Iowa Neonatology Handbook

Handbook Home General Temperature Jaundice Pulmonary Neurology Metabolic Fluid Management Feeding
Iowa Neonatology Handbook

Edward F. Bell, M.D. Professor of Pediatrics Jeffrey L. Segar, M.D. Professor of Pediatrics Director, Division of Neonatology The University of Iowa Peer Review Status: Internally Peer Reviewed First Published: November 8, 1994 Last Revised: January 2006 Chapters Table of Contents (or View Expanded Contents)
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Infection
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Hematology Pharmacology Procedures Abbreviations Commonly Used in the Nursery
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General Temperature Jaundice Pulmonary Neurology Metabolic Fluid Management Feeding Infection Hematology Pharmacology Procedures Abbreviations Commonly Used in the Nursery
Preface Contributing Authors
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Handbook Home General Temperature Jaundice Pulmonary Neurology Metabolic Fluid Management Feeding Infection
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General
Edward F. Bell, M.D.
Peer Review Status: Internally Peer Reviewed
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Blood Pressure in the Newborn Indications for Hearing Screening of Neonates High Risk Infant Follow-up Program Immunization of the Infant in the Hospital Intrauterine Growth Retarded (IUGR) Infants New Ballard Score for Gestational Age Assessment Newborn Metabolic Screen Neonatal Transport to University of Iowa Hospitals & Clinics Transfer of Infant to Referring Hospital from University of Iowa Hospitals & Clinics (back-transport) Nonviable Infant Admission Protocol Guidelines for Pediatric Attendance in the Delivery Room Comments on Oxygen Toxicity and Retinopathy (ROP) in the Premature Infant ROP Surveillance
Title Page
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Handbook Home General Temperature Jaundice Pulmonary Neurology Metabolic Fluid Management Feeding Infection Hematology Pharmacology Procedures Abbreviations Commonly Used in the Nursery
Temperature
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Detection and Management of Abnormal Body Temperature Servocontrol: Incubator and Radiant Warmer When and How to Move Babies from Radiant Warmer to Incubator, and from Incubator to Open Bed
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Jaundice
John A. Widness, M.D.
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Management of Hyperbilirubinemia in the Newborn Period Use of Phototherapy
Title Page
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Pulmonary
Jonathan M. Klein, M.D.
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Management of Neonatal Apnea Nasopharyngeal Continuous Positive Airway Pressure (NPCPAP) Protocol for Initial Respiratory Settings for Mechanical Ventilation of Infants Use of Mechanical Ventilation in the Neonate High Frequency Ventilation (HFV) Management Strategies with High Frequency Ventilation in Neonates Using the SensorMedics 3100A High Frequency Oscillatory Ventilator Management Strategies with High Frequency Ventilation in Neonates Using the Infant Star 950 High Frequency Ventilator Neonatal Resuscitation Medications for Use in Neonatal Resuscitation Care of the Infant with the Meconium Aspiration Syndrome Treatment of Pulmonary Hypertension Present Guidelines for Nitric Oxide (NO) Therapy of Persistent Pulmonary Hypertension of the Newborn Inhalational Nitric Oxide (iNO) Treatment of the Respiratory Distress Syndrome Guidelines for Surfactant Administration (surfactant Replacement Therapy) Surveillance of pH and Blood Gas Status of Neonates Sampling Techniques for Arterial Blood Gas Samples Pulse Oximetry
Title Page
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Handbook Home General Temperature Jaundice
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Neurology
Michael J. Acarregui, M.D.
Pulmonary Neurology Metabolic Fluid Management Feeding Infection Hematology Pharmacology Procedures Abbreviations Commonly Used in the Nursery
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Neurological Disorders: Asphyxia Neonatal Seizures Intracranial Hemorrhage
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Handbook Home General Temperature Jaundice Pulmonary Neurology
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Metabolic
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Metabolic Fluid Management Feeding Infection Hematology Pharmacology Procedures Abbreviations Commonly Used in the Nursery
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Hypocalcemia Guidelines for the Detection and Management of Hypoglycemia, Hyperglycemia, and Normoglycemia in Preterm and Term Neonates Metabolic Problems in Infants of Diabetic Mothers (IDM'S) Recommendations for Plasma Glucose Testing of Neonates While in Hospital Mean Blood Glucose in First Hours of Life
Title Page
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Fluid Management
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Fluid And Electrolyte Management in the Newborn Fluid Therapy in the Neonate
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Handbook Home General Jaundice Pulmonary Neurology Metabolic Fluid Management Feeding Infection Hematology Pharmacology Procedures Abbreviations Commonly Used in the Nursery
Feeding
Susan J. Carlson, M.M.Sc., R.D., C.S.P., L.D., C.N.S.D. and Ekhard E. Ziegler, M.D.
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Nutritional Management of the Preterm Infant Parenteral Nutrition Enteral Feedings Guidelines for Use of Human Milk in the Nursery Guidelines for the Use of Human Milk Fortifier in the Neonatal Intensive Care Unit Guidelines to Enhance Successful Breast-feeding
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Infection
Thomas N. George, M.D.
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Congenital Infections Management of Perinatal Herpes Simplex Infections Hepatitis B Diagnosis of Infections Caused by Herpes Viruses and Chlamydia Care of the Infant Born to a Mother with Prolonged Rupture of Membranes Suggested Management of Term Infants Whose Mothers Are Positive for Group B Streptococcus Suspected Sepsis in the Newborn Use of Drug Monitoring Levels in the Special Care Nurseries Reference Range for WBC Indices (after Manroe Et Al) Scalp Abscess Immunoglobulin Therapy Tolerance of IVIG Administration To Neonates Management of Infants with RSV (Respiratory Syncytial Virus) Infection Guidelines for Immunoprophylaxis Against Respiratory Syncytial Virus in High-Risk Infants
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Hematology
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Transfusion Guidelines for Preterm and Term Infants UI NICU Guidelines for Administering 15mL/kg Erythrocyte Transfusions to Neonates Hemolytic Disease of the Newborn Due to Maternal Erythrocyte Alloimmunization Polycythemia-Hyperviscosity Syndrome Bone Marrow Aspiration: Indications
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Pharmacology
Jeffrey L. Segar, M.D. and John M. Dagle, M.D., PhD
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Antiarrhythmic Drugs Anticonvulsants Antimicrobials Digoxin Diuretic Agents Effects of Drugs on the Fetus or Newborn The Effect of Drugs Taken by Nursing Mother on Her Infant Emergency Drug Doses NICU Intravenous Drug Compatibility Chart Inotropic Agents Monitoring Gentamicin Therapy by Single Serum Sample Determination Pharmacologic Closure of PDA Protocol for Use of Prostaglandin E1 Pharmacologic Therapy for Neonatal Systemic Hypertension Neuromuscular Blockers in Neonates Analgesics and Sedatives Apnea Bronchodilators for Reactive Airway Disease Infants of Drug-Abusing Mothers Drug Half-Life Studies
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Iowa Neonatology Handbook: Procedures

Handbook Home General Temperature Jaundice Pulmonary
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Procedures
Iowa Neonatology Fellows (including Jon E. Mazursky, M.D., Chetan A. Patel, M.D., Mark W. Thompson, M.D.)
Neurology Metabolic Fluid Management Feeding Infection Hematology Pharmacology Procedures
Technique for Insertion of an Endotracheal (ET) Tube Suctioning of Endotracheal Tubes Lumbar Puncture Circumcision Collection of Arterial Blood Gas Samples Obtaining Blood Via Heel Stick Suprapubic Bladder Tap Insertion of Umbilical Vessel Catheters Exchange Transfusion Technique for Insertion of a Chest Tube Technique for Insertion of a Pericardial Tube Intraosseous Infusion Percutaneous Placement of Central Venous Catheters Apt Test for Fetal Hemoglobin
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Abbreviations Commonly Used in the Nursery
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4WINT - 4 West Intermediate Care Nursery A/B - apnea/bradycardia spell A/B/D - apnea/bradycardia desaturation spell AGA - appropriate for gestational age ASD - atrial septal defect ATB - antibiotics BBT - baby's blood type BM - bowel movement Br Milk - breast milk (.67 kcal/cc) BPD - bronchopulmonary dysplasia C/S - cesarean section CHD - congenital heart defect CHF - congestive heart failure CMV - cytomegalovirus CNS - central nervous system COC - circumoral cyanosis CPAP - continuous positive airway pressure CPD - cephalo-pelvic disproportion CPT - chest physiotherapy CS - chemstrip CSF - cerebrospinal fluid CXR - chest x-ray DIC - disseminated intravascular coagulation DR - delivery room ETT - endotracheal tube FOC - frontal-occipital circumference FSBG - fingerstick blood gas FTP - failure to progress G-P- - gravida ____para____ (pregnancies; live births) GBS - group B streptococcus HCS - hemacombistick HCT - hematocrit HFV - high frequency ventilation HFOV - high frequency oscillating ventilation HMD - hyaline membrane disease HMF - human milk fortifier (makes breast milk .8 kcal/cc) HTN - hypertension HUS - head ultrasound IDM - infant of diabetic mother IMV - intermittent mandatory ventilation IUGR - intrauterine growth retardation IVF - in vitro fertilization IVH - intraventricular hemorrhage LGA - large for gestational age LLSB - lower left sternal border LMD - local medical doctor LSB - left sternal border MAP - mean airway pressure MAS - meconium aspiration syndrome MBT - mother's blood type
MCL - midclavicular line MGM - maternal grandmother NAD - no apparent distress NC - nasal cannula NEC - necrotizing enterocolitis NICU - Neonatal Intensive Care Unit NNS - neonatal screen NPCPAP - nasopharyngeal continuous positive airway pressure NPO - nothing by mouth NVN - neonatal venous nutrition PDA - patent ductus arteriosis PEEP - peak and expiratory pressure PF - premie formula (.8 kcal/cc) PFC - persistent fetal circulation PGE1 - prostaglandin E1 PGF - paternal grandfather PIE - pulmonary interstitial hypertension PIH - pregnancy induced hypertension PIP - peak inspiratory pressure PIV - peripheral intravenous line PKU - phenylketonuria, a disease detected on the NNS PMI - point of maximum intensity PNP - pediatric nurse practitioner PPHN - persistent pulmonary hypertension of the newborn PPS - peripheral pulmonic stenosis PRBCs - packed red blood cells (concentrated) PROM - premature rupture of membranes PTL - preterm labor PVL - periventricular leukomalacia RA - room air (21% oxygen) RCM - right costal margin RDS - respiratory distress syndrome ROM - rupture of membranes OR range of motion ROP - retinopathy of prematurity RSV - respiratory syncitial virus SAB - spontaneous abortion SF - stock formula (.67 kcal/cc) SGA - small for gestational age TCM - transcutaneous monitor (PO2, PCO2) TG - true glucose TTN - transient tachypnea of the newborn UAC - umbilical arterial catheter UVC - umbilical venous catheter VLBW - very low birth weight baby VSD - ventricular septal defect VS - vital signs Title Page
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Handbook Home General Temperature Jaundice Pulmonary Neurology Metabolic Fluid Management Feeding Infection Hematology
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Expanded Table of Contents

Edward F. Bell, M.D. and Jeffrey L. Segar, M.D.
General
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Pharmacology Procedures Abbreviations Commonly Used in the Nursery
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Blood Pressure in the Newborn Indications for Hearing Screening of Neonates High Risk Infant Follow-up Program Immunization of the Infant in the Hospital Intrauterine Growth Retarded (IUGR) Infants New Ballard Score for Gestational Age Assessment Newborn Metabolic Screen Neonatal Transport to University of Iowa Hospitals & Clinics Transfer of Infant to Referring Hospital from University of Iowa Hospitals & Clinics (back-transport) Nonviable Infant Admission Protocol Guidelines for Pediatric Attendance in the Delivery Room Comments on Oxygen Toxicity and Retinopathy (ROP) in the Premature Infant ROP Surveillance
Temperature
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Detection and Management of Abnormal Body Temperature Servocontrol: Incubator and Radiant Warmer When and How to Move Babies from Radiant Warmer to Incubator, and from Incubator to Open Bed
Jaundice
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Management of Hyperbilirubinemia in the Newborn Period Use of Phototherapy
Pulmonary
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Management of Neonatal Apnea Nasopharyngeal Continuous Positive Airway Pressure (NPCPAP) Protocol for Initial Respiratory Settings for Mechanical Ventilation of Infants Use of Mechanical Ventilation in the Neonate High Frequency Ventilation (HFV) Management Strategies with High Frequency Ventilation in Neonates Using the Infant Star 950 High Frequency Ventilator Neonatal Resuscitation Medications for Use in Neonatal Resuscitation Care of the Infant with the Meconium Aspiration Syndrome Treatment of Pulmonary Hypertension Present Guidelines for Nitric Oxide (NO) Therapy of Persistent Pulmonary Hypertension of the Newborn Inhalational Nitric Oxide (iNO)
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Treatment of the Respiratory Distress Syndrome Guidelines for Surfactant Administration (surfactant Replacement Therapy) Surveillance of ph and Blood Gas Status of Neonates Sampling Techniques for Arterial Blood Gas Samples Pulse Oximetry Transcutaneous Oxygen (TcPO2) Monitors Transcutaneous Carbon Dioxide (TcPCO2) Monitors
Neurology
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Neurological Disorders: Asphyxia Neonatal Seizures Intracranial Hemorrhage
Metabolic
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Hypocalcemia Guidelines for the Detection and Management of Hypoglycemia, Hyperglycemia, and Normoglycemia in Preterm and Term Neonates Metabolic Problems in Infants of Diabetic Mothers (IDM'S) Recommendations for Plasma Glucose Testing of Neonates While in Hospital Mean Blood Glucose in First Hours of Life
Fluid Management
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Fluid And Electrolyte Management in the Newborn Fluid Therapy in the Neonate
Feeding
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Nutritional Management of the Preterm Infant Parenteral Nutrition Enteral Feedings Guidelines for Use of Human Milk in the Nursery Guidelines to Enhance Successful Breast-feeding
Infection
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Congenital Infections Management of Perinatal Herpes Simplex Infections Hepatitis B Diagnosis of Infections Caused by Herpes Viruses snd Chlamydia Care of the Infant Born to a Mother with Prolonged Rupture of Membranes (PROM) Suggested Management of Term Infants Whose Mothers Have Positive Group B Streptococcal Cultures And/or Have Received Intrapartum Chemoprophylaxis Against Group B Streptococcus Suspected Sepsis in the Newborn Use of Drug Monitoring Levels in the Special Care Nurseries Reference Range for WBC Indices (after Manroe Et Al) Scalp Abscess Immunoglobulin Therapy Tolerance of IVIG Administration To Neonates Management of Infants with RSV (Respiratory Syncytial Virus) Infection Guidelines for Immunoprophylaxis Against Respiratory Syncytial Virus in High-Risk Infants
Hematology
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Transfusion Guidelines for Preterm and Term Infants
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UI NICU Guidelines for Administering 15mL/kg Erythrocyte Transfusions to Neonates Hemolytic Disease of the Newborn Due to Maternal Erythrocyte Alloimmunization Polycythemia-Hyperviscosity Syndrome Bone Marrow Aspiration: Indications
Pharmacology
Antiarrhythmic Drugs Anticonvulsants Antimicrobials Digoxin Diuretic Agents Effects of Drugs on the Fetus or Newborn The Effect of Drugs Taken by Nursing Mother on Her Infant Emergency Drug Doses NICU Intravenous Drug Compatability Chart Inotropic Agents Monitoring Gentamicin Therapy by Single Serum Sample Determination Pharmacologic Closure of PDA Protocol for Use of Prostaglandin E1 Pharmacologic Therapy for Neonatal Systemic Hypertension Neuromuscular Blockers in Neonates Analgesics and Sedatives Apnea Bronchodilators for Reactive Airway Disease Infants of Drug-Abusing Mothers Drug Half-Life Studies
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Procedures
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Technique for Insertion of an Endotracheal (ET) Tube Suctioning of Endotracheal Tubes Lumbar Puncture Circumcision Collection of Arterial Blood Gas Samples Obtaining Blood Via Heel Stick Suprapubic Bladder Tap Insertion of Umbilical Vessel Catheters Exchange Transfusion Technique for Insertion of a Chest Tube Technique for Insertion of a Pericardial Tube Intraosseous Infusion Percutaneous Placement of Central Venous Catheters Apt Test for Fetal Hemoglobin
Abbreviations commonly used in the nursery Title Page

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Preface
Edward F. Bell, M.D. and Jeffrey L Segar, M.D.
The Iowa Neonatology Handbook represents an ongoing effort by the Division of Neonatology at the Children's Hospital of Iowa to provide physicians, nurses, and medical students who care for newborn infants a collection of protocols outlining rational approaches to the care of critically ill neonates. In no way is this document a comprehensive review of the field of neonatology, nor is it implied that the therapeutic approaches outlined in this book are established policies or standards of care. Rather, they represent a compilation of the experience and clinical styles of the members of our division and are intended only as a guide to therapy. This monograph should be regarded as an educational document. Some of the information provided will be outdated by the time you discover it; other information is subject to controversy. The Handbook is designed only to supplement and not to replace the education gained from the teaching of the faculty and fellows and the experience of taking care of infants in the neonatal ICU. The Handbook was added to the Virtual Hospital site in 2003 so that it would be more widely available and could be updated by section as needed. The material contained in the first on-line draft was taken from the 1995 printed edition. The date of the last revision is shown on each page. The Handbook is a document that has evolved over many years, since the first edition appeared in the early 1980s. The current product, which continues to evolve, has been built upon the efforts of many present and former faculty members and fellows, as well as nurses and residents who wrote, reviewed or edited sections of this book. The transition from printed to online format could not have been accomplished without the technical contributions of Nola Riley and Mark Hart. Edward F. Bell, M.D. Professor and Director Division of Neonatology edward-bell@uiowa.edu Jeffrey L Segar, M.D. Associate Professor Division of Neonatology jeffrey-segar@uiowa.edu
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Contributing Authors
Jaundice Pulmonary Neurology Metabolic Fluid Management Feeding Infection Hematology Pharmacology Procedures
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Michael J. Acarregui Valerie Bailey Edward F. Bell Susan J. Carlson John M. Dagle Diane L. Eastman Thomas N. George Janet F. Geyer Charles Grose Herman A. Hein Ronald V. Keech Jonathan M. Klein Maria A. Lofgren Jon E. Mazursky Lou Ann Montgomery Chetan A. Patel Jeffrey L. Segar Mark W. Thompson John A. Widness Ekhard E. Ziegler
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The Joint Office for Marketing and Communications (JOMC) is University of Iowa Hospitals and Clinics official communications link for local, national, and international media. Office hours Monday through Friday 8 a.m. to 5 p.m. After office hours or on weekends, call 319356-1616 and ask to have Tom Moore paged. For patient condition reports 319-356-2731 Media contact 319-356-3945
Media Relations Team

Tom Moore Media relations coordinator 319-356-3945 thomas-moore@uiowa.edu
This week's news tips Sign up for daily e-mails of UI Health Care news Community Events Calendar University of Iowa Health Care weekly headlines
Clancy Champanois Associate editor 319-384-9171 clancy-champanois@uiowa.edu News and Publications Archives Rita Liddell Media/project specialist 319-356-7126 rita-liddell@uiowa.edu Diana Lundell University News Services current and archived press releases Joint Office for Marketing and Communications About Us Quick Facts Michael Sondergard 319-356-7123 Fax: 319-384-7099 e-mail: michael-sondergard@uiowa.edu Janet Wright Administrative support 319-384-9049 janet-wright@uiowa.edu Recognition and Reputation Best Doctors in America Magnet Award U.S.News & World Report News and Publications UI Health Care weekly headlines by medical specialties
Mailing address UI Health Care Media Relations E110 GH 200 Hawkins Drive Iowa City, Iowa 52242
319-356-4303 Fax: 319-384-9150 e-mail: diana-lundell@uiowa.edu
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Patient Representative Program

Patients and/or Visitors can contact a Patient Representative when they need:
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Someone to advocate for them Someone to listen Support or assistance Response to a complaint Explanation of hospital policies and procedures Help in a crisis situation Help with problem solving Information about hospital and community services
Hours The Patient Representative Office is open 8 a.m. - 5 p.m., Monday Friday Location First floor General Hospital, Room C-100A, north of the compass near elevator B, last door on right side of corridor. Phone Call 6-1802 from a beige in-house phone or Hospital Operator "0" and ask for a Patient Representative. From outside the hospital call 319356-1802. Additional program services
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Assist patients/visitors/staff with requests, information and referral Work with patients and visitors who are dissatisfied Provide support/assistance in critical care areas and during crisis Visit patients/families throughout the hospital Process tort claims and make reimbursement recommendation for missing/damaged property Investigate potential breach of confidentiality reports Maintain Patient Need Fund for small loans and purchases Assist the Red Cross with service to military families Provide staffing for Day of Surgery Lounge Supervise volunteers who assist visitors in intensive waiting areas and who visit inpatient units
Lois Boulware Day of Surgery Lounge The Day of Surgery Lounge is the waiting are for visitors of patients who are having surgery in the main operating room. The patient representatives facilitate surgical reports and provide information for waiting visitors. The Lounge is unlocked by 6 a.m. and staffed continuously by a patient representative from 8: a.m. until closing. 8 a.m. - 6 p.m., Monday and Tuesday 7:30 a.m. - 6 p.m., Wednesday - Friday
Location: 6th floor, John W. Colloton Pavillion, south of Elevator H. Phone: 6-1963 from a beige in-house phone Helen K. Rossi Volunteer Guest House
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Department of Social Service

Social Service home Department services Financial resources Community resources Staff directory Health care resources Support groups
Interpretation and Translation

Oral interpretation and written translation services are provided to non-English speaking and hearing impaired patients and their families. When a patient is hospitalized, the primary illness may be compounded by anxiety, reactions to separation from family and familiar surroundings, and fear of the unknown. In addition, cultural and ethnic beliefs may affect a patients attitude toward illness. A patient who cannot communicate suffers additional anxiety and fear because of the inability to tell staff members what the problem is and to understand staff members explanation and advice. For maximum benefit to be gained from health care services, it is imperative that the staff make an accurate assessment of the patients symptoms and feelings, and that the patient have a clear understanding of the prescribed medical treatment. Language interpretation and translation services are available to assist non-English-speaking or hearing-impaired patients and families during clinic visits, hospital stays, or other communication with hospital staff. The primary interpreting service requested at the University of Iowa Hospitals and Clinics are Spanish interpreters followed by sign language interpreters. Two full-time staff interpreters provide Spanish interpreter services. One half-time staff interpreter provides American Sign Language interpreter services and provides Spanish translation services for hospital documents. A Language Bank of over 135 free lance persons as well as volunteers provide interpreter services, as needed, in over 40 languages. Please contact our interpreting program if you are bilingual and willing to participate in our Language Bank. To request services or information please call (319) 356-1967. Who to contact:
Nory Arango Hospital Interpreter 319/356-7117 nory-arango@uiowa.edu
Ozzie Diaz-Duque, PhD Coordinator of Interpreting and Translation Services (7 - 11 a.m.) 319/356-7116 ozzie-diazduque@uiowa.edu
Mary Solis Hospital Interpreter 319/356-1967 mary-solis@uiowa.edu
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Language Interpretation Resources Limited English Proficiency Resources Other Resources for UI Hospitals and Clinics Staff and Language Bank
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Welcome to the Helen K. Rossi Volunteer Guest House!

Patient and Visitor Programs
The Helen K. Rossi Volunteer Guest House is a 14-room hospitality house located within the hospital for adult patients and their families. Guests are eligible to stay while the patient is receiving medical treatment at University of Iowa Hospitals and Clinics. The staff and volunteers at the Guest House understand the importance of being close by a loved one during a hospital stay. The following information provides an overview of the services. Contact the Guest House office for further information. Referral Referrals to the Guest House are accepted from any UI Hospitals and Clinics staff, or guests may refer themselves. Since no one is asked to leave by a certain day, rooms are available only as other guests check out. No reservations are taken, and guests are accommodated as rooms are available. Guests may continue to stay as long as they meet criteria, and comply with policies and guidelines of the Guest House. Guest names will be placed on the waiting list when no rooms are available. Office Hours Monday-Friday Weekends/ Holidays Office Telephone 8 a.m. - 5 p. m. 9 a.m. - 1 p. m. 319-3849240
Cost The room charge is $30 per night. Guests must keep their room payments current. After registering in the Guest House, payments may be made at the Cashier's Office, first level between elevators B and C. Cashier's window
hours are 7:30 a.m. - 5 p.m. (Monday-Friday). Payment may be made in cash, by personal check, or by MasterCard or Visa credit cards. Check-In We strongly encourage guests to check-in between 11 - 2 p.m. Check-Out We ask that guests check-out by 11 a.m.
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Make sure all your personal items are removed from your room Remove all of your food from the cupboards and refrigerator Check the laundry room to make sure you haven't left anything behind Check out with the Guest House clerk Settle any outstanding room fees with the cashier's office
Guidelines The Guest House rules are established for the safety and well being of all guests. For this reason, we ask that all guests comply with the following guidelines:
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Quiet hours are 10 p.m. to 8 a.m. During these hours, we ask that everyone's need for rest be respected. Please pick up after yourself, put things back where you found them, and respect others' property. Since the eating/vending area is shared by all, please clean and properly store items after use. Eating, cooking and heating appliances are not allowed in guest rooms. Guests must be properly attired at all times. Proper attire means being fully clothed with shoes or slippers on the feet. Enter and exit through the front door only. Keep your door closed and locked at all times. We encourage you to leave valuables at home. Do not leave cash and jewelry in your room. Safekeeping of valuables no larger than a wallet is available through the Cashier's Office. No UI Hospitals and Clinics medical/nursing care is available in the Guest House. Guests requiring assistance must have a caregiver accompanying them. Children must be supervised by an adult at all times. Smoking is not allowed. The Guest House and UI Hospitals and Clinics are smoke-free environments. Smoking is permitted only in designated areas outside. Fire code regulations limit room occupancy to three adults and one child. Open flames (candles, matches, cooking flames, etc.) are not allowed. For the health and safety of all guests, illegal drugs, alcoholic beverages, weapons and pets are not permitted.
We hope that the Guest House provides comfortable accommodations while you are at UI Hospitals and Clinics. We continually strive to provide a supportive environment for all patients and families staying with us. Please let us know if there is anything we can do to make your stay more comfortable. Mail If guests are expecting mail, note "Guest House, C-157, GH" on the envelope along with the hospital address: 200 Hawkins Drive, Iowa City, IA 52242. Mail arrives in the early afternoon. Letters and packages will be available for pick-up in the Guest House office. Telephone All rooms have a private telephone number. These numbers will not be given out by the Guest House staff. Please give your number to nursing unit staff and any others you wish to reach you directly in your room.
After four rings, your phone will automatically transfer to voice mail. If you are not in your room, callers can leave a message for you. Instructions for retrieving your messages are located near the phone. To make a call within UI Hospitals and Clinics, dial just the last five digits of the number. To reach an outside line (outside of UI Hospitals and Clinics), please dial 9. Personal calling cards or collect calls may be utilized to make long-distance calls. The Guest House number is 319-384-9240. After-Hours When the Guest House concierge is not on duty, general questions should be referred to the Information Desk on first foor at 319-356-2456. Emergency telephone numbers are posted on each telephone. Guest Rooms Each room has two twin beds and a foldout chair. Cribs are available from the Guest House office. Each room contains a private bathroom and a television with a remote control. Guest rooms remain locked at all times; doors automatically lock when closed. You must keep your key with you. Kitchenette A vending machine, two refrigerators, and microwave oven are located in the eating area within the Guest House. Laundry The laundry room offers washers and dryers. Housekeeping Services Rooms are cleaned weekly and at the time of check-out. Clean bath towels will be provided by the housekeeper Monday-Friday when trash is emptied. Other Services Please see the Patient and Visitor Information Directory brochure for information on other University of Iowa Hospitals and Clinics Services. The Helen K. Rossi Volunteer Guest House is named in recognition of the splendid contributions of the volunteers at UI Hospitals and Clinics. As one of the founders of the Volunteer program, Helen Rossi has worked tirelessly to enhance humanism in serving our patients. She has provided inspiration, leadership and vision to the hundreds of Volunteers who have served with her. By honoring Helen Rossi as a sensitive, caring, enthusiastic and selfless Volunteer, the contributions of all UI Hospitals and Clinics volunteers are also recognized. As patients, visitors and staff, we salute you who are UI Hospitals and Clinics volunteers for giving to others the ultimate gift yourselves.
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Patients and Visitors Maps and Directions Refer a Patient Health Topics A-Z Rankings and Reputation News and Publications
Prescription Refill Service
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Online Service Telephone
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Physician Consultation and Referral Directory Home UI Consult UI Health Access Refer a patient
How to Use the Directory | Clinical Departments | Multi-Specialty Programs and Services | Patient Information Physician Directory--Alphabetical | Departmental | Clinical Expertise
How to Use the Directory

Request an appointment
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Letter of Introduction How to Use the Directory Patient Appointments How to Reach Us r UI Consult r UI Health Access r Children's Hospital of Iowa r Emergency Communications r Air Medical and Mobile Critical Care Transport Services University of Iowa Health Care University of Iowa Hospitals and Clinics UI Carver College of Medicine Children's Hospital of Iowa University of Iowa Hospitals and Clinics Service Record
Clinical Departments
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Anesthesia Dermatology Family Medicine Hospital Dentistry Internal Medicine Neurology Neurosurgery Obstetrics and Gynecology Ophthalmology and Visual Sciences Orthopaedics Otolaryngology Pathology Pediatrics Psychiatry Radiation Oncology Radiology Surgery Urology
Multi-Specialty Programs and Services

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General Clinical Research Center James A. Clifton Center for Digestive Diseases Rehabilitation Therapies Respiratory Care UI Behavioral Health
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UI Heart Care CHAMPS Holden Comprehensive Cancer Center
Patient Information
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Patient/Visitor Services Local Accommodations Parking
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Project Art Home About Project Art Art in State Buildings Permanent Collection Temporary Exhibits Glass Art Tour Performing Arts
Frequently called telephone numbers

UI Health Access: 319-384-8442 or 1-800-777-8442 For assistance scheduling an appointment, finding a physician, registering for a class or seminar, or for health information General/Patient Information Emergency Services Iowa Statewide Poison Center (toll-free within Iowa) Patient Services Children's Miracle Network Interpreter Services
319-356-1616 319-356-2233 1-800-222-1222
319-335-8484 319-356-1967 319-356-2456 319-356-1200 319-384-9240 319-356-3939 319-356-4999
Art Cart & Art Supplies Artwork Request Calendar of Events
Patient Room Information Patient and Visitor Programs Patient Guest House Ronald McDonald House TDD/TTY Children's Hospital of Iowa (pediatrics): 319-384-5437 (KIDS) or 1-888-573-5437 UI Family Care Family Care Center Family Practice Center Pediatric Clinic Internal Medicine Clinic UI Family Care, Southeast Iowa City Lone Tree Family Practice Center
319-384-7222 319- 384-7333 319- 384-7444 319- 339-7472 319- 629-4214
UI Family Care Center, North Liberty UI Family Care Center, Belle Plaine UI Family Care Sigourney Marengo Medical Center Lowden Family Medical Clinic Center for Disabilities and Development Dentistry Oral & Maxillofacial Surgery Prosthodontics & Orthodontics Dermatology Holden Comprehensive Cancer Center Appointments Cancer Information Service Internal Medicine Allergy-Immunology Cardiology Digestive Diseases Center Endocrinology-Metabolism Infectious Diseases (including HIV/AIDS) Nephrology Gastroenterology-Hepatolog General Medicine Hematology/Oncology
319- 626-5680 319- 444-3210 319- 622-3840 319- 642-5213 319- 944-5361 319-353-6900 319-356-2743 319- 356-2205 319- 356-2601 319-356-7546 319-356-4200 319- 356-4200 1-800-237-1225
319- 356-8486 319- 356-7102 319- 356-4060 319- 356-8133 319- 356-8133 319- 356-8133 319- 356-4060 319- 384-7444 319- 356-4200
Occuptational Medicine Pulmonary Rheumatology Neurology Neurosurgery Obstetrics and Gynecology Family Planning Clinic General Gynecology General Obstetrics Gynecologic Oncology Infectious Disease In Vitro Fertilization Menopause Nurse Practitioners Premenstrual Syndrome Reproductive Endocrinology & Infertility Uro-Gynecology & Pelvic Reconstructive Surgery Vulvovaginal Disease High Risk Obstetrics Nurse Midwives Prenatal Diagnosis & Genetic Screening Prepared Childbirth & Parenting Classes
319- 356-8462 319- 356-8486 319- 353-6757 319-384-8111 319-356-2237 319-356-2294 319- 335-8541 319-356-2294 319-356-2294 319- 356-2015 319- 356-2294 319- 356-8483 319- 356-2294 319- 356-2294 319- 356-2294 319- 356-1767 319- 356-2294 319- 356-2294 319- 356-2294 319- 356-2294 319- 356-8892 319- 353-7877
UI Family Care Center, North Liberty Ophthalmology Adult Appointment Scheduling Pediatric Appointment Scheduling Emergency Eye Care on Evenings, Weekends, and Holidays Iowa Lions Eye Bank Laser Vision Correction Orthopaedics UI Back Care Otolaryngology - Head & Neck Surgery Hearing Aids Pathology Psychiatry/UI Behavioral Health: 384-8999 or 1-877-384-8999 Adult Service Child Service Chemical Dependency Inpatient Referrals Plaza Center One office North Liberty office Radiation Oncology Radiology Diagnostic Nuclear Surgery UI Community HomeCare
319- 626-5680 319-356-2852 319- 356-2852 319- 356-2859 319- 384-8442 319- 356-2871 319- 353-7625 319-356-2223 319- 356-7037 319-356-2201 319- 356-2222 319-384-9605 319- 353-6314 319- 356-1188 319- 384-8765 319- 353-6953 319- 354-6285 319- 626-5680 319-356-2253 319- 356-3350 319- 356-1911 319-356-2902 319-337-8522
UI HealthWorks: 319-665-2111 or 1-800-327-5605 UI Heart Care: 319-384-8442 or 1-800-777-8442 Urology Specialty Services DeGowin Blood Center Geriatric Services Hyperbaric Medicine Center Pain Management Service Travel Medicine State of Iowa Workers Health Clinic
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319-356-2421 319- 356-2058 319- 384-7222 319- 356-7706 319- 356-2320 319- 356-4252 319- 353-8653
About Us Home Patients and Visitors
Health Care Services Throughout Iowa

The table below compiles clinic location information for five UI Health Care community services:
Maps and Directions

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Specialty Outreach Clinics - outreach clinics staffed by University of Iowa physicians and nurses support the community-based health care system in Iowa by providing adult and pediatric specialty services in towns and cities throughout the state. Child Health Specialty Clinics - a public health program that serves children with special health care needs and their families. UI Family Care - a network of UI Family Care centers that offer wide-ranging health care services for individuals of all ages. The Renal Dialysis Center - a network of outpatient units that provide all modalities for adult and pediatric renal dialysis. UI HealthWorksTM - partners with employers and other health care entities to provide solutions to improve the health status of workers and to lower work-related health care costs. UI HealthWorksTM provides services to area employers at the North Liberty Family Care Center and in Ottumwa and Clinton. Clinic types/Services available Internal Medicine: Geriatrics Internal Medicine: Cystic Fibrosis Orthopaedics: Pediatrics Pediatrics: Cystic Fibrosis Family Medicine: UI Family Care Internal Medicine: Pulmonary Child Health Specialty Clinic Child Health Specialty Clinic Ob/Gyn: Maternal Fetal Family Medicine: UI Family Care Internal Medicine: CardiacElectrophysiology Internal Medicine: Endocrinology Radiation Oncology: Radiation Therapy UI HealthWorksTM Behavioral Health: Geriatrics
City Amana
Ames
Belle Plaine
Bloomfield Burlington Carroll Cedar Rapids Centerville
Clinton
Columbus Junction
Coralville
Internal Medicine: Geriatrics Behavioral Health: Geriatrics Child Health Specialty Clinic Child Health Specialty Clinic Child Health Specialty Clinic Ob/Gyn: Maternal Fetal Pediatrics: Cardiology Pediatrics: Endocrinology Pediatrics: CardiacElectrophysiology Pediatrics: Hemoglobinopathy Pediatrics: Neurology Pediatrics: Neuromuscular Child Health Specialty Clinic Pediatrics: CardiacElectrophysiology Pediatrics: Immune Disorders Pediatrics: Neuromuscular Child Health Specialty Clinic Ophthalmology: Low Vision Ophthalmology: Retina Pediatrics: Cardiology Pediatrics: Neuromuscular Internal Medicine: Geriatrics Internal Medicine: Hematology/Oncology Internal Medicine: Pulmonary Neurology: General Child Health Specialty Clinic Internal Medicine: Medical Oncology Internal Medicine: DialysisInpatient Internal Medicine: DialysisOutpatient Internal Medicine: Nephrology/Renal Consults Neurology: General Internal Medicine: Geriatrics Behavioral Health: Geriatrics
Council Bluffs Creston
Davenport
Des Moines
Dubuque
Fairfield
Ft. Dodge Ft. Madison
Grinnell
Hills
Iowa City
Child Health Specialty Clinic Internal Medicine: Cardiology Internal Medicine: DialysisInpatient Internal Medicine: Geriatrics Behavioral Health: General Behavioral Health: Geriatrics Family Medicine: UI Family Care Family Medicine: UI Family Care Internal Medicine: Geriatrics Behavioral Health: Geriatrics Internal Medicine: Cardiology Internal Medicine: Hematology/Oncology Internal Medicine: Cardiology Internal Medicine: Hematology/Oncology Internal Medicine: Pulmonary Behavioral Health: General Behavioral Health: Geriatrics Surgery: Vascular Behavioral Health: Geriatrics Family Medicine: UI Family Care Family Practice: Geriatrics Internal Medicine: Geriatrics Behavioral Health: Geriatrics Family Medicine: UI Family Care Internal Medicine: Pulmonary Internal Medicine: Geriatrics Family Medicine: UI Family Care Child Health Specialty Clinic Pediatrics: Gastroenterolgy Pediatrics: Neuromuscular
Iowa City-South East
Kalona
Keokuk
Keosauqua
Keota
Lone Tree
Lowden Manchester
Marengo
Mason City
Mt. Pleasant
Internal Medicine: Hematology/Oncology Internal Medicine: Pulmonary Behavioral Health: Geriatrics Internal Medicine: Cardiology Internal Medicine: DialysisOutpatient Internal Medicine: Hematology/Oncology Internal Medicine: Nephrology/Renal Consults Internal Medicine: Pulmonary Behavioral Health: Geriatrics Internal Medicine: Cardiology Internal Medicine: DialysisOutpatient Behavioral Health: Geriatrics Family Medicine: UI Family Care UI HealthWorksTM Child Health Specialty Clinic Internal Medicine: Cardiology Pediatrics: Diabetes/ Endocrinology Internal Medicine: Endocrinology Family Medicine: UI Family Care Internal Medicine: Geriatrics Neurology: General Radiology: General Family Medicine: UI Family Care Child Health Specialty Clinic Pediatrics: Cardiology Pediatrics: Neuromuscular Pediatrics: CardiacElectrophysiology Pediatrics: CardiologySpecialty
Mt. Vernon
Muscatine
North Liberty
Ottumwa
Pella Perry
Sigourney
Sioux City
Sioux Falls
Solon
Internal Medicine: Geriatrics Behavioral Health: Geriatrics Child Health Specialty Clinic Otolaryngology: Cleft Palate Family Medicine: UI Family Care Internal Medicine: Pulmonary Behavioral Health: General Family Medicine: UI Family Care Behavioral Health: Geriatrics Internal Medicine: DialysisInpatient Internal Medicine: DialysisOutpatient Internal Medicine: Nephrology/Renal Consults Behavioral Health: General Behavioral Health: Geriatrics Child Health Specialty Clinic Internal Medicine: Infectious Disease Pediatrics: Diabetes/ Endocrinology Pediatrics: Hemoglobinopathy Pediatrics: Neuromuscular Behavioral Health: Geriatrics Internal Medicine: Geriatrics Behavioral Health: Geriatrics Internal Medicine: Geriatrics Child Health Specialty Clinic Internal Medicine: Endocrinology Pediatrics: Diabetes/ Endocrinology Behavioral Health: Geriatrics Internal Medicine: Geriatrics
Spencer
Toledo
Vinton
Wapello
Washington
Waterloo
Wayland
Wellman
West Branch
West Burlington
West Liberty Williamsburg
Wilton Winfield
Behavioral Health: Geriatrics Internal Medicine: Geriatrics
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DeGowin Blood Center home About us Blood or platelet donations Blood drives 2005-06 Donor Rewards Program Blood Center faculty Administrative Staff Contact us Blood facts FAQs What's new Department of Pathology
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UI Community HomeCare home About Us Notice of Privacy Practices Infusion Therapy Durable Medical Equipment Continuous Positive Airway Pressure Career Opportunities Staff Directory Contact Us
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UI HealthWorks Home About us Services Locations Contact us WORKSAFE Iowa
UI HealthWorksTM
About Us
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Services Locations Contact Us

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About Us
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Welcome
The breadth of the UI Department of Cardiothoracic Surgery services includes all aspects of minimally invasive cardiothoracic procedures including: mitral valve replacement, epicardial lead placement, and soon to be established coronary artery bypass grafting with the use of robotic techniques. . (MORE)
Patients
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Residency Program Perfusion Technology

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UI Heart and Vascular Care Holden Comprehensive Cancer Center
About the Program Admission Curriculum Tuition Contact Us
What's New
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Cardiothoracic Surgery Department Created Robotic Mitral Valve Repair An Iowa First
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Patient Information Services Faculty
Providers
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Emergencies UI Consult Refer a Patient Faculty Services
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Physician Consultation and Referral Directory Home To make an appointment UI Consult
Department of Hospital Dentistry
Endodontics
UI Health Access Outreach services Clinical Trials Job opportunities
The Division of Endodontics provides prevention, diagnosis, and treatment of diseases and other abnormalities of the dental pulp and periapical tissues. Jeffrey P. Lilly, DDS Richard E. Walton, DDS
Family Dentistry The Division of Family Dentistry provides comprehensive diagnostic, preventive, and therapeutic oral health care for patients of post-adolescence age and routine restorative dentistry for children through adolescence. Patricia Meredith, DDS, Director Mark A. Dittmer, DDS Lance P. Forbes, DDS Stephanie Cooper, DDS Jeffrey Wolfe, DDS
Oral and Maxillofacial Surgery The Division of Oral and Maxillofacial Surgery provides the diagnosis and the surgical and adjunctive treatment of the diseases, injuries, and defects of the human jaws and associated structures of the oral-maxillofacial region. Richard G. Burton, DDS Kirk L. Fridrich, DDS Daniel Lew, DDS Teresa Morgan, DDS Bruce Partnoy, DDS William J. Synan, DDS Sherwood H. Wolfson, DDS
Oral Pathology and Diagnosis The Division of Oral Pathology and Diagnosis provides for the diagnosis and therapeutic management of patients with oral and paraoral lesions. Axel Ruprecht, DDS Steven D. Vincent, DDS
Orthodontics The Division of Orthodontics provides the diagnosis and orthodontic treatment of growth and development problems of human craniofacial complex as well as the orthodontic correction of dental and skeletal discrepancies. James J. Wheeler, DDS, Director John C. Casko, DDS
Pediatric Dentistry The Division of Pediatric Dentistry provides comprehensive diagnostic, preventive, and therapeutic oral health care of children from birth through adolescence and of special patients beyond the age of adolescence who demonstrate mental, physical, and/or emotional problems. Stephen J. Goepferd, DDS David C. Johnsen, DDS Michael J. Kanellis, DDS Kaaren Vargas, DDS Jerry D. Walker, DDS
Periodontics The Division of Periodontics provides the diagnosis, prevention, and treatment of diseases of the supporting tissues of the teeth. Paul J. Collins, DDS Janet M. Guthmiller, DDS Benny F. Hawkins, DDS Georgia K. Johnson, DDS
Prosthodontics The Division of Prosthodontics provides practice of the branch of dental science concerned with the construction of appliances designed to replace missing teeth or other parts of the oral cavity and face. Jeffrey C. Markt, DDS, Director Stephen A. Aquilino, DDS Terry J. Lindquist, DDS Robert L. Schneider, DDS Clark M. Stanford, DDS
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Department of Dermatology home Appointments Welcome For patients For Health Care professionals Clinical services and referrals Clinical trials Faculty News Outreach services Patient education information Research Residencies and fellowships Department of Dermatology (uiowa.edu website) UI Carver College of Medicine
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UI Family Care
UI Family Care home UI Department of Pediatrics UI Department of Family Medicine UI Department of Internal Medicine UI Maternity Center UI Department of Obstetrics and Gynecology Services in your community Behavioral Health Child Health Specialty Clinics Children's Hospital of Iowa UI Community Medical Services home
Individual Clinic Information

See map Belle Plaine | Centerville | Iowa City - UI Hospitals and Clinics | Iowa City - Southeast | Lone Tree | Lowden | Marengo | North Liberty | Ottumwa | Perry | Sigourney | Toledo | Wapello
UI Family Care Center Belle Plaine 105 Ninth Avenue Belle Plaine, IA 52208 319-444-3210 319-444-4099 Fax Open Monday-Friday 8 a.m.-5 p.m. Saturday 8 a.m. - Noon Carol Schumacher Practice Administrator To the top Centerville Medical Clinic 19876 St. Joseph Drive Centerville, IA 52544-8850 641-856-8684 641-856-3009 Fax Open Monday-Friday 8 a.m.-5 p.m. Saturday 8 a.m.-Noon Teressa Bogle Practice Administrator To the top
Services
Providers
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Family medicine Pediatric medicine Podiatry services Community health and wellness programs On-site radiology laboratory services
Family Medicine Saleem Shamsee, M.D. Natalie Lanternier, M.D. Pediatrics Michelle Malloy, A.R.N.P.
Services
Providers
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Family medicine On-site laboratory services Community health and wellness programs
Family Medicine Nancy Barton, M.D. James McConville, M.D. Larry Heikes, M.D. David Fraser, M.D. Virginia McConville, P.A.C.
Belle Plaine | Centerville | Iowa City - UI Hospitals and Clinics | Iowa City - Southeast | Lone Tree | Lowden | Marengo | North Liberty | Ottumwa | Perry | Sigourney | Toledo | Wapello
UI Family Care Center UI Hospitals and Clinics Lower level of the Pomerantz Family Pavilion (off Melrose Avenue) 200 Hawkins Drive Iowa City, IA 52242 For New Patients call UI Health Access: 319-384-8442 800-777-8442 Family Practice Clinic: 319-384-7222 Pediatric Clinic 319-384-7333 Internal Medicine Clinic: 319-384-7444
Services
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Open Monday 8 a.m. - 5 p.m.

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Tuesday-Friday 8 a.m. - 5 p.m. Saturday 8 a.m. - Noon
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Family medicine Pediatric medicine Internal medicine Counseling and health promotion services, including individual and family therapy, nutrition and weight management, biofeedback, and stress management Geriatric Health Assessment Clinic Complimentary and alternative medicine Women's health r Obstetrics and gynecology r Family medicine Obstetrical care r UI Maternity Center r Family medicine Convenient, free parking Sports medicine On-site radiology, lab, and pharmacy
Family Medicine George Bergus, M.D. Peg Bouska, PA Richard Dobyns, M.D. John Ely, M.D. Jill Endres, M.D. Daniel Fick, M.D. Scott Frisbie, PA Robert Garrett, M.D. Gerald Jogerst, M.D. Cynda Johnson, M.D. Susan Langbehn, M.D. Barcey Levy, M.D. Michael Maharry, M.D. Kelly Skelly, MD Peter Stanford, PA Alicia Weismann, M.D. Steven Wolfe, M.D. Internal Medicine Gwen Beck, M.D. Ann Broderick, M.D. Todd Burstain, M.D. Christopher Goerdt, M.D. Barbara Happel, A.R.N.P Farheen Hasnain, M.D. Melinda Johnson, M.D. Lisa Kaufman, M.D. Jamshed Khan, M.D. Richard LeBlond, M.D. Paul Mulhausen, M.D. Jose Ness, M.D. Sherry McKay, A.R.N.P. Nicole Nisly, M.D. John Rachow, M.D. Jacqueline Reger, A.R.N.P. Margo Schilling, M.D. Alexandra Thomas, M.D. Todd Wilbin, M.D. Pediatrics Lori Christensen, M.D. Brenda Cruikshank, M.D. Donna D'Alessandro, M.D. Claiborne Dungy, M.D., MPH Lois Dusdeiker, M.D., M.S. Mary Larew, M.D. Ellen Link, M.D. Vera Loening-Baucke, M. D. Stacy McConkey, M.D. Tammy Meehan, M.D. Jody Murph, M.D., M.S.
Resmiye Oral, M.D. George Phillips, M.D. Shannon Sullivan, M.D. Gretchen Vigil, M.D. Jerold Woodhead, M.D. To the top Belle Plaine | Centerville | Iowa City - UI Hospitals and Clinics | Iowa City - Southeast | Lone Tree | Lowden | Marengo | North Liberty | Ottumwa | Perry | Sigourney | Toledo | Wapello UI Family Care Southeast Iowa City 1130 Scott Boulevard Iowa City, IA 52240 (Scott Blvd. and Muscatine Ave.) 319-339-7472 Open Monday-Friday 8 a.m.-5 p.m. Lindsey Jones Practice Administrator To the top Lone Tree Family Practice Center 109 W Jayne Street, P.O. Box 417 Lone Tree, IA 52755 319-629-4214 319-629-4619 Fax Open Monday - Friday 8 a.m.-5 p.m. Linda Forbes Practice Administrator To the top Belle Plaine | Centerville | Iowa City - UI Hospitals and Clinics | Iowa City - Southeast | Lone Tree | Lowden | Marengo | North Liberty | Ottumwa | Perry | Sigourney | Toledo | Wapello Lowden Family Medical Clinic
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Family medicine Geriatric medicine Obstetrical care r UI Maternity Center On-site radiology and laboratory services Community health and wellness program Cardiology Specialty Clinic
Family Medicine Daniel Dunn, M.D. Harriet J. L. Echternacht, MD Adelaide Gurwell, M.D. Michael Jurgens, M.D. Family Medicine with Geriatrics Matthew Lanternier, M.D.
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Family medicine Obstetrical care r UI Maternity Center Community health & wellness programs Nutrition counseling On-site laboratory
Family Medicine David Bedell, M.D. Heather Haug, P.A.-C.
Services
Providers
305 McKinley Avenue P.O. Box 309 Lowden, IA 52255 563-941-5361 563-941-5453 Fax Open Monday, Tuesday, Thursday and Friday 8 a.m.-5 p.m Wednesday 8 a.m.-noon Deanna Welch Practice Administrator To the top Marengo Medical Center 255 West Lucas Street, P. O. Box 184 Marengo, IA 52301 319-642-5213 319-642-3636 Fax Open Monday 8 a.m.-7 p.m. Tuesday-Friday 8 a.m.-5 p.m. Carol Schumacher Practice Administrator To the top UI Family Care Center North Liberty 3 Lions Drive North Liberty, IA 52317 (Lions Dr. and Hwy. 965) 319-626-5680 319-626-5687 Fax Open Tuesday, Wednesday and Friday 8.am.-5 p.m. Monday and Thursday 8 a.m-6 p.m. Cindy Snedigar Practice Administrator
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Family medicine Community health and wellness programs On-site radiology laboratory services
Family Medicine Daniel Dunn, M.D. Ann Reid, P.A.-C.
Services
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Providers Family Medicine Jil Getner, P.A.-C. Saleem Shamsee, M.D. Pediatrics Michelle Malloy, A.R.N.P.
Family medicine Internal medicine Pediatric medicine Community health and wellness program On-site laboratory services
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Providers
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Family medicine Women's health r Obstetrics and gynecology r Family medicine Obstetrical care r UI Maternity Center Behavioral health services Occupational medicine Community health and wellness programs Nutrition counseling On-site radiology and laboratory services Cardiology Specialty
Family Medicine Britt Marcussen, M.D. Jason Powers, M.D. Internal Medicine (Women's Health) Leslie Riley, M.D. Obstetrics/Gynecology Marygrace Elson, M.D. Psychiatry Debra Suda, M.D. Arnold Andersen, M.D. Social Work/Counseling Karen Olmstead, M.S.W., L.I.S.W.
Clinics
To the top Belle Plaine | Centerville | Iowa City - UI Hospitals and Clinics | Iowa City - Southeast | Lone Tree | Lowden | Marengo | North Liberty | Ottumwa | Perry | Sigourney | Toledo | Wapello Medical Oncology Hematology of Ottumwa 1005 Pennsylvania Avenue, Suite 207 Ottumwa, IA 52501 641-682-2514 641-682-3215 Fax Monday-Friday 8 a.m.-5 p.m. Carla Schindler Practice Administrator
Services
Providers
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Hematology disorders Oncology On-site laboratory services
Maleka Ahmed, M.D. Elias Hazzi, M.D.
To the top Belle Plaine | Centerville | Iowa City - UI Hospitals and Clinics | Iowa City - Southeast | Lone Tree | Lowden | Marengo | North Liberty | Ottumwa | Perry | Sigourney | Toledo | Wapello UI Family Care Perry 616 Tenth Street Perry, IA 50220 515-465-3553 515-465-4319 Fax Monday-Friday 8:30 a.m.-5 p.m. Melody Lager Practice Administrator To the top Belle Plaine | Centerville | Iowa City - UI Hospitals and Clinics | Iowa City - Southeast | Lone Tree | Lowden | Marengo | North Liberty | Ottumwa | Perry | Sigourney | Toledo | Wapello UI Family Care Sigourney
Services
Providers
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Family medicine Women's health Community health and wellness programs On-site laboratory services
Family Medicine Kurt Klise, M.D. Steve Sohn, M.D. William Durbin, M.D. Eric Ash, M.D. Haydee Stewart, M.D. Deb Medici-Feick, P.A.-C. Christa Lozano, PA-C
Services
Providers
1314 S Stuart Street, P.O. Box 148 Sigourney, IA 52591 641-622-3840 641-622-3529 Fax Open Monday-Friday 8 a.m.-5 p.m. Deb Horras Practice Administrator To the top Deer Creek Family Care 401 1st Avenue Toledo, IA 52342 641-484-2602 641-484-5031 641-484-6837 Fax Open Monday-Friday 8 a.m.-5 p.m. To the top
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Family medicine Community health & wellness programs On-site laboratory services
Family Medicine John Buckingham, D.O. Robert Baker, P.A.-C.
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Providers Family Medicine Sherry Parks, P.A.-C. Scott Piper, M.D. James Henderson, M.D.
Family medicine On-site radiology laboratory services On-site physical therapy
Belle Plaine | Centerville | Iowa City - UI Hospitals and Clinics | Iowa City - Southeast | Lone Tree | Lowden | Marengo | North Liberty | Ottumwa | Perry | Sigourney | Toledo | Wapello UI Family Care Wapello 218 N 2nd Street Wapello, IA 52653 319-523-8205 319-523-8840 Fax Open Monday - Friday 8 a.m.-5 p.m. Linda Humiston Practice Administrator
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Services
Providers
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Family medicine On-site laboratory services Women's health Community health and wellness program
Family Medicine Abdul Khalique Panhwar, M.D.
Department of Psychiatry
Consultation Services
Consultation services are available throughout the general medical inpatient units and in the outpatient setting. Raymond R. Crowe, MD, Director Jim J. Amos, MD Russell Noyes, MD
Eating Disorder Program The Eating Disorder Program is world renowned for successful treatment of adolescent and adult men and women. Anorexia and bulimia are treated in the outpatient, partial hospital and outpatient setting. Patients who live too far away to participate in the partial hospital program are housed at the University or in some other local setting that is agreeable to the patient/family. Arnold E. Anderson, MD, Director Beng C. Ho, MD Kay Evans, ARNP Wayne A. Bowers, PhD Karen Olmstead, LISW Patty Kane, RN, BSN
Employee Assistance Program An Employee Assistance Program (EAP) is based on the premise that prevention, early intervention, and brief counseling for mental health and substance abuse issues can decrease employer costs in excessive absenteeism and the use of more extensive services. Employers purchase the program to assist staff in obtaining short-term counseling outside of their mental health benefits. Counseling sessions are confidential and information discussed is not available to the employer or to the insurance company. Lance Clemsen, LISW, Manager
Geriatric Program UI Behavioral Health's geriatric specialists provide specialized inpatient and outpatient care as well as outreach and educational services to nursing facilities and other assisted living programs. Judith H.W. Crossett, MD Mary Johnson, ARNP Colleen Brems, ARNP
Susan Schultz, MD
Medical Psychiatric Program The Medical-Psychiatric program treats patients with concurrent medical and psychiatric conditions. Patients requiring treatment on an inpatient medical service receive daily care by a medical and psychiatric physician. A joint residency program sponsored by the departments of Internal Medicine and Psychiatry trains residents in the diagnosis and treatment of patients at the interface of medicine and psychiatry. Physicians become board eligible in medicine and psychiatry. Caroline C. Carney-Doebbeling, MD Teresa Crounquist, RN, BSN, Nurse Manager
Neuropsychology The clinical neuropsychology service provides comprehensive psychological evaluation services to assess cognitive functioning in persons with known or suspected brain dysfunction. Neuropsychological evaluations are also helpful in assessing persons with congenital or acquired cerebral dysfunction, learning/developmental disabilities, and the cognitive/emotional aspects of neuropsychiatric disorders. Neuropsychological assessment involves systematic evaluation of intellectual functioning, memory, language, visuospatial abilities, planning/organization, academic skills, and emotional processing. A neuropsychological assessment is used to clarify diagnosis, monitor mental status change, assess and monitor disability status and assess metal abilities that affect capacity for independent living, decision making, vocational planning and other areas of daily living. Jane S. Paulsen, PhD, Director John D. Bayless, PhD David Moser, PhD
Obsessive-Compulsive Clinic The program provides evaluation and treatment of obsessive-compulsive and related disorders, such as Trichotillomania (hair pulling) and body dysmorphic disorder. Donald W. Black, MD Nancee Blum, LISW
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Department of Respiratory Care

Respiratory Care home Internal Medicine Pulmonary Medicine Division Employment opportunities Patient education
Hyperbaric Medicine Service

What is a hyperbaric chamber A hyperbaric chamber is a large, steel tank that administers 100% oxygen in a high pressure environment. The 2-person chamber purchased in 1988 was replaced by a much larger version in the interest of efficiency, patient convenience and the opportunity to expand hyperbaric applications. Where is the hyperbaric medicine chamber The chamber is located on the 5th floor of JPP, sited at the center of clinical activity. The chamber was lifted by crane through a hole in the west wall of the seventh floor of the John Pappajohn Pavilion. This hole was created by temporary removal of the precast exterior. The precast material was returned immediately after the chamber was lifted onto the seventh floor. From there, the chamber was lowered through an existing shaft to the fifth floor, where it was permanently installed. The shaft was created for installing equipment in UI Hospitals and Clinic's new operating suites. Patient treatments in the chamber began after a four- to six-week installation and training period. Features The hyperbaric chamber, manufactured by Perry Baromedical, Riviera Beach, Florida, is 22 feet long, 7 feet in diameter, and weighs 24,000 pounds - the largest in Iowa. It can hold up to six patients at one time for treatment sessions, plus up to two hyperbaric medicine specialists. While sitting or lying in the chamber, patient activities may include reading, writing and table games. What conditions are treated with hyperbaric oxygen Common uses of hyperbaric oxygen therapy include treating infections that cannot be managed with conventional therapy, facilitating wound healing, treating carbon monoxide poisoning, and preparing patients for skin grafts. "Carbon monoxide poinsoning is only one of several conditions that uses the physical therapies of high pressure oxygen. There are wide ranges of conditions where hyperbaric oxygen is used for healing purposes," says Peter J.R. Jebson, M.D. How does it work The chambers specialized atmosphere resembles a deep sea dive with a maximum depth achieved of 16 stories. The effects of treatment are due to an increase in surrounding pressure, and the patient breathing 100 percent oxygen by mask or hood. This combination of concentrated oxygen and atmospheric pressure causes the blood to carry greater concentrations of oxygen to the area in need of healing. Staff J. Eric Greensmith, M.D., PhD Professor of Anesthesia and Director, Hyperbaric Medicine and Wound Care Service 319-356-7706
Former Duo-Place Hyperbaric Chamber Department of Respiratory Care UI Hospitals and Clinics 200 Hawkins Drive Iowa City, Iowa 52242 Phone: 319-356-3474 Fax: 319-356-8365
Multiplace Hyperbaric Chamber being lifted by crane.
Tim Ruffin, R.C.P.T. Assistant Director, Respiratory Care 319-356-0834 Sue Mooney, R.R.T., C.H.T. Supervisor, Hyperbaric Medicine and Wound Care Service Supervisor, Diagnostic Services 319-356-7706
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Physician Consultation and Referral Directory Home To make an appointment UI Consult UI Health Access Outreach services Clinical Trials
Department of Internal Medicine: Allergy-Immunology
Zuhair K. Ballas, MD, Director Mary Beth Fasano, MD, MSPH Marta M. Little, MD Barbara A. Muller, MD Nicholas Zavazava, MD Cellular Immunology Diagnostic Lab
Job opportunities
The Cellular Immunology Diagnostic Lab provides state-of-the-art tests that examine multiple aspects of a patient's immune system. Fully certified by the College of American Pathology, tests permit the diagnosis of certain immunodeficiencies that might otherwise go undetected. Zuhair K. Ballas, MD Clinical Study Center The Clinical Study Center provides Phase II and Phase III clinical studies for newer therapies for asthma and allergic diseases. All Internal Medicine, Allergy-Immunology staff Fiberoptic Rhinoscopy Fiberoptic rhinoscopy is a specialized procedure used to evaluate intranasal and nasopharyngeal lesions including mucosal changes, anatomic abnormalities, sinus infections, and nasal polyps. All Internal Medicine, Allergy-Immunology staff Food Allergy The prevalence of food allergy, and in particular peanut allergy, has doubled in American children less than age 5 over the past five years. It is currently estimated that 4-6% Americans are afflicted with food allergies. Factors influencing the development of food allergy are largely unknown, however, animal models have suggested that a genetic predisposition toward a dominant TH2 response or a dominant TH1 response after antigen ingestion might be linked to susceptibility and resistance to food allergy respectively. Using human subjects recruited from the newly developed Food Allergy Clinic at UIHC, we are investigating the role of activated allergen-specific T-cells and specific cytokine production in individuals with clinically significant food hypersensitivity. It is hoped that a better understanding of the mechanisms leading to the development, as well as loss of food allergy, will result in novel therapeutic modalities for this potentially life-threatening condition. All Internal Medicine, Allergy-Immunology staff Immune Disorders Clinic The Immunodeficiency Clinic is a unique service designed to evaluate patients with recurrent infections, or multiple immune system abnormalities, or "immune-deviation."
Zuhair K. Ballas, MD Immunomodulation Therapy The advent of numerous new pharmacotherapeutics aimed at modulating the immune system illustrates the need for a specialist well versed in their mechanism of action, indications and side effects. Examples include anti-IgE and IVIG therapy. Latex Allergy Clinic The Latex Allergy Clinic is designed to coordinate the care and education of patients allergic to latex. High-risk categories for latex allergy include health care workers, patients who require multiple surgery, patients who have frequent contact with latex medical products, workers in the rubber industry, and people with existing allergic sensitivities. Barbara A. Muller, MD
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Physician Consultation and Referral Directory Home To make an appointment UI Consult UI Health Access Outreach services Clinical Trials Job opportunities
Department of Internal Medicine: Cardiovascular Diseases

Neal L. Weintraub, MD, Interim Director Christopher J. Benson, MD Theresa Brennan, MD Donald D. Brown, MD Barry Cabuay, MD John S. Chase, MD Robert B. Felder, MD Rufino Festin, MD Ellen E. Gordon, MD William Haynes, MD Donald D. Heistad, MD Phil Horwitz, MD Dinesh Jagasia, , MBBS Richard E. Kerber, MD Michael G. Kienzle, MD Paul Lindower, MD Allyn L. Mark, MD James B. Martins, MD Francis J. Miller Jr., MD Brian Olshansky, MD Catherine Pesek-Bird, DO James D. Rossen, MD Phillip G. Schmid, MD David J. Skorton, MD Peter M. Snyder, MD Robert M. Weiss, MD Chad Williams, MD Adult Congenital Heart Disease The Adult Congenital Heart Disease service provides multidisciplinary care for adult outpatients and inpatients with congenital and heritable heart diseases. David J. Skorton Cardiac Catheterization Lab Cardiac catheterization and angiography are used to diagnose cardiovascular disease and to define cardiac anatomy and function. Therapeutic services include percutaneous transluminal coronary angioplasty (PTCA), intracoronary stents, coronary atherectomy, coronary thrombectomy, and laser angioplasty for treatment of coronary artery disease and Inoue balloon valvuloplasty for patients with mitral stenosis. Investigational therapy for coronary artery disease includes the use of blood vessel growth factors and localized radiation treatment. James D. Rossen, MD Cardiac Electrophysiology Electrophysiologists evaluate and treat patients for cardiac rhythm disturbances using
pacemakers, internal cardiac defibrillators, invasive study techniques, and ablation therapy. Brian Olshansky, MD Cardiac Nuclear Imaging/Positron Emission Tomography (PET) Cardiac Nuclear Imaging/Positron Emission Tomography is designed to diagnose coronary artery disease, assess myocardial viability in patients being considered for revascularization (percutaneous transluminal coronary angioplasty - PTCA or coronary artery bypass surgery CABG), and to assess ventricular function. David J. Skorton Cardiac Rehabilitation The UI Cardiovascular Health Assessment Management and Prevention Services (CHAMPS) provides a full range of services to patients with known heart disease and individuals at risk for developing heart disease. Services include dietary counseling, exercise programs, a prescription service, lipid assessment, and smoking cessation. Ellen E. Gordon, MD Cardiac Transplantation Physician specialists, nurse coordinators, dietitians, social workers, and physical therapists combine efforts to provide a multidisciplinary approach to cardiac transplantation for appropriate candidates with advanced heart failure. Cardiology Inpatient Units Cardiology Inpatient Units include the Cardiovascular Intensive Care Unit and the Intermediate Cardiac Care Units, each dedicated to comprehensive cardiovascular care with state-of-the-art arrhythmia monitoring. Theresa Brennan, MD Cardiology Outpatient Clinic Cardiology Outpatient Clinics include daily general cardiology clinics plus specialized clinics that include Heart Failure Clinic, Cardiac Transplantation Clinic, Arrhythmia Management Clinic, Pacemaker/Defibrillator Clinic, and Lipid Clinic. Staff cardiologists assist and consult with referring physicians as requested on all aspects of care for patients with suspected or diagnosed cardiovascular disease including preoperative and postoperative cardiovascular evaluation and care for patients undergoing cardiovascular, peripheral vascular, and non-cardiac surgery. Echocardiography Laboratory The echocardiography laboratory is staffed by cardiologists with special expertise in cardiac ultrasound and by cardiac sonographers using state-of-the-art equipment. The echo lab offers flexible scheduling and a full range of echo services for outpatients and inpatients, including comprehensive precordial exams, multiplanar transesophageal echo, exercise echo, dobutamine stress echo, contrast echo, and intraoperative echo. Richard E. Kerber, MD Electron Beam Computed Tomography (EBCT) Electron Beam Computed Tomography is an advanced cardiac imaging technique that precisely measures left and right ventricular mass, volumes, and contractile function. It is especially useful for quantitation of the severity of valvular insufficiency and for definitive
diagnosis of hemodynamically significant pericardial disease. The technique is also useful for measuring calcification in the coronary arteries, an indicator of atherosclerotic burden and a powerful predictor of coronary events. Robert M. Weiss, MD UI Consult 800-322-UHIC (8442) Available anytime day or night, year around, members of this consultation team are available to provide telephone consultation and assistance with arranging Outpatient Evaluation or transfer to UI Health Care. Heart Failure Heart Failure services provide long-term multidisciplinary care for patients with all degrees of heart failure. Therapeutic options include conventional medical therapy, experimental medical therapy, outpatient inotropic infusion, non-pharmacologic therapies (patient education and follow-up), cardiac transplantation, and implantable ventricular assist devices. Pacemaker Service The Pacemaker Service provides comprehensive pacemaker-related services to patients and community physicians, including implantation, revision, lead extraction, clinic and telephone follow-up, and troubleshooting. Brian Olshansky, MD Pregnancy and Heart Disease The Pregnancy and Heart Disease service offers consultation to women with known or suspected heart disease before, during, and after pregnancy. Catherine Pesek-Bird, DO Treadmill Stress Testing Laboratory The Treadmill Stress Testing Laboratory provides stress tests for diagnosis, assessment of functional state or capabilities, and evaluation of effectiveness of anti-angina and heart failure therapy.
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Department of Internal Medicine: Endocrinology Metabolism
Robert S. Bar, MD, Director of Division Joseph S. Dillon, MD Udaya M.C. Kabadi, MD Thomas O'Dorisio, MD Janet A. Schlechte, MD William I. Sivitz, MD Robert G. Spanheimer, MD General Endocrinology and Diabetes Services Certified specialists provide care in all areas of general endocrinology, including diabetes, thyroid disease, disorders of mineral metabolism, including calcium disorders, adrenal, pituitary, and gonadal dysfunction, and osteoporosis. Endocrinologists, certified diabetes nurse educators, social workers, and dietitians provide coordinated and comprehensive care to adult patients with diabetes. Joseph S. Dillon, MD Gregory C. Doelle, MD, PhD Udaya M.C. Kabadi, MD Thomas O'Dorisio, MD Janet A. Schlechte, MD William I. Sivitz, MD Robert G. Spanheimer, MD
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Department of Internal Medicine: Gastroenterology Hepatology
Kyle Brown, MD David E. Elliott, MD, PhD F. Jeffrey Field, MD Henning Gerke, M.D. Frederick C. Johlin, MD Douglas R. LaBrecque, MD Ika Peleg, MD Satish S.C. Rao, MD, PhD Warren N. Schmidt, PhD, MD Konrad S. Schulze, MD William B. Silverman, MD Robert W. Summers, MD Cyrus Tamboli, M.D. Michael D. Voigt, MD For additional information, see: James A. Clifton Center for Digestive Diseases Division of Gastroenterology and Hepatology (Internal Medicine web site) Clinical Services General Gastroenterology and Hepatology Members of the Division of Gastroenterology-Hepatology provide assistance and consultation to referring physicians on all aspects of care for adult patients with suspected or diagnosed gastrointestinal or liver disease. Protocol-based experimental therapies, which are available only in clinical trials are also offered. David E. Elliott, MD, PhD F. Jeffrey Field, MD Venkatesh Lakshman, MD Ika Peleg, MD Satish S.C. Rao, MD, PhD Konrad S. Schulze, MD Dany Shamoun, MD Robert W. Summers, MD Diagnostic and Therapeutic Endoscopy Unit The Endoscopy Service offers the entire spectrum of procedures associated with gastroenterology and hepatology, including upper endoscopy, colonoscopy, endoscopic retrograde cholangio-pancreatography (ERCP), ultrasonic endoscopy, liver biopsy, paracentesis, GI motility procedures and endoscopic treatments, such as polypectomy, laser therapy, argon plasma coagulation, variceal banding, dilatation and placement of percutaneous endoscopic feeding gastrostomies and jejunostomies or insertion of luminal stents. Robert W. Summers, MD, Director Specialty Clinics and Services
A variety a clinics provide specialized care for individuals with less common diseases or unique needs. In addition to receiving state of the art therapy, patients also have the opportunity to participate in clinical trials coordinated by these clinics.
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Celiac Disease Clinic The Celiac Disease Clinic provides diagnostic and consultation services to patients with a known or suspected intolerance to grain products or other types of malabsorption syndromes. David E. Elliott, MD F. Jeffrey Field, MD Joel Weinstock, MD
Colorectal Cancer Screening Service The Colorectal Cancer Screening Service utilizes flexible sigmoidoscopy and colonoscopy to assess for colorectal polyps and cancers in patients over the age of 50 who are without symptoms and without a personal or family history of polyps or colorectal cancer. Additional screening and surveillance strategies exist for patients with known or possible genetic cancer syndromes, such as familial adenomatous polyposis or hereditary non-polyposis colon cancer. Robert W. Summers, MD, Director
Defecation Disorder, Neuromuscular Conditioning, and Colorectal Pain Service This service provides consultation and treatment to patients with defecation disorders, such as constipation, fecal incontinence or perineal or anal pain. Biofeedback training is one of several methods of treatment for bowel problems such as constipation and incontinence. Satish S.C. Rao, MD, PhD Konrad S. Schulze, MD
Endoscopic Ultrasonography Service The endoscopic ultrasonography service utilizes a variety of ultrasound techniques to diagnose benign or malignant diseases of the esophagus, mediastinum, stomach, duodenum, pancreas and anorectum. It also offers fine needle aspiration or therapeutic drainage procedures. Henning Gerke, MD, Director Frederick C. Johlin, MD
Gut Failure/Total Parenteral Nutrition (TPN) Clinic The TPN Clinic specializes in the delivery and management of nutrition to patients with short bowel syndrome or non-functional gut that requires parenteral nutritional support. Inflammatory Bowel Disease (IBD) Clinic The IBD Clinic offers a multidisciplinary program of comprehensive evaluation, treatment and follow-up of patients with inflammatory bowel disease, including Crohn's disease and ulcerative colitis. David Elliott, MD, PhD Robert W. Summers, MD
Liver Failure Clinic/Transplant Utilizing state-of-the-art diagnostic and therapeutic techniques, the liver failure and transplant service provides comprehensive management services to all patients with acute or chronic liver failure and liver cancer. Michael D. Voigt, MD
Neurogastrointestinal and Gastrointestinal Motility Service The GI Motility Service provides evaluation and therapy of patients with disorders that may be due to gastrointestinal muscle or nerve problems, including non-cardiac chest pain, swallowing difficulties, heartburn, gastroparesis, unexplained nausea and vomiting, indigestion in the presence of diabetes, voice hoarseness, asthma and gastroesophageal reflux disease (GERD). Diagnostic techniques include manometry, pH studies, impedence planimetry, hydrogen breath testing, pudendal nerve latency testing and barostat. S. Satish C. Rao, MD, PhD Konrad S. Schulze, MD Robert W. Summers, MD
Pancreaticobiliary Service The Pancreaticobiliary Service evaluates patients with suspected pancreatic or biliary disease using endoscopic techniques such as endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasonography (EUS). Manometric analysis of the biliary and pancreatic sphincters are also used for the evaluation of patients with sphincter of Oddi dysfunction (causing pain syndromes from the pancreas and biliary systems). Therapy for patients with pancreaticobiliary obstructive diseases is provided. Frederick C. Johlin, MD, Director William B. Silverman, MD
Swallowing Disorder Clinic and Non-Cardiac Chest Pain Clinic Patients in the swallowing disorder clinic are evaluated by a multidisciplinary team to identify and treat neuromuscular diseases, strictures, tumors or other potential causes for oropharyngeal or esophageal dysphagia or non-cardiac chest pain. Viral Hepatitis Clinic The viral hepatitis clinic offers multidisciplinary evaluation and treatment for patients with infectious diseases and their complications. Kyle Brown, MD Douglas R. LaBrecque, MD Warren Schmidt, MD Michael Voigt, MD
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Department of Ophthalmology and Visual Sciences
Comprehensive Eye Care and Cataract Clinic

Physicians provide basic eye examinations and perform all types of cataract surgery. Comprehensive Eye Clinic physicians work closely with referring physicians and subspecialists within the department. Hilary A. Beaver, MD Sara L. Butterworth, OD A. Timothy Johnson, MD, PhD Brian R. Kirschling, OD Hansjoerg E. Kolder, MD, PhD, Professor Emeritus Thomas A. Oetting, MD
Contact Lens Service Contact lens evaluations and fittings are provided for both medical and cosmetic needs by optometrists, opticians, and ophthalmologists. Brian R. Kirschling, OD Christine W. Sindt, OD Trudy Grout, Optician
Cornea and External Disease The clinic evaluates and treats patients with corneal and external eye diseases. Services provided include corneal topography, confocal microscopy, tear flow analysis, and corneal transplants. John E. Sutphin, MD Kenneth Goins, M.D.
Echography The service uses A-scan and B-scan echography to examine the eye and diagnose disorders that require ultrasound evaluation. Ultrasound is used to examine parts of the eye when not visible by light and also to examine the soft tissue structures surrounding the eye when diagnosing infections, orbital tumors, congenital abnormalities, and other diseases. H. Culver Boldt, MD
Glaucoma
The clinic evaluates and treats patients with glaucoma and increased ocular pressure. The service treats patients of all ages from newborn infants with congenital glaucoma to the elderly. Wallace L.M. Alward, MD Young H. Kwon, MD, PhD
Inherited Eye Diseases The department has special expertise in evaluating and diagnosing inherited diseases involving the eye and body. Edwin M. Stone, MD, PhD
Vision Rehabilitation Service The service participates in the evaluation and rehabilitation of patients with poor vision through the use of special corrective lenses and high-tech devices. A variety of devices used to enhance vision are available on a trial basis. Mark E. Wilkinson, OD
Neuro-Ophthalmology The clinic evaluates patients with a variety of neurological disorders that affect vision and the brain. Randy H. Kardon, MD, PhD Andrew G. Lee, MD H. Stanley Thompson, MD, Professor Emeritus Michael Wall, MD
Ocular Oncology Service The service utilizes a team of practitioners to evaluate and treat eye tumors such as malignant melanoma of the choroid and retinoblastoma. H. Culver Boldt, MD Thomas A. Weingeist, MD, PhD
Oculoplastics and Orbital Surgery The clinic treats patients with disfiguring injuries and diseases involving the eyes, lids and orbit as well as those desiring cosmetic plastic surgery. Services include blepharoplasty, artificial ocular implants, and optic nerve decompressions. Keith D. Carter, MD Jeffrey A. Nerad, MD
Ophthalmic Photography The department has one of the most advanced ophthalmic photography programs in the nation offering fundus photography, fluorescein and indo-cyanine green angiography, slitlamp photography, and confocal laser photography. Tracy Aly, COA, CRA
Orthoptics The Orthoptics service offers a variety of evaluations and strategies for treating misalignment of eye muscles in adults and children. Pamela Kutschke, CO Wanda Ottar, CO
Pediatric Ophthalmology/Adult Strabismus The clinic evaluates children and adults with ocular motility problems in addition to eye diseases in children. Ronald V. Keech, MD Richard J. Olson, MD William E. Scott, MD
Refractive Corneal Surgery (Laser Vision Correction) Clinic physicians perform corneal refractive surgery utilizing state-of-the-art techniques to reduce or eliminate the need for corrective lenses. John E. Sutphin, MD Kenneth Goins, M.D. Lisa Milder, RN, Administrative Coordinator
Vascular Disease of the Eye The clinic evaluates patients who are losing vision due to strokes and other blinding diseases caused by poor or blocked circulation in the eye. Sohan S. Hayreh, MD, PhD, DSc
Vitreoretinal Diseases and Surgery The clinic evaluates and treats patients with a large range of diseases affecting the retina and vitreous. These include diabetic eye disease, retinal detachments, macular holes, macular degeneration, hereditary retinal diseases, uveitis, and ocular tumors. H. Culver Boldt, MD James C. Folk, MD Karen M. Gehrs, MD Andrew Lotery, MD
Stephen R. Russell, MD Edwin M. Stone, MD, PhD Thomas A. Weingeist, MD, PhD
Outreach Services The Department of Ophthalmology provides clinical care services at community-based sites that may provide more convenient access for some patients. Dubuque Retina Outreach Clinic
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319-5890592
Department of Orthopaedics and Rehabilitation Home Contact Us/Appointments Patients Health Care Professionals Faculty, Staff, and Students Residents and Fellows Clinical Services and Referrals Clinical Trials Faculty and Staff News UI Carver College of Medicine
Excellence and Leadership in Patient Care, Research and Teaching Since 1913
Mission Statement: Improve the lives of people suffering from diseases, deformities and injuries of the spine and limbs Goals:
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Provide exemplary, compassionate and effective patient care Critically evaluate the initial and long term results of medical, surgical and physical treatments Develop more effective medical, surgical and physical treatments and ways of preventing diseases and injuries Advance knowledge of the structure, function, diseases, injuries and restoration of the limbs and spine and tissues, cells and molecules that form them Teach medical, graduate and undergraduate students, resident physicians and practicing physicians the structure, function and pathophysiology of the musculoskeletal system, the values, ethics and methods of the arts and sciences of orthopaedics and rehabilitation
SCOR Grant
Department of Orthopaedics and Rehabilitation The University of Iowa Hospitals and Clinics 01008 JPP 200 Hawkins Drive Iowa City, IA 52242 (Patient inquiries regarding appointments should be directed to: 319-356-2223 or https://wws.uihealthcare.com/appts/ptselfreferform.html)
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Pediatrics Home Appointments Children's Hospital of Iowa Clinical Services and Referrals Clinical Trials Faculty News Outreach Services Research Residency Fellowships UI Carver College of Medicine
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UI Behavioral Health Home Appointments Department of Social Service Department of Psychiatry Psychiatry: Neuropsychology Lab Department of Neurology Neurology: Neuropsychology Lab Department of Pediatrics: Division of Psychology Center for Disabilities and Development Pain Management Rehabilitation Therapies
Welcome to UI Behavioral Health at University of Iowa Hospitals and Clinics.
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Iowa Neonatology Handbook: General

Handbook Home General Temperature Jaundice Pulmonary Neurology Metabolic Fluid Management Feeding Infection Hematology Pharmacology Procedures Abbreviations Commonly
Blood Pressure in the Newborn

The following figures and table can be used to assess normal blood pressure in young premature infants. Hypotension should not usually be treated without other signs of insufficient cardiac output (e.g. poor skin perfusion, metabolic acidosis, anuria).
Used in the Nursery
Mean and 95% confidence limits for blood pressure during the first 12 hours after birth. Predicted systolic blood pressure (mmHg) in symptom-free low-birth weight newborns from 3 to 96 hours of age
References: Moscoso P, Goldberg RN, Jamieson J, Bancalari E. Spontaneous elevation in arterial blood pressure during the first hours of life in the very-low-birth-weight infant. J Pediatr 1983;103:114-117. Tan KL. Blood pressure in very low birth weight infants in the first 70 days of life. J Pediatr 1988;112:266-270. Versmold HT, Kitterman JA, Phibbs RH, Gregory GA, Tooley WH. Aortic blood pressure during the first 12 hours of life in infants with birth weight 610 to 4,220 grams. Pediatrics 1981;67:607-613.
Section Top | Title Page

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Indications for Hearing Screening of Neonates*

I. The following are indications for hearing screening prior to discharge: A. Family history of childhood hearing loss B. Congenital defects of the ear, nose, or throat C. Birth weight <1500 grams D. Meningitis E. Congenital infection F. Hyperbilirubinemia requiring an exchange transfusion G. Pulmonary hypertension ( persistent fetal circulation) H. Maternal rubella infection I. Birth asphyxia (5-minute Apgar score below 7) J. Fetal Alcohol Syndrome K. Other anomalies or relevant diagnoses that the physician believes warrants a hearing screen. A consult can be requested at the physician 's discretion. II. Infants who satisfy any of these criteria (A-J) will normally be identified by an audiologist from the Department of Otolaryngology. The audiologist will place an E-1 consultation form on the baby's chart with the indicators for hearing test marked. The baby's resident physician should verify that the indication is met and sign the form as requesting physician. III. Administration of aminoglycoside antibiotics is not an indication unless one of the above criteria is also met or if serum levels were in the toxic range. IV. Please schedule the hearing screening test at least one week prior to discharge. *Note: It is anticipated that universal hearing screening may be implemented in the Special Care Nurseries within the lifetime of this edition. Section Top | Title Page

High Risk Infant Follow-up Program

Diane L. Eastman, R.N., A.R.N.P., C.P.N.P.
I. Background A. Follow-up for children who have required special care as neonates is an integral part of the continuum of their care. There are several reasons why follow-up services are important. A. To identify developmental and special health needs in children born at risk; B. To determine how new treatments offered by the perinatal care system influence long-term outcome. B. In response to these needs, the Iowa High Risk Infant Follow-up Program was developed in 1978. Its goal is to provide developmental screening for certain categories of high risk infants. At this time follow-up services are available nearly statewide. Currently, enrollment and evaluation centers are located at University of Iowa Hospitals & Clinics, and in Cedar Rapids, Ottumwa, Sioux City, Mason City, Waterloo, and Davenport. Other evaluation centers are also located in Spencer, Fort Dodge, Council Bluffs, Carroll, and Creston. Satellite evaluation centers that the UIHC nurse practitioners staff in Davenport and Waterloo are for children from those areas who spent most or all of their hospitalization at the University of Iowa. Des Moines has a follow-up program similar to this and accepts transfers for follow-up services. C. The follow-up program provides developmental screening by a pediatric nurse practitioner. This program will not diminish the role of the local physician who provides primary health care for the child. II. Entry Criteria A. Certain categories of infants have been defined as being at risk and who therefore should receive follow-up. The criteria for the program include: 1. Birth weight less than 1500 grams. 2. Respiratory distress syndrome (RDS) requiring mechanical ventilation for two hours or more. 3. Other forms of respiratory distress requiring mechanical ventilation for more than two hours. 4. CNS infection 5. Asphyxia neonatorum as indicated by a five-minute Apgar score below 7. 6. Hypoglycemia as proven by two consecutive blood glucose levels below 40 mg/dl. 7. Neonatal seizures, as documented by physician observation with concurrence of staff neonatologist in Iowa City, or attending pediatrician in Level II Centers. 8. Hypotonia on discharge examination. 9. Polycythemia: Venous hematocrit of 65 or higher or 60-64 with signs and partial exchange transfusion, with resolution of signs. 10. Maternal substance abuse during pregnancy. 11. Other: Infants not included in criteria 1 through 10 but felt to be at risk by the attending physician. Examples include: a. Sepsis b. SGA c. Hyperbilirubinemia (requiring exchange transfusion) d. Intraventricular hemorrhage e. Sibling meets criteria f. Intrauterine transfusion g. Those who will be entering living environments which present serious psychosocial concerns.
B. Infants moving into Iowa from other states are accepted if one or more of the above criteria occurred within the neonatal period. III. Process A. Developmental screening is done by pediatric nurse practitioners supervised by a pediatrician. In Iowa City, patients are seen in the Hospital School Outpatient Clinic. Appointments are scheduled at 4, 9, 18 and 30 months of age. Fees are waived for the screening evaluation except in Cedar Rapids where a fee is charged. At each appointment physical and neurological examinations and the Denver II screening test are performed. B. Infants who are at greater risk or who require more detailed evaluations may be scheduled in a Neonatology Clinic staffed by a neonatologist. Usual clinic fees apply for this clinic. Examples of children who may be served in the Neonatology Clinic are as follows: infants with unresolved medical problems, such as bronchopulmonary dysplasia or significant intraventricular hemorrhage, and infants discharged on oxygen, monitors, or respiratory stimulant drug. In Neonatology Clinic, the same neonatologist and nurse practitioner follow an infant, in cooperation with his local physician, until the infants care can be fully transferred to the local physician. C. Appointments for screening examinations and for Neonatology Clinic may be made by calling 353-6880. D. Infants eligible for follow-up should be identified by the pediatric nurse practitioner or the resident physician relatively early in the hospital course. The parents can then be contacted and informed of the availability of follow-up services. Questions concerning any aspects of the follow-up process may be directed to:
Diane Eastman, R.N., C.P.N.P. - 319-353-6880 (Iowa City) Darla Noel, R.N.,C P.N.P. - 319-353-6880 (Iowa City) Mary Ann Gureno. - 319 369-7166 (Cedar Rapids) Cyndy Hockman, R.N., C.P.N.A. - 515-964-9987 (Des Moines) Cheryll Jones, R.N., P.N.P.; 515-682-8145 (Ottumwa); 712-279-3411 (Sioux City) Maureen Horsley, R.N., P.N.P. - 712-279-3411 (Sioux City) Peg Macek, R.N., P.N.P. - 319-383-1441 or 1442 (Davenport) Jean Westendorf R.N., P.N.P. - 515-424-7388 (Mason City) Jane Sielman, R.N., P.N.P. - 319-236-4560 (Waterloo) Kathleen Richardson, R.N., P.N.P. - 712-792-5530 (Carroll) Kieran Einwalter, R.N., P.N.P. - 515-955-8326 (Fort Dodge) Judith Anderson, R.N., P.N.P. - 712-328-6798 (Council Bluffs) Jan Foote, R.N., P.N.P. - 515-782-6435 (Creston)
Questions pertaining to administrative matters should be addressed to the director of the program: Herman Hein, M.D., 319-356-2637. The secretary is Ms. Tina Howsare. The central office is located in Hospital School, Room S267 319-353-6880. Section Top | Title Page
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Immunization of the Infant in the Hospital

I. All infants, pre term or term, who are in the hospital at 2 months of age (chronological, not adjusted) should be considered for initiation of their immunizations. II. At two, four and six months after birth, give Tetramune (0.5 ml IM), polio vaccine (see point III below). Hepatitis B vaccine (0.5 ml IM) may be given at birth - 2 months of age, then every 2 months for a total of three doses. III. If the infant is going to remain an inpatient, give one dose (0.5 ml) of inactivated (Salk) polio vaccine subcutaneously. If the infant is being discharged, give one dose of oral trivalent polio vaccine PO immediately prior to discharge. IV. Infants with chronic lung disease who are 6 months or older should be given influenza virus vaccine when available each season (as should their immediate family and hospital caregivers). V. A signed informed consent is required prior to administration of immunizations. VI. Please mark the immunizations given on the A-9 form ("Vaccination and Diagnostic Screening Examination Record") in the chart and give the parents an immunization card with the dates and vaccines marked. Remind the parents when the next immunizations will be due. VII. Please include the immunization history in the interim, transfer, and discharge summaries, as well as off-service notes. References: Bernbaum JC, Daft A, Anolik R, et al. Response of preterm infants to diphtheria-tetanuspertussis immunizations. J Pediatr 1985;107:184-188. American Academy of Pediatrics Committee on Infectious Diseases. Report of the Committee on Infectious Diseases. (23rd ed.) Elk Grove Village: American Academy of Pediatrics, 1994:5152. Section Top | Title Page
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Intrauterine Growth Retarded (IUGR) Infants

I. Every newborn infant should be evaluated for gestational age by the Ballard method and have his head circumference, weight and length plotted against gestational age on the Lubchenco curves. Those infants whose weights fall below the 10th percentile for gestational age may have intrauterine growth retardation. The following is suggested management of these infants. II. Hematocrit by heelstick should be monitored in the first hour of life and repeated at six hours. If the value is greater than 65%, a venous or arterial hematocrit should be obtained. If this value is also greater than 65%, the possibility of a partial exchange transfusion with removal of red cells and replacement with plasma to prevent complications of hyperviscosity syndrome should be considered and discussed with the fellow or staff neonatologist. III. Plasma glucose determinations should be monitored during the first 24 hours, especially if the infant is not yet receiving intravenous glucose or enteral feeds. If the true blood glucose is less than 30 mg/dl, an infusion of D10W, 2 ml/kg, should be given IV over one minute, followed by an infusion of D10W or D10/0.2 NS at a rate of 100 ml/kg/day (7 mg/kg/minute). If the true glucose is between 30 and 40 mg/dl and the infant's condition allows, enteral feedings should be given. Refer to guidelines for management of hypoglycemia. IV. The maternal history should be reviewed for possible etiologies of the growth retardation. If possible, a description of the placenta should be obtained. The two most common causes of intrauterine growth retardation are placental insufficiency and intrauterine viral infection (the TORCH complex: toxoplasmosis, rubella, cytomegalic virus and herpes). V. Titers may be sent to aid in the diagnosis of syphilis and the TORCH complex if intrauterine infection is suspected. The best screening test for CMV infection is a urine culture for CMV.

New Ballard Score for Gestational Age Assessment

Used in the Nursery
Reference: Ballard JL, Khoury JC, Wedig K, Wang L, Eilers-Walsman BL, Lipp R. New Ballard score, expanded to include extremely premature infants. J Pediatr 1991;119:417-423. Section Top | Title Page
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Handbook Home General Temperature Jaundice Pulmonary Neurology Metabolic Fluid Management Feeding Infection Hematology Pharmacology Procedures
Newborn Metabolic Screen

Newborn screen
In Iowa, all newborns are screened by the Iowa Birth Defects Institute for hypothyroidism, phenylketonuria, galactosemia, maple syrup urine disease, hemoglobinopathies, and adrenal hyperplasia. Neonatal screening has been done in Iowa since 1983. The diseases screened for vary from state to state. Criteria for screening include: 1. A disorder that is sufficiently common to justify screening. 2. A relatively simple, accurate and inexpensive screening test should be available, that has a high sensitivity with a high negative predictive value. 3. Treatment should be available for the disorder, and there should be a demonstrable benefit to starting treatment before clinical symptoms appear and the diagnosis is made on clinical grounds. 4. The test should be possible from the spot of blood obtained on the NNS card.
Sampling
Screening is mandated by Iowa State Law [Code of Iowa, Chapter 4:641 (136A)]. The ultimate responsibility for screening newborns rests with the attending physician. Should a parent refuse the test, they must sign a waiver form which is available in the Nursery. This waiver shall become a part of the medical record and a copy sent to the Birth Defects Institute of the Department of Public Health. The information portion of the screening form will be filled out by the ward clerk. The circles on the filter paper should be filled almost to the black lines. At present, one additional drop of blood should be added. Each circle should be filled with a single large drop of blood obtained by heelstick or from an indwelling catheter. Multiple small drops will result in layering, which will give inaccurate results. Blood obtained through an umbilical catheter is not acceptable for testing if medications or parenteral nutrition solutions have recently been administered. Screening should be done prior to discharge, ideally no sooner than 48 hours after birth (to allow phenylalanine levels to rise) and before 5 days. Repeat screen immediately if: 1. specimen rejected because of poor quality, insufficient blood, slip is incomplete or give incorrect demographic data. 2. a presumptive positive on previous screen. Repeat by 14 days if first NNS: 1. done at < 48 hr. age - test for PKU and MSUD may be false-negative as blood levels for the amino acids may be normal at birth. 2. Infant on antibiotics - must wait 24 hours after last dose to repeat NNS. If the infant is to go home before twenty-four hours, the repeat test should be performed at the time of discharge, and an additional repeat screening should be performed by the infants
physician by 14 days age. Multiple births may affect test results. Be sure to indicate - especially if twin-twin transfusion involved. Transfusions
q q
can potentially affect all tests. re-test 6 weeks after last transfusion to be certain of test results.
If positive results
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the patients UIHC physician will be notified by the University Hygienic Laboratory. confirmatory diagnostic tests and treatment should follow.
Hemoglobinopathies
A very complicated group of diseases that involve defects in the kind or the amount of hemoglobin in red blood cells. Early detection identifies families at risk for having future affected children and allows early treatment of affected infants. The major disorders of clinical significance in the US are sickle cell disease and hemoglobin C disease. Iowa detects abnormalities in the a and b chains including:
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Hemoglobin-S, C, E, O, G, and D. Also detects Barts hemoglobin in a-thalassemia.
Because of the high levels of hemoglobin F at birth, it may be difficult to accurately quantitate the hemoglobins. However, identification of hemoglobin S, C etc., defines a group of infants who should have a quantitative electrophoresis repeated at 3 - 6 mo. age. The test is done by isoelectric focusing and confirmed by high pressure liquid chromatography (HPLC). The test is affected by red blood cell transfusions and should not be performed within 6 weeks following a transfusion.
Phenylketonuria (PKU)
Incidence: 1 in 10-15,000 births. Autosomal recessive. Deficiency of liver enzyme phenylalanine hydroxylase (PH) that metabolizes phenylalanine to tyrosine. Gene for PH is on chromosome 12q, with > 20 different mutations identified. Screening: Currently, all 50 states screen newborns for this disease. Phenylalanine levels are normal in the cord blood of neonates and only rise after milk feedings have been initiated, hence screens obtained prior to 48 hours may give false negative results. In cases of infants discharged before 24 hours, most states recommend that a sample be obtained at discharge and subsequently repeated. In the case of sick newborns, who are not being fed, the initial newborn screen should not be withheld indefinitely but should be submitted at the recommended time, because screening for some other disorders, such as hypothyroidism is not affected by the feeding history. After feedings are started, a repeat screen should be submitted for PKU. Since a bacterial inhibition assay is used for screening, antibiotics given to the infant can interfere as well, hence screens should be repeated 24 - 48 hr. after stopping antibiotics. Spectrum: Severe deficiency - classical form; Milder deficiency - variant forms Pathophysiology: Leads to accumulation of phenylalanine and its metabolic byproducts in the blood and urine of affected individual. The urine of affected individuals has a peculiar musty odor. Brain
myelination is abnormal. PKU should be considered in an infant who loses developmental milestones in the first 6 to 12 months of life. Treatment: Dietary restriction of phenylalanine is highly successful in preventing mental retardation, but the diet is unpalatable. A special formula (Lofenalac) low in phenylalanine is utilized in order to provide other necessary nutrients. However, Lofenalac alone is not an adequate diet for any infant, including infants with PKU, and caution should be exercised in placing children on low phenylalanine diets unless the diagnosis has been clearly established, and only after consultation with a center experienced in the management of PKU. Dietary restriction was once maintained for 5 to 6 years of age and then discontinued. However, some patients exhibited neurologic deterioration and loss of IQ points after discontinuation of the diet. In addition, this leads to potential adverse effects of maternal metabolic derangementis on fetal growth and development. Treatment is now maintained indefinitely in most cases. Maternal PKU: In the past, patients with PKU were severely retarded and did not reproduce. This changed completely with the initiation of newborn screening and early dietary management. It is especially important that affected women resume a strict dietary avoidance of phenylalanine prior to, during, and after pregnancy (esp. for those wishing to breast feed their infants), so that the fetus/infant does not see abnormally high levels of phenylalanine. For anyone who has been on a normal diet, the phenylalanine-restricted diet is a onerous diet, and is a very difficult goal to achieve. The maternal metabolic environment in this condition has extremely harmful effects on fetal development. Over 90% of infants of these mothers (most of whom do not themselves have PKU) are affected. These infants exhibit mental retardation (>90%), microcephaly (72%), growth retardation (40%), congenital heart disease (12%). The risk of these abnormalities is correlated with the mothers blood phenylalanine level.
Galactosemia
Incidence: 1 in 50-75,000 births, or 2 infants in Iowa per year. Autosomal recessive. Pathophysiology: Deficiency of either i. galactose-1-phosphate uridyl transferase (GPUT) or ii. galactokinase (GK) or iii. uridine diphosphate galactose-4-epimerase Galactose ----GK^ Gal-1-P + UDPG ----GPUT^ glucose-1-P + UDP-galactose Classical galactosemia generally presents in the newborn period with failure to thrive, jaundice, hepatomegaly and renal failure. If unrecognized, death may result by 4 to 10 days of age, or a chronic course of cirrhosis, cataracts (w/ galactokinase deficiency), brain damage, seizures, and mental retardation may ensue. Liver biopsy shows marked fatty accumulation in hepatocytes and fibrosis that may be quite extensive even in the first weeks of life. Newborns have a greater risk of infection (esp. E-coli sepsis) if treatment is delayed. The screening test is done by Beutler immunofluorescence and is affected by transfusions, as the RBCs contain the enzyme necessary for glycolysis. Dried blood disks are mixed with Gal-1-P and UDPG, and if the reaction is completed by GPUT from the infants blood, NADPH is made and detected by fluorescence. Note, this test does not detect galactokinase or epimerase deficiency, but will detect transferase deficiency regardless of prior dietary intake of galactose. Treatment: A positive test should be treated as a medical emergency. Immediately institute a strict diet low in lactose, galactose and milk solids (e.g. soy formula). Confirm diagnosis quickly by direct enzyme and galactose-1-phosphate measurement in red cells, and test for presence of urine
reducing substances. It is very difficult to maintain strict dietary restriction because of the ubiquitous use of lactose as a food additive. Dietary treatment should be continued throughout the persons life.
Hypothyroidism
Incidence: 1 in 5000 births, or 9 infants/yr. in Iowa; In North America, Female : male is 2 : 1. Pathophysiology: A variety of disturbances of morphogenesis involving the hypothalamic-pituitary axis and the thyroid gland may result in congenital deficiency of thyroxine. If undetected, the deficiency results in severe mental and growth retardation. Initial signs appearing over the first few weeks of life include lethargy, hypothermia, hypoactivity, hypotonia, large anterior and posterior fontanels, poor feeding, respiratory distress (myxedema of the airway), perioral cyanosis, pallor, poor or hoarse cry, mottled skin, constipation, and prolonged physiologic jaundice. The classic features of cretinism usually appear after 6 weeks of life, including the typical facies (depressed nasal bridge, narrow forehead, puffy eyelids, thick dry cold skin, coarse hair), abdominal distention, umbilical hernia, and large cranial fontanels. Test done by radioimmunoassay - T4 assayed as initial screen; each day bottom 5 -10% are assayed for TSH. False positives occur frequently in LBW and premature infants. Indications for re-testing: (normal level of T4 7 -10 mcg/dl in infants)
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T4 5-7 mcg/dl with normal TSH (<20) - repeat q month until T4 > 7 T4 3-5 mcg/dl with normal TSH - repeat q 14 d until > 5, then every month until > 7 T4 < 3 mcg/dl - obtain serum T4, free T4 and TSH
Treatment: The prognosis and outcome are greatly improved by early diagnosis and treatment with thyroid hormone replacement begun prior to 3 months of age. Confirmatory testing for primary hypothyroidism should be done prior to 3 weeks of age.
Maple Syrup Urine Disease (MSUD)

Incidence: 1 in 150,000 - 206,000 births, or 1 infant in Iowa every 1 to 4 years. Pathophysiology: Branched chain ketoacidemia due to congenital deficiency of branched-chain ketoacid dehydrogenase (BCKD) that initiates degradation of branched-chain amino acids (BCAA) leucine, isoleucine, and valine. Urine has a sweet syrupy odor. If untreated the severe neonatal form leads to poor feeding, vomiting, tachypnea or irregular respirations, ketoacidosis, hypoglycemia and progressive neurologic dysfunction - rigidity alternating with periods of lethargy, or seizures, and often death. If the patient survives the initial episode, the disorder leads to severe mental and motor retardation, growth failure, hypertonia and seizures. The disorder is fatal if not appropriately treated. Death can occur by 4 to 7 days age due to acidosis and hypoglycemia. Test done by bacterial inhibition assay; test can be affected by antibiotic use. Confirm diagnosis by specific blood and urinary testing looking for the characteristic large amounts of these three amino acids in the blood, and the urinary a ketoacids and organic acid patterns. Treatment: Given the rapid onset of this disease, immediately institute a special diet with reduced BCAA
intake (amino-acid mix free of leucine, isoleucine, and valine) with added oil and dextromaltose. Since a minority of patients have thiamine-responsive defects some cases, supplementation with pharmacological doses of thiamine, a co-factor for the first component of the enzyme BCKD, is recommended. In practice, these patients require complex treatment and should immediately be referred to a center experienced in the management of patients with MSUD.
Congenital Adrenal Hyperplasia (CAH)

Incidence: 1 in 12,000-14,000 births Pathophysiology: Deficiency or abnormal form of one of five enzymes involved in adrenal steroid synthesis - leads to inability to synthesize the stress hormone cortisol, causing a secondary increase in ACTH. ACTH in turn stimulates adrenocortical hyperplasia and increases adrenocortical steroidogenic activity in an attempt to normalize cortisol production. The 21- and 11b-hydroxylase deficiencies, and to a lesser extent deficiency of 3b-hydroxysteroid dehydrogenase) result in excess formation of precursors steroids, which leads to excess androgen production that induces masculinization of affected female fetuses in utero. Affected females (pseudohermaphroditism) should be identifiable at birth. Affected males with 21- or 11b-hydroxylase deficiency will develop penile enlargement or other virilization postnatally if untreated. Affected males with 3bhydrosteroid dehydrogenase deficiency will have ambiguous genitalia because of testosterone deficiency. Except for 17b-hydroxylase, the five enzymes involved in the synthesis of cortisol from cholesterol are also necessary for mineralocorticoid (aldosterone) biosynthesis. 21hydroxylase deficiency is the most common cause of CAH accounting for 90% of cases. Three forms are recognized. Two forms are seen in neonates - a simple virilizing form (partial deficiency), and a salt losing form (a more complete deficiency) that may present at 1 - 2 weeks age with adrenal crisis, history of poor feeding and vomiting, and have profound hyponatremic dehydration, acidosis, hypoglycemia, and hyperkalemia. There is also a late-onset very mild enzyme deficiency that does not have clinical manifestations in the fetus, neonate, or infant. Test is done by radioactive immunoassay - quite accurate False positives seen in premature infants - Re-test them as soon as possible Treatment: Provide physiological replacement of end products (cortisol, aldosterone, gonadol sex steroid), i. e. cortisone, hydrocortisone, florinef, sodium supplementation etc. Section Top | Title Page
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Neonatal Transport to University of Iowa Hospitals & Clinics

Edward F. Bell, M.D. and Lou Ann Montgomery, PhD, R.N., C.C.N.S., C.C.R.N.
Jaundice Pulmonary Neurology Metabolic Fluid Management Feeding Infection Hematology Pharmacology Procedures Abbreviations Commonly Used in the Nursery
I. The neonatologist will page the primary call transport nurse on beeper 3210 and notify the nursing unit of the admission. II. The primary call transport nurse will: A. Take report from the physician. B. Consult with the neonatologist regarding the preferred mode of transport. C. Contact the Air Care dispatcher (353-6440), inform dispatcher of preferred mode of transport, and request dispatcher assistance in assembling team. D. Inform the pediatric nursing supervisor of the transport, admission unit, and expected time of arrival at University of Iowa Hospitals and Clinics. III. The Air Care dispatcher will call: A. Second call transport nurse (beeper #4645 7:00 AM - 3:00 PM or beeper #3210 3:00 PM - 7:00 AM). B. Respiratory therapist (for ground transport). C. Driver or pilot as requested. NOTE: The call schedules for respiratory therapy and the second call nurse will be in the dispatcher's office. Any changes in the schedule will be communicated to the Air Care dispatcher. IV. The transport team will assemble at the Air Care dispatcher's office within 20 minutes. V. The primary call transport nurse will contact the referring hospital and obtain nursing report and patient registration information by completing the Neonatal Pre-Transport Information Sheet. An ETA will be given to the referring hospital. VI. Upon admission to the NICU or Intermediate Care Nursery, a referring physician callback card will be stapled to the front of the baby's chart by the unit clerk (or physician if no unit clerk is available). This card shows the referring physician's name and phone number and is used to document telephone reports by our staff to the referring physician. Calls to referring physicians are the responsibility of the staff physician (unless delegated to the fellow or resident). The frequency of such calls depends on the patient's condition and may vary from daily (for the newly admitted critically-ill infant) to monthly (for a long-term chronically-ill infant). Section Top | Title Page
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Transfer of Infant to Referring Hospital from University Of Iowa Hospitals & Clinics (back-transport)
I. The following procedures must be completed (when applicable) before the physician schedules a transfer back to referring hospital. A. ROP check B. Hearing screening C. Newborn metabolic screen D. Subspecialty consultations E. Special tests (i.e., chromosomes) II. The physician will contact the social worker (beeper 3885) to verify the availability of funds to pay for transfer. III. The physician must obtain from the parent(s) permission for transfer (written or by a monitored phone call). IV. The physician will contact the infant's local doctor to arrange the transfer. V. A typed discharge summary MUST be signed by the resident and staff physician and on the baby's chart by 0800 on the day of the transfer. VI. The discharge card should be signed by the discharging nurse and return appointments scheduled. VII. To schedule a transfer the PL2 or PL3 resident should call Nancy Krutzfield, Neonatal Transport Coordinator, on pager 4645, or her backup on pager 3210 . A. The transfer must be arranged no later than 1200 the day before the desired transport date. Monday transfers should be arranged by 1200 the previous Friday. B. Transfers will normally leave at 8:30 AM Monday through Friday. VIII. The parent(s) and the infant's physician will be called to inform them of the transfer schedule. IX. The transfer will be cancelled if any of the above procedures has not been completed before the scheduled transfer. Section Top | Title Page
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Nonviable Infant Admission Protocol

Edward F. Bell, M.D. and Lou Ann Montgomery, PhD, R.N., C.C.N.S., C.C.R.N.
I. The following protocol will be followed by NICU and Ob-Gyn/Labor & Delivery: A. An infant of 20 weeks gestation or more with an Apgar score of one or more at any time after delivery is considered liveborn, regardless of whether the patient dies in the Delivery Room or NICU and regardless of whether the pediatric team was in attendance. B. An infant with an Apgar score of zero at all times after delivery is considered stillborn and will be entered into Labor & Delivery statistics, but not admitted to the NICU. II. For liveborn but nonviable infants: A. If the infant is physically admitted to the NICU: A. The NICU unit clerk will: a. Notify UIHC Registration of the infant's birth and obtain a hospital number. b. Admit the patient to the NICU by entering the hospital number and patient data into the UIHC computer system and the census book. Discharge the infant as a death on the computer and census book. c. Enter the appropriate data into the Neonatal Registry field on the UIHC computer system (using gestational age by dates). d. Assemble a chart which will include a record of labor and delivery, white identification card, doctor's notes, including Delivery Room resuscitation if required, and other pertinent information. B. Nursing personnel will: a. Complete the admission assessment form. b. Notify Central Nursing Office and the pediatric nursing supervisor of the infant's death. C. The pediatricians will complete the physician's note. B. If the infant is not physically admitted to the NICU (regardless of whether pediatrics physicians or nurses ever attended the infant): A. The nursing unit clerk from Labor & Delivery will: a. Notify UIHC Registration of the infant's birth and attain a hospital number. b. Admit the infant to Labor & Delivery on the UIHC computer system and discharge by computer when infant dies. c. Enter the appropriate data into the Neonatal Registry field on the UIHC computer system (using gestational age by dates). d. Assemble a chart for the infant. e. Notify Central Nursing Office of the infants death. B. If a pediatric physician provides any assessment or treatment, a note will be written for inclusion in the infants medical chart. C. The physician in attendance at the time of death, regardless of department, will be responsible for completing the chart. D. Labor & Delivery personnel will be responsible for notifying Central Nursing Office of the infant's death. Section Top | Title Page
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Guidelines for Pediatric Attendance in the Delivery Room

I. Personnel in Attendance: A. A pediatric team should be present at ALL high-risk deliveries. All deliveries that are high-risk will be listed on the board in the NICU. In addition, the pediatric team will attend any other deliveries when requested to do so by the obstetric staff. B. The pediatric resident will be notified of a high-risk delivery ahead of time so that s/he may familiarize himself with the mother and her problem in order to prepare for the type of neonatal emergency care that might be required. The pediatric resident and the NICU should be given an approximate expected time of delivery. C. The most senior pediatric resident available will attend all high-risk deliveries (PL3 assigned to the NICU during the day and PL-2 assigned to the NICU during the night). At night or on weekends the PL-2 in the NICU will notify the PL-3 covering the hospital prior to all high-risk deliveries. The attending neonatologist (or fellow) in the NICU will decide on a case-by-case basis which members of the pediatric team should attend each high-risk delivery. At least twice daily, the cases on the high-risk board in the NICU will be reviewed with the supervising resident: in the morning with the PL3, and in the evening with the PL2. The attending neonatologist will determine whether fellow or faculty attendance at the delivery is advisable. A neonatal intensive care nurse will accompany the resident, as well as an intern. D. The delivery of an infant equal to or less than 1500 grams is a special situation. The infant who is less than 1500 grams should be resuscitated by the most skilled person available. Time is critical. Therefore, intubation will generally be performed by the PL-3 or PL-2. There are many other opportunities for the intern, either pediatric or obstetric, or the family practice resident to gain skills in the intubation of larger infants. Free, frank communication should take place prior to the delivery so that each person understands his role. The senior pediatric resident will decide on the timing of transfer to the NICU. E. Pediatric personnel should be present in the delivery room to assist with effective resuscitation even in certain borderline situations when the obstetric staff have decided against fetal intervention. If the estimated gestational age on a "23 week er" is wrong, for example, and a depressed "26 weeker" is delivered, an immediate and full resuscitation effort is required. F. ALL pediatric personnel who attended a resuscitation should be listed on the Labor and Delivery Record (form B-13) placed in the infant's chart. In addition, if the resuscitation was attended by the staff neonatologist, a stamped procedure note entitled "Delivery Room Resuscitation" should be placed in the chart with the physician's admission notes; this procedure note should be signed by the neonatologist. II. Equipment A. A resuscitation tray will be kept stocked and available in the NICU at all times. It will be the responsibility of the NICU nurse who is attending the delivery of a high-risk infant to take this tray with her. Items on the resuscitation tray should include: A. 2 each ET tubes: 2.5, 3.0, 3.5, 4.0 B. 1 MEC ET tube pack C. 2 stylets D. 250 cc anesthesia bag and masks (1 preemie; 1 newborn) E. 1 oxygen connecting tubing F. 1 roll adhesive tape G. 1 roll 1/4" yellow tape
1 can adhesive spray 2 laryngoscope handles 2 Miller 0 blades 1 Miller 1 blade 2 scissors (sterile) 1 steri-drape 1 hemostat (sterile) Suction equipment q 1 bulb syringe q 2 DeLee traps q 2 8 fr suction catheters q 1 8 fr suction catheter with glove q 1 6 fr suction catheter with glove q 2 sterile gloves q 4 sterile sims connectors q 4 RT saline (5 ml) P. NG tubes q 2 8 fr q 2 5 fr Q. Umbilical arterial catheters q 2 3 1/2 Fr q 2 5 Fr R. Needles and syringes q 2 25 gauge short butterflies q 2 23 gauge long butterflies q 2 25 gauge needles q 2 22 gauge needles q 2 20 gauge needles q 2 18 gauge needles q 2 20 gauge IV catheters q 2 22 gauge IV catheters q 2 24 gauge IV catheters q 1 20 cc syringe q 1 10 cc syringes q 2 3 cc syringes q 2 1 cc syringes S. Medications: q 2 NaHCO3 q 1 Atropine Sulfate q 1 Epinephrine 1:10,000 q 1 Plasmanate q 1 Calcium Gluconate 10% q 2 Narcan (Naloxone Hydrochloride) (0.4 mg/ml OR 1.0 mg/ml solution) q 1 Sterile Saline for injection T. Other q 1 razor q 4 #11 blades q 10 black caps q 2 4x4's q 1 needle aspiration pack q 2 Stopcocks q 10 Alcohol preps B. Each of the radiant heater beds is equipped with a portable oxygen tank. Following resuscitation and stabilization, the infant should be transferred to the NICU on the heater bed, not in the arms of the House Officer. Section Top | Title Page
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H. I. J. K. L. M. N. O.
Iowa Neonatology Handbook: Pulmonary

Comments on Oxygen Toxicity and Retinopathy (ROP) in the Premature Infant

Edward F. Bell, M.D. and Jonathan M. Klein, M.D.
In the newborn period, an infant may require an increased ambient oxygen concentration in order to maintain a normal arterial blood oxygen tension. There appears to be a relationship between a higher than normal oxygen tension in the retinal arteries and retinopathy of prematurity (ROP). Susceptibility to ROP is increased in the preterm infant. An FiO2 of 0.4 or lower may be sufficient to raise the retinal artery oxygen tension to a dangerous level in many infants. Therefore, when an infant's clinical condition requires an oxygen enriched environment, frequent measurements of arterial blood gases and pH are mandatory. I. The normal PaO2 in utero is 30 mm Hg, while a normal infant breathing room air will have a PaO2 of 60-100 mm Hg. II. The PaO2 of a premature infant in oxygen enriched environment should not exceed 80 mm Hg and should be maintained between 50-70 mm Hg. An arterial oxygen tension of 40-50 mm Hg may be adequate, providing cardiac output and peripheral perfusion are normal. A term infant may require a PaO2 of 55-70 mm Hg to be adequately oxygenated. III. An infant requires the measurement of arterial blood gases and pH as frequently as demanded by the clinical status. When the condition is rapidly changing, measurements must be performed more frequently. IV. When an infant is placed in an oxygen enriched environment, the FiO2 delivered to the infant must be measured by an oxygen analyzer at least once an hour. V. Mixtures of oxygen and air delivered to an infant by endotracheal tube, nasal CPAP, hood, or incubator should be warmed and humidified. VI. An infant recovering from Respiratory Distress Syndrome should have the FiO2 lowered in steps of no more than 0.10 at intervals of not less than 15-20 minutes, or with the use of continuous pulse oximetry, the FiO2 can be decreased at a faster rate as long as the O2 saturation remains within acceptable limits. An infant with chronic lung disease, especially those requiring oxygen therapy for more than 5-6 days, may require lowering of the FiO2 in steps of 0.02 0.05. VII. Exposure of the infant's eyes to bright light should be minimized.

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Handbook Home General Temperature Jaundice Pulmonary Neurology Metabolic Fluid Management Feeding Infection Hematology
ROP Surveillance
Ronald V. Keech, M.D. and Edward F. Bell, M.D.
Because of the continuing incidence of ROP, certain infants must have their fundi examined by an ophthalmologist prior to discharge from the hospital. The PL1 resident or PNP should fill out a blue consultation sheet on the following patients at the appropriate time (see below). Physician Guidelines for the Evaluation of Infants at Risk for Retinopathy of Prematurity Any one of the following criteria qualifies the patient for ROP screening
q q q
Infants with a birth weight of <1500 grams Infants with an estimated gestational age at birth of < 32 weeks Infants who do not meet the first two criteria but are deemed at risk due to other medical conditions
Method for Determining the Timing of the first ROP examination

Pharmacology
q
Procedures
q
For infants born at < 27 weeks gestation: first eye exam at 32 weeks postnatal age (gestation age at birth + chronologic age). For infants born at > 27 weeks gestation: first eye exam at five weeks chronological age.
If the infant qualifies for an ROP screening but is to be discharged or transferred before the normal time for the first examination, then use the following guidelines: If the scheduled discharge or transfer date is within two weeks of the designated time for the first ROP examination (see above), arrange for the ROP examination to be performed before discharge. If the scheduled discharge or transfer date is more than two weeks before the designated time for the first ROP examination, then recommend a date for the first examination based on the standard criteria and include it on the ROP discharge form (Form #__). Section Top | Title Page
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Iowa Neonatology Handbook: Temperature

Detection and Management of Abnormal Body Temperature

The normal axillary temperature of a newborn infant, if correctly measured for 5 minutes, is from 36.5 to 37.4C (mean + 1.5 S.D.). This range should be applied to both the term and premature infant. If measured for a shorter period (less than 5 minutes), the normal range is somewhat lower but has not been clearly defined. In order to avoid the incorrect diagnosis of hypothermia, an axillary temperature below 36.5C should only be recorded and reported to the physician if read after the thermometer has been held in place for a full 5 minutes. If the axillary temperature is above 37.4C (or rectal temperature above 37.5C), it is important to decide whether the infant has a fever or environmental hyperthermia. With fever, as seen sometimes with infection, the hypothalamic set point is elevated and the infant uses his thermoregulatory control systems to maintain a high body temperature. In some situations this high temperature may help to fight the infection. A febrile infant often has peripheral vasoconstriction with cool skin and extremities. An infant with a fever may be difficult to cool; in fact, it may be undesirable to lower axillary temperature to normal if the skin is already cool. First, it is important to record both skin (probe) and axillary temperature of a febrile infant as well as the air temperature for the infant in an incubator. If the skin temperature is 36.0 to 36.5C and the axillary (or rectal) temperature is 38.0C or less, the thermal environment should not be changed. If necessary, the skin temperature set point can be lowered to 35.5 or even 35.0C in order to keep the axillary temperature below 38.0C. If a skin temperature of less than 35.0C is required to keep the axillary temperature below 38.5C, the fellow or staff neonatologist should be consulted. The infant with environmental hyperthermia should be cooled to a normal axillary temperature by decreasing environmental heating or reducing thermal insulation (blankets or clothing). A bath or cooling mattress should not be necessary to correct hyperthermia caused by environmental overheating. An infant with hypothermia can be rewarmed by a radiant heat or an incubator with higher air temperature. The simplest way to avoid overheating during rewarming with a radiant warmer is to use the skin temperature servocontrol with a set point of 36.5C. The rate of rewarming is probably not critical. Reference: Mayfield SR, Bhatia J, Nakamura KT, Rios GR, Bell EF. Temperature measurement in term and preterm neonates. J Pediatr 1984;104:271-275. Section Top | Title Page
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Servocontrol: Incubator and Radiant Warmer

I. Careful attention to providing the best possible thermal environment increases the chance of survival and the quality of outcome, particularly in the small premature infant. Servocontrol is an electronic feedback system which functions as a thermostat to maintain a constant temperature at the site of a thermistor probe (usually on the skin over the abdomen) by regulating the heat output of an incubator or radiant warmer. Maintaining a constant abdominal skin temperature between 36.0 and 36.5C is the simplest way to provide a "thermoneutral" environment, minimizing the number of calories needed to maintain normal body temperature and reducing the risks of cold stress or overheating. Although either skin or air temperature control can be used safely for most infants, skin temperature servocontrol is probably better for very young, small (below 1500 g) infants because the desired control temperature is more easily determined. Servocontrol is the only acceptable method of heat regulation for the infant cared for under a radiant warmer. II. The following guidelines apply to both the incubator and radiant warmer: A. Insert probe plug securely into hole in heater unit. B. Choose the desired abdominal skin temperature, usually 36.5C. Some older infants will require a lower set point, e.g., 36.0C to avoid overheating. C. Check the setting of the control panel. Adjust if necessary. D. Attach the probe to the exposed abdominal skin at mid-epigastrium, halfway between the xiphoid and the umbilicus. If the infant is prone, attach the probe to the skin over either flank (not between the scapulae). The probe should not be placed in the axilla. E. Under the radiant warmer, protect the probe with a foil-backed shield. F. Read the skin temperature from the temperature gauge on the heater unit. If it registers below the set point (36.5C), the heater should be on. Check the heater indicator light or dial. If the heater is not on, check all connections. G. If the skin temperature does not rise as quickly as you think it should, make sure the heater is on and WAIT. Increasing the set point will not cause faster warming. H. When the abdominal skin temperature reaches the chosen set point, check the axillary or rectal temperature to be sure it is within the normal range (36.5 to 37.4 C). I. Adjust the set point slightly if the axillary (or rectal) temperature is abnormal. Do not change the set point if the axillary (or rectal) temperature is normal. J. Check frequently to be sure the probe is in solid contact with the skin. Poor contact will cause overheating. Entrapment of the probe under the arm or between the infant and mattress will cause underheating K. Record incubator air temperatures along with infant skin and axillary (or rectal) temperatures. A clearly decreasing (or increasing) trend in incubator temperature may indicate the development of sepsis or a neurological problem. Section Top | Title Page
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When and How to Move Babies from Radiant Warmer to Incubator, and from Incubator to Open Bed
I. Radiant Warmer to Incubator: Most newly-admitted infants are cared for on radiant warmer beds in order to provide accessibility for resuscitation or procedures without jeopardizing thermal stability. As long as an infant remains critically ill and is likely to require resuscitation or frequent procedures, he should be kept on a warmer bed. Most very small infants (<1000 grams) can be kept warm more easily on a radiant warmer than in an incubator, since incubator air temperature drops rapidly when the door is opened. If a very small infant has difficulty maintaining normal body temperature on a radiant warmer, plastic food wrap can be stretched across the bed (from side to side). This reduces the movement of cool air over the baby's body surface. When the condition has stabilized so that frequent procedures are not likely to be needed, an infant can be moved to a preheated incubator, on skin temperature servocontrol. Axillary temperature should be checked 30 minutes after moving the baby to the incubator, and every hour thereafter for four hours. The very small infant is at greatest risk of heat loss through an open incubator door. Whenever possible, procedures performed on a baby in an incubator should be performed through the ports (diaper change, vital signs, phlebotomy, etc.). Any infant who weighs less than 1000 grams should be cared for on a radiant warmer or in a servocontrolled double-walled incubator. If an infant consistently requires an air temperature above 37 C, it may be necessary to operate the incubator in the air temperature control mode to avoid periodic increases in air temperature to above 38 C, which may cause the heater to stop completely. Some infants who require a radiant warmer for temperature support may not need routine vital signs as often as other infants under radiant warmers. The frequency of vital signs may be reduced at the discretion of the infant's nurse and physician. II. Incubator to Bassinet: A. If an infant has been maintained in an incubator operated by skin temperature servocontrol, the incubator should be changed to air temperature servocontrol in the following manner, before attempting the move the infant to a bassinet. A. Change to air temperature servocontrol setting the control temperature to equal the average incubator air temperature during the previous 24 hours (from the nursing notes). B. Check the baby's axillary temperature in 30 minutes and each hour for four hours. C. If the axillary temperature remains normal (36.5 to 37.4C), disconnect and remove the skin probe if desired. B. When an infant reaches 1700 to 1800 grams, has no respiratory distress and only occasional apnea, and has been stable in an incubator operated in the air temperature control mode with air temperature 32C or less, an attempt can be made to move him to a bassinet as follows: A. Dress the infant in shirt and diaper and wrap him in a single blanket. Turn the air temperature control to 28C. B. Check the baby's temperature in 30 minutes and each hour for four hours. C. If the baby's axillary or rectal temperature drops to below 36.5C, reheat him in the skin temperature servocontrol mode until his skin temperature is 36.0C and return to manual or air servocontrol mode as described above (try again in two or three days). D. If the baby's temperature is stable for eight hours, bundle him in extra
blankets and move him to a bassinet. E. Check body temperature in 30 minutes and each hour for four hours; if the axillary or rectal temperature drops to below 36.5C, return infant to incubator, reheat on skin temperature servocontrol as described above, then revert to air temperature control; try again in two or three days. Reference: Bell EF. Infant incubators and radiant warmers. Early Hum Dev 1983;8:351-375. Section Top | Title Page
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Iowa Neonatology Handbook: Jaundice

Management of Hyperbilirubinemia in the Newborn Period

I. Hyperbilirubinemia is an extremely common problem occurring during the newborn period. The etiology of the jaundice is quite varied; although most causes are benign, each case must be investigated to rule out an etiology with significant morbidity. II. Since 97% of term babies have serum bilirubin values <13 mg/dl, all infants with a serum bilirubin level >13 mg/dl require a minimum work up. Other criteria of non-physiologic jaundice are visible jaundice on the first day of life, a total serum bilirubin level increasing by more than 5 mg/dl per day, a direct serum bilirubin level exceeding 1.5 mg/ dl, and clinical jaundice persisting for more than 1 week in term babies (may persist longer in breast-fed infants). III. Following the identification of an icteric infant, the maternal and preceding neonatal history are reviewed. After a complete physical examination, the following is the minimal work up necessary in each infant: serum bilirubin level (both direct and indirect) CBC with smear, and infants blood type and Coombs' tests; if not recorded on the maternal chart, a maternal sample should be sent for type and Coombs. A urinalysis, and urine testing for reducing substances should be done only if sepsis, urinary tract infection, or galactosemia is suspected. Be particularly aware that infants with ABO incompatibility may have extremely rapid increases in their serum bilirubin values. As such the frequency of monitoring their bilirubin levels may need to be more frequent (see table below). IV. Suggested guidelines for frequency of monitoring serum bilirubin in healthy term infants are as follows: Days of Age 1 Visibly Jaundiced Serum indirect biliribuin* (mg/dL) on do total & direct bilirubin repeat in 3-5 hr repeat in 34hr; notify staff/fellow repeat in 2-3 hr discuss exchange transfusion with staff 2 Transcutaneous Bilirubinometer repeat x 1 in 8-12 hr 3 Transcutaneous Bilirubinometer repeat Transcutaneous Bilirubinometer repeat in 6-8 hr
5-10
10-15
repeat in 4-6 hr repeat in 2-4 hr; notify fellow/staff
day specified 15-20
repeat in 4-6 hr
>20
repeat in 2-3 hr;
repeat in 3-4 hr; notify fellow/staff
* If direct bilirubin is <1.5 mg/dL, may use total bilirubin Anticipates peaking of serum bilirubin at 72 hours Shaded area = consider institution of phototherapy In infants found to be clinically jaundiced during the first 2-3 days, it is helpful to document the rate of rise in the serum bilirubin level. A rise of >0.5 mg/dl per hour may indicate brisk hemolysis. V. The need for phototherapy or exchange transfusion is an individualized decision influenced by the following factors: gestational age, weight, clinical condition, and
etiology of the hyperbilirubinemia. Check a bilirubin level prior to discontinuing phototherapy and a rebound level 8-12 hours later. Phototherapy should be used sparingly in healthy term infants because they are at low risk of kernicterus. Phototherapy is used more liberally in sick, preterm infants, in whom the risk of kernicterus is less clearly defined. VI. Jaundice in a breast-fed infant is not normally an indication for stopping or interrupting breastfeeding. Special note must be taken of the drugs administered to the mother who is breastfeeding since it is known that drugs can be excreted in human milk and will have potential for absorption in the infant and competition for the bilirubin binding sites on albumin in the newborn. This may alter exchange criteria. Infants receiving phototherapy may continue to be breast-fed or bottle-fed by their mothers. The need for water supplementation should be decided by monitoring weight changes and urine specific gravity. VII. Full-term Caucasian infants in the normal newborn nursery with clinical jaundice should be screened for hyperbilirubinemia by transcutaneous bilirubinometry. When the transcutaneous bilirubinometer reading on the sternum is 19 or greater, a serum bilirubin level will be obtained. Transcutaneous bilirubinometry cannot be used in preterm infants, infants receiving phototherapy, or in non-Caucasian infants. Management of Hyperbilirubinemia in the Healthy Term Newborn TSB* Level, mg/dL (mol/L) Exchange Transfusion if Intensive Phototherapy Phototherapy Fails 15 (260) 18 (310) 20 (340) 20 (340) 25 (430) 25 (430) Exchange Transfusion and Intensive Phototherapy 25 (430) 30 (510) 30 (510)
Age, hours 24 25-48 49-72 >72
* TSB indicates total serum bilirubin. Intensive phototherapy should produce a decline of TSB of 1-2 mg/dL within 4-6 hours and the TSB level should continue to fall and remain below the threshold for exchange transfusion. If this does not occur, it is considered a failure of phototherapy. Term infants who are clinically jaundiced at 24 hours old are not considered healthy and require further evaluation. Appended from American Academy of Pediatrics, Provisional Committee on Quality Improvement. Pediatrics 94:558-565, 1994. Section Top | Title Page
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Iowa Neonatology Handbook: Jaundice

Use of Phototherapy
I. Infant receiving phototherapy should be left unclothed except for eye protection (mask) and a diaper. Care should be taken to ensure that the mask is not too loose such that it can slip over the nose and obstruct respiration. To increase the area of skin exposed to light the diaper may be omitted by a physician's order in cases where it is desirable to lower plasma bilirubin more quickly (required because diaper protects gonads from potentially harmful exposure to light). To keep control over the mess that loose phototherapy stools can cause, a surgeons face mask may be used as an alternative to a diaper. II. To monitor the potential for increased insensible water loss occurring with the use of overhead phototherapy, daily weights and urine output should be monitored every shift. III. The output of the phototherapy units will be monitored by the nursing staff with a Bilimeter (Olympic Mark II ) as follows: A. The phototherapy unit should be placed 40 cm above the infant and have a plexiglass shield between the light bulbs and the infant. B. Connect sensor head to Bili-meter and set range switch to 0.1 - 19.9. C. Place the Bili-meters sensor head on the infant's abdomen (if supine) or back (if prone) and aim toward the center of the phototherapy light. D. Press the "READ" button and record reading in microwatts per square centimeter per nanometer. For example, if the display reads 7, the reading is recorded as 7 w/ cm2/nm. In the unusual situation where the display blinks rhythmically, it means that the reading is above 19.9. For adequate phototherapy, the display should read between 7 and 12 w/cm2/nm. E. If adequate reading is not obtained, replace bulbs and repeat procedure. F. Monitoring of the phototherapy lights will be performed every 48 hours. IV. Phototherapy blankets instead of phototherapy lights should be considered for extremely premature infants who require phototherapy. Use of phototherapy blankets should reduce inadvertent exposure of the developing retina to bright ambient light, a putative factor in retinopathy of prematurity. References: Maisels MJ, Conrad S. Transcutaneous bilirubin measurements in full-term infants. Pediatrics 1982;70:464-467. Hyperbilirubinemia. In: Guidelines for Perinatal Care, Frigoletto FD and Little GA (eds). 1992, American Academy of Pediatrics, Elk Grove, IL, pp 208-210. Section Top | Title Page
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Management of Neonatal Apnea

I. Definition: Apnea is a "pause in breathing of longer than 10 to 15 seconds, often associated with bradycardia, cyanosis, or both." (Martin et al). Apnea at UIHC is defined as cessation of breathing for 20 seconds with the above symptoms. II. Sequelae: A. Apnea in premature infants can result in a failure of the mechanisms that protect cerebral blood flow, resulting in ischemia and eventually leukomalacia. B. During apneic episodes, in an attempt to protect cerebral blood flowcardiac output is diverted away from the mesenteric arteries resulting in intestinal ischemia and possibly necrotizing enterocolitis (NEC). III. Etiology: The most common cause of apnea in the NICU is apnea of prematurity, but first ALWAYS investigate and rule out the following disorders: A. Infection - Sepsis, especially in the first day of life, and nosocomial infections and/ or NEC in the first weeks of life B. Neurological - Intraventricular hemorrhage, intracranial hemorrhage, neonatal seizures, perinatal asphyxia, or other pathology which could lead to increased intracranial pressure C. Cardiovascular - Impairment of oxygenation from congestive heart failure and pulmonary edema (PDA, coarctation, etc.), or from shunting (cyanotic heart disease) D. Pulmonary - Impairment of oxygenation and ventilation from lung disease (surfactant deficiency disease, pneumonia, transient tachypnea of the newborn, meconium aspiration, etc.) E. Metabolic - Hypocalcemia, hypoglycemia, hyponatremia or acidosis F. Hematological - Anemia G. Gastrointestinal - NEC or gastroesophageal reflux H. Temperature Regulation - Hypothermia or hyperthermia I. Drugs - Prenatal exposure with transplacental transfer to the neonate of various drugs (narcotics, beta-blockers). Postnatal exposure to sedatives, hypnotics or narcotics. IV. Pathophysiology: Mechanisms of apnea of prematurity: A. Central Apnea - A pause in alveolar ventilation due to a lack of diaphragmatic activity. In other words, there is no signal to breathe being transmitted from the CNS to the respiratory muscles. This is due to immaturity of brainstem control of central respiratory drive. The premature infant also manifests an immature response to peripheral vagal stimulation. For example, stimulation of laryngeal receptors in the adult results in coughing. However, stimulation of these same receptors in the premature infant results in apnea. This reflex apnea can be induced by gavage feeds, aggressive pharyngeal suctioning and gastroesophageal reflux. B. Obstructive Apnea - A pause in alveolar ventilation due to obstruction of airflow within the upper airway, particularly at the level of the pharynx. The pharynx collapses from negative pressure generated during inspiration, because the muscles responsible for keeping the airway open, the genioglossus and geniohyoid are too weak in the premature infant. Once collapsed, mucosal adhesive forces tend to prevent the reopening of the airway during expiration. Neck flexion will worsen this form of apnea. Excessive secretions in the nasopharynx and hypopharynx may also cause obstructive apnea. C. Mixed Apnea - A combination of both types of apnea representing as much as
50% of all episodes. V. Surveillance: All newborns less than 34 weeks gestational age, or less than 1800 grams birth weight, should be monitored for both apnea and bradycardia. This is done by applying ECG leads to the chest which are connected to a bedside respiratory and heart rate monitor. An alarm should sound if respiration ceases for more than 20 seconds, or if the heart rate drops below 100 bpm. Bradycardia by itself is often a sign of obstructive apnea. No apnea alarm is sounded because the chest wall is moving even through air flow is absent. Also reflex apnea can lead to bradycardia within 2 seconds of onset, thus setting off the cardiac alarm 10 to 15 seconds ahead of the apnea alarm. VI. Management: A. Acute - When the alarm sounds, the infant should immediately be observed for signs of breathing and skin color. If apneic, pale, cyanotic or bradycardic, then tactile stimulation needs to be given. If the infant does not respond, bag and mask ventilation, along with suctioning and airway positioning, may be needed. B. Chronic - The management of apnea of prematurity always involves diagnosing and correcting other potential etiologies, before attributing a specific neonate's apnea to prematurity alone. The decision to initiate chronic therapy is based on clinical judgment. Factors to be considered include the frequency and duration of the episodes along with the level of hypoxia and the degree of stimulation needed. Chronic management of apnea of prematurity involves three major therapies: 1. Pharmacologic Therapy - The most common drugs used to treat apnea are the methylxanthines: Caffeine (1,3,7-trimethylxanthine) and Theophylline (1,3-dimethylxanthine) a. Mechanism of Action - Methylxanthines block adenosine receptors. Adenosine inhibits the respiratory drive, thus by blocking inhibition, the methylxanthines stimulate respiratory neurons resulting in an enhancement of minute ventilation. b. Dosages - The following is a guide to the initiation of medical therapy. Further dosing should be based on drug levels and clinical response. c. Caffeine Citrate - 20mg/ml containing the equivalent of 10 mg/ml of caffeine is available for either IV/po use. i. Loading Dose - 20 mg/kg/dose of caffeine citrate IV/po ii. Maintenance Dose - 5 mg/kg/day of caffeine citrate given QD iii. Plasma Half Life - 37-231 hrs iv. Therapeutic Level - 8-20 ug/ml v. Toxic Level - >30 ug/ml d. Theophylline: i. Loading Dose - 6 mg/kg/dose IV/po ii. Maintenance Dose - 6 mg/kg/day divided Q6H/Q8H/Q12H IV/po iii. Plasma Half Life - 12-64 hrs iv. Therapeutic Level - 6-12 ug/ml v. Toxic Level - >20 ug/ml vi. Administration - ALWAYS INFUSE SLOWLY over a minimum of 20 minutes. Rapid IV pushes have been associated with SUDDEN DEATH from CARDIAC ARRHYTHMIAS e. Major side effects - tachycardia, vomiting, feeding intolerance, jitteriness and seizures. f. Choice of Methylxanthine - This decision depends on the clinical situation and should take into account the following factors. Caffeine has a longer half life (QD dosing) and is less toxic. At UIHC, caffeine is preferred for the routine management of apnea of prematurity. Theophylline is a bronchodilator and in neonates with BPD it offers the advantage of treating both apnea and bronchospasm. 2. Continuous Positive Airway Pressure (CPAP) - CPAP is effective in treating both obstructive and mixed apnea, but not central apnea. CPAP is most commonly delivered by nasal prongs or by an endotracheal tube placed in the nasopharynx (see also separate section on CPAP). a. Mechanism of Action - Proposed mechanisms include alteration of the Hering-Breuer reflex (leading to higher lung volumes which minimize inspiratory duration and thus decrease the potential for
airway collapse by prolonging expiratory time). Furthermore, CPAP increases stabilization of the chest wall musculature and decreases activity of the intercostal inspiratory inhibitory reflex. However, the most likely explanation is that CPAP splints the upper airway with positive pressure during both inspiration and expiration, thereby preventing pharyngeal collapse b. Initial Settings - Use either nasal prongs or a nasopharyngeal tube to deliver a CPAP of 5 cm H20. Further adjustments should be based on clinical response. c. Side Effects - Barotrauma, nasal irritation, abdominal distention and feeding intolerance. Feeding difficulties can be minimized by switching the patient to continuous drip feeds. 3. Intermittent Mandatory Ventilation (IMV) - If significant apnea persists despite using both pharmaco-therapy and CPAP, the infant should be intubated and ventilated. Initial settings need to be clinically adjusted to prevent episodes of desaturation or cyanosis. In order to minimize barotrauma short inspiratory times should be used along with minimal peak inspiratory and expiratory pressures. The infant may need to remain on a minimal rate for a few weeks while the respiratory control system matures. VII. CONCLUSION: Apnea of prematurity is one of the most common and frustrating conditions that nurses, physicians and neonates face in the intensive care unit. A calm, rational team approach to this problem is beneficial for all involved. References: Higgins RD, Richter SE, Davis JM: Nasal continuous positive airway pressure facilities extubation of very low birth weight neonates. Pediatr 1991;88:999-1003. Marchal F, Bairam A, Vert P. Neonatal apnea and apneic syndromes. Clin Perinatol 1987;14:509-529. Hodson WA, Truog WE. Special techniques in managing respiratory problems. In: Avery GB, (ed). Neonatology: Pathophysiology and Management of the Newborn. 3rd ed., Philadelphia: JB Lippincott, 1987: 483-484. Martin RJ, Miller MJ, Carlo WA. Pathogenesis of apnea in preterm infants. J Pediatr 1986;109:733-741. Rall TW. Central nervous system stimulants. In: Gilman AG, Goodman LS, Rall TW, Murad F (eds): Goodman and Gilman's The Pharmacological Basis of Therapeutics, 7th ed., New York: Macmillan Publishing Company, 1985: 589-603.

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Nasopharyngeal Continuous Positive Airway Pressure (NPCPAP)

A technique of airway management that maintains positive intrapulmonary pressure in the lung during spontaneous breathing. I. The purpose of Nasopharyngeal CPAP is to reduce the morbidity due to barotrauma and subglottic stenosis from having a neonate intubated and mechanically ventilated because of respiratory failure or apnea. II. Indications for NPCPAP: A. Apnea of Prematurity - obstructive and/or mixed apnea. B. Respiratory Distress (i.e., tachypnea, and/or retractions) - RDS, TTN and chronic lung disease (CPIP and BPD). C. Weaning from the ventilator. III. Types of NPCPAP: A. Nasopharyngeal Tube - an endotracheal tube whose tip is placed in the nasal pharynx. 1. Advantages: a. May be used on any size infant. b. Minimal risk of nasal septum necrosis. c. Easy to place infant in any position. d. Preferred method at UIHC. 2. Disadvantages: a. May become occluded or plugged with secretions despite suctioning b. Higher resistance to spontaneous breathing. B. Nasal Prongs: 1. Advantages: a. Easier to apply (less traumatic). b. Lower resistance to spontaneous breathing 2. Disadvantages: a. Easily dislodged from nares. b. Nasal septal necrosis c. Difficult to position infant. IV. Complications of NPCPAP: A. Pneumothorax - minimize incidence by using minimal pressure needed to accomplish aims. B. Nasal irritation - mucosal swelling or erosion, excessive nasal dilatation or septal necrosis. Minimize by proper positioning of infant and alternating nares every 5 to 7 days. C. Abdominal distention and feeding intolerance - Minimize by using continuous drip feeds along with placement of the infant on the stomach or side. Additionally, the placement of an oral gastric tube to straight drain will minimize accumulation of air in the GI tract V. Management of NPCPAP Pressure - set CPAP at 4-7 cm of H2O pressure, use the previous MAP setting that the infant has been at, before extubation, as a guide (usually 5 cm works well of most infants.) VI. Trouble-shooting while on NPCPAP A. Increasing O2 requirement or episodes of desaturation and apnea - "plugged tube." Prevent by routine suctioning,and adequate humidification. If necessary, replace the tube. B. Excessive bradycardia with movement - tip of ETT placed in oral rather than nasal pharynx: correct by repositioning tube. C. Excessive nasal irritation - move NP tube to the opposite side, change position of
infant. D. Significant apnea or increasing respiratory acidosis or O2 requirement of 80100%; NPCPAP failure - intubate and ventilate patient. VII. Weaning off NPCAP: A. Oxygen requirement <30% B. Decrease CPAP pressure gradually to 4-6 cm and maintain the pressure at this level until tachypnea and retractions have resolved. C. If obstructive apnea still occurs after removal of nasal CPAP, you should RESTART the NPCAP and wait until the infant has achieved adequate nutrition with good weight gain and weight is >1000g; if significant apnea reoccurs even on room air, restart NPCPAP and wait a week before weaning off CPAP again. VIII. Placement of the NPCPAP tube and care of the neonatal patient on NPCPAP EQUIPMENT: r ETT (2.5mm ID) r Six Fr suction catheter r Water soluble lubricant r Adhesive tape - 3/4 or 1 inch wide r Hollister spray r Stethoscope r EKG monitoring equipment r O2 source with connecting tube r Anesthesia bag r Mask r Suction source A. Procedure: 1. Insertion: a. Prepare equipment: i. Thread entire suction catheter through ETT until thumb control is located at the end of the ETT adapter. ii. Lubricate tip of ETT with water soluble lubricant. b. Pass suction catheter nasally as if inserting a nasogastric tube to 1012 cm. (*See procedure for nasogastric tube placement.) This is to allow for increased ease of nasal ETT insertion. Advance lubricated ETT nasally while maintaining placement of suction catheter. c. Depth of placement - Advance ETT to: 4 cm at naris if weight < 1500 g 4.5 cm at naris if weight 1500-2000 g 5 cm at naris if weight > 2000 g d. Remove suction catheter, maintaining placement of ETT tube (now called NP tube). e. Secure tube with hollister spray and adhesive tape using double "H" technique. One piece over bridge of nose and around tube as an in oral intubation. One piece inverted on lip and around tube. This increases the security of the tube and ensures proper placement; minimizing trauma to mucus membranes. f. Connect NP tube to oxygen source per ventilator or anesthesia bag. Per M.D. order, O2 may be adjusted per oximeter. CPAP setting may be adjusted via blood gas results. g. NPCPAP is usually ordered at between 4-7 cm of pressure. Five cm works well for most infants. h. Suction NP tubes as indicated (see Endotracheal Tubes, Suctioning of). When ventilating using a resuscitation bag, the infant's mouth must be closed or the mask should be applied to face and infant ventilated/oxygenated per mask. B. Precautions, considerations, and observations: 1. Appropriate NP tube size is usually the same or smaller than that required for intubation. < 1500 g = 2.5 1500-2000 g = 3.0 2. The above procedure is recommended to increase ease of initial insertion. Subsequent reinsertions may be accomplished the same way or by following procedure for insertion of nasogastric tubes. Placement guidelines should be strictly adhered to in either case. 3. A physician's order is required to initiate or discontinue NPCPAP. It is recommended that a physician be present for both initial insertion and final removal of NPCPAP tube.
4. An oral/nasogastric tube should be placed to straight drainage to provide gastric decompression. References: Chernick V. Continuous distending pressure in HMD: devices, disadvantages and daring. Pediatrics, 1973;52:114. Gregory GA, Kitterman JA, Phibbs RH, Tooly WH, Hamilton WK. Treatment of the idiopathic respiratory distress syndrome with continuous positive airway pressure. N Engl J Med, 1971;284:1333. Higgins RD, Richter SE, Davis JM: Nasal continuous positive airway pressure facilities extubation of very low birth weight neonates. Pediatr 1991;88:999-1003. Kim EH, Boutwell WC: Successful direct extubation of very low birth weight infants from low intermittent mandatory ventilation rate. Pediatrics, 1987;80:409-414. Martin RJ, Miller MJ, Carlo WA: Pathogenesis of apnea in preterm infants. J Pediatr, 1986;109:733-741. Wung JT, Driscoll JM Jr., Epstein RA, Hyman AI. A new device for CPAP by nasal route. Crit Care Med, 1975;3:76. Kim EH, Boutwell WC. Successful direct extubation of very low birth weight infants from low intermittent mandatory ventilation rate. Pediatrics, 1987;80:409-414. Higgins RD, Richter SE, Davis JM. Nasal continuous positive airway pressure facilitates extubation of very low birth weight neonates. Pediatrics, 1991;88:999-1003.

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Protocol for Initial Respiratory Settings for Mechanical Ventilation of Infants

I. RDS A. After initial resuscitation and stabilization, the following should be the ventilator settings used: A. Rate: 30-40/minute B. Peak inspiratory pressure (PIP) - determined by adequate chest wall movement. a. An infant weighing less than 1500 grams: 16-28 cm H2O. b. An infant weighing greater than 1500 grams: 20-30 cm H2O. C. Positive end expiratory pressure (PEEP): 4 cm of H2O OR 5-6 cm if FiO2 > 0.90. D. FiO2: 0.4 to 1.0, depending on the clinical situation. E. Inspiratory time: 0.3-0.5 sec. B. After 15 to 30 minutes, check arterial blood gases and pH. A. If the PaO2 or the O2 saturation is below accepted standards, the FiO2 can be raised to a maximum of 1.0. If the PaO2 or O2 saturation is still inadequate, the mean airway pressure can be raised by increasing either the PIP, PEEP, inspiratory time or the rate, leaving inspiratory time constant. B. If the PaCO2 is elevated, the rate or peak inspiratory pressure can be raised. C. Arterial blood gases and pH must be checked 15 to 30 minutes after changing any setting of the respirator: rate, peak pressure, or inspiratory time. Changes in FiO2 may be monitored by pulse oximetry or transcutaneous oxygen monitor. D. When lowering the respiratory rate without a concomitant decrease in I:E ratio, the inspiratory time can become quite prolonged. The total inspiratory time should not exceed 0.6 second. E. When increasing the respiratory rate above 60/minute, the I:E ratio should be 1:1. II. Other Respiratory Conditions Recommendations for the initial respiratory settings for other neonatal conditions will be found on the following table. The peak pressure used is a reflection of the anticipated compliance of the lung. Subsequent changes in settings will be determined by arterial blood gases and pH values and the clinical course. During the acute phase of the disease process, arterial blood gases and pH MUST be measured 15 to 30 minutes after a change in ventilatory settings. III. When placing a neonate on mechanical ventilation, an order is written indicating: A. Conventional Mechanical Ventilation A. Mode (IMV or conventional sigh breaths when using HFV) B. Rate (breaths per minute) C. FiO2 D. Inspiratory time (seconds) or I:E ratio E. Peak inspiratory pressure (cm H2O) F. PEEP (cm H2O) B. High Frequency Ventilation (HFV) A. Frequency (HZ) B. Amplitude or power C. PEEP or MAP (cm H2O) C. Synchronized Intermittent Mandatory Ventilation (SIMV) A. Rate (use up to 40 bpm when on Servo 300, up to 60 on Star Synch) B. PC (pressure control); set a peak pressure, Based on adequate chest wall movement C. PS (pressure support); number of cm H2O pressure above the PEEP,
usually start at a PS = (PIP-PEEP)/2, minimal PS = 4-6 cm D. VC (Volume Control) set a tidal volume usually 5-7 cc/kg for premature infnats and 7-10 cc/kg for term infants: Any change in the above parameters must be written as an order. See the following Use of Mechanical Ventilation in the Neonate table for details.

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Handbook Home General Temperature Jaundice Pulmonary Neurology Metabolic Fluid Management Feeding Infection Hematology Pharmacology
Use of Mechanical Ventilation in the Neonate

Suggested Initial Respirator Settings Condition RDS Primary Apnea Congestive Heart Failure (Pulmonary Edema) Meconium Aspiration Syndrome Pneumonia Rate1 (Breaths/Min) 30-40 15-25 15-25 30-60 30-40 PIP2 (CM H2O) 16-24 14-20 18-22 24-30 24-30 PEEP (CM H2O) 4-6 3-4 4-6 4-6 6-8 FiO2
* * * ** **
(1) Inspiratory Time--All neonates should have an inspiratory time of 0.3 to 0.5 seconds and an expiratory time not less than 0.5 seconds unless the rate exceeds 60/minute. At rates above 60, use equal inspiratory and expiratory times (I:E=1:1). (2) Confirmation of correct PIP should always be determined by appropriate chest wall excursion.
Procedures Abbreviations Commonly Used in the Nursery
* Adjust FiO2 as indicated to maintain oxygen saturation 85%-95% (PaO2 50-70mm Hg).
** Because of the risk of right to left shunting (PFC), the FiO2 in this condition is adjusted to maintain the
oxygen saturation greater than 95% (PaO2 > 80mm Hg) in term infants.

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High Frequency Ventilation (HFV)

I. Introduction: The use of surfactant replacement therapy has helped to decrease neonatal mortality from respiratory distress syndrome (RDS), but the incidence of pulmonary interstitial emphysema (PIE) and bronchopulmonary dysplasia (BPD) in ventilated neonates (700-1350 grams) is still relatively high (PIE 20-25%, BPD 15-19%; U.S. Exosurf Pediatric Study Group 1990). Thus new therapies involving alternative methods of managing respiratory failure are currently being utilized. One of these new therapies is high frequency ventilation. A. HIGH FREQUENCY VENTILATION (HFV): is a new technique of ventilation that uses respiratory rates that greatly exceed the rate of normal breathing. There are three principal types of HFV: 1. High frequency positive pressure ventilation (HPPV, rate 60-150/minute); 2. High frequency jet ventilation (HFJV, rate 100-600); 3. High frequency oscillatory ventilation (HFOV, rate 300-3000/minute). The advantage of high frequency oscillatory ventilation as compared to either conventional positive pressure or jet ventilation is its ability to promote gas exchange while using tidal volumes that are less than dead space. The ability of HFOV to maintain oxygenation and ventilation while using minimal tidal volumes allow us to minimize barotrauma and thus reduce the morbidity associated with ventilator management of RDS B. INFRASONICS INFANT STAR High-Frequency Ventilator: We are currently using the Infrasonics Infant Star ventilator at a frequency of 15 Hz (900 breaths/minute) in premature infants who develop PIE while on conventional mechanical ventilation. The Infant Star is a flow interrupter, not a true oscillator, but its physiological effects and advantages are similar to those of true oscillators. While on Infant Star, one observes rapid vibration of the infant's chest wall instead of the normal chest wall excursion that is seen with conventional ventilation. The Infant Star is used for the treatment of pulmonary air leaks, primarily pulmonary interstitial emphysema (PIE) and pneumothorax. HFV with the Infant Star allows gas exchange to occur even while the lung is atelectatic, thus the size of the air leak is diminished, allowing for more rapid resolution of air leak syndromes. Thus, by decreasing the severity of PIE, HFV should allow us to minimize the mortality and morbidity (BPD) associated with barotrauma.
COMPARISON OF HFV TECHNIQUES Technique Rate/(min) HFPPV HFJV HFOV 60-150 100-600 300-3000 Tidal Volume > dead space > dead space < dead space
II. Gas Exchange: During conventional mechanical ventilation or spontaneous respiration, gas exchange occurs because of bulk transport (convective flow) of the O2 and CO2 molecules from the central or conducting airways to the peripheral airways. The volume of inhaled gas must exceed the volume of dead space. A. GAS EXCHANGE DURING HFV: Theories on why ventilation can still occur when using tidal volumes that are less that dead space: 1. Augmented Diffusion; 2. Bulk Axial Flow; 3. Interregional Gas Mixing (Pendelluft); 4. Axial and Radial Augmented Dispersion (Taylor Dispersion); 5. Convective Dispersion. B. INDICATIONS FOR HFV: 1. BAROTRAUMA - pulmonary airleaks. a. PNEUMOTHORAX b. PULMONARY INTERSTITIAL EMPHYSEMA (PIE) 2. Respiratory failure unresponsive to conventional ventilation (compassionate use). C. HFV SETTINGS (Infrasonics INFANT STAR High-Frequency Ventilator) - Consult with Staff Neonatologist before instituting high frequency ventilation. 1. FREQUENCY: 15 Hz (900 "breaths per minute") 2. AMPLITUDE: a rough representation of the volume of gas flow in each high frequency pulse or "breath." Adjust the amplitude until you achieve vigorous chest wall vibrations, usually occurs at an amplitude of 20-30. If conventional rate is greater than 60, decrease rate to 40 and increase PEEP by 1 to 2 cm, before adjusting the amplitude. This will give the patient adequate expiratory time for the assessment of vibrations. 3. MAP: Adjust by decreasing conventional rate (by 5 bpm) while increasing PEEP (by 1 cm H2O) until conventional rate is 4 breaths per minute ("sighs") and the MAP becomes approximately equal to the PEEP. IT IS VERY IMPORTANT TO KEEP MAP CONSTANT DURING THE CONVERSION TO HFV TO PREVENT EXCESSIVE ATELECTASIS AND LOSS OF OXYGENATION. The goal being a MAP equal to or slightly (1-3 cm) below the previous MAP. 4. IMV RATE (sighs): The conventional or "sigh" breaths should be similar to the previous settings in terms of PIP, however the inspiratory time should be 0.4 - 0.6 seconds. 5. PEAK PRESSURE (sighs): The PIP is usually set at a pressure equal to MAP +6 cm. D. BLOOD GAS MANAGEMENT: 1. Inadequate oxygenation (low PO2): Manage by increasing the FiO2, increasing the MAP by increasing the PEEP (i.e. PO2 is directly proportional to MAP or by decreasing atelectasis by manually ventilating the infant with an anesthesia bag and then adjusting the "sigh" breaths by increasing either the rate, inspiratory time or PIP of the conventional breaths).
IMPORTANT: If oxygenation is lost during weaning when Peepwas decreased, manually "bag" the infant back up to restore lung volumes and reset Peep at 2-3 cm above the previous value. Once adequate oxygenation has been reestablished weaning can begin again, but proceed more slowly with changes in Peep. 2. Inadequate ventilation (high PCO2): Manage by increasing the AMPLITUDE (i. e., PCO2 is inversely proportional to AMPLITUDE). E. COMPLICATIONS OF HFOV: 1. ATELECTASIS: treat by increasing the rate or PIP of the conventional breaths ("sighs"); 2. INCREASED MOBILIZATION OF SECRETIONS: treat by increasing frequency of suctioning of ETT as needed; 3. HYPOTENSION: treat by lowering MAP by decreasing PEEP, if other methods such as volume and positive inotropic agents have been inadequate. F. WEANING: 1. Reduce the amplitude of the oscillations by 3 units per change (Q1-2h) until the PCO2 rises. After a change in AMPLITUDE, always observe the chest wall to confirm that it is still vibrating, if vibrations have ceased the AMPLITUDE is too low and thus should be reset at the previous setting. A minimal AMPLITUDE tends to occur around 12-14 units. 2. Once oxygenation is adequate (FIO2 less than 0.70) slowly lower the MAP by decreasing the PEEP by 1 cm H2O per change (Q4-8h). Minimal HFOV settings tend to be reached around a MAP of 7 cm with an O2 requirement that is less than 40%. At this point depending on the patient, you can remain on the HFOV while the patient grows, you can convert the patient back to convention ventilation at a low respiratory rate (usually 15-20 bpm), or you can extubate the patient to Nasal CPAP.
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Management Strategies with High Frequency Ventilation in Neonates Using the SensorMedics 3100A High Frequency Oscillatory Ventilator Management Strategies with High Frequency Ventilation in Neonates Using the Infant Star 950 High Frequency Ventilator
References: Boynton BR et al. High-frequency ventilation in newborn infants. J Intensive Care Med, 1986;1:257-269. Bryan AC, Froese AB. Reflections on the HIFI Trial. Pediatr, 87:565-567;1991. Clark RH, Gerstmann DR, Null Jr DM, De Lemos RA. High-frequency oscillatory ventilation reduces the incidence of severe chronic lung disease in respiratory distress syndrome. Am Rev Respir Dis 141:A686;1990. Courtney SE, HIFO Study Group. High frequency oscillation strategy decreases incidence of air leak syndrome in infants with severe respiratory distress syndrome. Pediatr Res 29:312A;1991. Frantz ID III. Newer methods for treatment of respiratory distress. In: The Micropremie: The Next Frontier. Report of the 99th Ross Conference on Pediatric Research. Columbus, OH: Ross Laboratories: 29-35;1990. Frantz ID III et al. High-frequency ventilation in premature infants with lung disease: Adequate gas exchange at low tracheal pressure. Pediatrics, 1983;71:483-488. Gaylord MS et al. High-frequency ventilation in the treatment of infants weighing less than 1500 grams with pulmonary interstitial emphysema: A pilot study. Pediatrics, 1987;79:915-921.
Gerstmann DR, de Lemos RA, Clark RH: High-frequency ventilation: Issues of strategy. Clin Perinatol 18:563-580;1991. Wetzel RC, Gioia FR. High frequency ventilation. Pediatrics Clin North Am, 1987;34:15-38. Section Top | Title Page
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Management Strategies with High Frequency Ventilation in Neonates Using the SensorMedics 3100A High Frequency Oscillatory Ventilator
SensorMedics 3100A Oscillatory Ventilator The 3100A is a true high frequency oscillator with a diaphragmatically sealed piston driver. It is theoretically capable of ventilating patients up to 30 kg. Tidal volume typically delivered 1.5-3.0 cc/kg (< dead space). The 3100A is an extremely efficient ventilator secondary to an active expiratory phase, but it is not capable of delivering sigh breaths for alveolar recruitment.
INITIAL SETTINGS:
A. FREQUENCY: Set initially at 10 Hz (600 BPM) for term infants and 15 Hz (900 BPM) for premature infants (< 2.5 kg). For children between 6-10 kg, use 8 Hz, and for children > 10 kg, use 6 Hz for an initial setting. B. INSPIRATORY TIME (I.T.): Set initially at 33% (e.g. 22 milliseconds at 15 Hz, 41 milliseconds at 8 Hz, 55 milliseconds at 6 Hz). 1) Warning - The percent of I.T. should never be increased because it will lead to air trapping and fulminant barotrauma. Total I.T. should only be increased by decreasing frequency, thus leaving the I:E ratio constant. I.T. can be decreased to 30% to heal air-leaks. 2) I:E ratio: 1:2 for 3-15 Hz at 33% I.T.
C. POWER: A rough representation of the volume of gas generated by each high frequency wave. Range (1.0 10.0). Maximum true volume of gas generated by the piston is 365 cc. Maximum amplitude or volume delivered is highly variable and depends on the following factors: circuit tubing (compliance, length and diameter), humidifier (resistance and compliance - water level), ET tube diameter and length (FLOWis directly proportional to r4/l, where r = radius of airway and l = length of airway), the patient's airways and compliance. 1) Set the POWER initially at 2.5 if wt <2.0 kg, 3.0 if wt < 2.5 kg, 4.0 if wt 2.5 - 4.0 kg, 5.0 if wt 4.0 - 5.0 kg, 6.0 if wt < 10 kg, 7.0 if wt > 20 kg.
q
Check ABG's every 15-20 min until PaCO 40-60, i.e., titrate POWER setting based on
2
PaCO desired.
2
q q
Chest wall needs to be vibrating. If not vibrating, increase power. Many HFOV centers have you order amplitude or delta P (P) to regulate ventilation instead of power. We have decided that the Power setting is a more reliable way of adjusting this ventilator and thus we order changes in power in order to regulate ventilation.
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2) Alveolar ventilation is directly proportional toPOWER, so the level ofPaCO is inversely proportional to the power. 3) During HFOV, alveolar ventilation (Ve) (TV) f as compared to CMV where Ve TV(R). Thus we primarily adjust the power (amplitude) to change tidal volume in order to manipulate ventilation. 4) Management of ABG's (Ventilation - Ve): a) Change POWER by 0.2-0.3 to change CO 2-4 mm Hg
2 2
b) Change POWER by 0.4-0.7 to change CO 5-9 mm Hg

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c) Change POWER by 0.8-1.0 to change CO 10-15 mm Hg

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5)Warning - It is extremely important to normalize PaCO rapidly by weaning Power in order to

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avoid volutrauma from excessive tidal volumes.Check ABG's frequently (Q15-20 min) and
decrease POWER accordingly until PaCO > 35. A PaCO < 35 correlates with an increased risk of
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pneumothorax. Thus to minimize the risk of volutrauma, it is important to use the least amount of TV (POWER or AMPLITUDE) possible to achieve ventilation. 6) Hypercarbia - If PaCO still remains elevated at high POWER setting (>8.0), decrease
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FREQUENCY by 2 Hz every 15-20 min until maximum tidal volume is reached (3-4 Hz at a POWER of 10.0). The lower frequency leads to a longer I.T. leading to a larger tidal volume of gas being displaced towards the infant. This increased TV leads to improved alveolar ventilation (HFOV, Ve (TV) f). 7) Manual Ventilation: Hand bagging while on the SensorMedics Ventilator should be avoided secondary to the risk of barotrauma due to over distention. Suctioning should be performed using just the ventilator breaths alone (an inline suctioning adapter would be best). If bagging has to be done, the PIP while bagging should not exceed 8-10 cm above the MAP and a PEEP of 6-8 cm should be maintained as tolerated. D. MAP: Oxygenation on HFOV is directly proportional to MAP, which is similar to CMV, however with the SensorMedics HFOV the MAP is generated by PEEP. Thus during HFOV: MAP = PEEP. 1. Initial MAP Settings: a) Neonates - Initial MAP should be 2-4 cm above the MAP on CMV. b) Infants/Children - Initial MAP should be 4-8 cm above the MAP on CMV. c) If starting immediately on HFOV - use a MAP of 8-10 cm in neonates and 1518 cm in infants/children. 2. Management of ABG's (Oxygenation is directly proportional to MAP): a) If not oxygenating adequately at initial MAP (12-18 cm), obtain CXR to assess lung volume. If lung is not hyper-inflated (flattened diaphragm) or is below optimal lung volume around 9-10 ribs then increase MAP by 2-4 cm every 20-30 min until adequate oxygenation is achieved or lung starts to become over-inflated (e.g. FiO
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0.6-0.7 increase by 2-4 cm, FiO 1.0 increase by 4-8 cm).

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b) Maximum potential MAP = 40-45 cm c) Warning - If oxygenating adequately, but the lung is hyper-inflated immediately decrease the MAP by 1-2 cm every 2-4 h until lung volumes return to normal. If the lung is allowed to remain hyper-inflated for prolonged periods of time the risk of barotrauma increases dramatically. d) If not oxygenating with lung becoming hyper-inflated, you can decrease frequency as a way to increase I.T. while keeping I:E ratio constant.
II. MANAGEMENT STRATEGIES:

The SensorMedics HFOV is usually used for premature infants, term infants or young children with respiratory failure not responsive to CMV. A. TERM INFANT WITH SEVERE RESPIRATORY FAILURE (PPHN, MAS, GBS pneumonia, RDS):
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Start at a frequency of 10 Hz and a Power of 3.0 to 5.0. Initial MAP 4 cm above MAP while on CMV. Check CXR 2 hrs after converting to HFOV, then adjust MAP to achieve optimal lung volume (9-10 ribs expanded). If not oxygenating, increase MAP by 2 cm every hour until oxygenation improves. Adjust Power to keep PaCO 45-55.
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B. AIRLEAKS: Pneumothorax or PIE

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The goal is to minimize both tidal volumes and peak pressures generated by any given TV. Practice permissive hypercarbia and accept high PaCO 's to minimize the TV.
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Tolerate transiently increased FiO requirements (0.6 - 1.0) in order to keep MAP at a minimum.
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Use a FREQUENCY of 12-15 Hz in order to minimize both total I.T. and TV in order to heal the airleak. Decrease I.T. to 30%.
C. ARDS: The goal is to minimize volutrauma, barotrauma and oxygen toxicity. Thus use the minimum POWER
possible at the appropriate FREQUENCY in order to keep PaCO adequate (e.g. 55-65 mm Hg). Increase MAP as
2
high as necessary to keep FiO < 1.0. Also decrease frequency to increase I.T. to improve oxygenation.
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D. RDS: Give surfactant replacement therapy using manual bagging. Start with frequency of 15 Hz, I.T. of 33%. Use MAP of 8-10 cm or 2 cm above MAP on CMV. Wean FiO until <0.50 then MAP as tolerated to avoid over2
inflation. Wean power/amplitude to keep PaCO 45-60 mmHg. Follow blood gases Q30-60 min after SRT until
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stable and wean appropriately to avoid hypocarbia. E. Rescue Therapy For Premature Infant With RDS: To be used for premature neonates who cant ventilate on either CMV or the Infant Star HFV or who require a MAP > 20 cm to achieve oxygenation while on the Infant Star. Use initial frequency of 15 Hz, Power of 3.0 - 4.0, MAP 2 cm above MAP on the Infant Star HFV, or MAP 4 cm above the MAP on CMV. F. BPD: The goal is to minimize volutrauma, barotrauma, atelectatrauma, biotrauma and oxygen toxicity. Use minimum power/amplitude to keep PaCO adequate (e.g., 50-70 mmHg). Increase MAP as necessary to keep
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FiO <0.50 if possible. Use I.T. of 33%. Use frequency of 10-15 Hz. Use lower frequencies (6-10 Hz) if having
2
difficulty with oxygenation or use the higher frequencies if having problems with hypocarbia or PIE. G. Other Potential Indications: CHF/Pulmonary Edema, Chest Physiotherapy, Hypoplastic Lungs and Post-op Heart Patients H. Not Beneficial For Asthma: Increased risk of air trapping with reactive airway disease.
III. WEANING:
A. OXYGENATION: Once oxygenation is adequate and the patient is ready to be weaned follow these steps: 1) First only wean FiO until < 0.50-0.60 unless hyper-inflated.
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2) Once FiO < 0.50-0.60 or hyper-inflated, decrease MAP by 1 cm Q4-8h; if OXYGENATION is

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lost during weaning then increase MAP by 3-4 cm to restore lung volumes and begin weaning again, but proceed more slowly with decreases in MAP. 3) Minimal MAP 8-16 cm with FiO < 0.40-0.50, at this point one can convert to CMV or remain
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on HFOV while the patient continues to heal and grow (e.g., 8-12 cm < 2.5 kg, 13-16 cm > 2.5 kg). B. VENTILATION: Reduce POWER by 0.2-0.3 units per change whenever PaCO decreases below threshold,
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until minimal POWER is reached (1.5-4.0) depending on the size of the patient. If frequency is below the standard frequency for the patient's weight, then first wean by increasing frequency back to baseline which also decreases the tidal volume, then decrease power as described. 1) Extubation Most infants are ready to be extubated for a trial of NPCPAP when they meet the following criteria:
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MAP < 10 cm FiO < 0.40

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Power < .5 for term, < 1.5 for preterm Extubate to NPCPAP of 6-9 cm.
2) Conventional Ventilation Most term neonates are ready for conversion to conventional mechanical ventilation (SIMV) when they meet the following criteria:
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MAP < 16-17 cm FiO < 0.40 - 0.45

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Power < 4.0 To convert to conventional mechanical ventilation (CMV) use a MAP 3-4 cm less than the MAP on HFV [e.g., MAP = 16-17 on HFV, use a MAP of 12-13 on CMV (PIP = 26, PEEP = 8, Rate = 40, IT = 0.4)]
IV. COMPLICATIONS ASSOCIATED WITH HFOV:

A. Hyperinflation or Barotrauma: Decrease MAP B. Secretions: Increase frequency of suctioning
C. Hypotension: Decrease MAP, and rule out other causes (e.g., pneumothorax, sepsis, dehydration, etc.).
V. EFFECTS OF CHANGING FREQUENCY ON VENTILATION USING THE SENSORMEDICS HIGH FREQUENC OSCILLATORY VENTILATOR.

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Management Strategies with High Frequency Ventilation in Neonates Using the Infant Star 950 High Frequency Ventilator
Jonathan M. Klein, M.D., Associate Professor of Pediatrics, University of Iowa Infrasonics Infant Star Ventilator -- A flow interrupter which functions like an oscillator with a negative pressure phase generated by a Venturi effect. Normally used for premature infants < 2.5 kg. Theoretically delivers a tidal volume of 1.5 - 3.0 cc/kg in a 2 kg infant with normal compliance. I. Initial HFV Settings A. FREQUENCY 12-15 Hz (900 BPM) is the usual starting frequency in a premature infant with RDS (range used of 6 - 15 Hz). Changes in frequency are rarely made in the hour-to-hour management of ABGs. A frequency > 15 Hz may worsen ventilation. 1. I.T.: The inspiration time for the High Frequency breath is fixed at 18 msec (0.018 sec), therefore the I:E ratio is dependent on the frequency. At 15 Hz, I:E is 1:3 while at 6 Hz I: E is 1:8. 2. Decreased Frequency (6 - 12 Hz) is used: 1. To treat air leaks: PIE, pneumothorax. 2. To avoid hypocarbia from excessive ventilation when at minimum amplitude. 3. To minimize inadvertent air trapping. 3. Increased Frequency (from 6 Hz up to 15 Hz) 1. To increase alveolar ventilation when the patient remains hypercarbic despite increasing amplitude. 2. To improve oxygenation by increasing lung volume from decreased expiratory time (i.e., shorter I:E ratio). B. AMPLITUDE A rough representation of the volume of gas generated by each high frequency pulse through the proportioning valves (maximum generated volume with all 10 valves open is 36 cc). THIS IS NOT THE TIDAL VOLUME DELIVERED! 1. Tidal volume delivered is attenuated by the following: circuit tubing, humidifier (e.g., water level), ET tube diameter and length (FLOW is proportional to r4/L), the patient's airways and compliance. Thus, the theoretically delivered tidal volume is on the order of 1.5 cc/kg in a 2 kg infant. 2. Initial Amplitude Settings: Range (approx 11 - 51 cm H2O) a. Adjust amplitude until you see vigorous chest wall vibrations (amp = 24 - 34 cm H2O) then titrate based on PaCO2 (e.g., RDS PaCO2:45 - 60).
b. Alveolar Ventilation (Ve) on HFV is directly proportional to the Amplitude. c. Amplitude Drift: If the amplitude (a measured value) is drifting from ordered values, it is usually due to a change in the compliance of the system (i.e., the infant is improving, secretions in the ET tube or the water level in the humidifier is low). 3. Management of PaCO2 (Ventilation on HFV): During HFOV: Alveolar Ventilation (Ve) = (Vt)2 x freq as compared to CMV where Ve = Vt x Rate Thus, PaCO2 is primarily regulated during HFV by changes in amplitude, not frequency! See table below for guidelines on adjusting the amplitude (minimal AMP change is 3 cm H2O). a. To change PaCO2 2 - 4 mm Hg increase or decrease AMP by approx 3 cm H2O b. To change PaCO2 5 - 9 mm Hg increase or decrease AMP by approx 6 cm H2O c. To change PaCO2 10 - 14 mm Hg increase or decrease AMP by approx 9 cm H2O C. PEEP or MAP: Oxygenation on HFV is directly proportional to MAP which is similar to CMV; however, with HFV almost all of the MAP is generated by PEEP. Thus, during HFV: MAP = PEEP. 1. Initial PEEP settings: Initial PEEP should be equal to or slightly (1 cm) above the MAP on CMV. If starting immediately on HFV use a PEEP/MAP of 10-12 cm for RDS or 7-9 cm for more compliant cases (i.e. after surfactant replacement). When converting from CMV to HFV increase PEEP by 1 cm while decreasing rate by 5 bpm in order to keep MAP constant during the conversion. Keep decreasng rate and increasing PEEP until rate of CMV is 4 bpm (sighs) and MAP becomes equal to PEEP. It is very important to keep MAP constant during the conversion to HFV to avoid excessive atelectasis and concomitant loss of oxygenation. a. Follow CXR closely to assess for appropriate lung volume (approx 9 - 10 ribs)! 2. Management of ABGs (Oxygenation): Oxygenation is directly proportional to PEEP or MAP a. Oxygenation inadequate -- if below optimal lung volume increase PEEP by 2 - 4 cm H2O (e.g., if FiO2 0.6 - 0.7 increase by 12 cm H2O, if FiO2 1.0 increase by 2-4 cm H2O), use sigh breaths or generate manual sighs by bagging. b. Sighs -- Conventional IMV breaths used for recruitment of alveoli to improve oxygenation without need for excessive PEEP. Normal settings: Rate = 1 - 4, I.T. = 0.4 - 0.6 sec., PIP = PEEP + 6 cm H2O (minimal adequate PIP). c. Warning: Oxygenation is directly proportional to PEEP (MAP)
unless lung is overinflated. If hyperinflated, may need to decrease PEEP to improve oxygenation. II. Management Strategies A. RDS: 1. Surfactant Replacement Therapy -- give surfactant then switch to HFV. 2. Conversion to HFV: a. Set frequency to 15 Hz. b. Increase amplitude over 1-3 min until you achieve vigorous chest wall vibrations which usually occurs at an amplitude of 24-34. However, if conventional rate is > 60, decrease rate to 40 and increase PEEP by 1 - 2 cm, before adjusting the amplitude. This will give the patient adequate expiratory time for the assessment of vibrations. c. Keep MAP constant during the conversion to HFV to avoid excessive atelectasis and concomitant loss of oxygenation. d. Use a stepwise process to set MAP: Thus, adjust MAP by decreasing conventional rate (by 5 bpm) while increasing PEEP (by 1 cm H2O) until conventional rate is 4 breaths per minute ("sighs") and the MAP becomes approximately equal to the PEEP. IT IS VERY IMPORTANT TO KEEP MAP CONSTANT DURING THE CONVERSION TO HFV TO PREVENT EXCESSIVE ATELECTASIS AND LOSS OF OXYGENATION. The goal being a MAP equal to or slightly (1 cm) above the previous MAP. e. Wean amplitude to keep PaCO2 45 - 60 mm Hg. f. Wean FiO2 until < 0.50 then PEEP, unless overinflated. g. The lower the FiO2, the more frequently the PEEP needs to be weaned to avoid overinflation. Minimal PEEP 3 - 6 cm H2O with FiO2 < 0.40 and appropriate lung inflation on CXR. h. In infants <1000 grams, once FiO2 < 0.40 and amplitude < 20, start to decrease frequency to minimize risk of inadvertent air trapping. B. AIRLEAKS: Pulmonary Interstitial Emphysema (PIE) or Pneumothorax: 1. Minimize the number and intensity of IMV breaths. Thus decrease sighs (decrease PIP, decrease IT, decrease rate) or use no sighs, and set IMV rate to 0. 2. Permissive Hypercarbia -- Decrease AMPLITUDE to keep PaCO2 55 - 70 mm Hg. 3. Decrease Frequency -- Because of the fixed I.T. decreasing the frequency will increase the expiratory time, thus minimizing air trapping (e.g., at 10 Hz the I:E ratio is 1:5; at 6 Hz the I:E ratio is 1:8; at 4 Hz the I:E ratio is 1:13). 4. Decrease PEEP -- Transiently tolerate increased FiO2 requirements (0.5 - 0.75) in order to heal severe PIE. C. BPD:
1. The goal is to minimize barotrauma, volutrauma, and oxygen toxicity. 2. Minimize AMPLITUDE to keep PaCO2 adequate (e.g., 50 - 70 mm Hg). 3. Increase PEEP as necessary to keep FiO2 < 0.40 - 0.50 with minimum PIP and allow the patient to "self-wean by outgrowing the ventilator." 4. Decrease PEEP by 1 cm H2O every 4-7 days once FiO2 remains < 0.40 - 0.45 after each change. III. Weaning A. OXYGENATION: Once oxygenation is adequate and the patient is ready to be weaned, follow these steps: 1. Only wean FiO2 until < 0.50, unless overinflated. 2. Once FiO2 < 0.50, decrease PEEP by 1 cm H2O Q4 - 8h, if FiO2 < 0.30 - 0.35, decrease PEEP by 1 - 2 cm H2O Q2 - 4h to avoid overinflation. 3. Also decrease PIP of Sigh breaths at the same time and by the same amount that you decrease the PEEP (e.g., PIP 16 and PEEP 10 to PIP 15 and PEEP 9). 4. Minimal PEEP or MAP approximately 3 - 7 cm H2O with FiO2 < 0.40. At this point one can convert to conventional ventilation at low rates (approximately 15 20 bpm), or remain on HFV while the patient matures (anti-apnea settings) and grows, or extubate to NPCPAP if ready. B. VENTILATION 1. Reduce AMPLITUDE by at least 3 cm H2O per change whenever PaCO2 decreases below threshold, until minimal AMPLITUDE (11-13) is reached. 2. Always observe chest wall after a decrease in AMPLITUDE to confirm vibrations, if vibrations have ceased the AMPLITUDE is too low and should be readjusted to previous settings. 3. If PaCO2 is still too low (< 35 mm Hg) on minimal amplitude, and the infant is not ready for extubation, decrease frequency to 10 Hz and then to 6 Hz to decrease alveolar ventilation. C. EXTUBATION Patients are usually ready for a trial of extubation with NPCPAP when they meet the following respiratory support criteria: 1. RDS: PEEP or MAP < 7 - 8 cm H2O with FiO2 < 0.35 extubate to a NPCPAP of 6 - 8 cm H2O. 2. BPD: PEEP or MAP < 10 - 12 cm H2O with FiO2 < 0.45 extubate to a NPCPAP of 8 - 10 cm H2O. 3. Mechanical support required for ventilation is minimal (see table below). WEIGHT 750 - 1000 g AMPLITUDE (cm H2O) < 18 - 20
1250 g 1500 g > 1750 g
< 22 - 24 < 26 - 28 < 32
IV. Complications Associated with HFV: A. ATELECTASIS - increase PEEP, or increase the PIP, I.T., or rate of the sigh breaths (0-4). B. SECRETIONS- Suction more frequently. C. HYPOTENSION- decrease PEEP to decrease MAP to improve venous return if low BP is due to hyperinflation. D. OVERINFLATION- decrease PEEP and decrease PIP if using sighs to decrease MAP. E. APNEA- Increase amplitude or frequency, increase sighs to 4-6 BPM, or consider converting to conventional ventilation. HFV is not an optimal mode for the management of apnea. PDF format | Word doc PDF format | Word doc
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Effects of Changing Frequency on Ventilation using the Infant Star High Frequency Ventilator Representative Figures Demonstrating the Effects of Management Strategies using the Infant Star High Frequency Ventilator

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Handbook Home General Temperature Jaundice Pulmonary Neurology Metabolic Fluid Management Feeding
Neonatal Resuscitation
I. Resuscitation in the delivery room (see following charts). II. Use of Medications in the delivery room (see following charts). III. Term infants who have required aggressive resuscitation in the delivery room (birth asphyxia, meconium aspiration, etc.) are at risk of developing persistent pulmonary hypertension of the newborn (PFC) and initially should be closely observed on 100% oxygen for signs of respiratory and right to left shunting, before slowly decreasing their supplemental oxygen (see section on PFC). Reference:
Infection
Bloom, Copley (eds). Textbook of Neonatal Resuscitation. Dallas: American Heart Association, 1990.
Hematology Pharmacology Procedures Abbreviations Commonly
Used in the Nursery

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Medications for Use in Neonatal Resuscitation

Drug or Volume Expander Epinephrine
Concentration to Administer 1:10,000
Preparation (based on recommended concentration) 1 mL in a syringe Can dilute 1:1 with normal saline if giving I.T.
Dosage 0.1-0.3 mL/kg
Route/ Rate I.V. or I.T. Give rapidly
Volume Expanders
q q
5% Albumin/ Saline Solution Normal Saline Ringer's Lactate
40 mL to be given by syringe or I.V. drip
10 mL/kg I.V. Give over 5-10 minutes
Sodium Bicarbonate
0.5 mEq/mL (4.2% solution)
10 mL prefilled syringe
2 mEq/kg I.V. Give slowly over at least 2 minutes (1 mEq/kg/ min)
Naloxone Hydrochloride (NARCAN)
1.0 mg/mL
2 mL ampul
0.1 mL/kg I.V., I.M., S.Q., or I. T. Give rapidly

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Care of the Infant with the Meconium Aspiration Syndrome

Meconium staining of amniotic fluid occurs in 11-22% of all deliveries. Meconium aspiration syndrome occurs in approximately 2% of these deliveries (1). Release of meconium into the amniotic fluid is usually the result of in utero hypoxia and/or fetal distress. If meconium is passed more than 4 hours before delivery, the infant's skin will be meconium stained. The distressed fetus will make reflex gasping movements and aspirate meconium stained fluid into the tracheo-bronchial tree. After the first breath, the infant will deposit the aspirated meconium stained fluid further down the bronchial tree and therefore cause a mechanical blockage of alveoli and small airways with a resultant ball-valve type obstruction. An infant born via breech presentation will often pass meconium prior to delivery, even without fetal distress. I. Treatment in the delivery room: A. Thin Meconium 1. The infant's oro- and nasopharynx should be suctioned by the obstetrician prior to delivery of the shoulders. 2. In a clinically well-appearing newborn, visualization of the larynx and intubation should not be necessary. 3. In a depressed newborn, intubate and suction first, then proceed with the resuscitation. B. Thick Meconium 1. The infant's oro- and nasopharynx should be suctioned by the obstetrician prior to delivery of the shoulders. 2. Following suctioning of the oro- and nasopharynx by the obstetrician, the infant's oro- and nasopharynx should be immediately suctioned by the pediatrician followed by endotracheal intubation and suctioning of any meconium that is present below the cords. In a clinically well-appearing, vigorously crying newborn without meconium at the level of the vocal cords, intubation may not be necessary. 3. Visualize the cords via direct laryngoscopy and remove as much of the meconium from below the cords as possible. Do not apply suction to the tube by your mouth. Use an adapter connecting the endotracheal tube directly to wall suction, with the pressure set at 40 to 60 TORR. Repeat the intubation as often as necessary to clear the lower airway of meconium, even if the infant has cried. 4. Following suctioning, ventilate the infant as necessary. 5. Keep the infant warm and dry to prevent hypothermia and shunting. Continue to monitor the infant's heart and respiratory rates. 6. After the infant has been stable for a least five minutes, the stomach can be aspirated to remove as much of the meconium-stained fluid as possible.
7. If warranted by the clinical history (fetal distress, depressed infant, etc.), intubation should be performed even if meconium is not seen on the cords. II. Treatment in the nursery: A. The infant should be monitored and observed carefully for signs of respiratory distress, i.e., cyanosis, tachypnea, retractions, and grunting. B. Arterial blood gases and pH should be monitored for evidence of either metabolic or respiratory acidosis. C. Obtain a chest x-ray to rule out air leak (pneumothorax, pneumomediastinum, or pneumopericardium), secondary to air trapping from ball-valve obstruction. D. An infant with a history of meconium aspiration who develops respiratory distressshould be placed in a hood to maintain O2 saturations greater or equal to 99% to prevent episodes of hypoxia and shunting. E. Postural drainage should be done as clinically indicated. F. Consider intubation and suctioning below the cords in the nursery, since meconium can be removed from the upper airways even after the infant has initiated spontaneous respirations. G. If the infant experiences persistent respiratory distress after one-half hour of life, antibiotics should be started after first obtaining blood, tracheal aspirate, and CSF cultures. Urine, for Group B Strep Latex, should also be obtained, but antibiotics should not be withheld while waiting for urine. H. Monitor the infant for pulmonary hypertension with evidence of right-to-left shunting (See protocol for Treatment of Pulmonary Hypertension). Reference: Holtzman R.B., et al. Perinatal management of meconium staining of the amniotic fluid. Clin Perinatol, 1989;16:825-838.

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Treatment of Pulmonary Hypertension

I. Pulmonary Hypertension may be a primary or secondary cause of hypoxia in the neonate. II. The diagnostic evaluation should include: A. Central hematocrit, serum glucose and calcium levels, platelet count B. Chest x-ray, EKG C. Hyperoxia (100% oxygen) challenge test D. Simultaneous pre- and postductal arterial PaO2 or TcPO2 E. Cardiology consult, if indicated for echocardiography to rule out cyanotic congenital heart disease. III. MEDICAL MANAGEMENT of PPHN 1) Minimize Pulmonary Hypertension/Vasoconstriction AVOID: HYPOXIA, HYPOTHERMIA, ACIDOSIS, ANEMIA,
Used in the Nursery
HYPOTENSION AND STIMULATION ! 2) Maximize Pulmonary Vasodilatation (Decrease pulmonary vascular resistance) a) OXYGEN (FiO2 = 1.0) b) ALKALINIZATION - METABOLIC ALKALOSIS (pH > 7.55) 3) Support Cardiac Output and Blood Pressure a) VOLUME b) INOTROPIC AGENTS: Dobutamine, Dopamine and Epinephrine 4) Relieve Pain and Anxiety a) ANALGESIA: Morphine or Fentanyl b) SEDATION: Lorazepam, Chloral Hydrate, Phenobarbital, Midazolam and Thorazine c) PARALYSIS: Pavulon 5) Administer Pulmonary Vasodilating Agents a) "INHALED NITRIC OXIDE" b) TOLAZOLINE c) PROSTAGLANDIN E1 d) ISOPROTERENOL 6) Avoid Barotrauma
a) Small tidal volumes with high rates (i.e., HFOV) b) Avoid hyperventilation (pCO2 30) to minimize barotrauma IV. Initial Therapeutic Guide A. Correct hypothermia, hyperviscosity and metabolic problems. B. 100% oxygen and transient hyperventilation with goal of an arterial pH value greater than 7.55 (1), and PaCO2 of 30-35 mm Hg, and a PaO2 of 55 mm Hg or greater. This may transiently require rapid ventilation with rates of 60 to 80 BPM (I:E = 1:1). However, to avoid barotrauma alkalinize metabolically and then use gentler ventilation (PaCO2 35 mmHg) with HFOV. C. Alkalinization by metabolic means with the use of a bicarbonate infusion (1-2 meq/kg/hr) (2). D. Analgesia with morphine infusion (0.1 - 0.2 g/kg/hr) and sedation with Lorazepam (0.1 - 0.3 mg/kg/ dose PRN Q2H) or chloral hydrate (50 mg/kg/dose Q8H-Q12H). Consider transient neuromuscular blockade with Pavulon if infant is "fighting" the ventilator. E. Aggressively support blood pressure with appropriate volume and use Dobutamine (10-20 g/kg/hr) and Dopamine (5-10 g/kg/min). Consider NO if PaO2 < 70 on 100% O2. V. Start Nitric Oxide at 40 ppm as per experimental protocol if PaO2 < 55 mmHg. VI. Pharmacologic intervention with Priscoline (Tolazoline) may be indicated if ventilation, correction of acidosis, and treatment of the primary lung disorder do not lower pulmonary arterial pressure. A. Tolazoline is an alpha-adrenergic blocking agent. Given IV, the onset of action is within minutes. The biologic half-life is approximately two hours. It is excreted, largely in the unchanged form, by the renal tubules. B. Indications for use: 1. Documented right-to-left shunt, with a PaO2 gradient >20 TORR
2. ECHO documentation of pulmonary arterial hypertension. 3. Failure of hyperventilation and metabolic alkalosis as initial therapy. 4. Tolazoline should NOT be given without consultation with the staff Neonatologist. C. Dose: 1.0 mg/kg IV over 10 minutes followed by a constant infusion of 0.5-2.0 mg/kg/hour via a scalp, or an upper extremity, vein. The hourly dose is infused in the same volume of IV fluid that the infant has been previously receiving. D. During the infusion, monitor: 1. Systemic blood pressure; if low, be ready to treat immediately with volume expansion 2. Urine output 3. Heart rate 4. Arterial blood gases pre- and postductal 5. Evidence of GI hemorrhage 6. Platelet count E. Consider starting Dopamine or Dobutamine at 5-10 ug/kg/min. prior to the use of Tolazoline to support systemic blood pressure. F. If improvement is documented (an increase in PaO2 of 20 mm Hg, or a decrease in ventilator settings) within two hours, maintain the same dose. If no improvement is documented, slowly increase the dose of Tolazoline by increments of 0.5 mg/kg/hour. If no response is seen in another two hours, discontinue the infusion. G. Tolazoline is excreted by the kidney. If the infant is anuric or oliguric, caution must be used when administering this drug.
VII. Additional pharmacologic Therapy: A. Consider the use of other vasoactive drugs such as Isoproterenol, Nitroglycerin, Epinephrine, or PGE1 after consulting with the staff Neonatologist. References: Perkins R.M. and Anas N.G. Pulmonary hypertension in pediatric patients. J Pediatr 1984;105:511-522. Dwortz A.R., et. al. Survival of infants with persistent pulmonary without extracorporeal membrane oxygenation. Pediatrics 1989;84:1-6.

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Present Guidelines for Nitric Oxide (NO) Therapy of Persistent Pulmonary

I. Exclusion Criteria: 1. Neonates < 34 weeks gestation (NO inhibits platelet aggregation . Thus, it should be used with great caution in neonates <34 weeks and only at the discretion of the attending neonatologist.) 2. Congenital heart disease (except incidental PDA, ASD, or VSD) II. Enrollment Criteria (should fulfill all of the following): 1. Diagnosis of persistent pulmonary hypertension of the newborn (PPHN) 2. Sufficient cardiac evaluation to r/o congenital heart disease, may need echocardiogram to r/o structural disease 3. Mean airway pressure of at least 12 - 15 cm H2O on HFOV (SensorMedics) with adequate inflation (9-rib expansion) to ensure delivery of NO. 4. Arterial pH > 7.40 or if still acidemic despite vigorous attempts at pharmacologic alkalinization with adequate ventilation (PaCO2 60 mm Hg). 5. Pressor/Inotropic drug 6. aDO2 600 mm Hg by 2 ABG's 30 minutes apart or PaO2 70 mm Hg on FIO2 = 1.0. AaDO2 = PAO2 - PaO2, PaO2 = arterial PO2, PAO2 = alveolar PO2 = FiO2 (713) PaCO2/0.8. III. Nitric Oxide (NO) Therapy (see NO-HFOV flow sheet): 1. Initiate NO therapy, after meeting eligibility criteria and obtaining parental consent. 2. Continue maximal conventional treatment. 3. Start at 40 ppm nitric oxide for 1 hour. If PaO2 does not improve, increase to 80 ppm for 1 hour. After PaO2 improves ( 70 mm Hg) decrease NO to 40 ppm, if PaO2 remains 100-150 mm Hg, decrease NO to 20 ppm and maintain. If PaO2 continues to remain 100-150 mm Hg for more than 24 h consider weaning NO to 10 ppm and maintain until shunting has resolved. If PaO2 drops below 60 mm Hg, restart NO at previous dose and maintain until shunting has resolved. Test for resolution of shunting every 2 to 3 days by stopping the NO for 10-15 minutes and checking the PaO2. Duration of NO therapy will vary with etiology of pulmonary hypertension. 4. Follow methemoglobin (met-hgb) levels at 1, 2, and 4 hours then Q6h - 8hwhile on 40 ppm until met-hgb level is stable. If NO < 40 ppm follow met-hgb Q12h. 5. Notify Dr. Jim Bates (#3830) of patient enrollment. 6. The in-line concentration of NO will be continually analyzed by Respiratory Therapy unless if
on Star on HFV then measured Q2h. If the concentration of NO measured is greater than ordered by 10% or less than ordered by more than 20%, the flow of NO will be readjusted.

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Inhalational Nitric Oxide (iNO)

I. Definition a. NO or endothelium-derived relaxing factor is produced within endothelial cell from L-arginine by nitric oxide synthase (see Figure). b. NO is a potent vasodilator of vascular smooth muscle and when delivered by the inhalational route is a selective pulmonary vasodilator. II. Mechanism of Action a. Diffuses rapidly from alveolus to pulmonary vascular smooth muscle b. Stimulates guanylate cyclase activity which increases the concentration of cyclic GMP which causes vasodilation c. Selectively reverses acute pulmonary vasoconstriction caused by hypoxia or thromboxane d. Rapidly inactivated by forming methemoglobin therefore does not cause systemic hypotension III. Dosing of NO (see guidelines for use) a. Continuous inhalational agent given through inspiratory limb of the breathing circuit b. Serum half-life is 3-4 seconds c. Theoretical effective range: 6-80 ppm d. Verify inhaled concentration of NO by using inline chemiluminescence IV. Side Effects of NO a. Methemoglobinemia - (NO + Hgb) - NO avidly binds to Hgb, thus Hgb is not available to carry oxygen (see Table) 1. metabolic acidosis - increased dyspnea and tachypnea on exam 2. gray central cyanosis occurs at levels of 10-15% (NL < 2%) 3. blood appears brown even with a high PaO2 4. treatment: 100% O2, methylene blue, exchange transfusion, hyperbaric oxygen b. Nitrogen Dioxide (NO2) 1. levels > 3 ppm: cell injury, increased lung fluid 2. normally < 2% of NO level 3. NO2 and H2O -- H2NO3 (nitric acid) c. Inhibits platelet aggregation References: 1) Kinsella JP, Neish SR, Ivy DD, et al. Clinical responses to prolonged treatment of persistent pulmonary hypertension of the newborn with low doses of inhaled nitric oxide. J Pediatr 1993; 123:103-108. 2) Geggel RL. Inhalational nitric oxide: A selective pulmonary vasodilator for treatment of persistent pulmonary hypertension of the newborn. J Pediatr 1993; 123:76-79. 3) Davidson, D. Inhaled nitric oxide (NO) for neonatal pulmonary hypertension. Am Rev Respir Dis 1993; 147:1078-1079.
4) Kinsella JP, Abman SH. Inhalational nitric oxide therapy for persistent pulmonary hypertension of the newborn. Pediatr 1993; 91:997-998. 5) Kinsella JP, Neish SR, Shaffer E, et al. Low-dose inhalational nitric oxide in persistent pulmonary hypertension of the newborn. Lancet 1992; 340:819-820. 6) Roberts JD, Polaner DM, Lang P, et al. Inhaled nitric oxide in persistent pulmonary hypertension of the newborn. Lancet 1992; 340:818-819. 7) Fineman JR, Wong J, Soifer SJ. Hyperoxia and alkalosis produce pulmonary vasodilation independent of endolithium-derived nitric oxide in newborn lambs. Pediatr Res 1993; 33:341346. 8) Rossaint R, Falke KJ, Lpez F, et al. Inhaled nitric oxide for the adult respiratory distress syndrome. New Eng J Med 1993; 328:399-431. 9) Bone RC. A new therapy for the adult respiratory distress syndrome. New Eng J Med 1993; 328:431-432. 10) Kinsella JP, Toews WH, Desmond H, et al. Selective and sustained pulmonary vasodilation with inhalational nitric oxide therapy in a child with idiopathic pulmonary hypertension. J Pediatr 1993; 122:803-806.
Figure 1. Metabolism of endogenous nitric oxide in the lung. Endogenous NO is produced from L-arginine by nitric oxide synthase (NOS) within endothelial cells. After diffusing into subjacent smooth muscle. NO affects vascular smooth muscle relaxation by interacting with guanylate cyclase (GS) and increasing cyclic guanosine 3'.5-monophosphate (cGMP). (Adapted from Fractacci MD, Frostell CG. Chen TY, et al: Inhaled nitric oxide: A selective pulmonary vasdilator of heparin0-protamine vasoconstruction in sheep. Anesthesiology 75:990-999, 1991; with permission.) Section Top | Title Page
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Treatment of the Respiratory Distress Syndrome

The treatment of the Respiratory Distress Syndrome (RDS) is directed at correction of the pathophysiological conditions that exist in this disease process: A) surfactant deficiency, B) hypoxia, C) acidosis, D) pulmonary vasoconstriction, E) atelectasis, and F) shock. I. SURFACTANT REPLACEMENT THERAPY (page 64) II. Correction of hypoxia with oxygen. Infants requiring increased ambient oxygen concentration, and who are breathing spontaneously, can be placed on NPCPAP. The concentration of inspired oxygen should maintain the infant's arterial oxygen tension at 50-70 mm Hg. If oxygen required is greater than 50%, consider endotracheal intubation with surfactant replacement (see relevant section). Always confirm diagnosis with a chest radiograph. III. Nasal pharyngeal CPAP for RDS should start at 6 cm H2O. If the infant is having recurrent apnea, persistent respiratory acidosis (pH less than 7.20) or if the PaO2 is inadequate in 50% or more oxygen with usage of nasal CPAP, the infant should be intubated and treated with surfactant. IV. Once intubated, the neonate with RDS should be ventilated by a pressure respirator according to the protocol found on page 36. To minimize both barotrauma and BPD, peak inspiratory pressures should be decreased as tolerated to keep the pCO2 between 40 and 60 mm Hg as long as the pH > 7.25. If pCO2 remains above 60 mm Hg, consider increasing the respiratory rate first, then, if necessary, increase PIP. V. If barotrauma occurs (PIE or pneumothorax), consider high frequency ventilation (see separate section on HFV). VI. To maintain body temperature, the infant is placed in an incubator or on a radiant heater bed. The skin probe is placed on the mid-epigastrium and covered with heat reflecting tape. The servocontroller is set at 36.5C. VII. Intravenous fluids (D10W or D5W) are given at an initial rate of 60-80 ml/kg body weight per 24 hours with fluid therapy reassessed every 8-12 hours. Infants with birth weights less than 750g should be given fluids at an initial rate of 80-150 ml/kg per day due to their increased insensible losses and fluid therapy should be reassessed every 6-8 hours. Sodium received as sodium bicarbonate will also have to be taken into consideration when calculating the daily sodium requirement. IT IS IMPERATIVE THAT FLUID THERAPY BE READJUSTED EVERY 8 TO 12 HOURS, BASED ON INTAKE AND OUTPUT, CHANGE IN BODY WEIGHT, SERUM ELECTROLYTE CONCENTRATIONS AND SERUM AND URINE OSMOLALITY DETERMINATIONS. See section on fluid therapy for additional details. VIII. Metabolic acidosis (pH< 7.20) is corrected by a slow infusion of sodium bicarbonate (0.5 mEq/ml.; 4% solution) through a peripheral IV at the rate of 1 mEq/kg body weight per hour. The formula for calculation of the base deficit is: mEq of NaHCO3 = base excess x 0.6 x body weight in kg. Give one-half of the calculated dose and then recheck pH and pCO2 within onehalf hour. IX. Shock is corrected by use of normal saline or Plasmanate R; the dose is 10 cc/kg infused over 15 to 30 minutes. Normal values for systolic and mean aortic pressures are found on pages 1 and 2. Please note the values for infants <1000 grams. Carefully evaluate the need for
correction of low BP based on numbers alone in a premature infant who is otherwise well oxygenated, since acute changes in blood pressure may be an etiologic factor in intracranial hemorrhage. X. Oral feedings may be initiated even if the infant is mechanically ventilated, or on nasalpharyngeal CPAP, however, feedings should not be initiated until the infant's condition is stable. Ultimately, the oral intake should provide 100-120 calories/kg/day (see feeding protocol). XI. When the infant is on CPAP or mechanical ventilation, a chest film should be obtained immediately after initiating therapy and subsequently at least once every 24 hours until the infant's condition is stable. References: Kraybill EN, et al. Risk factors for Chronic lung disease in infants with birth weights of 751 to 1000 grams. J Pediatr 1989;115:115-120. Van Marter LJ, et al. Hydration during the first days of life and the risk of bronchopulmonary dysplasia in low birth weight infants. J Pediatr 1990;116:942-949. Avery ME, et al. Is chronic lung disease in low birth weight infants preventable? A survey of eight centers. Pediatrics 1987;79:26-30. Carlo WA, Martin RJ. Principles of neonatal assisted ventilation. Pediatr Clin North Am, 1986;33:221-237. Stark AR, Frantz ID. Respiratory distress syndrome. Pediatr Clin North Am, 1986;33:533-544.

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Guidelines for Surfactant Administration (Surfactant Replacement Therapy)

I. Indications: A. The primary use is for the treatment of intubated infants on 40% or more oxygen whose clinical presentation and chest x-ray are consistent with RDS. B. Anticipatory or prophylactic administration may be used in infants weighing below 1.35 kg. C. Any other indications should be considered experimental until further information is available. II. Dosing: The recommended doses are: Exosurf - 5 ml/kg every 12 hours; Survanta- 4 ml/kg every 6-12 hours. Subsequent doses are generally withheld if the infant requires less than 30% oxygen. Surfactant is usually not continued beyond 3 days of life (72 hours). The Pharmacy Department requires that all Surfactant orders be signed or countersigned by the staff neonatologist. The technical details of administration are discussed in the package insert and in the NICU Nursing Protocol on Exosurf and Survanta administration. III. Surveillance after administration: The clinical response is unpredictable. Lung compliance usually improves, sometimes quite rapidly. Blood gases should be monitored frequently, and the ventilator should be adjusted to keep the PCO2 above 40 if possible. Occasionally, gas exchange deteriorates after Surfactant administration, requiring a temporary increase in PIP. In either case, close surveillance of chest wall movement and frequent monitoring of blood gases, especially during the first 3 hours after dosing, will minimize the complications of barotrauma and atelectasis. Section Top | Title Page
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Surveillance of pH and Blood Gas Status of Neonates

I. Hyperoxemia: Due to the persistent, continuing incidence of retinopathy of prematurity (ROP), any premature infant < 34 weeks gestation who is in an increased ambient oxygen concentration must have his/her arterial oxygen tension monitored. However, ROP has been noted in infants whose PaO2 have not been higher than 100mmHg. Furthermore, efforts aimed at avoiding hyperoxemia in term and preterm neonates are indicated in most clinical conditions with the possible exception of pulmonary hypertension (persistent fetal circulation). II. Hypoxemia: Although rigorous clinical studies have not defined precise limits, hypoxemia has been associated with IVH, PFC, and poor neurologic outcome. Hypoxemia(PaO2 values below 45-50 mmHg), and acidosis (pH < 7.20), are to be avoided since both have been associated with reopening of the ductus arteriosus leading to increased pulmonary vascular resistance, decreased pulmonary perfusion, and further hypoxemia. Section Top | Title Page
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Sampling Techniques for Arterial Blood Gas Samples

I. 0.2 ml of blood is required for arterial blood gas sampling. If the syringe is heparinized, the heparin should be removed as completely as possible before drawing blood into the syringe; excess heparin left in the syringe decreases the pH value, dilutes the sample, and lowers the PaCO2. Before drawing a sample from an indwelling arterial line, the line should be cleared by withdrawing 1 to 2 ml of blood which is returned immediately thereafter. II. An infant without an arterial line who is not severely ill can have his oxygenation status monitored by continuous pulse oximetry or by transcutaneous PO2 monitoring. Any infant being monitored by capillary blood gas samples should have arterial sticks done periodically to validate the capillary sample results or should have continuous pulse oximetry or transcutaneous PO2 monitoring. III. Arterial sticks are sometimes performed in severely ill neonates who do not have an indwelling arterial line. A percutaneous arterial stick can be performed using the temporal or radial artery. The brachial artery may be use in emergency situations. A femoral arterial stick should be avoided if at all possible, as there is an increased incidence of aseptic necrosis of the femoral head when this site is used for sampling. Since many infants shunt through the ductus arteriosus, the arterial site from which the sample is obtained should be noted on the blood gas sample requisition. IV. The frequency of sampling is dependent upon the patient's clinical condition. Any changes in ventilator or CPAP setting must be monitored by a blood gas sample within 15-30 minutes. Any acutely ill child in the NICU in an increased ambient oxygen concentration must have at least daily arterial or fingerstick blood gas sampling V. Indwelling catheters should not be placed into the temporal or brachial artery. Section Top | Title Page
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Pulse Oximetry
I. Pulse oximeters determine oxygen saturation noninvasively through absorption spectrophotometry. Oxygen delivery to the tissues is a direct function of cardiac output, oxygen capacity (hemoglobin concentration) and the oxygen affinity of the patient's hemoglobin (see Figure 1). In the presence of both normal cardiac output and normal Hgb, measurement of oxygen saturation can be a guide to both oxygen exchange and delivery. We tend to keep the oxygen saturation in premature infants between 88% - 95% (higher in term infants). Pulse oximeters are accurate within 4%, thus a reading of 95% could represent a saturation of 99% with a concomitant PO2 of 160 (see Figure 2). Thus, to avoid hyperoxia, we would decrease the oxygen concentration for saturations greater than or equal to 95%. II. Causes for Inaccurate Readings: A. Jaundice - causes falsely decreased values. B. Direct high intensity light - i.e. phototherapy lights - increases inaccuracy, so cover sensor site from lights, or use a phototherapy blanket. C. Impaired perfusion - need good pulsatile blood flow for accurate readings, manage by treating shock. D. Severe hypoxemia - at saturations less than 70% accuracy begins to fall off with the pulse oximeters overestimating the measured value. Manage by directly checking an arterial PaO2, or by using a transcutaneous oxygen monitor References: Oski FA, and Delivoria-Papadopoulos M. The red cell, 2, 3-diphosphoglycerate, and tissue oxygen release. J Pediatr, 1970;77:941-956. Tobin MJ. Respiratory monitoring in the intensive care unit. Am Rev Respir Dis 1988;138:16251642.

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Iowa Neonatology Handbook: Neurology

Neurological Disorders: Asphyxia

The term asphyxia infers an impairment of gas exchange resulting in a fall in PO2 and a rise in PCO2. Degrees of asphyxia exist, varying from total asphyxia, characterized by anoxia and extremes of hypercarbia, to the more commonly encountered situation of partial asphyxia, involving hypoxia and moderate elevations of PCO2. Asphyxial events may occur in utero, at birth, or during postnatal life. Ischemia is often an integral component of asphyxia. Thus the term hypoxia-ischemia is often used interchangeably with asphyxia. A gold standard definition of asphyxia does not exist, and different criteria have been used to diagnose asphyxia including: fetal heart rate patterns, meconium stained amniotic fluid, Apgar scores, umbilical artery pH, need for resuscitation at birth, seizures, electroencephalographic abnormalities, and the development of a clinical neurologic syndrome. At birth there is often insufficient information to readily determine if an asphyxial insult has occurred, and if it has occurred, whether any organ system dysfunction has resulted. For example, seizures may not occur immediately after birth and a clinical neurologic syndrome may evolve over 2-3 postnatal days. This may pose potential problems since inappropriate triage of infants may occur and result in delay in management when obvious problems develop. In spite of these considerations it is critical to note that asphyxial insults in the perinatal period do not account for the majority of infants with brain injury in early childhood. Perinatal asphyxia leads to multi-organ system dysfunction. Virtually any organ system can be affected, and care in the nursery should be oriented to determining the presence or absence of dysfunction of critical organ systems. Cardiovascular involvement may include alterations in blood volume, redistribution of cardiac output and a syndrome of transient myocardial dysfunction. Neurologic involvement is characterized by the evolution of a characteristic hypoxic-ischemic encephalopathy of which seizures may be a part. The Sarnat stages (I-III) of post-hypoxic encephalopathy represent a convenient description to characterize the extent of neurologic involvement and important features are listed in the table. Salient Features of Sarnat Stages of Post-hypoxic Encephalopathy Stage I Level of consciousness hyperalert Neuromuscular control normal Muscle Tone mild distal Posture flexion Stretch reflexes Complex Reflexes Suck Moro Autonomic Function Seizures overactive weak strong; low threshold generalized sympathetic none Stage II lethargic or obtunded mild hypotonia strong distal flexion overactive weak or absent weak:incomplete high threshold generalized parasympathetic common; focal or multifocal Stage III stuporous flaccid intermittent decerebration decrease or absent absent absent both system depressed uncommon
Metabolic involvement may include hypocalcemia, hyponatremia (as a result of inappropriate
ADH secretion or direct renal injury), and alterations in glucose metabolism. Pulmonary involvement may include persistent pulmonary hypertension, aspiration syndromes (usually meconium) and asphyxial lung disease (rare). Direct renal injury may occur leading to acute tubular necrosis. Ischemic bowel disease may occur presumably as a result of the redistribution of cardiac output (dive reflex response). Less commonly, hematologic alterations (thrombocytopenia and DIC) and subcutaneous fat necrosis occur. Clinical care of these infants should be directed at surveillance and management of specific organ system dysfunction. Fluid management should be cautious. Section Top | Title Page
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Neonatal Seizures
I. Background
It is important to recognize the presence of seizures in the neonatal period since they are often related to a significant underlying illness. In addition, seizures may be sustained for considerable periods of time, interfering with essential supportive care. There are 4 major types of seizures in neonates: 1. Subtle seizures are relatively common in the neonatal period and are more often encountered in the preterm than full term infant. Such seizures include oral-buccallingual movements, certain ocular phenomena, peculiar limb movements, autonomic alterations and apnea. 2. Clonic seizures include focal and multifocal varieties which may migrate to another part of the body in a non-ordered fashion. 3. Tonic seizures include focal episodes (less common) and generalized episodes (more common). Generalized tonic seizures may mimic decerebrate and decorticate posturing. 4. Myclonic seizures may be focal, multifocal or generalized and are the least common of the four varieties during the neonatal period. Seizure-like phenomena may not be accompanied by seizure activity on EEG and possibly represent movements or posturing generated by diencephalon-brainstem activity when released from the inhibitory effects of the cerebral cortex. Careful clinical assessment is often necessary to distinguish seizure from nonseizure activity. Non-seizure activity is usually provoked by sensory stimulation, suppressed by passive restraint, associated with normal eye movements, and not accompanied by autonomic phenomena. II. Pathophysiology A number of etiologies should be considered for neonatal seizure. These include: 1. Asphyxia/hypoxia-ischemia: There is usually an interval of time between the event and the onset of seizures, but this interval is quite variable (1-36 hr). 2. Intracranial hemorrhage: Seizures may be a manifestation of any form of intracranial hemorrhage including subarachnoid, intraventricular or intraparenchymal hemorrhage. 3. Metabolic disturbances: Seizures may accompany alterations of glucose, calcium or sodium homeostasis, as well as inborn errors of metabolism, e.g., hyperammonenia. 4. Intracranial infection: Meningitis, encephalitis. 5. Drug withdrawal: Heroin, methadone. 6. Structural defects of the central nervous system. III. Diagnosis A detailed history of prenatal and postnatal events is paramount in diagnosing neonatal seizures. At the time of the seizure, attention should be directed to identifying treatable causes, as outlined in the previous section. A short term screening EEG may be helpful in establishing diagnosis and prognosis. Other studies, including head ultrasound, CT or MRI and skull X-rays, should be considered depending upon the history obtained. IV. Treatment Once a seizure has been diagnosed, treatment directed at the underlying disease needs to be initiated. Anticonvulsant therapy includes the following: 1. Phenobarbital is the drug of first choice to treat neonatal seizures. It is relatively effective, the side effects are well appreciated, and the pharmacokinetics are reasonably well understood for term and preterm infants. A loading dose of phenobarbital (20 mg/kg) will achieve a therapeutic level of approximately 20 g/
ml, which is not affected by birth weight or gestational age. The intravenous route is preferred because of the more rapid onset of action and more reproducible effects on blood levels. The maintenance dose of phenobarbital is lower in the first week of life (3.5 mg/kg/day) and increases to 5 mg/kg/day with increasing postnatal age. 2. Dilantin is often the second drug of choice to be added when seizures are not controlled by phenobarbital alone. A loading dose of 20 mg/kg intravenously will achieve therapeutic blood levels (approximately 15 g/ml) and a maintenance dose is 5 mg/kg/day. 3. Lorazepam is useful for infants with "uncontrolled" seizures in spite of therapy with phenobarbital and dilantin. The usual dose is 0.05 - 0.1 mg/kg per dose. Due to the possibility of respiratory depression (especially with phenobarbital on board), the safest use of these drugs is when ventilatory support has been initiated. Section Top | Title Page
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Intracranial Hemorrhage
I. Background
There are four major types of intracranial hemorrhage which may affect the neonate. These include subdural hemorrhage, primary subarachnoid hemorrhage, intracerebellar hemorrhage and periventricular-intraventricular hemorrhage (PVH-IVH). In the Intensive Care Nursery PVHIVH is the most common of the four and for the preterm infant represents the type of hemorrhage of greatest clinical significance. The incidence of PVH-IVH varies considerably in the literature, the majority of centers reporting an incidence of 20-30% for infants with a birth weight <1500 g. Different incidence figures among centers reflects multiple factors such as the proportion of inborn and outborn births (the latter group have been shown to have a higher incidence of PVH-IVH compared to inborn infants), timing of sonography, and whether all eligible infants were evaluated. There are several classifications to characterize the extent of PVH-IVH. A relatively simple classification which is often used is as follows:
q q
Grade I: hemorrhage limited to the germinal matrix (subependymal hemorrhage) Grade II: hemorrhage which has extended into the ventricular system but without dilation of the lateral ventricles. Grade III: hemorrhage extending into the ventricular system with the blood resulting in ventricular dilatation. Grade IV: hemorrhage which extends into the brain tissue (this grade is also referred to as PVH and associated with intraparenchymal echodensity (IPE) by some).
A problem with this grading system that needs acknowledgment is that objective determination of ventricular dilation is difficult. Determination of the extent of hemorrhage is important since most follow-up studies have found that the probability of neurologic morbidity (cognitive, motor, etc.) is high (>50% depending upon the study) for more extensive hemorrhage (grade III and IV). In contrast, it appears that the presence of a grade I or II PVH-IVH does not measurably increase the chance of neurologic morbidity. Lesions which occur in the periventricular white matter occur in 3-10% of infants with birth weight <1500 g, are frequently bilateral, are felt to be ischemic in origin, and will evolve into cystic lesions of the periventricular white matter (periventricular leukomalacia, PVL). The presence of PVL carries a high risk of neurologic morbidity (most often spastic diplegia). II. Pathophysiology As the name implies, PVH originate in the tissue abutting the lateral ventricle, e.g., germinal matrix. In most infants, PVH arise in the germinal matrix at the level of the foramen of Monroe, although in extremely preterm infants (<28 wks) PVH often arise further posteriorly in the germinal matrix. From multiple sonographic studies of the matural history of PVH-IVH, it is evident that most hemorrhages remain confined to the germinal matrix area (60-70% of PVHIVH depending upon the study). Many hemorrhages will be clinically silent, and very few hemorrhages have a catastrophic presentation (e.g., profound alteration in neurologic state, hypotension, apnea, bulging fontanel, drop in hematocrit, etc.). The pathogenesis of PVH-IVH remains unclear. A complex multifactorial etiology is likely. There have been a number of clinical trials to prevent the occurrence of PVH-IVH using phenobarbital, Vitamin E, indomethacin, Vitamin K, and ethamsylate, all without conclusive
results. If PVH-IVH occurs, additional sonograms will be needed to monitor for extension of the hemorrhage and post-hemorrhagic complications (porencephaly, hydrocephalus). Using serial sonography, it has been shown that the occurrence of post-hemorrhagic hydrocephalus is relatively uncommon after PVH-IVH (~ 13%). However, using serial cranial sonography, it has been shown that enlargement of the lateral ventricles may precede change in head circumference. Thus, once PVH-IVH has occurred follow-up cranial ultrasound is indicated. Similarly, when post-hemorrhagic hydrocephalus (PHH) is evolving (50% of Grade III IVH will be complicated by PHH), management (if any) should be discussed with the Attending Staff. III. Diagnosis Since it is difficult to predict the presence or absence of neonatal intracranial hemorrhage by clinical criteria, the following schedule is used for routine head ultrasounds for "all" infants 1500 g birth weight:
q q q
Ultrasound 1. 5-7 day Ultrasound 2. 28-30 day or before discharge If PVH-IVH is detected on ultrasound, should be obtained more frequently (weekly) to evaluate progression of ventricular dilitation or cystic change.
The timing of the above head ultrasound schedule takes into account that most PVH-IVH occurs in the first week of life. However, the presence of late PVH-IVH does occur and necessitates an ultrasound examination at a month of life. IV. Post Hemorrhagic Hydrocephalus It has been well demonstrated that enlarging head circumference is an insensitive sign of hydrocephalus in the premature infant. Ventricular dilatation after neonatal intracranial hemorrhage probably begins soon after the hemorrhage in many infants and pre-dates the increase in the rate of head growth by days to weeks. Infants with hydrocephalus have a poor prognosis, and one important factor in their outcome may be a delay in the detection and treatment of hydrocephalus. Recommendations: The following is the recommended approach to the identification and care of these infants: A. All infants <1500 grams will be screened by ultrasound for evidence of intraventricular hemorrhage. The screening ultrasound will be done on or about the seventh day of life. The daytime nursery ward clerks will be responsible for identifying which babies are seven days of age from the census book and filling out an x-ray request. Ultrasounds will be performed daily Monday through Friday. If an infant's seventh day falls on the weekend, the scan should be done on Friday or Monday, whichever day is closer to the seventh day. Abnormal ultrasounds will be presented at the daily radiology conference. B. The house staff will be responsible for identifying and ordering ultrasounds on infants >1500 grams who might be at risk for significant hemorrhage. C. Once a hemorrhage has been identified by screening ultrasound, the pediatric house officer then becomes responsible for ordering ultrasounds on a weekly basis until it is clear that the hemorrhage has resolved and that there has been no progression of ventricular size. D. If there is clinical evidence of an intraventricular hemorrhage (drop in hematocrit, seizures, full fontanel, bloody CSF, unremitting acidosis, etc.) an ultrasound should be ordered by the resident on the day that it is desired. Emergency ultrasounds can be done whenever indicated. Serial Lumbar Punctures: Serial lumbar punctures have been used to control increased intracranial pressure when there is clinical evidence of rapidly progressive ventricular size. There is little evidence in the literature of the efficacy of serial lumbar punctures for the prevention of hydrocephalus. However, it appears that serial lumbar punctures can be beneficial in protecting the cortical mantle in an infant with progressive hydrocephalus who is too small to be shunted. The care of each baby needs to be individualized, and there may be changes in our
approach to these infants as new information becomes available. Decisions with regard to lumbar punctures should be made with the attending neonatologist. In general the following recommendations appear reasonable: A. Minimally dilated ventricles without progression do not warrant the use of serial lumbar punctures. B. If progressively enlarging ventricles are identified on ultrasound (with or without clinical signs of increased intracranial pressure), daily LP's may be indicated. Enough fluid should be removed to soften the fontanel, usually 10 to 15 ml. Those with significant intracranial pressure may need 20 to 30 ml removed. The taps should be continued until the ventricles stabilize or decrease in size, or until the infant is large enough to undergo a ventriculoperitoneal shunt. If taps are discontinued because the ventricles have decreased in size, a follow-up ultrasound should be obtained in about seven days to insure that ventricular size remains stable. C. Enlarged ventricles may be secondary to cerebral atrophy. In such cases, ventricular dilatation is a passive process and not related to change in CSF dynamics. Serial lumbar punctures are not indicated in such cases. D. In cases in which progressive ventricular enlargement and clinical signs of increased intracranial pressure cannot be controlled by periodic taps and in which the child's weight is still sufficiently low that shunting cannot be done, other modes of therapy should be considered after appropriate consultation. E. If the decision is made to undertake serial lumbar punctures, certain precautions must be observed. The lumbar puncture must be done with meticulous technique because meningitis is a potential risk. In addition, electrolytes should be measured periodically if large volumes of fluid are removed. F. Repeat head ultrasound exams should be done at weekly intervals whenever blood has been identified in the ventricles in order to monitor changes in ventricular size. Discontinuation of ultrasounds must be decided on an individual basis. In addition, consideration should be given to ordering a late head ultrasound exam at about 6 weeks of age in infants born at 26 weeks or less; the purpose of this late exam is to screen for periventricular leukomalacia. G. Depending upon the severity of the initial hemorrhage and the clinical presentation, a single CT scan might provide information about cerebral cortical and white matter pathology not available by other means of investigation. If desired for prognostic reasons, the CT scan should be performed near the time of discharge. H. At the time an infant with post hemorrhagic hydrocephalus is discharged, arrangements should be made for follow-up in the Neonatology Clinic in four weeks. In some cases a repeat ultrasound may be necessary at that time. The infant who has had a shunt procedure during the hospitalization should also be followed in the Neurosurgery Clinic. References: Goldstein GW, Chaplin ER, Maitland J. Transient hydrocephalus in premature infants: treatment by lumbar puncture. Lancet 1976;1:512-514. Papile LA, Burstein J, Burstein R, Koffler H, Koops BL, Johnson JD. Posthemorrhagic hydrocephalus in low-birth-weight infants: treatment by serial lumbar punctures. J Pediatr 1980;97:273-277. Kreusser KL, Tarby TJ, Kovnar E, Taylor DA, Hill A, Volpe JJ. Serial lumbar punctures for at least temporary amelioration of neonatal posthemorrhagic hydrocephalus. Pediatrics 1985;75:719-724. Szymonowicz W, Yu VYH, Lewis EA. Post-haemorrhagic hydrocephalus in the preterm infant. Aust Paediatr J 1985;21:175-179. Volpe J. Intraventricular hemorrhage and brain injury in the premature infant: neuropathology and pathogenesis. Clinics in Perinatology 1989;16(2):361-386. Volpe J. Intraventricular hemorrhage and brain injury in the premature infant: diagnosis, prognosis and prevention. Clinics in perinatology 1989;16(2):387-411. Section Top | Title Page
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Hypocalcemia
I. Definition: plasma ionized calcium concentration < 3 mg/dL (0.75 mmol/L). II. Infants at risk: A. premature infants B. infants of diabetic mother C. infants with birth asphyxia infants with certain congenital, genetic and hormonal disorders III. Categorization by age of onset: A. Early: In pre-term infants who has received sodium bicarbonate for the treatment of metabolic acidosis, the risk is greatest at 12 to 24 hours of life. Most hypocalcemic neonates without symptoms will normalize their serum calcium levels by 72 hours of age with or without treatment. B. Late: after 7 days infants receiving formulas with low calcium and high phosphorus contents (rare today). C. Very late osteopenia of prematurity: see section on neonatal nutrition. IV. Symptoms: extreme jitteriness, seizures (including apnea), bleeding and/or decreased myocardial contractility. V. Treatment: Treatment of infants whose symptoms are thought to be due to hypocalcemia should be begun as soon as possible. Treatment of asymptomatic infants is controversial since in the vast majority of infants the condition is currently thought to have no short or long terms effects. Nevertheless, some authorities recommend treatment of low calcium levels. A. Once a decision to treat has been made, initial treatment should be 100 to 200 mg/ kg of 10% calcium gluconate by slow i.v. "push", i.e., over at least 30 minutes, followed by a continuous i.v. infusion of 400 mg/kg/day calcium gluconate. Alternatively, calcium may be administered as a slow infusion (over 30 to 60 minutes), given at a dose of 100 mg/kg every 6 hours. If other calcium salts are used, e.g. calcium chloride, the dose will be different. Calcium gluconate should be infused through a peripheral venous line and not given with sodium bicarbonate, dioxin, or antibiotics. If there is a question as to compatibility of calcium with other drugs, contact the Hospital Pharmacy (6-1849). B. In treated infants plasma ionized calcium level should be monitored every 12 to 24 hours. Once the calcium level has normalized, and parenteral and/or enteral sources of calcium intake have been begun, the infusion of calcium should be decreased by 50% after 24 hours, and then discontinued after an additional 24 hours if follow-up plasma calcium levels remain normal and the patient is asymptomatic. C. To prevent the very late osteopenia occurring most commonly in sickest and least mature premature infants, optimal enteral and parenteral calcium nutritional support on a long term basis are needed (see sections on neonatal nutrition and feeding). Reference: Salle BL, Delvin E, Glorieux F, David L. Human neonatal hypocalcemia. Biol Neonate 1990;58:1:22-31. Section Top | Title Page
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Iowa Neonatology Handbook: Metabolic

Handbook Home General Temperature Jaundice Pulmonary
Guidelines for the Detection and Management of Hypoglycemia, Hyperglycemia, and Normoglycemia in Preterm and Term Neonates
Jump to: Hypoglycemia | Hyperglycemia | Normoglycemia | Glucose Infusion Rates Table

Neurology Metabolic Fluid Management Feeding Infection Hematology Pharmacology Procedures Abbreviations Commonly
Hypoglycemia
I. Definition: Plasma glucose < 40 mg/dL in both term or preterm infants. II. Incidence: The definition of neonatal hypoglycemia has been based on statistical criteria.2 The incidence of this condition in term AGA infants is approximately 2%. III. Infants at Risk immediately following birth: IDMs, IGDMs (especially those whose mothers received oral hypoglycemic agents), LGA (>90%ile), SGA (IUGR <10%ile), post-asphyxiated, APGAR < 5 at five minutes, polycythemic, immune hemolytic disease, suspected sepsis, hypothermia (rectal temperature <35C), congenital anomalies, Beckwith-Wiedman syndrome, infants 36 wks gestation, infants 42 wks gestation, & those whose mothers received large amounts of i.v. glucose prior to delivery. IV. Signs: Non-specific, including tremulousness, twitching, jitteriness, irritability, exaggerated Moro reflex, high pitched cry, seizures, apnea, limpness, poor feeding, cyanosis, temperature instability, and coma. V. Screening of Infants at Risk (see table at end of this section): Screen by plasma glucose measurements at 1, 2, 4, 8 and 24 hours of age if not receiving glucose containing i.v. fluids, or when symptomatic.
Used in the Nursery
VI. Diagnosis: By plasma glucose measurements only. For diagnostic purposes it is imperative that plasma glucose be measured in the NICU or Hospital laboratory by quantative chemical analysis and NOT by a semi-quantitative reagent strip method (e.g., Chemstrip bG). Although use of reagent strips is widespread, their use, even for glucose screening purposes, is controversial1. This is because of their inaccuracy and imprecision relative to accepted laboratory determined glucose values. Treatment decisions in infants without signs ("asymptomatic") of hypoglycemia should not be based on Chemstrip data. VII. Treatment: A. Asymptomatic Infants: Severity Plasma Glucose Treatment objective is to raise the plasma glucose concentration to 50-200 mg/dL Oral: If developmentally capable of feeding orally, and if clinical condition permits (i.e., no significant respiratory distress, etc.), immediately offer ad lib oral glucose solution (D5W), infant formula, or allow breast-feeding. If enteral feeding is not possible, treat parenterally (see next). Parenteral: Treat with i.v. 4-8 mg glucose/kg/min using D10W (see Figure at end) as for "symptomatic" infants.
Mild
<40 mg/dL
Severe
<20 mg/dL
B. Symptomatic Infants: s Immediate Bolus: 0.20 grams of glucose/kg, i.e., 2 ml/kg of i.v. 10% glucose, given over 1-2 minutes. (Do not use D25W or D50W.) s Continuous Infusion: 6-8 mg glucose/kg/min using D10W (or D5W); this is equivalent to 90-120 ml/kg-day as 10% dextrose in water--see Figure at end of section. VIII. Guidelines for Monitoring Plasma Glucose in Hypoglycemic Infants In hypoglycemic infants, plasma glucose values should be repeated 1-2 hours after initiation of treatment if the infant remains asymptomatic, or every 20-30 minutes if symptomatic (see table at end of this section). If signs of hypoglycemia persist or recur, or if plasma plasma glucose concentration as determined by the neonatal or hospital laboratory remains below 40 mg/dL, increase glucose infusion rate to 10 to 12 mg/kg/min. If further hypoglycemia persists, IMMEDIATELY notify staff neonatologist for consideration of further treatment and diagnosis. After the plasma glucose has been normal for 24 hours, and enteral feedings have been started,
taper i.v. glucose infusion rate by 1-2 mg/kg/min every 4 to 8 hours as tolerated. (This may necessitate a reduction in the concentration of dextrose in the i.v. fluid being used.) Intravenous glucose intake usually cannot be reduced below 4-6 mg/kg/min until enteral feedings are begun.
Hyperglycemia
I. Definition: Unknown and controversial, although the neonatal staff has suggested a definition of plasma glucose as >200 mg/dL.2 Hyperglycemia almost always occurs in the first hours to days of life. II. Incidence: Unknown. III. Infants at Risk: Infants with birth weights > 1 kg receiving intravenous fluids at high dextrose infusion rates >8mg/kg/min); VLBW infants < 1 kg at moderate glucose infusion rates (4-8 mg/kg/ min); infants with congenital diabetes mellitus (rare); infants receiving, or whose mothers received, selected drugs, e.g. diazoxide. IV. Signs: Polyuria due to glycosuria (rare if blood glucose < 250 mg/dL); intracranial hemorrhage if hyperglycemia occurs rapidly as a result of an abrupt increase in plasma glucose concentration, e. g., following an i.v. D25W or D50W glucose bolus. As noted above, use of either of these high concentration glucose solutions is to be avoided. V. Diagnosis: Same as hypoglycemia, i.e., plasma glucose measurement is needed--NOT Chemstrip. VI. Treatment: If plasma glucose > 200 mg/dL. A. Reduce glucose infusion rate. B. IV insulin administration (0.1 U/kg/hr) if reducing the rate of glucose infusion is not effective, or is not possible. This treatment should not be undertaken without first consulting the staff neonatologist. VII. Guidelines for Monitoring Plasma Glucose in Hyperglycemic infants: Plasma glucose measurements should be determined every 1 to 4 hours depending on the degree of hyperglycemia, with therapy adjusted according to plasma plasma glucose results. Glucose determinations should be done on capillary blood from an extremity, or from a non-glucosecontaining indwelling catheter.
Normoglycemia
I. Definition: Plasma glucose 50-100 mg/dL in infants not receiving i.v. fluids. II. Guidelines for Monitoring Plasma and Urine Glucose in Infants Receiving I.V. Fluids: A. Blood Glucose Monitoring (see table at end of this section):
Monitoring of plasma glucose concentrations in sick and premature infants receiving parenteral fluids is indicated. When clinically feasible, try to do this at times when other blood work is being done. This will reduce the number of heelsticks. 1. Newly admitted infants without risk factors for hypoglycemia should have a plasma glucose value measured between 1 and 4 hours after birth and again between 8-16 hr unless clinical circumstances mandate earlier glucose testing. 2. Subsequently, infants at high risk who are receiving only i.v. fluids, should have plasma glucose determinations done every shift for 3 days and once a day for days 47 after birth. In infants not at high risk, consider monitoring plasma glucose levels once or twice a day in the first week of life. 3. In infants who have been on i.v. fluids for over 1 week, and whose plasma glucose values have been within the normal range monitoring of plasma plasma glucose, may be decreased to twice a week. Use of blood glucose screening using semi-quantitative reagent strips, i.e. Chemstrips, is to be discouraged.2 In addition, do not use blood from arterial lines for glucose determination. Infants whose plasma glucose values are < 200 mg/dL may have their infusion rate of glucose (and lipid) increased to provide additional energy if their caloric intake is deemed suboptimal (< 90 kcal/kg/dL). It is prudent to increase glucose infusion rate slowly (1-3 mg/ kg/min) with change made once/day. For infants receiving long-term i.v. fluids, the upper limit of the glucose infusion rate used may be defined by the infant's plasma glucose values. An infant whose glucose has been stable on plain IV fluids may show hyperglycemia with the addition of lipids. Conversely, the addition of protein (NVN) may require an increase in the role of dextrose administration.
B. Urine: Urine should be tested by the nursing staff once a shift for glucosuria. Some infants, especially those <1,000g, may not be able to fully utilize high glucose infusion rates, and will spill glucose in their urine. Although glucose-induced osmotic diuresis is rare in neonates, it should be looked for once glucosuria is present. The presence of glucosuria is an indication to perform a chemical determination of plasma glucose for the purpose of defining an individual infant's renal glucose threshold. If glycosuria is present and the
plasma glucose is <200 mg/dL, it is NOT necessary to decrease the glucose infusion rate. In the management of extremely small infants weighing <700 g, it may be advisable to perform less frequent plasma glucose monitoring (once daily), and to rely more on the results of urine glucose testing. In these situations, if plasma glucose testing documents the absence of hypoglycemia, urine glucose testing may be substituted for blood glucose testing for the purpose of avoiding hyperglycemia. Infants whose blood glucose values are within the normal range, and whose urine glucoses are negative, may have their glucose infusion rate increased to increase energy intake if deemed appropriate. References: Cornblath M, Schwartz R, Aynsley-Green A, Lloyd JK. Hypoglycemia in infancy: the need for a rational definition. Pediatrics 1990;85:834-837. Cornblath M, Schwartz R. Disorders of Carbohydrate Metabolism in Infancy. 3rd ed. Philadelphia: W.B. Saunders, 1991, pp. 87-124, 225-246.
This graph may be used in your management of neonates as an aid for determining: 1. the i.v. rate needed to achieve a desired glucose infusion rate, i.e., in mg/kg/min as is needed for writing orders; or 2. determining the glucose infusion rate of an existing i.v. to determine an infant's caloric intake. As an example, a 2.5 kg infant whom you would like to have receive 6 mg/kg/min of glucose should be receiving 9.5 cc/hr of D10W (equivalent to 90 cc/kg of i.v. fluid). Section Top | Title Page
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Metabolic Problems in Infants of Diabetic Mothers (IDM'S)

I. Maternal Factors: The degree of illness in the IDM has been associated with the duration, severity and control of the mother's diabetes. Hence, essential points in the maternal history are: A. White's Class of diabetes (increasing from "Classes" A->R), B. Therapy (diet, insulin, oral hypoglycemic drugs, etc.), C. Time of the last insulin injection prior to delivery since this affects maternal glucose, D. Amount and type of IV fluids given during labor and delivery, E. Estimated gestational age , and F. Degree of chronic glucose control during pregnancy by HgbA1c and/or by maternal outpatient glucose "home" monitoring. II. Congenital Anomalies: Because the incidence of congenital anomalies is increased in IDM's, a thorough physical examination is essential. In particular, the incidence of congenital heart disease and anomalies of the nervous system, e.g., anencephaly, spina bifida, microcephaly, caudal regression syndrome, are higher in IDM's. (This knowledge also has important implications in counseling diabetics who have delivered and adolescent girls who have diabetes.) III. RDS: The IDM is at greater risk for RDS than most non-IDM infants of comparable gestational age. During the first hours of life, all IDMs should be observed carefully for this morbidity and treated promptly. IV. Hypoglycemia: The incidence of hypoglycemia in IDMs has been reported as high as 50% in some studies. Optimally, cord blood obtained at delivery should be sent to STAT for a true plasma glucose level. The higher the cord plasma glucose value, the greater the likelihood the infant will develop hypoglycemia within the first hours of life. The incidence of hypoglycemia is highest at 1-4 hours of age after the fall in plasma glucose following the cessation of maternal glucose infusion (see Figure). In the asymptomatic infant, true plasma glucose should be monitored at 1,2,4,6,9,12, and 24 hours. Because of their inaccuracy, Chemstrips are not recommended for this purpose. The hypoglycemia in IDMs is usually transient and easily treated. (See section on hypoglycemia for therapeutic approach.) All IDM's without respiratory distress should be fed by nipple or gavage by 2 hours of age. If the clinical condition is such that s/he cannot tolerate enteral feedings by 2 hours of age, an IV infusion of D10W should be considered. V. Hypocalcemia: The infant should be monitored for hypocalcemia frequently occuring in the first 24 hours (see section on "Hypocalcemia"). VI. Polycythemia: A screening capillary hematocrit should be obtained at 4 to 6 hours of life since the incidence of hyperviscosity is higher in IDM's. Values > 65% should be repeated immediately by a peripheral venous ("central") hematocrit. (see section on "Polycythemia/Hyperviscosity"). References: Cornblath M & Schwartz R. Disorders of Carbohydrate Metabolism in Infancy. (3rd Ed.). Philadelphia:W. B. Saunders, 1991. Widness JA . Fetal risks and neonatal complications of diabetes mellitus. In Brody SA, Ueland K and Kase N. Endocrine Disorders in Pregnancy. Norwalk, CN: Appleton & Lange,1989:273297.

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Recommendations for Plasma Glucose Testing of Neonates While in the Hospital

Jaundice Pulmonary Neurology
Infant's Age After Birth 4-7 d(if on i. v. fluids) >4 d (enterally fed) >7 d (if on i. v. fluids
0-24 hr
Metabolic
1-3 d
Hypoglycemia
Fluid Management Feeding Infection Hematology Pharmacology Procedures Abbreviations Commonly Used in the Nursery
Screening Infants at risk x5: 1, 2, 4, on i.v. fluids 8, &24 hr * (includes enterally fed & without i. v.) Infants not at x2: 1-4 hr & risk on i.v. 8-16 hr fluids Infants not at prn clinical risk enterally signs fed Any infant with signs of STAT x1 hypoglycemia Confirmed gluc <40 mg/dL Asymptomatic Symptomatic Hyperglycemia Screening Confirmed gluc >200 mg/ dL same as for high & low risk hypoglycemia above every 1-4 hr until <200 mg/dL depending on severity every 1-2 hour with Tx until normal, then resume screening every 20-30 minutes with Tx until asymptomatic & gluc >40, then resume screening x3/d => x1/ shift (includes those enterally fed x1/d (only if on parenteral fluids) x2/wk (only if on parenteral fluids)
prn clinical signs
x1-2/d
x1/d
prn clinical signs prn clinical signs
x2/wk
prn clinical signs
NA
NA
STAT x1
STAT x1
STAT x1
STAT x1
Infants at risk include: IDMs, IGDMs (especially those whose mothers recieved oral hypogylcemic agents), LGA (>90%ile), SGA ("IGUR": <10%ile>, post-asphyxiated, APGAR <5 at five minutes, polycythemic, immune hemolytic disease, suspected sepsis, hypothermia (rectal temperature >35C), congenital anomalies, Beckwith-Weidman syndrome, infants < 36 wks gestation, infants > 42 wks gestation, & infants whose mothers recieved large amounts of i. v. glucose prior to delivery. *In the "micropremie" with transparent skin which could break down, consider decreasing the number of plasma glucose determinations by monitoring urine "dipsticks" for the appearance of dextrose. Since these infants will invariably have parenteral glucose infusions runing,
hyperglycemia is often a more common clinical finding. Section Top | Title Page
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Mean Blood Glucose in First Hours of Life

Figure: Serial Changes in the concentration of glucose in the blood of infants immediately following delivery. The group from mothers with gestational diabetes have abnormal intravenous glucose tolerance tests during pregnancy but received no insulin therapy. Note initially elevated levels in the mothers. (Adapted from McCann, et al, N Engl J Med. 1966; 275:1, with permission.) Section Top | Title Page
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Iowa Neonatology Handbook: Fluid Management

Fluid and Electrolyte Management in the Newborn

Edward F. Bell, M.D. and Michael J. Acarregui, M.D.
Careful fluid and electrolyte management is essential for the well being of the sick neonate. Inadequate administration of fluids can result in hypovolemia, hypersomolarity, metabolic abnormalities and renal failure. In the near term and term neonate excess fluid administration results in generalized edema and abnormalities of pulmonary function. Excess fluid administration in the very low birth weight infant is associated with patent ductus arteriosis and congestive heart failure, intraventricular hemorrhage, necrotizing enterocolitis and bronchopulmonary dysplasia. A rational approach to the management of fluid and electrolyte therapy in term and preterm neonates requires the understanding of several physiologic principles. Physiology: A. Body Composition and Surface Area 1. The body composition of the fetus changes during gestation with a smaller proportion of body weight composed of water as gestation progresses. 2. The preterm fetus or neonate is in a state of relative total body water and extracellular fluid excess. After birth this excess water must be mobilized and excreted. 3. A proportion of the diuresis observed in both term and preterm infants during the first days of life should be regarded as physiologic. 4. 4. The surface area of the newborn is relatively large and increases with decreasing size. Therefore, insensible water losses will be greatest with small size and decreased gestational age. B. Hormonal Effects: 1. The Renin-angiotensin system is very active in the first week of neonatal life resulting in increased vascular tone and elevated levels of aldosterone. 2. Increased aldosterone levels enhance distal tubular reabsorption of sodium resulting in an impaired ability to excrete a large, or acute, sodium load. 3. Arginine vasopressin (AVP, ADH) levels rise after birth. AVP secretion is increased in response to stress, such as birth, asphyxia, RDS, positive pressure ventilation, pneumothorax and intracranial hemorrhage. C. Renal Hemodynamics: After birth, renal blood flow increases in response to increased blood pressure (renin-angiotensin) with a secondary increase in glomerular filtration rate. However, the neonatal kidney is less efficient at excreting an acute sodium or water load than the kidney of an infant or child. D. Sodium Homeostasis: 1. Sodium is required for fetal growth with an accretion rate of 1.2 mEq/kg/day between 31-38 weeks. 2. Sodium retention is aided by increased aldosterone levels in newborns. 3. In preterm infants <34 weeks sodium reabsorption is decreased, the fractional excretion of Na may exceed 5%. However, the preterm infant is unable to rapidly increase sodium excretion in response to high sodium levels or a large sodium load. E. Water Handling: Both term and preterm infants are able to excrete dilute urine. Conversely, preterm infants are able to concentrate urine to ~ 600 mOsm/L and the term infant to ~ 700 mOsm/L. (Adults can concentrate to ~ 1300 mOsm/L.) Therefore, both preterm and term neonates generally have the capacity to regulate their intravascular volume within a range of fluid intakes. Based on the above principles:
1. One should expect a 10-15% weight loss over the first 5-7 days of life (up to 20% in infants <750 g). 2. Infants which experience significant intrapartum stress will be slow to void and will therefore require less fluid over the first 24-48 hours. 3. The small or extremely immature infant <1000 g will experience increased insensible water losses (IWL). IWL = (I-O) - ( wt). 4. As the preterm and term infant is able to regulate urine output in response to hypovolemia, urine output will reflect intravascular volume. In other words, the infant will generally not maintain inappropriately high urine output in the face of intravascular volume depletion. Recommendations 1. Initiate fluid therapy at 60-80 ml/kg/d with D10W, (80-150 ml/kg/d for infants 26 weeks). 2. Infants <1500 g should be covered with a saran blanket and strict I&O should be followed. For infants < 26 weeks the saran blanket should be applied directly upon the infant to minimize IWL. 3. Infants <1000 g should have electrolytes and weights recorded every 6-8 hours; every 12 hours for infants 1000-1500 grams. 4. For serum Na+ >145 mEq/L, increase infusate by ~10 mL/kg/d without Na+ in the infusate. 5. Increase fluids for urine output <0.5 mL/kg/hr by ~10 mL/kg or, in infant 26 weeks, calculate IWL and change fluids accordingly. 6. Infuse Na+ free fluids (including flushes) until serum Na+ <145 and good urine output is established (post diuretic phase). Then add 3-5 meq/kg/d Na+. 7. Add KCl (2-3 meq/kg/d) to IV fluids after urine output is well established and K+ <5 mEq/L (usually 48-72 hours). 8. Increase fluid administration gradually over the first week of life to 120-130 cc/kg/d by day 7, allowing for expected physiologic weight loss.
Special Cases
While the above guidelines are more directed toward the LBW infant, especially <1000 g, they are generally applicable to most neonates; however, there are instances where these guidelines should be modified. Some of the more common modifications are noted below: 1. Postoperative abdominal surgery: Fluid requirements may be twice or three times that noted above. The more extensive the procedure the greater the needs! These infants may require 125-150 ml/kg/day immediately postoperative with subsequent increases as determined by blood pressure measurements and urine output. Isotonic saline also may be required because of third spacing of fluid into tissues and other spaces, e.g., the bowel lumen. Strict I&O is mandated. Gastric drainage is replaced q8-12h, depending on volume, with isotonic saline. Colloid also may be needed because of rapid fluid shifts, decreases in arterial pressure, and increases in capillary filling time (i.e., > 3 sec.). 2. Asphyxiated infants: These infants may have increased secretion of arginine vasopressin (which is likened to SIADH) and are thought to be at increased risk for cerebral edema. Their fluid intake should be kept on the low side for 48-72 h, i.e., 60 ml/kg/day, or until seizures are no longer considered a problem. These infants require close monitoring of serum sodium and weight. Treatment of SIADH is by restriction of fluids, not increased sodium intake. 3. Infants of diabetic mothers: These infants receive i.v. glucose because of increased danger of hypoglycemia; however, they frequently do not receive sodium and have been found to develop rather substantial hyponatremia at 24 h if this is not added at or before this time. This danger is greater the greater rate of glucose needed to maintain blood glucose. Addition of sodium should be considered at 16-18 h. Section Top | Title Page
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Iowa Neonatology Handbook: Fluid Management

Fluid Therapy in the Neonate

Edward F. Bell, M.D. and Michael J. Acarregui, M.D.
Fluid therapy for the neonate can be rationally planned if several physiologic concepts are kept in mind. Firstly, the neonate has an excess of total body water at birth, particularly extracellular water, which must be redistributed and excreted. The renin-angiotensin system is in high gear during the first week after birth; thus not only is plasma angiotensin II likely to be elevated, but also aldosterone, which is a mineralocorticoid and has the potential to modulate sodium excretion/reabsorption. The surface of the newborn is large and increases with decreasing size; therefore there is a greater likelihood of excess insensible water loss (IWL), which may be exaggerated as birth weight and gestational age decrease and open radiant warmers rather than incubators are used. Finally, in most instances the neonatal kidney has the capacity to not only dilute urine, but also to concentrate it, reaching values of 600-700 m0sm/L (specific gravity 1.015). It should be noted, however, that this is less than that seen in adults or term infants. These observations are contrary to previous "beliefs," and each of these aspects of the neonate are reviewed elsewhere (J Pediatr 101:387, 1982). Our goal in the low-birth-weight (LBW) infant 1599 g is to allow a gradual weight loss over the first week, i.e., 5-6% over the first 24 h and 12-15% by the end of the first week. We also attempt to maintain urine output 0.5 ml/kg hr. If IWL plus urine output significantly exceeds intake, weight loss may be greater than desired and occur more rapidly in the preterm LBW infant. This in turn may result in development of hypernatremia since fluid losses through the skin are essentially free water. To take each of these into account, the first approach to fluid therapy is adequate monitoring and appropriate supportive care. Thus, all infants 1000 g birth weigh should be maintained on a bed scale, kept on "strict" input and output measurements, and covered with a "saran blanket" to minimize IWL, especially if cared for in an open radiant warmer. It is estimated that the nongrowing neonate requires 60-75 kcal/kg/day and that fluid losses are closely related to caloric expenditure. Thus, in the first 1-3 days after birth fluid requirements are likely to be in the range of 65-75 ml/kg/day in a neutral thermal environment. To accomplish this we use 10% dextrose in water (D10W). Therefore, at 24 h the fluid should be changed to D10 with 1/4 isotonic saline. The addition of KCl to the infusate should be considered by day 3 if there are no contraindications, e.g., poor renal function or hemolytic disease, at 2-3 mEq/kg/ day. Although negative potassium balance occurs with this approach it is quickly corrected. Our approach to fluid therapy has been to gradually increase the volume to approximately 75-80 ml/kg/day on day 2, 90-95 ml/kg/day on day 3, and -125 ml/kg/day by day 7. At 14 days most infants are receiving about 135 ml/kg/day. References: 1. 2. 3. 4. 5. J Pediatr 101:387, 1982. J Pediatr 101:423, 1982. The Body Fluids in Pediatrics, Winters RW (ed), Boston, Little Brown & Co., 1973. Clinics in Perinatology 9:483, 1982. The Micropremie: The Next Frontier, 99th Ross Conference on Pediatric Research, Columbus, OH, 1990.
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Iowa Neonatology Handbook: Feeding

Nutritional Management of the Preterm Infant

Ekhard E. Ziegler, M.D.
Recent years have seen marked changes in the general approach to the nutritional management of preterm infants. The changes reflect a growing awareness of the potential for adverse consequences from starvation and undernutrition during the neonatal period. There can be no doubt that neurodevelopmental processes are susceptible to nutritional insults. The temporary postnatal growth arrest, which we have come to accept as inevitable, is potentially preventable, if not in its entirety, then at least to a large degree. Somatic growth is a useful indicator of nutritional sufficiency. When somatic growth is near normal, significant nutritional insults to the CNS are unlikely. On the other hand, when somatic growth is abnormal, there is always the possibility of adverse effects on neurodevelopment. Therefore, nutritional efforts aimed at enabling somatic growth as it would have occurred in utero are well justified because they enhance the chance that growth and development of the CNS will continue without interruption. The trend in recent years has been towards earlier and more aggressive use of parenteral nutrition. This was made possible by expanded use of percutaneously placed central vein catheters. An innovation in enteral feedings has been the use of "trophic" feedings starting very soon after birth. The idea is to prevent intestinal atrophy from occurring, so that, when feedings start in earnest, the gut does not have to go through a lengthy rehabilitation period. Together these two developments have made for greatly improved nutritional management, especially of very small preterm infants. Section Top | Title Page
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Handbook Home General Jaundice Pulmonary Neurology Metabolic Fluid Management Feeding Infection
Parenteral Nutrition
Ekhard E. Ziegler, M.D.
General concepts
Most neonatologists now embrace the idea that a nutritional insult (starvation) is unlikely to have beneficial effects in an infant already under intense stress. Efforts at minimizing the duration and severity of starvation must, of necessity, rely heavily on the parenteral provision of nutrients. The prevailing hormonal milieu, which accounts, among other things, for glucose intolerance, places limitations on our ability to provide nutritional support. But, within these limitations, nutritional intake should be maximized -- and the earlier, the better. Enteral nutrition should be pursued all the while, but with a view toward nourishing the gut rather than the whole baby.
Indication and time of intiation

The smaller the infant, the greater the need for parenteral nutrition and the greater the urgency to initiate it. Thus, infants with birth weights less than 1500 g should, with few exceptions, receive parenteral nutrition as a matter of routine. These infants should be on TPN by 48 hours of age at the latest. There is no rationale for withholding TPN in these infants for a period longer than is technically required to order and start TPN. Postponing the initiation of TPN simply means that greater nutrient deficits will accrue and that it will take more time later on to make up for the deficits. On the other hand, larger infants require parenteral nutrition only when enteral feedings are not possible for periods of more than a few days. Because larger infants have greater nutrient reserves, the urgency to start nutrition support is much less than in smaller infants.
Prescribing parenteral nutrition

Three neonatal venous nutrition (NVN) solutions are available. Their main components are listed in Table 1. Table 1: Composition of Neonatal Venous Nutrient Solutions1 (per liter) Standard Amino acids2 (g) Dextrose (g) Sodium (mEq) Chloride (mEq) Potassium (mEq)3 Calcium (mEq) 1.4 25-250 35 10 0 20 High Amino Acid 2.1 25-250 35 10 0 20 10 4 20 High Amino Acid electrolyte-free 2.1 25-250 1 0 0 20 0 4 10
Phosphorus (mmol) 10 Magnesium (mEq) Acetate (mEq) 4 17
All solutions also provide (per liter): 2 mg zinc, 0.4 mg copper, 0.2 mg manganese, 4 g chromium, 10 g selenium; 2 Trophamine or Aminosyn PF; cysteine is added at 14 mg/g amino acids 3 Higher when potassium is added (e.g., 30 mEq when K is 20 mEq) The standard and high-amino acid solutions differ only in their amino acid content. We retain the designation "standard" for the solution providing 1.4% amino acids, although high amino acid solutions are now used at least as frequently as the standard solution. The concept behind the standard solution is that in 100 ml/kg/day it provides 1.4 g amino acids per kg/day, the presumed maintenance requirement. If one of the high amino acid solutions is prescribed at 60-70 ml/kg/ day, that same amino acid intake is achieved, albeit in a smaller volume. In patients with labile electrolyte and/or blood glucose levels, the remainder of the daily fluid volume can be provided from glucose-electrolyte solutions that can be changed readily in response to changing needs. Potassium, when it is needed after the first few days, has to be prescribed as a separate item. The electrolyte-free solution is free of sodium, potassium and chloride. It is intended for the small preterm infant during the first few days of life and provides maximum flexibility in working around the common fluid-electrolyte problems of small infants. It goes without saying that, once the electrolyte disturbance has been resolved that prompted the use of an electrolyte-free solution, supplemental electrolytes must be provided or an electrolyte-containing solution used. Vitamins (MVI Pediatric) must be prescribed separately. The dosage is 2.0 ml/kg/day for babies weighing up to 2.5 kg. Babies weighing >2.5 kg receive the maximum dose of 5.0 ml/day.
Dosage of amino acids

There is no rational basis for intakes less than 1.4 g/kg/day (i.e., maintenance, Table 2) at any time, even on the first day that TPN is given. Whenever energy intakes exceed 40 kcal/kg/day, intakes of amino acids should be increased beyond 1.4 g/kg/day. As a rough guideline, an amino acid/energy ratio of approxiamately 3.5 g/100 kcal should be maintained. In this way it is ensured that the infant receives sufficient amino acids at all times, especially if and when growth occurs. In larger infants, a lower ratio, e.g., 3.0, should be used. Table 2: Suggested Amino Acid Intakes Of Preterm Infants (g/kg/day) <1000g Parenteral maintenance 1.4 maintenance & growth 3.2 Enteral 4.0 1.4 3.0 3.8 1.4 3.0 3.5 1.4 2.8 3.2 1000-1500g 1500-2000g 2000-2700g
Special needs
When higher than usual intakes of calcium and phosphorus are desired, e.g., in case of marked osteopenia, or simply to prevent osteopenia, increased concentrations of these minerals can be given. The permissible concentrations depend on the amino acid and glucose concentrations in the TPN solution. Consult the dietitian and/or pharmacist regarding prescribing information. If additional acetate is desired for the management of metabolic acidosis, it can be added as the Na or K salt. The choice of salt(s) will depend on serum electrolyte levels.
Parenteral Lipids
The primary reason for providing parenteral lipds remains the provision of essential fatty acids. That objective is achieved with a lipid intake of 0.5 g/kg/day. There are good reasons for using lipid also as source of fuel, although it appears that a good portion of lipids goes into storage rather than being oxidized as fuel. Intakes of up to 2.5 g/kg/day are commonly used in preterm infants and appear to be safe, as long as they are given slowly. Lipid emulsions are available as 10% and 20% emulsions, with some reports suggesting more favorable metabolic effects with 20% emulsions than 10% emulsions.
Certain rules must be followed. Lipids should be given as slowly as possible, i.e., spread out over 20 hrs each day whenever possible, leaving 4 hrs for administration of intravenous medications. Triglyceride levels should be monitored if rates greater than 150 mg/kg/hr are used. If visible lipemia is noticed, the lipid infusion should be stopped and a serum triglyceride level measured.
Monitoring
Because blood glucose and electrolytes are already being closely monitored in preterm infants, no routine monitoring is required specifically for infants receiving parenteral nutrition, with one exception. Because electrolyte-free TPN is also phosphate-free, serum phosphorus must be monitored if such a solution is used for more than 2 days. Whatever the BUN is, a small rise of it is to be expected when TPN is started or when the amino acid intake is increased. An important rule in monitoring is never to draw the blood sample from a line that contains the substance to be monitored. No amount of flushing can guarantee that you are not obtaining a falsely high value! Section Top | Title Page
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Handbook Home General Jaundice Pulmonary Neurology Metabolic Fluid Management Feeding Infection Hematology Pharmacology Procedures
Enteral Feedings
Ekhard E. Ziegler, M.D., and Susan J. Carlson, M.M.Sc., R.D., C.S.P., L.D., C.N.S.D.
Feeding the Gut (Trophic Feedings) The provision of small amounts of feedings starting soon after birth aims at preventing atrophy of the gut. A number of studies in recent years have demonstrated the general feasibility of this approach as well as beneficial clinical effects, with no recognizable increase in the risk of necrotizing enterocolitis. Although we have no formal protocol for the use of trophic feedings, such feedings are being used increasingly and their use is encouraged. Colostrum/human milk should be used whenever available. Otherwise, preemie formula should be used. The use of dilute formula, although practiced widely, has no rational basis and no demonstrated benefits, except that the larger volume may improve gastric emptying. Trophic feedings should be initiated at a volume not to exceed 15 ml/kg/d. These feedings are traditionally given in small boluses of 1 - 3 ml/kg per feeding. Trophic feedings should continue until the infant's respiratory and cardiac status have stabilized. Older preterm infants (i.e. > 27 weeks) and infants with minimal respiratory compromise may bypass trophic feeds and begin feedings using a nutritive feeding regimen. Feeding the Baby (Nutritive Feedings)
When feedings begin in earnest in the stable baby, feedings should be advanced slowly. The rate of increase should not exceed 20 ml/kg/day except in situations where feedings were held and are being restarted. Feeding volume is increased first by reducing the interval between feeds to q 3 hrs or q 4 hrs and subsequently by increasing the bolus volume. Infants less than 1200 g may tolerate larger volumes with continuous (3 hr on, 1 hr off) feedings than bolus feedings. Intestinal motility is often impaired in the infant in the Special Care Nursery due to immaturity, sedation, or critical illness and thus feeding aspirates are common. Aspirates should be checked but, as a rule, should be refed, except when they are clearly bilious or when there are other clear signs of bowel obstruction. Aspirates greater than 2 ml, especially if they contain mostly milk or formula rather than gastric juice, should prompt a physical examination of the infant, and subsequent aspirates as well as the infant's medical condition should be monitored closely. Human Milk Milk provided by the infant's mother is, of course, the feeding of choice. Fresh milk that has not been frozen is preferred when available. Freezing entails some loss of nutrients, but, with the exception of live neutrophils and lymphocytes, all the protective components of breast milk remain essentially intact. Expressed, stored milk should always be fed in the order in which it was obtained. In this way, the infant receives the colostrum first, which is most protective, followed by transitional and mature milk. If mother's milk is not available, donor milk from the Mother's Milk Bank of Iowa may be substituted. Donor milk is mature human milk and likely contains less protein and sodium than mother's preterm milk but still confers most of the immunological and nutritional benefits of human milk. Table 3: advisable Intakes of Growing Premature Infants and Composition of Feedings (per 100 Kcal) Advisable Intakes Preterm Human Fortified Human Preterm Enfamil Premature
7001000 g Protein (g) Na (meq) Cl (meq) K (meq) Ca (mg) P (mg)

1"Preterm"
10001500 g 3.3 2.7 2.4 2.0 154 107
15002000 g 3.0 2.4 2.0 1.9 148 102
Milk1
Milk
Formula
3.6 3.3 2.9 2.3 175 120
2.3 1.7 2.0 2.2 36 20
3.3 2.4 2.2 2.7 143 79
3.0 2.5 2.5 2.5 165 83
milk at 2 weeks of lactation
Because human milk does not contain protein and minerals in amounts needed by the growing preterm infant, fortification is necessary. Table 3 indicates the estimated nutrient requirements ("Advisable Intakes") of preterm infants and contrasts these with the composition of unfortified and fortified human milk. It is evident that fortified milk comes close to meeting the needs of larger infants, but that the needs of smaller infants are met only partially. Fortification should be started when milk feeds of approximately 50 - 80 ml/kg/day are achieved. The composition of the Enfamil Human Milk Fortifier is indicated in Table 4. Standard fortification is one envelope per 25 ml of human milk. Table 4: Enfamil Human Milk Fortifier (nutrients Added To 100 Ml Of Milk) Protein 1.1 g Fat Na Cl K Ca P Fe Mg Zn Cu Mn 1g 0.7 mEq 0.4 mEq 0.7 mEq 90 mg 50 mg 1.44 mg 1 mg 0.7 mg 44 g 10 g
13 vitamins Fortified milk has a caloric density of 80 kcal/dl (24 kcal/oz), assuming caloric density of native breast milk to be 67 kcal/dl. Expressed breast milk is frequently low in fat content and thus contains fewer calories than the assumed 67/dl. Use of calories to quantify breast milk is a convenient practice, but we must always remember that the actual intake of calories is likely to be less than the stated value. In selected cases it may be beneficial to increase fortification by decreasing the volume of milk to which one envelope is added (e.g., to 15 ml). Situations where this might be indicated include very small infants, infants on fluid restrictions, or any infant who fails to gain satisfactorily in spite of receiving what appears to be an adequate intake. The addition of extra fortifier to human milk substantially increases calcium and phosphorus intake, particularly in infants receiving >120 kcal/kg/d from feeds. Routine monitoring of ionized calcium and phosphorus are indicated to prevent the development of hypercalcemia or hyperphosphatemia. The iron content of human milk is negligible. The iron content of Enfamil Human Milk Fortifier will provide a daily iron intake of 2.2 mg/kg/d in infants fed 120 kcal/kg/d. This level of intake is sufficient to meet the
iron needs of growing premature infants. Formula The composition of a typical premature infant formula is included in Table 3. Premature formula has a caloric density of 80 kcal/dl (24 cal/oz). As Table 3 shows, the formula meets the protein needs of larger infants but not of smaller infants. Infants requiring concentrated feedings will receive premature formula mixed with term formula concentrate. Please contact the dietitian if concentrated feedings are required. The addition of carbohydrate and/or lipid is not a suitable means of increasing caloric density of feedings for premature infants as protein and mineral density of the premature formula is significantly reduced. Feedings at Discharge Fortified Human Milk and Premature Formula should be used until the infant is feeding ad libitum or a weight of 3000 g has been reached, whichever comes first. Prior to discharge the infant must be transitioned to an appropriate homegoing regimen. Selection of the appropriate feeding for discharge depend on a number of factors including infant weight, degree of growth failure, need for fluid restriction, and oral feeding skills. The use of Preterm Discharge Formulas (e.g. Enfacare, Neosure) as formula, or mixed with breast milk, may enhance growth in preterm infants discharged to home before reaching term size. Preterm Discharge Formulas are routinely prepared at 22 kcal/oz and have a higher protein and mineral content than term formulas. Concentrated term formula (24, 27 kcal/oz) may be indicated for larger infants (e.g. >2500 g) with inadequate oral feeding skills. Vitamin D and iron supplements are indicated for infants breastfeeding at discharge. No additional vitamin or iron supplements are needed for the formulas fed infant. Table 5 lists guidelines for selection of an appropriate discharge feeding regimen. Table 5: Recommended Feeding Regimens for Infants at Discharge Feeding Type - weight as discharge Breast feeding - weight > 3000 g Recommended Regimen Breastfeeding + ADC/Fe supplement 1 mL/d Breastfeeding + Supplemental feeds 2 - 3 x /day with 24 or 27 kcal/oz Breast milk (Breast milk + Term formula powder) + ADC/Fe supplement 1 mL/d Breastfeeding + Supplemental feeds 2 - 3x / day with 24 or 27 kcal/oz Breast milk (Breast milk + Preterm Discharge Formula powder) + multivitamin/Fe 1 mL/d 20 kcal/oz Term Formula; Use higher kcal formula (24, 27 kcal/oz) if poor intake or fluid restricted 22 kcal/oz Preterm Discharge Formula; Use higher kcal formula (24, 27 kcal/oz) if poor intake or fluid restricted
Breastfeeding - weight > 3000 g poor growth / intake, or increased energy needs
Breast feeding - weight < 3000 g (consider supplemental feeds if slow weight gains)
Formula feeding - weight > 3000 g
Formula feeding - weight < 3000 g

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Guidelines for Use of Human Milk in the Nursery

Janet F. Geyer, R.N., A.R.N.P., C.P.N.P. and Ekhard E. Ziegler, M.D.
I. Expressed human milk is to be fed only to the infant whose mother provided the milk. II. Expressed milk is precious to the mother and the baby and should be treated as a valuable commodity. It should be discarded only for a good reason. III. Containers for storage of expressed milk should be small in size (4 oz. or less). If milk is to be frozen it should be stored in airtight containers (plastic or glass containers, or disposable baby bottle bags) with as little head space as possible. IV. Milk that will be fed within 48 hours of expression should not be frozen but be kept refrigerated at all times, including while being transported to the hospital. It is preferable to collect such milk in plastic containers. Sterile urine containers are acceptable. V. Milk that will be stored for 48 hours or more should be frozen immediately after expression and transported to the hospital in the frozen state. Transport (on ice or in a cooler) should occur at least once a week, preferably more often. Milk should be frozen in portions approximately equal to the amount needed for one or two feedings. VI. Once thawed, milk should not be kept at room temperature for more than 4 hours. If kept refrigerated, it may be kept for up to 24 hours. VII. Instructions given to the mother should be specific and complete, with emphasis on cleanliness. Washing of hands with soap and water and of the breasts with water alone should be stressed. Mothers should be instructed to empty breasts as completely as possible because incomplete emptying produces milk with low caloric content (low fat). Rules pertaining to ingestion of drugs by the mother are listed in "The Effect of Drugs Taken by the Nursing Mother on Her Infant" (p. 102). The mother should notify her own and the baby's physician of any symptoms of mastitis, and milk from an infected breast should not be fed. VIII. Milk may be expressed by hand, manual pump or electric pump. The most effective and least traumatic pumps are the Medela and Egnell electric breast pumps. Electric breast pumps are available for rent from drugstores and medical supply businesses across Iowa. Rental sources in Iowa City include Pearson's Drugs, Towncrest Drugs, Miller Medical Supply and Hawkeye Medical Supply. University Hospital has a lending service available for indigent and Medicaid patients. Some insurance companies will pay for the rental of an electric breast pump with a prescription for breast milk. The collection container for the breast pumps needs to be washed in hot soapy water and rinsed in hot water between use. The Davol hand pump (looks like a bicycle horn) should not be used for expression of milk that will be stored long term because of the reported high contamination which occurs due to the difficulty in cleaning the pump. Section Top | Title Page
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Guidelines for the Use of Human Milk Fortifier in the Neonatal Intensive Care Unit
Susan Carlson RD, CSP, LD, Beth Wojcik RD, LD, and Jonathan Klein MD - 5/31/05 Peer Review Status: Internally Peer Reviewed
Background: Fortification of Human Milk is indicated for preterm infants to meet protein and mineral requirements for growth. Current practice in our NICU is to begin HMF when the infant tolerates feeds of 50 &endash; 80 cc/kg/d. Data collected on VLBW infants admitted to the UIHC NICU in 2004 demonstrated that unfortified human milk is used for a period of 2 -3 weeks before fortification is initiated. Mean Age to Start HMF 19 16 12 15 Mean Age to D/C IV fluid 33 24 17 23
Birth Weight <750 g 1000 - 1300 g All Infants
n 25 43 102
750 &endash; 1000 g 34
During the period of time that infants receive unfortified breast milk, they accrue a mineral deficit. Protein intake may also be limited particularly when unfortified breast milk comprises >50% of total fluid intake. These deficits are particularly of concern in the smallest infants (<1000 g) who have higher protein and mineral needs for growth. Studies have shown that the addition of human milk fortifier is associated with short-term improvements in weight, length, and head circumference growth. Other studies suggest human milk fortifier may improve bone mineralization and neurologic outcome. (1-4) The addition of human milk fortifier is well tolerated. An early study by Lucas et al showed an increase in infections (43% versus 31%) and NEC (5.8% versus 2.2%) in infants fed fortified versus unfortified human milk, however the infants in the study received >50% of their feeds from formula (5). Other studies with human milk fortifiers showed an increase in osmolality of the breast milk feeding after initiation of the supplement (6). Recent changes in fortifier composition have minimized this effect by adding fat and reducing the carbohydrate content of the supplement. The addition of human milk fortifier appears to have no effect on the IgA content of human milk or on the concentrations of natural killer cell subsets in preterm infants fed the fortified milk (6,7). While the addition of human milk fortifier may temporarily delay gastric emptying and cause a short tem increase in gastric residuals and emesis, it is not associated with an increase in number of held feedings, incidence of blood in stools, incidence in apnea and bradycardia, or a delay in advancement to full enteral feeds (8-10). Guidelines for the Use of Human Milk Fortifier: 1. Human Milk Fortifier (24 kcal/oz) is indicated for all breast milk fed infants weighing less than 2000 g. 2. Human Milk Fortifier (24 kcal/oz) should be initiated when the infant is tolerating breast milk feeds of > 25 ml/day.
3. Infants who have shown tolerance to breast milk + HMF feeds and were then made NPO should be restarted on breast milk + HMF feeds. 4. Indications for using concentrated breast milk feeds (27 kcal/oz or 30 kcal/oz) in infants who are already tolerating full feeds with HMF (24 kcal/oz) include:
q q q
Fluid restriction < 140 ml/kg. Poor weight gain (<10-15 g/kg/d) on 120 kcal/kg of 24 kcal/oz Breast Milk + HMF Metabolic bone disease (alkaline phosphatase > 600 U/L) with poor bone mineralization on x-ray requiring increased intakes of calcium and phosphorus
5. Infants >3000 g who require concentrated breast milk feeds should receive breast milk mixed with Term Formula Concentrate. 6. Infants on breast milk concentrated with HMF (27 kcal/oz or 30 kcal/oz) who develop hypercalcemia (ionized calcium > 6.5 mg/dl) or hyperphosphatemia (phosphorus > 7.5 mg/dl) should be switched to term formula concentrate to reduce excess mineral intake and receive a Nutrition Consult. Monitoring Guidelines for Infants on Breast Milk + HMF Preterm infants fed breast milk + HMF are at risk for hyponatremia due to the limited sodium content of these feeds and increased urinary sodium losses. Infants fed concentrated breast milk feeds (> 27 kcal/oz) are at risk for hypercalcemia and hyperphosphatemia secondary to the increased mineral content of these feeds. 24 kcal/oz Breast Milk + HMF
q
Check electrolytes weekly until the electrolytes are stable (within normal limits) and the patient is no longer receiving IV fluids or oral electrolyte supplements.
27 kcal/oz Breast Milk + HMF

q
Check electrolytes weekly until the electrolytes are stable (within normal limits) and the patient is no longer receiving IV fluids or oral electrolyte supplements. Check ionized calcium and phosphorus weekly while patient is on concentrated breast milk + HMF. Contact NICU RD if ionized calcium is > 6.5 mg/dl or phosphorus is > 7.5 mg/dl for recommendations to reduce mineral intake with the use of term formula concentrate.
30 kcal/oz Breast Milk + HMF

q
Check electrolytes weekly until the electrolytes are stable (within normal limits) and the patient is no longer receiving IV fluids or oral electrolyte supplements. Check ionized calcium and phosphorus weekly while the patient is on concentrated breast milk + HMF. Contact NICU RD if ionized calcium is > 6.5 mg/dl or phosphorus is > 7.5 mg/dl for recommendations to reduce mineral intake with the use of term formula concentrate.
References: 1. Faerk J, Petersen S, Peitersen B, Michaelsen KF. Diet and bone mineral content at term in premature infants. Pediatr Res. 2000 Jan;47(1):148-56. 2. Gross SJ. Bone mineralization in preterm infants fed human milk with and without mineral supplementation. J Pediatr. 1987 Sep;111(3):450-8. 3. Nicholl RM, Gamsu HR. Changes in growth and metabolism in very low birthweight infants fed with fortified breast milk. Acta Paediatr. 1999 Oct;88(10):1056-61. 4. Pettifor JM, Rajah R, Venter A, Moodley GP, Opperman L, Cavaleros M, Ross FP. Bone mineralization and mineral homeostasis in very low-birth-weight infants fed either human milk or fortified human milk. J Pediatr Gastroenterol Nutr. 1989 Feb;8(2):217-24. 5. Lucas A, Fewtrell MS, Morley R, Lucas PJ, Baker BA, Lister G, Bishop NJ. Randomized outcome trial of human milk fortification and developmental outcome in preterm infants. Am J Clin Nutr. 1996 Aug;64(2):142-51. 6. Jocson MA, Mason EO, Schanler RJ. The effects of nutrient fortification and varying
7.
8. 9. 10.
storage conditions on host defense properties of human milk. Pediatrics. 1997 Aug;100(2 Pt 1):240-3. Tarcan A, Gurakan B, Tiker F, Ozbek N. Influence of feeding formula and breast milk fortifier on lymphocyte subsets in very low birth weight premature newborns. Biol Neonate. 2004;86(1):22-8. Epub 2004 Feb 20. Ewer AK, Yu VY. Gastric emptying in pre-term infants: the effect of breast milk fortifier. Acta Paediatr. 1996 Sep;85(9):1112-5. McClure RJ, Newell SJ. Effect of fortifying breast milk on gastric emptying. Arch Dis Child Fetal Neonatal Ed. 1996 Jan;74(1):F60-2. Moody GJ, Schanler RJ, Lau C, Shulman RJ. Feeding tolerance in premature infants fed fortified human milk. J Pediatr Gastroenterol Nutr. 2000 Apr;30(4):408-12.
Recipes for Fortified Human Milk - Hospital Use: Breast Milk + Human Milk Fortifier for Preterm Infants 24 kcal/oz Breast Milk + HMF 25 mL breast milk 1 packet Human Milk Fortifier 27 kcal/oz Breast Milk + HMF 100 mL breast milk 7 packets Human Milk Fortifier 30 kcal/oz Breast Milk + HMF 100 mL breast milk 7 packets Human Milk Fortifier 30 mL Term Formula Concentrate Reduced Calcium / Phosphorus Breast Milk + HMF 27 kcal/oz Reduced Mineral Breast Milk + HMF 100 mL breast milk 5 packets Human Milk Fortifier 20 mL Term Formula Concentrate 30 kcal/oz Reduced Mineral Breast Milk + HMF 100 mL breast milk 5 packets Human Milk Fortifier 50 mL Term Formula Concentrate Concentrated Breast Milk Feeds for Term Infants 24 kcal/oz Breast Milk 100 mL Breast Milk 25 mL Term Formula Concentrate 27 kcal/oz Breast Milk 100 mL Breast Milk 50 mL Term Formula Concentrate 30 kcal/oz Breast Milk 50 mL Breast Milk 50 mL Term Formula Concentrate

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Guidelines to Enhance Successful Breast-feeding

Janet F. Geyer, R.N., A.R.N.P., C.P.N.P.
A. Advocating for breast-feeding of ill or preterm infants: For inpatient mothers, the Labor and Delivery or Postpartum nurses will:
q q q
Give breast-feeding handouts and discuss feeding options with mother Instruct the mother on pumping and storage of breast milk Assure that pumping is initiated within the first 24 hours after delivery
For mothers of transported infants, the transport nurses will:

q q q
Give breast-feeding handout to mother Ask the local maternity nurse to assure that pumping begins with 24 hours Reinforce decision to breast-feed at regular "call back" times
B. Initiating non-nutritive "time at the breast": Baby meets these criteria:

q q q q
Corrected gestational age about 32 weeks Has ability to swallow own secretions Stable outside incubator at least 10 minutes Tolerates kangarocare
Nursing interventions:
q q q q
Discuss goals of non-nutritive "time at the breast" with mother Help position the baby at the breast Review pumping techniques with mother and assess her ability to pump Arrange housing for the mother close to the nurseries
C. Progress toward non-nutritive sucking Baby displays these signs:

q q q
Mouth is at breast, but may not latch on or suck May swallow once or twice May fall asleep at the breast
q q q q
Avoid feeding with a bottle; continue with orogastric or nasogastric gavage Time feedings with infant hunger cues if possible Teach mother infant feeding cues Begin using the SAIB (Systematic Assessment of Infant at Breast) scale to assess progress toward nutritive sucking Review with mother the importance of pumping every 3 hours (8 times a day) or 100 minutes per day
D. Progress toward nutritive sucking: Baby displays these signs:

q q q
Consistently latches on Feeds for about 5 minutes Shows progress on the SAIB scale
q q q q q q q q q
Communicate infant's feeding progress with physicians and/or nurse practitioners Continue supplements as ordered If infant breast feeds < 5 minutes, provide the entire ordered feeding volume by gavage If infant breast feeds 5-10 minutes, provide 1/2 of the ordered feeding by gavage If infant breast feeds > 10 minutes, nsupplementation is needed Use cue-based feedings when possible Use finger feeding when the mother is unavailable to breastfeed Teach mother to continue to pump between or after feedings if needed Minimize pacifier use until breast-feeding proficiency is achieved
E. Successful transition tbreast-feeding:

q q q q q
Baby wakes up for feedings Mother identifies nutritive suck and swallow Baby feeds well based on SAIB scale Baby shows adequate hydration and weight gain without supplementation Mother is confident in her ability to breast-feed baby at home
q
q q
When mother is not available for breast-feeding, provide milk or formula by finger feeding or, at mother's request, provide milk or formula by bottle Arrange for local breast-feeding support (M.D., La Leche League, lactation specialist) Complete discharge teaching, document in patient record
Written by the Pediatric Nursing Research Committee

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Iowa Neonatology Handbook: Infection

Congenital Infections
Charles Grose, M.D. and Herman A. Hein M.D.
I. Congenital Infections The infant suspected of being infected with syphilis, rubella, herpesviruses (HSV, VZV, CMV), HIV or other agents, particularly the enteroviruses, represents a risk to other infants and hospital personnel, particularly pregnant women. Because it is not possible to isolate all newborns who might have one of these congenital infections, the purpose of these policies is to minimize the risk of nosocomial transmission. II. Rubella Immunity All personnel working in the 4 West Nurseries, both male and female, must be immune to rubella (see personnel policy). III. Precautions A. The infant with known or suspected infection or with known or strongly suspected congenital syphilis, rubella, or enterovirus infection should be placed in strict isolation. If the clinical condition allows (see separate policy for Herpes simplex infections), the infant may be placed in strict isolation with his mother. Pregnant women should not have contact with these infants and a notice to this effect should be posted at the entrance to the room. B. The infant suspected of possibly having a congenital syphilis, rubella or enterovirus may be segregated within an incubator or admitted to an isolation room and placed on excretion-secretion precautions. Pregnant women should not have contact with these infants. The incubator or heater bed should have a secretions precautions label affixed and a label prominently posted stating that no pregnant women should have contact with this patient. C. The requirements for isolation or segregation for other viral or bacterial pathogens can be found in the Hospital Isolation Manual. IV. Universal Precautions: Universal infection precautions should be used with all infants. Those include wearing gloves when performing invasive procedures (such as drawing blood or starting IVs) or when handling a newly born infant who has not been bathed for the first time. A mask, gloves and goggles (or eyeglasses) should be worn when performing procedures where blood may be propelled or splashed into the eyes (such as insertion of arterial catheters). V. HIV Infection: While congenital HIV infection is an uncommon disease in Iowa, knowledge about caring for these infants is very important. Vertical transmissions from an infected mother to her child is the cause of over 90% of AIDS cases in children; it has become the primary cause of new cases as other modes of transmission have been eliminated, e.g., transfusion of contaminated blood products. The perinatal transmission rate is estimated to be 13-39%. Intrauterine, intrapartum, and postpartum infections contribute to this perinatal transmission rate, which is reduced by approximately two-thirds with zidovudine therapy of seropositive pregnant women and their newborns. The newborn therapy involves 6 weeks of oral zidovudine. Breastfeeding by sero-positive mothers is contraindicated in the U.S. where safe, alternative sources of feeding are available. HIV has been detected in breast milk and transmission of HIV by this route has been demonstrated. When a baby is born to an HIV seropositive mother, the nursery health care personnel
should always wear gloves when handling the newborn infant. If possible, the baby should room in with the mother. Diagnosis and testing of a newborn infant of a seropositive mother should include an infectious disease physician consultation as they will play an active role in the infants follow-up. Testing of newborn infants by virologic tests, initially with PCR or culture is recommended at 1 month of age and then between 4 and 6 months of age with subsequent serologic testing and the initiation of antiretroviral therapy if and when indicated. Coinfection with other bacteria or viruses is possible e.g., CMV and excretion-secretion precautions are indicated. Section Top | Title Page
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Handbook Home General Temperature Jaundice Pulmonary Neurology Metabolic
Management of Perinatal Herpes Simplex Infections

Charles Grose, M.D.
Situation I
Oral maternal herpes, or presence of genital vesicles or culture positive genital herpes, with infant delivered by C-section with intact membranes. Management:
1. Secretion precautions for both baby and mother. 2. Newborn to room in with mother if possible; baby can go to and from mothers room in bassinet; mother not allowed in nursery. 3. Mother should be instructed on the importance of careful hand washing before and after caring for their infant and wear a clean loving gown to help avoid contact of the infant with lesions or secretions. 4. Mother with herpes labialis should wear a mask when touching her infant and should not kiss or nuzzle the infant until the lesions are cleared. 5. Ask obstetrician to culture any maternal vesicles (if not already done); culture babys nasopharynx 24 hours after delivery. If the infant is asymptomatic, obtain surface cultures 24-48 hours after delivery and initiate antiviral therapy if cultures are positive.
Situation II
Presence of genital vesicles or culture positive genital herpes with infant delivered per vagina or by C-section after rupture of membranes. Management: 1. 2. 3. 4. Strict isolation of the baby from other infants; secretion precautions for the mother. Baby to room with mother; mother not allowed in nursery. Mother should use gloves when handling her baby. Ask obstetrician to culture any maternal vesicles (if not already done); culture baby 24-48 hours after birth, sooner if symptomatic or acyclovir therapy is to be started. 5. For an infant delivered vaginally whose mother has primary, first-episode infections (risk of infection 30-50%), consider empiric acyclovir treatment after cultures are obtained. 6. For an infant delivered vaginally to mothers with active recurrent genital herpes, the risk of infection is 5% and emperic treatment is not required.
Situation III
History of previous genital herpes with unknown culture result and infant delivered vaginally or by C-section after rupture of membranes. Management: 1. Secretion precautions for baby and mother until maternal culture is negative for >72 hours. Observe infant closely and obtain surface cultures 24-48 hours after delivery. 2. Baby can go to and from mothers room in a bassinet; mother is not allowed in the nursery until her culture is negative for >72 hours. 3. If maternal culture is positive, initiate antiviral therapy and revert to management as in
Situation II. Notify the senior staff obstetrician and neonatologist.
Situation IV
History of previous genital herpes with unknown culture result and infant delivered by C-section with intact membranes. Management: 1. No isolation required. 2. If maternal culture is positive, revert to management as in Situation I.
Situation V
History of previous genital herpes but no active lesions at delivery. Management: 1. No isolation required. 2. Monitor infant for signs of neonatal HSV infection. 3. No routine cultures of an asymptomatic newborn recommended.
Mother in Situations I, II or III should be in a private room if available. Neonates with documented HSV infection or those suspected of HSV infection (even if no risk factors are present) should be in an isolation room with secretion precautions. Neonates with a low suspicion of HIV infection but who are being treated with acyclovir can be placed in the nurseries in an isolette with secretion precautions. Since neonatal HSV infection can occur as late as 6 weeks after delivery, physicians must be vigilant and not ignore a new rash or symptoms that might be caused by HSV. Section Top | Title Page
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Hepatitis B
Charles Grose, M.D.
Mothers are routinely tested for the Hepatitis B surface antigen (HBsAg) status during their pregnancy. There is a risk of both vertical perinatal transmission to the newborn from a mother who is HBsAg -positive, and horizontal transmission to the infant during the first 5 years of life. Thus, it is critical that the infants born to mothers who are HBsAg -positive are recognized and therapy initiated. Hep B Vaccine Maternal HBsAg Status Positive Unknown HBIG Within 12 h of birth Determine maternal HBsAg status: if positive, HBIG within 7 days. If negative, no HBIG No First Within 12 h of birth Within 12 h of birth Second 1-2 months 1-2 months Third 6 months 6 months
Negative
Birth to 2 months
One month after first
6 months after first
Preterm Infants For preterm infants born to HBsAg-positive mothers, both HBIG and Hep B vaccines should be given within 12 h. For those born to HBsAg-unknown mothers, the first vaccine should be given within 12 h and if the maternal status cannot be determined within 12 h, HBIG should be given. Infants born to HBsAg-positive mothers should be serologically tested for anti-HBs and HBsAg 1 to 3 months after completion of the vaccination series; further vaccinations may be required. Section Top | Title Page
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Diagnosis of Infections Caused by Herpes Viruses and Chlamydia

Charles Grose, M.D.
Laboratory Hours and Location

Location: The University of Iowa Hospitals' Viral Diagnostic Laboratory is located in 265 Medical Research Center Telephone Number: 356-4463 Hours: The University of Iowa Hospitals Viral Diagnostic Laboratory is open from 8:00 am to 4:30 pm Monday through Friday and from 8:00 to 11:00 am Saturday and Sundays. Specimens should be in the laboratory no later than 4:00 pm Monday through Friday for processing. Receipt of Specimens After Hours: Every effort should be made to get specimens to the laboratory on the same day they are collected (by 4:00 pm). Overnight storage of specimens, especially urines and tissues, should be avoided; it is preferable to obtain the specimen early the next morning. When this is not feasible, specimens should be taken after 4:00 pm M-F and 0800 to 0800 S-S to 6248 RCP, Specimen Control. All specimens must be on ice.
Transport Media
Collection of the specimen into appropriate transport media is essential to ensure viability of the organisms to be cultured. Transport Systems Swabs: Virocult; Chlamydia Transwab Available from Hospital Stores during regular working hours. Specimen Control during off-hours. Tissue: Broth medium available in the Virology Lab, Specimen Control, 6248 RCP, Frozen Section Room.
Specimen Collection Guidelines For Clinical Virology Lab
A. Send all specimens to 265 MRC or Specimen Control 6248 RCP ON ICE. B. Procedures Available: Isolation and Identification of Herpes simplex, cytomegalovirus, varicella-zoster, respiratory syncytial virus, Chlamydia trachomatis; rotavirus antigen detection; varicella-zoster immune status; and rubella immune status. A. Do not clean area to be cultured with alcohol. B. Viral a. Herpesviruses (CMV, HSV, VZV) i. Vesicle Fluid: Virocult swab of fluid obtained from disrupted vesicle or lesion. ii. Spinal Fluid: Aseptic collection into sterile containers. iii. Biopsy and autopsy tissue: Immerse tissue in broth transport media. iv. Ulcerative lesions: Swabs (anal, genital, ocular). Use Virocult swab and scrape surface of lesion. v. Urine: Freshly passed AM urine is preferable. Collect clean voided midstream sample or suprapubic aspirate in sterile container. At least two or three specimens should be obtained to maximize recovery of CMV. vi. Blood: q Rubella and Varicella serology: Submit at least 2 ml of clotted whole blood (red top tube) not necessary to hand carry or put on ice. q Buffy coat culture: Submit at least 1 ml of heparinized blood (green top tube). b. Respiratory Syncytial Virus: NP Washings, Tracheal aspirates, sputum; Throat swab as last resort. c. Human Immunodeficiency Virus (HIV) i. Blood HIV serology. Submit at least 2 ml of clotted whole blood (red top tube). ii. Culture. Call State Hygienic Laboratory in Iowa City to obtain current instructions about methods for culturing HIV from blood or other specimens. Remember to obtain consent forms prior to submitting specimens. C. Chlamydia (trachomatis) a. For best results specimens should be aseptically collected with some vigor (swabbing or scraping) to insure an adequate number of epithelial cells in collection media. i. Swab: sterile Chlamydia Transwab * Conjunctiva: firmly stroke the everted lower eyelid with swab; place swab into transport media and transport to the lab on ice. ii. Nasopharyngeal Wash: (Transwab acceptable) q Draw approximately 1-3 ml phosphate buffered saline (PBS) into an infant bulb syringe (or normal saline without preservatives). q Inject fluid into nostrils carefully. q Aspirate fluid from nostril into bulb syringe. Place contents into
sterile tube. iii. Urine: Not suitable for Chlamydia culture. D. Rotavirus Antigen Detection Liquid fecal specimen in sterile container. Swabs not acceptable.
Transport of Specimens
A. Specimen Transport: Carry all specimens ON ICE to: Virology Lab 265 MRC M-F 8 a.m. - 4:30 p.m. Specimen Control 6248 RCP all other times. B. Storage of Specimens After Hours: Viral lability away from living cells necessitates that all viral specimens be transported on ice as rapidly as possible to the laboratory. When a specimen must be obtained after the laboratory is closed, specimens should be refrigerated at 4C, if storage is less than or equal to 48 hrs. Otherwise specimens should be stored frozen at -70 C. Exceptions are urine specimens and tissue specimens which should not be frozen and ideally should be obtained the day they are to be cultured. Clinical Disease Commonly HSV - I, II Associated with Virus Mouth + Lips: gingivostomatitis recurrent herpes labialis Eye: acute follicular conjunctivitis corneal ulceration stromal keratitis CNS: encephalitis throat swab Virocult Brain bx*; CSF; HSV PCR Tissue Transport Media; vesicle fluid or swab; Virocult Clinical Specimens vesicle fluid or swab; throat swab Transport System Virocult
aseptic meningitis Skin: vesicle Generalized Infections: newborn
Buffy coat vesicle fluid* or swab
Green top tube
urine*; Buffy coat*; biopsy; vesicle swab*; throat swab*; bronchial washings; rectal swab*; conjunctivae vesicle fluid lesion swab or fluid (CSF) serum throat swab, vesicle swab* or fluid, CSF*, urine, bronchial washings
Heparinized (green top) tube Virocult Virocult Virocult Red top tube Virocult
VZV
Chickenpox Zoster Generalized Infections: newborn (pregnant mother with chickenpox)
CMV
Generalized Infections: newborn urine*, buffy coat; saliva, CSF CNS: infections Other: hepatitis, pneumonia, mononucleosis urine*, buffy coat; biopsy Green top tube, Tissue Transport Media Chlamydia transport media CSF, urine* Green top tube, Virocult
Chlamydia Trachomatis
Eye: neonate and adult conjunctivitis Respiratory: neonate pneumonia ? adult pneumonia
swab*
nasal wash*;
Chlamydia transport media
nasopharyngeal swab
* Recommended specimen for optimal growth in culture

Care of the Infant Born to a Mother with Prolonged Rupture of Membranes

Herman A. Hein, M.D. and Robert D. Roghair, M.D.
q q
q q q q
Prolonged rupture of membranes is arbitrarily defined as rupture of membranes for greater than 12 hours. If asymptomatic, the infant should be observed in the hospital for 48 hours. A screening CBC with differential may be obtained at birth. If the infant shows clinical signs of illness, a sepsis work-up as outlined below should be performed. If the infant shows clinical signs of illness, a sepsis work-up should be performed. If a sepsis work-up has been performed, the infant should be reassessed at 72 hours. One can consider discontinuing the antibiotics if the clinical course and lab results have not been suggestive of infection and the cultures are negative. If the blood culture is positive, treat for a minimum of 10 days. If the CSF culture is positive, treat for a minimum of 14-21 days. The attending neonatologist should be consulted regarding duration of therapy in all cases. If there is any evidence of chorioamnionitis along with the PROM, a sepsis work-up must be initiated and the baby begun on intravenous antibiotics as soon as possible. The length of antibiotic therapy should be based on the clinical course, lab results, cultures as well as the suspected etiology of maternal fever. The association of maternal fever with epidural analgesia is well known. Please note that if chorioamnionitis is suspected, it is not longer necessary to treat the infant with 10 days of antibiotics if there are no other associated findings pointing to sepsis in the infant.
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Suggested Management of Term Infants Whose Mothers Are Positive for Group B Streptococcus
Edward F. Bell, M.D., Jonathan M. Klein, M.D., Robert D. Roghair, M.D.
Term/preterm Infants With Clinical Signs Of Sepsis A sepsis work-up should be performed to include a CBC with differential, a blood culture and CSF for analysis and culture, and antibiotic therapy initiated. The infant should be reassessed at 72 hours. Consideration can be given to discontinuing antibiotics if the clinical course has not been suggestive of infection, there are no maternal risk factors identified, (e.g., +GBS, chorioamnionitis), lab results are reassuring, e.g., negative serum GBS latex, normal I:T ratio on CBC, normal serial CRPs at 24-72 hours, and the infants cultures are negative. Be aware that the cultures may be negative if there was maternal pretreatment with intrapartum antibiotics. If the infants cultures are positive, if signs of sepsis persist or strong maternal risk factors are identified, longer courses of antibiotics are warranted. Term Infants Without Clinical Signs Of Sepsis With Or Without Pretreatment With Intrapartum Antibiotics These infants should be closely observed without the need for cultures or antibiotics for 48 hours if they are asymptomatic. A screening CBC with differential should be obtained. If the infant becomes symptomatic or if the CBC with differential has an I:T >15%, a sepsis work-up as outlined above should be performed. The length of antibiotic therapy will depend upon the clinical course, lab results, maternal risk factors and infants cultures.

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Suspected Sepsis in the Newborn

I. Due to various factors, newborn infants, both preterm and full-term, are highly susceptible to sepsis during the newborn period. In contrast to older infants, children and adults, the signs of sepsis in the newborn are vague and nonspecific. The earliest signs may be apnea, respiratory distress or poor feeding. Other signs and symptoms include lethargy, temperature instability, hyperbilirubinemia, bradycardia, seizures and acidosis. II. When sepsis is suspected, a sepsis work-up should be performed to include a CBC with differential, blood culture and CSF for analysis and culture. Antibiotics should be started as soon as the work-up is complete. Urine culture may be omitted from sepsis work-ups done at birth but should be included in subsequent sepsis work-ups. If there are other circumstances indicating the origin of the sepsis, additional appropriate cultures should be obtained, such as tracheal fluid or from an area of cellulitis. III. Infants with sepsis frequently have an elevated absolute band count, and/or depressed absolute neutrophil count, or increased I:T ratio (See Total Granulocyte Count, p. 106, and reference values for WBC indices, p. 107). However, a normal WBC count in an infant with signs of sepsis (see I), does not rule out infection, and thus antibiotics should be started while awaiting culture results. IV. The antibiotic regimen for sepsis work-ups performed at birth, or admitted as a neonate less than 30 days old, is ampicillin and gentamicin. If the infant has been in the nurseries and sepsis is suspected, the antibiotic regimen should include vancomycin and gentamicin. Piperacillin should also be considered if there is suggestion of possible gram-negative infection, e.g., in a tracheal aspirate gram-stain, or if pseudomonas is
Used in the Nursery
V.
VI. VII.
VIII. IX.
X.
present in the nursery. Acyclovir therapy should be considered if HSV infection is possible, pending the results of a workup for HSV. This work-up should include surface cultures for HSV, liver function tests and CSF for cell count and HSV PCR. When a sepsis work-up has been performed, the infant should be reassessed at 72 hours. Consideration can be given to discontinuing antibiotics if the clinical course has not been suggestive of infection and the cultures are negative. If the blood cultures are positive, treat for 10 days. Obtain a repeat blood culture after 24-48 hours of therapy to insure effective therapy. If the CSF culture is positive, treat for 14-21 days. In infants with positive cultures, antimicrobial therapy is adjusted according to the sensitivities. Serum levels of antibiotics should be followed as recommended on page XX. If C-reactive proteins (CRP) are obtained, an initial CRP of <1 is not a definite confirmation of the absence of infection. If obtained, serial levels 24 to 72 hours after the sepsis work-up is performed should be obtained, and these values along with the clinical course of the patient and the results of CBCs and cultures will determine the duration of antibiotic therapy. Isolation requirements will be determined according to the organism and the site of infection. Please consults the isolations manual. If the patient is neutropenic, several therapies are possible: q G-CSF at a dose of 10 g/kg subQ or IV qday to b.i.d. can be administered until the ANC is >1500. q IVIG can be administered to augment the immune system until the ANC has recovered. q A granulocyte transfusion can be considered following discussion with the staff neonatologist if definite or strongly suspected infection is present. See Guidelines for Neonatal Transfusion Therapy, p. 203. If the absolute neutrophil count is very low, a granulocyte transfusion may be considered. This option should be discussed with the staff neonatologist.
Reference: Manroe BL, et al. The neonatal blood count in health and disease. I. Reference values for neutrophilic cells. J Pediatr 1979;95:89-98.

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Use of Drug Monitoring Levels in the Special Care Nurseries

Jonathan M. Klein, M.D. and Thomas N. George, M.D.
General guidelines
q
Antibiotic dosing and intervals for gentamicin and theophylline should be administered as described in the Iowa Neonatology Handbook (pp 133,134). Vancomycin should be dosed at 15mg/kg, at the same intervals as described in the Handbook. Antibiotics should be withheld until the level is known, and an order to that effect should be written. If the trough level is greater than acceptable, the drug should not be given and another level checked 6 hours later, and this should be repeated as needed until a safe level is obtained. Peak levels are not necessary for patients being treated with a course of antibiotics without an identified organism. If a blood culture is positive, and an organism and sensitivities are identified, both peak and trough levels should be obtained to ensure adequate dosing. If 10 days of antibiotics are planned, and the first trough level obtained is acceptable, consider repeating the trough levels at 4 to 6 days into therapy to ensure non-toxic levels, especially if there is evidence or concern of impaired renal function.
Gentamicin
q
A gentamicin trough level should be obtained within 1 hour of the dose: Gestational age 30 weeks, obtain level prior to the administration of the 3rd dose. Gestational age < 30 weeks, obtain level prior to the administration of the 2nd dose. If impaired renal function is a concern, a level should be obtained before the 2nd dose. An acceptable trough is < 2 mg/mL. Peak levels are not necessary for patients being treated with a course of antibiotics without an identified organism. If obtained, an acceptable peak is 5 8 mg/mL and should be obtained 30 minutes after the infusion.
Vancomycin
q
A vancomycin trough level should be obtained within 1 hour of the dose: Gestational age 30 weeks, obtain level prior to the administration of the 3rd dose. Gestational age < 30 weeks, obtain level prior to the administration of the 2nd dose. If impaired renal function is a concern, a level should be obtained before the 2nd dose. An acceptable trough is < 10 mg/mL. Peak levels are not necessary for patients being treated with a course of antibiotics without an identified organism. If obtained, an acceptable peak is 20 40 mg/mL and should be obtained 30 minutes after the infusion.
Theophylline
q
Either a trough or peak level will provide adequate information regarding dosing. A theophylline trough level should be obtained 0 - 2 hours before the scheduled dose, and the dose administered without awaiting the result. Consider writing the theophylline order to reflect times of administration to be at 8 am, 4 pm and 12 am. This would allow the level to be drawn with morning labs if the patient is on a q 8 h schedule. An acceptable theophylline trough level is 8 12 mg/ml. If obtained, an acceptable peak level is 15 - 20
mg/ml, and should be obtained between 2 and 4 hours after drug administration.

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Reference Range for WBC Indices (after Manroe Et Al)

Herman A. Hein, M.D.
Used in the Nursery

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Scalp Abscess
Herman A. Hein, M.D.
I. Electronic Tracing Electronic fetal heart rate monitoring has become an integral part of high risk obstetric management. Nearly one-half of the infants born at University Hospitals are presently monitored with an in-utero spiral electrode applied to the scalp or other presenting part. II. Complications A. A complication of this type of fetal monitoring, recognized in less than 1% of these infants during hospitalization, is the development of an abscess at the site of the electrode attachment. Microbiology reflects contamination by vaginal bacterial flora (predominantly anaerobes, occasional strep and gram negatives, and not staph aureus). If the infant is clinically ill, cultures should be obtained and the usual systemic antibiotics should be given providing the results of the cultures. If the infant is clinically well, the primary therapeutic modality is incision and drainage, followed by local wound care. B. Parental instruction in wound care and precautions as well as local physician follow-up remain integral to successful management. Section Top | Title Page
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Immunoglobulin Therapy
Chetan A. Patel M.D. and Edward F. Bell, M.D.
Maternal IgG is the major source of fetal and neonatal IgG; hence, the antibody profile of the neonate is dependent on the profile of antibodies in the maternal circulation. Since significant transfer of maternal IgG across the placenta to the fetus does not begin until the 32nd week of gestation, VLBW (<1500 g) infants are born with relatively low levels of IgG compared with full-term infants. Furthermore, in all infants, serum immunoglobulin levels decline further after birth. In term infants, the postnatal physiologic trough occurs at 4 - 6 months of age, but serum IgG levels usually remain above 400 mg/dl. Preterm infants can have levels as low as 60 mg/dl by 3 months of age. Infectious diseases are a significant cause of morbidity and mortality among preterm infants. The risk of neonatal sepsis is 4 to 10 times higher among infants < 2500 g than in term infants. The incidence of sepsis is gestational age dependent, infection rates reported as high as 50% in infants <1000 g. The survival of low birth weight infants has improved greatly in recent years. But the care of these infants involves procedures (endotracheal intubation, catheters, lines, broadspectrum antibiotics) that increase their risk of nosocomial infection. Together, the increased risk factors for sepsis and the relative quantitative and qualitative IgG deficiency in preterm infants (that increases with postnatal age) provide a rationale for intravenous immunoglobulin (IVIG) therapy as a means for prophylaxis and treatment of neonatal sepsis. However, clinical studies have failed to substantiate consistently a beneficial effect of prophylactic use of IVIG in reducing the incidence of hospital-acquired infections in VLBW infants (Baker 1992; Fanaroff, 1994). A meta-analysis of studies done does however suggest a demonstrable benefit of prophylactic IVIG in preventing sepsis in LBW newborns (Jensen, 1997). Recent evidence suggests that the use of immunoglobulin may be appropriate in the following group of infants. The use of IVIG must be cleared by the attending physician. This list and the references below are not meant to be comprehensive. I. Prophylaxis to prevent nosocomial infections in preterm infants with BW < 750 g: IVIG 500 mg/kg IV over 3 - 4 hours (@ 10 ml/kg volume), starting the first week of life and every 2 weeks as long as the infant has an indwelling IV line (maximum of 5 doses). Whenever possible, administer doses on Mondays to reduce cost by allowing multiple infants to be treated from the same vial of IVIG. Further rationale for prophylatic use of IVIG and the results of several large clinical trials are described in the references cited at the end of this section. II. Treatment for infants with proven early-onset neonatal sepsis (esp. with Group B strep infection or with accompanying neutropenia): IVIG 500 mg/kg IV over several hours. The immunoglobulins serve both a therapeutic role (enhancing humoral immunity and clearing the organism) as well as a prophylactic role in helping to prevent superimposed infections. Shortening the bacteremic phase may also limit damage from secondary immune or nonimmune factors contributing to the shock-like state. Total IgG titers in treated, septic neonates remain elevated for 10 days. Meta-analysis of the effectiveness of IVIG in the treatment of early-outset sepsis shows that the addition of IVIG to standard therapies increases the survival nearly six-fold (Jensen 1997).

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Tolerance of IVIG Administration to Neonates

Chetan A. Patel M.D. and Edward F. Bell, M.D.
IVIG should be administered by itself, with careful monitoring during the infusion. Vital signs should be monitored during the infusion (preferably q 15 min. X 2, then q hr). In the large multicenter trials involving infants, very few adverse reactions were noted during infusion. These consisted of mild increases or decreases in blood pressure, heart rate, or temperature (that were reversed by slowing the rate of infusion) or acute fluid overload. Since the dose of IVIG is equivalent to an approximately 10 ml/kg fluid bolus, the infusion is administered over several (typically 3 - 4) hours. Brand name Gammagard (Baxter) Gamimune N (Miles-Cutter) Form 0.5, 2.5, 5 and 10 g vials Characteristics pH 6.8, 2% glucose, 0.3% albumin Reconstituted In Cautions Sterile Water Rate dependent side effects on HR, BP, Temperature
5% solutions pH 4.25. (Premixed)
10% maltose (For Above; Isotonicity) Hyperglycemia, and rare decreased pH 0.9% NaCl, D5W, or sterile water Above, Hyperglycemia
Sandoglobulin (Sandoz)
1, 3, and 6 g vials
pH 6.6, 5 or 10% sucrose (1.67 g)
References: Jensen HB, Pollock BH. Meta-analysis of the effectiveness of intravenous immunoglobulin for prevention and treatment of neonatal sepsis. Pediatrics, 1997; 99:E2. Baker CJ, Melish ME, Hall RT, et al. Intravenous immune globulin for the prevention of nosocomial infection in low-birth-weight neonates. N Engl J Med 1992; 327:213-9. Fanaroff AF, Korones SB, Wright LL, et al. A controlled trial of intravenous immune globulin to reduce nosocomial infections in VLBW infants. N Engl J Med 1994; 330:1107-1113. Kliegman RM and Clapp DW. Rational principles for immunoglobulin prophylaxis and therapy of neonatal infections. Clin Perinatol 1991; 18:303-24. Weisman LE, Stoll BJ, Keuser TJ, et al. Intravenous immune globulin therapy for early-onset sepsis in premature neonates J Pediatr 1992; 121:434-43. Section Top | Title Page
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Management of Infants with RSV (Respiratory Syncytial Virus) Infection

RSV infection causes bronchiolitis and pneumonia in infants. Morbidity is high in infants with chronic pulmonary disease or congenital heart disease. RSV infection can be quickly diagnosed in the virology laboratory, by rapid antigen testing on a nasopharyngeal swab. A respiratory panel culture can also diagnose RSV. Infants hospitalized with RSV should be placed in strict isolation. Infants who are at high risk for significant morbidity and/or mortality should be identified and treated prophylactically. Two prophylactic therapies are available:
q
RespiGam is RSV immunoglobulin that also may afford protection against other viral pathogens. It requires intravenous administration over 3-4 hours every 4 weeks. Hence, its use is limited to infants with evidence of more severe chronic lung disease. See "Guidelines for Immunoprophylaxis against RSV". Synagis is RSV monoclonal antibody that is specific against RSV. It requires intramuscular injections every 4 weeks. It should be considered for preterm infants without evidence of significant chronic lung disease. See "Guidelines for Immunoprophylaxis against RSV".
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Guidelines for Immunoprophylaxis Against Respiratory Syncytial Virus in High-Risk Infants

Division of Neonatology, Children's Hospital of Iowa The following guidelines are suggested for selecting patients to receive RSV immune globulin (RespiGamTM) or humanized RSV monoclonal antibody (SynagisTM) to reduce the risk of serious RSV infection during RSV season. RespiGamTM Infants with severe chronic lung disease, defined as follows, should be considered for monthly infusions of RespiGamTM.
q q
Infants less than 6 months of age requiring home oxygen therapy at _ lpm or more, and Infants 6 months to 1 year of age requiring home oxygen at _ lpm or more.
These infusions should begin at the onset of RSV season or, if the infant is discharged from the hospital during RSV season, at the time of discharge; the infusions should be continued once monthly until the end of RSV season. SynagisTM Other infants (below 2 years of age) who require home oxygen therapy (or who have just come off oxygen therapy in the 2 months prior to the onset of RSV season) but do not meet any of the above criteria for RespiGamTM, should be considered for monthly injections of SynagisTM. In addition, monthly injections of SynagisTM should be considered for infants of gestational age 28 weeks or less even if they do not require home oxygen provided they are discharged during RSV season (or shortly before) and are less than 6 months old. These injections should begin at the onset of RSV season or, if the infant is discharged from the hospital during RSV season, at the time of discharge. Finally, any other infants born at or before 32 weeks gestation who are discharged during RSV season should be considered for a single dose of SynagisTM at the time of discharge. Departures from these guidelines may be appropriate in individual cases based on exposure risk, other confounding medical problems, and other factors. The presence of a cardiac lesion with systemic-to-pulmonary shunting increases the risk of a complicated course with RSV infection; infants with such lesions should be considered for prophylaxis with SynagisTM or RespiGamTM. References Groothuis JR, Simoes EAF, Hemming VG, et al. Prophylactic administration of respiratory syncytial virus (RSV) immune globulin in high risk infants and young children. N Engl J Med. 1993; 329:1524-30. RespiGamTM Product Information. MedImmune, Inc. Gaithersburg, MD. 1996 (January). Impact-RSV Study Group. Palivizumab, a humanized respiratory syncytial virus monoclonal antibody, reduces hospitalization from respiratory syncytial virus infection in high-risk infants. Pediatrics. 1998; 102:531-7.
SynagisTM Product Information. MedImmune, Inc. Gaithersburg, MD. 1998 (19 June).

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Iowa Neonatology Handbook: Hematology

Transfusion Guidelines for Preterm and Term Infants

I. Diagnosis of Anemia:
Well established, scientifically founded criteria for the diagnosis of anemia in the neonate are not available at present. This void is in part due to the difficulty in studying patients who are unable to communicate how they feel ("symptoms") and the fact that objective clinical "signs" of neonatal anemia are non-specific and thus frequently are indicators of problems other than anemia, e.g., sepsis, apnea, seizures, growth failure ("failure to thrive"), etc. Defining when clinically significant anemia is present is an area of active research. See UI NICU Guidelines for Administering 15mL/kg Erythrocyte Transfusions to Neonates for our NICU's transfusion guidelines for preterm infants. Infants should not be treated to replace phlebotomy losses alone. Instead, as shown in the Table, a combination of the patient's clinical condition (primarily his/her respiratory status) and the presence of peripherial hematocrit values below levels specified for the various degrees of illness are used. II. Treatment and Prevention of Anemia: A. Mimimize phlebotomy losses: s Keep laboratory testing to only those tests which are needed. This is especially true in the first weeks of life when sick infants have the greatest amount of blood drawn due to their often tenuous condition. B. Transfusion with packed red blood cells (PRBCs): s Good clinical practice dictates and regulatory agencies advise that chart documentation of the reason that the transfusion is being administered should be recorded. Transfuse to achieve a calculated hematocrit of approximately 45%, or give a maximum volume of 15 mL/kg. As a "rule of thumb," for each 1 mL of PRBCs transfused (Hct of 85%)/kg, anticipate a 1% increase in the patients hematocrit. Hence for 15 mL of PRBC/kg, a pre-transfusion hct of 32% should rise to approximately 47% when checked several hours after transfusing. s Transfuse using irradiated (only infants with birth weights <1.5 kg) filtered to reduce CMV risk, packed red blood cells (Hct 85%). The blood bank routinely screens all blood for other viral pathogens including HIV, hepatitis B, hepatitis C, and HTLV I/II. Assuming a packed cell hematocrit of 80-90% and a blood volume of 80 mL/kg: C. Erythropoietin (EPO): s Multicenter U.S. and European VLBW clinical trial results indicate that EPO therapy is of marginal clinical benefit as it is currently being administered. Thus, if EPO therapy is considered this needs to be discussed with the staff attending. If EPO is to be used, the dose is 200-300 U s.q./kg/ d every other day. Enteral iron intake should be increased to 6 mg/kg/d during EPO treatment.
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UI NICU Guidelines for Administering 15mL/kg Erythrocyte Transfusions to Neonates**

"WELL" <------------------SEVERITY OF ILLNESS------------------> "SICK" CATEGORY I Subgroup CATEGYOR CATEGORY CATEGORY Subgroup A Subgroup B II (mild resp III (mod IV (severe C (pre(asymptomatic) (symptomatic) dis) respir dis) resp dis) surgical) <20% (& A. REQUISITE Retics <100K/ HEMATOCRIT: uL or < 2%) B. RESPIRATORY DISEASE: Conventional ventilation High frequency ventilation CPAP < 25% < 30% < 30% < 35% <40%
<--------None to mimimal---->
Mild MAP < 6 cm. water MAP < 8 cm. water MAP < 6 cm. water
Moderate MAP 6-10 cm. water MAP 9-12 cm. water MAP 6-10 cm. water
Severe
None None None
None None None
None None None
Yes Yes Does not apply
FI02 Nasal Cannula with 100% o2 C. CLINICAL SIGNS:
< 0.25 <1/16 L/min.
< 0.25 <1/16 L/min. Any 1 of 4 signs listed below*
< 0.25 <1/16 L/ min.
>0.25 but <0.35 1/8 - 1/4 L/ min.
>0.35 >1/4 L/min.
>0.35 Does not apply
Absent
Major Sepsis, NEC, surgical Often present Often present blood loss, procedure etc.
* 1) sustained tachycardia averaging > 180/min. for >24 hours based on the nursing record; 2) sustained tachypnea > 80/min. for >24 hours based on the nursing record; 3) >10 apnea or bradycardia/8 hours, or > 2 apneic or bradycardic episodes reuiring bag & mask ventilation in 24th; or 4) weight gain < 10 g/day x 4 days while receiving > 100 kcal/kg; Rule of Thumb: For each 1 mL or PRBC's transfused (hct of almost 85%) kg, anticipate a 1 % increase in the hematocrit. Hence for the recommneded Tx volume of 15 mL PRBC/kg, a pre-transfuion hct of 32% should rise to approximately 47% when checked several hours after transfusion. References: Oski FA, Naiman JL, Stockman III JA., & Pearson HA (1982). Polycythemia and Hyperviscosity in the Neonatal Period. In: M. Markowitz, ed. Hematologic Problems in the Newborn: Volume IV. Major Problems in Clinical Pediatrics (3rd ed.). Philadelphia: PA: Saunders, 1982:56-83. Stockman JA III. Anemia of prematurity: Current concepts in the issue of when to transfuse. Pediatric Clinics of North America 1986;33:111-128.
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Hemolytic Disease of the Newborn Due to Maternal Erythrocyte Alloimmunization

I. Historical Perspective & Overview Hemolytic disease of the newborn has become a less and less common condition due largely to improved preventative measures such as the maternal administration of Rh immune globulin during the early 3rd trimester and the immediate postpartum period. With rare exceptions, it is presently possible to prenatally detect all non-ABO affected fetuses by testing for antibodies in maternal blood. Most recently fetal cordocentesis has been utilized with increasing success to detect and to treat fetal anemia, i.e., with intravascular transfusion, in pregnancies identified prenatally, perinatal mortality and morbidity have been significantly improved. Infants followed by the High Risk Obstetrical service at the University of Iowa, are most commonly born close to term, have no to mild anemia, and are not jaundice in the first 24 hours. The most common neonatal problem today is that of anemia developing following discharge. II. Diagnosis A. ABO blood group incompatibility: Since blood type is not routinely tested at birth, the diagnosis is almost always made after it is recognized that the infant is jaundice. It is uncommon for these infants to be significantly anemic and very rare for them to present with hydrops at birth. The diagnosis is made when the infant is A, B or AB and has a positive direct Coombs test and a positive indirect Coombs result for anti-A or anti-B. The mother will lack the A or B antigen which is positive in the indirect Coombs test. B. Rh and other "minor" blood group incompatibilities: Due to maternal screening for this condition, these infants are almost recognized prior to delivery. A positive direct Coombs test on the neonates blood with identification of a specific serum antibody known to be associated with hemolytic disease (some blood group antigens, e.g., Lewis are not) makes the diagnosis. III. Management: A. ABO blood group incompatibility: Although anemia should be looked for, hyperbilirubinemia is the primary morbidity associated with ABO blood group incompatibility. Management of this condition follows that described elsewhere in this manual (see section on "Management Of Hyperbilirubinemia in the Newborn Period"). The chance for this occurring again in future pregnancies is unpredictable. B. Rh and other "minor" blood group incompatibilities 1. Prior to delivery a. obtain a careful history of past and present obstetrical history and a history of previous neonatal outcomes including 1. Outcome of previous pregnancies, i.e., fetal & neonatal deaths, prematurity, etc. 2. past & present history of in utero erythrocyte transfusion(s) 3. past & present hydrops, and 4. previous neonatal exchange transfusion for hyperbilirubinemia. b. In cases where a severely affected, anemic infant is anticipated (a rarity in recent years), packed type O Rh- blood cross-matched against maternal serum should be available for possible immediate booster transfusion (see Neonatal Blood Bank Procedure Manual). 2. At delivery
a. Severely Affected Infants: Immediately following birth, the severely affected infant may have problems with circulatory and respiratory failure due to intrapartum depression and anemia, not bilirubin toxicity. Fortunately, this is a rare event with present obstetrical management. If present, ascites may create ventilatory embarrassment and paracentesis should be considered. Pulmonary problems similar in infants with neonatal depression and/or RDS may also occur. After initial stabilization, the infant should be transferred to the NICU. In the rare event that severe anemia is thought to be present and the infant's primary problem, a small exchange transfusion with packed red blood cells, 20-40 mL/kg given in the delivery room, may be indicated. b. Mild to Moderately Affected Infants: If the delivery room assessment of infants indicates that the infant is not severely affected but still has some concerning signs, these infants should be transferred to the NICU (or Intermediate Care Nursery if appropriate). c. Infants With No Signs Of Clinical Illness Or Jaundice: These infants may be sent to normal nursery if they meet this nursery's other criteria for admission. d. Cord Blood Laboratory Determinations: Before the umbilical cord blood clots, an immediate blood sample should be drawn with a large gauge needle and syringe from the placental portion of the umbilical cord and placed in an EDTA anticoagulated tube (lavender top) and red top tube. These samples should be sent to the for the hospital laboratory for blood group and direct Coomb's test. 3. In the nursery: a. Severely Affected Infants: Following transfer to the NICU most severely affected infants warrant having an umbilical or peripheral arterial catheter inserted for monitoring blood pressure, pH and blood gases. As noted above, if severe anemia is present, a small exchange transfusion with packed red cells, 20-40 mL/kg, may be indicated. An infusion of D10W with maintenance electrolytes should be initiated through an arterial line or peripheral IV. A full "two volume" exchange for hyperbilirubinemia should be delayed for several hours until the infant's initial condition has stabilized (see below). If blood is not needed to treat anemia, hypotension may be corrected with Plasmanate. b. Mild to Moderately Affected Infants: Treatment of less severely affected infants starts with correction of hypotension and acidosis. If clinical condition and gestational age allow, oral feedings should be started in first four hours of life. c. All Affected Infants, i.e., those which are Coombs positive: 1. Laboratory Determinations: Bilirubin: The frequency of laboratory determinations will depend on the severity of the hemolytic disease, previous values and therapy. Data available on the cord blood sample will be helpful in anticipating these needs as well. In the first 12-24 hours, severely affected jaundiced and/or anemic infants should be started on phototherapy and have their serum total bilirubin levels be measured every 2-4 hours to establish a trend in its rate of rise. Less severely affected and apparently normal infants may be managed without phototherapy but should have serum bilirubin levels measured every four to six hours for the first 24 hours of life. Measurement of direct bilirubin should be one once, preferably during the first day. Infants found to have an elevated direct bilirubin in cord blood should liver enzyme determinations made and be repeated weekly. Hemoglobin and hematocrit values should be determined at 8-12 hours of age, before and after each exchange transfusion and daily until stable. Since the severely affected infant often has -cell hyperplasia, the infant should be monitored and treated in a similar manner to infants of diabetic mothers. In addition, blood glucose levels should be
monitored 1 and 2 hours after each exchange transfusion in which CPDA-1 blood is used. 2. Phototherapy: Phototherapy should be initiated within the first 4 hours of life based on the cord bilirubin level and the subsequent rate of rise of the serum bilirubin concentration. This may avoid the need for an exchange transfusion. It is essential that the infant continue to have serum bilirubin levels monitored while under phototherapy. 3. Exchange Transfusions: The need for and timing of exchange transfusions should be done in consultation with the attending physician. Criteria for exchange transfusion do not change because of phototherapy. After exchange transfusion, serum bilirubin levels should be measured by the chemical method at 2-4 hours after the exchange, and then every 4-6 hours. 4. Intravenous Immune Globulin Therapy Although the mortality rate for exchange transfusion is probably lower than 1%, treatments as effective but less invasive and which have fewer risks would be appealing. One such treatment appears to be evolving. Rh antibodies do not fix compliment and do not induce intravascular hemolysis. The mechanism of destruction of antibody-sensitized red blood cells is probably antibodydependent cellular cytotoxic effects mediated by cells of the RE system. Thus, erythrocyte destruction is similar to destruction of antibody-sensitized platelets in neonatal isoimmune thrombocytopenia. It has been shown in this latter disease that high dose intravenous immune globulin therapy can produce beneficial effects. Accordingly, it seemed plausible that similar therapy might alter the course of bilirubin production and reduce the rate of exchange transfusions in infants with Rh isoimmunization. The results of a recent study that tested this hypothesis concluded that, although the mechanisms was yet unknown, that indeed, high dose intravenous immune globulin therapy (500 mg/kg i. v. over 2-3h as soon as Rh incompatibility is established) did reduce serum bilirubin levels and the need for blood exchange transfusions in children with Rh hemolytic disease (J PEDIATR 1992;121:93-7). The optimum dose of intravenous immune globulin, the most efficacious number of infusions, and the best preparation remain to be determined. Undoubtedly, some of these questions are being answered in trials currently in progress. We would encourage ongoing dialogue of house staff with attendings on the neonatology services to ascertain the current status of this treatment. 4. At Discharge: Post-hospital Care Plan a. Parents: Parents need to be aware that affected infants who may or may not have been anemic at birth (especially those who received one or more in utero erythrocyte transfusions) are at considerable risk for developing clinically significant anemia during the first 3-4 months of life. Their infants should have weekly hematocrit and reticulocyte counts performed and receive simple packed erythrocyte transfusions (20-25 mL/kg of PRBCs) if clinical symptoms appear if Hb levels fall below 6-7 gm/dL without evidence of a reticulocytosis, i.e., reticulocyte count <1%, or <100,000 per L. Although infants can become sufficiently anemic to develop congestive heart failure, more often they manifest evidence of poor feeding or lack of activity. Life threatening clinical signs can occur in the presence of superimposed acute illnesses, i.e., viral infections. b. Local Physician: S/he should be contacted and given the same information as the parents along with an offer to provide the opportunity for future telephone consultation with an NICU staff neonatologist (Dr. Widness or Bell are particularly interested in
following these infants).
References: Millard DD, Gidding SS, Socol ML, et al. Effects of intravascular, intrauterine transfusions on prenatal and postnatal hemolysis and erythropoiesis in severe fetal isoimmunization. J Pediatr 1990;117:447-454. Weiner CP, Williamson RA, Wenstrom KD, Sipes S, Grant SS, Widness JA. Management of fetal hemolytic disease by cordocentesis: I. Prediction of fetal anemia. Am J Obstet Gynecol 1991;165:546-553.

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Polycythemia-Hyperviscosity Syndrome
I. Diagnosis: True whole blood viscosity cannot be routinely measured on blood samples. Viscosity increases with increasing central venous or arterial hematocrit, the diagnosis rests on the presence of polycythemia (hematocrit > 65%) and in the presence of clinical signs consistent with the diagnosis. This condition is almost always found in high risk infants during the first 24 hours of life. II. High risk infants: A. SGA infants E. Transfusions, e.g., twin-twin, maternal -> fetal B. LGA infants C. IDMs F. Trisomies, e.g., Down Syndrome, 13, & 18 D. Delayed cord clamping III. Clinical signs of hyperviscosity: A. Lethargy F. Tremulousness B. Hypotonia G. Seizures C. Weak suck H. Plethora D. Difficult to arouse I. Tachypnea or respiratory distress E. Irritable when aroused J. Abdominal distention IV. Screening: High risk infants who are asymptomatic for hyperviscosity should have a screening capillary hematocrit obtained at 4-6 hours of age. This allows equilibration of postnatal hematocrit following placental transfusion at delivery. Infants with symptoms consistent with hyperviscosity should be tested immediately. A. Capillary hematocrit > 65% at 4-6 hours of life should be followed up immediately with a peripheral venous (or arterial) spun hematocrit. B. Capillary hematocrits > 60% drawn before 4 hours of life should be repeated with a second capillary hematocrit at 4-6 hours of life. V. Associated laboratory findings: A. Abnormal chest X-ray: cardiomegaly, increased vascularity, hyperaeration, alveolar infiltrates, pleural effusions. B. Thrombocytopenia C. Hypoglycemia D. Hyperbilirubinemia (not apparent for at least a day or two) VI. Associated clinical conditions attributable to hypervisocity: A. Increased pulmonary vascular resistance leading to pulmonary hypertension B. Increased systemic vascular resistance C. Increased myocardial strain D. Hypoxemia E. Pulmonary venous congestion
F. Decreased regional blood flow s Gut (NEC) s Kidney s Brain s Myocardium (CHF) G. Thromboses and gangrene H. Increased glucose utilization I. Local consumption of platelets VII. Treatment A. Treatment of the asymptomatic infant with a hematocrit between 65-70% is controversial. B. Treatment of the symptomatic infant with partial exchange transfusion. Estimated blood volume = 80-85 mL/kg; Hct desired = 50-55%; Example: A 3.3 kg infant has a venous hematocrit of 72% and needs a partial exchange transfusion. You woulld like his post exchange Hct to be 50%: Avoid push-pull technique through the UV catheter. To do so, remove blood through umbilical venous (or arterial if necessary) catheter while infusing an equal volume of Plasmanate or normal saline at a similar rate through a peripheral vein. The push-pull method has been associated with an increased risk of NEC. References: Goldberg KE, Wirth FH, Hathaway WE, Guggenheim MA, Murphy JR, Braithwaite WR, and Lubchenco LO. Neonatal hyperviscosity II. effect of partial plasma exchange transfusion. Pediatrics 1982;69:419-425. Gross GP, Hathaway WE and McGaughey HR. Hyperviscosity in the neonate. J Pediatr 1973;82:1004. Hein HA and Lathrop SS. Partial exchange transfusion in term, polycythemic neonates: absence of association with severe gastrointestinal injury. Pediatrics 1987;80:75-78. Oski FA, Naiman JL, Stockman III JA., and Pearson HA. Polycythemia and hyperviscosity in the neonatal period. In: M. Markowitz, ed. Hematologic Problems in the Newborn: Volume IV. Major Problems in Clinical Pediatrics (3rd ed.). Philadelphia: PA: Saunders, 1982:87-96.

Bone Marrow Aspiration: Indications

I. Chromosome Analysis To obviate the need for doing an unnecessary bone marrow analysis, it is essential to check that a prenatal chromosome analysis via CVS, amniocentesis, or cordocentesis has not previously been done. Infants with multiple anomalies may have been previously evaluated by Ob-Gyn and thus tested. A. Situations in which procedure may be considered: Although a diagnosis can be made in a relatively short time (6-30 hours vs. 48-96 hours for peripheral blood samples), the use of bone marrow aspirations should be reserved for the diagnosis of conditions which are considered to be incompatible with life such as Trisomy 13, 18, or Triploidy (rarely). Accordingly, a patient with probable Down Syndrome would normally not be a candidate. In considering bone marrow aspiration, the technical of doing so must be considered. These include: 1. The failure rate for chromosome results for bone marrow sample is high (810%) relative to that of peripheral blood (<1%) 2. Chromosome morphology is generally poor, not allowing for identification of small, chromosomal rearrangements 3. Even in successful cases, the yield of analyzable cells is small increasing the risk of missing mosaicism. While the results are pending, most situations are ones in which non-surgical life support therapies should be offered after discussion with the medical staff and the family. B. Who to contact: 1. Weekdays before 3 pm: Prior to bone marrow aspiration, contact the Cytogenetics Laboratory staff must be called (6-3877) so that the necessary preparation for processing a specimen can be made. If possible, schedule the aspiration prior to 3 pm on weekdays since specimen processing takes approximately 2 hours. To obtain a bone marrow specimen, the pediatric hematologist may be consulted (beeper 339-9023) and the Bone Marrow Laboratory notified (62543) if a smear of the marrow is desired. Since it is the nursery's responsibility to provide the necessary equipment, Central Sterilizing Service must be contacted to provide a "bone marrow aspirate set-up tray". Delivery takes appropriately one half hour. 2. Evenings or weekends: Prior to bone marrow aspiration contact the staff geneticist on call (131-1681), and the cytogenetics lab person on call (call the Cytogenetics Lab at 6-3877 for the recorded message of the current beeper number, or call the long-distance beeper: 1-800-202-8098). Do not perform the bone marrow aspiration until someone from the Cytogenetics Laboratory has been contacted since results cannot be obtained from the specimen if the sample is not processed within 1-2 hours. C. Procedure: Obtain 1-3 cc of bone marrow sample in a green-top heparinized tube. Also obtain a blood sample (2-3 cc) in a green-top tube for a chromosome analysis in case the marrow specimen fails to yield adequate results. If there is enough volume from a marrow sample, the specimen can be set up for both 2 and 24 hour processing. In small aspirate samples, only the 24 hour culture will be set up. Preliminary results from banded chromosomes will be available within six to thirty hours. The final report will be provided in 5-10 days.
II. Thrombocytopenia Bone marrow aspiration for neonatal thrombocytopenia (platelet count < 50,000/mm3) is usually not necessary. However, in difficult or persistent cases, it may be helpful to discuss the evaluation and treatment of this condition with a member of the pediatric hematology division. References Christensen R D, Rothstein G, Anstall H B, Bybee B Granulocyte transfusions in neonates with bacterial infection, neutropenia, and depletion of mature marrow neutrophils. Pediatrics, 1982;70:1-6. Cordle D G, Strauss R G (1993). Guidelines for Neonatal Transfusion Therapy - 1993. Iowa City:UIHC Elmer L. DeGowin Memorial Blood Center, University of Iowa Hospitals and Clinics, 1993. (reprinted in this book, pp. __ - ___). Strauss R G. Current status of granulocyte transfusions to treat neonatal sepsis. J Clin Apheresis 1989;5:25-29.

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Iowa Neonatology Handbook: Pharmacology

Antiarrhythmic Drugs1
Jeffrey L. Segar, M.D.
Dosage Recommendations and Pharmacokinetics of the antiarrhythmic drugs1 Renal Excretion GI Protein (% Absorption Binding Metabolism unchanged)
Drug Adenosine
Effective Plasma Initial Dose Maintenance Conc T 1/2 50 mcg/kg IV push increasing by 50 mcg/kg q2 min until sinus rhythm. Max: 250 mcg/kg See page 135 10 sec
Adverse Effects Flushing, dyspnea
Digoxin
1-2 ng/ml 15-72 hrs (range of means) 10-50 mcg/ kg/min IV 1-5 mcg/ 15-30 ml min
70%
20%
Liver, GI tract
60%
Heart block, arythmia
Lidocaine
1-5 mg/kgIV
<35%
10-50%
Liver
<10%
CNS, decreased myocardial contractility, arrhythmia
Phenytoin
2-5 mg/kg IV 2-8 mg/kg q over 5-10 8-12 hrs P.O. min, repeat up to 20 mg/ kg 3-10 mg/kg IV over 10 min 10-20 mcg/ kg IV over 10 min 20-80 mcg/ kg/min IV 39 mg/kg q4 hrs P.O. 0.05-2 mg/kg q 6 hrs P.O.
5-18 mcg/ml
8-197 hrs (range of means)
>80%
>70%
Liver
<10%
lethargy
Procainamide
3-10 2-4 hrs mcg/ml
>75%
15%
Liver
50-60%
arrhythmia, p ercarditis, pneumonitis bradycardia, hypotension arrhythmia, hypotension
Propranolol
20-100 ng/ml
3-6 hrs
>90% (<30% bioavailable) >90%
90%
Liver
5%
Quinidine
1
Not 5-15 mg/kg q 2-6 mcg/ 6-7 hrs recommended 6 hrs P.O. ml
70-80%
Liver
20-50%
Portions of this information were derived from adult patients
References: Gelband and Rosen, 1975; Guntheroth, 1978; Somogyi et al, 1981; Schreeweiss, 1990; Roberts, 1984 Section Top | Title Page
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Dosage Recommendations for Anticonvulsants Employed in Neonatal Seizures

Jaundice Pulmonary
Drug
Neurology Metabolic Fluid Management Feeding Infection Hematology Pharmacology Procedures Abbreviations Commonly Used in the Nursery
3Phenytoin
Recommended Dosage
Therapeutic Serum Level
Toxicity / Remarks
Phenobarbital 1Loading 15-20 mg/kg IV over 15 - 20 min.

2Maintenance:
3-5 mg/kg IV, IM , POq 12 - 24 hr. (first dose given 12 to 24 hours after loading)
15 - 40 mg/L Sedation, respiratory arrest, hypotension, T1/2 96 h / increase 1st two wk of life; induces drug metabolism (interactions), sensitivity reactions IV push < 1 mg/kg/min.
Loading: 15 - 20 mg/kg IV 10 - 20 mg/ *Maintenance: 5 - 8 mg/kg/ L4 d q 8 - 12 hr IV
*If >1 wk old, may need to increase dosage to 8 mg/kg IV q12 h or q 8h to maintain therapeutic effect / levels *Give first maint. dose 24 hr after loading IV push<0.5 mg/kg/min. IM
Lorazepam
0.05 - 0.1 mg/kg/dose slow IV push over 2 - 3 min.
Onset within 5 min. Duration of action 3 - 24 hr. May increase Phenobarbital level. May cause respiratory depression 0.15 0.3mcg/ml CNS depression, respiratory depression including apnea, phlebitis. Doses may be repeated q 15 - 30 min. x 2 to 3 doses total
Diazepam
50.2
to 0.75 mg/kg slow IV push. Give in maximum increments of 0.2 mg/kg q 2 min. If seizures stop before completion of dosing, discontinue infusion. Rectal dose: 0.5-1.0 mg/kg.
Footnotes: 1. If seizures are noted to continue after the initial phenobarbital loading dose, an additional 5 mg/kg bolus dose can be given every 15 - 30 minutes (total load dose should not exceed 35 mg/kg). Sedation occurs at serum concentrations above 40 mg/L. Respiratory depression may develop with larger loading doses (serum concentrations above 60 mg/L) or if given in conjunction with diazepam. 2. Maintenance phenobarbital doses of 5 mg/kg/day may occasionally result in accumulation of serum levels to >30 mg/L in the neonate less than 1 week of age. Unless undue sedation occurs (monitoring of serum phenobarbital levels will be of assistance in
identifying and managing such patients) little adverse consequences should be anticipated from the higher serum levels. Therapeutic levels may be > 45 mg/L and require very careful respiratory monitoring. 3. Phenytoin is contraindicated in patients with heart block or sinus bradycardia. 4. Maintenance doses of phenytoin are impossible to accurately establish because of marked individual variation. Frequent plasma phenytoin concentration measurements are essential, particularly in the rapidly changing period of the first 3 weeks of age. Drug is highly protein bound; free fraction of drug may be increased in patients with hypoalbuminemia. If the therapeutic range is based on the premise that in the neonate there is a greater concentration of unbound phenytoin in plasma at any given total plasma concentration, then a total plasma phenytoin concentration of 6-14 mcg/ml will provide the same concentration of unbound phenytoin as a 10-20 mcg/ml total concentration in an adult (Loughnan et al, 1977). However, the actual relationship between serum levels and anticonvulsant activity of phenytoin (alone) has not been demonstrated in the neonate. The plasma level 8 hr. after dosing should be the most representative of the average phenytoin concentration. 5. The total acute IV dose of diazepam necessary to control neonatal seizures has ranged from less than 0.1 mg/kg to 2.7 mg/kg. Based on the proposed therapeutic serum level of diazepam, a dose of 0.5 mg/kg should produce levels in excess of that ordinarily necessary. Only in very unusual circumstances should alternate routes of administration be considered. Evidence does exist to support the efficacy of rectal administration. The parenteral injection form is used in conjunction with a syringe and catheter inserted 5 cm into the rectum. It is important to note that there is no evident advantage in using diazepam instead of phenobarbital, but to maintain anticonvulsant effect, a longer acting anticonvulsant such as phenobarbital is generally used following diazepam or lorazepam (as this combination often produces respiratory depression, close monitoring of the patient is essential).

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Iowa Neonatology Handbook: Pharmocology

Recommended Antimicrobial Dosage Schedules for Neonates

Jeffrey L. Segar, M.D. and Chetan A. Patel
Drug
Dosage Acyclovir 30 mg/kg/d divided q 8 hr IV administer over 1 hr
Major Indications / Remarks Herpes Simplex & Varicella. increase dosing interval with <34 wk gest or with significant renal / hepatic failure Gram negative enteric bacteria peak 20-30, trough 5-10 mcg/ml Most systemic fungal infections & severe superficial mycoses; Give over 4 to 6 hr. Decreases renal blood flow / GFR; Monitor renal / hepatic status closely. total dose: 15-30 mg/kg
Metabolic Fluid Management Feeding Infection
Amikacin* 7.5 - 10 mg/kg per dose IV / IM see Gentamicin for dosing schedule Amphotericin B test dose: 0.1 mg/kg initial dose: 0.25 mg/kg
Hematology
increment : 0.125 - 0.25 gm/kg/d

Pharmacology Procedures Abbreviations Commonly Used in the Nursery
maintenance dose: 1 mg/kg/d qd or 1.5 mg/kg/d qod Ampicillin 200 mg/kg/d q 12 hr Mild - Moderate IV or IM, q 8 hr 1 week age infection 400 mg/kg/d q 8-12 hr Meningitis Group B streptococcus, enterococcus, E coli, Listeria monocytogenes
Cephalothin 20 mg/kg q 6-8 hr IV / IM Cefazolin < 7 days: 20 mg/kg q 12 hr IV / IM > 7 days: 20 mg/kg q 8 hr Cefotaxime & 50 mg/kg dose IV over 30 min. Ceftazidime Postnatal Interval Gest. age age (q) < 29 wk 0 to 28 d 12 hr > 28 d 8 hr 30 -36 0 to 14 d 12 hr wk > 14 d 8 hr 37 wk 0 to 7 d 12 hr > 7 d 8 hr Ceftriaxone 50 - 75 mg/kg/dose IV/IM <1.2 kg: <28 d:q 24 h; >28 d: q12 h >1.2 kg: < 7 d: q 24 h; > 7 d: q12 h Clindamycin Preterm <1mo: 5 mg/kg q 8 h IV Preterm >1mo: 5 mg/kg q 6 h Full term: 5 - 10 mg/kg q 6 h Erythromycin 10-15 mg/kg q 8-12 hr. PO Gentamicin* 2.5 mg/kg/dose Gest. age Postnatal Interval age (q) 0 to 14 d 24 hr < 28 wk 14 to 28 d 18 hr > 28 d 12 hr 29-34 0 to 14 d 18 hr wk > 14 d 12 hr 0 to 7 d 12 hr 37 wk >7d 8 hr
Gram + cocci Gram + cocci ; may cause false positive urine reducing substance Cefotaxime: Gram - enteric bacteria penetrates well across BBB and good for use in meningitis Ceftazidime: Gram - , esp. Pseudomonas ; Consider two antibiotics with positive Pseudomns. cultures Gram - bacteria and gonococcal infection
Gram + cocci and bacteroides Psuedomembranous colitis most serious adverse effect bloody diarrhea, fever Chlamydia and Mycoplasma Gram negative aerobic bacilli; Ototoxic effects synergistic with lasix. Need to monitor serum levels: Trough: < 2; Peak: 4 - 8 mg/L For high trough levels, increasing dosing interval to next higher level is usually sufficient - always recheck levels again after adjusting dosage/interval
Isoniazid 10 mg/kg PO q d Methicillin 25 - 50 mg/kg/dose IV / IM & < 2 kg: < 7 d: q12 h; > 7 d: q 8 h Nafcillin > 2 kg: < 7 d: q 8 h; > 7 d: q 6 h Metronidazole Loading dose: 15 mg/kg IV Maintenance dose: 7.5 mg/kg IV q12 h Oxacillin 25 mg/kg/dose IV / IM < 7d: q 12 hr. > 7 d: q 6-8 hr Mezlocillin & 50 - 100 mg/kg/dose IV / IM Piperacillin See Methicillin for dosing schedule Penicillins Pen G: Meningitis 75,000 - 100,000 IU/kg/dose IV Pen G: Sepsis 25,000 - 50,000 IU/kg/dose See Methicillin for dosing schedule
Mycobacteria Penicillinase-producing Staphylococcus aureus. Use Nafcillin for renal dysfunction pts. Use the higher doses for meningitis
anaerobic infections; begin maintenance dose 48 h after load in preterm infants & after 24 h in term infants Penicillinase-producing Staphylococcus Aureus
Pseudomonas, Gr B Strep, most Klebsiella pneumoniae and Serratia marcescens Non-producing Penicillinase organisms See Methicillin for dosing schedule Treatment of susceptible organisms: streptococci , cong. syphilis, gonococci For group B strep sepsis: 200,000 IU/kg/d and 400,000 IU/ kg/d with meningitis
50,000 units/kg one dose IM Benzathine 50,000 U/kg IM q wk x 3 doses
Syphilis (No clinical findings and only if follow-up cannot be ensured) Syphilis > 1 yr. in mother
Procaine 50,000 units/kg q day IM Ribavirin Dilute 6 gm in 300 ml sterile water. Administer by aerosol over 12 - 18 hr daily for 3 - 7 days
Syphilis Respiratory syncytial virus (severe herpes). Most effective if begun early in course of illness. May worsen respiratory distress
Rifampin Children: 5 - 10 mg/kg PO/IV q 12 hr Ticarcillin 75 mg/kg/dose IV < 1.2 kg: 0-4 wk: q 12 hr < 2 kg: < 7 d q 12 h; > 7 d q 8 h > 2 kg: < 7 d q 8 h; > 7 d q 6 h Tobramycin* 2.5 mg/kg dose See Gentamicin for dosing schedule
Mycobacteria; causes red discoloration of body secretions.
Pseudomonas may cause decreased platelet aggregation, bleeding diathesis, hypernatremia, hypocalcemia, increased AST
Aerobic gram-negative bacilli (e.g., E coli, Pseudomonas, Klebsiella) Need to monitor levels Trough: < 2 mg/L. Peak: 5 - 10 mg/L
Vancomycin* 10 mg/kg per dose IV, give by syringe pump over 60 min.
Methicillin-resistant staphylococci (e.g., S aureus and S epidermidis) and penicillin-resistant pneumococci. Note: Red man syndrome results from rapid IV infusion. Need to monitor serum levels
< 1 kg: < 7 d: q 24 h; > 7 d: q 18 h 1-2 kg: < 7 d: q 18 h; > 7 d: q 12 h >2 kg: <7 d: q 12 h; > 7 d: q 8 h * Serum drug level montoring recommended Table 3: Ususal Theraputic Range PEAK (g/ml) TROUGH (g/ml) Gentamicin 5-8 1-2 1-2
Trough: 5-10 mg/L; Peak: 25 - 40 mg/L Give 15 mg/kg/dose if CNS infection
Tobramycin 5-8
Kanamycin Amikacin
20-25 20-25
5 - 10 5 - 10 5 - 10
Vancomycin 25-40
q
These data represent usual starting and maintenance doses for seriously compromised infants or LBW weight premature infants (< 2 kg or <34 wk. gestation) and full-term infants. Monitoring of serum drug levels will assist in optimizing dosage adjustments, particularly with changing organ function as the newborn matures or recovers from the initial illness. Optimum time to obtain levels is 30 min. prior to next dose for trough levels, and 30 minutes after completion of IV infusion for peak levels. With high serum levels, usually an increase in interval of administration is warranted rather than lowering of individual dose, although both may be necessary in some neonates.
References Young TE, Mangum OB. Neofax A manual of drugs used in neonatal care. Sixth edition, Columbus, Ohio; Ross Laboratories, 1993. Johnson KB. The Harriet Lane Handbook. 13th edition. Mosby - Year Book, Inc., St Louis, MO, 1993 Brown & Campoli-Richards, 1989; (4) Beretz & Tato, 1988; and (5) Remington & Klein, 1990.

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Iowa Neonatology Handbook: Pharmocology

Recommended Digoxin Doses in Premature and Full-term Neonates and Infants

Loading Dose (Total)1 Preterm: <1.5 15 mcg/kg IV kg 15-20 mcg/kg IV 1.5-2.5 kg Full-Term 30 mcg/kg IV Neonates 40 mcg kg PO2
Maintenance Dose2 3-4 mcg/kg/day IV3 4-6 mcg/kg/day IV4 6-8 mcg/kg/day IV 8-10 mcg/kg/day PO5
Under 2 yr. 30-40 mcg/kg IV or 40-50 mcg/kg PO 8-12 mcg/kg/day. PO 1. "Digitalization" is generally used when treating dysrrhythmia. The total loading (digitalizing) dose is administered in three divided doses given every 8 hours. Administer IV slow push over 5 to 10 minutes. Do not administer IM (causes pain and tissue damage). The first maintenance dose should not be given any earlier than 24 hours after the last loading dose in the premature infant and 12 hours in the full-term neonate and infant (1-12 months old). 2. Daily maintenance dose is generally 25% of the digitalizing dose divided into 2 doses. Conversion to oral dosing traditionally involves increasing the intravenous dose by 25 to 30 % because of the assumed bioavailability differences. Whether this dose modification for intravenous to oral administration translates to meaningful pharmacological equivalency in patients is unknown. 3. Dosing the premature infant at 24 hour intervals is based on the prolonged plasma clearance of digoxin. It can be anticipated that renal function will increase sufficiently to require the same recommended dose every 12 hours at approximately one month of age. Measurement of the serum digoxin level will confirm the need for such dosing changes (although in newborns may overestimate injected digoxin levels, because of endogenous digoxin-like substances). 4. Dose should be increased at one month of age to that of the full-term newborn (6 -8 mcg/ kg/day). Measurement of the serum digoxin level will confirm the need for such dosing changes. 5. Dose should be increased at one month of age to that of infant (8-12 mcg/kg/day). Measurement of serum digoxin levels will confirm the need for such dosing changes. References Preterm - Berman et al (1978), Pinsky et al (1979), Warburton et al (1980), Nyberg and Wettrell (1980), Collins-Nakai (1982b) Full-Term - Wettrell and Anderson (1977), Nyberg and Wettrell (1980) Infants - Nyberg and Wettrell (1980)
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Recommended Doses of Diuretic Agents in Neonates and Toxicity

Drug Furosemide (Lasix) Inhibits chloride reabsorption in the ascending limb of the loop of Henle, inhibits tubular sodium transport
Dosage
Toxicity Causes major urinary loss of sodium and chloride; also potassium and calcium. Increases prostaglandin secretion and renal blood flow. Peak effect 1 - 3 hr after IV dose; duration 6 hr. Monitor for dehydration and electrolyte (Na, Cl, K) imbalances, ototoxicity, metabolic alkalosis, renal nephrocalcinosis.
Initial dose: 1 mg/kg dose IV slow push, IM, or PO. May increase dose as required to a maximum of 2 mg/kg/dose IV or IM and 6 mg/kg/dose PO. For oliguria, repeat max. effective dose as required, but no more often than every 12 hr (fullterm) or 24 hr (premature)1
Spironolactone (Aldactone) antagonist of aldosterone
Oral: 1 to 3 mg/kg/d q 12 - 24 hr
increased Urine Ca++, Mg++, Na+, Cl-; Urine K+; clinical effect usu. seen 2 -3 days after start therapy. Monitor for hyperkalemia, drowsiness, GI upset, masculinization, rash
Chlorothiazide (Diuril, Diurigen) decreased sodium reabsorption in the distal nephron
PO or IV: 10 - 20 mg/kg increased Urine Na+, K+, Mg++, Cl-, HCO3-, phosphorus; Urine Ca++ . Monitor q 12 hr.2 for dehydration and electrolyte imbalances, metabolic alkalosis, hypercalcemia ,hyperglycemia, hyperuricemia; Dont use in pts w/ sig. liver / renal disease Oral: 0.2 - 0.4 mg/kg / day divided q 12 - 24 hr. Same as chlorothiazide; hypokalemia is major electrolyte imbalance
Metolazone decreased Na+ reabsortion in distal nephron
Footnotes 1. The plasma clearance of furosemide varies considerably in the neonate (Aranda et al 1980, Chemtob et al 1987). Since the diuretic effect occurs subsequent to renal tubular secretion, the excessive plasma concentration is more likely to result in displacement of bilirubin or ototoxicity than enhanced diuretic effect. Avoiding an excessive plasma concentration of drug by appropriate dose and dosing intervals is prudent. Attention to the duration of diuretic response along with frequent assessment of diuretic needs (particularly when initiating therapy) will assist in determining the appropriate dose and dosing interval (as opposed to an arbitrary every 12 or 24 hour routine) (Vert et al 1982). 2. The thiazides have a relatively flat dose response curve indicting that significant increases in dose are not associated with comparable increases in diuretic or antihypertensive effects. Because of the dependence of diuretic effect on renal elimination, an increase in dosing interval is recommended with renal failure (give every 24 hours with 50 percent or less of normal creatinine clearance).

Effects of Drugs on the Fetus or Newborn

Used in the Nursery
Addendum:
Cocaine: Prematurity, IUGR, Developmental-behavioral problems, intracranial hemorrhage, nonduodenal intestinal atresia-infarction, limb reduction defects, urinary tract anomalies Jones, 1991 From: Roberts, R. J. DRUG THERAPY IN INFANTS, 1984

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The Effect of Drugs Taken by the Nursing Mother on her Infant

One of the most frequently asked questions of pediatricians, obstetricians and nurses concerns the effect of various drugs taken by the nursing mother on her infant. A comprehensive reference to guide you in your decision as to whether or not a mother receiving a given drug should continue to breast feed will be found in the literature. References include: Roberts, Drug Therapy in Infants (Chapter 11); Briggs, et al, Drugs in Pregnancy and Lactation, 1991; White and White, Breast feeding and Drugs in Human Milk, Vet Human Tox Suppl. I, Vol 22, 1980. There are only a few known categories of drugs which when given to the mother warrant the interruption of breast feeding. It may be possible to minimize infant drug exposure by instructing the mother to take the medication immediately after completing breast feeding or by collecting breast milk for subsequent feeding just prior to taking medication. If drug therapy in the mother is to be of short duration, interruption rather than complete termination of breast-feeding should be advised.
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Emergency Drug Doses

Drug (Conc.) and indication Bicarbonate (0.5 mEq/ml)
Dose 1 - 2 mEq/kg IV slowly
Administration / Remarks NOT routinely given for resuscitation. Note: Use only 0.5 mEq/ml solution for infants
Metabolic Fluid Management Feeding Infection Hematology Pharmacology Procedures Abbreviations Commonly Used in the Nursery
Documented Metabolic acidosis Epinephrine (1 : 10,000) Severe Bradycardia and hypotension Heart rate should rise to > 100 within 30 seconds start at 0.05 mcg/kg/min. after bolus infusion. 0.1 - 0.3 ml/kg IV or intratracheal
Warning: Never use undiluted 1 : 1,000 concentration.
equal to 0.01-0.03 mg/kg/ And NEVER inject into an artery dose of 1:10,000 concentration IV push or IT followed by 1 ml For continuous infusion - normal saline Do not mix with bicarbonate If heart rate remains < 100, may repeat dose q 5 min. as needed
Volume Expanders Plasmanate, NS Hypotension or hypovolemia with evidence of acute blood loss or decreased effective plasma volume Glucose (D10W) Hypoglycemia Naloxone (Narcan, 1.0 mg/ml) Severe respiratory depression AND maternal narcotic within the past 4 hours
10-15 ml/kg IV over at least 10 min. but preferably over 30 - 60 min. IV - 2 ml/kg of D10W and/or constant infusion of D10W at rate of 100 ml/kg/d 0.1 ml/kg inject rapidly IM, IV, IT, SQ
Consider if poor response to resuscitative efforts or weak pulses with a good heart rate
(8 mg glucose/kg/min.)
Delivery room: 1 ml vial. May repeat in 3 - 5 min. If no response during resuscitation Duration (1-4 hr) may be less than the narcotic, needing repeated doses
Dopamine To give 10 mcg/kg/min. @ 1 ml/hr : weight x 30 = mg of dopamine (in kg) in 50 ml D5W/NS Phenobarbital (Anticonvulsant)
Begin at 5 mcg/kg/min. May increase in increments of 2.5 - 5 mcg/kg/min. as needed up to 20 mcg/kg/min.
Consider if poor peripheral perfusion, evidence of shock, or thready pulses after epinephrine and volume expansion (and bicarbonate)
*Loading dose 15 - 20 mg/kg IV push; Maximum loading dose 30 - 40 mg/ kg
Maintenance dose: 2 - 4 mg/kg/dose q 12 hours IV, IM , or PO *may cause respiratory depression

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NICU Intravenous Drug Compatibility Chart

Maria A. Lofgren, R.N., A.R.N.P., C.P.N.P., Valerie Bailey, PharmD, and Chetan A. Patel, M. D.

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Intropic Agents
Commonly used vasoactive drugs in the NICU include dopamine, dobutamine, and epinephrine. Vasodilating drugs such as tolazoline or nitroprusside are generally not used in the NICU anymore. Since these agents mediate their effects via adrenergic and dopaminergic receptors, an understanding of these receptors is essential for the proper use of vasoactive agents. The following is a brief synopsis of the various receptors, and the physiologic responses resulting from their activation. Adrenergic Receptor 1 : Response Increase intracellular calcium; muscle contraction 2 : Decrease cAMP Inhibit NE release 1 : Increase cAMP Physiologic Response Inhibit insulin secretion Vasoconstriction - all vascular beds, ventricular dysrhythmia Vasodilation Negative chronotrophy Inotropic action - myocardial contractility Chronotropic action - increases heart rate 2 : Increase cAMP Smooth muscle relaxation. Enhance glucagon secretion *DA1 : Increase cAMP. Smooth muscle relaxation *DA2 : Central CNS Decrease cAMP (*DA = Dopamine receptor) Inhibit prolactin, TSH, aldosterone Bronchodilation Vasodilation - splanchnic and skeletal muscle beds Vasodilation - renal and splanchnic beds
Epinephrine
Indications Cardiac arrest, profound shock, low cardiac output, failing myocardium unresponsive to other inotropic agents. Dose Range Initial dose 0.05 g/kg/min. Titrate dose to desired response, not to exceed 1.0 g/kg/min. An
epinephrine dose of 0.05 g/kg/min. may be more effective than a dose of dopamine at > 15 g/ kg/min. Mechanism of action Epinephrine is an endogenous compound formed from norepinephrine. It is principally produced with stress and produces widespread metabolic and hemodynamic effects via effects on b1 , b2 , and a-adrenergic receptors. The effects of epinephrine depend on the dosage selected and the range of plasma concentration achieved in the individual patient. b1 receptors are most sensitive to epinephrine, and are affected by very low plasma concentrations resulting in inotropic and chronotropic effects (that increase myocardial oxygen consumption). Stimulation of b2 receptors leads to vasodilation of splanchnic and skeletal muscle beds. Vasoconstriction from a- receptor stimulation in skin and renal vascular beds occurs at all concentrations, while at higher concentrations, vasoconstriction effects in the pulmonary, splanchnic, skeletal muscle, cerebral, and coronary vascular beds predominate. As the concentration of epinephrine increases, myocardial irritability occurs, manifested by atrial and ventricular dysrhythmias. Metabolic effects occur at higher plasma concentrations, including hyperglycemia from a-adrenergicmediated suppression of insulin release that leads to ketogenesis, gluconeogenesis, and accelerated glycogenolysis with resulting lactic acidemia. Hypokalemia is attributable to b2 adrenergic receptors linked to Na+-K+ ATPase in skeletal muscle. Other effects include hypophosphatemia, and activation of lipase. Adverse effects Adverse effects include increased myocardial and global oxygen consumption, tachycardia, and hypertension. The extent to which the increased oxygen utilization is balanced by improved coronary blood flow depends on the state of the myocardium. Epinephrine increases pulmonary vascular resistance. In addition, pulmonary arterial and venous pressures increase because of increased systemic to pulmonary shunt, which can lead to pulmonary edema. Higher doses induce widespread vasoconstriction that may terminate in hypertensive crisis, renal failure, and gangrene of distal extremities. Infiltration into local tissues or intra-arterial injection can produce severe vasospasm and tissue injury. If extravasation is followed by pallor and other signs of impaired local perfusion, the attending physician should be notified immediately, and consideration given to local injection of phentolamine (an a-adrenergic antagonist, 0.3 - 0.5 mg of 1 mg/ml solution).
Dopamine
Indication for use To improve cardiac output, blood pressure, and urine output in critically ill patients with shock, renal failure, and CHF. Mechanism of action and Dose Range 1 - 3 g/kg/min. - DA1 receptor 3 - 10 g/kg/min. - 1 receptor 11 -20 g/kg/min. - receptor Increased splanchnic and renal perfusion, increased renal sodium and water excretion inotropic effects, increased cardiac output, little change in TPR systemic vasoconstriction, variable pulmonary vasoconstriction chronotropic effect. (Doses > 15 g/kg/min. rarely useful)
To calculate a drip that infuses 10 g/kg/min. at 1 ml/hr: multiply weight (kg) by 30 = number of mg Dopamine to add to 50 ml IVF (D5W, D10W, NS, D5NS) Dopamine is found in sympathetic nerve terminals, the adrenal medulla, and is a central neurotransmitter. Dopamine stimulates D1 and D2 receptors in the brain and in vascular beds of the kidney, mesentery, and coronary arteries. Higher concentrations stimulate b1 and a receptors,
and may cause renal vasoconstriction. Dopamine exerts a positive inotropic effect on the myocardium, acting as a b1 agonist. Tachycardia is less prominent during infusions of dopamine than of isoproternol. Dopamine improves myocardial efficiency because coronary arterial blood flow increase more than does myocardial oxygen consumption. Adverse effects Through central D2 receptors, dopamine suppresses secretion of thyrotropin and prolactin. It also inhibits release of aldosterone, which may facilitate a desirable diuresis. Dopamine may depress the ventilatory response to hypoxia and hypercarbia. Its effects on insulin secretion and glucose metabolism are similar to epinephrine. A decrease in serum potassium is also frequently noted. Since dopamine promotes release of norepinephrine from synaptic terminal and is also converted to norepinephrine in vivo, even at doses as low as 1.5 g/kg/min., severe limb ischemia has been reported; risk is particularly increased with extravasation or presence of an arterial catheter. If this occurs, notify attending physician immediately, discontinue dopamine infusion, and in severe cases consider local infiltration with phentolamine administered with a fine hypodermic needle).
Dobutamine
Indications Inotropic support in patients with shock, hypotension, pulmonary hypertension with hypoxemia Dose Range 2 to 20 g/kg/min.; usually dont need doses higher than 15 g/kg/min. Usual starting dose range: 2 - 5 g/kg/min. Adjust upward in increments of 2 - 3 g/kg/min., based on desired increase in cardiac output / blood pressure. Doses should be individualized to the patient response is observed within 1 - 2 min., with maximal effect within 10 min. Must be administered by continous IV infusion because brief half-life. To calculate a drip, see Dopamine section. Mechanism of action Dobutamine is a synthetic catecholamine that primarily produces a significant inotropic effect via b1 -receptor stimulation in the heart) and mild to moderate chronotropic effect. Systemic vascular resistance generally decreases since in the peripheral circulation the b2 effect predominates over the a effect. May see cutaneous vasodilation. It dose not activate dopaminergic receptors, and causes no renal and mesenteric vasodilation. Dobutamine improves renal blood flow by increasing cardiac output. Adverse effects May cause hypotension if patient is hypovolemic. Volume loading to ensure adequate preload is recommended before starting dobutamine therapy. Dobutamine usually increases myocardial oxygen demand, but coronary blood flow and oxygen supply increase to keep pace with demand. However, when dobutamine increases heart rate and decreases diastolic time for coronary artery perfusion, myocardial oxygen balance is unfavorably affected. At infusion rates between 7.5 and 10 g/kg/min, a 10 - 20 % increase in heart rate is generally observed. In the non-asphyxiated neonate, this is generally well tolerated. Dysrhythmia can be induced or exacerbated with electrolyte imbalance, high infusion rates, or myocarditis, although the incidence of dysrhythmia is lower than that reported for dopamine or isoproterenol. Tissue ischemia may occur with infiltration.

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Monitoring Gentamicin Therapy by Single Serum Sample Determination

This nomogram is for use only in term neonates (<30 days old) receiving gentamicin or tobramycin 2.5 mg/kg given IV every 12 hours. Illustration of the upper and lower range of acceptable gentamicin serum concentrations (heavy dashed and solid parallel lines). The mean + S.D. for the peak serum gentamicin concentrations of 81 neonates is shown as well as individual gentamicin disappearance curves for 31 neonates who required dosing adjustment (Zone I = required increased dosage; Zone II = required decreased dosage). A single blood sample is drawn between 8 and 12 hours after the start of drug infusion. Any value falling within the Normal Zone is bordered by the following: upper 8 and 12 hour serum values = 3.5 and 2 mcg/ml; lower 8 and 12 hour serum values = 1.8 and 1 mcg/ml. Dosage adjustment: If 8 to 12 hour level is below the Normal Zone, the dosing interval should be shortened to every 8 hours. Recheck the drug level 1 to 2 hours prior to dosing. Acceptable level would be between 1 and 2 mcg/ml. If 8 to 12 hour level is above the Normal Zone, perform the following calculation (% RDR = percent required dose reduction): observed conc. - maximum acceptable conc. x 100
Zone I:
Zone II: %RDR =
observed conc. If the %RDR calculated is <25%, then reduce the dose by the calculated percent and continue dosing every 12 hours. If the %RDR calculated is > 25%, then increase the dosing interval to every 24 hours while keeping the dose at 2.5 mg/kg per dose. Recheck drug levels 1 to 2 hours prior to dosing. Acceptable levels would be between 1 and 2 mcg/ml. Reference: Leff RD, Andersen RD, Roberts RJ. Simplified gentamicin dosing in neonates: a time- and costefficient approach. Pediatr Infect Dis 1984;3:208-212.

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Pharmacologic Closure of PDA

I. Indomethacin (an inhibitor of prostaglandin synthesis) is sometimes used to promote the closure of a clinically significant PDA. The decision to use indomethacin MUST be discussed with the attending neonatologist. II. Serum creatinine, BUN, and platelet count, should be obtained prior to giving indomethacin. A reduced fluid intake prior to indomethacin may improve the congestive heart failure secondary to the PDA, as well as improve chances of PDA closure. Infants should be made NPO prior to indomethacin administration because of the effect of the drug on mesenteric blood flow. III. Contraindications: A. Renal Failure B. GI bleeding C. Thrombocytopenia D. Acute NEC IV. Dose: 1st dose: 0.2 - 0.3 mg/kg IV 2nd dose: 0.2 mg/kg IV 12-24 hours after 1st dose if PDA persists. 3rd dose: 0.2 mg/kg IV 12-24 hours after 2nd dose if PDA persists. V. Indomethacin is given IV over 30 minutes, as slower injection may avoid decreased cerebral blood flow after indomethacin. VI. Indomethacin also has a number of significant non-cardiac effects that should be kept in mind when using this drug. These include a decrease in the blood flow velocities (up to 120 minutes after administration) of the cerebral, renal, and mesenteric vascular beds, an attenuation of ET-suctioning induced increase in cerebral blood flow velocity, an inhibition of platelet aggegation and prolonged bleeding time up to 48 hours after last dose of indomethacin, interference with the oxygen consumption autoregulation mechanisms in the mesenteric circulation, renal effects including decreased GFR, urinary volume, and FENa+, and increased sytemic vascular resistance mean arterial pressure. VII. Accurate fluid intake and urinary output during therapy is important to prevent fluid overload with dramatic changes in urine output. Decreased urine output is expected and is not a contraindication for further indomethacin therapy, although administration of dose may be deferred if urine output falls to less than 0.5 ml/kg/hr. Fluid intake should normally be reduced during indomethacin treatment in anticipation of decreasing urine output. Volume expansion in response to a decreased urine output is contraindicated and will not induce a diuresis. Co-administration with dopamine at a dose of 2 - 3 mcg/kg/ min. may counteract the oliguric effect of indomethacin.

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Protocol for Use of Prostaglandin E1

(Alprostadil -- generic)
(Prostin VR -- Upjohn)
I. Indication: An infant suspected of having a ductal-dependent congenital cardiac defect and ductaldependent pulmonary blood flow should be treated with prostaglandin E1 because he/she is at risk for progressive hypoxia and metabolic acidosis if the ductus closes. Prostaglandin E1 will prevent the ductus arteriosus from closing and reestablish ductal patency if closure has already occurred, and thereby increase PaO2, and mitigate the onset of metabolic acidosis. This drug is indicated for the temporary management of the neonate with ductus-dependent congenital heart disease while awaiting transfer to a tertiary care nursery for evaluation and surgical therapy. It is also used to stabilize a neonate's condition until surgery can be completed. II. Patient Population: Most often the neonate with ductal-dependent congenital cardiac disease is a full term infant whose size is appropriate or large for gestational age. The drug is indicated for use in the neonate with ductal-dependent pulmonary blood flow, including: pulmonary atresia, tricuspid atresia, Tetralogy of Fallot, and will often improve systemic oxygen saturation in infants with transposition of the great vessels. Note, in infants with obstructive total anomalous pulmonary venous return, a left right shunt via a PDA can decrease systemic blood flow and increase blood flow to the pulmonary bed resulting in pulmonary vascular congestion and worsening of infants condition. III. Patient Identification: The infant should have the following studies performed prior to the initiation of prostaglandin therapy. r Hyperoxic Challenge Test: Right radial artery blood gases obtained in an FiO of 2 1.0 (pCO2 35-40 torr [normal] and PaO2 less than 100 torr is consistent with
r r
cyanotic congenital heart disease). Chest x-ray: Decreased pulmonary vascularity Serum glucose: If the neonate is hypoglycemic, treat appropriately and reassess arterial blood gases and pH. Hematocrit: Central venous hematocrit of greater than 60% may result in hyperviscosity syndrome (plethora, cyanosis and dyspnea). Adequate ventilation: If there is any question as to the adequacy of ventilation, the neonate should be mechanically ventilated and arterial blood gases reassessed. These studies will aid in the identification of the neonate with another etiology for central cyanosis. Only definitive echocardiography and cardiac catheterization will clearly identify infants with ductal dependent pulmonary blood flow.
I. Administration: Prostaglandin E1 is packaged in a 1 ml ampul of 500 micrograms (0.5 mg). Use one of the following methods to prepare a solution for infusion. i. Dilute one ampul in 500 ml D5W or D10W = 1 mcg/ml (0.001 mg/ml) solution. To give 0.05 mcg/kg/min. = 3.0 ml/kg/hr ii. [weight (kg) 10] = # mg PGE1 in 100 ml IVF @ 3 ml/hr = 0.05 mcg/kg/min iii. Dilute one vial in 100 ml of D5W or D10W = 5 mcg/ml solution. To give 0.05 mcg/kg/min. = 0.6 ml/kg/hr
Make sure the drug is thoroughly mixed in solution and all lines are purged. Once mixed, the solution is stable for 24 hours. Prostaglandin E1 is infused continuously by pump via a large peripheral vein (preferably not scalp vein) or umbilical ine. There is evidence that doses greater than 0.1 mcg/kg/min are -not more- effective, and may cause an increase in adverse reactions. II. Response and Duration of Action: The neonate generally responds with an increase in PaO2 10-15 minutes after initiation of the drug. Some patients may not respond until several hours of drug infusion have elapsed. The half-life of the drug is one circulation time; therefore, continuous uninterrupted infusion must be maintained. Once the patient responds, the dose can be reduced to one-half or less of the initial effective dose. III. Precautions: Monitor respiratory rate, temperature, blood pressure and arterial blood gases and pH at the initiation of and intermittently during infusion. IV. Adverse Reactions: About 20% of infants who receive this drug have one or more adverse reactions. Three common side effects are apnea (12%), fever (14%), and flushing (10%). Non-central nervous system twitching, fever, and peripheral flushing - particularly if given intraarterially, will usually cease with reduction of the dose by 50%. Apnea is an indication for assisted or mechanical ventilation. A decrease in systolic arterial pressure of greater than 20% is an indication for volume expansion by 10 ml/kg of colloid. Hypoglycemia may develop after several hours of treatment. This protocol is presented as a suggestion for the use of the drug. Particular questions involving patients should be directed to the Neonatologist (319-356-1616; Beeper 3792) and/or Pediatric Cardiologist (319-356-1616; Beeper 3609) on-call at University Hospitals.

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Iowa Neonatology Handbook : Pharmacology

Pharmacologic Therapy for Neonatal Systemic Hypertension

I. Definition (not fully clear): r Term infants: > 90/65 mm Hg r Preterm infants: > 80/45 mm Hg (Liberman) II. Management should be directed towards correcting the underlying etiology. It is uncertain whether moderate hypertension associated with bronchopulmonary dysplasia requires therapy, since it is mostly transient. Renovascular hypertension can be managed pharmacologically. Agent Dosage Toxicity hypotension hypoglycemia, hypotension neutropenia, proteinuria, renal failure
Hydralazine 0.1-0.5 mg/kg/dose q 4-6 h IV Propranolol Captopril 0.25 - 1.0 mg/kg/day q 6-12 h PO 0.05 -0.1 mg/kg/dose q 6-8 h PO
Methyldopa
10 mg/kg/day q 6-12 h, followed by increments of 5-10 mg/kg/day every 24 days up to 65 mg/kg/day
hepatitis, leukopenia

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Handbook Home General Temperature Jaundice Pulmonary Neurology Metabolic
Neuromuscular Blockers in Neonates

Used to facilitate ventilation when the infant's respiratory efforts are not coordinated with the ventilator. With the use of sedatives and synchronized ventilation, this can usually be avoided. Table 4. Dosage Recommendations for Neuromuscular Blocking Agents in the Neonate Onset of Paralysis "Intubating Dose" After Intubating (mg/kg) (min.) 0.15 0.6 - 0.8 0.15 2 mg IV 4 - 5 mg IM * Not Recommended for prolonged duration. (From: Costarino & Polin, 1987) When administering neuromuscular blockers, it is also necessary to administer sedatives (includes narcotics). ED95 = dose for effective response 95% of the time. 1.5 - 2.0 1.5 - 2.0 1.5 -2.0 0.5 - 1.0
Ed95
Agent Pancuronium
(mg/kg) 0.05
Dosage Intervals (min.) 60 - 120 20 - 30 30 - 40 5 - 10*
Atracurium 0.15 - 0.3 Vecuronium Succinylcholine 0.03 2.2

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Analgesics and Sedatives

Systemic narcotics are the most commonly used agents for management of pain in the postoperative patient. They are also the most frequently used agents given to ventilated children, particularly when paralyzed with neuromuscular blockers, or those with bronchopulmonary dysplasia. DRUG Narcotic analgesics and sedatives Morphine DOSE 50 mcg/kg (optional) followed by 10 20 mcg/kg/h IV Fentanyl 1-3 mcg/kg/h IV (may need up to 10 mcg/kg/h) COMMENT Increased enterohepatic circulation prolongs T1/2 in preterm infants. Higher doses needed as tolerance develops Minimal hemodynamic effects. Rapid onset of tolerance. Consider 510 g/kg for sedation prior to ETT suction in unstable PPHN patients.
Benzodiazepines:
Lorazepam Midazolam
0.05 - 0.3 mg/kg q 6 h IV 0.2 mg/kg followed by 0.4 mcg/kg/min. IV 5 mg/kg/dose q 12 - 24 h enhanced sedation with analgesics. Contains benzyl alcohol tolerance to sedation develops rapidly Cardiac toxicity at high levels. Repeated high doses in TPN dependent patients increase risk of cholestasis
Barbiturate sedative/ anticonvulsant: Hypnotic:
Phenobarbital
Chloral hydrate
25 - 50 mg/kg/ dose q 6-12 h
Non-narcotic analgesic:
Acetaminophen 10-15 mg/kg/ dose PO; PR
Treatment of withdrawal (abstinence) from narcotics: Treatment as needed to alleviate symptoms and signs of withdrawal.
q q
Preferably with narcotics (e.g., paregoric, methadone) Phenobarbital may also be used.
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Apnea in Newborns
The cause of apnea should be thoroughly investigated (see Pulmonary section). Only if no treatable cause can be found, the diagnosis of apnea of prematurity can be considered (diagnosis of exclusion). If necessary, central apnea of prematurity may be treated using one of the following drugs. Plasma Concentration (mcg/ Toxicity ml) > 50 mcg/ml (see Theophylline)
Agent Caffeine citrate
Dose
20 mg/kg IV/PO 5 - 20 followed by 5 mg/ kg/day may need up to 7.5 mg/kg/d
*Theophylline 5 mg/kg IV 5 - 15 followed by 2 mg/ kg q 8 - 12 h Doxapram1 1 - 2 mg/kg/h IV 1 - 2 12 - 24 mg/kg q 6 h PO
> 20 mcg/ml Irritability, tachycardia, arrhythmia, seizures > 5 mcg/ml Hypertension, feeding intolerance, seizures. Contains benzyl alcohol
1 Further studies needed on bioavailability, toxicity, and long term efficacy. Potential toxicity with vehicle which contains benzyl alcohol. The drug of choice caffeine. If apnea persists despite appropriate doses, doxapram may replace caffeine. If response is still inadequate, both drugs may be combined.

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Bronchodilators for Reactive Airway Disease

Agent b- agonists: Albuterol (aerosol) Isoproterenol
Dose
Toxicity
0.2 mg/kg in 1.5 ml NS q 4 h Increased HR, Agitation can increase to 0.5 mg/kg 0.1% aerosol q 4-6 h (1:200 solution in 2 ml of 0.45 NS) Increased HR, Agitation
Methylxanthines: *Theophylline 5-7 mg/kg load followed by Increased HR, irritability, arrhythmia, seizures 2-4 mg/kg q8-12h. Metabolism varies with age* Therapeutic levels (peak): 10 - 20 mg/L Caffeine 10 mg/kg load followed by Increased HR, irritability, 2.5 mg/kg/day q 12 h PO, IV arrhythmia, seizures (Davis, 1986)
* Monitoring
of serum levels are required. (From Blanchard et al, 1987)

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Infants of Drug-Abusing Mothers

It has been reported that women account for approximately 30% of the drug-addicted population and the majority of them are of childbearing age. Thus, drug abuse not only affects the mother but may harm the fetus and child. I. Clinical Manifestations A. Signs of heroin withdrawal occur in 50-75% of infants born to addicted mothers and usually begin within the first 24-72 h of life. The incidence of withdrawal depends on several factors, including dosage, duration of addiction, and time of last maternal dose. Heroin use may be associated with delayed symptomatology up to 7 days, signs from methadone may occur even later. B. The signs of drug withdrawal may be subtle or overt, consisting of a combination of any of the following: 1. Gastrointestinal: Diarrhea, vomiting, ravenous appetite, poor feeding. 2. Neurologic: Irritability, jitteriness, restlessness (rubbed knees, rubbed nose), erratic sleeping, fist-sucking, shrill cry, hypertonia, hyperreflexia, myoclonus and less often seizures. The incidence of seizures is higher in methadone-maintained mothers (10-15%) than in those abusing heroin. 3. Urinary and/or meconium drug testing should be performed for any baby with signs consistent with neonatal withdrawal. II. Treatment A. Obtain a Social Service consult B. Swaddling - most infants can be managed in this manner C. Small, frequent feedings if gastrointestinal signs present D. Medications: Neonatal Abstinence Scoring Systems exist to assess the severity of withdrawal. However, clinical expertise, rather than a numerical score, should be used in the decision to use medications. Generally, severe irritability interfering with feeding and sleep, vomiting and diarrhea, temperature instability, severe tachypnea, and seizures are indications for treatment. Schedule for Treatment of Infant in Withdrawal Drug Dosage 3-6 drops q4-6 h PO; if no improvement, increase dose by 1-2 drops. Begin gradual wean after 4-6 days 0.2 - 0.5 mg/kg/day dose PO q8h 0.1 - 0.5 mg/kg/day PO q4-12h Phenobarbital 15-20 mg/kg loading dose, then 3-6 mg/kg/d maintenance Paragoric Diazepam Methadone
Duration of treatment in neonatal heroin withdrawal may vary from 4 days to 6 weeks, longer with methadone withdrawal.
III. Other Drugs A. Marijuana:

q q q
Crosses the placenta, slowly metabolized by fetus Higher incidence of tremors and altered visual responses in offspring of heavy users No known overt withdrawal
B. Cocaine:
q q q q
Vasoconstrictive effects lead to neurologic complications (infarct, IVH, cystic lesions) Higher incidence of prematurity, LBW, abruptio placenta Associated with higher incidence of genitourinary tract and gastrointestinal anomalies Short and/or long term neurobehavioral abnormality
C. Alcohol:
q q
Acute ingestion: hyperactivity, tremors for 72h, followed by lethargy for 48h Chronic ingestion: consider fetal alcohol ingestion and its spectrum of abnormalities including CNS, growth deficiency, facial features, cardiac and musculoskeletal anomalies

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Drug Half-Life Studies

Purpose: To Determine Patient Drug Kinetic Parameters Enabling Optimal Dosage Selection I. When To Use: Drug half-life studies are most valuable in cases of: A. drug with narrow therapeutic index (little difference between therapeutic and toxic blood levels). B. unpredictable variations in individual pharmacokinetics (i.e., aminoglycosides in neonates). C. suspected alteration of drug metabolism and/or elimination (renal disease, liver disease, shock, etc.). II. How To Accomplish Accurate T1/2 Determination:
In most situations, half-life studies should be done rather than single "peak" or "trough" studies particularly in situations I.A - I.C above. A. Blood sampling times should be selected to assure maximum accuracy. This means that one should avoid sampling "too close to the time of administration" (drug still being infused) yet not sample at a time when the concentration of drug may be too low to chemically detect. B. The time interval between sampling should be sufficient to allow the drug concentration to decrease by one-half (i.e., T 1/2). This will avoid errors in "extrapolation". If the patient is known or suspected of having a prolonged T 1/2, the draw times should be greater in interval than the prolonged T 1/2, but not greater than the dosing interval (see recommendation in Table 2). C. Two or preferably three blood samples should be drawn to assure greatest accuracy. All information regarding patient's weight, drug dose, dosing interval, time of administration, route of administration, and time blood samples were drawn should be provided. This information will then appear in the chart record and will allow accurate pharmacokinetic calculations to be made. III. A. Determination of T1/2: (First Order) ln Co - ln Ct t ( Co: initial concentration; Ct: concentration after time = t) 0.693 t1/2 = kel =
Kel B. Optimal Dosing Schedule (T): T= log (Cmax/Cmin) x 3.3 x t 1/2 (Cmax: maximum concentration after dose Cmin: trough concentration) IV. When To Do T1/2 Studies Vs. Single Time Blood Level Studies Single blood level determinations have only limited utility since they can be used for dosage adjustment only on a very limited scale. They are useful as a screening procedure to assure that adequate dosing is being accomplished. Drugs with relatively longer half-lives (very little difference in peak and trough levels) can ordinarily be followed by single blood levels determinations. When a single blood level is used for monitoring the progress of the patient, be sure to select a time which avoids problems of IV delivery time. Generally, a -2-3 hour single time pointfollowing IV administration is best.
TABLE 1: RECOMMENDED SINGLE BLOOD LEVEL SAMPLING TIMES DRUG Digoxin Phenytoin SAMPLING TIME (1) 6-8 hrs. post dose (2) Depends on formulation
Phenobarbital (2) Time consistent with previous levels (if any) Theophylline (3) 2 hrs. post dose (rapidly dissolving tablet or liquid) In general, T 1/2 studies are not absolutely needed until several doses of the drug have been given (1 to 2 days). The exception is the patient with severe organ dysfunction who will require repeated blood level determinations to adjust dosage. In these compromised patients, T 1/2 studies should be done after the first dose and before subsequent dosing. T 1/2 studies only need to be repeated if a marked change occurs in the patient's organ function status. TABLE 2: RECOMMENDED T 1/2 SAMPLING TIMES SELECTED DOSING INTERVAL (hr.) 6 8 12 RECOMMENDED T 1/2 SAMPLING TIMES (hr.) #1* 2 2 2 #2 3 3 4 #3 4 4-6 6
*Sampling within 1 hr. of drug administration is likely to be confusing because some drug may still be in the process of being infused or absorbed.
TABLE 3: USUAL THERAPEUTIC RANGE PEAK (ug/ ml) Gentamicin Tobramycin Kanamycin Amikacin 5-8 5-8 20-25 20-25 TROUGH (ug/ ml) 1-2 1-2 5 - 10 5 - 10
Chloramphenicol 20 Vancomycin 25-40
5 - 15 5 - 10

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Technique for Insertion of an Endotracheal (ET) Tube

Iowa Neonatology Fellows
I. Indications. A. Provide airway for mechanical ventilatory support. B. Relieve critical upper airway obstruction. C. Provide route for selective bronchial ventilation. D. Assist in pulmonary hygiene when secretions cannot be otherwise cleared. E. Obtain direct tracheal cultures. II. The correct endotracheal tube (ETT) size and length of insertion (tip to lip distance) can be estimated from the infant's weight. Weight ETT Depth of Insertion (cm) 7 8 9 Insertion Depth (cm) = 6 + wt (kg) The tube should not fit tightly between the vocal cords in order to minimize upper airway trauma. III. In most cases an infant can be adequately ventilated by bag and mask so that endotracheal intubation can be done as a controlled procedure. The ONE IMPORTANT EXCEPTION is in cases of known or suspected congenital diaphragmatic hernia. Preparation is important to performing successfully. Check availability of following equipment prior to procedure - suction, laryngoscope with functioning light source, appropriate laryngoscope blade size (Miller 0 or Miller 1), supply of ETTs, stethoscope, tape and adhesive. Use of oxyscope blade (laryngoscope blade with port built-in for blow-by oxygen) may allow patient to tolerate procedure better. IV. Technique. A. Prior to attempting insertion of ETT and as indicated by clinical condition, ventilate the infant with bag and mask using 80-100% oxygen. If unable to insert the ETT within 30 seconds, ventilate the infant again for 30-60 seconds before reattempting intubation. B. Infant's head should be slightly extended (in the sniffing position) with the body aligned straight. C. The laryngoscope is held with the thumb and first 1-2 fingers of the left hand.
1 kg 2 kg 3 kg 4 kg
2.5 3.0 3.5
4.0 Add 1 cm for each additional kg of body weight.
Pushing down gently on the larynx with the fifth finger (or leaving an assistant do it) may help to visualize the vocal cords. Avoid extreme tension or tilt of the laryngoscope. D. The ETT is held in the right hand and inserted between the vocal cords so that the tip is 1-2 cm below the vocal cords. E. Check tube position by auscultation of the chest (and abdomen) to ensure equal aeration of both lungs and observation of chest movement with positive pressure inflation. F. Secure ETT by applying adhesive (Hollister spray) to upper lip followed by two pieces of 1/4 inch adhesive tape placed on lip and securely around ETT. G. Verify ETT position by chest x-ray. V. Intubation should be attempted without the use of a stylet. If a stylet is necessary, be sure the stylet tip does not extend beyond the end of the ETT. VI. If the infant will require intubation for greater than 7 days, consider use of palate plate to prevent formation of a palatal groove. Palate plates can be obtained by requesting a consultation from Pediatric Dentistry.

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Suctioning of Endotracheal Tubes

I. Indications. A. To clear airways of secretions. B. To keep artificial airway patent. C. To obtain material for analysis of culture. In-line suctioning preferred for indications other than obtaining material for culture. II. Pre-assemble suction equipment. Recommended suction catheters are 5 or 6 French for 2.5 mm ET tube, 6 French for 3.0 ET tube and 8 French for 4.0 ET tube. The amount of suction applied to the catheter should be between 40-80 mmHg. III. Suction between feedings or discontinue feedings for period of treatment.
IV. Auscultate chest prior to suctioning. Oxygenation prior to suctioning will be done with an FiO2 no greater than 0.10 above that being used to ventilate the infant. Monitor heart rate continuously. Suction should not be applied while the catheter is being inserted down the ET tube. The tip of the suction catheter will not be inserted beyond the end of the tube. When withdrawing the catheter, continuous suction is applies. The procedure should not take longer than 10 seconds. Following suctioning, ventilate the infant with an FiO2 no greater than 0.10 above that used prior to suctioning. The PaO2 should be raised to a level comparable to that prior to suctioning. V. Do not add saline unless necessary. Saline may be used if the infant has thick tenacious secretions which cannot be extracted by using suctioning alone. Normal saline for secretions for Respiratory Therapy use is instilled into ET tube and 3-5 ventilated breaths performed prior to suctioning as above. VI. Vibration and percussion (CPT) will not be performed routinely prior to suctioning. If the need for CPT is documented, it must be ordered by a physician describing the area to be treated and the frequency of treatments.

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Lumbar Puncture
I. Lumbar puncture (LP) should be performed for the following indications: A. Diagnosing or ruling out sepsis in the neonatal period. Meningitis may be present in as many as 25% of cases of neonatal sepsis. The choice and dose of antibiotics and the duration of antibiotic therapy may be longer for patients with meningitis than with sepsis. B. To monitor efficacy of antibiotic therapy with repeat cell count and culture, or occasionally drug levels of antibiotics. C. LP is sometimes used as a treatment for communicating hydrocephalus. II. Possible Contraindications: A. Severe bleeding diathesis B. Superficial infection at the LP site C. Vertebral anomalies D. Increased ICP with decreased communication of spinal fluid E. Severe cardiorespiratory instability of patient III. Technique: A. Have assistant restrain patient in either lateral decubitus or sitting position with spine flexed. The head need not be flexed too far, as some infants develop increased respiratory difficulty with flexing of the head. Some people prefer the lateral decubitus for the more unstable patients. Complete immobilization of the spine is extremely important in larger and stronger infants. B. Palpate the spinous process that is even with the iliac crests. This is L4. Locate one interspace above (L3-L4) or one space below (L4-L5) as the site. C. Glove. D. Prep 3 times with alcohol and sponges from the LP tray. Drape with the drape in the tray or with a Steridrape R. E. Use 22-gauge short spinal needle from kit or one with a clear hub from the cupboard. Hold needle/stylet with both hands, thumb on the hub and first fingers guiding into the interspace, aiming for the umbilicus. Insert slowly. One may not feel "pop" as is common with the larger children. Remove stylet and check for CSF. Return stylet and advance if no return. One may need to rotate the needle slightly to increase or initiate the flow. If unsuccessful repeat attempt in next interspace up or down, but never go above the L2-L3 interspace.
F. When collecting for diagnostic purposes, the spinal fluid should be collected in the tubes from the kit in the following order; Tube 1 - culture and STAT gram stain, Tube 2 - glucose and protein, Tube 3 - cell count. G. The stylet should be replaced and the needle removed, covering the site with a 2 x 2 gauze until a bandage can be placed. Section Top | Title Page
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Circumcision
The controversial indications for circumcision have been discussed in the literature at length and is dealt with in recent publications including Report of the Task Force on Circumcision, Pediatrics 1989;84:388-391 and The Status of Circumcision of Newborns, NEJM 1990;322:1308-1315. Enclosed is an excerpt from the consent form presently used at the UIHC: I. "What are the potential advantages of newborn circumcision? The glans of the penis is easier to keep clean if the male is circumcised. Because of this ease of cleanliness, certain infections which can occur in uncircumcised boys or men with poor hygiene cannot occur in those who are circumcised. Circumcision will prevent several conditions that cause an accumulation of fluid and swelling around the foreskin and glans, as well as a problem known as phimosis, which is the inability to retract the foreskin. Newborn circumcision protects against the later development of cancer of the penis, although this is an extremely rare disease. In recent years some new evidence, which is preliminary, suggests that the incidence of urinary tract infection in male infants may be decreased when circumcision is performed during the newborn period. II. What are the potential risks and disadvantages of circumcision? The immediate risks of circumcision are bleeding, inadvertent injury to the remainder of the penis, and infection. Although circumcision is considered to be a generally safe procedure, in rare cases these or other complications can lead to severe problems and even death. Inflammation of the external urethral opening (meatitis) is more common in circumcised boys. Newborn circumcision is usually performed without anesthesia. Although the procedure is relatively brief, the newborn experiences some pain and discomfort. III. What about local anesthesia? Traditionally newborn circumcision has been done without anesthesia because of the misconception that the newborn does not experience pain. In recent years, there has been more interest in providing local anesthesia for this procedure, but by no means is this universally accepted. Local anesthesia is provided by injecting a medication into the nerves at the base of the penis. If performed properly, this procedure will reduce the infant's pain and behavioral changes. Complications due to local anesthesia are rare and consist mainly of bleeding and damage to the skin where the injection occurs. Local anesthesia adds an additional element of risk to the procedure and thus far has not been used in large numbers of babies.
IV. The pediatric resident serving on the newborn nursery rotation and the obstetric resident assigned to the postpartum ward will be given instruction in Gomco clamp circumcision and dorsal penile block. They will be supervised by an attending member of the circumcision squad and will be signed off after demonstrating sufficient skill. The Gomco clamp method is described in detail in the chapter entitled "Circumcision" 378-388 in Atlas of Procedures in Neonatology, 2nd edition. Fletcher and MacDonald (eds), 1993, JB Lippincott Co., Philadelphia.

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Collection of Arterial Blood Gas Samples

I. Due to the persistent, continuing incidence of retinopathy of prematurity (ROP), any infant in an increased ambient oxygen concentration must have his arterial oxygen tension or saturation monitored. Retinal changes have been noted in children whose PaO2s have not been higher than 100 mm Hg. II. An ill infant without an indwelling arterial catheter should have arterial O2 tension monitored by arterial puncture, or PO2 catheter, or transcutaneous PO2 monitor. An acceptable alternative would be continuous pulse oximetry with upper limits of saturation in the low 90's, but caution should be used to prevent exposure to high amounts of oxygen. If questions arise regarding the appropriate level of oxygen saturation, peripheral arterial puncture should be performed. III. Frequency of sampling depends on the clinical situation and the reliability of the other monitoring devices. Generally, a change in respirator or CPAP setting should be followed by a capillary or arterial sample within 15 minutes to an hour. If performing a peripheral arterial puncture for blood gas purposes, note should be made of the location, as many infants have shunting through the ductus arteriosus that may effect the interpretation. IV. Blood gas sampling with peripheral arterial puncture or indwelling arterial catheter requires 0.1 ml of blood. If electrolytes, ionized calcium and hematocrit are also run in the NICU laboratory, 0.3 ml of blood are obtained. Generally, the tuberculin syringe should be heparinized by withdrawing 0.1-0.2 ml of 100 U/ml heparin solution, coating the surfaces and disposing of the remainder. Excessive heparin left in the syringe will dilute the sample, decrease the pH value and lower the PaCO2. If using blood in the syringe for other labs, including spun hematocrit in the NICU lab, heparin cannot be used and one must notify the blood gas technician to run the sample immediately. V. Arterial puncture, although not as commonly used in NICU's as other methods of monitoring, can be performed with relative ease, using the radial temporal, posterior tibial, or dorsalis pedis artery. The brachial and femoral artery should be used only in emergency situations, because of the risk of complications at those sites. Indwelling catheters may be placed in the radial, posterior tibial or dorsalis pedis artery but should not be placed the temporal or brachial artery. VI. Prep the site with 3 alcohol swabs and wear appropriately fitting gloves. Goggles or eyeglasses are also recommended. The artery should be easily palpable or visible with transillumination. If using the radial artery, an Allen test should be performed prior to puncture. An arm board may be useful to prevent extreme dorsiflexion of the wrist which makes the procedure more difficult. A 25 gauge butterfly needle, with TB or 3 ml syringe should be used. The bevel up position should be used, except in the most superficial arteries. The angle of insertion should be 25o for a superficial and 45o for a deep artery, against the flow of the artery. Blood should flow spontaneously or with gentle suction. VII. After the needle is removed, continuous pressure should be applied for 5 minutes, with care not to squeeze with the fingertips. If hematoma formation is prevented, the artery may be used multiple times. Observe the extremity for 15-20 minutes after the procedure for arterial spasm. Section Top | Title Page
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Obtaining Blood Via Heel Stick

I. Adequate quantities of serum may be obtained via heel stick in almost any neonate. If done properly, hemolysis should not be a significant problem. The skin's blood supply is located at the junction of the dermis and subcutaneous tissue, 0.35 to 1.6 mm from the skin surface. II. Prewarming with the commercially-available heel warmers or with a diaper which has been warmed under a warm faucet and taped around the heel often increases the blood supply and arterializes the sample. The area should be cleaned thoroughly with alcohol swab. The person performing the procedure should wear appropriately fitting gloves. III. The heel puncture should be done on the most medial or lateral portions of the plantar surface of the heel, not on the posterior curvature, to avoid the calcaneous. The lancets are designed to enter no deeper than 2-3 mm. If using a scalpel blade, the blade should enter the skin no more than 2-3 mm. After the puncture, wipe the first small drop off to rid the skin of the tissue juices that may increase clotting at the site. IV. Hold the ankle area with the 3 fingers on your ulnar side while placing your thumb behind the heel and your second finger just below the ventral surface of the toes. By alternately pressing the lateral three fingers , followed by a milking motion of the second finger, blood can be expressed. The fingers should be relaxed for a few seconds periodically to allow refilling. To prevent bruising, caution should be used to limit squeezing with the finger tips. To prevent hemolysis, allow large droplets to form, collecting the drops as they form into the microtube, not scraping the blood into the tube. V. Fingerstick sampling is used for capillary blood gas analysis in our NICU and may be used for additional laboratories as well. The technique is similar to heelstick in that only the medial and lateral aspects of the finger are stuck. The milking motion includes the whole finger and even portions of the hand. References: Blumenfeld, et al: Recommended site and depth of newborn heel skin punctures base on anatomical measurements and histopathology. Lancet 1979;1:230.

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Suprapubic Bladder Tap

I. Indications: bladder aspiration is performed to obtain sterile urine for culture. A suprapubic bladder tap is not necessary for Group B strep latex antigen studies (i.e., a bag specimen is adequate). II. Be certain that voiding has not occurred within the previous hour so that the bladder has an adequate amount of urine. The infant is restrained in the frog leg position. The pubic area is prepped 3 times with an alcohol swab. A 25-gauge needle attached to a 3-ml syringe is directed perpendicularly to the skin just superior (0.5 cm) to the symphysis in midline and advanced to its hub. Full-term infants sometimes require a 22-gauge needle (which need not be inserted to the hub). The needle is withdrawn, slowly, with slight pressure pulling back on the syringe. III. A minimal amount of hematuria may be seen after an attempt, but otherwise the risks are minimal. Rare complications include bladder wall hematoma, lacerated vessel on anterior bladder wall, perforation of hollow viscus, osteomyelitis of pubic bone or abdominal wall abscess. IV. If no urine is obtained, the infant should have a U-BagR placed with repeat attempt in 1 hour. If unable to obtain a specimen, a catheterized specimen may need to be obtained but this procedure is more difficult to perform and may be riskier.
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Insertion of Umbilical Vessel Catheters

I. Umbilical artery catheters (UAC), are used primarily for monitoring blood pressure and obtaining samples for blood gases. In order to maintain the patency of the catheter, a saline and dextrose solution is infused through the line. Drugs and other solutions, including parenteral nutrition solutions, should be given through a venous line (peripheral or central), unless discussed with the staff physician. II. Umbilical vein catheters (UVC), are used for exchange transfusions, monitoring of central venous pressure, and infusion of fluids (when passed through the ductus venosus and near the right atrium); and for emergency vascular access for infusions of fluid, blood products or medications. III. Before the procedure is begun, the correct depth of the umbilical artery catheter insertion should be estimated (see #7 below). Gloves and goggles (or eyeglasses) should be worn. A sterilized umbilical catheterization tray with the necessary instruments and drapes is available in the nursery. After opening the tray, alcohol and sterile syringes, stopcocks, catheters and saline will be placed on it. Sterile technique must be observed; the use of goggles (or eyeglasses) is recommended. IV. An umbilical catheter with a single end hole may be used for the catheterization of either umbilical artery or vein. On certain occasions, it may be advantageous to place a multi-port UVC. Infants with a birth weight of less than 1.5 kg will usually require a 3.5-Fr catheter for arterial catheterization. 5-Fr catheters are used for arterial placement in larger infants or umbilical venous placement regardless of infant size. V. Catheters (4 and 5-Fr) with PaO2 monitoring capability (Neocath) are also available for umbilical artery catheterization . This device allows continuous monitoring of PaO2. Additionally, multiple-lumen catheters and catheters with oxygen saturation measurement capabilities for determination of SVO2 are available for umbilical vein catheterization where clinically indicated. VI. If a luer-lock adapter is not present on the catheter end, approximately 9 cm of the wide end of the catheter can be cut off and a blunt end needle inserted. The 3.5-Fr catheter requires a 20gauge and the 5-Fr catheter an 18-gauge blunt needle. A sterile stopcock is then attached and the system flushed with saline. VII. External measurements are made to determine how far the catheter should be inserted. In a high setting, the arterial catheter tip should be positioned between the sixth and tenth thoracic vertebrae on chest x-ray. This can be achieved by inserting the catheter 1 cm more than the infant's umbilical-to-shoulder length. A low-lying catheter should have the tip at the third to fourth lumbar vertebra. VIII. The infant's abdomen and cord are cleaned with alcohol. The alcohol should be sparingly applied to prevent pooling under the infant's back and buttocks. The area is then draped so that only the cord is exposed. IX. Tie a piece of umbilical tape around the base of the umbilical cord tightly enough to minimize blood loss but loosely enough so that the catheter can be passed easily through the vessel.
X. Using a surgical blade, the cord is cut cleanly 1.0 to 2.0 cm from the skin. XI. The cord is stabilized with a forceps or hemostat, and the vessels identified. The single, large, thin walled oval vein can readily be distinguished from the two smaller, thick-walled round arteries (see diagram). XII. The arteries are usually constricted, so that the lumens appear pinpoint in size. By gently inserting the closed tips of the curved iris forceps into the lumen of the artery until the cut end of the artery is at the bend in the forceps, and then allowing the spring of the forceps to gently spread the tips, the artery can be dilated. XIII. Grasping the catheter between the thumb and forefinger or with a forceps, the catheter can be inserted into the lumen of the dilated artery. Supporting the stump is usually necessary. Once the catheter has ben inserted, it may encounter resistance at the level of the anterior abdominal wall or at the bladder. This resistance can usually be overcome by application of gentle steady pressure. Repeated probing movements or excessive pressure must be avoided. If unsuccessful, wait 2-3 minutes until the vasospasm ceases, or attempt the other umbilical artery. XIV. After the catheter is advanced the appropriate distance, the position of the catheter should be confirmed by x-ray. If, after sterile technique has been broken, the catheter is found to be in the wrong position, it can only be pulled back--IT MUST NEVER BE ADVANCED. XV. Observe both legs for evidence of blanching, cyanosis or mottling. If a "blue leg" develops (presumably from vasospasm), the catheter should be removed or carefully observed for a short period of time to allow for resolution of the impaired circulation. XVI. After placement of the catheter, a purse-string suture is placed around the umbilicus taking care not to puncture the catheter. XVII. The procedure for catheterization of the umbilical vein is similar; differences are as follows: A. Remove any visible clots from the lumen of the vein with forceps. B. Never leave the catheter open to atmospheric pressure. The abdominal venous system is under negative pressure; with a deep inspiration air can enter the catheter with resultant air embolism. C. For administration of fluid, the venous catheter must be in the inferior vena cava, just below the right atrium.Inserting the catheter two-thirds of the shoulderto-umbilicus distance is a good estimate. A catheter in the portal venous system must not be used for the administration of fluids or medications and should be removed. D. For the purpose of an exchange transfusion, the catheter should be advanced only until there is a free flow of blood, but never more the 8 cm in the full term infant. This catheter should be used only for withdrawal of blood (see section on Exchange Transfusion). E. If code medications and/or fluid need to be given in the delivery room, a UVC should be placed and advanced only until there is a free flow of blood as in "D" above. XVIII. To sample blood from an umbilical catheter, withdraw 1 ml of blood into a sterile syringe, keeping the syringe perpendicular to the infant. this will cause the blood to settle near the tip of the syringe. The tip of the syringe should be kept sterile, and not placed in the infant's incubator or bed. XIX. The blood sample is then withdrawn into a second syringe and the initially withdrawn blood reinfused and the system flushed with a small amount of saline until free of blood. XX. The alcohol should be washed off with sterile water after the procedure is completed. This is important to prevent clinical burns, especially in very small infants.
XXI. Heparin is not routinely added to the IV solution, except with the use of the Neocath. Whether the use of heparin decreases the incidence of thrombolitic complications has not been well studied. XXII. The umbilical artery catheter is removed slowly when it is no longer needed. With proper care, the catheter need not be changed for the duration of its use.

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Exchange Transfusion
I. A. If an exchange transfusion is necessary, compatible blood must be ordered. If a severely affected ( i.e. hydropic) infant with Rh hemolytic disease is anticipated at birth, it may be necessary to have blood available in the nursery prior to the delivery. The request should be for O negative packed red blood cells of the specific volume needed and of the appropriate CMV status. This blood may be utilized in any one of the following ways: 1. The RBC's may be given as a simple transfusion (with or without additional Plasmanate) while stabilization of the infant is accomplished. 2. The RBC's may be used for a partial exchange transfusion to acutely elevate the hematocrit without changing the blood volume in a severely anemic baby. B. When the need for an emergency, complete exchange transfusion is virtually certain, arrangements can be made in advance for O negative whole blood or O negative PRBC's resuspended in fresh frozen plasma. C. For double-volume exchange transfusions for hemolytic disease of the newborn or for hyperbilirubinemia without hemolysis, the blood used will be packed cells (type O, Rh specific for the infant) resuspended to the desired hematocrit in compatible fresh frozen plasma. D. A partial exchange transfusion is often done for polycythemia (see section on polycythemia). II. Although the standard anticoagulant (CPD) is acidic, the blood need not be buffered. If the infant is severely acidemic, consult the staff neonatologist. III. If possible, the infant should be NPO and the stomach contents aspirated prior to the procedure. IV. The exchange transfusion should be done under a radiant warmer using sterile technique. V. The donor blood should be warmed using the blood warmer to a temperature not exceeding 37oC. VI. The infants blood pressure, respiratory rate, heart rate and general condition should be monitored during the exchange transfusion according to standard nursing protocol. VII. If the serum bilirubin concentration is at a dangerous level and the blood for exchange transfusion is not yet ready, consider priming the infant with 1 gram/kg (4 ml/kg) of a 25% solution of salt-poor albumin to bind additional bilirubin and keep it in the circulation until the exchange can be accomplished..
VIII. The umbilical vein catheter should be inserted until there is free flow of blood immediately prior to starting the exchange transfusion. See section on placement of umbilical catheters for technique. The exchange transfusion should not be done through an umbilical artery line unless the UAC is used only for blood withdrawal with simultaneous replacement through the umbilical vein or peripheral IV. At the beginning of the exchange transfusion, the first blood sample withdrawn should be sent for for 1)total and direct bilirubin; 2) hemoglobin and hematocrit; 3) glucose; and 4) calcium. IX. Use the "exchange transfusion kit", which contains catheters, stopcocks, waste bag, and calcium gluconate. X. Ideally, blood (or colloid in the event of a partial volume exchange) should be infused through a peripheral vein at a rate equal to blood withdrawal from the UVC. If the "pushpull" (single catheter) technique is utilized, no more than 5 ml/kg body weight should be withdrawn at any one time. XI. The exchange volume is generally twice the infant's blood volume, (generally estimated to be 80 ml/kg). The total volume exchange should not exceed one adult unit of blood (450-500 ml). A standard two-volume exchange will remove approximately 85% of the red cells in circulation before the exchange and reduce the serum indirect bilirubin level by one-half. The exchange of blood should require a minimum of 45 minutes. XII. The need for giving supplemental calcium is controversial. If used give 0.5 to 1.0 ml of 10% calcium gluconate IV, after each 100 ml of exchange blood. Monitor heart rate for bradycardia. XIII. At the end of an exchange transfusion blood should be sent for sodium, glucose, calcium, total and direct bilirubin, and hemoglobin and hematocrit. XIV. At the end of an exchange transfusion, the umbilical vein catheter is usually removed. In the event of a subsequent exchange, a new catheter can be inserted. XV. Hypoglycemia often occurs in the first or second hour following an exchange transfusion. It is therefore necessary to monitor blood glucose levels for the first several hours after exchange. XVI. The serum bilirubin concentration rebounds to a value approximately halfway between the pre- and post- exchange levels by two hours after completing the exchange transfusion. Therefore, the serum bilirubin concentration should be monitored at two to four hours after exchange and subsequently every three to four hours. XVII. Feedings may be attempted two to four hours after the exchange transfusion. Section Top | Title Page
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Technique for Insertion of a Chest Tube

Pulmonary air leak is an anticipated risk of mechanical ventilation. Drainage of air or fluid accumulation in the thorax is an important and necessary skill and is often performed emergently. I. Indications. A. Evacuation of pneumothorax B. Evacuation of large pleural fluid collections 1. chylothorax 2. empyema 3. hemothorax A small spontaneous pneumothorax in the absence of lung disease will most likely resolve without intervention. II. When evaluating a suspected pneumothorax, auscultation and transillumination of the chest should be performed. Note that false positives may result from subcutaneous edema or air. If positive, consider needle aspiration performed with a 20 or 22 gauge needle connected to a 30 cc syringe via a 3-way stopcock. After prepping with alcohol, insert needle 3-5 mm into the chest wall in the fourth or fifth intercostal space in the anterior axillary line. If the infant is supine, air may be easier to access via the second intercostal space in the mid-clavicular line. III. If pneumothorax is under tension or reaccumulates following needle aspiration, the insertion of a chest tube (CT) will be necessary. Appropriate insertion sites include the fourth, fifth or sixth intercostal spaces in the anterior axillary line. The nipple is a landmark for the fourth intercostal space. IV. Insertion. (see figure on next page) A. A 8, 10 or 12 French CT used depending on the size of the infant. B. Position infant supine or with the affected side elevated 45-60 degrees off the bed using a towel or blanket as back support. This has an advantage of allowing air to rise to the point of entry and of encouraging the correct anterior direction of the CT. C. The skin is prepped with alcohol and sterilely draped. D. A 1 cm incision is made through the skin on top of the rib to facilitate entry of the CT. Using a small curved forceps, separate the tissue down to the pleura. F. Grasping the end of the CT with the tips of curved forceps, apply pressure until the pleural space is entered. Do not use the trocar. Direct CT toward apex of thorax (midclavicle) and advance CT assuring that side holes are within thorax.
Observe for cloudiness, vapor or bubbling in CT to verify intrapleural location. E. The chest tube should be inserted 2-3 cm for a small preterm infant and 3-4 cm for a term infant. (These are approximate guidelines only.) V. After CT insertion connect the tube's distal end to a water seal system such as a PleurevacR. To apply suction, use 15-20 cm of water in the PleurevacR column. If multiple CTs are placed, each CT should be connected to it's own water seal system and suction source. Secure CT to skin with suture and cover incision site with vaseline gauze and/or TegadermR dressing. VI. After thoracentesis or CT insertion a chest x-ray, A/P and lateral should be obtained. VII. If there is a persistent pneumothorax despite a properly placed CT, consider increasing the column of water by 5 cm increments up to 30 cm before inserting a second CT. IX. Prior to removal, the CT should be clamped for 2-4 hours or longer. If there is no reaccumulation of air, the CT can be removed. X. Complications. A. Misdiagnosis with inappropriate CT placement B. Malpositioned CT C. Trauma 1. lung laceration or perforation 2. laceration and hemorrhage of major vessel (axillary, intercostal, pulmonary, internal mammary) 3. puncture of viscus with path of tube D. Infection
Reference:
Mehrabani D, Kopelman AE: Chest tube insertion: A simplified technique. Pediatr 1989;83:784785.

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Technique for Insertion of a Pericardial Tube

Pneumopericardium generally occurs in infants receiving assisted ventilation or vigorous resuscitation. Pneumopericardium becomes clinically significant when the pericardial air is under enough pressure to impede cardiac output and tamponade the heart. I. Indications. A. Pneumopericardium with tamponade. B. Pericardial effusion with tamponade. II. Evaluation. Physical examination of an infant with suspected pneumopericardium will reveal tachycardia or bradycardia, muffled or distant heart sounds and decreased blood pressure. Chest x-ray, time permitting, will demonstrate air encircling the heart on both the anterior-posterior and lateral views. The volume of pericardial air seen on x-ray may not correlate with the clinical signs of circulatory compromise. Transillumination is sometimes positive, but pneumopericardium may be confused with pneumothorax or pneumomediastinum. III. Technique. A. Cleanse skin over xiphoid, precordium, and upper abdomen with alcohol. B. Use (1 1/2 inch) 16, 18 or 20 gauge angiocath attached to a 3-way stopcock and 30 cc syringe. If clinical situation permits, consider cutting 1 or 2 small (1 mm) holes (to function as sideports) near end of catheter using blade. C. Insert the catheter 0.5 cm to the left of and just below the infant's xiphoid, directing it toward left shoulder, aspirating with the syringe as the catheter is advanced. When the pericardial space is entered and air is obtained, remove stylet. Aspiration of air usually results in immediate improvement in hemodynamic status (see figure). IV. If air reaccumulates, secure catheter in place and attach to continuous suction via water seal system using 5-10 cm of water in the column. V. Confirm catheter position by chest x-ray. VI. Potential complications include myocardial puncture or irritation, hepatic laceration, injury to major vessel, pneumothorax, hemothorax, and infection.

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Intraosseous Infusion
I. Indication: In critically ill infants, placement of intravenous catheters is often difficult and time consuming. The intraosseous route offers immediate vascular access required for emergency administration of drugs during resuscitation. Intraosseous infusion uses the rich vascular network of long bones to transport fluids and drugs from the medullary cavity to the circulation. The response and distribution of fluid and drugs injected via the intraosseous route appears to be very similar to that after intravenous injection. The procedure should be limited to emergencies in which intravenous access (including umbilical vein catheterization) cannot be established in a reasonable length of time, usually 2-5 minutes. II. Method: A. Insertion of a needle into the medullary cavity of a long bone should be rapid and simple. B. In infants less than 12 months of age, a 16- or 18-gauge spinal needle with a stylet is recommended. C. The preferred site is the medial proximal tibia because of its broad flat surface and thin layer of skin covering the bone. D. A point is selected 1 to 2 cm below the tibial tuberosity on the medial flat surface of the anterior tibia. E. The needle is directed at an angle of 60 degrees pointing away from the joint space and growth plate with a screwing motion. F. Entry into the marrow space is noted by a decrease in resistance. The distance from the skin through the bony cortex is rarely more the 1 cm. A common mistake is to advance the needle into or through the opposite side of the bone. G. To confirm placement, a saline filled syringe is attached to the catheter and infused slowly while palpating the limb for extravasation. H. Drugs may be administered rapidly or by slow infusion. I. Conventional vascular access should be established with discontinuation of the intraosseous infusion as soon as reasonably possible. III. Complications: A. Success rate is about 80%. B. The most common complication is subcutaneous or subperiosteal infiltration of fluid. C. Risks of cellulitis and osteomyelitis are less than 1% and related to duration of
catheter placement. D. No lasting negative effects on growth plate development have been reported.

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Percutaneous Placement of Central Venous Catheters

I. Background and General Information: A. Percutaneously placed, central intravenous catheters have become an important part of neonatal patient management over the past several years at the University of Iowa and elsewhere. They have proved of value in helping to provide adequate long-term nutritional support as well as providing long-term vascular access for the administration of medications such as antibiotics and prostaglandin E1. The risks of percutaneous, and intravascular central catheters are lower than those of catheters placed surgically. These include local or systemic infection, and thrombosis with or without infiltration. Manifestations of the latter include redness or swelling of an extremity, the chest wall, and/or the neck. B. When used for nutritional purposes, glucose concentration up to 25% may be used to provide adequate calories if the catheter has been successfully placed in the vena cava or right atrium. However, in doing so one should try to use less concentrated dextrose solutions since the risk of thrombosis goes up with the use of increasingly hyperosmolar solutions. Attempts should be made to fully utilize other less hyperosmolar means of providing calories. This might include using lipid solution to provide additional calories and/or to use a faster rate of infusion with a less concentrated dextrose solution. These considerations should be evaluated on a continuing basis. II. Catheterization Procedure: Commonly used sites for catheterization include the basilic, cephalic, saphenous popliteal, external jugular, and temporal veins. (The vessels with the highest success rate of catheterization are those which have not been previously used for peripheral IV's.) Cap, mask, sterile gloves and sterile gown are worn by the operator (mask only by nurse assistant), and the procedure is performed aseptically. Ideally the catheter tip should lie a few centimeters from the right atrium. This can be estimated by knowing the catheter length and how far from its insertion site it needs to be threaded. To confirm this, a post-insertion AP x-ray will be taken and the tip identified. The x-ray to be ordered for most catheters is a single AP view of the lower chest and upper abdomen. III. Care of Percutaneous Central Catheters: A. IV fluids need not contain heparin if the flow rate is 5 ml/hr or greater; if flow rate is < 5 ml/hr fluid should contain heparin, usually at a concentration of 0.25 0.5 unit/ml, but at a rate not to exceed 100 U/kg day; (50 U/kg/day in infants <1000 g). B. Initial IV fluids should contain dextrose at a concentration not greater than 10%; if the catheter tip is positioned in a central vein ,the dextrose concentration may be advanced slowly to as high as 25% (see A above). C. IV rates should be kept at 3 ml/hr or greater, and less than that recommended by the catheter manufacturer (generally <20 ml/hr for a 27 or 28-gauge catheter) D. 24-gauge silastic catheters may be repaired by cutting the hub and cannulating
the catheter with a 28-gauge blunt needle. This should be done with sterile technique. 27 and 28-gauge catheters cannot be repaired. The dressing is not routinely changed. E. Blood samples should not be drawn through the catheter. If suspicions occur regarding the need to remove the catheter or if other questions about the catheter arise, consult a nurse or physician member of the Neonatal Percutaneous Central Catheter Team. F. More detailed nursing instructions for the placement, care and handling of the catheter are available on the NICU in the Policy and Procedure Manual. G. Removal of a percutaneous central catheter should be performed by a nurse or physician member of the Percutaneous Central Catheter Team, if possible. H. At the time of its removal, the length of the catheter from its tip to entry point into the plastic hub should be measured and recorded on the special form in the patient's chart. IV. Requesting Placement of Central catheters by Patient's Physician: A. Requests for central line placement can be made by consulting a member of the Neonatal Percutaneous Central Catheter Team. (This needs to be followed by a written order.) A Catheter Team member will inspect the patient's veins for suitability of catheter placement and report his/her impression to the resident, fellow or staff physician making the request. If the patient appears suitable the following need to be done by the patient's physician in coordination with the physician placing the catheter: 1. schedule the date and time of the procedure with a Catheter Team member; 2. order IV solution and have present on unit. 3. discuss procedure with patient's parent(s). B. Responsibilities of the Percutaneous Catheter Team include: 1. answering additional questions parents may have after their discussion with their baby's primary physician; 2. order and examine chest x-ray following catheterization procedure 3. put procedure note in Progress Notes and fill out Percutaneous Line Consult Sheet. 4. discuss results of procedure with baby's primary physician. Section Top | Title Page
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Apt Test for Fetal Hemoglobin

I. Purpose: To differentiate fetal blood from swallowed maternal blood in the evaluation of bloody stools. II. Method: Mix specimen with 3-5 ml of tap water and centrifuge. Supernatant must have a pink color to proceed. To 5 parts of supernatant, add 1 part of 0.25 N (1%) NaOH. III. Interpretation: A pink color persisting over 2 minutes indicates fetal hemoglobin. Adult hemoglobin gives a pink color that becomes yellowish brown in 2 minutes or less indicating denaturation of the adult hemoglobin.
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Copyright 2006 The University of Iowa All information contained within the UI Health Care site is the property of the University of Iowa unless otherwise noted. Duplication of any information contained within the UI Health Care site for reasons besides personal use requires the expressed written permission of the University of Iowa. "UI Healthworks," "UI Health Access," "UI Consult," and "University of Iowa Health Care" are all Trademarks of the University of Iowa.
Disclaimer Medicine is an ever-changing science. As new research and clinical experience broadens our knowledge, changes in treatment and drug therapy are required. The authors have checked with sources believed to be reliable in their efforts to provide information that is complete and generally in accord with the standards accepted at the time of publication. However, in view of the possibility of human error or changes in medical sciences, neither the authors nor the University of Iowa nor any other party who has been involved in the preparation or publication of this work warrants that the information contained herein is in every respect accurate or complete, and they are not responsible for any errors or omissions or for the results obtained from the use of such information. Readers are encouraged to confirm the information contained herein with other sources.
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