Nicu Must-Knows: A. B. C. A. B. C. D

 

NICU MUST-KNOWS

 APGAR SCORE

 

ESSENTIAL NEWBORN CARE

1.  Immediate and thorough drying (prevent hypothermia) 2.  Early skin to skin contact (thermoregulation, bonding, skin flora)  3.  Properly timed cord clamping (reduce anemia) TERM: 1-3 mins PRETERM: 30 sec-1 min 4.  Non-separation of newborn to mother for early initiation of breastfeeding ROUTINE NEWBORN CARE

1.  Identification: done twice in delivery room and in NICU 2.  Vitamin K prophylaxis A.  K1 Phytomenadione: Natural B.  K2 Menaquinone: rebound hemorrhage C.  K3 Menadione: rebound hemorrhage 3.  Eye prophylaxis  A.  0.5% Erythromycin B.  1% tetracycline

BAL LARD SCORE

C.  1% Silver nitrate  – chemical conjunctivitis D.  2.5% povidone iodine (WHO) 4.  Cord care 5.  Bathing: 6th hour of life 6.  Vaccine A.  BCG B.  Hepa B NEWBORN SCREENING

1.  2.  3.  4. 

Congenital Adrenal Hyperplasia Congenital Hypothyroidism Phenylketonuria Galactosemia

 

Maple Syrup Disease 5.  G6PD 6. METHODS OF HEAT LOSS

*DUBOWITZ: BALLARDS

1.  EVAPORATION: lost by water evaporation from the skin of the infant Ex: Thorough drying of infant after delivery 2.  RADIATION: heat loss from the infant (warm) to a colder nearby (not in contact) object Ex: Use of droplight 3.  CONDUCTION: direct heat loss from the infant to the surface w/ which he/she is in direct contact Ex: Using pre-warmed linen and cloth 4.  CONVECTION: heat loss from the infant to the surrounding air Ex: Turn the aircon off

NORMAL VALUES

HC > CC  – birth to 6 months HC = CC  – 6-12 months 

 

REFLEXES

 

PURPOSE OF INITIAL PE:  1.  To ensure that there is no evidence of significant s ignificant cardiopulmonary instability that requires intervention  2.  To identify congenital anomalies  BREASTFEEDING

BENEFITS OF BREASTFEEDING B –  est  est for infants  R –  educes allergies  E –  economical  A –  antibodies (IgA  – most abundant)  S - terile  T –  emperature is always right   F –  resh E –  asily digested  E –  motional bonding  D –  iarrhea is reduced   I –  mmediately available  N –  utritionally optimal  G –  astroenteritis

NOT contraindicated  contraindicated in Mastitis Breastfeeding is NOT Mothers taking Magnesium Sulfate CAN still CAN still breastfeed their babies PHYSIOLOGIC CHANGES IN THE NEWBORN PERIODS OF REACTIVITY

1.  Tears often are not present with crying until after 1-3 months

1.  First period

 

2.  Physiologic jaundice: appears after 24 hours

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4.  5.  6. 

Peaks: Day 2-3 Disappears 5th day of life Caput succedaneum: fluids, edema; crosses midline resolves in days/weeks Lumbar lordosis: up to 6 years of age   Physiologic balding: up to 4 months of age Witch’s milk: galactorrhea in neonates because of persistence of mother’s estrogen in neonate’s blood

PHYSICAL EXAM OF THE NEWBORN

TIMING OF PHYSICAL EXAMINATION

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2.  -  -  3.  - 

 

Immediately after birth  1.  Nursery 2. room within 24 hours after birth   3.  Focused examination within 24 hours before discharge 

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30 minutes after birth. Usually alert and attentive/responsive. Regularly reflect a state of sympathetic discharge Irregular respiratory effects and relative tachycardia Exhibits spontaneous startle reactions, tremors, bursts of crying, side to side movements of the head, smacking of lips, and tremors on extremities. Sleep phase After the burst of activity, the newborn enters a period of depressed activity and sleep Newborn are difficult to awaken Second period Emerges between 2-6 hrs of age a ge with same motor and autonomic manifestations same as the 1 st  period Gagging and vomiting are evident Variable duration lasting for 10mins to several hours.

 

JAUNDICE

PHOTOTHERAPY

  Normal Bilirubin production in NEWBORNS: 6-8mg/kg/day Estimated total bilirubin level based on dermal affectation: af fectation: CEPHALOCAUDAL  KRAMER’S INDEX  

FACE = 5mg/dL CHEST = 10mg/dL ABDOMEN = 15mg/dL

3.  Body temperature should be monitored 4.  Irradiance should be measured directly 5.  Genitalia protected

PALMS AND SOLES = 20mg/dL

BHUTANI: Bilirubin LUNG MATURITY

DEXAMETHASONE: 6mg q12 x 4 doses (IM) BETAMETHASONE: 12mg q24 x 2doses PHYSIOLOGIC VS PATHOLOGIC JAUNDICE

PHYSIOLOGIC nd

rd

PATHOLOGIC

Appears on 2  to 3  DOL Disappears by the 5th DOL

May appear on 1st 24 HOL Variable

Peaks on Days 2 to 3 Total Bilirubin  – usually 5 mg/dL Conjugated bilirubin >2mg/dL at anytime

Presents after 48th HOL TB increases NOT >5mg/dL/day  TB peaks at 14-15 mg/dL

Direct bilirubin is 0.5mg/dL/day  TB increase to >15 mg/dL  Serum bilirubin: >12 mg/dL in full term, 10-14 mg/dL in preterm neonates

COMPLICATIONS 1.  Loose stools 2.  Erythematous macular rash/purpuric rash 3.  Overheating 4.  Dehydration: increase insensible loss, diarrhea 5.  Hypothermia 6.  Bronze baby syndrome 7.  Corneal damage 8.  Anemia 9.  Thrombocytopenia 10.  Constipation 11.  Burns 12.  Sterility MECONIUM STAINING

CAPUT SUCCADANEUM CEPHALHEMATOMA  CAPUT SUCCEDANEUM VS CEPHALHEMATOMA

Direct bilirubin is >10% of TB (>2mgdL) Persists beyond: 1 week in term; 2 weeks in preterm

BREASTFEEDING VS BREASTMILK JAUNDICE

1.  CAPUT SUCCEDANEUM DESCRIPTION:  diffuse, ecchymotic, edematous swelling of the soft tissues. EXTENSION: extend across the midline and suture lines PATHOPHYSIOLOGY:  associated with molding of the head and overriding of parietal bones RISK FACTORS:  long difficult delivery; vacuum/forceps delivery RESOLUTION: 1st few days COMPLICATIONS: hyperbilirubinemia JAUNDICE

 

2.  CEPHALHEMATOMA DESCRIPTION: firm tense mass with a palpable rim localized over 1 area of the skull EXTENSION: limited to the surface of 1 cranial bone PATHOPHYSIOLOGY: subperiosteal hemorrhage RISK FACTORS: forceps delivery; large head; 1st pregnancy  –  difficult prolonged labor RESOLUTION: 2 weeks to 3 months, m onths, calcify by the end of the nd 2  week COMPLICATIONS: hyperbilirubinemia, infection

3.  IDM 4.  LGA 5.  Rare medical causing hypoglycemia

CBG IDM  At Birth 30 mins 1 hr 1 hr and 30 mins 2 hrs 4 hrs

8 hrs 12 hrs 24 hrs 36 hrs 48 hrs

3.  SUBGALEAL HEMORRHAGE DESCRIPTION: collection of blood EXTENSION: beneath the aponeurosis that covers the scalp and serves as the insertion of the occipitofrontalis muscle PATHOPHYSIOLOGY: secondary to rupture of emissary veins connecting the dural sinuses within the skull with the superficial veins of the scalp. RISK FACTORS: associated with vacuum-assisted delivery RESOLUTION: over 2-3 weeks COMPLICATIONS: hypotension, anemia, hyperbilirubinemia hy perbilirubinemia

NEVI

RASHES

FORMULAS

CBG

INDICATIONS: 1.  Preterm 2.  SGA

 

CORRECTED AGE OF PRETERM INFANTS EARLY BALLARD + (AGE IN DAYS ÷ 7) HMD VS TTN

II. TRANSIENT TACHYPNEA OF NEWBORN: RDS TYPE 2   Transient: usually improves within 24 hours; •  disappears within 72 hours •  Wet-lung syndrome term to late preterm •  Early onset respiratory distress •  Mild. self-limited disorder, recovery within 3 days •  INCREASED INCIDENCE Term or late preterm •  Premature, precipitous & operative births -> •  prolonged delivery Male, born to asthmatic mother •  Delayed cord clamping •  Macrosomia •  Multiple gestation • 

ETIOLOGY/PATHOPHYSIOLOGY Surfactant deficiency: produced by Type 2 •  pneumocytes; LS ratio 2:1  Maturation of surfactant system -> Phosphatidy •  glycerol  FRC fails to develop -> collapsed lung/atelectasis  •  •

 

     

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High O2 concentration (damage epithelial lining cells)  Genetics, hypoxia  Hyper/Hypoxemia  Lungs are liverlike, atelectasis  

DIAGNOSIS •  Premature infants with distress CXR: Fine reticulo-granularity (ground glass), air •  bronchogram, typical pattern seen at 6-12 hours ABG: progressive hypoxemia, hypercarbia, •  metabolic acidosis, high base excess   CLINICAL MANIFESTATIONS •

   

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Peaks in 3 days then gradually improves   Babies are born pinkish with very loud cry but signs appear few minutes after birth   Tachypnea  Grunting  IC and SC retractions  Alar flaring  Duskiness 

MANAGEMENT Intratracheal surfactant replacement •  Oxygen (O2 sat at 88-94%) •  Permissive hyoercapnea (55-65) •  IVF, NPO, CPAP, Mech. vent, infection control: use •  of orogastric tube

PATHOPHYSIOLOGY: Absence of hormonal changes that accompany •  onset of spontaneous labor •  Abdominal delivery (non-spontaneous labor) −  No thoracic squeeze Transient pulmonary edema d/t delayed clearance •  of fetal lung liquid Fluid accumulation in peribronchiolar lymphatics •  and bronchovesicular spaces Diminished lung compliance and distensibility •  CLINICAL MANIFESTATION: Typically presents at 6 hours of life •  Mild to moderate respiratory distress •  •  Improves in 24 hours; can last up to 72 hours in severe cases Rapid recovery, absence of radiographic findings •  of RDS •  CXR: prominent pulmonary vascular finding fluid in interlobar fissures overaeration o  flat diaphragms o  rarely: small pleural effusion o  o  mild to moderate cardiomegaly MALIGNANT TTN: refractory hypoxemia due to PPHN in infants born via CS give ECMO •  MANAGEMENT: Supportive: humidified O2, IVF, NPO, Antibiotics •  Caffeine or theophylline: increase central •  respiratory drive by lowering the threshold of response to hypercapnia as well as enhancing contractility of the diaphragm and preventing

 

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PREVENTION Prevent prematurity • 

diaphragmatic fatigue Coxopram: patent respiratory stimulant, acts predominantly on peripheral chemoreceptors and

 

   

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is effective in neonates with apnea of prematurity that is unresponsive to methylxanthines m ethylxanthines Transfusion of packed RBC Nasal continuous positive airway pressure (CPAP, 3-5 cm H2O) and high flow humidification using nasal canula 1-2.5L/min) CPAP is preferred for mixed or obstructive apnea

microorganism frequently seen. Usually ampicillin + aminoglycoside (gentamicin) or cefotaxime Susceptibility profile o  o  Site o  Penetration of antibiotic Safety o  RESUSCITATION

 APNEA

INVERTED TRIANGLE OF NEONATAL RESUSCITATION

 

cessation of breathing more than 10-20 sec or for any duration accompanied by bradycardia or oxygen desaturation 1.  SERIOUS APNEA: preterm infants defined as cessation of breathing for o  longer that is 20 sec or for any duration if accompanied by cyanosis and bradycardia

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2.  OBSTRUCTIVE APNEA: pharyngeal instability, neck flexion) o  Characterized by absence of airflow but persistent chest wall motion 3.  CENTRAL APNEA: caused by decreased CNS stimuli to respiratory muscles, both airflow and chest wall motion are absent

4.  MIXED APNEA: most common pattern (50-75% of cases) with obstructive apnea preceding (usually) o  or following central apnea SEPSIS NEONATORUM

 

Systemic bacterial infection with (+) blood culture

   

in 1st month of life  Signs and symptoms often nonspecific   High index of suspension is required to identify and evaluate at risk infants 

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Commonly caused by: Group B Streptococcus, E. coli, L. monocytogenes and H. influenza

Early-onset = causes break up of polysomes into non-functional monosomes DRUGS OLDER Streptomycin Kanamycin

Gentamicin Tobramycin Neomycin

Hygromycin B *Clindamycin is a 50s inhibitor

NEWER Amikacin Netilmicin Sisomicin Paramomicin

 

COVERAGE: Gram-negative enteric bacteria; tuberculosis (2nd line); not active vs anaerobes CLINICAL USE: Serious life-threatening g(-) infection  •  Complicated skin, bone or soft tissue infection  •  Complicated UTI  •  Septicemia  •  Peritonitis and other severe intra-abdominal •  infections Severe pelvic inflammatory disease •  Gold standard: clindamycin + gentamicin o  Endocarditis •  Mycobacterium infection •  Neonatal sepsis •  Ocular infections and otitis externa •  ADVERSE EFFECTS: Among elderly, dehydrated patient or those with renal or hearing impairment and treatment >5 days Nephrotoxicity •  Ototoxicity  – auditory and vestibular •  •  Neuromuscular blockade -> respiratory paralysis (neomycin)  – antidote = Calcium gluconate or neostigmine CNS  – headache, tremors, lethargy, numbness, •  seizures Blurred vision •  Rash, urticaria, fever, pain at injection site •  Diarrhea, nausea/vomiting (paramomycin) •  CONTRAINDICATIONS: tinnitus, vertigo, high frequency hearing loss, reduced renal function, dehydration, pregnancy and lactation, infants, elderly CHARACTERISTICS: requires oxygen uptake, bactericidal Structure: hexose ring either streptidine (streptomycin) or 2-deoxystreptamine (others), amino sugar, glycosidic linkage Resistance: enzyme inactivation, impaired entry of drug due to cell mutation in deletion PHARMACOKINETICS Poorly absorbed from intact GIT except when •  there’s ulceration Entire oral dose excreted in feces after oral •  administration Highly polar compounds that do not enter cells •  readily but penetrate inflamed meninges (20%) Water-soluble, stable in solution, more active at •  alkaline Synergistic with beta-lactams or vancomycin •  Tissue concentrations not high except in renal •  cortex, bile (50%), pleural or synovial fluid (50-

 

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90%) Half-life: 2-3hrs, increasing to 24-48hrs with significant impairment of renal function Concentration-dependent killing activity

 

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Post antibiotic effect

Administered sing-daily dosing: as effective and often less toxic, determination of serum concentration is probably unnecessary, achieves greater post-antibiotic effect. DILATED FUNDOSCOPIC EXAM

Performed in the ff: All infants born ≤30 weeks AOG •  Infants born ≥30 weeks AOG but with unstable • 

 

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clinical course, including those that require cardiorespiratory support Any infant weighing