Neonatal Resuscitation
Warm/Dry
Tube=Age/4+4 (3.5 in premies, 4 in FT)
Depth is 6+KG or 3xET Size or 9-10 in NBs
UV line-only one vein, 2 arteries. Tie umbilical tape around stump. Cut at 1 cm beyond skin. Use 3.5 feeding tube in premies, 5 in FT. Insert 4-5 cm or 12 cm. In between there is a risk of being in the liver, so avoid infusing sclerosing fluids. Umbilical artery line is like an a-line in adults, use for BP monitor and for arterial sampling. Should not infuse any sclerosing fluids.
Do not need to suction vigorous, meconium infants (Cochrane Review)
CPR for HR<60 after 30 seconds of adequate ventilation
anything that decreases oxygen tension or increases pulmonary resistance leads to transitional circulation, and therefore shunting with decreased sats.
Pain in the neonate can have long lasting physiologic consequences. It may permanently effect pain pathways.
Infants warm not by shivering but by metabolic process in liver. Can rapidly lead to acidosis
>40 is normal sugar, but they are quite susceptible to hypoglycemia.
oxygen can destroy the retina (ROP) and cause respiratory distress syndrome
Maybe 100% oxygen is worse than room air for neonatal resus (Pediatrics 112(2):296, August 2003 )
fluctuations are probably even more damaging than any one level
If the baby has one anomaly, there is probably a second and there might be a heart murmur. This is what causes these kiddies to code.
2 pulse oxs one on right arm or ear (preductal), one anywhere else
irradiate all blood products, cmv filtered. Kids can get graft vs. host disease from leuks.
If you’re giving blood and see hypovolemia, think hypocalcemia: give calcium
Choke, Cough, Cyanosis=Esophageal Atresia. Try to pass og and get neck film
The Critically Ill or Comatose Infant
Immediate Steps
Stabilize and Secure an Airway
Get IV access
Normal Saline Bolus 20 cc/kg
Get Vital Signs and Fingerstick
Get Labs and Blood Cultures
Start Antibiotics
Consider other tests and interventions
History
Determine if infant has been doing its job (eating, sleeping, pooping, and peeing)
What Happened?
When did you first notice the problem, and how quickly did the baby get worse?
Complications during pregnancy and birth?
Any past medical history?
How has the baby been feeding and what is he or she being fed? Does the baby become sweaty or dyspneic during feeds?
How have the BMs been?
Has there been vomiting, if so is it green?
Is the child urinating well?
Has there been any fever?
What was the birth weight?
Is the baby taking any medications? Could there be exposure to any home remedies/meds?
Diagnoses that may be missed
Ductus Dependant Heart Lesions
Myocarditis
SVT
Infant Botulism
Congenital Adrenal Hyperplasia-presents with either hypoglycemia or salt wasting
CAUSES OF SHOCK/SEVERE ILLNESS IN THE NEWBORN: (THE MISFITS)
T- Trauma/ NAT (non-accidental trauma) H- Heart disease- congenital/hypovolemia/hypoxia (respiratory complaints) E- Endocrine (Congenital adrenal hyperplasia, thyrotoxicosis) M-Metabolic disturbances I-Inborn errors of metabolism S-Sepsis F-Formula dilution or over concentration I-Intestinal catastrophes T-Toxins (home remedies) S-Seizures
Vitals
BP>60 in 1stmonth, >70 after this
140 is normal heart rate, >220 suggests SVT, <80 is non-perfusing
Resp Rates are 30-60 for 1stmonth, then 25-50
Get a rectal temperature
Get the weight
Physical Exam
Palpate the fontanelle
Interventions
If you are spending more than a few minutes trying to get an IV, attempt IO access
If infant needs blood, dose is 10 cc/kg PRBCs
If infant needs sugar: <3 months old, use D10W at dose of 5-10 cc/kg. >3 months, use D25W at dose of 2-4 cc/kg.
If infant is in shock, continue with 20 cc/kg boluses until they are not. If you have given 4 boluses, consider dopamine 6-10 mcg/kg/min, preferably through central line.
Give prostaglandin E1 for persistent hypoxia despite high flow O2
Antibiotics: Up to 6 weeks, give Ampicillin 100 mg/kg and Cefotaxime 50 mg/kg. In older children, can use Ceftriaxone 100 mg/kg, If strep meningitis is suspected, add Vancomycin. If abdominal infection is suspected, use Amp, Genta, Flagyl.
SVT: adenosine .1 then .2 mg/kg. Cardioversion .5 J/kg
Labs
In all, get CBC, Chem, UA, U C+S, Blood Cx, ABG. Possibly tox screen, CSF, LFTs, and if inborn errors of metabolism, get Ammonia, Ketones.
Normal Neonatal Hemoglobin is 13-20.
UMBILICAL VEIN LINE Umbilical vein remains patent for at least 1 week after birth; used for newborns or young neonates who require emergent vascular access and peripheral attempts have been unsuccessful. Updated 3/1/00 Pediatric Procedures Lab 14 Equipment – Antiseptic solution and sterile gauze pads – Sterile drapes – Umbilical tape or 3-0 silk suture on a straight needle – Small hemostat – Sterile scalpel – 3.5 or 5F umbilical catheter (can also use 5F feeding tubes) – 3 way stopcock – 10cc syringe – Saline flush Place newborn supine and restrain extremities as necessary Newborn should be placed on a cardiac monitor and pulse oximeter; also monitor newborns temperature; use warming bed or lamps if possible Attach 5F umbilical catheter (or feeding tube) to the 3-way stopcock an syringe filled with saline flush catheter with saline clean umbilical stump and abdomen from xyphoid to pubic symphysis Loosely tie umbilical tape or silk suture around base of umbilical stump cut the cord 1-2cm from the abdominal wall identify the vessels (the umbilical vein is a single, thin walled, large diameter lumen, usually located at 12 oclock; the arteries are paired and have thicker walls with a smaller diameter lumen; cut end of cord resembles Oh no, Mr. Bill from Saturday Night Live gently remove any clot from in the umbilical vein insert the catheter until free return of blood (about 5-6 cm) Confirm catheter placement with abdominal x-ray; catheter should not curve into RUQ might be entering hepatic portal circulation; x-ray should show placement at or above the diaphragm COMPLICATIONS Infection Embolization or thrombosis Vessel perforation Hemorrhage Ischemia of extremities or intra-abdominal organs
Bad Billi
>5 first day
Increase greater than .5 per hour or 5 per day
Direct > 1.5
>12.5 after three days
CAUSES OF SHOCK/SEVERE ILLNESS IN THE NEWBORN: (THE MISFITS)
T- Trauma/ NAT (non-accidental trauma) H- Heart disease- congenital/hypovolemia/hypoxia (respiratory complaints) E- Endocrine (Congenital adrenal hyperplasia, thyrotoxicosis) M-Metabolic disturbances I-Inborn errors of metabolism S-Sepsis F-Formula dilution or over concentration I-Intestinal catastrophes T-Toxins (home remedies) S-Seizures
Consider inborn errors of metabolism, get abg, ammonia, and electrolytes.
Recent Changes to PALS
1. Keep the baby warm, position the baby, and clear the
airway. Stimulate the baby to breathe by drying;
however, if the baby is depressed and has meconium,
clear the meconium by intubating and suctioning.
Minimal stimulation should be used in these infants.
There is no longer a recommendation to suction the
trachea of a vigorous infant with meconium staining
regardless of how thick the meconium is. However, the
meconium should be suctioned from the mouth, nose,
and posterior pharynx after delivery of the head, but
before delivery of the shoulders.
2. In newborns who still have ineffective respirations
after stimulation, positioning, and drying, begin bagand-
mask ventilation, followed by intubation if
necessary. If the heart rate remains low, chest
compressions are indicated.
3. The new PALS recommendation is to start CPR for an
absent heart rate or heart rate less than 60 BPM in spite
of assisted ventilation for 30 seconds. It is important to
remember that this recommendation is not based on
any actual published data, but was made by panel
consensus. The old PALS/Neonatal Resuscitation
Program (NRP) recommendation was to initiate
compressions in the newborn for a heart rate of less
than 80 BPM.
4. The preferred method for CPR in the newborn is the
thumb-hand technique. (Wrap your hands around the
infants chest and back, and use the thumbs to compress
the chest over the sternum.) Better compressions are
achieved with this method as compared to the twofinger
compression technique.
5. Try vagal maneuvers while preparing for drug therapy or
cardioversion for patients with supraventricular
tachycardia. Crushed ice in a plastic bag placed over the
infants face initiates the dive reflex and works
particularly well in this age group.
Apparent Life Threatening Event (ATLE)
1. Hypoxia
2. Hypoglycemia
3. Meningitis
4. Mechanical
5. Sepsis
6. Metabolic Cause
7. GI Reflux
8. Inborn errors of metabolism
9. Dysrhythmias
These patients need a sepsis work-up and admission if no other reason for the event is found.
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