Presented To

Department of Nursing

March 5, 2008

Carol Burke, APN

Evidenced Based PracticeNeonatal Hypoglycemia

Teamwork pays off with

hypoglycemia protocol!

admissions from 116 to 35 to NICU related to hypoglycemia in 1 month!•Moms and babies stay together•Better glucose control for babies

Identification of babies at risk

Assistance with feeding

Compliance to protocol from 19% to 85%

Keep up the excellent work

Recognizing quality patient care and nursing excellence,

the ultimate benchmark patients can expect to receive

Evidenced Based Practice

• A problem-solving approach utilizing the current best evidence in making decisions about patient care.

• Evaluate and revise current nursing practice based on research and expert opinion and standards of practice.

Hey, you could have shared some glucose

Glucose Stabilization

Continuous supply of maternal glucose via placenta

Mean glucose readingMean glucose reading

IDM can be a very low IDM can be a very low glucose readingglucose reading

Glucose Stabilization after Birth

0

20

40

60

80

100

120

Glucosevalue

Hours of age

Reserves needed in immediate neonatal period when transfer of glucose is abruptly stopped

Normal newborn Glucose at PWH is

> 55mg/dL

Glucometer accuracy

+10mg/dL+10mg/dL

55

45

75% of the time, the glucometer

overestimatesblood glucose

May be

Neonates “at risk” for hypoglycemia

Too much Too much insulininsulin

Too much insulin?

IDM & LGA

Too few reserves

Too few reserves?Preterm

SGA, IUGR

Too muchdemand

Too much demand?

Resuscitation, HypothermiaTachypnea

Sepsis

Can we do anything

to minimize the drop

in glucose?

Keeping baby warm and early feeding will minimize the decrease in blood sugarwill minimize the decrease in blood sugar

0

20

40

60

80

100

120

Originalglucosevalue

Effect offeedingandwarmth

Glucose fall is potentially decreased

Nursing practice priorities immediately after birth

• NRP stabilization

• Keep baby warm – skin to skin

• Feed baby within 30-60 minutes

Glucose is primary fuel for brain function

For For ALLALL babiesbabies

When to assess glucose?

0

20

40

60

80

100

120

Glucosevalue

Hours of age

Feedfirst

A status checkA status checkon glucose on glucose

stabilitystability

Schedule for feeding and glucose measurement

Risk factor 30 min

1 hr 3hr 6hr 9hr 12hr 15 18 21 24

IDM X X X X X X X X

< 37 wks, SGA

X X X X X X X X

LGA X X X X Discontinue if last 3 readings >55mg/dL

APGAR < 6

X XDiscontinue if last 3 readings > 55mg/dL

Symptomatic When symptoms present – follow #7 (Intervention Pathway)

= feed BEFORE glucose check X = feed AFTER glucose check

If ANY glucometer reading is If ANY glucometer reading is 55 or less55 or less

the infant just bought a ticket to the the infant just bought a ticket to the

ANY Glucose check<40mg/dL

Newborn on protocol

NICU

Formula Feed10ml/Kg

Significant HypoglycemiaSignificant Hypoglycemia

Glucose check40-49mg/dL

Newborn on protocol

NICU

Formula Feed10ml/KgWait 30 minutes,

then recheck glucose

Second glucose reading

Is < 55 mg/dL

Second glucose readingAfter the feeding is

> 55

Moderate HypoglycemiaModerate Hypoglycemia

Glucose check50 - 55mg/dL

Newborn on protocol

Wait 30 minutes,then recheck glucose

Glucose > 55

3rd reading

NICU

Breastfeed orFormula Feed Formula Feed

10ml/KgWait 30 minutes,then recheck glucose

Second reading remains < 55Third reading remains < 55

Hatched area indicates safe areas for puncture site.

Warm site with soft cloth, moistened with warm

water up to 100, or use heel warmer for 3-5

minutes

Cleanse site with alcohol prep. Wipe DRY with sterile gauze pad.

Puncture skin,

wipe off first drop of blood with sterile gauze

use second drop

of blood

Compliance with Hypoglycemia Protocol

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Pe

rce

nt

Co

mp

lian

ce

0

20

40

60

80

100

120

140

Nu

mb

er

of

Hy

po

gly

ce

mia

Ca

se

s

Compliance with Hypoglycemia Protocol Total Cases

New HypoglycemiaProtocol

implemented

Privileged and Confidential Under the Illinois Medical Studies Act

Summary

• Moms and babies stay together• Stabilized glucose control for babies Identification of babies at risk Assistance with feeding Compliance to protocol from 19% to 85% admissions to NICU• Incidence of hypoglycemia congruent with

expected volume