NICU Learning Objectives Learn about transitional physiology and how this relates to neonatal resuscitation Learn the differences between sick and well infants and when an infant needs a higher level of care in a NICU ID: 933591
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Slide1
NICU Basics
Kirsti Martin, MD PGY5
Slide2NICU Learning Objectives
Learn about transitional physiology and how this relates to neonatal resuscitation
Learn the differences between sick and well infants, and when an infant needs a higher level of care in a NICU
Learn about the care of and diseases affecting premature infants, to gain perspective when you care for them in a primary care setting
Learn and build upon basic ICU concepts in your first exposure to ICU care
Do as much cool stuff as possible!
Slide3Today’s Learning Objectives
Learn some basics about prematurity, including
Definition
Potential Complications
Delivery Room Management
Systems-Based Approach to Preterm Admission
Milestones of the Hospital Course
Discharge Criteria
Highlight important information to know on your first day in the NICU
Slide4Prematurity
Preterm labor
Maternal infection
Neonatal infection
Premature rupture of membranes
Advanced cervical dilation
….. ?
Preterm induction of labor or preterm c-section delivery
Most commonly seen for pre-eclampsia
Delivery for fetal decelerations in HR while mother admitted for other reasons (non-reassuring fetal heart tracing)
Slide5Prematurity
Periviability
– 23-24 weeks gestation
Lungs still in canalicular phase of embryonic development
Canaliculi form from terminal bronchioles
respiratory
bronchioli
and alveolar ducts (not sacs yet)
Type 1 pneumocytes (primary structural cell of alveoli) just differentiating from type II
Capillary network surrounding terminal bronchioles from mesenchyme just forming
Surfactant begins to be produced by type II pneumocytes by 24 weeks
Parents counseled about active ICU care vs comfort care without resuscitation
Extremely preterm – less than 28 weeks gestation
Very preterm – less than 32 weeks gestation
Thought process behind the care of these infants is similar, with lower gestational ages more complicated due to higher risk for hemodynamic instability, poor respiratory status, feeding intolerance,
etc
Slide6Prematurity
Infants born less than 32 weeks or 1500g (3
lbs
4.9 oz) at risk for
Respiratory Distress Syndrome – difficulty with oxygenation and/or ventilation due to lack of surfactant production
Bronchopulmonary dysplasia – the lasting respiratory effects of being born prematurely with underdeveloped lungs; can involve chronic changes to lungs as a result of mechanical ventilation – defined as the need for oxygen or respiratory support at 36 weeks corrected gestational age
Intraventricular hemorrhage – bleeding of the vessels in the germinal matrix, found in the lateral ventricles of the brain
Necrotizing enterocolitis – disease of the intestines with multifactorial causes; can cause bowel inflammation/necrosis, abdominal perforation requiring abdominal surgery for resection of affected areas
Retinopathy of prematurity – abnormal development of retinal blood vessels secondary to exposure to supplemental oxygen; can cause blindness
Apnea of prematurity – prolonged pauses in breathing secondary to immature neural regulation of breathing
Hypothermia
Hypo/hyperglycemia
Infection
……
Slide7How we care for preterm infants
The OB team calls you to say that they will be going to the OR shortly for the delivery of a 27+4 week infant
Mother is a 29 year old G1P0; came to triage for rupture of membranes earlier today, and now the fetal heart rate keeps decreasing into the 80s before recovering; lasting ~3 minutes
Prenatal labs –
A+, ab negative, Hep
BsAg
neg, HIV negative, RPR non-reactive
, rubella immune, varicella immune, G/C negative, GBS unknown
Mother received one dose of
betamethasone
this morning, as well as
IV magnesium
and
antibiotics
Estimated fetal weight from this morning’s ultrasound is 800g
Slide8Important Highlights
Blood type and antibody status
Risk of hyperbilirubinemia due to hemolysis from Rh disease, ABO incompatibility, other Ab mediated process
HIV
If positive would need to initiate treatment urgently (IV zidovudine)
HepBsAg
If positive or unknown, would need Hep B vaccine and HBIG within 12
hrs
RPR
If positive would need to initiate treatment urgently (IV penicillin)
Betamethasone
Antenatal steroids work to rapidly mature the fetal lung to prepare for birth
Complete course (two doses 24
hrs
apart; complete 48
hrs
from first dose) decreases risk of BPD, IVH, NEC,
etc
…
Magnesium
A tocolytic but has also been shown to decrease the risk of cerebral palsy in premature infants
Antibiotics
Treat an infection that may have been caused by or be a result of premature rupture of membranes
May partially treat fetal infection
Slide9Delivery Room
All infants less than 32 weeks
Thermal mattress
Thermal hat
Plastic wrap
Infant mask
RAM cannula
NeoPuff
Appropriate laryngoscope and ET tube
Surfactant
Slide10NeoPuff
Demonstration
https://www.youtube.com/watch?v=G9-KezhaXJM
Slide11Infant is born
Infant with good tone and spontaneous respirations, so delayed cord clamping x30 seconds
By transfer to the warmer, infant no longer breathing
Simultaneously
Infant placed in
NeoWrap
, on the thermal mattress, and thermal hat placed
RAM cannula placed into nose and pulse oximeter placed on right hand
Nurse listens to heart rate
HR is 70, and infant is still not breathing
Breaths given via RAM cannula – NIPPV (non-invasive positive pressure ventilation) with peak inspiratory pressure (PIP) 25 and positive end-expiratory pressure (PEEP) 7
HR increases to 140, breath sounds are heard bilaterally, and infant begins to have spontaneous respiratory effort
FiO2 is titrated to maintain saturations appropriate for time of life
At 10 minutes of life, on NIPPV 25/7 x30, FIO2 30%, infant placed in transporter and brought to NICU for admission
Slide12Systems
Respiratory – consider the need for early surfactant based on FIO2 requirement, work of breathing, or blood gas
Access- place UVC with goal to be finished with placement and
xray
by 1 hour of life
Cardiovascular – make sure blood pressure/perfusion is appropriate
FEN/GI – write TPN/IV fluids and feeds for the infant
Hematology – assess the infant’s hematology status
ID – assess the infant’s risk for infectious disease
Neuro – is the infant at risk for IVH?
Slide13Respiratory
During transport, infant with desaturations requiring increase in NIPPV to 28/8 x30, FiO2 40%
Due to high FiO2 requirement suggestive of respiratory distress syndrome, infant will likely benefit from administration of exogenous surfactant to decrease surface tension in the alveoli and prevent atelectasis, promote gas exchange
Infant is intubated, surfactant is administered by injection through a feeding tube into the ET tube in two equal aliquots, and infant is extubated back to NIPPV (INSURE method)
After surfactant, FiO2 decreases to 21% (nice job!)
Sometimes, the need for surfactant is not this obvious early on
FiO2 requirement doesn’t happen until later (if at all)
May have good oxygenation but poor ventilation (need blood gas to tell)
Apnea of prematurity may start with resultant worsening respiratory status
Slide14Access
Central access required to provide concentrated IV nutrition (total parenteral nutrition, TPN)
Also used to draw labs
Umbilical venous catheter
Inserted through umbilical vein, passes through ductus venosus, into the inferior vena cava
Goal location above diaphragm, at ~T7-8
All infants less than 31 weeks or 1500g; 31-32 weeks depends on clinical preference
Umbilical arterial catheter
Inserted into one of two umbilical arteries, passes into internal iliac artery, common iliac artery, and into aorta
Carrier fluid is run through the line, and outputs a blood pressure waveform
Goal location is T6-9
Less commonly used in our unit unless infant requires significant respiratory support or is hemodynamically unstable
Slide15You place the UVC
You’ve placed the UVC in to your estimated depth, draw back on your syringe, and see blood (good job!)
Draw your initial labs now – 2.5 to 3 ml
Venous blood gas – assess respiratory and metabolic status
Blood glucose
Complete blood count with differential
Blood culture
Type and Screen (if cannot be obtained from cord blood)
Extra for repository study
Call for x-ray to confirm placement
Slide16Respiratory
VBG - pH 7.25/pCO2 55/pO2 75/HCO3 19/ base excess -4
At the time the VBG was drawn, the transcutaneous CO2 monitor (TCOM) was reading 58
As you settle the infant after securing the UVC and putting the top of the “giraffe” (humidified
isolette
) down, the TCOM continues to downtrend and settles at 45
Infant receives first dose of caffeine at 4 hours of life (20 mg/kg), then daily after this (10 mg/kg) for prevention of apnea of prematurity
Slide17Cardiovascular
Blood pressure typically obtained by cuff pressure, less commonly via UAC
Desired mean arterial pressure (MAP) = infant’s gestational age in weeks
Premature infants can have slight dip in MAP a few hours after birth (just below expected range), but if perfusion is good, urine output is stable, and infant otherwise stable, will typically recover without extra intervention
Slide18Hematology
CBC
WBC count 10.5 with ANC 3000, 2 bands, 50 neutrophils
Hb/
Hct
15.3/45.7
Platelets 200
Normal premature
Hct
is 45, normal term
Hct
is 55
Transfuse PRBCs on first day for less than 35
Normal platelets 150-450k
Transfusion thresholds vary with illness severity; typically between 30-50k
Assess white blood cell count to see if it suggests infection
Normal WBC count roughly 5,000-30,000
Make sure ANC >1500
Calculate the I:T ratio (
bands+other immature forms divided by neutrophils plus all immature forms)
if >0.2, more suggestive of infection
Slide19Hematology
Order daily serum total bilirubin levels to start the second day of life
Premature infants at higher risk for hyperbilirubinemia due to
Increased RBC turnover due to decreased life span of premature RBC
increased bilirubin production
Decreased bilirubin clearance and conjugation due to immature liver
Increased enterohepatic circulation of bilirubin
At higher risk for bilirubin induced neurologic dysfunction
Due lower albumin
more free, unbound bilirubin that can cross the blood-brain barrier
See survival guide for premature bilirubin curve for when to start phototherapy
Slide20Infectious Disease
All infants under 32 weeks get 48 hour “sepsis rule out”
While blood culture pending, ampicillin and gentamicin given x48 hours
Dosage and intervals in Epic!
Optimal coverage for most common neonatal infections - Group B strep, E. coli
Remember to obtain mother’s HIV,
HepB
, RPR, and GBS status
GBS frequently unknown with preterm delivery, that’s ok
Slide21Fluids/Feeds
Enteral feeds must be advanced slowly due to small stomach and risk of NEC
Breast milk or donor breast milk (need consent)
Preterm formula has significantly increased risk of NEC vs breast milk
Fed via small orange feeding tube either through nose or mouth into stomach
Refer to feeding protocol for recommendations for fluid amounts by GA
On your survival guide!
For 27
weekers
, we start at 90 ml/kg/day
Start feeds at 10 ml/kg/day within 6-8 hours of birth, advance by 10 ml/kg BID
Start TPN/Intralipids and carrier fluid through the second port of UVC at 80 ml/kg/day
Slide22Feeds
Starting at 10 ml/kg/day
10 ml
x 0.8 kg = 8 ml/day
kg/day
8 ml/day divided by 8 feeds in 24 hours (feeds are q3hrs) =
1 ml q3hrs
To increase by 10 ml/kg BID
10 ml/kg = 1 ml q3hrs as above
Write to increase feeds by 1 ml every 12 hours
Slide23Maximum Feeds
Max feeds are typically 160 ml/kg/day
Use birthweight to calculate this until infant surpasses birth weight
160 ml
x 0.8 kg = 128 ml/day , divided by 8 feeds/day =
16 ml/feed
kg/day
Initial feed order –
Start feeds at 1 ml q3hrs. Advance by 1 ml q12hrs to a max of 16 ml q3hrs.
Slide24TPN/Carrier fluid
Stock TPN started on first day typically – protein and glucose (D10 base)
Carrier fluids (heparinized ½ sodium acetate at 0.5 ml/
hr
or 12 ml/day) plus TPN to equal 80 ml/kg/day
Carrier fluid –---
12 ml
divided by 0.8 kg = 15 ml/kg/day
day
80 ml/kg/day – 15 ml/kg/day = 65 ml/kg/day
TPN ----
65 ml
x 0.8 kg = 52 ml/day, divided by 24
hr
/day = 2.16 ml/
hr
(2.2 ml/
hr
)
kg/day
Slide25Intralipids
The source of fat in TPN; stock TPN does not include this
When you write custom TPN the next day, you must account for the intralipid as part of your total fluids
1g IL = 5 ml/kg/day, 2g IL = 10 ml/kg/day, 3g IL = 15 ml/kg/day
Total fluids of 80 ml/kg/day = 15 ml/kg/day carrier + 65 ml/kg/day TPN/IL
So if we start 2g IL, our TPN amount will decrease from 65 to 55 ml/kg/day
55 ml
x 0.8 kg = 44 ml/day, divided by 24
hrs
/day = 1.8 ml/
hr
kg/day
Slide26Decreasing IV fluids
(TPN/IL) 80 ml/kg/day + (feeds) 80 ml/kg/day = Total fluid 160 ml/kg/day
Feeds will continue to increase, but your TPN will need to decrease as feeds increase to keep total fluids at 160 ml/kg/day
Feeds increase by 1 ml every 12 hours
The IV fluid equivalent of 1 ml feed every 3 hours is
1 ml
= 0.33 ml/
hr
3 hours
With each feed increase of 1 ml every 12
hrs
, decrease IV fluids by 0.3 ml/
hr
to maintain TF 160 ml/kg/day
Slide27Other things to order on admission
AM daily BMP while on TPN, to adjust TPN electrolytes or fluid status as needed
AM daily triglycerides as needed when intralipid introduced or increased
Head ultrasound to assess for IVH one week from birth; would rather have it 7-10 days out than earlier than 7 days from birth
Caffeine!
Vitamin K and erythromycin!
Slide28General Progression of Hospital Course
Infant weans slowly from NIPPV to CPAP over the course of weeks; FiO2 remains in the low 20s, increasing mostly with apnea of prematurity spells; at 32-33 weeks CGA, infant trialed off of CPAP in room air, and is hopefully successful!
Sometimes need positive pressure for longer, sometimes need low flow nasal cannula; some infants go home with nasal cannula
Caffeine discontinued when apnea spells decrease (around 33+5 weeks)
UVC comes out between DOL 5 and 6 when feeds reach 120 ml/kg/day, reaches full feeds by 1 week
Feed and grow!
At 34 weeks, neurologically mature enough to suck, swallow, and breathe; can start to learn to orally feed at breast or with bottle
Slide29Discharge Criteria
No apnea, bradycardia, or desaturation spells at rest requiring intervention for at least 5 days
Must be 10 days off of caffeine
Must be 1800 grams (4 pounds –
carseats
do not fit infants smaller than this)
Must be able to keep themselves warm in an open crib while dressed and swaddled
Must be able to take enough feeds by mouth (without NG tube) to stay hydrated and gain weight; typically between 120 and 160 ml/kg/day
Must pass
carseat
test without A/B/D episodes
Typically between 37-44 weeks CGA
Slide30Note
This is how an uncomplicated, ideal NICU course may go, and there are plenty of infants who have uncomplicated, ideal courses!
However, there are many things that can go wrong, or be more severe, that make things more complicated – you will learn about all of these things along the way!
Keep this system by system thought process in your head with each premature admission, and you will be able to write the admission orders and understand the care super well!
Never be afraid to ask for help!