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