Mod 4 Critically Ill Neonates Flashcards
1
Q
How often are humidified circuits changed?
A
Once a week
2
Q
When gathering a patient history, what would you expect to see as major clinical events?
A
- Vent changes/mode
- Major meds (were they weaned?)
- Is the ventilation conservative or non conservative?
3
Q
When assessing a babe, what should you do before disturbing the babe?
A
Visual inspection, check vital signs, vent monitoring
4
Q
Why do you avoid disturbing the babe?
A
Neonates may appear more distressed than they are,
5
Q
Generally, what are the 3 levels for Goals of Care Designation?
- “code status”
A
- Resuscitative
- Medial
- Comfort
6
Q
What code status allows medical care, interventions, and resuscitation, followed by neonatal ICU?
A
Resuscitative
7
Q
What code status seeks medical care and interventions, but excludes resuscitation
A
Medical
8
Q
What are your primary goals when handling temperatures for babes?
A
- Maintain Neutral Thermic Environment (NTE)
- Skill and auxiliary temp probes should aim to be (36.5-37)
- Avoid hypothermia and hyperthermia
9
Q
What are heart rate targets you should aim for in neonates?
- how is it monitored?
A
120-170 bpm (General baseline)
- Gold standard is ECG in NICU
- Advanced airways always need to be ECG monitored
10
Q
How can you take a babes Heart rate?
A
- Palpate pulse at the base of umbilical cord
- Brachial pulse
- Auscultate over the precordium for apical beat
11
Q
Normal Respiratory Rate (RR) for neonates?
A
40-60 bpm
- the lower the gestational age, the higher the RR (w/normal range)
12
Q
What can Tachypnea indicate?
A
Hypoxemia, acidosis, anxiety, pain
13
Q
What can Bradypnea indicate?
A
- Meds
- Hypothermia
- Neurologic impairment
14
Q
How does gestational age affect respiratory rate?
A
Distress or level of development.
- higher RR within normal range w/lower gestational age
15
Q
How do you estimate mean arterial pressure (MAP) in neonates?
A
Gestational age +5
16
Q
Normal Blood pressure for neonates?
A
Hard to say because it increases as the babe gets older/heavier.
17
Q
For Hemodynamics monitoring, how much blood should we take at a time from a neonate?
A
Take < 0.5 mL bc blood volume is a concern
- only take when necessary
- blood pressure more reliable
18
Q
How is invasive monitoring generally performed in neonates ?
A
- Umbilical Artery Catheter
- Radial/tibial arterial line
19
Q
What is the most common drug used to treat seizures in the NICU?
A
Phenobarbital
20
Q
What drug class can’t be used in premature neonates?
- why?
A
Benzo’s can’t be used bc they can cause neurological problems.
21
Q
Why can’t fentanyl be used in premature neonates?
A
Fentanyl can cause respiratory depression and chest wall rigidity
22
Q
What is phenobarbital used for?
A
Seizures caused by hypoglycaemia, fever, and IVH
23
Q
What drug class does Pancuronium fall under?
- what is its function?
A
Paralytic, stops all muscle movement.
24
Q
Left off at UVC…
A
25
What’s not normal apnea?
Apnea of prematurity. aka lasts longer than 10-15 seconds (depending on source)
26
What is associated with normal respirations of neonates?
- Diaphragm is the primary muscle of respiration, **chest wall moves very little**
- Obligate nose breathers
- Irregular respirations
- Small interruptions in respiration are normal for a neonate
- Signs of work of breathing?
27
What are indications for a UVC line?
- Infusion of fluid
- Exchange transfusions
- Diagnostic contrast study
28
Normal SpO2 for infants on a Pulse Ox?
Typically 88-95%
- special considerations for cyanotic heart defect
29
How would you troubleshoot if a neonate desats?
- Stimulate the infant
- Observe for self recovery (short period of time)
- Increase FiO2 in small increments (2-3%)
- Bagging (last resort)
30
What do Histograms monitor?
Optimal SpO2 ranges/trends over a 24 hr period.
- Ranges, as in SpO2 trends in 91-95, 100-105 etc. etc.
31
What adjustments can you make to respiratory support to optimize SpO2 targets?
Goal is to achieve optimal FRC
- Adjust CPAP fit and seal
- Secretions
- Increases in pressure
32
What changes should you make if over distension is occurring?
- what does overdistenion mean?
Decrease support. Overdistension means O2 therapy is above targeted SpO2 ranges.
33
What is Transcutaneous Monitoring?
Non-invasive way of measuring CO2 and O2 tensions in the skin.
**Heated electrodes applied to skin arterioles, resulting values are approximates of arterial values)
34
What are 2 types of transcutaneous monitoring?
- Clark type (PO2)
- Severinghaus type (PCO2)
35
What are correction factors for Transcutanous Monitoring?
- aka what should you keep in mind about tc monitoring values?
tcpCO2 values are slightly higher and tcpO2 values are slightly lower
36
What are indications for Transcutaneous Monitoring?
- High frequency ventilation
- Invasive ventilator support (when etCO2 not an option)
- Non-invasive resp. support
- **Any neonate where ventilation is a concern**
37
Contraindications for Transcutaneous Monitoring?
- Very low birth weight infants (<28)
- Poor skin integrity
- Burns
- Allergy/Sensitivity to adhesive
38
What is the rule of thumb regarding Transcutaneous Monitoring temperature settings ?
Start w/low temps to assess skin integrity and reduce risk of burns.
- Lower temp settings will take greater time to equalize.
- Correlate w/ABGs (only one draw if line isn't in)
39
What is temperature setting and frequency of site change dependant on?
Gestational Age
40
Optimal Sites for Transcutaneous Monitoring?
- Chest (below clavicles)
- Abdomen
- upper thigh
- upper arm
41
Where should you avoid putting Transcutaneous Monitors?
Over bone or nipple area bc they’re at greater risk of skin breakdown
42
Environmental considerations for babes?
Ambient noise, light, neutral thermal environment
43
What basic neurological assessment should be checked for infants?
Tone and reflex. A healthy baby will have spontaneous movement.
- high risk babes need a more in depth neuro assessment
- more tone as babes get closer to gestational age.
44
What neurological tests are performed for high risk infants?
Ballard/Dubowitz assessment
- done by nicu neoatlogist
45
What population/characteristics would be considered as a high risk infant?
- Premature
- Intrauterine Growth Restrictions (IUGR)
- Asphyxia
- “Torch” infections
- Meningitis
- Hypoglycemia or polycythemia
- Neonatal Abstinence Syndrome (NAS)
46
what are alerting signs of neurological compromise?
- Seizures
- Jitteriness
- Abnormal tone
47
Would you see decreased or increased tone in a hypoxic infant?
Decreased tone (floppy/flaccid)
48
What does hypertonia imply after a infant is stablized?
possible neurological injury (babe is super rigid)
49
What's the difference between jitteriness and seizures?
If you gently hold hands and feet, jitter will stop. seizure won’t.
50
What are common causes of Jitteriness?
- Hypoglycemia and hypocalcemia
- Drug withdrawal
- Neonatal encephalophagy
51
What are traits of Jitteriness?
Symmetrical, rapid movements of hands + feet
- movements usually occur do to stimulus
- Jitteriness ends when held
52
What are traits of seizures
Subtle changes in activity, clonic movements, tonic posturing and **do not stop when limb held**
- Abnormal gaze/eye movement
- Autonomic changes (tachycardia, hypertension, apnea)
- **Clonic jerking**
53
Seizure management/treatment?
- Check airway and breathing
- Admin O2 therapy if needed.
- Check blood glucose levels
- establish continuous monitoring (cardiorespiratory)
- Treat w/phenobarbital
- Treat hypoglycemia if present
- EEG
54
After assessing tone for neurological damage, what are other neurological assessments that should be done?
- Pain
- Fontanels
- Pharmalogical interventions
- Therapeutic interventions
55
How is pain measured in infants?
Premature Infant Pain Profile (PIPP)
56
What procedures are used to test pain in infants?
Suction, ABG, CBG
57
When should PIPP be tested?
every big physical assessment before procedure
58
Why is pain difficult to assess in infants?
Their heart rates don't spike or increase to pain. In adults, it is common to see tachycardia w/pain. **because**
- **babes have a immature autonomic nervous system** , they're HR may not spike
59
According to the PIPP, what pain score range would you not have do anything?
Score 0-6
- No action required
60
According to the PIPP, what pain score range indicates slight to moderate pain?
- Interventions?
Score 7-12
- Give comfort measures
61
According to the PIPP, what pain score range would indicate severe pain?
- Interventions?
Scores > 12
- Pharmalogical interventions would be indicated
62
What are pain comfort measures?
- Sucrose
- Skin to skin (kangaroo care)
- Avoid excessive handling
- Repositioning/swaddling
- Decrease environmental stimuli (noise, light)
63
How does skin to skin (kangaroo care) provide comfort/pain relief?
- Stabilizes HR and RR
- Improves O2 sats
- Better regulates infants body temp and conserves calories
64
What does vent synchrony tell us about the baby?
They're in pain or uncomfortable
65
Why is sedation and analgesia used in critically ill babes?
- Prevents pain and anxiety
- Decrease O2 consumption
- Decrease stress response
- Patient-vent synchrony
66
What do analgesics do?
Decrease sensation of pain
67
what are 4 groups of analgesia used for neonates?
- EMLA cream (local/topical)
- Lidocaine (local/topical)
- Tylenol (analgesic and antipyretic)
- Opioids
- NSAIDs
68
Why would you use morphine rather than fentanyl on neonates?
Both can cause respiratory distress, but **fentanyl causes chest wall rigidity** makes it harder to ventilate neonates.
69
What drug is safe to use wean babes off of NAS or fentanyl?
Methadone or Buprenorphine
70
What drug is used to close PDAs?
Ibuprofen and Indomethacin.
- But generally, the NSAID group.
71
Aside from respiratory depression, what problem can Paralytics cause?
Third spacing of fluid
72
What is sdedation?
Decreased CNS stimulation
73
What is the function of ketamine?
Used exclusively for procedures
- sedation and analgesia during procedures
- Causes bronchodilation
- Dissociative anesthetic
74
What are Fontanels?
"soft spot" on babes head.
- Normal should feel flat, inline with skin (spongy)
75
What does a depressed Fontanel indicate?
Decreased volume
- hypovolemia
- dehydration
- Shock states
76
What does a full/bulging Fontanel indicate?
Patient is fluid overloaded, in premies we suspect IVH
- Increased volume
- Hypervolemia
- Bleeds?
77
What does overriding Fontanel indicate?
78
What is the most common method in evaluating neonates brain?
ultrasound
79
Why are ultrasounds the gold standard?
No sedation or radiation required.
- can be performed a bedside
80
What can ultrasounds assess in neonates?
- Intracranial hemorrhage
- IVH
- Hydrocephalus
81
Why are EEG used for neonates?
To diagnose/confirm seizures and encephalopathy
82
Why are MRI's used for neonate assessments?
Diagnose/confirm intracranial pathology.
- less false negatives and positives and doesn’t use radiation
83
Why are ultrasounds and MRIs preferred over CT scans?
Babe needs to be still, so sedation is most likely needed.
84
What are CT scans used for neonates?
Diagnose or confirm intracranial pathology
85
What is the purpose of a lumbar Puncture?
Obtain Cerebral Spinal Fluid (CSF)
86
What is Colostrum?
Moms first milk
- has antibodies and immunoglobulins
87
What are H2 blockers?
Decrease stomach acid production
- Ranitidine (Zantac)
- Cimetidine (Tagamet)
- Know what H2 blockers do, don’t worry about the mech.
88
What are feeding pathways for children?
- Bottle (EBM & Formulas)
- Total/gavage (EBM & Formulas)
- Total Parental Nutrition (TPN)
89
What does cerebral spinal fluid (CSF) help diagnose?
Meningitis
- Bacterial, viral, and fungal infections
90
What is the practical purpose of a Lumbar Puncture?
- hint, not diagnosing wise
Admintiser intrathecal medications
91
What reduces the risk of Hypoxic Ischemic Encephalopathy (HIE)
Therapeutic Hypothermia
92
What is the purpose of Therapeutic hypothermia?
Improves neurologic and risk of death is late to term babes
93
When is Therapeutic Hypothermia performed?
- What is the timeline of treatment?
After resuscitation, within 6 hours.
- The babe is cooled to 33-34 degrees
- Maintained for 72hrs w/frequent monitoring of temp, PIPP, glucose, neuro, and vitals
- After 72 hrs, babe is rewarmed
94
How does Therapeutic Hypothermia work?
- Controls/reduces swelling, bleeding, & infection (reduces metabolic demand and minimizes inflammation)
- Inhibits release of excitatory transmitters and production of free radicals (slows cell injury aka apoptosis)
- Prevents cerebral tissue injury (reduces swelling/bleeding)
95
What are some negative affects of therapeutic hypothermia?
- Bradycardia and hypertension (reverses w/rewarming)
- clotting disorders (Lower platelet counts & prolonged prothrombin times)
- Metabolic acidosis
- Skin breakdown
- Hyponatremia & hypokalemia
96
Why is there skin breakdown after Therapeutic Hypothermia?
Secondary to decreased perfusion & lack of movement (sedation or paralysis)
97
Once effective ventilation and oxygenation are established, what are common causes of cardiovascular instability?
**Decreased O2 delivery to tissue**
98
What are potential causes for decreased O2 delivery to tissue?
- Insufficient circulating blood volume
- Poor heart muscle function (myocardial dysfunctions
- Anatomical abnormalities of the heart (CHD)
- Abnormality of heart rhythm
99
What does the color pink indicate about a babies condition?
Oxygenated blood and well perfused skin
100
What does Pale/Mottled/Gray color indicate about a babies condition?
- Poor skin perfusion
- Decreased CO (hypovolemia, impaired cardiac function)
- Cold stress, acidosis, or pain
101
What does Ruddy/Plethora color tone indicate about a babies condition?
- Redish/blue tone
- Polycythemia, neonatal hyperviscosity, hyperthermia
102
What does the Dusky/blue indicate about a babies condition?
Cyanosis (peripheral or central)
103
What range of hemoglobin is considered Cyanotic?
**>5 g/dL of hemoglobin desaturated**
- decreased depends on initial count
104
When might cyanosis not be observed as hypoxemia?
In the presence of marked anemia
105
When might a neonate appear cyanotic, but hypoxic
In the presence of increased hematocrit AKA **Polycythemia**
106
Where does the issue of Central cyanosis orginate?
Can be Cardiac or respiratory
107
How do you know if Central Cyanosis is caused by Respiratory issues?
Respiratory distress and responds to increased FiO2
108
How do you know if Central Cyanosis is caused by Cardiac issuess?
- strongly suggested in absence of respiratory distress and is unresponsive to 100% fiO2
- Occurs in “right to left shunt” – cyanotic heart defects
- A neonate with a documented PaO2 of 150 mmhg is unlikely to have cyanotic heart disease
109
What tests can help differentiate if central cyanosis is a cardiac or respiratory problem?
***Hyperoxia test or pre and post ductal**
110
On assessment, what elements would give you information on perfusion?
- Temperature
- Capillary Refill Time
- Urine output
111
What does temperature tell us about a patients level of perfusion?
Cold hands and feet = poor perfusion
- skin temp of extremities should be the same as core if perfusion is sufficient
112
What is a normal capillary refill time?
Normal is <3 seconds
- longer cap refill time indicates decreased peripheral perfusion
- For neonates, remember to compare central and peripheral cap refill
113
What indicates decreased perfusion to the kidneys?
Decreased urine output (u/o)
114
What do weak pulses indicate?
Low cardiac output, like shock.
115
What point of reference should be used for pulses, when assessing perfusion?
Compare peripheral to central pulse.
- Weak peripheral pulses when compared to central can indicate poor peripheral perfusion (present in many CHD).
116
What does a bound pulse tell us about perfusion?
Presence of a PDA w/ (L->R) shunt
- lowers systolic pressure and widens pulse pressure.
117
What is a bounding pulse?
An arterial pulse that feels forceful and prominent when palpated. It is characterized by a rapid and strong expansion of the artery during each heartbeat.
- Rapid rate and forceful
118
Why is a bounding pulse associated with cardiac steal?
**Bounding occurs when cardiac steal is happening during diastole, as systolic recovers from cardiac steal**
To sum statement below:
Vasodilation -> Redistribution of blood supply -> Ischemia
- Cardiac steal is when the blood supply to a specific area of the heart muscle (myocardium) is temporarily reduced due to changes in blood flow resulting from the admin of meds or other interventions.
119
Are newborns more hypotensive or hypertensive in the first 24hrs of life?
Hypotensive (premies especially)
120
What is a primary element of Intrauterine to extrauterine changes?
Low SVR to SVR (inversly high PVRto low PVR)
- problems in transition = hypotensive state
121
What is the gold standard for measuring blood pressure in neonates?
UAC or intra-arterial catheter
- its the most reliable, invasive monitoring method
122
How can lower blood pressures be measured in neonates?
Cuff or Doppler Ultrasound probe
123
When are non-invasive cuffs unreliable when measuring BP?
When systolic BPis under 40
124
What should you keep in mind when assessing blood pressure for neonates?
- **IMPORTANT**
Hypotension should not be treated based on numbers along. **signs of shock/symptoms must accompany**
125
What is a estimated adequate BP in neonates?
- Why is it considered adequate?
When Systolic BP is higher than the infants gestational age
- Its allowable bc newborns are bad at regulating stroke volume, they rely on HR to increase cardiac output
- **MAP normal for neonate is gestational age + 5**
126
What is the most common pathological factors for hypotension in newborns?
Dysfunction of immature myocardium
- Inappropriate basal reaction resulting in hypertension (increasing afterload) or hypotension (decreased SVR)
- will see increased heart rates when they're hypotensive
- cant compensate with stroke volume and more profound in
congenital heart defects
127
How do you treat Hypotension in neonates?
Look at numbers and Pt status for signs of shock (poor perfusion) to decide if they need the following:
- Volume replacement
- Inotropic support
128
When would you use volume replacement to treat hypotension in neonates?
Its the initial treatment, followed by BP reassess.
- replacement w/volume if its obvious (PRBC, FFP, Albumin)
- if not obvious, bolus/infusion of isotonic normal saline (slow drip)
- Assess CVP, if CVP is normal and hypotension remains, it is not a volume problem.
129
What is the role of CVP when treating Hypotension in neonates?
It guides treatment. CVP reflects BP and pressure in central veins, which return blood to the right side of the heart.
- If CVP is normal then probably problem with stroke volume
130
How does Inotropic support guide Hypotension treatment in Neonates?
Treatment w/intropes improves myocardial contractility.
- Cautiously used in low doses
131
What are common NICU inotropes used for hypotension?
- Dopamine
- Dobutamine
- Epinephrine
132
Normal Neonate HR?
- Whats considered abnormal?
Term neonates have greater variance in HR than premies.
- Normal HR 120-170
- Abnormal > 220
133
Is Transient tachycardia normal or abnormal?
Transient tachycardia with stimulation or agitation is normal
134
Where is the point of Maximal Impact for neonate HRs?
Near sternum, between the 5th and 6th rib.
- Can be seen in infant bc of their thin/flexible chest wall
135
Need to add info on this slide
136
Why is suctioning a useful tool to assess a newborns heart rate?
We want to watch how long it takes a babe to recover from brady
137
Are dropped beats (PAC's) normal or abnormal?
Dropped beats (PACs) are usually benign
- Newborns have high incidence of arrhythmias within the first few days of life.
- 1-5% of neonates have some disturbance in HR or rhythm
138
What happens if a babe presents a irregular rhythm?
ECG is performed and treated w/antiarrhythmics
139
What do heart murmurs tell us about neonates?
Some murmurs are heard in specific areas and can indicate heart defect/malformation.
- Most murmurs in neonates are normal and resolve with closure of the patent ductus arteriosus (PDA)
- murmurs sound like rushing sound on auscultation
140
What is generalized edema indicative of in neonates?
fluid balance [renal] issues, hydrops fetalis, cardiac problems, third spacing
141
Presentation of edema?
Face & eyes may be bruised and swollen
142
What is Caput succedaneum?
Edema on the scalp secondary to delivery; accompanied by bruising; it crosses the midline of the scalp and is outside the periosteum.
- looks like a xenomorph head
143
Why is a pre/post ductal SpO2 test performed?
- what should you expect on each ductal section?
Pre and Post-Ductal SPO2 are Performed to differentiate between a cardiac or pulmonary cause of hypoxemia
- Pre: Right arm will have higher O2 Saturation
- Post: L arm and lower extremities will have lower O2 Saturation
144
What is a Echocardiography?
Investigates Ductal and Atrial shunting
- Assess Pulmonary artery pressure
- Calculates R and L ventricular output
- Assess Myocardial function
145
What is the difference in fluid overload vs volume overload?
- Fluid overload in pulmonary system usually seen in PDA
- volume overload from systemic system dumping into pulmonary system (CHF)
146
Why is Nitric Oxide preferred from other vasodilators?
- How is it used?
selective for pulmonary system so it doesn’t vasodilator systemically
- see if its making a difference immediately
- see during inhalation
- start at 20ppm and should see increasing stat and decreasing
SpO2 requirements, approved for used in neonate use
147
What are the mechanics of ECMO?
Typically veno-arterial where both heart and lung supported.
- Blood removed from right atrium
- Gas exchange occurs in a membrane
- Rewarmed to body temperature and returned to right common carotid artery
148
What is Sildenafil used for in neonates?
To manage Pulmonary hypertension of the newborn (PPHN)
- Causes pulmonary vasodilation
- Improves oxygenation by reducing resistance to blood (allows better flow)
149
What are the primary vasodilators you would use for neonates to improve perfusion and oxygenation?
(also treat PVR)
iNO and Sildnefil
150
When would you opt for ECMO?
(needs editing)
where oxygen index is greater than 40 and you have to
take over gas exchange
- cannilating vessels with issues like infections and same problems
like therapeutic hypothermia where patient is sedated
- gas exchange happening outside, pt is on vent but we don’t
control oxygenation, preventing atelectasis during ecmo,
appropriate peep and set vt and RR but oxygenation is outside
membrane by perfusionist
151
How do PDA's close?
On its own or...
- Indomethacin or Ibuprofen
- Angiography w/intravascular coil insertion (coil placed in pda)
- PDA ligation (Surgical clipping)
- Interventions may also need increases to FiO2
152
When would PDA interventions be necessary?
When they remain open because of increased PVR
153
What conditions would you want the PDA to remain open after birth?
Cyanotic heart defects that are ductal dependent rely on ductus for tissue oxygenation.
- the PDA may be necessary for survival
154
How is the Ductus Arteriosus kept open?
Prostaglandin E1
155
How are PDA closures confirmed/assessed?
ultrasound
156
What is the most common cause of cardiorespiratory failure in the newborn?
Hypoxemia
157
What is required for successful transition from fetal to neonatal circulation?
Establishment of ventilation and prevention of hypoxia
158
Emergency Equipment at the bedside
Bagging units and masks (one hooked up to gases and “ready to go,” one as a back up)
- pressures and FiO2 reflect Pt settings
159
What is Apnea of Prematurity?
Apnea that lasts longer than 10-15 seconds
- associated w/cyanosis, bradycardia, and hypotonia.
- **not normal**
160
When is jet ventilation commonly used?
Conditions like congenital diaphragmatic hernias, resp failure and lung protection strats
161
Indications for CxRs in Neonates?
- Confirm Intubation (ETT position check)
- Confirm line placement (umbilical catheters)
- When a complication/pathology is suspected
- Assess overall progression of disease
- Assess if over and under ventilating the Pt.s
162
How does positioning for a CxR affect ETT placement?
- Chin up causes ETT to move up high in trachea
- Chin down causes ETT to move down in trachea
163
What are key points that should be kept in mind/done for a neonate getting a CxR?
- High risk of extubation during CxR
- No extension or flexion (head up or down)
- Turn Pt. head slightly to 1 side.
- RT's finger hold ETT place, and vent circuit out of image
164
Where are RT's during a CxR for neonates?
Head of bed holding the ETT
165
Where should the ETT be placed?
Between the clavicles and the carina (T2)
166
