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Peri Test 2

WillWallace Perinatology Ch 6,7,8,9

Normal airway clearance effective mucociliary action and effective cough
increased mucus may lead to obstruction and airtrapping, atelectasis, ineffective gas exchange, inflammation and infection
*ACT airway clearance techniques
*why are premature neonate prone to atelectasis secondary to lack of pulmonary surfactant present with RDS
Severe atelectasis can lead to large areas of shunting with worsening blood gases
*why is airway clearance used to prevent atelectasis and to help reinflate those areas that are atelectic
*complications of RDS atelectasis, lung tissue damage from ventilator pressures, oxygen and lack of surfactant, leading to BPD
*BPD bronchopulmonary dysplasia
*small airways in newborns can cause what if secretions accumulate severe imbalances in ventilation/perfusion ratios
*Indications for airway clearance retained secretions (atelectasis, RDS, BPD, intubation), excessive secretions (CF, pneumonia, asthma, bronchitis, bronchiectisis), aspiration (meconium, foreign body), prophylaxis (post intubation)
*disease processes that cause increased lung secretions CF, pneumonia, asthma, bronchiolitis, bronchiectisis
*contraindications of airway clearance therapy pulm hemorrhage, excessive agitation or hypoxemia during TX, feeding previous 45-60 mins, hx of reflux, neonate <1200g, <32 weeks, hx of intraventricular hemorrhage > grade 1 or <7days post bleed, pheumothorax, CHF, bradycardia
*hazards of postural drainage emesis (vomiting) and aspiration (never do with in 1 hour of feeding), never with hx of reflux, >ICP (in trendelenburg)
*Increased ICP predisposes early gestation baby to what IVH, intraventricular hemorrhage-never on baby less than 1500g
*skin integrity and percussion never on preemies less than 1200, may cause edema, excoriations (tearing of skin) and bruising
*percussion rhythmic clapping over affected lung area to loosen secretions, 1-5 mins
Why is caution used when percussioning baby with BPD may have fragile bones
*vibration rapid, constant motion, rather than rhythmic clapping. Used for loosening secretions in the airway, best done during exhalation, 30 seconds per side
Auscultation listening to the sounds produced in the lungs during the ventilatory cycle
Wheeze high pitched continuous sound
Rhonchi/course crackles continuous low pitched sound (secretions)
Crackles discontinuous sounds (fine crackles)
The goal of TX with aerosolized meds is deliver an adequate amount of med to the desired site in pulm tree with minimum side effects
*effective aerosolized TX depends on 4 factors 1. Size and amount of particles produced, 2 characteristics of particles, 3 anatomy of the airways, 4 pt vent pattern (cannot be altered by RT)
Jet nebulizer particle size and amount are dependant on what type of nebulizer used
What is the drawback of when running a jet nebulizer continuously much of medication is lost during expiration, reducing amount delivered to the lungs
*how can the loss of medication during exhalation be reduced slightly by adding a reservoir that collects some of the aerosol produced during exhalation and makes it available on next inspiration-spacer distal to the neb
*hydroscopic growth aerosol particles grow larger when added to environment of high humidity
*what is the major characteristic of aerosol particles that affects deposition it's ability to take on additional water-hydroscopic growth, making particle deposit higher in airway (dont make it to lungs)
*characteristics that determine aerosol deposition concentration and viscosity of drug and velocity it is delivered-more drug is delivered when the volume of diluent is increased
*lung deposition of aerosolized drugs to intubated infants less than 1/20 of non intubated adult and less than 1/10 of intubated adult-implication is higher dose needed for intubated infant to achieve dose equivalent to nonintubated pt
*how much aerosolized drug makes it to infant terminal airway and alveoli probably negligible, narrow airway, ett, etc are cause
*what is best ventilatory pattern for best aerosol delivery laminar flow fallowed by pause-slow deep breath with inspiratory pause.
*How can RT aid in deposition of meds in mechanical vent pt >Itime, <flow and add short inspiratory pause at end inspiration
*why do aerosolized drugs have limited use in NICU unknown side effects and dosages in neonates (liver not functioning yet, baby can get toxic build up)
*what is the advantage of svn requires little pt coordination, works well in acute distress with reduced inspiratory flows and volumes, modification of drug concentration, can aerosolize almost any liquid, effective with minimal breath hold
*disadvantages of svn expensive, less easily transported, cleaning and prep, inefficient dose delivery, cold, medium for bacteria,
*disadvantages of inline jet neb with ventilator high humidity may aid hydroscopic growth causing deposition in circuit or upper airway-reducing drug delivered
LVN used for continuous neb in acute asthma
Indications for aerosolized drugs bronchodilators, mucolytics and steroids
Indications for bronchodilator in preemie and peds <breath sounds, <chest expansion, wheeze and retractions, >RR, nasal flaring, grunting, >ventilatory pressures, increasing FIO2 requirements, and an increasing PaCO2
Indications for aerosolize steroids an inflammatory pulmonary process is present like BPD
*the most common nebulizer is what type updraft, used in the vertical position with a T piece attached
*what is a mainstream nebulizer and what is the advantage no additional tubing to adapt into circuit, designed to work in horizontal position, so works well inside incubator
*what is the biggest hazard associated with aerosolized meds inline to vent circuit potential increase in VT and peak pressures
*why do VT and peak pressures go up during inline aerosolized med TX’s during mech ventilation? nebulizer requires 6-8L/min flow (on top of what mach is already set, adds VT and PIP)
*what is the recommended solution to keep VT and PIP at manageable levels during aerosolized TX? place the nebulizer at the humidifier outlet and nebulize the med during exhalation, this allows meds to fill the expiratory limb of circuit, and deliver during pt's next breath.
To prevent excess condensation during inline svn on mech ventilated pt, what can RT do turn off humidifier (or bypass)
If circuit has a distal temp probe, RT should place neb distal to the probe, why? if proximal, then when neb removed, then heated gas could potentially burn pt
*Hazards if SVN TX nosocomial infection, medication side effects, drug reconcentration, ventilator malfunction, excessive noise (place svn on circuit outside incubator), sticky expiratory valve from medication deposits
*what is a SPAG (small particle aerosol generator) designed and intended for admin of ribavirin to treat RSV (no other meds should be used in it)
how does a SPAG unit work compressed gas into unit, reduced to 26psi, ½ then to flowmeter for nebulizer, ½ then to particles exiting nebulizer. 2 flows together with particles enter drying chamber (dries and reduces particle size 1.2-1.4 microns), then to pt.
What are the risks associated with administering riboviron to a vent pt, and what can we do to reduce those risks riboviron precipitates and accumulates on the walls of vent tubing and ETT tubes-<risk with highly trained, suction 1-2 hrs, monitor vent press, one-way valves to med into vent flow into spag (change often), bacteria filters
What is the purpose of bacteria filter and why do we change it often when using spag unit slows riboviron from entering environment on exhalation
how often should neonate be suctioned as little as possible, 4-6 hours as needed, never suction with in 20 mins of ABG
Suction Equipment cardiac, O2, and/or trancutaneous monitors, stethoscope, resuscitation bag with O2 source and press manometer, saline, suction catheter kit w/gloves, suction regulator at appropriate level, water soluble jelly if needed
Neonate ETT sizes 2.5-4
Suction catheter size for intubated neonate 5, 6 to 8-10
Suction catheter size for nonintubated baby preemie 5, 6 neonate to 6 months 5, 6-8
What is difference in suctioning baby from adult to avoid injury, babies are suctioned only to the tip of the ET tube, hyperoxygenate at 10-15 percent high than current setting (not 100%), no more that 5seconds of suction press (total time 10 seconds for procedure)
Hazards of suctioning neonate bradycardia, hypoxemia, mucosal damage, atelectasis, airway contamination, accidental extubation
What are the common causes of bradycardia when suctioning vagal stimulation (prevent by suction time less than 10 seconds total) and hypoxemia induced (prevent with hyperoxygenate and suction press applied for only 5 seconds)
Indications for O2 therapy hypoxemia
Hypoxemia in neonate (defined) PaO2 less than normal on room air (40-70mmHg)
PaO2 norms for term infant at birth-16mmHg, 20 mins 51mmHg, 3-5 hours 75mmHg, preemie at 3 to 5hrs-60mmHg and preemie at 24 hrs 73mmHg
S and S of hypoxemia in a neonate retractions, expiratory grunting, nasal flaring and cyanosis
Hazards of O2 therapy in neonates ROP, O2 toxicity leading to BPD (bronchopulmonary dysplasia), cerebral vasoconstriction, fire
What is BPD and how is it caused long exposure to high levels of O2 causes destruction of alveolar tissue, causing loss of surface area for gas exchange, leading to >hypoxemia and > need for O2, vicious circle
Cerebral vasoconstriction hazard high levels of O2 can lead to constriction of the vasculature in the brain, constriction leads to <blood flow in developing brain
Goal of O2 therapy in neonates keep PaO2 between 50-70 mmHg, high enough to avoid hypoxemia, but low enough to avoid ROP, BPD and toxicity
what is an oxygen blender and why do we use them series of regulators that lower wall pressure to more comfortable level, while mixing air and O2 for desired concentration (flow meter placed on outside is used to insure proper flow to pt), FIO2 IS APPROXIMATE! NOT ACCURATE! MUST ALWAYS USE O2 ANALYZER
O2 analyzers since blenders are giving an approximate FIO2, when precise O2 is desired analyzer is place in the system to monitor babies FIO2 delivery
Where is O2 analyzer placed in the circuit, proximal to humidifier (wet gas will give erroneous readings), calibrate every 4-8 hours to ensure accuracy and prevent drifting, always document calibrations
What is a low flow humidifier aka bubble humidifier (aka diffuser), flow <10L/min and usually non heated, used with simple mask and nasal cannula
Physics of bubble humidifier as bubbles of gas rise through the sterile water, the gas picks up water molecules
wick humidifier highflow humidifier, >10L/min, uses heated, water-saturated wick (spongey, absorbs water by capillary action) surrounded by heated tank, tank heats, evap from wick occurs, gas flow through the tank picks up heated water vapor and delivers it to pt
why do heated humidifiers create so much condensation? as heated-humidified gas flows through tubing, cold air outside tubing cools the air inside the tubing, as the air cools humidity falls out of the air-called a rain out effect, causing condensation to build up on the walls of the tubing
to prevent condensation from collecting and draining into babies lungs what must RT do collection device should be placed in the tubing at the lowest point between humidifier and pt, or heated wire circuit to keep gas temperature at desired level all the way through tubing
*oxygen hood FIO2 and Liter flow <50% at 7L/min
*where and why is FIO2 monitoring done when pt is using Oxygen hood at the level of the pt's face and nose, to assure accurate FIO2 because of layering effects
*Hazards of oxygen hoods flow to low and CO2 retention inside hood (keep flow >7L/min), pt face or neck against hood or neck hole occluding airway, high or low gas temperature causing thermoregulation problems (maintain gas temp to that of incubator)
When is O2 cannula used with neonate chronic need for O2 and weaning from oxygen hood
Flow for cannula always less than 1L/min
Chronic oxygen use in neonates is associated with what BPD
Flows >4L/min on cannula leads to what mucosal drying and epistaxis (nose bleed)
FIO2 for cannula are dependant on what pt age, size, VT and RR
FIO2 of NC at .25L/min 24-27%
FIO2 of NC at .50L/min 26-32%
FIO2 of NC at 1L/min 30-35%
How is NC kept in place for neonate with out causing skin damage IV site tape
Why are neonates and preemies kept in incubators temperature-controll and quit environment
How are O2 needs met with pt in incubator blended, warmed and humidified gas is blown in at desired FIO2
How is FIO2 checked for pt in incubator same as hood, as close to baby face (because of possible layer)
What is the main problem associated o2 delivery in incubators maintaining FIO2 because of constant opening of doors and port holes and the large size of incubators (fio2 >.25 may cause layering)
*when should a hood be used inside an incubator when pt requires >.25 FIO2 (to prevent layering)
*self inflating bag reinflate following decompression, must always have bag and O2 attached, used in emergency and short term modality, always with 100% O2 (gas in bag is entrained on each reinflation-then delivered to pt on decompression)
*flow-inflating bag aka flow-rating bags, have advantage over self inflating because exact FIO2 can be used. Flow rates are adjusted to meet the pt needs (bag fills based on flow, faster RR, needs faster flow)
*why do neonate resuscitation bags have two ports one for O2 and one for press manometer (prevent barotrauma)
On intubated pt, which port is for O2 and why is this important port that is distal to pt connection, prevents retardation of exhalation caused by direct flow of gas into end of ET tube
Indications for CPT atelectasis, CF, prolonged bed rest (never for asthma)
*do we hyperoxygenate neonate prior to CPT no
Which modality of aerosolized medication requires the least amount of pt coordination svn
Are retractions an indication for aerosolized meds no indicates CPAP
*what is the advantage of a mainstream nebulizer? it can be used horizontally, so great for incubator
Placing neb in vent circuit between humidifier and the distal temp probe may cause what overheating of the circuit when the neb is removed
*hazards of aerosol drug therapy infection, med side effects, drug reconcentration and over hydration
What is the greatest hazard of ribavirin administration with mech vent pt precipitation and accumulation of drug on vent tubing and ETT
While suctioning pt following CPT, pt becomes bradycardic, what should RT do stop, hyperoxygenate and shorten duration of following suction attempts (always less than 10 seconds)
Anaerobic absence of oxygen
*brown fat fat found in newborns, it's unique thermogenic activity is a heat source for newborns, highly vascularized and innervated by neurons from the sympathetic NS, it is stored around the great vessels, kidneys, scapulas, axilla and nape of the neck
*crigler-najjar syndrome congenital, familial autosomal abnormality, glucuronyl transferase is deficient or absent, causes nonhemolytic jaundice, an accumulation of unconjugated bilirubin and severe disorders of the CNS
Encephalocele protrusion of the brain through a congenital defect in the skull
Enteral pertaining to the intestines, often associated with feeding or meds
Galactosemia congenital defect characterized by deficiency of enzyme galactose-1-phosphate uridyl transferase, causes hepatoplenomegaly, cataracts and mental retardation
Gastroschisis congenital defect characterized by incomplete closure of the abdominal wall with protrusion of the viscera
Guaiac wood resin used on a reagent strip to test for presence of blood in the stool or urine
hydrops fetalis massive accumulation of fluid in the fetus or newborn often associated with erythroblastosis fetalis, effusions of the pericardial, pleural and peritoneal spaces also occur
Hypersosmolar increase concentration of osmotically active components such as electrolytes and proteins
Hypotonia having a smaller concentration of solute to solution ration than that found in intravascular or interstitial fluids
*kernicterus abnormal toxic level of bilirubin that accumulates in the tissues of the CNS, can cause degenerative disorders
Lucey-driscol syndrome syndrome passed as autosomal recessive train, characterized by inhibited uridine disphosphate glucuronosyl transferase and leads to rapid progressive jaundice and kernicterus
Omphalocele congenital herniation of the intraabdominal viscera through the abdominal wall near the umbilicus
Parenteral pertaining to the uptake of substances or meds by any route other than the digestive tract
Servo-controlled any device that uses a feedback loop for control. Like a home thermostat-temp falls below set and thermostat triggers heater, in incubators probe monitors skin temp, must be kept at 36-36.5
Sodium-potassium exchange resin (kayexalate) resin contain solution administered via enema (mark says they're his favorite,), in which sodium ions are released from solution and replace by potassium ions in the intestines, used to treat hyperkalemia
Stratum corneum outer most layer of skin, composed of dead cells converted to keratin, bodies barrier to microorganisms
Turgor normal resiliency of the skin, results from outward pressure of cells and interstitial fluid
What is the most important factor in care of a neonate thermoregulation
*thermoneuteral zone temperature range in which the metabolic rate is at a minimum and thus O2 consumption is at it's lowest
*what environmental temperature should neonates be kept at no exact temp recommended, should be maintained so that baby can achieve thermoneuterality, with a recommended rectal temp of 36.5 to 37.5
*why is there no exact environmental temperature for neonates because of the diversity of metabolic rates, gestational age and weight
*how do adults regulate body temp metabolic and physical activity (shivering) if cold, and sweating to cool.
*neonates rely on what for the production of heat relies entirely on the metabolism of brown fat (do not shiver)
*at what gestational age does brown fat appear? 26-30 weeks
*what is the process of brown fat to heat stimul symp NS to cold causes >norepinephrine release, >NE activates lipase, lipase breaks down brown fat to free fatty acids, acids are then hydrolyzed into glycerol and nonsterified fatty acids-oxygenation of ns fatty acids produces heat, > baby temp
*nonshivering thermogenesis breakdown of brown fat with the subsequent production of heat
*what are the two gradients of physiological heat loss in neonates internal thermal gradient and external thermal gradient
*internal thermal gradient (ITG) temp difference between warm body core and cooler skin
*how is ITG regulated BSA (body surface area), metabolic rate (crying will >), amount of subcutaneous fat, and distance from body core to the skin surface
*why do neonates have diminished capacity to maintain ITG large surface area to body weight (>area to lose heat), this skin, <amounts of subcutaneous and brown fat, and brown fat depletes rapidly (losing nonshivering thermogenesis), unable to take in enough calories to maintain nutrition for heat production
*external thermal gradient (ETG) temp difference between skin and environment, and is determined by the environmental factors controlled by RT
*what are the 4 factors that determine heat loss through ETG radiant heat loss, conductive (transfer) heat loss, convective heat loss and evaporative heat loss
*radiant heat loss dissipation of heat from baby to cold object-radiates from one object to another, does not have to be by contact, can be window close by or cold object placed into incubator
*what is an example of radiant heat gain heat from the sun
*conductive heat loss transfer of heat from body to cooler surface-put blanket under baby before putting on scale or table
*convection heat loss losing heat from skin by moving air, velocity and temp of air determine amount of heat loss, think convection oven (normal oven filled with heat chicken takes 1 hour, convection oven has fan to move heat-chicken takes 35 minutes)
*evaporative heat loss as water changes from liquid to gas, heat is released
*insensible heat loss evaporative heat loss from the skin (thin skin) and respiratory tract (normal)
*sensible heat loss evaporative heat loss from sweating from the skin
*what kind of evaporative heat loss do babies do insensible only, they do not sweat
*what is cold stress hypothermia, any lowering of the thermoneuteral temperature
*where are the most sensitive thermoreceptors located in the face (and respond the quickest)
*what is the body’s initial response to hypothermia peripheral vasoconstriction (shunts blood from surface)
*what does peripheral vasoconstriction cause and why is it dangerous anaerobic metab and met acidosis (lactic), leads to pulm vasoconstriction >hypoxemia and acidosis, hypoxemia then restricts babies response to cold and >acidosis, same time, nonshiv thermogenesis kicks in > metab of brown fat, <glucose (hypoglycemia)
*what is a neonates initial response to hyperthermia vasodilation of peripheral vessels to allow for dissipation of heat, followed by >metabolism and >O2 consumption
causes of hyperthermia infection, dehydration, broken incubators, radiant warmer, humidifiers, and phototherapy lights-avoid by always monitor pt and environment
*what is the goal of thermoregulation in the delivery room and how is done maintain environmental temp such that neonate core temp stays between 36.5-37.5, prevent evaporation (dry fast), radiant (wrap in warmed blanket and place under radiant light), convective and conductive (warm mattress and prewarmed incubator)
What is the advantage/disadvantage of an open warmer access to the pt, difficult thermal regulation and environmental control
Advantage and disadvantage of incubators advantage is controlled environment for better thermal management, quieter, barrier to handling, disadvantage is pt access
physiologic considerations of high-risk neonate nervous system anatomically immature-chem and physiologic function is primitive, cerebral hemisphere show poor distinction between gray and white matter-neuro function is controlled by brain stem and spinal cord and existing brain function is hyperactive
What are the effects of overstimulation neonate immature or stressed neonates have limited energy and can be exhausted by excessive stimulation-developmental handicaps and morbidity if overstimulation is increased
What is the best way to keep visual and acoustic stimulation from over stimulating a neonate blanket over the incubator
Stimulation of the neonate should be avoided when during sleep, behavioral stress cues or physiologic stress cues are present
What are the behavioral stress cues gaze aversion, facial grimace, hiccoughs and irritability
What are the physiologic stress cues cyanosis, hyperoxemia
what is the best way for practitioner to avoid over stimulating handle only when behavioral and physiologic signs dictate, avoid clustering care giving and procedures to avoid over stimulating, delay or postpone nonemergency procedures
Environment controls to avoid stress in the nicu are low or no light (better SaO2), workers and family avoid loud talking and laughing
Physiological factors in premature neonate skin very permeable (potential for systemic side effects from toxins), diminished cohesion between surface epidermis and underlying dermis, very thin stratum corneum (top layer-main barrier to microorganisms)
What is the best way to dissolve adhesives from baby skin citrus oil, they are nontoxic
Why dont we use spray on skin barriers or traditional adhesive removal when TX preemies permeable skin will allow plastic polymers in skin barrier or solvent from adhesive to absorb through skin
Trancutaneous monitors (TCM) and pulse ox can be place on skin how coban wrap, fabric straps with Velcro
What is the best way to TX baby skin that has been broken or damaged from tape removal IV site dressing, will protect and allow healing and keeping microorganisms out
How is fetal fluid and electrolyte status regulated maternal and fetal mechanisms
Maternal disorders that effect fetal fluid and electrolyte balance diseases that affect uterine perfusion, and IV therapy during labor
Abnormalities in fluid and electrolytes occur with certain neonate disease states they are respiratory disorders, asphyxia, congenital heart disease, hydrops fetalis, sepsis, renal disorders, urinary tract abnormalities, endocrine disorders and <skin integrity
hydrops fetalis massive accumulation of fluid in the fetus or newborn often associated with erythroblastosis fetalis, effusions of the pericardial, pleural and peritoneal spaces also occur
Abnormal loss of fluid in neonates occurs how diarrhea, emesis, nasogastic tube drainage, thoracotomy tube losses, damaged skin and other factors the >insensible water loss
Assessing fluid deficit and estimating amount pt requires hx, physical exam and lab values
Signs of dehydration or hypovelemia on exam are perfusion of skin is decreased, turgur decreased (pinch skin-slow return to normal is decreased), oliguria, dry mucus membranes, sunken fontenelle, sunken eyes, extreme are signs of shock-tachycardia, hypotension, pulse, poor perfusion
Insensible water loss (IWL) evaporation from skin and respiratory tract
Why is turgor in premature neonate difficult to asses? less subcutaneous fat
Factors that increase insensible water loss EGA, resp distress, >temp above neutrothermal zone (36-37.5), > body temp, skin breakdown, congenital skin defect (spina bifida), radiant warmer, phototherapy (>heat), >motor activity or crying (>metabolic rate)
Bilirubin byproduct of normal breakdown of RBC's
Life span of a RBC 120 days
How is bilirubin normally excreted passes through the liver and is excreted as bile through the intestines
*what is jaundice bilirubin builds up faster than a newborns liver can break it down and pass it from the body, caused by immature liver, to much bilirubin to handle, to much bilirubin being reabsorbed from the intestines before the baby gets rid of stool
*how much bilirubin is unsafe and can cause severe complications in baby 20mg
*complications of >20mg of bilirubin deafness, cerebral palsey, brain damage (hepatitis in adults)
*types of jaundice physiological (normal) j, jaundice of prematurity, breast milk j, blood group incompatibility j
*what is a simple test for jaundice press your fingertip to babies nose or forehead, if white no problem, if yellow jaundice is present
*jaundice TX mild to moderate levels will take care of itself by day 5-7, high levels may need phototherapy, increased feedings t help pass bilirubin
*once jaundice is treated and repaired do babies get it again unlikely
*physiological jaundice 50 percent of newborns get it, due to immaturity of liver, appears at 2-4 days and disappears at 1-2 weeks
*jaundice of prematurity occurs frequently in preemies, underdeveloped liver and longer time adjusting to excreting bilirubin effectively
*breast milk jaundice 1-2 percent of breastfeed babies, caused by breast milk and bilirubin rises to >20, prevents excretion, starts at day 4-7 and last 3-10 weeks
*blood group incompatibility jaundice Rh or ABO different from moms, moms antibodies destroy infants RBC's, increasing bilirubin, starts first day of life, preventable with Rh immune globulin to mom
*what is blood group (Rh) incompatibility moms blood Rh neg and fetus is Rh positive, if fetal blood gets into moms blood stream, mom will produce antibodies that could pass back to baby harming babies RBCs, first baby is fine, but subsequent babies will have problems. Can be treated with Rhogam
STABLE sugar, temp, airway, blood pressure, labs, emotion
NEC necrotizing enteroclitis (hot belly), idiopathic disorder characterized by ischemia and necrosis of the intestine, mild has abdominal distention, worst has perforation of intestines-leads to sepsis and death
Risk factors associated with NEC prematurity, asphyxia, and formula feeding
What are the 3 main factors that lead to NEC mucosal wall injury, bacterial invasion into damaged intestinal wall and formula in the intestine
What causes injury to mucosal wall in NEC may be secondary to ischemia and or decreased blood flow to the gut and maternal cocaine use
pneumatosis intestinalis necrosis and the formation of gas in the intestinal wall (can be seen in x-ray), leads to bacteria getting into circulation causing sepsis or perforation of intestine allowing bacteria into abdominal cavity causing profuse peritonitis
Factors that lead to ischemia (in NEC) RDS, apgar <5, abruptio placentae, apnea, hypertonic oral meds, bowel obstruction
Factors that lead to decreased blood flow (in NEC) PDA with R-L shunting, exchange transfusion, umbilical artery catheter (UAC), polycythemia, shock
Human breast milk may enhance gastrointestinal function and has been shown to be protective against what NEC
What is the first confirmatory sign of NEC guaiac-positive stools (blood in stool)
S and S of NEC abdominal distention, bile residuals and bile-tainted emesis (vomit), poor feedings, general signs of sepsis (lethargy and >fio2 requirements)
Best TX for NEC avoiding factors that lead to it
TX for NEC includes avoid factors that lead to it, good hand washing, stop feeding, nasogastic suction-to rid stomach of bile, antibiotics, x-rays to monitor, >fio2, continuous infusion of L-argine
L-arginine substrate of nitric oxide that reduces intestinal injury
Gastrointestinal perforation or full-thickness necrosis requires what surgical resection
What is the first sign of NEC increased abdominal girth
How is NEC confirmed guaiac-positive stools
Active transport movement of molecules across cell membrane via chemical activity, allows for large molecules that would normally be unable to pass
Beta-lactam (penicillin’s and cephalosporin’s) group of antibiotics that inhibit bacterial cell wall synthesis
Dyscrasias abnormal blood or bone marrow condition like aplastic anemia or Rh incompatibility
Extravasation a passage of blood, serum or lymph into the interstitial spaces of the tissue
Facilitated diffusion movement of ions or molecules through the cell membrane by the interaction with a carrier protein that aids its passage, done by binding chemically and shuttling it through the membrane
Hydrolysis the chemical alteration or decomposition of a compound with water
Ototoxic refers to a substance having a harmful effect on the eighth cranial nerve, or on the organs of hearing and balance
Pharmacokinetic study of all aspects of drug use on the body, routes of absorption and excretion, duration of action and biotransformation
Pheochromocytoma chronic hypertension caused by a vascular tumor of the adrenal medulla or sympathetic paraganglia, characterized by hypersecretion of epinephrine and norepinephrine
Pseudocholinesterase a nonspecific cholinesterase that hydrolyses noncholine esters as well as acetylcholine
Reduction the addition of hydrogen to a substance, the removal of oxygen from a substance, or a decrease in the valence of the electronegative part of a compound
Simple diffusion the movement of fluids or particles from an area of higher concentration to an area of lower concentration through a semi permeable membrane following Brownian movement
*teratogen any substance or agent that interferes with normal fetal development and causes one or more developmental abnormalities in the fetus
Ultrafiltration the act of filtering large molecules from small molecules by creating a pressure gradient across a filter containing small pores
Fetal concentrations of drugs can reach what level compared to maternal blood 50-100% higher
Why are fetal concentrations so much higher than maternal concentrations fetal liver immaturity
Mechanisms drugs use to cross the placenta are ultrafiltration, simple diffusion, facilitated diffusion, active transport and breaks in placental villi
Drug transfer across the placenta is determined by what concentration difference (across placenta), lipid solubility, degree of ionization of the drug, molecular weight of drug
*drugs that cause physical and/or mental developmental abnormalities in the embryo or fetus are called teratogens or teratogenic substances
*teratogens may cause what spontaneous abortions, congenital malformations, intrauterine growth retardation, mental retardation and carcinogenesis
*effects of teratogens are dependant on what factors dose of drug that reaches embryo, length of exposure, gestational age (at time of exposure) and other drugs mother is taking at the time
Drug absorption in the gastrointestinal tract is regulated by what pH-dependent diffusion and gastric empting time
*for a term neonate, gastric pH at birth is what 6-8, but falls to 1-3 in the first 24 hours (not low in preemies-immature acid secreting mechanism), pH returns to neutral and no more acid produced for 10-15 days after birth
*when is normal adult GI acidity reached 2 years of age
*the difference in pH of stomach for neonate may affect what normal absorption of both basic and acidic drugs like penicillin’s, Phenobarbital and phenytoin
*what is gastric emptying time in the newborn 6-8hrs, does not reach adult values until 6 months
Peristalsis digestion
Low muscle mass in neonate causes what to intramuscular absorption rates of drugs absorbs very fast
Why is absorption of drugs through the skin of newborns greatly increased newborns generally have thin, well hydrated skin which allows for increased permeability and enhanced absorption
Why is the neonate respiratory tract considered ideally suited for absorption of drugs combination of extensive vascularization, large surface area and thin tissue separating the airway lumen and vascular
What is the benefit of IV admin of drugs in neonates bypasses all of the unpredictability of other methods and complications of drug absorption, allowing for more accurately calculating doses
Lipid-soluble drugs that readily cross cell membranes are distributed where in the body throughout all fluid areas, very rapidly into the heart, brain, liver, kidneys and other highly vascularized tissues (more slow into muscles and fat cells)
Highly lipid-soluble drugs have increased chance of side effects where to highly vascularized tissue like the heart, brain liver kidney etc
Less lipid-soluble drugs and do not readily cross cell membranes can do what gather in tissues at higher concentrations than in plasma
Often more than 90% of a lipid-soluble drug will be bound to plasma proteins, what effect does this have leaves only 10% unbound or freely available to cross cell membranes and exhibit maximal pharmacologic activity
What is unconjugated bilirubin jaundice
What is drug metabolism changing or alteration of a drug to a different form, either active or inactive
Where is the primary site of drug metabolism liver (but also in plasma, kidney and GI tract)
What are the 4 types of drug metabolism that take place in the liver conjugation, oxidation, reduction, hydrolysis
Immaturity of preemie decreases drug metabolism how because all 4 metabolism functions are decreased, half life of drug or drugs is increased
Half-life amount of time required to reduce a drug level to ½ initial value
Drugs like Phenobarbital have what kind of effect on metabolism of drug in neonates and preemies increase enzymatic activity in the liver-causing mediation of metabolism-dosages of other drugs will need to be reevaluated if pt is taking it
Why is drug excretion the most important factor in the termination of a drugs effects in preemie and neonate because most drugs are poorly metabolized by premature liver
What is the primary route of elimination of drugs kidneys (also biliary and fecal excretion, sweat and saliva)
How is renal function measured creatinine clearance
*GFR glomerular filtration rate
*what effect does GFR have on some drugs because of immaturity of kidneys, drugs like diuretics may have to be increase due to <GFR.
*What kinds of drugs are dependent on GFR drugs that are not extensively metabolized and are primarily excreted through the kidneys, doc will give drug and see how it works, then adjust
*antibiotic groups are penicillin’s, cephalosporin’s, aminoglycosides, macrolides, quinolones, tetracyclines, sulfonamides, antifungals and antivirals
*what kind of antibiotic is penicillin beta-lactam, kills bacteria by penetrating outer membrane of bacteria through small canals (porins)
*penicillinase aka beta-lactamase enzyme produced by some bacteria in attempt to survive, inactivates beta-lactam drugs (especially staphylococcus)
*penicillinase-resistant penicillin’s a group of penicillin drugs that are resistant to penicillinase enzyme and are effective against staphylococcus (MRSA)
*what is another name for antiviral drugs chain terminators
*ribavirin broad-spectrum antiviral specifically used in neonates for bronchiolitis caused by RSV
Because of teratogencity with exposure to ribavirin, what precautions does RT need to take delivery with SPAG 2 unit, shut off remotely, deliver only in isolation room with negative pressure and adequate air exchange to outside
Adenosine indications acute TX of sustained SVT (supraventricular tachycardia)
Adverse effects of adenosine flushing irritability and dyspnea
*epinephrine indications resuscitation for TX of acute cardiovascular collapse, subcutaneously for acute bronchospasm
*digoxin aka Lanoxin indication for neonates CHF
*Indomethacin sodium trihydrate aka Indocin hemodynamically significant PDA (indicated by resp distress, continuous murmur, hyperactive precordium, cardiomegaly
Dopamine/Intropin indications correction of hemodynamic imbalances from shock syndrome due to < cardiac function in CHF, trauma, endotoxic septicemia, renal failure and myocardial infarction
*caffeine citrate and theophylline indications TX and management of neonatal apnea, and acute or chronic bronchospasm
*fentanyl citrate used to produce analgesia, sedation and anesthesia during invasive procedures like bronchoscopy
Calcaneus heel bone
TPN aka total parenteral nutrition aka hyperalimentation admin of nutritionally adequate hypertonic solution consisting of glucose, protein hydrolysates, minerals and vitamins through an indwelling catheter, usually in the superior vena cava
Spectrophotometric infrared analysis measurement of different species of hemoglobin in a blood sample by determining the amount of infrared light absorbed
*when is an ABG given to a neonate better to get to many than not enough, some may require every 20 mins, some every 2 weeks, each is different
*what are the 4 rules that apply in determining when a neonate gets a ABG drawn 1) signs of resp distress, 2) vitals, appearance or condition has changed for no apparent reason 3) 15-30 mins after any change in vent or FIO2 4) on a regular basis for vent pt to insure stable and helps document transcutaneous and pulse ox readings
*neonate ABG sites umbilical, radial, brachial (capillary too, but reflects mixed venous blood so PaO2 not accurate)
*why do we not want to take an ABG with baby crying and fussing drastically changes results, especially CO2
Transillumination light placed under wrist of neonate helps locate artery
*UAC umbilical artery catheter, is the preferred site for obtaining ABG because there is no pain for baby
*How is a suspected PDA verified right radial sample is drawn at the same time as UAC
*what is an easy (non-invasive way to detect a PDA place a trancutaneous monitor on the upper right chest, and another on the abdomen, a higher PaO2 in the upper right compared to the abdomen would indicate a right-to-left shunt, relative uniformity would rule out a ductal shunt (PDA)
*why do we use caution when increasing FIO2 in the presence of a PDA and low arterial PaO2 because arterial blood that supplies the head is before the shunt (picture page 262), so increasing FIO2 can lead to dangerous PaO2 levels in the brain (ROP)
*problems associated with UAC only used for 3-4 weeks because of clotting and infections, PaO2 may be low if PDA present
What is a good alternative to UAC RAC, radial artery catheter
Why is RAC a good source for ABG preductal flow
Hazards of RAC infection, air emboli, arterial occlusion, infiltration of fluids, nerve damage
Why are arterial punctures so difficult in neonates very small arteries, pain can lead to misleading results
What are the primary complications of an arterial puncture in neonates infection, bleeding, nerve damage, embolism, hematoma
*what are capillary samples used for assessing pH and PaCo2, but not PaO2 because they have mixed venous blood (PaO2 monitoring with pulse ox or transcutaneous monitoring)
*why are capillary samples used less hazardous to pt and more easily obtained than arterial sample
*contraindications of capillary sample posterior curvature of heel, callus developing on heel, fingers of neonates, previous puncture sites, inflamed, swollen or edematous tissue, localized infection
*capillary stick procedure heat heel to 45C for 4-7 mins (no exceptions), ready equipment, wipe, puncture, avoid arteries
*complications of capillary samples puncture of calcaneous bone (leads to osteomylitis or bone spurs), infections, burns, tibial artery laceration, pain, bleeding, hematoma, nerve damage, bruising, scarring
*PaO2 norm for a neonate is 50-70 mmHg
*PaCO2 norm for a neonate is 35-45 mmHg
What is PaCo2 it defines the adequacy of alveolar ventilation, the byproduct of aerobic metabolism that is excreted by the lungs, >45 is indication of hypoventilation and >60 is indication of respiratory failure
*Normal neonate pH 7.35-7.45 (7.30 to 7.50 is considered acceptable)
What are the disease states that most commonly cause respiratory acidosis in neonates BPD, meconium aspiration, and transient tachypnea of newborn TTN, maternal anesthesia or any other disorder that leads to hypoventilation
What are disease states that most commonly cause respiratory alkalosis in neonates mismanagement of ventilator rates or volumes, RDS, stimulation of CNS, hypoxia induced hyperventilation
What are the disease states that most commonly cause metabolic acidosis in neonates hypoxemia with resulting lactic acidosis, starvation, hyperalimentation, renal tubular acidosis (immature kidney cant excrete acid or reabsorb bicarb), and diarrhea (loss of bicarb)
What are disease states that most often cause metabolic alkalosis in neonates excessive loss of H+ from GI tract or kidneys or by addition of bicarb to blood. Gastric suctioning, vomiting, to much diuretics without potassium replacement
HCO3 norm for neonate is 22-26
Normal BE for neonates + or – 4
how do TCM's work Clark electrodes (same as blood gas monitor) heat the stratum corneum allowing faster diffusion of O2 through the skin, although it reads slightly lower than arterial blood gas, it is best used as a trending source
*what is a PDA patent ductus arteriosus, ductus arteriosus fails to close after birth, R-L shunt
S and S of PDA more fluid in lungs, trouble breathing, >need for vent support and O2, frequent chest infections, difficult digesting food, low BP (>risk of chronic lung disease, slow growth and motor development) TX is drug therapy or surgery to close
Fetal scalp Ph indicated to assess degree of fetal hypoxia
Normal scalp pH 7.25-7.35
*how much blood does a small preemie have can be as low as 100cc
How does RT know TCM will work check against ABG, if it closely parallels then it can easily be used
why does TCM use heat 3 reasons, heat changes lipid structure of stratum corneum allowing faster diffusion through skin, heating tissue and blood causes O2 curve to shift right enhancing O2 release from RBC, heat causes vasodilation of capillaries and arterilization of blood
Why are TCM PaO2 levels lower than ABG PaO2 levels because TMC measures tissue O2 too
What is the clinical use of TMC trending of PaO2 in neonate
what is the most important limitation of TCM cannot be used without periodic correlation of ABG, also may underestimate hyperoxemia, inappropriate temp adversely affects TCM, hemodynamic status, bad site choice on infant, underestimate lung disease pt, blistering
How often should TCM site be changed every 2-3 hours to prevent burns
Complications and hazards of TCM burns, erthema (red skin) for hrs or days, blistering, adhesive can cause epidermal stripping (use coban or Velcro), never use alone-always correlate with ABG
Capnography aka capnometry measures exhaled CO2 with spectrophotometric infrared analysis
What are the 2 types of capnography side stream and mainstream
Side stream capnography removes a continuous sample through small tube and carries it to analysis chamber-light weight
what is downside of side stream capnography sample must pass through tubing and water trap to reach sample chamber so less responsive to high RR, in neonate excessive samples leads to < delivered VT
Mainstream capnography chamber right at airway, heated with small wire to prevent condensation (reduces errors), gives current readings (unlike side stream), much more accurate than side stream, but not used much because very bulky and heavy
What is the downside to mainstream capnography bulky and heavy may cause accidental extubation, chamber causes increased deadspace
IUGR intra uterine growth retard
*Tolazoline aka Priscoline indications TX of persistent pulm hypertension of newborn, use when PaO2 cannot be maintained with FIO2 and or mech vent
Created by: williamwallace