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NEONATOLOGY

NEONATOLOGY. Introduction. Newborn: A recently born infant in the first few hours of life Neonate: Refers to infants in the first 28 days of life. Physiological Adaptations at Birth. Three major physiological adaptations necessary for survival

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NEONATOLOGY

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  1. NEONATOLOGY

  2. Introduction • Newborn: • A recently born infant in the first few hours of life • Neonate: • Refers to infants in the first 28 days of life

  3. Physiological Adaptations at Birth • Three major physiological adaptations necessary for survival • Emptying fluids from their lungs and beginning ventilation • Changing their circulatory pattern • Maintaining body temperature

  4. Chest • As the lungs are cleared of amniotic fluid and the fetus passes through the pelvis • The chest wall recoils and the newborn takes it’s first breath, stimulated by • Mild acidosis • Initiation of the stretch reflexes in the lungs • Hypoxia • Hypothermia

  5. As the lungs expand, resistance in the pulmonary vessels decreases and blood flow to the capillary beds increases The pulmonary vessels which were collapsed intrauterine, now dilate The Ductus Arteriosus immediately closes Circulatory System

  6. Circulatory System • The Foramen Ovale begins to close • The pressure changes in the lungs begins the diffusion of oxygen • When the cord is cut, the circulatory system must become an independently functioning unit

  7. Apnea • Primary apnea • A self-limited condition (controlled by PCO2 levels) • Common immediately after birth • Secondary apnea • Respirations absent and do not begin again spontaneously

  8. Causes of Hypoxia • Compression of the cord • Difficult labor and delivery • Maternal hemorrhage • Airway obstruction • Hypothermia • Newborn blood loss • Immature lungs (premature)

  9. Airway and ventilation: Stimulation Ventilate with BVM Suction Intubation Management • Circulation • Heart rate • Circulatory access • Pharmacological • Narcan (~ 4 hours prior) • No narcotic antagonist, if mother drug abuser • Dextrose 10%

  10. Preparation for Delivery • Effective triage • Preparation • Prior • Resuscitation • Postresuscitation

  11. Risk Factors • The incidence of complications increases as birth weight decreases • Causes of low birth weight include: • Premature births • Undernourishment in the uterus • Maternal factors

  12. Multiple gestation Inadequate prenatal care Mother’s age (<16 or >35) Hx of perinatal morbidity/mortality Post-term gestation Drugs/medications Toxemia, hypertension and/or diabetes Antepartum Risks

  13. Premature labor Meconium-stained amniotic fluid Rupture of membranes >24 hours Use of narcotics ~4 hours Abnormal presentation Prolonged labor or precipitous delivery Prolapsed cord Bleeding Intrapartum Risks

  14. Resuscitation Oriented History • Multiple pregnancy • Meconium • Prematurity • Maternal narcotic use

  15. Assessment and Management • Initial steps should include : • Prevent heat loss • Clear the airway • Provide tactile stimulation • Evaluate the infant Figure 41-1

  16. Prevention of Heat Loss • Immediately after delivery • Dry the infant's head and body • Remove any wet coverings from the infant • Cover with dry wrappings • Cover the newborn's head • Accounts for 20% of the newborn’s BSA

  17. Hypothermia • Great risk of hypothermia in the newborn • Large body surface area • Decreased tissue insulation • Immature temperature regulatory mechanisms

  18. Hypothermia • Neonate attempts to conserve body temp by vasoconstricting and increasing metabolism, which places them at risk for • Hypoxemia • Acidosis • Bradycardia • Hypoglycemia

  19. Open Airway • Open airway by: • Correct positioning • Suction the mouth then nose • Avoid deep or vigorous suctioning that can stimulate a vagal response

  20. Suction Equipment • Bulb suction • Suction catheters • Meconium aspirator

  21. Suctioning • Monitor newborn’s heart rate during suctioning • Allow time for spontaneous ventilation during suctioning

  22. Provision of Tactile Stimulation • If drying and suctioning do not induce respirations, provide additional tactile stimulation • Slapping or flicking the soles of the feet • Rubbing the infant's back

  23. Assessment • Drying, positioning, suctioning and stimulation are necessary in every newborn • The next step depends on the newborns • Respiratory effort • Heart rate • Color

  24. Respiratory Effort • Observe and evaluate the newborn’s respirations: • Normal crying • Inadequate or gasping is present • Slow or shallow rate • No response after 5 - 10 secs of stimulation

  25. Ventilation • If remains apneic after a brief period (5 to 10 seconds) of stimulation: • Immediately initiate positive-pressure ventilation with a pediatric BVM device and supplemental oxygen (40 to 60 ventilations/min)

  26. Heart Rate • Evaluate with a stethoscope or by palpating the umbilical cord or brachial artery: • Above 100 bpm, continue eval • Less than 100 bpm, BVM for 30 sec, re-eval • Less than 60 to 80 bpm, despite BVM, chest compressions • Does not respond to ventilation and compressions, Epi

  27. Chest Compressions

  28. Color • Assess the newborn’s color from central to the extremities: • Pink throughout • Peripheral cyanosis (acrocyanosis) • Central cyanosis

  29. Supplemental Oxygen • Free-flow oxygen can be given through: • A face mask and flow-inflating bag • An oxygen mask • Blow-by free flow at 5 L/min • Maximum oxygen conc can be achieved when tube is held half inch from the nose

  30. Routes of Drug Administration • Drugs rarely indicated • heart rate remains < 60 bpm despite adequate ventilation with 100% oxygen and chest compressions • Routes • tracheal route generally most rapidly accessible route • umbilical vein most rapidly accessible venous route • peripheral sites (scalp or peripheral vein) may be adequate but more difficult to cannulate • intraosseous (IO) route

  31. Umbilical Vein Cannulation • Identify umbilical vein after trimming cord • Insert umbilical catheter or angiocath into vein • Secure base of cord to hold catheter in place and stabilize catheter with tape Figure 41-5

  32. Drugs Used in Neonatal Resuscitation • Medications most frequently used during neonatal resuscitation • Epinephrine • Volume expanders • Naloxone

  33. Twins

  34. Premature Infant • Refers to a baby born before 37 weeks • Premature infants have an increased risk for: • Respiratory depression • Hypothermia • Head and brain injury

  35. Premature Infant • Premature infant characteristics: • Large trunk • Short extremities • Translucent skin • Birth weight between 0.6 to 2.2 kg • Resuscitation should be attempted with any signs of life

  36. Set in the Newborn Center, a 100 bed NICU in Memphis, TN,

  37. Meconium Staining • Presence of fetal stool in amniotic fluid • Associated with • Increased perinatal mortality • Hypoxemia • Aspiration pneumonia • Pneumothorax • Pulmonary hypertension

  38. Meconium Staining • Staining can range from: • Slight yellow or light green, to • Thick “pea-soup” appearance

  39. Meconium Staining • Thick meconium leads to aspiration of particulate matter, leading to: • Atelectasis • Development of pneumothorax • Death

  40. Meconium Staining • After meconium is observed in amniotic fluid, intervention is aimed at preventing or minimizing the risk of aspiration • Emergency care begins with preparation of necessary equipment

  41. Intubation equipment Meconium aspirator Bulb syringe or DeLee suction 10 French or larger suction catheter Portable suction and irrigation solution Gauze pads BVM device Equipment

  42. Meconium Staining • After delivery is complete, clear the infants airway • Suction the mouth, pharynx and nares • Routine suctioning is no longer recommended on the perineum

  43. Meconium Staining • If the neonate is depressed perform direct endotracheal suctioning using the ET tube as a suction catheter • Provide blow-by oxygen and monitor fetal heart rate for bradycardia

  44. Meconium Staining • Repeat the intubation-suctioning-extubation cycle • until no further meconium is obtained or bradycardia develops • Do not ventilate between intubations • After tracheal suctioning, continue resuscitation measures as needed

  45. Blood glucose < 40 mg/dL May be due to: Inadequate glucose stores Increased utilization of glucose Persistent low blood glucose levels may have catastrophic effects on the brain Hypoglycemia

  46. Risk Factors • Asphyxia • Toxemia • Smaller twin • CNS hemorrhage • Sepsis

  47. Twitching or seizure Limpness Lethargy Eye-rolling High pitched crying Apnea Irregular respirations Possible cyanosis Assessment Findings

  48. Management • ABC’s • Maintain body heat • Rapid transport • IV/IO D10 and repeat glucose checks

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