricted until the postnatal weight loss has occurred. Liberal fluid regimens in the first few days of life have been shown to be associated with worse outcomes in premature infants (increased patent ductus arteriosus, necrotising enterocolitis and death). Fluid requirements increase incrementally from day 1 of life (60ml/kg/day) to 150ml/kg/day at 1 week of life (up to 180ml/kg/day in a premature neonate with high evaporative losses) Temperature control • Thermoregulation in the neonate is limited and babies become cold easily. • Heat production is limited and there is a greater potential for heat loss (high body surface area to body weight ratio, increased thermal conductance, increased evaporative heat loss through the skin). The newborn infant is able to increase heat production through brown fat metabolism (non shivering thermogenesis, inhibited by volatile agents), however this is at the expense of increased oxygen consumption. • Hypothermia is associated with hypoxia, impaired wound healing, prolonged coagulation with reduced platelet function, reduced drug metabolism, cerebral depression, myocardial depression, acidosis, decreased immunity, patient discomfort. • The preterm baby is particularly vulnerable as the immature skin is thin and allows major heat (and evaporative fluid) losses. Central nervous system, nociception and the stress response • The lower limit for cerebral autoregulation in neonates is not known, but is thought to be around a cerebral perfusion pressure of 30 mmHg. Appropriate mean arterial blood pressures for extreme premature neonates are controversial but it generally accepted that the mean arterial pressure equates to the gestational age of the child during the first day of life, rising to a minimum of 30mmHg by 3 days. • Survival of extreme preterm infants has improved considerably in recent years, but this has been associated with high levels of disability. A major determinant of cerebral impairment is intraventricular haemorrhage (IVH) which usually occurs within the first few days of life. Steroids are thought to interfere with the development of the brain in the newborn and avoidance of postnatal dexamethasone is currently the single most important factor to improve neurological outcomes in premature infants. Developmental aspects of pain • Neonates, including premature neonates, show well developed responses to painful stimuli. The foetus shows a stress response (and behavioural changes) to painful stimulation from 18-20 weeks gestation, which can be attenuated by the administration of fentanyl. Attenuation of the stress response to surgery improves postoperative morbidity and mortality in neonates. • There is a great deal of neuronal fine tuning of pain pathways during early neonatal life which may be influenced by the activity of endogenous opioids (and by implication, administered opioids). • There is a question about the long term effects of exogenous morphine administration to neonates, also the long term effects of painful experiences in the neonatal period. Surgery should be avoided in neonates if possible. Pain in neonates should be treated using multimodal analgesia, but opiates should be used judiciously, for both pharmacokinetic (reduced drug metabolism) and pharmacodynamic reasons (increased opiate sensitivity). Further reading: An excellent account of all aspects of anaesthesia for children and neonates is to be found in the chapter by Simon Berg in the Oxford Handbook of Anaesthesia, Ed Allman K, Wilson I. 2nd edition 2006 Oxford University Press, Oxford. Answers to questions 1. Explain why atropine is useful for premedication or on induction in neonates. Atropine is a muscarinic acetylcholine antagonist. It causes vagal blockade at the AV and sinus node in the heart and increases heart rate. A dose of 40 mcg/kg PO or 20 mcg/kg IM/IV is used to prevent reflex bradycardia, for instance from hypoxia, deep volatile anaesthesia or from reflex vagal stimulation with intubation/laryngoscopy. Bradycardia results in a marked fall in cardiac output. Atropine also dries secretions, including after ketamine anaesthesia; secretions might obstruct the airway or cause laryngospasm. 2. What are the normal values for heart rate, respiratory rate and blood pressure in a term neonate? Heart rate 120-180 beats per min Respiratory rate 30-40 breaths per min Mean arterial blood pressure 30-50 mmHg Mean systolic BP 50-90 mmHg Mean diastolic BP 25-60 mmHg 3. What are the consequences of a patent arterial duct? (PDA); is a PDA always a bad thing? A PDA results in left to right shunting from the aorta to the pulmonary artery and increase in pulmonary blood flow. In the premature neonate this will result in cardiac failure. There is a low diastolic blood pressure which may cause gut hypoperfusion, resulting in necrotising enterocolitis, or intraventricular haemorrhage. In an older child, persistence of a PDA may cause mild cardiac failure presenting as frequent chest infections. If a child has a PDA for many years, this may eventually cause pulmonary hypertension and result in flow reversal across the duct (Eisenmenger circulation). There are a few conditions where patency of the arterial duct is required for survival: for instance, duct dependent systemic circulation in critical coarctation (blood flow to the lower body is from the pulmonary artery, via the duct), or duct dependent pulmonary circulation in pulmonary atresia (blood flow to the lungs is from the aorta, via the duct). Such children collapse about a week after birth as the duct closes and require a prostaglandin infusion to maintain the duct until a definitive procedure is undertaken (e.g. coarctation repair or a systemic to pulmonary artery shunt in pulmonary atresia, known as a modified Blalock Taussig shunt (mBT shunt). 4. Explain why you should support the ventilation in a neonate? The neonate is prone to upper airway obstruction so anaesthesia is best managed by intubation. The work of breathing is high and breathing through the high resistance of a tracheal tube further adds to the work of breathing and the neonate will tire rapidly. The neonate is prone to atelectasis and small airway collapse as the ribs are soft and lack elastic recoil to maintain lung volumes. In addition, the diaphragm is the principle muscle of respiration and tires easily; abdominal distension will further interfere with diaphragmatic movement. Neonates should therefore be intubated and ventilated for anaesthesia, using low pressure ventilation (<20cmH2O), to achieve the appropriate small tidal volumes (7ml/kg), with the application of a small amount of PEEP (4cmH20). If the neonate is breathing spontaneously under volatile anaesthesia on a facemask, an oropharyngeal airway should be considered with the application of a small amount of CPAP (4cmH20). A neonate breathing spontaneously under ketamine anaesthesia should have the airway supported by a chin lift and supplemental oxygen administered. 5. When is it safe to discharge a baby home on the day of surgery? Provided the baby has undergone minor uncomplicated surgery, without the use of opioids, is otherwise well, not anaemic, and the home circumstances are appropriate, a baby who was born at term can probably be discharged on the day of surgery when they are 1 month old. It is sensible for surgery to be performed in the morning to allow for observation in hospital during the day – any complications in the recovery room are a contraindication to discharge on the day of surgery. A baby who was born prematurely may be discharged when they are 60 weeks post conception. For instance, if the baby was born at 30 weeks conception, it would be reasonable to discharge them on the day of surgery when they have a PCA of 60 weeks, that is, they are 71/2 months old, provided they are otherwise well. Babies younger than this should be observed in hospital overnight after surgery. 6. What happens if babies get cold? If a baby becomes cold they may become hypoxic, may be slow to wake after surgery and may have increased bleeding and increased wound infections. 7. What are the principles of fluid administration in neonates? Neonates have reduced renal function and produce dilute urine. They are unable to tolerate dehydration; similarly, they cannot handle a high fluid load or sodium load in the first few days of life. They undergo a diuresis after a few days of life. If a baby requires intravenous fluids from birth, they should be given as 10% dextrose in the following volumes. Sodium 3 mmol/kg/day and potassium 2 mmol/kg/day should be added after the postnatal diuresis or if the baby becomes hyponatraemic: Fluid volume (ml/kg/day) Day 1 60 Day 2 90 Day 3 120 Day4 150 Day 5 150 A premature neonate may require an additional 30 ml/kg/day because of increased insensible fluid losses and may also require additional sodium supplements (4 mmol/kg/day). Replacement fluids (ie during surgery or to correct hypovolaemia) should be given as isotonic fluid (0.9% saline or Ringers-Lactate/Hartmann’s) or blood to maintain the haemoglobin at 10-12 g/dl. 50% dextrose 25ml may be added to 500ml of isotonic solution to give a 2.5% solution if the blood sugar is low. It is safer to administer fluids via a burette to avoid fluid overload. Postoperatively fluids should be restricted to 60% of maintenance (or remain at day1-2 levels of restriction if the child undergoes early surgery). ArticleDate:20070814 <br />