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chp 6-8 & 15

Core temp maintained at 37 degrees
Brown fat cells appear around 26 to 30 weeks
Where is brown fat stored? Around great vessels, kidneys, scapula, axilla & nape of neck
Term for when brown fat is broken down to produce heat Nonshivering thermogenesis
What is ITG? What does it mean? Internal Thermal Gradient = temp difference between body core and skin
How does ITG heat travel thru body? from warmer internal structures to cooler skin
What factors effect ITG? metabolic rate, fat present, surface area, distance from body core to skin
What is ETG? What does it mean? External Thermal Gradient = Temp difference between skin and environment
How does ETG heat travel thru body? from skin to the cooler environment
What are the four factors effecting ETG? Radiant heat loss, conduction, convection & evaporation
What are four types of heat loss? Radiant, conduction, convection, & evaporation
Radiant heat loss loss of heat from neonate to cooler objects surrounding it, but not in direct contact of
Conduction transfer of heat from skin to cooler surface in contact with neonate
Convection loss of heat from skin to air current passing over neonate
Evaporation release of heat due to water changing from liquid to gas
Evaporation - insensible from skin and respiratory tract
Evaporation - sensible from sweating from skin
Hypothermia peripheral vasoconstriction shunting blood away from skin
Results of hypothermia hypoxemia and acidosis due to anaerobic metabolism
What does hypothermia trigger? Nonshivering thermogenesis which results in hypoglycemia
Hyperthermia peripheral vasodilation to help release heat
Results of hyperthermia increases metabolism and O2 consumption
What are causes of hyperthermia? Infection, dehydration. Also malfunctioning incubators, radiant warmers, humidifiers, and phototherapy (equipment malfunction)
Thermoregulation in delivery room Prevention of Evaporative heat loss, radiant heat loss, and convective & conductive heat loss
Prevention of Evaporative heat loss at delivery Completely dry neonate with pre-warmed blanket/towel; most important head and face
Prevention of Radiant heat loss at delivery Place under warmer, wrap in warm blanket, place cap on head
Prevention of convective & conductive heat loss at delivery Keep neonate covered, small preemies placed on warming mattress and prewarmed incubators
Thermoregulation in Nursery Incubators and Open warmers
Incubators Adv = controlled thermal environment; temp reg by servo-control, skin temp increases/decreases heat in incubator, skin probe secured to skin
Open Warmers Adv = access to pt; Keep wrapped up, use shields and plastic sheets, don't place on cold surface
Behavioral based care times pt stimulation based on sleep/wake state, activity level, approachability, and O2 status
Sleep/Wake state Only stimulate when baby is awake
Risk Factors for Neonate for Upper Airway Occlusion Tongue large, lymphoid tissue in pharynx, epiglottis large, trachea small and/or short, swelling, & diaphragmatic breathing
3 factors for low reserve heart enlarged, no stability of ribs/sternum, large abdominal contents cause diaphragm not to flatten
Obstetrical history needed Gravida - #of pregnancies, Para - # of deliveries, Previous pregnancies ie: high/low risks & previous premies
PARA stands for P=total prior preg, A=Total premature dlvrs, R=total abortions/miscarriages, A=Total live births
Prenatal & intrapartum history needed Length of stages, fetal pres, Vaginal vs. C-section, Fetal hr, anesthetic or tocolytic used, NST or ST, PROM b4 37 wks, maternal steroids, placenta problems
Used for Gestational Age Naegele's Rule, Dubowitz, Ballard Score, Fetal ultrasound
Naegele's Rule Subtract 3 months + 7 days from 1st day of last menstrual cycle
Dubowitz (Objective & reproducible)11 physical and 10 neurological findings; higher score = longer gestation; score of 40= 40 weeks
Ballard score Uses 6 physical and 6 neurological findings
Fetal ultrasound Age determined by measurement of fetal head or femur diameter
Classifications of neonate AGA, SGA, LGA
AGA Average for gestational age
SGA Small for gestational age
LGA Large for gestational age
Quiet Examination Visual observances of color, skin, activity, inspect, and respirations
QE Color Central cyanosis, acrocyanosis, or jaundice
QE Skin Edema, diaphoresis, and/or flushing
QE Activity Anxiety & irritable - suggests hypoxia / increased RR; ↓SpO2 during handling - suggests intolerance or cardiac anomaly
QE Inspect chest deformity, abnormality, asymmetry
QE Respirations look for 3 cardinal signs of Resp distress; nasal flaring, grunting, and retractions
Cardinal signs of Respiratory Distress Silverman-Anderson scoring, retractions, nasal flaring & grunting
Silverman-Anderson scoring system Pic chart used to grade severity of retractions & grunting
Retractions (3 types) Substernal/subcostal (center)= lung disease, Intercostal (sides) = heart disease, Intrasternal/Marked substernal (center) = ETT obstruction
Nasal flaring an attempt to get airway dilation to ↓ airway resistance and ↑ gas flow and volume
Grunting sound used at end expiration to ↑ lung volume
Hands-on exam vital signs, chest, and abdomen
HOE Chest Look for asymmetry and auscultate for murmurs
HOE Abdomen Distended, Scaphoid, Omphalocele, Gastroschisis
Distended abdomen Marked inflation of abdomen = suggests over-ventilation or fluid
Scaphoid abdomen hollow concave abdomen (guts in chest) -- bowel sounds in chest which suggests diaphragmatic hernia
Omphalocele protruding intestines covered with membrane
gastroschiss protruding intestines not covered with membrane
Vital signs should include RR, apnea exam, pulse, temp, SpO2, BP
Normal RR 30 to 60 bpm
Apnea absence of breathing > 20 secs; due to aspiration, asphyxia, maternal drug use
Normal Pulse 100 to 160 bpm; Evaluate both brachial and femoral; if bounding = suspect cardiac anomaly; poor pulse = suspect coarctation of aorta
Normal temp 36-37 degrees
SpO2 84-94%
BP 50/30 for 1,000g, 60/35 for 2,000g, 65/40 for 3,000g
Pulse < 100 bradycardia; caused by hypoxia, heart disease, valsalva maneuver, drugs
Pulse > 200 tachycardia; caused by hyperthermia, heart disease, pain, crying, drugs
Pre-ductal ABG from R arm; if PaO2 more than 15 mm Hg> than Postductal = right to left shunt; suspect PDA or congenital heart defect
Post-ductal ABG from UAC; If PaO2 on pre-ductal is more than 15 > than postductal = right to left shunt; suspect PDA or CGD
Na+ for term 130 - 150
Cl- for term 87-114
K+ for term 5-6
HCO3 20-24
WBC's 7,000 -14,000
Urine output 2cc/kg per hour
BUN 4 - 17
Creatinine .11 - .68 g per 24 hr
Glucose 55-115 mg/dl; Hyperglycemia > 160 = septicemia, cord compression, stress ; Hypoglycemia < 40 = infection, SGA, IDM, cold stress
Bilirubin Term = < 6 @ 0-1 day old Preemie = <8 Hyperbilirubinemia is due to Rh and ABO blood incompatibility
ABG Norm for Neonate Ph=7.34-7.35, PCO2=26-40, PO2=50-70, HCO3=17-23, BE=+/- 2 to -10
ABG Norm for Infant Ph=7.34-7.46, PCO2=30-45, PO2=85-100. HCO3=20-28, BE=+/-2 to -4
Asymmetrical chest movement may be due to Pneumothorax, atlectasis, Improper ETT, pneumonia, diaphragmatic hernia or paralysis, phrenic nerve palsy
transillumination of chest bright fiber optic light; normal=forms a "halo"; abnormal=entire hemithorax lights up b/c of free air
indications for transillumination asymmetrical chest w/resp distress, ↓ breath sounds, and/or absent heart sounds, with trachea or mediastinum shift away
Neonatal reflex tests rooting, suck, grasp, moro
rooting reflex stroke corner of mouth, baby should turn that direction
Suck reflex place finger in mouth and baby should suck immediately
Grasp reflex place index finger in palm, baby should grasp; place thumb over fingers and should be able to pull baby towards sitting position
Moro reflex slowly lie baby back down (after grasp) and just b4 head touches, remove fingers. Baby should extend arms up and out
Physical exam to determine preterm baby Vernix=thick & all over, skin=thin, transparent, nails=short, sole=few creases, ears=flat, soft, little cartilage
Physical exam to determine term baby Vernix=very little, skin=pale, few visible vessels, nails=normal, sole=creases over 2/3, ears=firm, recoil easy
Physical exam to determine post-term baby No Vernix, Skin=thick, soft, may crack/peel, nails=long, sole=creases on entire sole, ears=firm, recoil easily
Acrocyanosis Arms and legs are blue but core is pink
acyanotic pink all over
cyanotic blue; worse condition--more critical immediately
4 Acyanotic CHD's that ↑ pulmonary blood flow ASD, VSD, AVCD, and PDA
ASD Atrial Septal Defect = L to R shunt thru opening in atrial septum; causes extra blood R heart; ↑ pulm BF (CHF); give lasix for CHF & perform surgical repair
VSD Ventricular Septal Defect = L to R shunt thru opening in vent septum; causes extra blood R heart, ↑ pulm BF(CHF); give lasix for CHF & do surgical repair
AVCD or AVC Atrioventricular Canal Defect = L to R shunt thru ASD, VSD; deformed mitral & tricuspid; causes CHF; give lasix & do surgery
PDA Patent Ductus Arteriosus = common in premies, more common in males, failure of ductus arteriosus to close; L to R shunt into pulm arts; ↑ pulm BF (CHF); give indocin and perform PDA ligation surgery
2 Acyanotic CHD's with NORMAL blood flow coarctation of the aorta and aortic stenosis "all systemic"
Coarctation of the Aorta Severe narrowing of aortic lumen; PDA present-keep open; give PGE to ↓ PVR due to extrapulm BF; Good pulse upper, weak pulse lower; perform surgery
Aortic Stenosis Narrowing of aorta causes blood backup into lungs; no shunts; give lasix for CHF; give PGE to vasodilate; perform surgery
Common Cyanotic CHD's with ↑ pulmonary blood flow TGA, Tricuspid Atresia, truncus arteriosus, TAPVR
TGA Transposition of the Great Arteries = BF from R vent to aorta, & L vent to pulm arts; has PDA & ASD and/or VSD for mixing; Give PGE until surgery
Tricuspid Atresia Tricuspid valve not developed, no entry to R vent from R atrium. ASD & VSD must be present to survive. Blood shunts from R to L thru ASD then from L vent thru VSD to pulm system
Truncus Arteriosus The two great vessels (pulm & aorta) are formed into one vessel. Blood shunts from L to R if VSD present
TAPVR Total Anomalous Pulmonary Venous Return = Pulm veins dump blood from lungs into R atrium, IVC or SVC. ASD must be present.
Common Cyanotic CHD's with ↓ pulm blood flow Tetralogy of Fallot = TET or TOF
Tetralogy of Fallot 4 heart defects=overriding aorta, pulm art stenosis, VSD, & R vent hypertrophy; poss ASD; Cyanosis w/crying & feeding; ↑ PVR and ↓ pulm BF causing R to L shunt; perform surgery
Increased O2 ↓ PVR = ↑ Pulm BF
Decreased O2 ↑ PVR = ↓ pulm BF
Increased CO2 (Hypoventilation) ↑ PVR = ↓ pulm BF = ↑ CBF (cerebral)
Decreased CO2 (Hyperventilation) ↓ PVR = ↑ pulm BF = ↓ CBF (cerebral)
Nitric Oxide (NO) vasodialates and ↓ PVR (doesn't systemically vasodilate due to short half life)
Prostaglandin (PGE) vasodilates and ↓ PVR
Viagra vasodilates and ↓ PVR
Ribavarin Used for RSV & dlvd via SPAG
Atropine used for brady; dosage .01-.03 mg/kg IV over 1 min
epinephrine used for brady & hypotension; dosage .1-.3 ml/kg
digoxin used for CHF; dosage 20-30 mcg/kg IV
indocin used to close PDA; dosage .1-.2 mg/kg IV given 12 hrs
prostaglandin maintain PDA until surgery; dosage .1 mcg/kg/min UAC
dopamine ++ CO; dosage 2-20 mcg/kg/min IV
tolazoline treats PPHN that is refractory O2 and vent; dosage 1-2 mg/kg/hr
lasix used for fluid overload, symptomatic PDA & PPHN; dosage 1 mg/kg then 2 mg/kg > 2hrs
aldactone for BPD & CHF; dosage 1-3 mg/kg/24hr PO
Corticosteroids for BPD & asthma; also given to Mom in premature labor to induce fetal lung maturity
types of steroids given by MDI beclomethasone (Vanceril), aerobid, dexamethasone, azmicort
Primary steroid given to Neonate for BPD & edema Dexamethasone (decadron); dosage .2-.5 mg/kg IV loading dose, then .1-.4 mg/kg/day IV
Cromolyn Sodium (Intal) prevent the release of asthma mediators; dosage DPI 20 mg
Theophylline or Caffeine to treat neonatal apnea, acute & chronic bronchospasm
Nitric Oxide (NO) treats PPHN
Artificial surfactant Prophylactically for infants <1350g at birth; and for infants >1350g with lung immaturity
types of surfactant Exosurf, survanta, infasurf
RDS aka hyaline membrane disease=scar-like tissue replaces normal alveolar tissue; usually at birth or soon after
Signs/Symptoms RDS RR>60, grunting, retractions, nasal flaring, cyanosis, severe edema, flaccid muscles, hypoactivity
CXR RDS ground glass appearance
Death RDS >72 hrs is usually due to 2 degree complications
Treatment RDS prevention, surfactant, low pressures, FiO2 to maintain PaO2 50-80, PCO2 <60 & Ph >7.25; diuretics for edema, monitoring
Complications RDS ICH, Pulm air leaks, DIC, infection and PDA
BPD bronchopulmonary dysplasia
BPD causes O2 toxicity, barotrauma, PDA, and fluid overload
BPD CXR ground glass & blood gas shows chronic lung disease
BPD treatment Prevention, ventilation, resp therapy, Fluid therapy, digoxin, nutrition, and vitamin E
Pulmonary Dysmaturity aka Wilson-Mikity Syn; neonates <1500 g at birth
PD CXR increased density and cysts, but pt not ventilated
Signs/Symptoms PD hyperpnea, transient cyanosis, retractions, severe resp distress, poor feeding, and vomiting
Treatment PD mech vent for apnea & progressive hypercarbia, O2 for hypoxemia; once pt ventilated, treat as BPD
ROP Retinopathy of Prematurity; formation of scar behind lens of eye caused by high PaO2
Contributing factors to ROP immaturity, hypoxia, IVH, apnea, infection, hypercarbia, PDA, Vit E def, lactic acid, bright lights, early intubation, hypotension, & NEC
Treatment ROP cryotherapy or laser therapy, vitrectomy, lensectomy, prevention
ICH/IVH Intracranial or intraventricular hemorrhage; bleeding in cranium
Subdural or subarachnoid bleeds more common in term neonates following birth trauma
Cerebellar tissue bleeds common in preterm between 24-32 weeks and/or <1500g
Choroid plexus most common area neonates bleed
diagnosis of ICH/IVH Ct scan or ultrasound
treatment ICH/IVH prevention, avoid wide fluxes in BP, O2, and pH
Complications ICH/IVH PHH caused by blocked CSF flow treated by removing CSF via lumbar puncture
6 types of Pulmonary Air Leaks (PAL) Pneumothorax, pneumomediastinum, pneumopericardium, PIE (Pulm interstitial Emphysema), Pulmonary air embolism, subcutaneous emphysema
PAL Pnuemothorax Most common, occurs when extra-alveolar air ruptures to external surface of lung into pleural space; must do thoracentesis or chest tube
PAL Pneumomediastinum Occurs when extra-alveolar air dissects thru lung interstitium and ruptures into mediastinum; need lower ventilatory pressures
PAL Pneumopericardium Occurs when air enters the pericardial sac; it compresses the heart impeding CO; must have needle aspiration
PAL PIE Pulm interstitial emphysema=air dissects thruout interstitial tissue of lungs caused by chronic high peep/pip; need lower vent pressures & high frequency vent
PAL Pulmonary air embolism Extremely rare; caused by high pressures used to vent stiff lungs; air enters the pulm vasculature; no effective treatment
Subcutaneous emphysema 2 degrees to other air leaks; occurs when air enters subcutaneous spaces; must fix primary air leak
PPHN Persistent Pulm Hypertension in Newborn; unknown cause; causes persistent pulm vasoconstriction ↑ ptressures & ↓ pulm BF causing persistence in fetal circulation
TTN Transient Tachypnea in Newborn
NEC Idiopathic disorder characterized by ischemia and necrosis of intestine; risk factors are prematurity, asphyxia, & formula feeding
3 main causes of NEC mucosal wall injury, bacterial invasion into damaged intestinal wall, and formula in the intestine
signs/symptoms NEC guaiac-positive stools, bile in emesis, poorly tolerated feedings, lethargy, ↑ FiO2 needs
Pulmonary Anomalies Tracheoesophageal anomalies, choanal atresia, diaphragmatic hernia, Pierre-Robin Syn aka Micrognathia
Respiratory Care for Cardiac defect ↓ BF Tetralogy of Fallot, tricuspid atresia; causes lung compliance to increase; use low pressures & increased frequencies
Respiratory Care for Cardiac defect ↑ BF VSD, PDA, Coarctation of Aorta; causes lung compliance to ↓; use higher pressures & Peep to maintain adequate V/Q ratio
Infections causes of persistent perinatal illness Bacteria, Virus, Protazoa
Treatment of persistent perinatal illness Isolation, Identify antigen, aseptic technique, fetal immunity
Five classes of fetal immunity IgA, IgD, IgE, IgG, IgM
IgA immunity Found in tears, saliva, bronchial & intestinal secretions, breast milk; Breast fed neos get IgA from breast milk
IgD immunity Found in serum tissue, unknown role, increases in presence of allergic reactions to milk, penicillin, insulin, & toxins
IgE immunity Found in lungs, skin, & cells of mucous membranes; provides primary defense against environment
IgG immunity only one thru placenta; protects neo up to 1st 3 months for any immunity Mother has
IgM immunity Produced by fetus @ 30 wks; used to test for infection; unreliable for early detection
Goals of mechanical ventilation normalize ABG's, prevent iatrogenic complications, support pts respiratory needs
Neonatal Ventilation Normally time cycled/pressure limited
Pediatric Ventilation Normally Volume cycled
Initial PIP set to achieve good chest excursion
Excessive PIP causes hyperinflation, barotrauma; ie: pneumo's, & BPD)
When you increase PIP ↑ PIP, ↑ PaO2 & ↓ PaCO2, by ↑ Ve, also ↑ MAP; doesn't affect I:E or I-time
PEEP highest for neos 6-8 cm H2O; prevents alveoli collapse and ↑ FRC; Improves Oxygenation & compliance; ↑ PEEP ↓ Vt
Frequency (Rate) on mech vent RR directly affects Ve, PaCO2, MAP (Paw); ↑RR = ↑Ve; ↑RR = ↓PaCO2; ↑RR = ↑ Paw (MAP)
Inspiratory Time on mech vent Itime directly affects MAP (Paw), Plateau press, intrapleural press; ↑Itime=↑MAP; ↑Itime=affect hemo press & venous return
MAP or Paw on mech vent Average press in airways; Most powerful influence on O2, as ↑MAP=↑PaO2; MAP adjusts by changing PEEP, PIP, Itime, RR, Flow; MAP<14cm H2O; ↓etime=↑Paw (MAP)
Tidal Volume on mech vent In time cycled/pressure limited Vt not set; Vt directly affected by PIP & PEEP; ↑ PIP & not PEEP= ↑Vt; ↑PEEP & not PIP=↓Vt; ↑PIP & PEEP=↑Vt
Inspiratory flow rate amt of speed to dlvr Vt; Directly affects MAP; ↑flows=↑vent & reverse atelectasis
Opening and driving pressures amt of press to keep alveoli open; "recruitment maneuver"=high level PEEP moving down to normal in short time
Driving Pressure Difference between PIP and PEEP
Indications for Neonatal ventilation Apnea, ICH, Drugs, to Normalize pH; pH<7.20, PaCO2>60, PaO2 <50 ever with O2, SaO2 <88% even with O2
Phase I ventilation Putting baby on ventilation
Phase II ventilation Monitoring baby on vent
Phase III ventilation Weaning baby off vent
Indications for Pediatric Ventilation Neuromuscular, Pulmonary disease, Post-resuscitation, ventilatory failure = pH <7.30, PaCO2 >50, PaO2 <70 w/O2
Initial vent settings Peds Vt 6 to 8 ml/kg; RR 12-20; Ve primary factory controlling PaCO2; If PaCO2 ↓, can ↓ RR or Vt
Modes of vent SIMV prefered over AC; PCV recommended when pt needs FiO2 > 60 & PEEP > 15, PIP >50, has RDS; often with inverse I:E
4 ways to assess Oxygenation and ventilation ABG, Transcutaneous monitor, Pulse Ox, Capnography
ABG Analysis -- when do you get it? Neo in resp distress, neo clinically changed for no reason, within 15-30 mins of changing vent settings, & per MD orders
Where do obtain ABG sample? UAC, Arterial line, Arterial puncture, capillary puncture; UAC is preferred method
UAC Samples Most preferred; can be compared to R radial ABG to see if PDA; disadvantage=UAC's only in place 3-4 wks
R arterial sample Vs. UAC sample R arterial is pre-ductal; UAC is post-ductal. If R artery is higher than UAC, R to L shunt is present
Radial Arterial Line Sample Catheter in radial artery; reflects pre-ductal flow which ais in minimizing risks of IVH & ROP
Arterial Puncture Sample Difficult to obtain; these are done blindly; not suggested unless no UAC
Capillary Puncture sample Used prim after UAC gone; not reliable for PaO2; Must warm heel to puncture
ABG Values PaO2 Neo = 50-70 ; ped = 85-100
ABG Values PaCO2 Neo / Ped = 35-45 ; if chronic=<60 ok
ABG Values pH Safe = 7.35-7.45; Acceptable = 7.25-7.50 for acute/chronic
ABG Values BE Neo / Ped = +/- 4
Alveolar Ventilation determined by Ve - Vd (Min vent - deadspace volume
Acidosis may result because of CO2 retention, Excessive H+ ions, removal of HCO3
Alkalosis may result because of Removal of CO2, Excessive loss of H+ ions, addition of HCO3
Transcutaneous using Clark noninvasively monitor O2, must changed frequently, PtcO2 can be lower than PaO2 by 2-3. ↓PtcO2 w/ N PaO2 = circulatory failure; ↓PtcO2 w/↓PaO2 = respiratory failure
Transcutaneous using Servinghaus PtcCO2 levels closely relate to PaCO2 levels, non invasively monitoring CO2 levels
Pulse Ox Neo = around foot or palm; Ped = toe, finger, ear; SpO2 withing 2-3 of SaO2; preemie alarms set 85-95
Capnography Noninvasive for CO2; determines end tidal PaCO2 (PetCO2); placed on ET tube or catheter in nose; trends are important with this, however inaccurate with severe resp distress
Created by: Beccaboop
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