"IT'S A SMALL WORLD" (An Introduction to Neonatology)

William J. Cashore, M.D., Editor Neonatal Attending Staff Neonatal Fellows Nutrition Team Nursing Staff Nurse Practitioners Pharmacy Staff Respiratory Therapy Team Division of Neonatal - Perinatal Medicine Women & Infants Hospital of Rhode Island The Warren Alpert Medical School of Brown University Never final, always being revised; Last revision June, 2007

CORRECT HAND HYGIENE

Upon Entering the NICU

1 minute scrub with anti-microbial soap Rings, watches, and bracelets should be removed Scrub from fingertips to elbows covering all surfaces including between fingers and under nails Dry thoroughly Apply waterless hand gel to hands and forearms and rub until dry (about 1 minutes) Jewelry should not be worn when performing patient care

Between Patient Care and Upon Returning to the NICU

(Preferred) 1 2 squirts of waterless hand gel (Purell or other product); rub all surfaces, including, around and under fingernails until hands are dry. or 15-second hand wash with a nickel-size squirt of anti-microbial soap; dry thoroughly.

SmallWorldSpecialCareNurseryOrientationIndex ContentsPages
I. Organization and Schedules Team Assignments Call Schedules Plan of the Day General Information and Survival Skills Neonatal Admission History and Physical Form Delivery Room/Operating Room Stabilization of the High-Risk Newborn Admission Routines (Includes overview of initial sepsis workup and respiratory management) Guidelines for Preventing Medication Errors in Pediatrics Fluids, Electrolytes & Nutrition 1. IV Fluids and Electrolytes 2. Feeding 3. Parenteral Nutrition Respiratory Care 1. Blood Gas Guidelines 2. Oxygen Administration 3. Surfactant 4. Neonatal Ventilators 5. Guidelines for Non-invasive Oxygen Monitoring Infectious Disease Issues 1. Infection control 2. Management of Neonatal Infections 3. GBS Guidelines for Women & Infants Hospital 4. HIV-exposed NewbornProtocol for Initial Management Metabolic Screening, Immunizations, Ultrasounds, and Eye Exams Some Common Clinical Problems 1. Hypoglycemia 2. Hypocalcemia 3. Procedure for Suspected Drug Exposure 4. Narcotic Withdrawal 5. Blood Pressure in Infants 6. Transfer of Drugs to Human Milk 7. Hyperbilirubinemia 8. Apneic Spells 9. Use of Blood Products in the Special Care Nursery Discharge Planning and Seasonal RSV Prophylaxis (Synagis) Instructions Clinical Practice Guidelines 1. Procedure-related Pain Management 2. HIE/Hypothermia Guidelines 3. Congenital Diaphragmatic Hernia 4 4 4 5 6 -7 8 -10 11-15 16 -17 18-24 25-38 25-29 30-34 34-38 39-45 39-40 40 40-41 41-44 44 -45 46-54 46-47 47-49 50-52 53-54 55-60 61-82 61 62-63 63-64 64-68 69-70 71-74 74-78 78-80 80-82 83-94 95-109 96-99 100-105 106-109

II.

III. IV. V.

VI.

VII.

VIII. IX.

X. XI.

I.

ORGANIZATION AND SCHEDULES Team Assignments:

Team 1 Attending Fellow 4 NNPs

Team 2 Attending Fellow PL-2s (Day and swing) PL-1's (3 or 4)

LDR PL-2 PL-1* (from Team 2) NNP

LDR coverage: *Days: NNP, LDR PL-2, Team 2 PL-1 (per assignment) *Nights: Add Normal Nursery (NNN) PL-1, when on call Teams 1 and 2 follow their patients in the Special Care Nursery (SCN). Admissions to teams are by census and nursing assignments. Team alignments may change, depending on the numbers of residents and NNP's available. Each PL-1 has 1 LDR assignment (+normal nursery LDR call). Patient load is reduced during this assignment. Resident Functions LDR PL-2: High-risk deliveries; day transports; supervises and stabilizes new admissions. Team PL-2: Regular patient assignments on Team 2; independent for many procedures, and supervises and helps PL-1's; shares senior call with delivery PL-2 and swing PL-2. PL-1: Admits and follows assigned patients; has one daytime LDR rotation, with reduced number of SCN patients. Learns and performs bedside procedures with supervision. Night call: SCN PL-1: q 4th night PL-2 : q 4 while Team member or on LDR assignment q 2 when on swing

"Plan of the Day" 1. Pre-round 6:30 - 7:30 a.m. - check: (earlier when a.m. conference) a. Patient status (update with patients nurse) b. Weight and totals c. Pending procedures and lab work d. Write new orders, if needed Team rounds at 8:00 a.m. and 4:00 p.m. (9:00 a.m. Wednesdays and some Thursdays) Following a.m. rounds: a. b. c. d. e. f. 4. Examine infants and check labs Review nutrition orders with nutritionist Complete discharges Start progress notes Telephone follow-up X-ray rounds (usually at approximately 1 p.m. Monday, Wednesday, & Friday)

2. 3.

Noon conference: a. b. c. d. Pathology 1st and 3rd Tuesday Perinatal Seminar each Thursday (Mortality and Morbidity, Infectious Diseases, Nutrition, Journal Club) Social Service Rounds each Friday Interdisciplinary Antenatal Management Conference 1st and 3rd Friday

5.

Attending teaching rounds: Monday, Tuesday, and Wednesday at noon.

6.

Sign-out rounds: Weekdays at 4:00 p.m. a. b. c. Brief, business-like Pick up new patients Emphasize active vs. static problems

II. SURVIVAL SKILLS IN SCN 1. Pre-round at bedside; develop a checklist 2. Present concisely; don't editorialize 3. Progress notes: a. Daily notes b. Note any significant change or procedure, e.g., 1) Endotracheal intubation* 2) Lumbar puncture* 3) Arterial or venous catheter placement* 4) Chest tube* 5) Cultures 6) Transfusions 7) Significant change in condition *Write Procedure note, and indicate when discontinued c. Document parent and physician contacts 4. Talk to parents and other physicians and inform parents of pending procedures. 5. Listen to the nurses! 6. Order sheets: a. Bedside - admission, nursing care, respiratory care, medications, and phototherapy. b. Consults, X-rays, regular lab work, etc. in Bay order books c. Respiratory orders in bedside chart d. Daily TPN orders - computer printout must be signed by M.D. 7. Labs - everything is on stat line a. Phlebotomy schedule 2-5-8-11 b. Computer terminals CERNER Systems c. STAT and summary print-outs d. Flow sheets - stay current 8. Discharge and Transfer Summaries a. Do as soon as possible b. Dictate using Cerner (See Discharge Template pages) c. Stay current 1) Penalties for delinquent records 2) Avoid overwhelming backlog 3) Medicolegal problems - record observations; avoid editorials, opinions, and undocumented statements, especially about obstetrical management

Patient Presentations Know your patients, and be concise. Be up to date on daily weights, management changes, procedures, and important lab values. Present a brief obstetrical or interval history. For older patients, a one-sentence summary may do (e.g., Baby X is a one month old, 25 week, 820g preemie with BPD and feeding intolerance. Try to avoid: o Calling babies products o Overuse of diminutive or disparaging terms (were not little, small doctors!). o Former to describe gestational age (The patient is not divorced or retired). Instead, try Baby Z is a 27 week premature, now 40 days old... o Editorializing (as I am doing now!) Social history is important, but may not require extensive discussion on work rounds. Follow your brief history and list all problems/diagnoses with a system-oriented presentation and your therapeutic plan. Unresolved problems and loose ends should be discussed along with the plan. Check with the bedside nurse during pre-rounds, and determine when each nurse will be available for team rounds on her patients. Afternoon rounds should be concise and deal with new admissions, major management problems, and the plan for the next two shifts. A brief check with the night nurses after 11:00 p.m. is important. Write a complete admission or observation note on each patient brought to Intensive Care Nursery: a complete history, physical exam, diagnostic impressions, and plan in legible and organized format. Pre-printed admission and progress note templates evolve over time, but all permanent printed forms should be approved by Medical Records (sample on next page). Progress Notes Write daily notes on all patients. Describe interval events clearly and concisely. System-oriented notes can be entered on approved pre-printed forms. Record significant exam findings, procedures, changes in the patients condition, and communication with the family. The team attending will write progress notes for all patients of residents going off call. On weekends, daily patient notes are written by the attending and a nurse practitioner. However, please document any procedures (cultures, transfusions, LPs, catheter placements, etc.) as well as any changes in the patients condition on weekend days. Summaries and Signatures Dont get behind on your records. You will feel overwhelmed, and medical records will chase you!

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Delivery Room/Operating Room Stabilization of the High Risk Newborn: Clinical Care Considerations, House-staff/NNP Responsibilities, and Educational Rotations The following is a summary of expectations for personnel involved in the care of high risk newborns in the delivery/operating rooms. A) Members of the Delivery Room team: Providers with responsibility for care and stabilization of newborns in the DR/OR include the Fellow, PL-2 and PL-1 on delivery room rotation, NNP, Respiratory Therapist and a representative of Nursing (either the Assistant Nurse Manager or Admission Nurse). Given the relatively short intervals the House-staff have for a dedicated delivery room rotation and the necessary program requirements that take House-staff out of the rotation (post-call, clinic), the NNP will serve as the Coordinator to supervise the House-staff while on the DR rotation. B) Communication between patient care areas and the NICU providers responsible for DR/OR coverage: Dedicated cell phones are used to facilitate communication among the DR/OR providers (physicians, nurses, RTs). The template for communication is that any area requiring NICU staff to respond to a delivery contacts the NICU secretary and the secretary uses the cell phone (single dedicated channel) to contact all members of the team (Fellow, PL-2, PL-1, NP, ANM, RT). This allows providers to communicate with each other and make sure that the appropriate individual is responding as needed. C) Preparation of infant warmers: All warmers will be set up in a standardized fashion in each patient care area where infant resuscitations could occur at or shortly after birth (LDRs, ORs, Newborn Nurseries, ABC, Triage). D) Providers attending deliveries: There are clear expectations regarding who should attend specific deliveries. There is also a clear delineation of an orderly sequence of who is the next person responsible for attending a delivery if the primary person is unavailable to respond. The following is the current working template and may be modified as needed: Guidelines for who is the primary individual(s) responding to specific types of deliveries: 1) 2) 3) 4) 5) 6) 7) Neonatal Fellow: Gestational age < 30 weeks Fetal hydrops Any potential life threatening congenital anomaly Crash cesarean section Infants not responding adequately to initial airway management Multiples < 34 weeks Infants requiring intubation: will depend on competency of the PL-2

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Senior Pediatric Resident (PL-2) or NP: 1) Gestational age < 33 weeks 2) Urgent cesarean sections (non-reassuring FHR, low biophysical profile, etc.) 3) Abruptio placenta 4) Placental previa with hemorrhage 5) Shoulder dystocia 6) Meconium with a non-reassuring fetal heart rate pattern 7) Emergent use of forceps or vacuum* 8) Vaginal breech presentation 9) Poor respiratory effort at birth (slow to start) 10) All indications requiring the presence of a fellow Pediatric Resident (PL-1): Gestational age 33 weeks Elective repeat cesarean section (irrespective of presentation) Non-emergent use of forceps or vacuum* Suspected growth restriction Oligohydramnios Chorioamnionitis/PROM Maternal medical problems: diabetes, hypertension Twins (need second provider) Meconium with a reassuring fetal heart rate Poor respiratory effort at birth (slow to start) once competent in bag/mask ventilation 11) Absent prenatal care 1) 2) 3) 4) 5) 6) 7) 8) 9) 10) 1) 2) 3) 4) Respiratory Therapist: All indications requiring a Fellow All indications requiring a PL-2/3 or NNP All deliveries with meconium stained fluid Poor respiratory effort at birth (slow to start)

ANM/NICU Nurse: 1) All deliveries requiring a fellow * Assessment of emergent or non-emergent use of forceps/vacuum may only be ascertained once in the DR/OR and then should prompt the appropriate personnel When the primary individual responsible for attendance at a delivery is unable to attend (in another delivery, stabilizing an infant in the NICU etc) the following sequence should be followed: 1) If a PL-1 delivery: Back-up order is PL-2, NP, fellow 2) If a PL-2 delivery: Back-up order is NNP, Fellow (PL-1 should accompany NP or Fellow)

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E) Training of new providers in the DR/OR setting: New providers to the LDR/ORs (PL-1, NP) need individualized instruction that is consistent from month to month. As much as possible a trained provider (e.g., fellow, PL-2, NP) will attend deliveries with new personnel and provide on site instruction until competency is demonstrated. For low risk deliveries of the PL-1 list above (e.g., elective repeat cesarean sections), preparation of equipment and proper handling/assessment of the infant need to demonstrated. For higher risk deliveries of the PL-1 list (e.g., meconium stained amniotic fluid) competency in recognition of the need for more support (e.g., oxygen, bag/mask ventilation), and bag/mask ventilation needs to be demonstrated. PL-1s who are not on DR/OR should also receive mentoring when they fill in for the PL-1 on DR/OR (e.g., during clinic hours and post-call). F) Responsibilities of the NP for the DR/OR: 1. Attend deliveries with the PL-1 until the PL-1 demonstrates competency in specific functions. 2. Orient PL-1 to the cell phone/communication system. 3. Conduct teaching sessions with the PL-1 4. Facilitate the PL-1 completing their work to allow time for attendance on rounds, attending deliveries and teaching sessions 5. Conduct quality assurance reviews of specific aspects of care in the DR/OR 6. Participate in the DR/OR coverage so that rounds can proceed uninterrupted in the morning and afternoon 7. Cover the DR/OR when the PL-2 is admitting a patient, in clinic, or post-call. 8. Be available to help with procedures during rounds so that the teams can continue their work. 9. Transport patients within the hospital system and to/from other hospitals. 10. Teach and orient the third year medical students on Tuesday and Thursday. G) Responsibilities of the DR PL-2 for the DR/OR (all responsibilities are shared with the NP): 1. Attend high risk deliveries 2. Admit patients to the NICU (perform exam, write history and orders, do blood work, consult with fellow etc) 3. Provide care for infants under observation status and complete the appropriate paperwork and communication if triaged to the Newborn Nursery 4. Evaluate problems of specific patients in the NICU during morning rounds to minimize rounds having to be stopped. This function should be done under the guidance and supervision of the Fellow. 5. Teach the PL-1s on DR issues when knowledgeable regarding specific topics.

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6. Transport patients within the hospital system and to/from other hospitals. 7. Teach and orient the third year medical students on Tuesday and Thursday. 8. Pick two topics per week on issues timely and pertinent to team II (e.g., imperforate anus, NEC etc). After reading neonatal sources, write on the board an over view of the topic (e.g., definition, pathogenesis, time of occurrence, risk factors, diagnosis, treatment, prognosis as pertinent for each topic). Leave on the board for 2-3 days for other team members to view. H) Responsibilities of the DR PL-1 for the DR/OR 1. Attend deliveries appropriate for level of training 2. Understand transitional events associated with birth 3. Learn how to appropriately triage infants to either the NICU or the Newborn Nursery 4. Learn how to admit new patients to the NICU I) Educational content of the DR/OR rotation: To ensure that specific basic information is conveyed to each house-officer/new NP as they rotate through the DR/OR (two week blocks for the House-staff), attempts should be made to cover focused topics pertinent to delivery room care. The topics for the PL-1 are as follows: 1. Orientation to the delivery service: tour of the physical plant (L&D, ORs, triage, ABC area, post-partum floors), communication system (wireless system and all hazards of this technology, measures to not lose phones, back-up system), bed set up as delineated under section A, organization of the delivery service as to who goes to what deliveries, expectations before they can function independently 2. Airway management part A (use senior RT staff either alone or with NNP): different type of bags (self-inflating, anesthesia, Neopuff), bagging techniques, seal, position, assessment of adequate ventilation, hands on experience with manikin/intubation head, airway stabilization for transport 3. Airway management part B (use senior RT staff either alone or with NNP): intubation issues including equipment (including appropriate size laryngoscope blade), ET tubes, positioning, visualization of structures (use of video??), indications for intubation 4. Meconium stained amniotic fluid: significance of meconium passage, Ob management, pediatric airway management, use of meconium aspirator 5. Temperature control in the DR: consequences of cold stress, preparation for delivery, use of warm blankets, proper drying and removal of wet blankets/towels, implications of LBW, use of hats, transport issues 6. Initiating CPR: indications for CPR, time expectations, proper sequences, proper chest compressions 7. Maternal pregnancy risk assessments: amniotic fluid volume, biophysical profile, fetal cord blood gases, rupture of membranes, chorioamnionitis,

14

diabetes, hypertension, growth restriction, breech, fetal heart rate abnormalities 8. Maternal exposure to drugs: anesthesia, analgesia, Mg exposure, other drugs given to the mother, illicit drug use, when to avoid narcan The PL-2 will also benefit from focused discussion of pertinent topics to their level of training. Some PL-2s may need a refresher of basic concepts covered as a PL1. The topics for the PL-2 are as follows: 1. Review of airway management (done with Senior RT staff): review techniques of bagging, assessment of adequate ventilation and response to bagging, intubation techniques, use video if necessary 2. Critical airway issues (done with Senior RT staff): proper approach to infants with critical airway compromise (Pierre-Robin sequence, other malformations of the upper airway), recognizing your limits, sequence of back up resources 3. Ambiguous genitalia and other unexpected findings in the DR/OR: appropriate discussions with families 4. Handling infants with abdominal wall defects, myelomeningocoele 5. Delivery room management for the premature infant: intubation vs. CPAP, prophylactic surfactant, initiation of care for infants at the borders of viability

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III. ADMISSION ROUTINES FOR NICU (See NICU Order Sheet) 1. PL-2, LDR PL-1 or LDR NNP admit and stabilize new patients 2. Orders (Refer to the pre-printed sheet, and modify as needed) a. b. c. d. e. f. Admit or "Observe" in NICU Admitting Diagnosis and condition Vital signs, monitoring, and glucose screens per NICU protocol Vitamin K and Hepatitis B vaccine X-rays, including indication for request IV fluids (see attached for guidelines) Route of administration (UA, UV, peripheral veins) Specific orders for additional lines Include all fluid intake in daily totals Feeding orders, or NPO Separate order sheet for parenteral nutrition (see guidelines) Admission Blood Work; check off as needed, and consider these as STAT requests Initial and follow-up metabolic screens Other e.g., initial medications, additional bedside procedures, etc. Urgent consults or special studies may require a separate order form

g. h. i. j.

3. Respiratory Care a. Use bedside order sheet to specify initial orders, follow-up changes, and blood gas requests b. O2 concentrations, ventilator settings and changes, and blood gas results are recorded on the pink bedside flow sheet and in CERNER c. Surfactant, initially for paO2 <80 mm HG in 40% O2 Repeat in 6-8 hrs if pO2 is <80 in > 30% O2 The dose of 4 mL/kg is often rounded to 4 or 8 mL Consult Respiratory Therapy, and Respiratory Care Guidelines pages. 4. Special Routines, e.g.: a. Indomethacin prophylaxis (<1250 gm): 0.1 mg/kg IV x 3 - now, in 24 hrs, and in 48 hrs. after first dose. Request cranial U/S on Day 1. b. Hepatitis B, high risk: give vaccine, 0.5 ml at birth or admission Determine maternal status ASAP HBIG if mother is HBs Ag positive c. Sepsis work up: See under Infectious Disease Issues d. HIV prophylaxis: See pages on HIV-Exposed Newborn - Initial Evaluation and Management e. Be sure that orders conform to nursing and pharmacy policies regarding dose, concentration, rate and route of administration

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IV. Guidelines for Preventing Medication Errors in Pediatrics

By Michael R. Muller, Pharm.D., NICU Clinical Pharmacist Specialist A. Elements of a Medication Order or Prescription 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Patients full name. Patients age (date of birth) and current weight. Diagnosis and other appropriate patient-specific data. Known allergies. Drug name, dosage form, and drug strength. Drug names should be printed for rarely used medications. Express concentrations in metric units. Number or amount to be dispensed. Express quantity, if appropriate, in metric units. Include calculations, or at least mg/kg/day dosing, so calculations can be independently double-checked; i.e. amoxicillin 40mg po q 8 hrs (40mg/kg/day). Prescribers name and pager or telephone number. Complete instructions for the patient including indication, directions for use including dose, frequency of dosing, route of administration, intended duration of therapy, and the number of authorized refills. Products to be administered by the patient or caregiver in the outpatient environment should be labeled expressing the dose in conventional units of measure. Listing equivalent measurements may be helpful to clarify the intended dose (i.e., 1 teaspoonful (5 mL) by mouth twice daily). Recommend or supply appropriate measuring devices. Discourage use of household teaspoons and tablespoons. Recommendations for Prescribers 1. 2. Legibility (i.e., printed or typed vs handwritten, prescriber computer order entry). Preprinted orders are another option but must be approved by a multidisciplinary team of the P&T Committee (Service Line Committee, W&I). Drug name should be either the official (generic) or trademarked name clearly spelled. For those medications that contain multiple ingredients, the use of the trade name is more appropriate. Abbreviations of the name, acronyms, and chemically or locally coined names should not be used because they may be misunderstood. Instructions should be written out, rather than expressed using abbreviations that are ambiguous or not approved within the institution. Vague instructions, such as take as directed, should not be used. Because many medications are available in varying strengths or concentrations, dosage strengths or concentrations and volumes should be expressed in exact metric units (e.g., mg, units), rather than dosage form units (e.g., # tablets, vials, ampules, capsules, mL). A leading zero should always precede decimal expressions less than one (i.e., 0.1 mg), but a trailing zero should never follow a whole number (i.e., 1.0 mg).

3. 4. 5. 6.

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7. 8.

9.

10. 11.

12. 13. 14. 15.

16.

To facilitate verification of the appropriateness of the dose by other healthcare professionals, any calculations used in determining the dose should be included in the medication order. For medications other than most topically administered, both the calculated dose AND the mg/kg or mg/m2 dose upon which the dose is based should appear in all medication orders for pediatric patients. This simple step helps assure that a nurse and / or pharmacist do not misread an order. It also promotes accurate dose calculation by facilitating redundant checks by nurses and pharmacists. If the order is for a drug product that is not on the formulary or for a new dosage of a formulary medication, the prescriber should provide information with the order or in the patients chart for other healthcare professionals. Use of a non-formulary medication introduces a new drug into the system that healthcare professionals may not recognize; thereby, increasing the risk of error. A healthcare provider may assume that it is another drug that sounds or looks similar to an agent with which they are familiar. Use of nonformulary items should be limited for the above reasons. If orders are changed, a new order should be written. For the ambulatory patient, new prescriptions should be written and remaining refills of previous doses should be canceled. The information should be communicated to the pharmacy providing outpatient services. In situations where the use of verbal prescriptions or orders is necessary, the prescriber should dictate the order slowly and clearly, spelling the drug name and any other words that may be misheard. Likewise, the prescriber should restate numbers that may be confused (i.e., 15 as one five). In order to verify accuracy, the prescriber should have the recipient repeat the order back to him or her. The prescriber should also be certain to verify the transcribed order within a designated time frame. When possible, without compromising patient care, odd dosages should be rounded-off for more convenient and accurate measurement. When appropriate, prescribers should write orders for commercially available drug products, rather than dosage forms prepared by manipulation of commercially available products. If at all possible, drugs should be prescribed for oral administration, rather than by injection. Prescribers should consider consolidating styles of managing patients. A variety of ways to manage a patients medical condition is possible and considered good medicine that is cost effective. However, diversity in writing medication orders may lead to confusion and errors. Consolidating styles in an intensive care unit setting so that all drips are written as either mcg/kg/minute or mg/kg/hour can avoid calculation errors that occur secondary to moving back and forth between systems. Prescribers should also counsel the patient and his or her caregiver, familiarizing them with the name, indication, route of administration, dose, dose frequency, potential adverse effects, and how adverse effects might be managed for each medication the patient is receiving.
(Adapted from Levine SR, et al. J Pediatr Pharmacol Ther 2001;6:426-42.)

Problem Order
Indocin (0.1/kg) .100mg IV q24 X iii

Better Order
Indocin (0.1mg/kg/dose) 0.1mg IV q24 hours X 3 doses

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Problem Order
Y in D5 w/ 2/2 Na/K 0.25 u hep @ 0.7cc/o cont TPN rate @ 1cc/o

Better Order
Y-site w/ TPN the following solution: D5W w/ NaCl 2mEq/100ml KCl 2 mEq/100ml heparin 25 units/100ml Run @ 0.7ml/hr Run TPN @ 1ml/hr

Problem Order
Decrease Morphine oral solution to 0.06ml po q4o prn finnegans

Better Order
Taper Morphine oral solution 0.4mg/ml to: 0.024mg (0.06ml) po q4 hrs For withdrawal symptoms

Problem Order
Resume PO meds

Better Order
Resume ADEK vitamins 0.5ml PO BID Ferinsol 5mg PO q day Ursodiol 17mg PO q8 hrs (10mg/kg/dose)

Problem Order
Indocin 2.7mg IV q12o X 3 doses

Better Order
Indocin 0.27mg IV q12 hrs X 3 doses for PDA (0.2mg/kg/dose, wt=1.35kg)

Problem Order
D10W w/ 2 mEq Na+ 1 mEq K+ /100 @7.6cc/hr for TF=90

Better Order
D10W w/ NaCl 2mEq/100ml KCl 1mEq/100ml Heparin 25 units/100ml

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Run @ 7.6ml/hr (TF=90ml/kg/day, wt=2.03kg)

Problem Order
Please mix D12.5 w/ Dopamine 5mcg/k/min @ 0.25cc/hr Mix 624 mg/50cc

Better Order
Mix Dopamine 62mg/50ml D12.5 Run @ 0.25ml/hr (5mcg/kg/min, wt=1.03kg)

Problem Order
Please increase to 8 mEq NaCl/kg/d Divided into 2 doses

Better Order
Increase NaCl to (8mEq/kg/day in divided doses) 1.1mEq PO q4 hrs w/ feeds (wt=0.825kg)

B. Continuous Infusion Medications Women & Infants Hospital Patients Name (Addressograph) Neonatal ICU Continuous Infusion Medication Order Sheet
Doctors Orders Date / Time: __________ / __________ Allergies: _______________________________________________________________

Medication Orders
Cardiovascular Medications Medication Concentration Diluent Dose______(mcg/kg/min) X Weight______(kg) X 60 Rate Alprostadil Standard D W ___________________________________________ = (mL/hr) Dobutamine Fluid Restrict D W Dopamine NS Concentration______(mcg/mL)
=================================================================================================================== =
10 5

Medication Concentration Diluent Dose______(mcg/kg/min) X Weight______(kg) X 60 Rate Alprostadil Standard D W ___________________________________________ = (mL/hr) Dobutamine Fluid Restrict D W Dopamine NS Concentration______(mcg/mL)
=================================================================================================================== =
10 5

Neurological Medications Medication Concentration Diluent Dose______(mcg/kg/hr) X Weight______(kg) Rate Fentanyl Standard D W _____________________________________ = (mL/hr) Midazolam Fluid Restrict D W Morphine NS Concentration______(mcg/mL)
=================================================================================================================== =
10 5

Medication Concentration Diluent Dose______(mcg/kg/hr) X Weight______(kg) Rate

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 Fentanyl Standard D W _____________________________________ = (mL/hr) Midazolam Fluid Restrict D W Morphine NS Concentration______(mcg/mL)

=================================================================================================================== =
10 5

Endocrinologic Medications Medication Concentration Diluent Dose______(unit/kg/hr) X Weight______(kg) Rate Insulin, Reg Standard D W _____________________________________ = (mL/hr) Fluid Restrict D W NS Concentration______(unit/mL)
=================================================================================================
10 5

Signature: ____________________________ M.D. / N.P. Name: ____________________________ Pager # ___________ ____________________________ R.N.
Authorization is hereby given to dispense a chemically identical drug (According to Hospital Formulary Policy) unless this box is checked. MR-336 (3-2005)

Standardized Infusion Formulary Cardiovascular Medications Neurological Medications Medication Concentration Diluent Medication Concentration Diluent Alprostadil (PGE1) 10 mcg/mL (Standard) D5W, D10W, NS Fentanyl 10 mcg/mL (Standard) D5W, D10W, NS 20 mcg/mL (Fluid Restricted) 40 mcg/mL (Fluid Restricted) Dobutamine 800 mcg/mL (Standard) D5W, D10W, NS Midazolam 100 mcg/mL (Standard) D5W, NS 3200 mcg/mL (Fluid Restricted) 400 mcg/mL (Fluid Restricted) Dopamine 800 mcg/mL (Standard) D5W, D10W, NS Morphine 50 mcg/mL (Standard) D5W, D10W, NS 3200 mcg/mL (Fluid Restricted) 200 mcg/mL (Fluid Restricted) Endocrinologic Medications Medication Concentration Diluent Insulin, Regular 0.1 unit/mL (Standard) D5W, D10W, NS 0.2 unit/mL (Fluid Restricted)

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ADDENDUM A: Women & Infants Standardized Concentrations: Pediatric Continuous Infusion Medications Formulary Standard Concentration Alprostadil 10 mcg/mL in D5W Alprostadil 10 mcg/mL in D10W Alprostadil 10 mcg/mL in NS Amiodarone 2000 mcg/mL in D5W Dobutamine 800 mcg/mL in D5W Dobutamine 800 mcg/mL in D10W Dobutamine 800 mcg/mL in NS Dopamine 800 mcg/mL in D5W Dopamine 800 mcg/mL in D10W Dopamine 800 mcg/mL in NS Epinephrine 32 mcg/mL in D5W Epinephrine 32 mcg/mL in D10W Epinephrine 32 mcg/mL in NS Fentanyl 10 mcg/mL in D5W Fentanyl 10 mcg/mL in D10W Fentanyl 10 mcg/mL in NS Heparin 40 units/mL in D5W Heparin 40 units/mL in D10W Heparin 40 units/mL in NS Inamrinone 1000 mcg/mL in 1/2NS Inamrinone 1000 mcg/mL in NS Insulin, Regular 0.1 unit/mL in D5W Insulin, Regular 0.1 unit/mL in D10W Insulin, Regular 0.1 unit/mL in NS Isoproterenol 10 mcg/mL in D5W Isoproterenol 10 mcg/mL in D10W Isoproterenol 10 mcg/mL in NS Standard Concentration Lidocaine 2000 mcg/mL in D5W Lidocaine 2000 mcg/mL in D10W Lidocaine 2000 mcg/mL in NS Midazolam 100 mcg/mL in D5W Midazolam 100 mcg/mL in NS Milrinone 50 mcg/mL in D5W Milrinone 50 mcg/mL in NS Morphine 50 mcg/mL in D5W Morphine 50 mcg/mL in D10W Morphine 50 mcg/mL in NS Nitroprusside 200 mcg/mL in D5W Fluid Restricted Concentration Alprostadil 20 mcg/mL in D5W Alprostadil 20 mcg/mL in D10W Alprostadil 20 mcg/mL in NS Dobutamine 3200 mcg/mL in D5W Dobutamine 3200 mcg/mL in D10W Dobutamine 3200 mcg/mL in NS Dopamine 3200 mcg/mL in D5W Dopamine 3200 mcg/mL in D10W Dopamine 3200 mcg/mL in NS Epinephrine 64 mcg/mL in D5W Epinephrine 64 mcg/mL in D10W Epinephrine 64 mcg/mL in NS Fentanyl 40 mcg/mL in D5W Fentanyl 40 mcg/mL in D10W Fentanyl 40 mcg/mL in NS

Inamrinone 3000 mcg/mL in 1/2NS Inamrinone 3000 mcg/mL in NS Insulin, Regular 0.2 unit/mL in D5W Insulin, Regular 0.2 unit/mL in D10W Insulin, Regular 0.2 unit/mL in NS Isoproterenol 40 mcg/mL in D5W Isoproterenol 40 mcg/mL in D10W Isoproterenol 40 mcg/mL in NS Fluid Restricted Concentration Lidocaine 8000 mcg/mL in D5W Lidocaine 8000 mcg/mL in D10W Lidocaine 8000 mcg/mL in NS Midazolam 400 mcg/mL in D5W Midazolam 400 mcg/mL in NS Milrinone 200 mcg/mL in D5W Milrinone 200 mcg/mL in NS Morphine 200 mcg/mL in D5W Morphine 200 mcg/mL in D10W Morphine 200 mcg/mL in NS Nitroprusside 1000 mcg/mL in D5W

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Nitroprusside 200 mcg/mL in NS Pancuronium 0.1 mg/mL in D5W Pancuronium 0.1 mg/mL in NS Pentobarbital 5 mg/mL in D5W Pentobarbital 5 mg/mL in D10W Pentobarbital 5 mg/mL in NS Phenylephrine 20 mcg/mL in D5W Phenylephrine 20 mcg/mL in NS Potassium Chloride 0.04 mEq/mL in D5W (Peripheral Line) Potassium Chloride 0.04 mEq/mL in D10W (Peripheral Line) Potassium Chloride 0.04 mEq/mL in NS (Peripheral Line) Potassium Chloride 0.08 mEq/mL in D5W (Central Line) Potassium Chloride 0.08 mEq/mL in D10W (Central Line) Potassium Chloride 0.08 mEq/mL in NS (Central Line) See W&I Policy on Neonatal/Pediatric IV Potassium Administration for additional details.

Nitroprusside 1000 mcg/mL in NS Pancuronium 0.8 mg/mL in D5W Pancuronium 0.8 mg/mL in NS Pentobarbital 10 mg/mL in D5W Pentobarbital 10 mg/mL in D10W Pentobarbital 10 mg/mL in NS Phenylephrine 60 mcg/mL in D5W Phenylephrine 60 mcg/mL in NS Potassium Chloride 0.08 mEq/mL in D5W (Peripheral Line) Potassium Chloride 0.08 mEq/mL in D10W (Peripheral Line) Potassium Chloride 0.08 mEq/mL in NS (Peripheral Line) Potassium Chloride 0.15 mEq/mL in D5W (Central Line) Potassium Chloride 0.15 mEq/mL in D10W (Central Line) Potassium Chloride 0.15 mEq/mL in NS (Central Line) Potassium Chloride 0.2 mEq/mL in D5W (Central Line) Potassium Chloride 0.2 mEq/mL in D10W (Central Line) Potassium Chloride 0.2 mEq/mL in NS (Central Line) See W&I Policy on Neonatal/Pediatric IV Potassium Administration for additional details. Fluid Restricted Concentration Procainamide 4000 mcg/mL in D5W Vecuronium 1 mg/mL in D5W Vecuronium 1 mg/mL in NS

Standard Concentration Procainamide 2000 mcg/mL in D5W Vecuronium 0.2 mg/mL in D5W Vecuronium 0.2 mg/mL in NS

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V. FLUIDS, ELECTROLYTES AND NUTRITION The more premature an infant is, the higher is his/her initial fluid requirement. This is based on the following principles: Initial fluid requirement is determined largely by insensible water loss. Sources of insensible water loss: Skin Lungs Smaller infants have larger surface area-to-body weight ratio and much more immature skin. Thus, the smaller the baby is, the more fluid is lost through the skin. Smaller infants are placed in open radiant warmers that increase skin losses. Smaller infants tend to breathe faster, which increases respiratory loss of fluid. We try to minimize insensible water loss by: 1. Covering infants on warmers with plastic wrap 2. Humidifying the surrounding air 3. Humidifying ventilator oxygen 4. Using giraffe incubators for tiny babies Therefore, starting fluid requirements (water requirement) are determined by gestational age and weight. (Note: not only by weight, because SGA infants will have skin maturity that resembles their age, not their weight) SAMPLE STARTING FLUID REQUIREMENTS Gestation Warmer Giraffe Incubator 23 24 weeks 100 110 ml/kg/day 90 100 ml/kg/day 25 26 weeks 90 100 ml/kg/day 80 90 ml/kg/day 27 31 weeks 80 90 ml/kg/day 80 ml/kg/day 32 36 weeks 70 80 ml/kg/day 70 80 ml/kg/day 37 42 weeks 70 ml/kg/day 60 ml/kg/day Fluid requirements may change in the subsequent 12-24 hours. Also, try to think of water requirements separately from sugar and electrolyte requirements. Set the fluid rate first; then add the glucose and lytes to that fluid.

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Changes in Fluid Requirements That Can Occur In the First Day 1. ELBW infants (<750g) It is not usual to underestimate insensible water loss, because even though we attempt to keep them covered and humidified, these infants are ill and we expose them intermittently for long or short periods of time. STRATEGY: a. Place on bed scale and weigh q 6hr b. Follow serum sodium q8-12 hrs c. Start with 85% humidity in the giraffe incubators, decreasing by 10-15% per day, to about 30% on Day 5 **Weight changes and changes in serum sodium are the most reliable indicators of fluid status in the first few days of life. Weight loss (which is normal) should not exceed 15% of birth weight over 3-5 days. Sodium should be maintained 135-145. Na+ above 150 indicates dehydration. Adjust fluid intakes as needed by 5% (a small change) to 25% (a large change). 2. VLBW Infant (<1250 g) on Indocin Prophylaxis Indomethacin exaggerates the normal low GFR in the first 24 hours of life by decreasing renal blood flow further. Infants receiving indomethacin may have low urine outputs for 1-3 days and may actually gain excess water weight on standard fluid volumes. STRATEGY: weigh infant q12 hours Check serum Na+ q12 hrs If weight goes up and sodium is going down to the low 130's, then the infant is likely fluid overloaded; cut back on fluids. 3. Infants with RDS In RDS there is a delayed diuresis from generalized capillary leak and perhaps as a result of SIADH induced by the lung disease. Overhydrating these infants will increase pulmonary lung fluid and exacerbate RDS. STRATEGY: Weigh infant q12-24 hr: Follow Na+ and urine output. Be patient. Keep fluids low (at starting level or lower if weight increases) until diuresis occurs naturally. As infant begins to void, lung function will improve. After allowing a moderate diuresis, increase fluids as you would for any other baby.

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4. Full term infants with Asphyxia. Moderate-severe asphyxia frequently causes either renal dysfunction or acute renal failure marked by oliguria or even anuria. Since we say "it's OK" for normal term infants to not void for 24 hours after birth, renal dysfunction from asphyxia may be difficult to detect. STRATEGY: For infants with low Apgar scores, start with 60 cc/kg/day. Keep strict I/O's, even place bladder catheter if necessary Watch for hematuria or proteinuria Check serum Na+ and Weight at 6-12 hrs of age. If sodium is low, weight is above birth weight, and urine output is low, then fluid restriction is appropriate. Infants who are anuric and are term (and thus have little fluid loss through the skin) have very low fluid requirements, on the order of 30-40 cc/kg/day. These infants will often need UV lines placed to give fluid with dextrose concentrations >D12.5 to supply the usual 4-6mg/kg/min of glucose. N.B.: In the first few days, pressors and inotropes to increase urine output are usually not necessary if 1) oliguria is an expected feature of the infants disease state, and 2) peripheral perfusion and SaO2 are adequate. Most infants with respiratory distress will spontaneously increase renal blood flow and urine output by day 3 4.

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Glucose Requirements STARTING POINT 4-6 mg/kg/min of glucose The Magic Formula: Glucose load provided = (Dextrose Conc)(Rate in cc / kg / day) ( mg / kg / min ) 144 EX. FT infant on D10 at 60cc/kg/day receives: (10)(60) = 4.2 mg / kg / min of glucose 144 EX. Preemie on D10 at 80 cc / kg day receives (10)(80) = 5.6 mg / kg / min of glucose 144 EX. an ELBW infant is receiving D10 at 140 cc / kg / day (increased from 120 because of weight loss and increasing serum sodium) (10)(140) = 9.7 mg / kg / min ! ! ** 144 ** Because ELBW and VLBW infants have such high WATER requirements in the first few days of life, we often need to give them lower dextrose concentrations to avoid hyperglycemia. Hyperglycemia causes hyperosmolality and increases risk of IVH. So, give this same infant D5 at 140, to provide the required amount of fluid (water) and glucose of (5)(140) = 4.9 mg / kg / min 144 Electrolyte Requirements Remember that most infants do not require electrolyte supplementation in the first 24 hours of life, with the exception of Ca++ in very small or asphyxiated infants. Low Na+ in the first day of life is more likely to reflect fluid overload than sodium depletion. After the first day, the basic requirements are: 2-4 mEq / kg / day Na+ CLK+ Ca++ Phosph= 1-2 mEq / kg / day 1-2 mEq / kg / day 100 - 200 mg / kg / day Elemental Calcium provide s.t. Ca/Phos Ratio = 2 / 1

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Summary
Starting Gestational Age Water Requirement Dextrose Conc. 23 - 24 100 110 cc /kg/day D5 25 - 26 90 -100 cc / kg / day D5 - D7.5 27 - 31 80 - 90 cc /kg / day D7.5 - D10 32 - 36 70 - 80 cc / kg / day D10 37 - 42 60 - 70 cc / kg / day D10 Asphyxia 40 cc / kg / day D12.5 - D 20 A giraffe with high humidity requires ~ 10% less water. Phototherapy, especially on a warmer, requires ~ 10% more; individualized by changes in weight and sodium concentration. Tips: Keep fluids at the minimum to provide hydration. (Higher fluids are associated with increased RDS, PDA, BPD and NEC) Increase fluids in response to weight loss and Na+ increases. Decrease fluids if weight goes above birth weight in the first 3 days of life. Add electrolytes after 24 hours when they are in normal range, but remember that changes in Na+ can reflect water status as well as Na+ requirement. And don't add K+ if the infant is not voiding or if a tiny infant is dehydrated with high Na+ and K+. Remember that the ELBW infant is at risk of hyperglycemia because of the high fluid requirements. Try to think of glucose requirement in terms of mg / kg / min. (nl = 4-6). Advance feeds slowly in small infants and sick term infants at risk of NEC. Ultimate goal 120 - 130 cc / kg / day will adequately hydrate infant > 1 week old (Decreased skin loss with keratinization), However, may need up to 150 cc / kg / day (PO) to provide optimal calories for growth.

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2. Feeding Infants in the Neonatal Intensive Care Unit

Mothers are encouraged to provide breast milk for their infants. Rather than asking if a mother plans to breast feed her infant, ask if she would be willing to provide breast milk while her infant is in the NICU. Even if a mother does not plan to breast feed, she may be willing to provide breast milk. The infants bedside nurse or a lactation consultant is able to help the mother get started pumping. Double pump set-ups are recommended to help mothers pump more efficiently. In order to establish a good milk supply, it is important for mothers to begin pumping as soon as possible after delivery, ideally within six hours. It is also possible to hand express breast milk while waiting for the pump or instruction. For most mothers and infants there are no contraindications to using breast milk. The neonatal nutritionist participates in interdisciplinary care rounds and suggests appropriate types and concentrations of enteral feedings based on the treatment course, nutrient needs, and growth progress of the infant. The physician or nurse practitioner determines and writes the feeding order, specifying the name of the feeding, strength (calories per ounce), the feeding schedule (feeding volume and frequency), and the mixing instructions, if necessary. For example, breast milk at 15 mL q 3 hr. The ultimate goal of feeding enterally - is to provide infants with an adequate intake of essential nutrients and calories via the gastrointestinal tract, to support growth and development. Initially, infants may receive a combination of parenteral and enteral nutrition. Over time, infants are transitioned to full feedings. At approximately 32 to 34 weeks post menstrual age, an infant is able to coordinate sucking, swallowing, and breathing. With that ability, an infant will begin to breastfeed/nipple feed. Prior to that, most infants are fed via a gavage tube every 3 or 4 hours. Continuous gavage feedings are used, as appropriate. Trophic feedings - Infants are fed enterally as soon as medically possible after birth, preferably starting within the first day or two of life. Full-strength breast milk, including colostrum, is preferred. If human milk is not available, an appropriate fullstrength infant formula is used. Trophic feedings are small, early feedings of breast milk or formula at 1-25 mL/kg/d to stimulate gastrointestinal tract development. Infants remain on these small volume feedings until, at the discretion of the medical team, they may be advanced.

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Advancing feedings - Feeding plans are individualized. Bolus feedings are usually initiated first. Increasing feedings by more than 20 mL/kg/day has been associated with an increased risk of NEC in premature babies. On the other hand, when feedings are advanced too slowly, infants remain on parenteral nutrition longer than necessary. In general for gavage fed infants, 20 mL/kg/d is a reasonable goal. Please note that some infants may need to progress more slowly (<20 mL/kg/d) while others may progress more quickly (up to 30 mL/kg/d). Continuous feedings may be an option for infants who have difficulty progressing beyond a certain volume of bolus feedings. General guidelines - When deciding whether to advance feedings, first consider the results of the abdominal exam and whether the exam provides indications for maintaining, advancing, or stopping feedings. If feedings for a 1 kg infant are increased by 2mL and the infant is fed q 3 hr, feedings will advance by 16 mL/kg/d: (2 mL increase x 8 feedings/d )1.0 kg body weight = 16 mL/kg/d).

Therefore, for AGA Preemies 500 750 g 1 mL/feed q 4 hours Change to q 3 hours, then increase by 1 mL 3 hours 800 1000 g 2 mL/feed q 3-4 hours Change to q 3 hours, then increase by 2 mL q 3 hours 1100 1200 g 2 mL/feed q 3 hours Increase by 2 mL q 3 hours 1300 1500 g 3 mL/feed q 3 hours Increase by 3 mL q 3 hours 1600 2000 g 3-5 mL/feed q 3 hours Increase by 3-5 mL q 3 hours **REMEMBER, THESE ARE GUIDELINES ONLY, AND STARTING VOLUME AS WELL AS RATE OF ADVANCEMENT MUST BE INDIVIDUALIZED BY DEGREE OF ILLNESS, H/O ASPHYXIA, AND MATURITY. Breast milk - is the gold standard for infant feedings. Besides containing highly bio-available nutrients, breast milk also contains anti-bacterial, anti-viral, antifungal, and anti-inflammatory factors as well as hormones and growth factors. Even though preterm breast milk may be slightly higher in some nutrients during the first month, the concentration of nutrients per ounce is lower than preterm infants require. Human Milk Fortifier is added once an infant is tolerating full feedings to increase calories and nutrients for preterm infants. The ultimate goal for breast milk-fed infants is to transition from bottle feeding pumped breast milk to breastfeeding. Infant formulas - The number of infant formulas available can be mind boggling. For that reason, it is easiest to remember them by category or type. a. Premature infant formulas - recommended for infants < 2500g and/or < 37 wk gestational age

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b. Transitional infant formulas - recommended for infants (>1850g but not yet full term) just prior to hospital discharge c. Full-term infant formulas - recommended for infants > 2500g and > 37 wk gestational age 1. Cows milk based 2. Soy protein based 3. Specialty infant formulas; e.g., Elemental and semi-elemental formulas Low mineral formulas for renal issues High MCT oil formulas for fat malabsorption Metabolic formulas for inborn errors of metabolism Increasing calories and nutrients - Infants most often begin feeding with 20 kcal/oz breast milk or infant formula. Once an infant is at full feedings (i.e., ~120 mL/kg/d), the breast milk or appropriate infant formula may be concentrated to 24 kcal/oz. Premature infant formulas are available as 20, 24, and 30 kcal/oz readyto-use. Full-term infant formulas are available as 20 and 24 kcal/oz ready-to-use. For preterm infants, fortified breast milk and premature infant formula produce a composition of weight gain and bone mineralization similar to a fetus of the same post-conceptional age. As appropriate, breast milk or formula may be concentrated from 24 kcal/oz to 27 or 30 kcal/oz to provide sufficient nutritional intake for growth and development. For bolus feedings, breast milk or fortified breast milk is concentrated further by adding one or more of the following: premature infant formula 30 kcal/oz, infant formula powder, infant formula concentrate, carbohydrate modular, or fat modulars. When breast milk is not available, ready-to-use infant formula is concentrated in the same manner as breast milk. Human Milk Fortifier is not added to infant formula because the GI osmolality and the potential renal solute load of the mixture may exceed safety limits. For continuous feedings, ready-touse and/or concentrated infant formula (appropriately diluted) is used whenever possible to maximize food safety. The neonatal nutritionist can advise on ways to concentrate calories and nutrients while maintaining the balance of nutrients, GI osmolality, potential renal solute load, and free water - all within normal limits. Recommended daily enteral intakes for stable, preterm infants Water: 150-160 mL/kg/day Calories: 110-120 Kcal/kg/day Protein: 3-4 gm/kg/day Carbohydrate:15-16 gm/kg/day Fat: 3-4 gm/kg/day Calcium: 120-230 mg/kg/day Vitamin D: 400 IU/d

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Iron: 2-4 mg/kg/d (maintenance) 6-8 mg/kg/d (therapeutic) But not greater than 15 mg/d total Growth progress - The goal of nutritional management is to maintain adequate growth during hospitalization. While optimal growth for preterm infants has yet to be defined, it remains important to follow growth - not only weight gain but also linear growth and head circumference. The bedside nurse measures body weight daily. The neonatal nutritionist plots weights of infants on approved growth grids that are located in each infants bedside chart. It is recommended that medical residents and nurse practitioners measure length and head circumference weekly on their stable patients and record measurements on the growth curve. Vitamin-mineral supplements - Infants are born with some nutrient stores. For example, iron stores for a normal, full-term infant may last 4 months without additional supplementation while iron stores for a preterm infant may last only 1 month. When assessing nutrient intake, it is important to include the nutrients available not only from supplements but also from feedings. An infant consuming iron-fortified formula at a volume that provides 110 Kcal/kg/d would receive 2.0 mg iron/kg/d from feedings. In the NICU, vitamin-mineral supplements for preterm infants are generally started after an infant is tolerating full enteral feedings. This may be 1 month of life. Supplements containing iron may be started as early as 14 days of life if an infant is at full feedings. A reasonable goal is 2-4 mg of iron per kg/d (feedings + supplements). Most infants do not require more than 0.5 mL of Poly-vi-sol with iron per day. Dividing the dose to give twice per day will reduce GI osmolality and enhance nutrient absorption. Common supplements used in the nursery include: Poly-vi-sol with iron - a multivitamin and mineral supplement that contains 10 mg iron and 400 IU vitamin D per 1 mL Ferinsol - contains only iron, 15 mg iron per 0.6 mL ADEK with Zinc - contains no iron but is a multivitamin that provides fat-soluble vitamins in a water-soluble form. It is appropriate for infants with conditions of fat malabsorption. Drisdol - contains only vitamin D. Two drops provide 400 IU of vitamin

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3.

Parenteral Nutrition for Neonates

The neonatal nutritionist generally orders the parenteral nutrition (PN). The neonatal nutritionist consults with physicians, nurse practitioners and/or pharmacists regarding individual orders, as needed. The orders are reviewed and signed by the physician or nurse practitioner. It is recommended that PL1 residents routinely practice entering PN orders with the nutritionists for one or two of their patients during their rotation, to become familiar with the process and to understand more fully the effect of medical decisions and an infants medical course on the nutritional content of the PN. On 3 holidays each year (Easter, Thanksgiving, and Christmas) PN orders are placed by the PL1 on call. The NICU has a computerized method for ordering PN. Daily entries must be made to enable the pharmacy to prepare the solutions. Information needed prior to entering the PN order include: current body weight, IV rate/hour, type of line (PIV or CL), laboratory results (serum glucose, electrolytes, or other pertinent labs), and whether or not the infant is on phototherapy. Below are guidelines for ordering PN in the NICU. The ultimate goal of parenteral nutrition is to provide infants with an adequate intake of essential nutrients and calories to support growth and development until the infant is able to tolerate full feedings via the gastrointestinal tract. Infants who receive parenteral nutrition for > 4 weeks with little or no enteral feedings are at increased risk of PN-related complications; e.g., cholestasis and nutrient deficiencies. Indications for use - Infant will not achieve full oral intake within 4 days. a. VLBW, extreme prematurity - feedings not tolerated or in conjunction with increasing oral calories b. Necrotizing enterocolitis c. Surgical lesions, omphalocele, gastroschisis, GI atresia, complicated anastomosis, short bowel (18 cm with ileocecal valve, 40 cm without ileocecal valve) ** PN IS NOT APPROPRIATE FOR INFANTS WITH ADEQUATE INTESTINAL FUNCTION WHO MAY BE MAINTAINED BY ORAL, TUBE, OR GASTROSTOMY FEEDINGS.

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Routes of administration a. Peripheral IV - short term use only For peripheral lines, the osmolality of the PN solution should be maintained between 600 and 1000 mOsm/L. PN ordered for a peripheral IV contains no heparin. b. Central venous catheter (CVL) - longer term use For central lines, the osmolality of the PN solution should be < 1500 mOsm/L. PN ordered for a CVL contains 0.5 U heparin/mL. 1. Perc line placed by a team in SCN 2. Surgically placed catheter - Broviac c. Umbilical catheter. PN ordered for a UVC contains 0.25 U heparin/mL.

When to start As soon as possible. Refer to the Early T.P.N. Order Sheet Early TPN: The goal is to provide parenteral nutrition as the first IV fluid for all infants with birth weights <1500 g. Evidence supports both the benefit and safety of initiation of amino acid infusion as early after birth as possible in these infants. The Early TPN solution is clear in color and contains dextrose water, amino acids, calcium, and heparin. The total volume per patient may range from 50 to 100 mL/kg/d depending on whether the infant requires fluid for other indications (e.g., arterial catheter, medication drips) aside from Early TPN. Standard Parenteral Nutrition: Standard PN begins after the next PN orders are filled, usually 24 hours after an infants birth. Standard PN solution is a clear, yellow color. The composition of the solution is more complete than the Early TPN (see below). Standard PN is hung between 5 pm and 7 pm daily. Ingredients and dosage requirements are individualized based on patient needs. a. Total fluids - ALWAYS calculate this first: mL/kg/day = mL/hr x 24 hr body weight (kg) Fluid requirements vary from patient to patient. General guidelines to follow: 1. Keep urine specific gravity 1.008 - 1.012. 2. For infants < 1250 gm, weigh as appropriate and respond to changes in weight with appropriate fluid therapy. Urine output should be 1-2 mL/kg/hr. 3. Anticipate appropriate weight loss during the first 7-10 days of life. Plot body weight from same shift each day on growth chart. 4. Calculate fluid needs by: Change in body weight = intake - (output + IWL)

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b. Dextrose: rough guideline is to provide 4 to 6 mg/kg/min first day of life, then advance as tolerated keeping serum glucose < 200 with minimal glucosuria. Infusion of up to 12.5% dextrose may be given via peripheral lines Infusion of up to 25% dextrose via central lines Glucose load: mg/kg/min = (Dextrose Conc) (Rate in mL/kg/d) 144 Dextrose provides 3.4 Kcal/gm in monohydrate form. If an infant develops hyperglycemia, check the glucose load and decrease as necessary. (Often, decreasing the glucose load by 2 to 3 mg/kg/min from the current glucose load will suffice. In the smallest infants, it may be necessary to reduce the load to 4 to 6 mg/kg/min.) Any infant who demonstrates hyperglycemia with glucosuria at a concentration of glucose that had previously been tolerated is suspect for sepsis. It is also necessary to observe infants closely for rebound hypoglycemia following abrupt termination of PN. c. Amino Acids: start with 1 to 2 gm/kg/day, increase by 0.5 1.0 gm/kg/day to a maximum of 3.5- 4.0 gm/kg/day. Watch urine output, BUN, metabolic acidosis, hyperammonemia; re-evaluate protein needs when these symptoms occur. Protein intake should not exceed 17% of total calories in the PN. d. Lipids: start lipids at 0.5 to 1 gm/kg/day and increase by 0.5 to 1 gm/kg/day to a maximum of 3.0 gm/kg/day. In general, check triglyceride levels when the PN lipid is at 2 g/kg/d. If the triglyceride level is > 200 mg/dL, decrease the lipid taking into account the total caloric intake and the nutritional balance between carbohydrate, protein, and lipid. Lipids are administered as Intralipid. The 20% solution provides 2 Kcal/mL. Lipids are infused over 24 hours or at a rate < 0.15 gm/kg/hour. Provide 0.51.0 gm/kg/day within first week of life to prevent essential fatty acid deficiency in VLBW infants. Lipids should provide less than 55% of total calories to avoid the risk of ketosis. e. Sodium and Potassium: After second day of life, the usual recommendations are 2-3 mEq Na+/kg/day and 1-2 mEq K+/kg/day. Adjustments will depend on infants serum values and hydration status. The amounts (ions) of sodium and potassium ordered must match the amounts (ions) of chloride, acetate, and phosphorus ordered. Acetate may be used if metabolic acidosis is present, since it is metabolized to bicarbonate. Phosphorus is discussed in the calcium, section f.

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f. Calcium: IV requirements are 60-90 mg/kg/day of elemental calcium, but this amount is difficult to provide parenterally due to solubility limitations. Both calcium and phosphorus are needed for bone mineralization. Calcium is ordered in mEq. On day 1 of PN, start with 2 mEq of calcium and no phosphorus. Increase calcium and add phosphorus on day 2. For optimal bone mineralization, keep the calcium to phosphorus ratio between 1.3:1 and 1.7:1. This will allow a maximum of 4 mEq calcium to 2 mmol or phosphorus. Listed midway on the right side of the order sheet is the conversion of calcium from mEq/kg/d to mg/kg/d. Along with that are the mg phosphorus/kg/d, the calcium to phosphorus ratio, and information about the precipitation limit. g. Magnesium: the recommendation for Mg+ intake is 0.25-0.5 mEq/kg/day. More may be needed, especially if losing gastric secretions so it is important to monitor levels. Mg+ is provided as MgSO4. In general, start with 0.4 mEq/kg/d MgSO4. If mother received magnesium prior to delivery, check infant's serum level before administering in PN. h. Multivitamins: MVI contains all water and fat soluble vitamins. Dose is body weight dependent. Infants who weigh: < 1 kg receive 1.5 mL MVI/day. 1-3 kg receive 3 mL MVI/day. > 3 kg receive 5 mL MVI/day. i. Trace elements are provided in a standard dosage of 0.2 mL/kg/day. Neotrace contains zinc, copper, manganese and chromium. Excretion of copper and manganese requires a normal biliary tract. If the infant has an elevated direct bilirubin associated with cholestasis, copper and manganese may build up due to sludging in the biliary tree. These elements are usually restricted in infants with significant cholestasis. It is possible to hold the trace element (TE) solution to limit copper and manganese intake, but it is important to add zinc separately at 400 mcg/kg/d while the TE solution is held. Chromium should be discontinued when renal function is impaired. Glomerular filtration rate has been inversely correlated with chromium intake, serum chromium concentration, and PN duration. Holding the TE solution will eliminate chromium intake from that source. Zinc may be added separately at 400 mcg/kg/d while the TE solution is held. Zinc is lost in diarrhea and stoma output. Failure-to-thrive patients are also at increased risk for zinc deficiency. Additional zinc may be indicated in such cases.

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j. Iron, selenium, iodine, or carnitines are not routinely added to the PN. k. When the osmolality of the PN solution is too high, consider the following suggestions: 1. Decrease the percent dextrose or decrease the protein (g/kg), keeping the percent of calories from carbohydrate, protein, and fat WNL. 2. Decrease electrolytes (sodium, potassium, and chloride), if appropriate, as the PN fluids decrease, maintaining serum electrolyte levels WNL. 3. Decrease calcium and phosphorus, keeping the Ca:P ratio WNL. (If the infants only source of calcium is in the PN, use at least 2 mEq Ca/kg/d.) 4. Continue to run lipids, keeping the percent of calories WNL. The additional fluids that lipids provide will reduce the PN osmolality. l. Laboratory values to monitor PN are obtained as medically appropriate. About mid-week of the 1st week on PN, obtain calcium, phosphorus, and magnesium levels. When lipids reach 2 g/kg/d, check a triglyceride level. Finally, a weekly or biweekly parenteral nutrition lab panel allows the monitoring of nutritional intake and the identification of metabolic complications. A PN panel includes (blood or plasma): sodium, potassium, chloride, bicarbonate, glucose, BUN, creatinine, total and direct bilirubin, albumin, prealbumin, calcium, phosphorus, magnesium, alkaline phosphatase, ALT/SGPT, GGTP, and triglycerides.

38

VI.

RESPIRATORY CARE 1. Blood Gas Guidelines Blood gas measurement should be supplemented in most infants by oxygen saturation monitoring. A blood gas measurement is appropriate in any respiratory, cardiac or surgical patient who has experienced any significant change in clinical status. Capillary Blood Gases: Capillary blood gas values are unreliable in the immediate newborn period (<4 hr) and in low perfusion states. Otherwise, pH and pC02 values should be quite close to arterial values. P02 values for capillary blood gases should be between 35 and 50 mmHg to predict an arterial p02 >40 and <100 mmHg. Values for capillary blood p02 >50 mmHg may represent arterial values >100 mmHg. The primary value of capillary measurements is to evaluate pH and pC02. The saturation monitor is better at assessing oxygenation than is the capillary blood gas. Arterial Blood Gases: Arterial gases drawn from umbilical or radial lines are the gold standard for assessment of infant status. General guidelines for normal values for normal term infants are: pH - 7.30-7.40; p02 - 70-100 mmHg; pC02 - 35-45 mmHg. Venous Blood Gases: Initial blood gases on an unstable infant can be drawn from the umbilical vein or other venous site. The pH and pC02 values will give an adequate initial assessment of acid-base and ventilatory status. Documentation of Blood Gases: In many infants with respiratory problems, deviations from normal values are appropriate. In general, preterm infants with respiratory problems may have p02 values in the 50-80 mmHg range. Significant deviations from the normal range should be intentional (e.g., high p02 for pulmonary hypertension) or recognized as part of the disease process (e.g., high pC02 in bronchopulmonary dysplasia). Initial abnormal blood gas values in an infant require a response. That response should be documented in the orders and in CERNER - a change in ventilator settings, a change in Fi02, etc., and the effect of the change documented in a timely fashion. For example, if p02 is high or low, the appropriate changes on the sat monitor within 5-10 minutes after Fi02 change (documented in the record) is sufficient. However, if pC02 or pH is out of range, a repeat blood gas is needed in a timely fashion to document improvement. If insufficient improvement has occurred, the process of problem recognition, response in terms of a change in ventilatory support, and documentation of the effect of the change may need to be repeated every 1530 minutes until the desired endpoint is achieved.

39

2.

Administration and Monitoring of Oxygen Oxygen is a drug and should be administered only with a written order from a physician. The order should include the concentration (volume percent delivered) or the desired range for p02 or oxygen saturation, and shall be reviewed, modified or discontinued periodically. The admission orders activate respiratory care. Initial respiratory care orders and all changes are written in the bedside order sheets, and the nursing flow sheets provide a continuous record of respiratory care at the bedside. Oxygen should be humidified before delivery to the patient. When assessing the oxygen concentration, sample the environment just adjacent to the nose or mouth. Avoid arterial oxygen tensions greater than 100 mmHg. Explicit exceptions are made for hyperoxia testing and in patients with increased pulmonary vascular reactivity. All measured arterial oxygen tensions should be in the patient's permanent record. All oxygen sensor systems should be calibrated to room air and to 100% oxygen every 8 hours. The alarm on the oxygen analyzer should be properly set and turned on at all times. Serial measurements of oxygen concentrations will be taken and recorded every two hours, before each blood gas is drawn, and at the discretion of the nurse or respiratory therapist. Whenever possible, a continuous oxygen analyzer-controller will be used to deliver the ordered oxygen concentration.

3.

Surfactant Treatment for RDS. WIH uses Survanta (Ross Labs) for the treatment of RDS. This surfactant is from bovine lungs and is expensive. Thus, it should be used only in infants with significant disease. Please check with the neonatal fellow or attending before giving surfactant. Only personnel experienced with its use should administer the drug. The general guidelines for use are as follows. a. Treat as soon as possible after birth, ideally within 1-3 hours, following initial assessment indicating significant respiratory distress. Infants with a late progression of RDS can be treated. There is no birth-weight or gestational age limit. Infants should have significant disease: intubated on a ventilator, usually with Fi02 > 0.4 and a peak pressure >18 cm H20 for the initial treatment. The CXR should be consistent with RDS.
7

b.

40

c.

Surfactant treatments can acutely increase pO2 and lung compliance. Therefore, infants receiving surfactant should be on a saturation monitor. Draw a blood gas within about 30 minutes of treatment to evaluate clinical response and to direct respiratory management. Treated infants may need sequential ventilator adjustments over several hours. Infants can be retreated after 6 hours of the initial treatment if respiratory distress persists. Generally candidates for re-treatment should still be intubated, and ventilated with >30% 02. However, if the infant is on very low pressures (<15-16 cmH20) and on 30-40% 02, a subsequent treatment may not be indicated. As many as 4 treatments can be given over 48-72 hours, but most infants require only 1 or 2 doses. Multiple dosing should be approved by the fellow or attending. Re-dose after pulmonary hemorrhage, which may inactivate intra-pulmonary surfactant. Infants with diseases other than RDS can receive surfactant if the attending or fellow feels that the treatment may help for severe, potentially lethal lung diseases. Decisions to treat such infants will be made on a case-by-case basis.

d.

e.

f.

4.

Neonatal Ventilators a. General Ventilatory support is needed for a large number of infants in the Special Care Nursery. We have a range of mechanical devices available, each with its own characteristics, advantages and disadvantages. The following is intended as a general guideline. Ventilatory support, like all forms of good medical care, is individualized. The staff in Respiratory Therapy are professionals and are there to help you and the patients. They are easily approached and offer extensive experience and good advice. b. Initiating ventilatory support Infants who require ventilatory support should have a rapid, careful, and complete physical exam carried out concomitantly with the initiation of support. Initial exam should focus on airway management first. Does the infant have normal or abnormal mouth, jaw, upper airway? Are there signs and/or symptoms of airway obstruction, stridor, etc? If any of the above is present, special precautions and/or special maneuvers may be needed. This includes careful positioning or intubation of infants with severe Pierre-Robin anomaly. The next portion of the airway to be assessed is the submandibular region of the neck. Infants with

41

congenital malformations and/or masses in the neck can present with significant airway obstruction. This includes but is not limited to infants with thyroid enlargement, cystic hygroma, or teratomas. Surgical airway management may be required in these infants. PIP: Lung inflation (inspiratory pressure): Ventilatory support is often begun with bag and mask ventilation, which may be sufficient to initiate spontaneous breathing in larger babies. Extremely LBW infants are sometime apneic at birth. They may respond to: a) Gentile tactile stimulation b) A few gentle puffs with bag and mask c) Prompt initiation of early postnatal CPAP. If they remain apneic, or if lung inflation and color do not improve rapidly with bag and mask or nasal CPAP, they should be intubated soon after initial assessment and given surfactant. Assess adequacy of ventilation by physical exam and pulse oximetry. The most reliable findings are axillary breath sounds and color. Chest excursions may be helpful, but may not be a reliable early sign when lung compliance is low. During manual ventilation, monitor peak inspiratory pressure with an in-line manometer. Use the manual PIP sufficient for effective air exchange as the initial peak inspiratory pressure for mechanical ventilation. Listen to the infant again, just after mechanical ventilation, to confirm. PEEP: End expiratory pressure of 3-4 cm H2O is a reasonable starting point for infants on mechanical ventilation. Increasing empirically to an optimal PEEP will improve oxygenation. Increases beyond that point may cause air trapping, hypercarbia, and all signs of over-inflation on the chest x-ray. Rate: Set a ventilator rate in the physiologic range sufficient to maintain gas exchange and oxygenation; a rate of 40 breaths/min is a reasonable starting point, with bedside adjustments based on blood gases, pulse oximetry, and patient-driven rate and effort. Avoid over-ventilation (paCO2 < 35-40 mm Hg). Inspiratory time: I-time in a neonate with adequate pulmonary function on conventional ventilatory support should be set at 0.3 to 0.35 seconds. On certain modes of conventional ventilation, I-times may be as short as 0.2 seconds; some patients may need longer I-times. Review individual cases with the respiratory therapists. c. Conventional rate, pressure-cycled ventilators. Our 2 conventional ventilators in current use are the Bear Cub 750 and the Drager Babylog. Both are flow-generated and adjustable at conventional rates (~ 10-100/minute) for pressure, rate, inspiratory time, and patient sensitivity. They have slightly different input controls and

42

displays. Because of software and design changes, older and newer versions of these ventilators may differ slightly from each other. Ventilation may be adjusted, according to examination findings and blood gas results, for flow, inspiratory and expiratory pressures, inspiratory time, rate, patient effort, and target tidal volume. In different modes of ventilation, some or all inputs may be fixed, while others may be allowed to vary, e.g., with patient effort or the ventilators mechanics. Several available conventional modes include: Intermittent/Synchronous intermittent mandatory ventilation: Pressures, I-time, and minimum rate are pre-set. Patient effort may initiate additional breaths. Assist/Control: Patient effort initiates full cycles at variable rates. With time delay, apneic pauses, or insufficient effort, back-up rate controls ventilation. Pressure Support/Volume Guarantee: A target tidal volume is set, usually 5 mL/kg, and delivered at variable rates and inflating pressures, proportioned to patient effort (Drager Babylog Ventilator). This mode may facilitate patient controlled weaning from prolonged ventilation or high settings. Conditions adverse to adequate conventional ventilation include high airway resistance, inadequate distal recruitment, air leaks (tube or chest), inadequate patient effort, or severe patient agitation with patient/ventilator dyssynchrony. d. High Frequency Ventilators: We have two modes of high frequency ventilation. Sensormedics 3100 A: The Sensormedics provides high frequency oscillatory ventilation (HFOV). The excursions are generated by an electromagnetic diaphragm. There are active phases of inspiration and expiration. Settings which the operator controls are: mean airway pressure (MAP), the frequency (in cycles per second or Hz), the delta P or amplitude of change in pressure, and the percent I time. We recommend initiating oscillatory ventilation at 10 Hz and with a mean airway pressure that is 2-4 cm. of water above the mean airway pressure on conventional ventilation. A chest x-ray should be obtained as soon as possible after initiation of this mode of ventilation (no later than within 30 minutes) in order to assess adequacy of inflation. As a general guideline, chose an initial mean airway pressure that inflates the lung to the 8th or 9th intercostal space. Higher mean airway pressures may be needed to improve oxygenation and allow lower fractional inspired oxygen concentrations and vice versa. The delta P should be set to generate a clearly visible chest wiggle by the patient. The percent I time is usually set by the respiratory therapist at 33%. Only in an unusual circumstance is the I time increased, and it should be done in consultation with the attending, fellow or respiratory

43

therapy staff. Other settings on this ventilator include control on flow rate, which is generally maintained above 10 liters, and bias flow, which is the balance between the inspiratory and the expiratory side of the oscillatory breath. These are set by the therapists. Fractional inspired oxygen concentration is adjusted to achieve the desired saturation. pCO2 can be lowered by increasing the P (wiggle), or by lowering the frequency (Hz) to provide a longer expiratory time. Bunnell Life Pulse: The Bunnell Life Pulse is a jet ventilator (HFJV). It generates HFV by pulsing in a jet of air at the desired frequency. The Jet ventilator is an appropriate choice for infants with air leaks, severe respiratory failure, and ventilatory diseases for which either form of high frequency ventilation is indicated. If one form of HFV (i.e. Oscillator or Jet) is not working, it is appropriate to try the other mode. The Jet can be used in low lung volume or high lung volume strategy. The low lung volume strategy would be appropriate for infants with pulmonary interstitial emphysema or other air leaks. The high lung volume strategy is more appropriate when lung compliance is low (RDS, pneumonias). On both the Jet and the Oscillator, lung volume is controlled by regulation of the mean airway pressure. On the Jet this is achieved by adjusting the PEEP setting on the in-line cub ventilator. The Jet is usually set at 420 bpm with an on Time (I time) of 0.02 sec which provides an I:E ratio of 1:6. As with the Oscillator, the adequacy of inflation should be gauged by a prompt chest x-ray after initiation of ventilation. Unlike the oscillator, the jet provides a background AIMV rate via in-line support by the Cub Ventilator. The Cub is generally set at 4-12 bpm, using a PIP and PEEP adequate to maintain alveolar recruitment. Fractional inspired oxygen concentration is adjusted to achieve the desired saturation. e. We have a sedation and analgesic protocol for elective intubations. However, we do not routinely sedate or paralyze ventilated newborns. An alert newborn with a short-term ventilator requirement is easier to extubate than a depressed one, and prolonged ventilation of sedated, pre-term infants may increase the risk of volu-trauma or baro-trauma. The art of neonatal ventilation includes finding comfortable settings for the patient. In some conditions, e.g., postoperative recovery or severe pulmonary hypertension, sedation may be appropriate. Consult with the fellows, bedside nurses, and respiratory therapists about the timing and type of chest physical therapy and inhalation treatments for your patients who require them. Suctioning and chest PT requirements vary for individuals patients. Scheduled routines of frequent suctioning and chest PT may paradoxically interfere with patient stability.

f.

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VII. 1.

INFECTIOUS DISEASE ISSUES Infection Control NB: Hand hygiene procedures are summarized inside the front cover. a. b. Initial 1 minute scrub with chlorhexidine followed by 1 minute application of alcohol-based antibacterial lotion. Hand washing before and between patient encounters (gloves alone are not adequate!); or a 30-second application of alcohol-based hand disinfectant lotion. Universal/Body Substance Precautions for blood + body fluid exposure: 1. Gloves for any invasive exam or procedure 2. Masks, face shields, goggles, long-sleeved gowns, as indicated by risk of exposure. 3. Contact precautions for risk of exposure and spread by hand contact; e.g., RSV, open drainage, diarrhea, etc. 4. Strict isolation for a. Maternal active TB b. Maternal or neonatal chicken pox c. Methicillin-resistant Staph. aureus Gloves and gowns are not needed for routine non-invasive exams, routine diaper changes, feeding, holding infants, etc. Attire: Clean scrubs, caps, masks, shoe covers, etc, as required by work area. When in doubt, consult Infection Control Manual or contact the hospitals Infection Control Practitioner. MRSA. NICU exposure to MRSA (Methicillin-resistant Staph. aureus ): 1. Isolate with gown, gloves, mask, visible barriers, and separate waste disposal 2. Cohort positive patients 3. Infection Control Staff will publicize cohorting and isolation procedures 4. Surveillance cultures (usually nasal) of exposed patients, family, and medical care staff 5. Nasal mupiricin prophylaxis for identified carriers 6. Follow-up cultures until negative x 2 or 3 7. Frequent communication with Infectious Disease and Infection Control services

c.

d. e. f. g.

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2.

Management of Neonatal Infections a. Evaluation: Laboratory Tests 1. 2. 3. 4. 5. Complete Blood count and Differential (may need follow-up in 12-24 hrs.) Blood culture - also attempt line culture if on TPN Cultures of surfaces and secretions are not routine Lumbar puncture, if indicated Bladder catheterization or tap urine culture, if indicated. (Even catheter specimens may be false-positive because of the small urethral opening and proximity to the GI tract.)

X-rays:
1. 2. 3. Chest, if respirations abnormal KUB, if abdominal exam abnormal Special studies by consultation with radiology (Call Hasbro radiologist for special imaging studies, or ultrasounds other than cranial.)

Other studies (e.g., viral studies, PCR, etc.) After consultation with neonatal staff, Infectious Disease service, or laboratory staff.

46

When to do lumbar puncture? 1. 2. 3. 4. 5. 6. Low yield immediately after birth (< 4h) More important when infant presents after the immediate post-delivery period Stabilize cardiac output and respirations Can look for pleocytosis, 'ed protein, and 'ed glucose after start of treatment Suspicion of congenital syphilis or congenital Herpes. ID consult is advisable for proven cases of meningitis

b.

Treatment Ampicillin and Gentamicin for: 1. "Rule out sepsis" -nearly all cases 2. "Rule out NEC" - nearly all cases 3. Non focal "clinical sepsis" - most cases 4. Suspicion of meningitis - most cases Cefotaxime/Ceftazidime/Cefepime for: 1. Patient intolerance to Gentamicin 2. Coverage of gentamicin - resistant Gram-negative organisms 3. CSF coverage in special cases 4. Not routine for Gram-negative coverage. Vancomycin for: 1. Coagulase-negative Staphylococcus (line sepsis) 2. Suspicion of peritonitis or post-op infection (some cases) 3. Not routine for broad-spectrum coverage. Oxacillin, Ticarcillin, Tobramycin, Carbenicillin, Clindamycin, etc., are seldom used, except for specific indications. Amphotericin B or fluconazole for proven disseminated Candida. Candida prophylaxis is not currently a standard procedure in the NICU. Antiviral Rx: 1. Acyclovir for high risk of neonatal Herpes 2. Retrovir (AZT) per protocol for perinatal HIV exposure Duration of Treatment: 1. "Rule out sepsis": 24-48 hrs. 2. Bacteremia: 5-10 days, usually 7

47

3. 4. 5. 6.

Pneumonia: 5-10 days, usually 7 (confirm by x-ray) "Clinical" sepsis: 5-10 days NEC: 5-10 days Meningitis: Varies with organism and sensitivities

Congenital Syphilis: IV penicillin x 10 days for 1. Inadequate maternal treatment I. History inadequate II. Course incomplete III. 1 month before delivery 2. 4-fold increase in maternal titer 3. Newborn titer 4x greater than mother's 4. Symptomatic congenital syphilis 5. May need longer treatment and follow-up for CNS syphilis Antenatal Maternal Treatment for GBS: 1. Appears to reduce perinatal bacteremia and pneumonia 2. Does not obligate work-up, treatment for every pre-treated or partially treated newborn 3. Follow AAP and departmental guidelines if mother untreated or inadequately treated 4. Individualize according to patient condition

Antibiotics Commonly Used in Newborn Infants Ampicillin, 200 mg/kg/day in divided doses; can be increased to 300 mg/kg/day in meningitis Penicillin, 100,000-300,000 IU/kg/day in divided doses Gentamicin, See NICU protocol Cefotaxime, 100-150mg/kg/day in divided doses Oxacillin, 50-150mg/kg/ day in divided doses Vancomycin, 15-30mg/kg/ day in divided doses*+ Lower dose and longer dose intervals for LBW infants Follow peak/trough blood levels and serum creatinine; follow pharmacy dosing guidelines.
+ *

Check dosage instructions with pharmacy, nursing, and a standard neonatal formulary, e.g., Neofax.

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See Discharge Planning for instructions regarding seasonal RSV Prophylaxis (Synagis). 3. GBS GUIDELINES FOR WIH a. Obstetrical Considerations 1. 2. Screening is recommended at 36 weeks; however, not all patients have been screened, especially those presenting before 36 weeks. Prophylaxis (2 4 doses) in labor is recommended for GBS-positive and unscreened patients. For various reasons, some patients get only one dose, which is still partly protective. Epidural analgesia: a. May prolong ROM and 2nd stage. b. Is associated with low-grade, short-term fever in 15-20% of cases (cause unknown). c. The fever may be the reason for maternal antibiotics.

3.

b.

Maternal Fever (15-20% with epidural) is more significant if: 1. 2. 3. 4. Pre-term Persistent or recurrent PROM (> 18 hours) No epidural

c.

Nursery Practice 1. 2. 3. 4. Published neonatal management guidelines for untreated or partly treated mothers are not validated (this is acknowledged by the AAP and CDC). One maternal dose is at least partly protective. The incidence of GBS bacteremia at WIH is < 0.5/1000 term births. Most newborns with GBS sepsis will be symptomatic at birth or in < 12 hrs; most remaining early onset cases become symptomatic between 12 & 24 hours.

49

5. 6. 7. 8.

Most blood cultures for GBS become positive in 12 to 24 hrs (mean is approximately 13 hrs). Therefore, An observed baby asymptomatic at 12 hrs, or an evaluated baby asymptomatic with a negative blood culture after 24 hours, is a low-risk patient. If no maternal screen or treatment, but no perinatal problems, we have a low-risk patient and no criteria for action. See the following recommended GBS guidelines for the nurseries at WIH.

GBS FOLLOW-UP GUIDELINES Summary: a. b. c. Culture negative no further screening for GBS Culture positive + mother treated no further screening Culture positive, mother not treated:

d.

evaluate - additional risk factors observe Culture results unknown review delivery history: Mother treated no further GBS screening
+ additional risk factors Mother not treated: + additional risk factors

evaluate - additional risk factors observe

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GUIDELINES FOR MANAGEMENT OF ASYMPTOMATIC NEWBORN (Asymptomatic implies the absence of respiratory distress, tachypnea, tachycardia, temp. instability) Maternal GBS Culture Done? RESULT Mother RX with ABX >4 HRS? Positive Yes Negative No or Unknown

Yes

No#

Yes

No#

Risk Factors Present? ## NEWBORNS AGE

Yes

No

Yes

No

<24 hrs

>24 hrs

<24 hrs

>24 hrs

RECOMMENDED PLAN For Newborn

# Mothers treated for < 4 hours are considered not treated. ## Risk Factors defined as one or more of the following: <37 weeks gestation, maternal fever (>100.40F), PROM > 18 hours. Strategy A Observe for 24 hours, no lab. evaluation, no antibiotics. B Observe for 48 hours, no lab. evaluation, no antibiotics. C Observe 48 hours, limited lab evaluation (CBC, differential and blood culture), no antibiotics. This guideline was formulated based on national recommendations and local data. It was reviewed and approved by the full time staff of the Department of Pediatrics. The clinician has the option of managing his/her infant differently. If so, it is recommended the rationale for this clinical decision be recorded in the infants chart

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3. HIV-EXPOSED NEWBORN - INITIAL EVALUATION AND MANAGEMENT (Division of Pediatric Infectious Disease and Neonatology; Revised 4/16/07) The following guidelines pertain to all newborns born to HIV-infected mothers. 1. Labor and Delivery or the Operating Room should communicate to the NICU any mother with a diagnosis of HIV. The mothers room number should be listed on the white L&D board in the NICU and a note indicating the diagnosis should be taped facing the board for privacy. The fellow should monitor the board and be aware of all cases in L&D to appropriately direct the medical staff. 2. Criteria for Pediatric attendance at delivery will be the same as Obstetric criteria for non-HIV deliveries. 3. If Pediatric providers are not needed at the delivery, L&D should request a Pediatric provider via the NICU secretary within the first hour following delivery. 4. A Pediatric provider (PL-1, if not available a PL-2 or NNP) will go to L&D or recovery and do the following: a. Write orders to start Zidovudine. Zidovudine should be started in all infants born to HIV infected mothers as soon as possible and within 12 hours of birth. Zidovudine should be started irrespective of medications taken by the mother, presence of maternal resistance to Zidovudine, and maternal viral load and is continued for six weeks. Dose for newborns 35 weeks: 2 mg/kg po every 6 hours Dose for newborns < 35 weeks or IV administration: refer to the Neofax Note: Bactrim PCP prophylaxis is not initiated until 4-6 weeks of life. Additional retroviral medications to prevent transmission of HIV are not needed immediately following birth and can be discussed with Pediatric Infectious Disease at the time of the consult (see below). b. Write orders for the appropriate blood work (see below). c. Write a progress note that Zidovudine has been ordered and the specific blood work that needs to be obtained. d. Directly communicate with the Private Pediatrician if designated and sign out to the House-staff responsible for the Newborn Nursery to insure that the blood work gets done. If the infant is triaged to the NICU make sure that the medical provider assuming care is aware of pending items for the infant. 5. The primary medical provider in the Newborn Nursery or the NICU should obtain a thorough maternal history including mothers viral load, CD4 count, and antiretroviral treatment (if known), presence of antiretroviral drug resistance (if known), mode of delivery, duration of rupture of membranes, and newborn physical exam including head circumference. 6. Blood work does not need to be obtained before starting Zidovudine. Within the first 2 days of life the primary medical provider should obtain HIV-1 branch chain DNA. This is a plasma viral load (PVL) test and is performed by branch chain DNA (bDNA) technology. The test will be automatically routed to Lifespan

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Laboratories at Miriam Hospital and is performed Tuesday and Thursday each week. A minimum of 2.5cc of blood (for 1 ml of plasma) is needed and placed in an EDTA (purple top) tube. The result will be available in Cerner. 7. Other blood work that should be obtained is a CBC with differential and platelet count. The CBC does not need to be obtained at the time of the HIV-1 branch chain DNA and can be obtained by the Laboratory via heel stick. 8. The primary medical providers should assess maternal RPR, Hepatitis B and C status: Give Hepatitis B vaccine +/- HBIG depending on risk assessment per the current Red Book. If Hepatitis C status is unknown, request the OB service to obtain an HCV IgG in the mother prior to discharge. Follow the current Red Book recommendations concerning evaluation for congenital syphilis for positive maternal RPR. HIV exposed infants should not be breastfed. 9. Consult Pediatric Infectious Diseases for all HIV-exposed infants. Please page the pediatric ID fellow at 350-0770 or contact the RIH page operator at 4445611 and ask for the Pediatric ID fellow on service. Advice is useful in deciding upon whether the infant requires antiretroviral medications in addition to Zidovudine, answering questions, and ensuring adequate follow-up. This information and consult can be obtained during day time hours. 10. Prior to d/c arrange for follow-up in the "Pedi-II" Clinic. Schedule an appointment at 1 month after discharge by calling 444-5980. This appointment does not take the place of primary care via the infants private pediatrician or clinic.

References:
1. American Academy of Pediatrics. Human Immunodeficiency Virus Infection. In:

Pickering LK, ed. 2006 Red Book: Report of the Committee on Infectious Diseases. 27th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2006: p. 347. 2. Guidelines for the Use of Antiretroviral Agents in Pediatric HIV Infection, October 26, 2006 www.aidsinfo.nih.gov. 3. Recommendations for the use of antiretroviral drugs in pregnant HIV-1 infected women for maternal health and to interventions to reduce perinatal HIV-1 transmission in the United States. October 12, 2006. www.aidsinfo.nih.gov.

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VIII. METABOLIC SCREENING, IMMUNIZATIONS, ULTRASOUNDS, AND EYE EXAMS Newborn Screening Overview: All newborns admitted to hospital nurseries in Rhode Island should have predischarge hearing screens. The purpose of metabolic screening is preclinical detection of disabling or potentially lethal disorders, in order to begin specific treatment and monitoring promptly. Initial screens are drawn on all infants in the NICU within 24 to 48 hours after starting IV or PO nutrition and, at the latest, by Day 3. ALL newborns transported to Women & Infants NICU from other hospitals should also have a newborn screen specimen drawn at their hospital of birth, regardless of age. Newborn screens from RI, MA, NH, VT and ME are sent to a regional Screening Program laboratory in Jamaica Plain, MA. RI results are reported to the RI Department of Health, and abnormal results are immediately reported to the NICU and to several designated hematologic and metabolic specialists as well as to the primary pediatrician. In addition to a hearing screen, routine newborn screening in Rhode Island tests for the following: Cystic Fibrosis Galactosemia Biotinidase deficiency Hemoglobinopathies o Sickle Cell Anemia (SS) o Sickle/Beta Thalassemia (S/Th) o Sickle/Hemoglobin C Disease (S/C) Amino Acid Disorders o Phenylketonuria (PKU) o Maple Syrup Urine Disease (MSUD) o Homocystinuria o Citrullinemia (CIT) o Argininosuccinic acidemia (ASA) o Tyrosinemia Type I (TYR 1) Fatty Acid Oxidation Defects o Medium-chain acyl Co-A dehydrogenase deficiency (MCAD) o Very long chain acyl Co-A dehydrogenase deficiency (VLCAD) o Long chain 3-OH acyl CO-A dehydrogenase deficiency (LCHAD) o Trifunctional protein deficiency (TFP) o Carnitine uptake defect (CUD) Organic acidemias o Isovaleric acidemia (IVA) o Glutaric acidemia, Type I (GA 1) o Hydroxymethylglutaric acidemia/HMG CoA lyase deficiency (HMG)

54

o Multiple carboxylase deficiency (MCD) o Methymalonic acidemia, due to mutase deficiency (MUT) o Methmalomic acidemia, cbl A and cbl B forms (CBLA, B) o 3-Methycrotonyl CoA carboxylase deficiency (3MCC) o Propionic acidemia (PROP) o Beta-Ketothiolase deficiency (BKT) Endocrine Disorders o Congenital Hypothyroidism (CH) o Congenital Adrenal Hyperplasia (CAH) The clinical response to abnormal screens varies with the acuity and severity of the suspect conditions. Examples: a) For mild suppression of T4 or mildly abnormal elevations of 17-OH progesterone in premature infants, a repeat screen is recommended before more detailed testing b) Marked elevations of galactose, organic acids, or abnormal fatty acid oxidation products require prompt endocrine-metabolic consultation and intervention in addition to further testing, since these disorders may present with sudden lifethreatening metabolic crises c) Hemoglobinopathies presenting without clinical illness at birth need to be referred for long-term management and, if indicated, early antibiotic prophylaxis. Reports of, or questions about abnormal metabolic screening tests should be referred promptly to the senior neonatologist and the appropriate consulting service, as well as to the infants identified primary pediatrician. See below for examples of special considerations when abnormal screen results are reported for premature infants or other NICU patients.

55

Special Considerations in NICU patients: Newborn screening should be performed on ALL NEWBORNS. However, testing in sick or preterm (VLBW) infants sometimes yields equivocal or abnormal values. In each of these settings, we follow specific retesting protocols and, occasionally, more definitive testing. Common examples of abnormal screens requiring follow-up include: 1. Hemoglobin Disorders: Dilution/replacement of fetal hemoglobin (HbF) by intrauterine, neonatal or exchange blood transfusion (adult RBCs). Follow-Up: Screening Program provides specific recommendations for retesting 2. Congenital Adrenal Hyperplasia: Elevated 17-hydroxyprogesterone (21-hydroxylase substrate) in very preterm infants Follow-Up: Birth weight stratified 17(OH)P normal ranges used; Screening Program provides specific recommendations for retesting; when 17(OH)P levels are significantly elevated, monitoring (weights, BP, electrolytes) and Pediatric Endocrinology consultation should be obtained 3. Amino Acid Disorders (PKU, MSUD, Homocystinuria): Elevations (usually slight) associated with parenteral nutrition mixtures Follow-Up: Screening Program provides specific recommendations for retesting 4. Congenital Hypothyroidism: Low T4 with normal or low TSH in VLBW infants Follow-Up: See NICU GUIDELINES as follows:

56

VLBW (<1500 g BW) ALGORITHM FOR REPEAT THYROID HORMONE SCREENING (Drs. L. Rubin and G. Goodwin; September, 2002) 1. This algorithm is designed to detect early and late onset congenital hypothyroidism in preterm infants. 2. Following the guidelines below, the responsible physician/ nurse practitioner writes an order to obtain the repeat blood specimen. 2. For all repeat specimen cards, fill in Date of Birth, Date of Repeat Specimen & CURRENT WEIGHT. 3. All out of range screening samples are reported to the NICU team fellow and/or attending neonatologist. 4. The New England Screening Program lab routinely performs a TSH on all NICU infants. ALGORITHM: 1. If TSH is >30 U/ml on any screening sample: CONSULT PEDIATRIC ENDOCRINOLOGY 2. Thyroid screens should be performed on ALL VLBW infants at 2 wks, 6 wks and 10 wks of age + 3 days. 3. If initial screen T4 is Low (but >3g/dl): a. Repeat on schedule at 2 weeks. b. If the week-2 T4 sample is either Normal or Low (but >3g/dl), repeat again at the routine week-6 screen. c. If the week-6 T4 sample is: Normal: obtain the routine week-10 screen Low (but >3g/dl): repeat the T4 screen immediately; if repeat sample is: Normal: obtain the routine week-10 screen Low (>3g/dl): CONSULT PEDIATRIC ENDOCRINOLOGY 4. If T4 is Very Low (<3 g/dl) on any screen: a. Obtain a FREE T4 level (Follow lab instructions, and confirm with Pediatric Endocrinology) b. If free T4 is Normal: treat as in #3 (i.e., repeat total T4 [using screening card] at 2, 6, and 10 weeks) c. If free T4 is Low: CONSULT PEDIATRIC ENDOCRINOLOGY ALL INFANTS REGARDLESS OF BIRTH WEIGHT OR AGE: CONSULT PEDIATRIC ENDOCRINOLOGY FOR ANY TSH >30 U/ML.

57

Immunizations in the Special Care Nursery

We give the first set of routine immunizations to babies in the Special Care Nursery at 2 months of calendar age. Follow current AAP, CDC, and Rhode Island Department of Health recommendations for the first series. Specific recommendations may change with the introduction of new products and combination vaccines. The initial series includes DTaP, Hib, inactivated Polio vaccine, and Hepatitis B vaccine. 1. Be sure parents are informed in advance, and have signed or initialed the immunization form. 2. Attenuated live virus vaccines (e.g., oral Polio vaccine) are not given to hospitalized inpatients. If required, these are given at time of discharge. 3. Do not reduce vaccine doses to compensate for low birth weight. Consult the attending neonatologist if a 2-month old ELBW infant still appears too tiny or fragile for immunizations at that time. 4. If Hepatitis B vaccine is given at birth to a high-risk VLBW infant, this initial vaccine dose should not be counted in the required 3 doses to complete Hepatitis B immunization. In low-risk preterm infants less than 2 kg at birth, the first dose of the recommended 3dose Hepatitis B series should be delayed until just before discharge if the infant weighs 2 kg or more, or until approximately 2 months of age when other immunizations are given. (AAP Red Book, 2006: pp.67-69, 336-348). N.B.: A. The 2 kg criterion is a guideline, not a requirement. B. Do not delete Hepatitis B vaccine from the 2-month schedule for infants weighing 1750 2000 gm at that time. (Red Book, pg. 347). C. Some preterm infants with maternal HBS Ag status positive or unknown will receive 4 doses of Hepatitis B vaccine, starting at birth. The 2-month/2 kg dose initiates the 3-dose sequence for complete immunization of VLBW infants. (Red Book, pg. 347).

58

Ultrasound and Eye Examinations in Very Low Birth Weight Newborns

Cranial Ultrasound examinations for intraventricular hemorrhage/periventricular leukomalacia are recommended for all preterm infants < 1500 grams or < 32 weeks gestation. This bedside imaging technique can also be used for initial diagnostic assessment of hemorrhage or CNS injury in older, larger babies. We recommend an initial ultrasound for intraventricular hemorrhage (IVH) in VLBW infants at 24-48 hours after admission. All abnormal results should be followed with repeat scans at 1 and 4 weeks of age. Routine 1 and 4 week follow-up exams are also advisable for infants < 1250 grams (approximately 28 to 30 weeks) even with a negative first ultrasound. For infants < 27 weeks, we also recommend a pre-discharge ultrasound for follow-up of ventricular size and possible evidence of cystic changes or attenuation of brain regions. Larger babies with a negative initial study and a stable clinical course may not need follow-up ultrasounds. Some clinical studies (e.g., Neonatal Network studies) may require ultrasound exams at non-standard intervals. Consult the fellow, attending, and/or research coordinator for orders pertaining to Network or other study protocols. Consult the attending radiologist directly to obtain any needed non-routine imaging studies.

Serial examinations for Retinopathy of Prematurity (ROP) are routinely

done in all VLBW infants (< 1500 gm, < 32 weeks) and in other preterm infants with O2 exposure beginning at 30-31 weeks of post conceptional age. These exams are repeated q 1-2 weeks until discharge, and are usually followed by 1 or more post-discharge exams. Medication orders to dilate the pupils are usually requested and written the evening before scheduled eye exams. If you have a patient at risk for ROP, be sure that the patient is appropriately scheduled for retinal follow-up.

59

IX. SOME COMMON CLINICAL PROBLEMS The following conditions are outlined as guidelines to help in the management of common problems. There are concomitant nursing protocols for some of these situations. 1. Hypoglycemia - All infants have a transient fall in blood glucose in the first hours after birth as the source of maternal glucose is removed and homeostasis is achieved by the infant. This transition is usually smooth but any infant is at risk for hypoglycemia. In general, hypoglycemia presenting in the newborn nursery results from inadequate liver glycogen stores, hyperinsulinism, or acute stress. a. Diagnosis - A blood sugar of <30 mg% in the full term or 25 mg% in the preterm indicates hypoglycemia. For practical purposes infants can be screened by reagent sticks. Repeat any screen < 40 mg/dl in 30-45 minutes. If the value remains low the baby should be treated and a blood sugar should be sent. Reagent sticks are made from unstable reagents and thus tend to read low, not high. Blood sugars are accurate only if the blood is chilled or an inhibitor of metabolism (NaF) is added immediately after the blood is drawn. Infants at Special Risk: 1) Hyperinsulinism: a. Infants of diabetic mothers (nursery protocol: initial dextrostick and dextrostix Acx3; blood glucose and CBC on admission) b. Erythroblastosis fetalis c. Beckwith Weidemann syndrome d. Nesidioblastosis or islet cell adenoma Inadequate glycogen stores: a. Small for gestational age infants b. Post-mature infants c. Premature infants Stressed Infants: a. Asphyxia b. Respiratory distress c. Hypothermia d. Infection e. Polycythemia

b.

2)

3)

c.

Symptoms: Most infants with transient hypoglycemia have NO symptoms. Therefore, infants at risk must be screened by reagent sticks. The symptoms, when present, are varied and nonspecific and include jitteriness, cyanosis, seizures, apnea, poor tone, and poor feeding.

60

d.

Therapy: Most infants require 2 ml/Kg of 10% Dextrose IV followed immediately by IV Dextrose - D10W at 80-100 cc/Kg/24 hr. This is equivalent to 5.5-7 mg/Kg/min glucose, or approximately the infant's glucose requirement. Avoid large bolus pushes of glucose as the infant is likely to release more insulin and develop rebound hypoglycemia. It is preferable to meet greater glucose requirements by increasing the rate of infusion or changing to 12.5% dextrose. Once hypoglycemia has been diagnosed, IV glucose should be given until feeding has started. The IV glucose then can be tapered slowly. Infants of diabetic mothers and other infants with hyperinsulinism should receive the same treatment; however, higher glucose concentrations and volumes may be required. These infants often need prolonged support, and a secure IV is essential. Severe hypoglycemia can result following a discontinued IV. Pediatric Endocrinology should be consulted for the management of infants who do not respond to IV glucose.

e.

Prevention: In infants at risk, who can feed, initiate early and frequent feedings of formula. Monitor blood sugars using reagent sticks. Start IV glucose with D10W if the infant will not feed soon after birth (e.g., small premature). Complications: Severe, prolonged hypoglycemia is associated with neurological damage. IV glucose is quite safe to administer; however, high dose glucose therapy can cause hyperosmolarity, osmotic diuresis, and dehydration. Infants may have rebound hypoglycemia if IV glucose is stopped acutely. Do not give >12.5% dextrose via a peripheral venous IV. Extravasation of concentrated glucose solutions may cause severe skin burns.

f.

2.

Hypocalcemia - Many infants have a slight lowering of serum calcium after birth, but the homeostatic adaptation is rapid. These changes are inconsequential. a. Diagnosis: Measurements of total serum calcium suffice in most clinical situations. Most infants do not become symptomatic unless calcium is <6 mg/100 ml; however, levels <7 mg/100 ml diagnose hypocalcemia and treatment should be considered.

61

b.

Infants at Risk: 1. Any stressed infant - asphyxia, respiratory distress, SGA infants, sepsis. 2. Premature infants. 3. Infants of diabetic mothers. 4. Other infants - many infants have a functional and transient hypoparathyroidism that presents as hypocalcemia. Symptoms: Symptoms include tetany, irritability, jitteriness, seizures, lethargy; many infants are asymptomatic, however. Therapy: 1. Treatment of symptomatic hypocalcemia or tetany is 1-3 ml/Kg of 10% calcium gluconate IV. Calcium slows the heart; thus, this should be given slowly and the heart rate monitored. IV calcium can also cause severe local necrosis if infiltration occurs. 2. Maintenance IV dosage for infants at risk is 200 mg/Kg/day IV calcium as calcium gluconate. The infants with risk factors for hypocalcemia (<1200 gm, asphyxia, SGA, meconium aspiration) may require treatment doses of 500-1000 mg/Kg/day.

c. d.

e.

Prevention: There is apparently no way to prevent hypocalcemia other than to provide those infants at risk with IV calcium. This preventative approach probably is appropriate for the small premature and SGA infant. Complications: Long-term complications have not been clearly associated with simple hypocalcemia. Occasional infants require long-term calcium supplementation. A low serum magnesium (<1.5 mEq/L) sometimes occurs in conjunction with hypocalcemia, and a dose of 0.1-0.2 ml/Kg of 50% Magnesium Sulfate may be required to return the calcium to normal. (Dilute the Magnesium Sulfate before administration.)

f.

3.

Procedure for Suspected Drug Exposure Maternal history or clinical findings suspicious for maternal drug use may require evaluation of mother and baby for illicit drug exposure. In Rhode Island and Massachusetts, certain state laws and regulations may also require drug testing and reporting for newborns suspected of exposure to maternal drugs. Women & Infants Hospital has a social worker assigned to follow up in such cases. Here are the current procedures for evaluation, testing, and follow-up if the maternal history is positive or clinical suspicion is strong. a. Order neonatal urine and meconium toxin screen.

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b. c. d.

e. 4.

Although prior informed consent is not needed, mother should be informed of neonatal drug screen and reasons for it (e.g., medical diagnosis, legal requirements). Consult Social Services re evaluation and follow-up. You may have to file a PRE (Physicians Report of Examination) with the Department for Children, Youth, and Families (DCYF). The social worker will call in the PRE to the state agency. The PRE places a temporary hold on the child and initiates a DCYF inquiry. Before discharge, check with Social Services re disposition and placement.

Narcotic Withdrawal Infants will manifest withdrawal symptoms to any opiate derivative and a variety of other agents. The diagnosis is one of exclusion since the history cannot always be relied upon. Since symptoms are multiple and non-specific, each suspect infant should be tested for electrolyte status, hypoglycemia and hypocalcemia, and urine tested for drugs. a. Indications for Screening 1. 2. 3. 4. 5. 6. b. (+) Maternal History - This may be elicited by anyone on the medical team. Jitteriness/Tremulousness/Agitation - outside of normal range. Also consider birth asphyxia. Hyperphagia - unexplained, greater than 200 cc/kg/day. Social Services Report Suspicious Maternal Behavior - Many erratic visitors, mother leaving hospital frequently. Abruption Placenta - may indicate cocaine use, if no other known cause.

Laboratory Evaluation 1. 2. 3. Who Orders Test - MDs or PNP's on newborn service may order urine toxicology test. Nursing staff noting unusual behavior or family reports should communicate with the RESIDENT or PNP. What to Order - Urine and meconium toxin screens. Send specimens to the laboratory as soon as they are obtained. Drugs to Screen - A screen when infant is jittery but has no history should include: AMPHETAMINES, BARBITURATES, CANNABINOIDS, COCAINE, OPIATES, and PCP. The list may change with community experience and available tests.

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4.

Other - When possible, test mother for HIV and Hepatitis B exposure. Neonatal HIV testing is occasionally indicated if maternal screening is impossible.

c.

Treatment 1. Infants who are suspected of prenatal exposure to addictive drugs should have the Neonatal Abstinence Score Flowsheet initiated. This includes infants of mothers who display signs/symptoms consistent with drug intoxication or withdrawal and are suspected of using: opiates, cocaine, amphetamines, barbiturates, hallucinogens such as PCP, or marijuana alcohol inappropriate use of prescription drugs (such as Valium) 2. 3. 4. Infants who would have urine toxicology screens ordered fall into this category. Any infant for whom abstinence scoring is indicated may be referred to Social Service for evaluation. The Neonatal Abstinence Score Flowsheet (Finnegan, et al) was developed to assess and treat neonatal opiate withdrawal (e.g., fentanyl, heroin, methadone). This score has not been validated for exposure to or withdrawal from non-narcotic drugs (e.g., cocaine, cannabis, barbiturates, benzodiazepines). Use of the Abstinence Flowsheet may be discontinued if: There is no history of maternal narcotic use or prolonged neonatal narcotic administration Urine toxicology screen for the mother and infant are negative for opiates and The infant does not display signs or symptoms of intoxication or withdrawal

C C 5. 6.

Scoring will be done by staff assigned to care for the infant, including nursery staff if the infant is in the nursery. A physician or pediatric nurse practitioner should assess the infant at least once every 24 hours.

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7.

Pharmacologic intervention may be indicated when the total score is 8 or higher for 3 consecutive scorings in the term neonate. The decision to initiate therapy remains that of the physician. Premature or very ill neonates may have therapy initiated for abstinence scores less than 8. The aim of therapy is to permit the infant to feed and sleep adequately. An infant who is consolable with swaddling or holding does not need therapy. However, if symptoms significantly interfere with feeding, sleeping, result in skin abrasions, or cause dehydration, the infant should be treated. Phenobarbital, 10 mg/kg loading dose, then 3-6 mg/kg PO or IV, q 24 hours, may shorten the duration and severity of withdrawal. Oral morphine solution, 0.4 mg/ml, may be given at a starting dose of 0.04 mg/kg, Q 3 or 4 hours, with feedings. If needed, increase by 0.02 mg/kg/dose until symptoms are controlled for several days. Then wean the dose by 10-20% per day, as tolerated. Consult pharmacy regarding weight-specific doses.

8)

If pharmacotherapy is needed, infant is scored at either 2 or 4 hour intervals as described below during therapy. If no pharmacotherapy is needed, infant should be scored for the first 4 days of life. Once pharmacotherapy is discontinued, assess every 4 hours for three days. If score remains less than 8, scoring may be discontinued. If during the 3 day period the scores consistently become 8 or greater, then scoring should be continued for 4 more days to ensure that the child is not being sent home while still developing symptoms of abstinence. Procedure: Instructions for use of Scoring Flowsheet: a) Start a new scoring sheet each day. There are enough spaces to allow for 2-hour assessments, if necessary, in a 24 hour period. Score at 4 hour intervals, starting at 2 hours after birth. Scoring should coincide with physical and vital signs assessments. If the infant's total score is 8 or higher, then every 2 hour assessments are begun.

9)

b)

c)

65

d)

If 2 hour scores have been 7 or less for 24 hours, then every 4 hour assessments can be resumed and the infant may remain in Level I Nursery or Rooming-in. All symptoms exhibited during the scoring interval should be considered, not just symptoms present at a single moment of time. The full-term infant should be awake for the exam. Sleeping should not be recorded for a scoring interval unless the infant has not been able to sleep for an extended period of time or whose condition would be compromised by being awakened. If you had to awaken the infant for the scoring, DO NOT score the infant for diminished sleep after feeding. Count respirations for one full minute. If the infant is crying, he/she must be quieted before assessing muscle tone, respiratory rate and Moro reflex. Score the infant for prolonged crying, even if it is not highpitched. Temperatures are routinely taken rectally for the initial measurements and axillary for subsequent measurements. Rectal temperatures are to be done routinely ONLY when ordered by the physician or nurse practitioner. If the infant is sweating solely because of conservative nursing measures (e.g., Swaddling), the infants should not be scored with a point.

e)

f)

g)

h) i)

j)

Reference: Finnegan LP. Neonatal abstinence syndrome. In: Nelson NM, ed. Current Therapy in Neonatal Perinatal Medicine - 2. Toronto, Canada:B.C. Decker Inc; 1990;314-320.

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Finnegan Scoring Sheet. For Neonatal Abstinence Todays Date Signs and Symptoms excessive high pitched cry continuous high pitched cry sleeps <1 hour after feeding sleeps <2 hours after feeding sleeps <3 hours after feeding hyperactive moro reflex markedly hyperactive moro reflex mild tremors disturbed moderate -severe tremors disturbed mild tremors undisturbed moderate-severe tremors undisturbed increased muscle tone excoriation (specify area ___________) myoclonic jerks generalized convulsions sweating fever <38.2 fever >38.2 frequent yawning >3-4 times/interval mottling nasal stuffiness sneezing (>3-4 times/interval) nasal flaring respiratory rate >60/minute respiratory rate >60/minute with GFR excessive sucking poor feeding regurgitation projectile vomiting loose stools watery stools Total Score/Initials From: Finnegan LP:Neonatal Abstinence, in Nelson N ed.: Current Therapy in Neonatal Perinatal Medicine, 1985-1986, Toronto, 1985, D.C. Decker, pp. 262-270. Reprinted by permission. (37.2-38.2 C 2 3 3 2 1 2 3 1 2 3 4 2 1 3 5 1 1 2 1 1 2 1 2 1 2 1 2 2 3 2 3 Age in Hours Score

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5.

Blood Pressure in Infants Normal blood pressure values (means 95% confidence limit) for infants based on birth weights are given in the figure (from Versmold et al Pediatrics 67:607, 1981). Most infants are not hypovolemic, and blood pressure abnormalities often represent acute responses to delivery. Blood pressure is just one assessment of an infant's status. In planning a clinical response to a low blood pressure, please also consider the pH and perfusion state. If the baby is very young, has a normal pH, and is pink and well-perfused, a slightly low blood pressure usually will increase spontaneously. Appropriate responses to a blood pressure abnormality require an assessment of the likely cause of the problem - low blood volume, high blood volume, pump (output) problem, abnormal vasodilation (sepsis).

68

69

6.

Transfer of Drugs to Human Milk The goal of every health care team member should be to encourage and promote breast feeding of newborn infants. There are few absolute contraindications to breast feeding from a medical point of view. Medications: While many medications may be excreted to some degree in breast milk, few have been associated with significant neonatal side effects. Obviously, since every medication ingested by a lactating mother represents a potential risk to her infant, a reasonable goal would be to such limit such exposure. Thus, the prescription of any drug during lactation should be carefully considered. Education of lactating mothers should include exposure to over-the-counter or illicit drug exposure, as well as nutritional guidelines. Ingestion of the following drugs is considered to preclude breast feeding. Cytotoxic Agents - Including vincristine, cyclophosphamide, gold salts, methotrexate, cyclosporine, and doxorubicin Radiopharmaceuticals 125 99 67

Require cessation of breast feeding until excreted

I,

131

I - two weeks

Tc - 3 d Ga - two weeks

The following categories of commonly encountered drugs are generally compatible with breast feeding. Anesthetics/sedatives The big offender in this category is alcohol which when taken in >1 g/kg/d (5 mixed drinks, 5-6 beers or glasses of wine) causes drowsiness, decreased intake or diaphoresis. No effect for heparin. Warfarin or coumadin may be secreted in breast milk. Phenobarbital can cause sedation in an infant if maternal serum levels >30 g/ml. Lamotrigine can produce therapeutic serum concentrations in nursing infants and its effect is unknown, but may be of concern.

Anticoagulants Antiepileptics -

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Antihistamines/Bronchodilators - No effect Antihypertensives - Atenolol has been associated with cyanosis and/or bradycardia in nursing infants. Anti-infective drugs All antibiotics are excreted to some degree in breast milk. Sulfonamides or other sulfa-derivatives have been associated with exacerbation of jaundice and hemolysis in infants with G-6-PD deficiency. Antithyroid drugs - Carbimazole has been associated with newborn goiter. Methimazole (but not propylthiouracil) may adversely affect thyroid function. Diuretics Hormones May decrease milk production Oral contraceptives have occasionally been implicated in neonatal breast enlargement. The use of low dose estrogen may ameliorate this effect. May cause drowsiness. Methadone is usually not associated with somatic symptoms if the dose is <20 mg/d. Salicylates have been reported occasionally to interfere with platelet function. NSAIDS are not associated with this effect.

Narcotics -

Analgesics -

Psychotropic drugs Occasionally, anxiolytics have been reported to cause sedation. Antidepressants and major psychotropics (Haloperidol, Trifluoperazine, Thioridazine, and Clozapine) are well tolerated by the infant. Lithium may produce 1/3 to 1/2 therapeutic blood concentrations in infants and is influenced by renal function. Drugs of abuse Amphetamine, cocaine, heroin, marijuana, and phencyclidine. Cocaine has been reported to cause irritability and altered sleeping patterns; a similar effect is seen with amphetamines. Caffeine and nicotine in excess have been associated with altered neonatal behavior/irritability.

Stimulants -

71

Vitamins -

No effects.

Food and Environmental Effects Aspartame (Nutrasweet) - Avoid use in phenylketonuric infants. Lead/methyl mercury Fava beans Tetrachlorethyline (cleaning fluid) While review suggests that there is little effect of these broad categories of medications in terms of neonatal exposure in breast milk, the rational approach dictates that all potential exposure should be minimized. Finally, recall that maternal HIV infection is a contraindication to breast feeding. 7. Hyperbilirubinemia Congenital Hemolytic Disease Maternal prophylaxis against Rh factor sensitization has nearly eliminated hemolytic disease. In a few cases, it appears that sensitization early in pregnancy is followed by increasing antibody titers as pregnancy progresses. Antenatal management includes: a. b. c. d. Serial maternal antibody titers Analysis of the amniotic fluid for bilirubin pigments if the titer is rising rapidly in late pregnancy. Some patients develop anemia in utero, which can be managed by Prenatal umbilical blood sampling for progressive hemolysis, and Intrauterine transfusions for severe fetal anemia. Neurotoxic G-6 PD hemolysis Jaundice

Postnatally, infants with Rh hemolytic disease present with jaundice and anemia of variable severity. In the most severely affected cases, early correction of the anemia is urgent; in others, the hematocrit falls and the bilirubin rises postnatally to levels where treatment with an exchange transfusion is warranted. The indications for exchange transfusion and the technique of the procedure are outlined in the accompanying tables. Major Group (ABO) Incompatibility a. Occurs in up to 25% of pregnancies.

72

b. c. d. e.

The infant's A or B cells are attacked by maternal preformed antibodies, which are widespread in nature. Most cases of ABO incompatibility are virtually asymptomatic or produce only mild hemolytic disease. A few patients have anemia at birth or an early high peak serum bilirubin, requiring treatment. Phototherapy may control jaundice in neonatal hemolytic disease, but does not prevent or correct anemia.

Jaundice Besides neonatal hemolytic disease, jaundice in the newborn may be associated with: a. b. c. d. e. f. A "physiologic" delay in bilirubin excretion. Inadequate milk intake. Breast feeding Bruising or enclosed hemorrhage Prematurity Neonatal polycythemia

Kernicterus: Subcortical central nervous system damage caused by unconjugated bilirubin. a. Acute presentation: opisthotonos, lethargy, poor feeding, and hypertonia. b. Later signs include hypotonia, choreoathetoid cerebral palsy, cranial nerve and basal ganglion dysfunction. c. Usually occurs in term infants when indirect bilirubin is 25-30 mg/dL or higher. d. Some preterm infants and some infants with Rh hemolytic disease have kernicterus at lower levels.

Anticipatory Management of Neonatal Jaundice a. Know Maternal Blood Type b. Know Baby's Blood Type if Mother is Rh-negative or Group 0 c. Identify Jaundice (Especially if Early Onset) d. Identify Risk Factors Present by history e. Laboratory evaluation:

Serum Bilirubin

Coombs' Test Hgb, Hcrit If indicated RBC Indices and Morphology

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d. g. h.

Estimate rate of increase in BR, in mg/dl/hr. Observe, Repeat, Discharge if rate of is <0.2 mg/dl/hr. Or Start Phototherapy if 1) Approaching Threshold for Treatment? 2) Risk Factors Present? Exchange Transfusion 1) Early, if conditions are met 2) Later, if phototherapy fails to control serum BR

Suggested guidelines to monitor and treat elevated serum bilirubin Do First BR Day 1 Day 1 Day 1 Day 1 or 2 Day 2 or when jaundiced when jaundiced when jaundiced when jaundiced Phototherapy* ~ 5 mg % 5 -6 mg % 6-7 mg % 8-10 mg % 10-12 mg % > 12 mg % 14-15 mg % 16-20 mg % Exchange Tx > 10 mg % > 10-12 mg % 12-15 mg % > 15 mg % 16-20 mg % ~ 20 mg % > 20-25 mg % 22-25 mg %

Weight < 750 < 1000 < 1250 < 1500 < 1750 < 2000 *< 2500 *> 2500

NB: Prophylactic phototherapy in ELBW infants is not effective. Cutaneous jaundice, usually appearing at approximately 5 8 mg/dl, must be established for photo-conversion of bilirubin in the skin and underlying capillaries. *For infants > 35 weeks, follow AAP guidelines of July, 2004 (next page)

Requirements for successful phototherapy: a. b. Adequate light source (20-30W/cm2/nm) Maximum area of skin exposed 1) 2) c. d. Unclothed except for eye patches and small diaper Multi-directional light source(s).

Time in relation to peak serum bilirubin - usually requires at least 8-12 hours for a clinical response. Intermittent phototherapy is effective if light source is adequate (i.e., can interrupt 30-45 minutes every few hours for feeding and care procedures.

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Guidelines for Phototherapy

Guidelines for Exchange Transfusion

75

Criteria for and complications of exchange transfusion Exchange Transfusion

Criteria Cord Hgb <10gm/dL Postnatal increase in Br >1mg/dL/h Anemia (Hgb 10-12 gm/dL) plus postnatal increase in Br >0.5 mg/dL/h Postnatal increase in Br >20mg/dL Technique Use citrate phosphate dextrose (CPD) blood, 160-170 mL/kg Umbilical vein catheter (or continuous vein-artery technique) Aliquots: withdraw/infuse 5 mL/kg/min Operating time: 60-90 min Ca2+ replacement: monitor heart rate continuously. Add 100 mg Calcium Gluconate to each 100 mL of citrated blood Hgb, Hcrit, and Br before and after exchange. No oral intake 1 h before and 5-6 h after procedure Results Decrease in plasma Br to 50% to 55% of pre-exchange value (30% rebound in 1 h) Decrease in tissue Br: re-equilibration with plasma Decrease in circulating antibody Replacement of susceptible RBCs Partial correction of blood volume and decreased RBC mass Complications Embolism Unstable cardiac output and blood pressure Ruptured spleen/liver Hyperkalemia Hypocalcemia Hyperglycemia, hypoglycemia Metabolic acidosis Infection Transfusion reaction 8. Apneic Spells a. Definitions Periodic Breathing: Recurrent asymptomatic 6-10 sec. apneic pauses during normal breathing. May occur normally in 5-8% of quiet time in normal newborns; more frequent in premature infants.

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Central Apnea: Apneic pauses 15-25 sec., with bradycardia or cyanosis (desaturation <85%). These are occasional in some term infants, common in preterm infants, and usually self correcting. By convention, neonatal cardiorespiratory alarms are usually set for 20 second apneic spells. Obstructive apnea: Loss of airflow despite chest wall movement, due to soft tissue upper airway obstruction. These occasionally have a vagal or cyanotic component (i.e., abrupt bradycardia or shunt reversal with obstruction or breath holding). Mixed apnea: combines central and obstructive components, and is sometimes associated with gastroesophageal reflux. Bradycardia: Persistent decrease in heart rate to <100 in the newborn period, or <80 after 1 month of age. It can be associated with apnea or vagal stimulation. Some term newborns have normal resting heart rates <100. By convention, neonatal monitor alarms are set for rates <100/min, lasting 20 sec. Desaturation: Persistent 02 saturation <85%, correlated with a true signal on the pulse oximeter. Saturation alarms may be set lower in some patients (e.g., VLBW infants or those with cyanotic heart disease.) Activity, procedures, or crying may give false pulse oximeter alarms. b. An Approach to Neonatal Apnea 1. 2. Evaluate at bedside; a timely quick exam may help to differentiate between central apnea, obstruction, or reflux with spitting. Expect central apnea in VLBW infants. Suggested approach: a. Wean from ventilator support to caffeine or aminophylline, which are central respiratory stimulants. I. II. III. IV. V. b. Loading dose 5-6 mg/kg (aminophylline) Maintenance 1-2 mg/kg/dose q8-12 hrs. Xanthine levels between 6 and 13 g/ml If apnea recurs 2o to low levels, repeat loading dose and/or increase maintenance. Toxicity begins at levels >15g/ml (tachycardia, agitation, spitting).

Caffeine has a longer 1/2 life, once-daily dose, and a higher toxicity threshold. I. II. Preferred maintenance drug for apnea, per pharmacy recommendations Loading Dose: 10mg/kg caffeine, or 20mg/kg caffeine citrate

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III. IV. V. c. 3.

Maintenance: 1.25-2.5 mg/kg/dose of caffeine, or 2.5-5.0 mg/kg/caffeine citrate, q 24 hrs. Therapeutic levels 8-20 g/ml. Toxic levels >40-50 g/ml.

About 33 weeks, D/C Xanthines and continue to monitor for central apnea (approx. 3-7 days).

Obstructive and mixed apneas a. b. c. Evaluate for upper airway patency and reflux (may need pH probe) Positioning and reflux precautions. If reflux is not severe, methyl xanthines may help by increasing respiratory drive.

4.

Sleep Pneumograms a. b. c. d. Are of limited diagnostic and predictive value. May differentiate between central and obstructive apneas, and identify reflux. Best performed as a 5 channel recording: (1) Heart rate (2) chest impedance (motion) (3) air flow (4) 02 saturation (5) lower esophageal pH. Not a good predictor of risk for SIDS

5.

Home Apnea Monitors a. b. c. d. e. Consider if clinically significant spells or 02 requirements are delaying discharge. Use may increase with earlier discharge and home care of preterm infants. Often prescribed for sibling history of SIDS; however, Efficacy for SIDS prevention is not proven. Duration of home monitoring: I. II. III. Variable for 02 dependent ex-prematures For apnea of prematurity, re-evaluate at 4-6 weeks past term gestational age (reassess apnea patterns and history of events at home). For family history of SIDS, continue 6-8 weeks after age at death of the sibling.

9.

Use of Blood Products in SCN a. For volume expansion, normal saline is preferred to plasma substitute (5% albumin) especially if albumin is in short supply. Dose 10-15 mL/kg by slow IV push Comment: a frequently used treatment

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b.

Fresh frozen plasma (FFP) Indication: replacement of plasma components in suspected hemorrhagic or immunocompromised states. Dose: 10-15 mL/kg by slow IV push Comment: Not the indicated treatment of choice for volume expansion Packed RBCs Indications: 1. iatrogenic loss > 10% of blood volume 2. hematocrit < 30% in critically ill patients 3. Anemia of prematurity or post-hemolytic anemia with symptoms (hematocrit <25-30% and symptoms related to anemia). Dose usually 10-15 ml/kg; may be given in two stages for volume sensitive patients. 4. Transfusion delays the reticulocyte response to anemia of prematurity. Comment: criteria are not absolute Relationship of apnea to anemia of prematurity is not proven; withhold RBCs if patient asymptomatic, hematocrit stable, and reticulocyte count elevated.

c.

d.

Platelets Indications: 1. Platelet disorder with bleeding or platelet count <25,000/mm3 or mL. 2. Platelet count 25,000-50,000/mm3 or mL with an ongoing hemorrhage or coagulopathy

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Use of Blood Products in the Special Care Nursery

Product Saline (preferred) or plasma substitute (5% albumin) Fresh frozen plasma (FFP) Indication Volume expansion replacement of plasma components in suspected hemorrhagic or immunocompromised states a) iatrogenic loss >10% of blood volume b) hematocrit <30% in critically ill patients c) anemia of prematurity or post-hemolytic anemia with symptoms (hematocrit <2530% and symptoms related to anemia) a) Platelet disorder with bleeding or platelet count <25,000 b) Platelet count 25,00050,000/mm3 with an ongoing hemorrhage or coagulopathy Severe neutropenic states Dose 10-15 ml/kg by slow IV push 10-15 ml/kg by slow IV push Comment A frequently used treatment Not the indicated treatment of choice for volume expansion

Packed RBCs

Usually 10-15 ml/kg; may be given in two stages for volume sensitive patients.

Criteria is not absolute; relationship of apnea to anemia of prematurity not proven; withhold RBCs if patient asymptomatic, hematocrit stable, and reticulocyte count elevated.

Platelets

1-2 adult units per 10 kg (do not pack)

Not routinely given for asymptomatic thrombocytopenia >25,00030,000 mm3

White cells

Packed white cells equivalent to one adult unit (consult transfusion service)

Seldom used; should be irradiated.

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X.

DISCHARGE PLANNING The infants hospitalization can be broken down into two phases: 1. Acute Phase -cardio-respiratory stabilization is #1 priority -remains in this phase until no longer requires ventilator support Recovery/Growth Phase -nutrition and preparation for discharge focus

2.

Discharge timelines have been developed to assist with management of the second phase. The Infant Role timeline identifies both desired outcomes and discharge criteria. The Physician Role timeline identifies responsibilities and guidelines on when specific orders are required. The Parent Role and Nurses Role timelines focus on the teaching/learning required prior to discharge. Discharge planning occurs during: 1. 2. Daily morning rounds Team and/or family meetings

The Discharge Process begins on admission when gestational age and medical diagnoses are determined. If discharge is projected for less than 10 days, planning begins immediately. For other infants in the acute phase, formal discharge planning occurs when the infant reaches 30 weeks post-conceptional age or he/she no longer requires ventilator support. Steps of Discharge Planning Process 1. Project discharge date - gestational age and diagnosis initial date - medical and educational needs revisions Weekly evaluation of discharge criteria achievement - recorded on Discharge Planning Process Form Implement steps outlined in Physician Role timeline - document on Discharge Process Checklist

2. 3.

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4. 5. 6.

Identify medical/equipment needs for post-discharge Identify follow-up appointments Communicate plan: 1. Documentation on Discharge Planning Process Form 2. Discussion during rounds 3. Direct communication with private physician and parents

The discharge coordinators assist with the following: 1. 2. 3. 4. 5. Follow-up appointments Home care Special equipment needs (i.e. oxygen, monitors, kangaroo pumps) Financial aid referrals Fills out discharge instruction sheet

The case managers role in our NICU will focus on outcomes and resource utilization throughout the infants hospitalization. The case manager may be consulted on issues pertaining to the discharge process, best practice guidelines, and documentation required for reimbursement by third party payers. Tips for Discharge 1. Prescriptions need to be written two days prior to discharge. Parents bring in medication to verify correct dose/concentration. Medications that need to be compounded by the pharmacy will likely require more than 2 days notice prior to discharge. Please identify these needs as early as possible. Discharge time is 1:00-2:15 p.m. unless other arrangements. Discharge physicals preferably done day before discharge. This makes your busy day less hectic without frustrated parents and nurses waiting on you for discharge. If unable to do on prior day, physical may be done during pre-rounds. Complicated discharges/transfers need transcribed summaries prior to leaving the hospital. Plan on doing stat dictations the day before. Availability of medical transcriptionists varies. Call before dictating if required stat. May need to be hand-written if dictating after 1:00 p.m. for discharge/transfer on that day. Follow the Discharge Template (next page) Order seasonal RSV prophylaxis for infants < 32 weeks gestation. 2 4 days before discharge (see index for RSV guideline

2.

3. 4.

5.

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Instructions for Discharge Template

The NICU Discharge Summary can be found under Clinical Notes in Cerner. Right click, select Add Document. Scroll under TYPE to find NICU Discharge Summary. If NICU discharge summary is not found under type, right click on the type field, select DOCUMENT LIST, then select COMPLETE. (This places all documents under TYPE and you can scroll down to find NICU discharge summary.) 1. The summary begins the day of admission. It can be updated and saved as information becomes available. (Once created it will be in a folder) 2. All bracketed areas need to be replaced by individualized data unique to your patient. 3. Double click to highlight the bracketed item, then just type. 4. For multiple options in bracket, you can highlight what you want to copy, copy it, and then double click entire bracket region, then paste. Or, just double click and then type what you want. 5. List all major operations and procedures performed on the patient including central line, spinal tap, endotracheal intubation, PRBC, surgical procedures, etc. Dont list every IV and blood draw or dates of procedures. 6. Under HPI, respond to all bracketed data areas. If necessary, there is additional room to elaborate (i.e.: patient in NN, got sick, came to ICU, etc.) under this section. 7. Under hospital course, if there were no issues for a section, you can delete all of the information under that section EXCEPT the statement no issues. 8. Likewise, if there were issues, delete the words no issues. 9. The discharge physical is a template of a NORMAL physical. Amend this for your patient. 10. Remember to complete Ongoing Health Care Issues (can list like discharge diagnoses) to alert PCP to active problems. 11. Once complete, click SAVE. You will no longer need to sign your documents. This will allow the attending to edit if necessary. 12. Right click and forward to WIH IN BOX (it will go to medical records where copies will be sent to everyone you listed at the bottom of the summary). 13. At the end of the summary under copies to, PROVIDE DETAILS (first, last name, group name if known; if specialist, list specialty). Medical records cant send a record to Dr. Smith without more identifiers. Case Management will identify the OB for you to document on the summary.

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Retrotransfer Policy
The process of retrotransfer should begin on the day of admission to Women & Infants intensive care unit. When a child from an outlying community no longer needs the support of a tertiary care facility, plans should be made to transfer the infant to a nursery closer to the family home suitable for the level of care required by the patient. The plan for transfer should be discussed with the family when medically appropriate. The family should be encouraged to tour the community facility prior to the anticipated day of transfer. The accepting facility should be made aware of the familys interest in order to help facilitate the process. The following is a timeline established to foster a seamless transition from the tertiary facility to the Level 2 Nursery in the community. In order to accomplish this goal the standard needs to be set that all paperwork including the discharge summary will accompany the patient to the community. Time Sequence Discuss with medical team suitability for transport Pursue insurance issues that might preclude transfer (discharge planner) Contact family for written (verbal) consent (discharge planner or medical team member) Establish bed availability, and insure agreement of accepting physician/hospital (charge nurse, discharge planner) Medical team prepares chart (resident or NNP) Discharge physical Transfer summary sheet Dictate discharge summary on stat line Respiratory department notified of transport (charge nurse) Medical team calls report (fellow, attending or NNP) Chart is copied after medical team has completed forms (secretary)* Imaging studies obtained (if necessary) (secretary) Ambulance is scheduled (secretary) Nursing calls report (bedside nurse) with ETA Transport bed is checked/ bags checked (bedside nurse) Call family with ETA if not given at initial call (charge nurse, bedside nurse or discharge planning) Review paperwork for completeness prior to leaving (see enclosure) (bedside/transport nurse) Community hospital is called when the ambulance leaves WIH (secretary) *In general, the entire chart is copied. If the patient has remained hospitalized for over 2 weeks, only the last week of nursing notes needs to be included. Make sure the bedside chart, which contains the most recent information, is included as part of the copied chart. Make sure eye exams are in the infant chart. Some nurseries may request that a copy of the most recent TPN sheet be faxed prior to the arrival of the patient in order to prepare the parenteral fluid for the day.

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RETROTRANSFER CHECKLIST (Initialed by transport nurse) Consent for transfer ________ ID Band on infant _________ Medical Record Bedside chart ________ Stored Breast Milk _________ Main chart ________ Transfer Summary Sheet ________ Personal Items _________ Discharge Summary ________ Nursing Flow Sheet ________ Report Called, Nursing ________ Information to include: Current Medications, time of last dose_______ Current feeds, time last feed ________ Isolette temperature if applicable ________ Oxygen requirement if applicable ________ Report Called, Medical ________ Transport Nurse Initial ________

For Transfer from the NICU or SCN to NNN at WIH:

1. 2. 3. 4, Use the NNN Transfer Order Sheet (see next page) Updated Progress Notes for Observation babies Longer note (Discharge Summary) for a longer or more complicated length of stay (> 48 hours) Notify NNN coverage and primary physician

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86

RSV Monoclonal Antibody (palivazumab, Synagis ) Guidelines for Synagis treatment and follow up for infants discharged between November and March
A. Eligible for Treatment: 1. 32 weeks gestation or less, and being discharged during RSV season which is November March. 2. Any preterm infant with BPD being readied for discharge during RSV season. 3. Selected other infants with chronic pulmonary insufficiency, e.g., postECMO (please check with attending physician or Dr. Cashore for these patients). B. Treatment for Synagis: 1. Be sure to give the first dose prior to discharge. Batching of doses is an acceptable practice where this is practical (check with both teams, pharmacy or Michael Muller). The dose is 15 mg/kg. 2. Schedule outpatient treatment with primary care pediatrician for repeat dosing 4-5 weeks after the first treatment. C. Discontinue prophylaxis after March of the calendar year.

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Discharge Medication Formulary

Generic Name Albuterol, aerosol Brand Name Proventil Ventolin Strength 90 mcg/puff Manufacturer Schering Allen & Hanburys Various (generic) Schering Various (generic) Dey Laboratories Note: Aminophylline is 79% theophylline Must be compounded by Pharmacy. Compound is stable for 91 days refrigerated. Chong E, Dumont RJ, Hamilton DP, Koke PM, Ensom MHH. Stability of aminophylline in extemporaneouslyprepared oral suspensions. J Inform Pharmacother 2000;2:100-6. Packaged in 50, 75, 80, 100, and 150 mL bottles. Medication is good for 14 days after being mixed by pharmacy. Boehringer Ingelheim supplies medication in 3 mL single-use vials. Comments

Albuterol, sol. for inh.

Proventil AccuNeb

2.5 mg/3 mL 1.25 mg/3 mL 0.63 mg/3 mL 3 mg/mL

Aminophylline oral suspension (also see theophylline)

Amoxicillin oral suspension

Amoxil

25 mg/mL 40 mg/mL 50 mg/mL 80 mg/mL 40 mcg/puff 20 mg/mL

S.K. Beecham Various (generic)

Beclomethasone, aerosol Caffeine citrate oral solution

QVAR Cafcit

3M Pharmaceuticals Boehringer Ingelheim

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Generic Name

Brand Name Capoten

Strength

Manufacturer

Comments

Captopril oral solution

1 mg/mL

Apothecon Various (generic)

Chlorothiazide oral susp. Digoxin oral elixir Ergocalciferol oral liq. Ferrous sulfate oral liq.

Diuril Lanoxin Pedi Elixir Calciferol Drisdol Fer-In-Sol

50 mg/mL 50 mcg/mL 8000 int. units/mL 125 mg/mL

Merck Glaxo Wellcome Roxanne Schwarz SanofiSynthelabo Mead Johnson & Co. Various (generic) Various (generic) Pfizer

Must be compounded by Pharmacy. Compound is stable for 14 days refrigerated. Nahata, M.C., Morosco, R.S., and Hipple, T.S. Am J Hosp Pharm, 1994, 51(1):95-96. Contains 0.5% alcohol and benzoic acid. Contains 10% alcohol Roxannes product is sugar-free. OTC 8000 int. units/mL = 200 mcg/mL. OTC 125mg/mL ferrous sulfate = 25mg/mL elemental iron

Furosemide oral solution Hydrocortisone oral susp.

Lasix Cortef

10 mg/mL 2 mg/mL

Levothyroxine tablets

Levothroid Synthroid

25 mcg 50 mcg 75 mcg 88 mcg 100 mcg, etc

Forest Pharm. Knoll Pharm. Various (generic)

Medium chain triglycerides Metoclopramide oral syrup

MCT Oil Reglan 1 mg/mL

Mead Johnson & Co. Robins Pharm. Various (generic)

Must be compounded by Pharmacy. Compound is stable for 90 days refrigerated. Fawcett JP, Boulton DW, Jiang R, et al. Stability of hydrocortisone oral suspensions prepared from tablets and poweder. Ann Pharmacother. 1995;29: 987-90. Brand name products are preferred over generic products. If using a generic product or if products are being changed, close followup of thyroid function tests are suggested. OTC

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Generic Name MVI with Fe liquid

Brand Name Poly-Vi-Sol with Iron ADEKs Pediatric AquADEKs Zegerid

Strength

Manufacturer Mead Johnson & Co. Various (generic) Axcan Pharma

Comments OTC

MVI with zinc & vit. K liq. Omeprazole susp.

OTC Must be compounded by Pharmacy. Compound is stable for 28 days refrigerated. Burnett JE, and Balkin ER. Stability and viscocity of a flavored omeprazole oral suspension for pediatric use. Am J Health-Syst Pharm. 2006;63: 22407. Make from 20 mg powder packets only for doses <14 mg. Contains alcohol. Contains alcohol <0.6% and sodium benzoate. Brand name product is preferred over generic product. If a generic product must be used, or if changing products, close follow-up of clinical status and serum phenytoin concentrations is suggested. NOTE: W&I uses only 20% KCl liquid. Contains 5% alcohol. Most products are sugar-free. Some 10% KCl products are alcohol, dye and sugar-free. NOTE: W&I uses only 4mg/mL liquid. Contains 0.6% alcohol Contains 7.5% alcohol Must be compounded by Pharmacy.

2 mg/mL

Santarus

Phenobarbital oral elixir Phenytoin oral susp.

4 mg/mL Dilantin-125 25 mg/mL

Various (generic) Parke Davis Various (generic)

Potassium chloride oral liq.

Kaon-Cl

1.33 mEq/mL (10%) 2.67 mEq/mL (20%)

Savage Various (generic)

Propanolol oral sol. Ranitidine oral syrup Spironolactone oral susp. Zantac Aldactone

4 mg/mL 8mg/mL 15 mg/mL 3 mg/mL

Roxanne Glaxo Various (generic)

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Generic Name

Brand Name

Strength

Manufacturer

Comments Uncoated tablets should be used. Compound is stable 28 days refrigerated. Mathur, L.K., and Wickman, A. Am J Hosp Pharm, 1989, 46(10):2040-2. Contains alcohol and sodium benzoate. Dosing recommendations are based on the trimethoprim component. Contains 20% alcohol Must be compounded by pharmacy. Compound stable 35 days if refrigerated. Johnson, C.E. and Nesbitt, A. Am J Health Syst Pharm, 1992, 52(16):1798-800. Contains sodium benzoate

SulfamethoxazoleTrimethoprim oral susp.

Bactrim Pediatric Sulfatrim Pediatric

40 mg-8 mg/mL

Roche Alpharma Various (generic)

Theophylline elixir (also see aminophylline) Ursodiol oral susp.

Elixophyllin Actigall

5.33 mg/mL 60 mg/mL

Forest Pharm Novartis Pharm.

Zidovudine oral syrup

Retrovir

10 mg/mL

Glaxo Wellcome

If you have any questions, please call our pharmacists at Women & Infants' Hospital of Rhode Island, (401) 274-1122, extension 1265 (Main Pharmacy). Michael Muller, Pharm.D. NICU Clinical Pharmacist Specialist (401) 274-1122, Extension 1540 Leslie Pires, Pharm.D., M.S. Director of Pharmacy (401) 274-1122, Extension 1263

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COMMUNICATION PROCEDURE FOR PROVIDENCE HEALTH CENTER BABIES

Providence Health Centers: $ $ $ $ $ Allen Berry Health Center Central Health Center Olneyville Health Center Fox Point Health Center Capitol Hill Health Center

Call June Carrara, (beeper 482-2015) between 7 a.m. and 5 p.m. Monday thru Friday, to give a report on a baby. She will give information to the correct pediatrician and make an appointment. After 5 p.m. or on weekends and holidays, contact the on-call pediatrician at 521-2131. A brief message may be left on the Newborn Hotline at 444-0400, Extension 3147. However, for any complicated discharge (i.e., any NICU issues), you should speak with the physician directly.

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Clinical Practice Guidelines

1. Procedure-related Pain Management 2. HIE/Hypothermia 3. Congenital Diaphragmatic Hernia

These guidelines will be updated periodically, as new guidelines are introduced and older ones are revisited and refined. They are not exclusive or wholly prescriptive, but are intended to clarify and guide certain standard practices in the nursery, based on best available evidence.

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Perinatal Hypoxic-Ischemic Encephalopathy (HIE): Role of Body Cooling

1) Terminology: Perinatal hypoxia-ischemia is commonly used to denote infants that experience an impairment of placental gas exchange proximate to birth. Asphyxia is a more accurate term for this event and it is important to recognize that asphyxia and hypoxia-ischemia are not physiologically equivalent. However the term asphyxia carries far greater medical-legal implications than hypoxia-ischemia and unfortunately these concerns are often inappropriate. Given that asphyxia, hypoxia-ischemia, and ischemia are often used interchangeably in the literature, it is best that discussions and charting be limited to the use of the term hypoxia-ischemia. 2) General Considerations: Newborn encephalopathy is characterized by difficulty initiating respirations at birth, and is accompanied by subnormal levels of activity, tone, reflexes, and consciousness, and possibly seizures. It is a diagnosis of near-term and term infants and is usually not considered for preterm infants since neurological features of Prematurity can be similar to encephalopathy. Recognition is typically at birth or shortly thereafter, although symptoms may evolve over the first few days. Encephalopathy is a non-specific response to multiple different events of which intrapartum hypoxia-ischemia represents one specific type. Based upon population studies, newborn encephalopathy may be attributable in part or in total to hypoxia-ischemia in up to 30% of cases (1,2). 3) Diagnostic Considerations: A reasonable approach to diagnosis is a step wise sequence in which the history is suggestive of an acute peri-partum event, followed by the presence of birth depression with fetal acidemia, and accompanied by organ system dysfunction noted in the first 48 hours following birth. The latter may be non-CNS alone, but if encephalopathy is present, there will invariably be other organ system dysfunction. Finally exclusion of other causes of encephalopathy is essential. Surveillance For Organ System Dysfunction and Metabolic Abnormalities: a) CNS Injury: The principal manifestation of hypoxic-ischemic cerebral injury is encephalopathy and severity is most easily characterized using the Sarnat stages (3). Sarnat stages are often used to provide prognostic information: follow-up studies indicate that prognosis is very accurate when the maximal extent of encephalopathy is Sarnat stages I or III (mild and severe) and corresponds to a good or poor outcome for death/disability, respectively. In contrast, there is a variable outcome for infants in whom the maximal stage of encephalopathy is Sarnat II. b) Renal Dysfunction: Assessment of renal function is the simplest means to assess the presence or absence of non-CNS organ dysfunction (4,5). Parameters that can be assessed include urine output, weight, serum [Na], urine analysis, and serum [BUN] and [creatinine]. c) Pulmonary Dysfunction: Persistent pulmonary hypertension of the newborn (PPHN) and meconium aspiration syndrome (MAS) can be associated with perinatal hypoxia-ischemia. d) Myocardial Dysfunction: Adverse effects on the myocardium are not common but can include tricuspid insufficiency, and global ischemia. e) Hematopoietic Abnormalities: Thrombocytopenia can occur following hypoxia-ischemia. f) Hepatic Dysfunction: Biochemical abnormalities supportive of hepatic injury can occur in response to hypoxia-ischemia but clinical manifestations are rare. g) Gastrointestinal Dysfunction: Evidence of bowel hypoxia-ischemia is difficult to assess due to absence of easily monitored laboratory parameters. h) Metabolic Abnormalities: Reductions in serum concentrations of glucose, calcium and magnesium should be actively surveyed. i) Electrolyte Disturbances: Hyponatremia can occur and may reflect excess free water administration or SIADH. Hypernatremia secondary to diabetes insipidus occurs but is rare.

4)

5) Differential Diagnosis: Since the diagnosis of HIE is a composite diagnosis (perinatal events, evidence of impaired placental gas exchange, respiratory depression at birth, and multi-organ system dysfunction), there can be multiple conditions that mimic the effects of hypoxia-ischemia. Considerations that should be considered include: a. Infection b. CNS malformation c. CNS vascular event

98

d. e. f. g. h.

CNS trauma CNS hemorrhagic lesions Drug and anesthetic effects Congenital neuromuscular disorders Inborn errors of metabolism

6) Brain Imaging: Given the above differential diagnosis, brain imaging is recommended for near term and term infants manifesting encephalopathy. 7) Initial Stabilization: Like any other acutely ill newborn, priorities for stabilization include securing the airway, effective ventilation, and supporting the circulation. Of particular importance in the acute stabilization are correction of hypotension, hypoglycemia, and metabolic acidemia. Both persistent hypotension and hypoglycemia will limit the recovery of cerebral high energy phosphorylated metabolites (eg, ATP) following acute hypoxia-ischemia (6). The urgency in correction of metabolic acidemia is less clear. Rationale for rapid correction of acidosis is potential deleterious effects on myocardial function and pulmonary vasomotor tone. Rapid correction of acidosis has little effect on cerebral tissue acidosis; correction of the latter is largely dependent upon establishment of adequate perfusion pressure and cerebral blood flow since there is limited passage of exogenous alkali across the blood brain-barrier. An alternative approach to rapid correction is serial measurements of blood gases and pH to determine the rapidity of self-correction. The latter may give important information regarding hemodynamic instability; metabolic acidemia is usually rapidly cleared in the presence of adequate myocardial function. 8) Therapy: Management and treatment of infants with evidence of hypoxia - ischemia can be considered as supportive care and brain specific interventions. i. Supportive intensive Care 1. Correct metabolic abnormalities 2. Correct hypotension/hypo-perfusion: Usual management guidelines of volume expansion followed by pressor support should be used judiciously in these patients, and only when assessments support hypo-perfusion. . 3. Fluid management: In general fluids should be administered judiciously for infants with hypoxia-ischemia once perfusion and blood pressure are stabilized. 4. Treatment of seizures: Phenobarbital and phosphenytoin are the drugs most commonly used in neonates and have been evaluated better than other agents for effectiveness (7). Consideration should be given to obtaining EEG studies early if there is an index of suspicion for seizures. 5. Bleeding and/or thrombocytopenia: Clinical bleeding from presumed DIC is usually responsive to replacement therapy. 6. PPHN and/or MAS: Treatment and management for these conditions should reflect broader approaches to these conditions. 7. Treatment of cerebral edema: Cerebral edema may be suspected based upon a full/bulging fontanel, or abnormalities on imaging. There is no evidence that intervention to reduce edema (osmotic diuretics, hyperventilation etc) change outcome. ii. Brain specific therapies 1. Modest brain cooling: The NICHD Neonatal Network randomized trial of modest hypothermia demonstrated that whole body cooling (esophageal temperature of 33.5oC) reduced the incidence of death and disability (moderate to severe in extent) in near term and term infants with moderate or severe encephalopathy (8). Benefits of this therapy were not associated with an increase in predefined serious adverse events. It is recommended that this therapy be offered only to infants that fulfill the entry criteria of the above study; evidence of effectiveness and safety of this therapy for infants who do not meet these criteria is unknown. 2. Other therapies: At this time there are no data to justify the implementation of other potential neuroprotective therapies.

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Algorithm For Potential Use of Modest Hypothermia: Inclusion Criteria: Infants will be evaluated in two steps; evaluation by clinical and biochemical criteria (Step A), followed by a neurological exam (Step B). Step A: All infants will be evaluated for the following: 1. History of an acute perinatal event (abruptio placenta, cord prolapse, severe FHR abnormality: variable or late decelerations).
2. 3. 4. 5. An Apgar score <5 at 10 minutes. Cord pH or first postnatal blood gas pH at <1 hour <7.0. Base deficit on cord gas or first postnatal blood gas at <1 hour >16 mEq/L. Continued need for ventilation initiated at birth and continued for at least 10 minutes. IF BLOOD GAS IS NOT AVAILABLE OR pH between 7.0 and 7.15, BASE DEFICIT 10 to 15.9mEq/L A2 Infant should have: (1 and 2 or 5 from above) Acute perinatal event and either An Apgar score <5 at 10 minutes

IF BLOOD GAS IS AVAILABLE: A1 Infant should have: (3 or 4 from above) Cord pH or first postnatal blood gas within 1 hour with pH <7.0

OR
Base deficit on cord gas or first postnatal blood gas within 1 hour at >16 mEq/L

OR
Continued need for ventilation initiated at birth and continued for at least 10 minutes

If an infant meets either A1 or A2, proceed to the neurological examination. Step B. The presence of moderate/severe encephalopathy defined as seizures OR presence of signs in 3 of 6 categories in the table below. Category
1. Level of consciousness 2. Spontaneous activity 3. Posture 4. Tone 5. Primitive reflexes Suck Moro 6. Autonomic system Pupils

Moderate Encephalopathy
Lethargic Decreased Distal flexion Hypotonia (focal, general) Weak Incomplete Constricted

Severe Encephalopathy
Stupor/coma No activity Decerebrate Flaccid Absent Absent Skew deviation/dilated/nonreactive to light Variable HR Apnea

Heart rate Respirations

Bradycardia Periodic breathing

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Performance of the examination: The neurological examination should be performed by physician examiners, the attending and fellow. Examinations should be performed independently by attending and fellow and then jointly discussed. This will provide important training for the fellows. The decision of eligibility as per the examination findings and whether to offer the treatment will be based on a joint decision of the fellow and attending. In cases where the decision to use the therapy is unclear either due to the findings of the examination or specific issues related to the infant, consultations with other available attendings should be pursued. Timing of the examination: In general there is decreasing efficacy of neuroprotective treatments the further into the therapeutic window treatment is started. Initial management needs to prioritize stabilization of the airway if intubated, adjustment of ventilator support, establishment of intravenous and/or arterial vascular access, correction of acid-base disturbances, insurance of adequate perfusion pressure, and maintenance of a normal blood glucose concentration. Categorizing neurological findings after birth is complex given the transitional physiology, maternal medications, evolving neurological abnormalities, and other non-CNS conditions. Thus, appropriate attention to the above priorities is beneficial to obtaining accurate assessments of the neurological examination since it prevents detailed judgments in the first 1-3 hours after birth. If examinations are performed too early after birth, more infants may be needlessly exposed to treatment. Given the uncertainty of duration of the therapeutic window, neurological examinations and a decision to initiate cooling must be made by 6 hours after birth. If an infant meets criteria A1 or A2 and criteria B and does not meet exclusion criteria, the infant is eligible for whole body cooling.

Exclusion Criteria
a. b. c. d. e. Inability to complete the neurological examination by 6 hours of age. Presence of known chromosomal anomaly. Presence of major congenital anomalies. Severe intrauterine growth restriction (weight <1800g). Infants in extremis for whom no additional intensive therapy will be offered by attending neonatologist.

Equipment Required a. Cincinnati Sub-Zero (CSZ) Blanketrol II Hyper-Hypothermia system with hoses b. Patient probe jack c. CSZ Esophageal temperature probe, 491B d. Two Maxi-Therm Lite blankets, 25 x 33 inches and 25 x 64 inches e. Two gallons of sterile or distilled water (not de-ionized) f. IV pole Operation of the CSZ Blanketrol Unit A separate summary is provided for operation of the cooling unit including salient features of the system, initiation of cooling, monitoring of cooling, re-warming infants, and an algorithm for trouble shooting problems with the cooling system. Monitoring of Temperatures and Vital Signs during Body Cooling a. During cooling all exogenous heat sources should be off. b. Temperatures should be recorded from the esophageal and skin probes at 15 min intervals for the first four hours of cooling to insure that the system is functioning properly. Of note, there is an initial overshoot in esophageal temperature with the present system (mean sd temperature of 32.70.9oC in the hypothermia group of the Network trial with initial cooling and by 2 hours increased to close to 33.5oC; thereafter temperature fluctuated around the set point from 33.0 to 34.0oC). c. Esophageal and skin temperatures should be recorded at hourly intervals from 12 hours until 72 hours, and at hourly intervals during reheating. d. Measurement and recording of axillary temperatures and other vital signs should continue as per NICU policy.

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Blood Gas and pH Measurements during Body Cooling Blood gases will be temperature corrected while infants are undergoing whole body cooling. This is an arbitrary recommendation since there is no firm data to drive the decision for or against temperature correction. Temperature correction of blood gases and pH was performed in the Network trial. 9) Follow-up of Infants with Perinatal Hypoxia-Ischemia: Given the potential link between perinatal hypoxia-ischemia and early childhood adverse neurodevelopmental outcome, it is recommended that all infants with a moderate or severe encephalopathy of any duration should be followed-up in Dr Vohrs clinic in addition to routine pediatric health maintenance. This recommendation is irrespective of imaging findings, absence of seizures, or normal evaluation at the time of discharge. Infants with no CNS involvement or encephalopathy limited to stage I Sarnat (mild encephalopathy) do not need follow-up with Dr Vohr unless there are unusual findings (eg, abnormalities on MRI imaging etc). References 1. Badawi N, Kurinczuk JJ, Keogh JM, Alessandri LM, OSullivan F, Burton PR, Pemberton PJ, Stanley FJ. Antepartum risk factors for newborn encephalopathy: The western Australian casecontrol study. BMJ 1998; 317:1549-1553 2. Badawi N, Kurinczuk JJ, Keogh JM, Alessandri LM, OSullivan F, Burton PR, Pemberton PJ, Stanley FJ. Intrapartum risk factors for newborn encephalopathy: The western Australian casecontrol study. BMJ 1998; 317:1554-1558 3. Sarnat HB, Sarnat MS. Neonatal encephalopathy following fetal distress. Arch Neurol 1976; 33:698-705 4. Martin-Ancel A, Garcia-Alix A, Gaya F, Cabanas F, Burgueros M, Quero J. Multiple organ involvement in perinatal asphyxia. J Pediatr 1995; 127:786-793 5. Perlman JM, Tack ED. Renal injury in the asphyxiated newborn infant: Relationship to neurologic outcome. J Pediatr 1988; 113:875-879 6. Laptook AR, Corbett RJT, Arencibia-Mireles O, Ruley J. Glucose-associated alterations in ischemic brain metabolism of neonatal piglets. Stroke 1992; 23:1504-1511 7. Painter MJ, Scher MS, Stein AD, Armatti S, Wang Z, Gardiner JC, Paneth N, Minnigh B, Alvin J. Phenobarbital compared to phenytoin for the treatment of neonatal seizures. NEJM 1999; 341:485-489 8. Shankaran S, Laptook A, Ehrenkranz R, Tyson J, McDonald S, Donavan E, Fanaroff A, Poole K, Wright L, Higgins R, Goldberg R and the NICHD Neonatal Research Network. Reduction in death or moderate/severe disability by whole body hypothermia for hypoxic-ischemic encephalopathy (HIE). Academic Pediatric Society Meetings, Washington DC, May 2005, Submitted

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Congenital Diaphragmatic Hernia Management Protocol

These guidelines, developed by the multidisciplinary health personnel involved in the care of these patients, are intended to provide a consistent approach to manage patients with CDH. Resource Faculty, expert in the field of CDH management, will be available 24 hours a day to provide support to the team caring for the patient. Communication among all services involved is essential. During the most critical periods of time, pediatric surgery and neonatology (with the input from cardiology) will meet twice a day (in the morning and in the afternoon) to discuss treatment plans. The patient management strategy and plan(s) will be supervised and directed by the Staff Pediatric Surgeon and Neonatologist and transcribed by one of the appointed team members. It has been our institutional experience that this collaboration provides the best care for patients by utilizing expertise of each program. The major goal of this protocol is centered on two themes. The first is to use the Gentle Ventilation principle to prevent baro/volutrauma. The second is to judiciously manage Pulmonary Hypertension to prevent heart failure.

A) Resuscitation and Initial Management ET tube placement with minimal bag mask/ventilation. Intestinal decompression by NG/OG tube to low continuous suction. Positioning patient on ipsilateral side of the CDH. Connect the patient to conventional ventilator, time cycled, pressure limited with synchronized breaths. See below under Respiratory for specific recommendations. UAC for blood pressure monitoring and blood samples. UVC catheter for venous access. Right radial line for preductal blood gases (a UAC may be sufficient if good pulse oximeter measurements can be obtained from the right hand). NPO, IVF D10W @ 60 ml/kg/day. Cardiology consult for Echocardiogram and initial assessment of pulmonary vasculature and heart function. Genetic consult if indicated. B) Transport If the patient is born outside our institution (and most likely undiagnosed prenatally) use the approach described in section A) once the diagnosis is made. Separate guidelines specifically oriented to out-born patients will be developed and distributed to level 1 and 2 hospitals. It is of paramount importance and is the responsibility of the Team in communication with the referring hospital (neonatal fellow, nurse manager, nurses, respiratory therapists, attending) that these guidelines are followed. C) Management by systems: 1) RESPIRATORY: Gentle ventilation approach: - Preservation of spontaneous respiration (minimal sedation, no neuromuscular blockade) - Permissive hypercapnia (no hyperventilation or induction of alkalosis) - Avoidance of high ventilator pressure - Target blood gas : pH=7.30-7.45, pO2=60-120 mmHg, pCO2=45-60 - FiO2 to keep pre-ductal O2 saturation between 90-95%. Do not use post-ductal values to adjust ventilator settings, since post-ductal saturations indicate less critical, non-cerebral perfusion. Realize that blood sampling from the umbilical artery is post-ductal. The preferable sampling site is the right radial artery. Remember that pre-ductal values indicate flow to the brain

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via carotid arteries and therefore are critical. The post-ductal pO2 or O2 saturations will often be < 60 mmHg or < 90%, respectively. NaHCO3 (1-2 meq/kg) can be administered to increase the pH if the above levels cannot be maintained without excessive ventilation, as long as pCO2 is below 60. Constant supervision at the bedside is critical when making ventilatory adjustments. It may take some time for the patient to adjust to the change.

Ventilatory management: - Connect to conventional ventilator SIMV initial setting: PIP=20, PEEP=5, Rate=40, FiO2=100%. Goal Tidal volume= 4-6 cc/kg. Wean PIP when FiO2 requirements are 60-40%. - For excessive labored spontaneous breathing (severe retractions, tachypnea) switch to PatientAssisted Ventilation mode. - If this strategy fails increase PIP up to 25 cm H2O. - Switch to High Frequency Ventilation (HFOV or HFJV) if pre-ductal SaO2<90% and PCO2>60 despite a PIP=25 cm H2O. - The HFV strategy has switched from rescue therapy to early intervention to limit lung injury. Therefore, consider HFV if PIP on conventional ventilator is 25 cm H20. - Also, and for the same reason, do not attempt lung recruitment since this would increase lung barotrauma. Surfactant is not routinely indicated 2) PULMONARY VASCULAR AND CARDIAC MANAGEMENT Major goals are to attenuate/reduce pulmonary hypertension and subsequent right side heart failure. Increased pulmonary vascular resistance (PVR) is almost universal in CDH patients. May not be detected by pre/post O2 saturation gradient if RVP<LVP or shunting through the foramen ovale. Cardiac Echo is becoming increasingly important to: Exclude congenital heart disease Assess right ventricular (RV) function Estimate pulmonary artery (PA) pressure (flattening of intraventricular septum,tricuspid regurgitation) Identify the patency of the ductus arteriosus and assess shunting (consider Prostaglandins to maintain ductal patency if PPHN is severe, and right heart failure a concern, after discussion with cardiology) Daily Echocardiograms should be performed (for the reasons mentioned above), at least until the patient is stable and after discussion with cardiology. Start with 20 ppm of iNO for patients with increased RV pressure and an oxygenation index (0I) 15 with FiO2 of 100%. Continue with NO treatment (despite the lack of improvement in oxygenation) if echocardiogram shows improvement of RV function; otherwise discontinue. If the patient improves with NO, wean FiO2 first (down to 40%) before weaning NO. Failure of NO may be associated with severe LV dysfunction Judicious use of dopamine and dobutamine (5-20g/kg/min) and fluid boluses (discussion with cardiology). Avoid excessive volume to manage hypotension, as third spacing will ultimately worsen pulmonary function Target blood pressure (MAP 45 in full-terms) 3) INFECTIOUS DISEASES - Start with ampicillin and gentamycin until cultures are negatives or CDH is repaired

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4) HEMATOLOGY - Maintain central hematocrit 40 while unstable. 5) METABOLIC Parenteral nutrition: - For full-terms begin with D12.5%, 2 g of protein/kg and 1 g of lipid/kg on the first day of life at 60 ml/kg/day and increase by 1 g/kg/d of protein and lipid up to a maximum of 3.5-4 g/kg of protein and 3 g/kg of lipid. To meet these goals IVF should be increased to 80 ml/kg/day by day 2. 6) NEURO - The goal is to keep the patient awake, breathing spontaneously and comfortably adjusted to the ventilator. - Sedation (phenobarbital, fentanyl, morphine, midazolam) may be necessary if the patient is agitated with hypoxia after ruling out respiratory causes (for example mucus plug, inadequate ventilation, etc). - If morphine/fentanyl are used keep in mind potential hypotension as a side effect. D) Transport to an ECMO center - Since we are a non-ECMO center, patients should be transferred prior to meeting ECMO criteria. - Decisions regarding the appropriateness of ECMO should be discussed within the team and with the ECMO referral center. - Cranial ultrasound (to rule out IVH) Indications: Failure of medical management, defined by: Oxygenation index (OI)> 30 on two preductal ABGs 30 minutes apart or PaO2 <40 on two ABG 30 minutes apart with trend consistent with progressive deterioration Persistent acidosis (pH< 7.25) Intractable hypotension Decompensation with severe hypoxia due to high pulmonary vascular resistance

Exclusion Criteria Irreversible disease due to severe pulmonary hypoplasia Genetic Anomalies Prematurity (gestational age cut off defined by the ECMO referral center) Significant hemorrhage/coagulopathy Major neurological disease Parental refusal

E) INDICATIONS FOR SURGERY REPAIR Surgical repair of the CDH is performed once the pulmonary hypertension has improved and the patient is on minimal ventilatory support.

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References: 1. Azarow K, Messineo A, Pearl R, Filler R, Barker G, Bohn D. Congenital diaphragmatic hernia--a tale of two cities: the Toronto experience. J Pediatr Surg. 1997 (3):395-400. 2. Bohn D. Congenital diaphragmatic hernia. Am J Respir Crit Care Med. 2002 166(7):911-5. 3. Boloker J, Bateman DA, Wung JT, Stolar CJ. Congenital diaphragmatic hernia in 120 infants treated consecutively with permissive hypercapnea/spontaneous respiration/elective repair. J Pediatr Surg. 2002 Mar;37(3):357-66. 4. Desfrere L, Jarreau PH, Dommergues M, Brunhes A, Hubert P, Nihoul-Fekete C, Mussat P, Moriette G. Impact of delayed repair and elective high-frequency oscillatory ventilation on survival of antenatally diagnosed congenital diaphragmatic hernia: first application of these strategies in the more "severe" subgroup of antenatally diagnosed newborns. Intensive Care Med. 2000 (7):934-41. 5. Downard CD, Wilson JM. Current therapy of infants with congenital diaphragmatic hernia. Semin Neonatol. 2003 (3):215-21. 6. Kays DW, Langham MR Jr, Ledbetter DJ, Talbert JL. Detrimental effects of standard medical therapy in congenital diaphragmatic hernia. Ann Surg. 1999 (3):340-8. 7. Kinsella JP, Ivy DD, Abman SH. Pulmonary vasodilator therapy in congenital diaphragmatic hernia: acute, late, and chronic pulmonary hypertension. Semin Perinatol. 2005 (2):123-8. 8. Muratore CS, Wilson JM. Congenital diaphragmatic hernia: where are we and where do we go from here?. Semin Perinatol. 2000 (6):418-28. 9. Muratore CS, Kharasch V, Lund DP, Sheils C, Friedman S, Brown C, Utter S, Jaksic T, Wilson JM. Pulmonary morbidity in 100 survivors of congenital diaphragmatic hernia monitored in a multidisciplinary clinic. J Pediatr Surg. 2001 (1):133-40. 10. Reyes C, Chang LK, Waffarn F, Mir H, Warden MJ, Sills J. Delayed repair of congenital diaphragmatic hernia with early high-frequency oscillatory ventilation during preoperative stabilization. J Pediatr Surg. 1998 (7):1010-4. 11. Sakurai Y, Azarow K, Cutz E, Messineo A, Pearl R, Bohn D. Pulmonary barotrauma in congenital diaphragmatic hernia: a clinicopathological correlation. J Pediatr Surg. 1999 (12):1813-7. 12. Wilson JM, Lund DP, Lillehei CW, Vacanti JP. Congenital diaphragmatic hernia-a tale of two cities: the Boston experience. J Pediatr Surg. 1997 Mar;32(3):401-5. 13. Wung JT, James LS, Kilchevsky E, James E. Management of infants with severe respiratory failure and persistence of the fetal circulation, without hyperventilation. Pediatrics. 1985 (4):48894. 14. Wung JT, Sahni R, Moffitt ST, Lipsitz E, Stolar CJ. Congenital diaphragmatic hernia: survival treated with very delayed surgery, spontaneous respiration, and no chest tube. J Pediatr Surg. 1995 (3):406-9.

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