resident packet

8/2005

NICU Resident Packet

Division of Neonatology Department of Pediatrics University of Washington Box 356320, RR542 HSB Seattle, WA 98195-6320

Phone 206.543.3200, FAX 206.543.8926 website: neonatal.peds.washington.edu

Sections Page Neonatal Medicine Goals & Objectives for Resident Training .............................................. 2

UWMC NICU Rotation .......................................................................................................... 4

Day-to-Day Tips for the NICU ............................................................................................... 5

Summary of Newborn Plus (NBP) Service Structure & Function ......................................... 6

Mechanical Ventilators .......................................................................................................... 8

Clinical Management Practice Guidelines (surfactant, Vitamin A, ventilatory management,

postnatal steroids, treatment of apnea of prematurity) ...................................................... 15

Intubation Guidelines for Neonates....................................................................................... 19

Rule-out Sepsis guidelines for Possible Neonatal Infections................................................ 21 Morphine Drip Guidelines...................................................................................................... 25

Red Blood Cell Transfusion Guidelines ................................................................................ 26

Cranial Ultrasound Examination in Neonates ....................................................................... 28

Tips on Lines......................................................................................................................... 29

PICC Information................................................................................................................... 30

NICU Nutritional Guidelines .................................................................................................. 31

Newborn Hearing Screening................................................................................................. 34

Suggested Format for an Admit/Discharge Notes/Face Sheet............................................. 36

Requesting Anesthesiologist at a Newborn Resuscitation Guidelines ................................. 38

“Who is in Charge in a Newborn Resuscitation” ................................................................... 38

Neonatal Attending Physician Attendance at Deliveries....................................................... 39

Consultations in the ISR........................................................................................................ 40

Readmission of Infants Discharged from the Newborn Nursery for Management of Hyperbilirubinemia

................................................................................................................................. 41

Infant Abduction Information ................................................................................................. 42

Interpretation of ROP Exam Results..................................................................................... 43

Web Tools and Online Resources ........................................................................................ 44

Blood Component Ordering and Administration, Guidelines for Administering Blood Products at UWMC .............................................................................................................................................. 45 Antiseptic Use in the NICU.................................................................................................... 48

Guidelines for Management of a Newborn with a Meningomyelocele………………………. 49

Erythropoietin in the Newborn Intensive Care Nursery………………………………………... 53

NICU Resident Packet of 54

NEONATAL MEDICINE GOALS & OBJECTIVES FOR RESIDENT TRAINING GENERAL OBJECTIVES

Obtain a broad understanding of the medical problems afflicting infants during the first month of life. Acquire an understanding of, and appreciation for, prenatal care of high risk patients Learn generally applicable principles in the NICU setting:

o physiology o ethics o reading, critiquing and applying the medical literature o the use of the National Library of Medicine database to access medical literature:

www.nlm.nih.gov/ SPECIFIC OBJECTIVES

1. Be adept in neonatal resuscitation procedures and obtain AAP/AHA certification in neonatal resuscitation (NRP) by the end of the R-1 year. Get materials from attending during your first UW rotation (Newborn or NICU).

2. Accurately obtain a history of pregnancy and perinatal events relevant to the newborn and understand the unique aspects of the physical examination of the premature and newly born full-term infant, including gestational age determination and assessment and management of LGA and SGA infants.

3. Understand the broad medical, social, and economic consequences of prematurity, including factors related to, or influencing, its incidence and the incidence of disorders unique to premature infants (e.g., lungs, eyes).

4. Understand the broad medical, social, and economic consequences of congenital defects, including factors related to, or influencing, its incidence.

5. Be familiar with birthweight and gestational age-related neonatal morbidity and mortality statistics and comparisons of perinatal, neonatal and infant mortality rates, regionally, nationally and internationally.

6. Be competent in the assessment and management of the infant in the delivery room with a background knowledge of transitional physiology (cardiopulmonary, metabolic, and temperature changes).

7. Recognize the clinical presentation and provide appropriate management of emergencies presenting the first month of life, including respiratory distress with/without cyanosis, shock, bleeding, or life threatening neurologic abnormalities.

8. Understand the physiology, pathophysiology, diagnosis, and treatment of acute and chronic respiratory disorders in the premature and full-term infant, including hyaline membrane disease, apnea, meconium aspiration, persistent pulmonary hypertension, transient tachypnea, pneumonia, pneumothorax, pulmonary interstitial emphysema, diaphragmatic hernia, pleural effusions, congenital pulmonary disorders, and bronchopulmonary dysplasia.

9. Demonstrate knowledge of the clinical and laboratory diagnosis, pathophysiology, and treatment of the following disorders of premature and full-term infants.

Infection:

1. Neonatal sepsis (bacterial, viral, fungal) 2. Congenitally acquired infections (HIV, CMV, toxoplasmosis, syphilis, rubella) 3. Localized infections (omphalitis, skin, osteomyelitis, arthritis, urinary tract) 4. Understand the peculiarities of host defense mechanisms in the newborn

Hyperbilirubinemia (physiologic, hemolytic, obstructive) Metabolic disorders (hypoglycemia, infant of diabetic mother, hypo- and hypercalcemia, inborn errors of protein, organic acid and amino acid metabolism)

Gastrointestinal disorders (necrotizing enterocolitis, bowel obstruction, gastrointestinal bleeding, abdominal wall defects)


Cardiovascular disorders (presentation of congenital heart disease in the neonatal period, patent ductus arteriosus, congenital cardiomyopathies, hypertension)

Hematologic disorders (neonatal coagulopathy, polycythemia, anemia) Renal disorders (acute renal failure, congenital malformation of the urogenital tract including agenesis, dysgenesis, cystic disease, obstructive uropathies, exstrophy of bladder)

Endocrine disorders (congenital hypo- and hyperthyroidism, adrenogenital syndrome, ambiguous genitalia, hypoglycemia). See also Metabolic Disorders

Thermoregulation Neurologic disorders (seizures, hydrocephalus, hypoxic-ischemic injury, neonatal asphyxia, intraventricular hemorrhage and outcome)


UWMC NICU ROTATION

SCHEDULE

Daily: 7-8:00 AM Preround – Collect numbers and examine patients 7-8:00 Senior Signout 8:00-10:30 Attending Rounds Weekly: 11:00 Discharge Conference (Tuesday) 11:00 Prenatal Diagnosis Conference (Friday) 12:30 Obstetrics/Pediatrics/Ethics (Thursday)

GOALS

See attached handout: “Neonatal Medicine, Goals, and Objectives for Resident Training ” RESOURCES

1. General Attending, fellows, residents, nurses Original articles, resident computer: Medline, web, database Books in resident room NICU-WEB at http://neonatal.peds.washington.edu/

2. Ventilators

In addition to 1) above: Respiratory Therapists See attached handout: “Mechanical Ventilators “ (also on web)

3. Pharmacy

In addition to 1) above: Pharmacists Red “Drug Reference” Binder (in each room)

4. Growth and Nutrition

In addition to 1) above: Joan Zerzan, Neonatal Nutritionist See attached handout: “NICU Nutritional Guidelines “

5. Other handouts (also on web)

“RBC Transfusion Guidelines “ “Guidelines for Treatment of Apnea of Prematurity “

6. Lab Computer Access: Contact Bill Uhrich at 206-669-6763.

Your computer access password will be forwarded to:

<Your Name>, care of <whoever is Attending> Neonatology, Box 356320


DAY TO DAY TIPS FOR THE NICU INFECTION CONTROL

1. A 3-minute scrub required for all staff when starting their shift 2. Do not wear any jewelry below the elbows 3. Do not wear watches 4. Please wash your hands before baby exams and between babies (use of alcohol hand cleaner is

acceptable also) 5. Scrubs: Only hospital provided scrubs are allowed. Scrubs are not to be taken home and

laundered. You must change into clean hospital-laundered scrubs at UWMC after your arrival or whenever your scrubs become soiled.

6. ISR or any Operative Delivery Room: a. wear a yellow waterproof cover gown b. wear a hat, mask, and gloves c. wear shoe covers

CONFIDENTIALITY

1. Do not discuss a baby while other parents and visitors are in the room or at the front desk. 2. Do dictation in your sleep room, X-ray room, or in the attending office, preferably not at the front

desk. If you must use the front desk, keep your voice lowered. 3. Tell parents they will be the only individuals receiving information on their infant. 4. Tell parents they must be present with any visitors. Siblings may visit if they’re older than 2 years

of age. 5. Do not discuss personal things or other patients in the labor/delivery rooms. Limit conversations to

the delivery at hand and speak quietly. 6. Please close the labor/delivery door after entering/exiting the room. 7. Dispose of all paper with identifiable health care information in paper recycle bins and not in trash.

ORDERS

1. Upon admission, a standing order sheet needs only to be signed and dated. If a specific order does not apply to the infant, it must be crossed out.

2. All orders must be signed, timed, and dated. 3. HA & drip orders need to be written by 11:00 am. 4. PRBC’s have a required form that that has to be filled out by nursing or housestaff. 5. Respiratory orders are written on the bedside flow sheet. This includes DC oximetry, etc. 6. Medication doses must be written in mg/kg per day, i.e. 50 mg/kg/day divided every 6 hours.

When writing medication orders please put current weight in the little bear on the order form! 7. We have addressograph cards for morphine, dopamine, dobutamine, Kupfers, immunizations,

indomethacin, and hearing screens. These medication orders include the dose calculations. 8. Leave the infants’ charts in the chart racks in the rooms.


SUMMARY OF NEWBORN PLUS SERVICE STRUCTURE & FUNCTION (MIC and NICU Newborn Plus Patients)

HOUSE-STAFF COVERAGE

There are 13 R1 rotations – for 11 there will be 2 Pediatric R1s and for 2 there will be 1 Pediatric R1 There are 12 SSR rotations and there will be 1 SSR for all 12

DAILY ATTENDING ROUNDS (House-staff prep for rounds should occur prior to 8:30 AM)

MIC ± 8:30 - 9:30 AM NBP ± 11:00 AM – 12:00 Noon

DELIVERY ROOM COVERAGE

Weekdays 7 AM – 5 PM: The NBP resident team will attend deliveries requiring pediatric presence in the following instances: all infants who are >34 weeks gestational age, including those who are delivered by C-section, those who are reported to have meconium stained amniotic fluid, intrapartum distress and/or those who are depressed at birth; the admitting NICU team will attend all other deliveries requiring pediatric presence, including infants who are <34 weeks gestational age and those who are scheduled to be delivered with major congenital anomalies (diaphragmatic hernias, congenital heart disease, neural tube defects, etc.).

Nights/Weekends: NICU House-staff Supervision: NICU Attending

WEEKEND COVERAGE

MIC AM rounds and admissions till noon by float resident and MIC Attending NBP AM rounds by NBP Attending and NICU House-staff

NIGHT COVERAGE

NICU House-staff Attending TEACHING

Bedside as indicated Topical discussions (20-30 minutes by schedule) When possible, during teaching rounds the delivery room should be covered by the NBP SSR or the NICU House-staff

TARGET CENSUS

6 stable NICU patients (growers/gainers, stable CLD, or other chronic/convalescent patients) 2 level-II type acute patients (R/O sepsis, TTNB, mild RDS)


NEWBORN PLUS TEACHING PROGRAM GUIDELINES

Ferret lab intubation procedure will be scheduled on the 1st Thursday late morning following rotation of NICU interns to the service (occurs on Wednesday).

Specific discussion topics to be covered, if at all possible, include: see attached schedule. NEWBORN PLUS TEACHING TOPICS

1. Normal infant nutrition 2. Breastfeeding 3. Substance abuse - alcohol, NAS, etc. 4. CPS utilization 5. D/C teaching, etc. 6. Jaundice 7. Congenital heart disease 8. Heme problems 9. R/O sepsis 10. Hypoglycemia 11. Ethics 12. Fetal Diagnosis 13. NRP 14. Outcome 15. Primary care of the former NICU patient


MECHANICAL VENTILATORS 1. Introduction to ventilator management and the different types of ventilators available in the NICU

There are three fundamentally different modes of ventilation available in the NICU: "pressure ventilators", "volume ventilators", and high frequency ventilators. They all serve to support adequate ventilation and oxygenation, but each has it's own particular niche. Ventilation (CO2 removal) is a function of minute ventilation which is respiratory rate (RR) multiplied by tidal volume (Vt). MINUTE VENTILATION = RATE x TIDAL VOLUME Arterial Oxygenation usually improves when either the fraction of inspired oxygen concentration (FiO2) and/or mean airway pressure (MAP) are increased. The first step in managing a patient on a ventilator is to choose appropriate goals for ventilation and oxygenation (i.e. blood gases). These goals depend on the patient's disease state. An otherwise healthy term infant intubated for choanal atresia might have as a goal pH=7.40, PaCO2=40, PaO2=60. In a small preterm infant (<1000g), to minimize lung injury due to mechanical ventilation, a strategy of mild permissive hypercapnea may be followed. In a patient with severe chronic lung disease gases with PaCO2 of 60-65 torr and SaO2 >88% may be acceptable. In contrast, a patient with persistent pulmonary hypertension of the newborn might have as a goal pH>7.45, PaCO2=30, PaO2>100 in an attempt to attenuate hypoxic pulmonary vasoconstriction. Ventilation goals can be a range of pH values and/or a range of PaCO2 values. Extreme acidosis (pH<7.10) is to be avoided but otherwise mild acidosis alone appears to be relatively well tolerated. Of greater concern are wide swings in PaCO2 which can have significant effects on cerebral blood flow. Also of concern is identifying and, if appropriate, treating the underlying cause of the acidosis. Ventilation can best be monitored using arterial blood gases. Capillary blood gases (and even more so venous) tend to give low values for pH (~0.05-0.1 lower depending on perfusion). The difference between arterial and capillary or venous pH is variable over time and between patients. As an estimate of ventilation, it does not work well in older infants with BPD, infants with hydrops, and other conditions that impair transcutaneous passage of capillary gas. If using a conventional ventilator (not High Frequency), end tidal CO2 monitoring (capnography) is another valuable non-invasive method of estimating ventilation though it may give inaccurate readings with chronic lung disease (e.g. BPD). Oxygenation goals can either be a range of arterial oxygen saturation or PaO2 values. Oxygen saturation (SaO2) best reflects arterial blood oxygen content (SaO2 x Hemoglobin x 1.34) and thus is of direct physiologic interest. PaO2 better reflects degree of shunt, and is more accurate than SaO2 at the lower range. Oxygenation can best be monitored by pulse oximetry or arterial blood gases. Capillary and venous blood gases are never useful measures of arterial PaO2. The appropriateness of initial ventilator support needs to be rapidly confirmed by checking a blood gas (within 15-20 minutes if possible) and making adjustments accordingly. Initial ventilator settings for pressure ventilators are typically chosen based on pressures and rates required when hand bagging. Initial settings on volume ventilators are usually chosen based on typical minute ventilation requirements (e.g. rate of around 20-30 breaths per minute with tidal volume of ~4-6 mL/kg). When switching from conventional ventilation to high frequency ventilation, a rule of thumb is to choose a mean airway pressure (MAP) for the high frequency ventilator that is 2 cmH2O greater than the MAP on the conventional ventilator. Amplitude starting point is chosen such that there is adequate shake (a rule of thumb being the umbilical line should be shaking slightly; alternative rule of thumb is to start at twice the MAP and back down from there until shake appears appropriate). Blood Gases: When evaluating a blood gas, first determine your goals for pH, PaCO2, and PaO2. Secondly, determine the type of specimen to decide if any correction for capillary or venous specimen is in order. Finally, evaluate the blood gas to see if any changes in inspired oxygen concentration or ventilator settings are needed. Before analyzing the blood gas it is worth determining whether the gas is


significantly different from previous gases and, if so, why (i.e. was a ventilator wean made, is the patient extubated, is there a pneumothorax, is the patient showing signs of sepsis, are there signs of persistent pulmonary hypertension of the newborn, is this an expected change given the patient’s diagnosis). If PaO2 is low, then FiO2 or MAP need to be increased. If the pH is low, one should determine if the acidosis is respiratory (PaCO2 high) and/or metabolic (calculated HCO3 low). Increasing ventilation is merely a temporizing act until the cause of the acidosis is determined. If the pH is low and/or the PaCO2 is high, indicative of a respiratory acidosis, then ventilation needs to be increased by increasing rate and/or tidal volume - how this is accomplished again varies from ventilator to ventilator.

Abbreviations: ETT: Endotracheal Tube PEEP: Positive End Expiratory Pressure CPAP: Continuous Positive Airway Pressure, PEEP with no rate PIP: Peak inspiratory pressure MAP: Mean Airway Pressure RR: Respiratory Rate Ti,Te: Inspiratory and expiratory times I:E: Ratio of inspiratory to expiratory time Vt: Tidal Volume, volume of each breath SaO2: Arterial oxygen saturation determined by arterial blood gas analysis SpO2: Arterial oxygen saturation determined by pulse oximetry FiO2: Fractional inspired oxygen HFV: High Frequency Ventilation HFOV: High Frequency Oscillatory Ventilator/Ventilation Amplitude: (aka Delta P) Setting on HFV. Difference between maximum and

minimum airway pressure 2. ”Volume Ventilators”

Historically, volume ventilators (time cycled, volume regulated, volume limited) were used in anesthesia (a bellows of defined tidal volume pumped at a given rate) and as pediatric and adult intensive care evolved. Initially these ventilators were not used in the NICU due to the difficulty achieving consistent small volumes (5-7 mL/kg in a 1200g infant!). Current volume ventilators are able to deliver small volumes consistently. In the past, triggering was inconsistent and increased the work of breathing. The last generation (Siemens 300) has resolved these problems. In the NICU their use has been primarily in larger infants with chronic lung disease (partly because SIMV was only available on volume ventilators until recently) or perioperatively (tradition - likely related to familiarity of operating room personal with volume ventilators). Their use in the acute NICU setting has extended into the micropremie population. The newest generation of “volume vents” includes the Drager Babylog 8000. This ventilator delivers smaller consistent tidal volumes, with minimal WOB problems associated with triggering. PROS: Stable minute ventilation with known tidal volume. Simpler models available for use outside hospital setting. Control or SIMV modes are available. Home ventilators currently available are typically "volume ventilators". CONS: Tidal volume is maintained at the expense of peak airway pressure. If lung compliance falls by 50% (i.e. ETT slipping down right mainstem), tidal volume is maintained by doubling of peak airway pressure. This increases the risk of volutrauma or barotrauma. Since these ventilators do not have constant flow, to breathe spontaneously the infant always has to trigger a valve to allow air flow. Large leaks around the ETT can be problematic due to difficulty maintaining tidal volume and "triggering" (patient cycling) of the ventilator causing frequent alarming.


Adjusting ventilation/oxygenation: To increase alveolar ventilation: Increase Rate or Increase Tidal Volume MINUTE VENTILATION = RATE x TIDAL VOLUME To increase oxygenation: Increase FiO2, or Increase PEEP, or Increase Tidal Volume OXYGENATION is improved by increasing MAP and/or FiO2 / \ Vt PEEP

3. High Frequency Ventilators

This is a radical innovation in ventilator design. The rate in "high frequency" is the Hz (range 3-15 Hz) (i.e. 180-900 breaths per minute). Since the tidal volume generated by these ventilators approximates dead space, simple pulmonary mechanics, physics, and physiology are inadequate to explain their operation. Gas exchange occurs by enhanced diffusion. HFOV (High Frequency Oscillatory Ventilation): (Sensormedics 3100A) uses a piston with a diaphragm unit to actively move gas in and out of the lung. This type of ventilator requires a special non-compliant breathing circuit. Indications for use of high frequency ventilation are unclear but include:

1. Initial and subsequent ventilatory support in very low birth weight infants with respiratory distress syndrome.

2. Air leak (pneumothorax, pulmonary interstitial emphysema). 3. Failure of conventional ventilation (pre-ECMO step) particularly in persistent pulmonary

hypertension of the newborn, meconium aspiration syndrome, pneumonia, pulmonary hemorrhage.

4. To reduce the risk of volutrauma and barotrauma when conventional ventilator settings are very high.

PROS: May allow gas exchange when conventional ventilation has failed. CONS: Unclear which patients will respond and there is some risk involved in "just trying". Switching ventilators on an unstable patient who is failing conventional ventilation may result in clinical deterioration. The high airway pressures often seen with high frequency ventilation can be transmitted to the heart (particularly with compliant lungs) and result in impaired cardiac output requiring volume boluses and/or inotropes. HFOV makes turning patients, taking x-rays, or performing ultrasounds more complex due to the heavy, non-flexible tubing. Stopping HFOV for suctioning or administering nebulized medications may negate its benefit. Adjusting ventilation/oxygenation: Ventilation is dependent on amplitude much more than rate. In larger infants paradoxically lowering Hz improves CO2 removal on the Sensormedics. This is postulated to occur by increased tidal volume (more inspiratory time) and better gas escape (more expiratory time). Mean airway pressure primarily effects oxygenation. MAP can also influence ventilation: too high a MAP and ventilation may drop due to decreased compliance from overdistention, too low a MAP and hypoventilation may occur secondary to atelectasis. To increase minute ventilation: Increase Amplitude, (although changes in MAP and Hz can sometimes have significant effects on CO2 also) MINUTE VENTILATION = RATE x TIDAL VOLUME / / \ Hz AMPLITUDE MAP


To increase oxygenation: Increase FiO2, or Increase MAP, (change in Hz may sometimes effect oxygenation also). Note, however, overdistention can impair oxygenation. When in doubt, a chest x-ray is indicated. OXYGENATION is proportional to MAP x FiO2

4. "Pressure Ventilators"

These are the most frequently used ventilators in the NICU. Traditional "pressure ventilators" are constant flow, time cycled, pressure limited devices. Constant flow implies that there is a constant flow of gas past the top of the endotracheal tube. Pressure limited means that once the pre-set PIP has been reached, it is maintained for the duration of the inspiratory cycle. Time cycled implies that breaths are given at fixed intervals, independent of the infants respiratory efforts. Newer "pressure ventilators" can sense infant’s breaths and synchronize to them. There may be some added work of breathing due to the need to trigger breaths - this has been hard to quantify and remains controversial. PROS: The constant flow permits the infant to easily take spontaneous breaths. Simple, reliable mechanical design. Pressure limitation prevents sudden changes in PIP as compliance changes (i.e. on a pressure ventilator if compliance falls by 50% PIP does not change - though tidal volume drops, for example ETT slipping down right mainstem). CONS: Variable tidal volume as lung compliance changes. Should lung compliance worsen then Vt will drop (if the ETT plugs Vt drops to zero, but the ventilator does not sense it). Should compliance improve (following surfactant for example) this may result in overdistention. If the child is exhaling during a non-synchronized ventilator breath, then the breath is ineffective. Adjusting ventilation/oxygenation: Key determinants of oxygenation (mean airway pressure, MAP) and ventilation (tidal volume) are not directly adjustable, but are derived from related parameters (Bold faced). Adjustments are thus less straightforward than with either "High Frequency" or "Volume Ventilators". Furthermore, there are interactions between the various parameters. Driving pressure conceptually is similar to "amplitude" on high frequency ventilation, but is not directly adjustable: it is proportional to the difference between PIP and PEEP. To increase ventilation: Increase Rate, or Increase PIP, or Increase Inspiratory Time, or Decrease PEEP (rarely done) MINUTE VENTILATION= RATE x TIDAL VOLUME / | \ / \ Ti Te I:E Driving Time Pressure Constant | / \ PIP-PEEP Resistance Compliance To increase oxygenation: Increase FiO2, or Increase MAP (see below) OXYGENATION is proportional to MAP x FiO2 (Ti x PIP)+(Te x PEEP) MAP= ------------------------------- Ti + Te This equation assumes Pressure vs. Time is a square wave.


Ways to increase MAP (See figure 1):

1. Increase PEEP 2. Increase PIP 3. Increase Ti 4. Increase RR 5. Increase Flow

Figure 1: Pressure vs. time

5. Ventilator Modes (terms and types)

IMV: Intermittent Mandatory Ventilation. Intermittent breaths (fixed PIP or Vt) at a fixed rate. Not synchronized to patient. Beyond the set rate, the infant is on his/her own. (See figure 2-IMV) Standard on most ventilators, but infrequently used. Generally good for small premature infants but when rates are high (>60) or large infant "fighting" ventilator (exhaling during ventilator's inspiratory cycle), the lack of synchronization may impair ventilation.

CON: No synchronization.

SIMV: Synchronous Intermittent Mandatory Ventilation. Like IMV but synchronized (senses infant's spontaneous breaths). Beyond the set rate the infant is on his/her own (See figure 2-SIMV). Since it is synchronized to the patient’s effort, it is the preferable mode. It will function exactly like IMV if the infant is apneic or the trigger/synchronization fails. Typically used in infants who can reliably trigger demand valve and those fighting a preset rate. Usually lower rates/pressures since at higher spontaneous rates (>60) may get inadvertent PEEP and air trapping. Also good for older ventilator dependent patients.

PRO: Synchronized to patient effort. CON: None, at worst is like IMV.

AC: Assist/Control. Synchronized (senses infant's spontaneous breaths) but with mandatory minimum set rate, all breaths the infant takes are a full assisted ventilator breaths (See figure 2-AC). Used in more active ventilator dependent infants not aggressively being weaned.

PRO: Infant can increase minute ventilation easily on demand, based on need. CON: When weaning can't wean rate, only PIP or Vt.

SIMV-PC with PS (Pressure Support): Term used on Servo 300 ventilators to describe an SIMV

"pressure ventilator" with set PIP/PEEP. Beyond a set background ventilator rate, spontaneous breaths are augmented (supported) with pressure - usually relatively low values (+4 to +8 cmH2O) (See figure 2-PC/PS). Uses: 1) To provide mandatory backup breaths (conceptually large sighs to prevent gradual progressive atelectasis) while allowing amount of PS to be weaned slowly to "train" respiratory muscles 2) As a means of providing intermediate respiratory support (less than conventional modes but more than CPAP or extubation) 3) Pressure support just enough to overcome resistance of ETT and ventilator circuit and maintain minimum adequate spontaneous ventilation. Uses as above, but in "pure pressure" support mode. (If set PIP and PS pressures are the same then essentially you have pressure AC mode).

NOTE ON WRITING PS: Pressure support is above PEEP. At the University of Washington NICU, writing an order for "PS 5, PEEP of 4" yields inspiratory pressures for assisted breaths of 5+4=9.


SIMV-VC with PS (Pressure Support): Term used on Servo ventilators to describe SIMV with set Vt. Beyond the set rate, spontaneous breaths are augmented (supported) with pressure - usually relatively low values. The difference between this mode of ventilation (VC/PS) and the mode described above (PC/PS) is that in VC/PS the SIMV breaths are volume breaths and in PC/PS mode the SIMV breaths are pressure breaths.

PC: Pressure Control. Term used on Siemens Servo ventilator to describe AC mode with a set

PIP/PEEP ("pressure ventilator" AC mode). VC: Volume Control. Term used on Siemens Servo ventilator to describe AC mode with a set Vt

("volume ventilator" AC mode). PRVC: Pressure regulated volume control. In this mode, a volume is set and the delivered pressure

self adjusts to achieve the set volume. With the Servo 300, the pressure will stairstep up over 5 breaths until the set volume is met. If apnea occurs, the ventilator sounds an audible alarm and switches to the PC backup mode. The therapist must manually change back to PRVC mode.

PSVG: Pressure support volume guarantee. This mode is available on the Drager Babylog 8000.

This mode is pressure limited with a set tidal volume. The pressure will stairstep up to meet the set tidal volume. There are two sets of values: Set (ordered) and Measured (spontaneous). Set values include tidal volume (4-8 mL/kg), inspiratory time, inspiratory pressure limit (PIP), rate, and PEEP. The set values are utilized when the infant is apneic. Otherwise, the infant regulates their own PIP to meet the set tidal volume. As infant's compliance improves, the PIP needed to deliver set tidal volume decreases.

Pro: Adjusts for compliance automatically, compensates for ETT leaks, no need to correct for tubing volume Con: Weaning mode only. If infant needs increasing support, switch to another mode on ventilator.

SIMV + VG: With the Drager Babylog 8000, the addition of VG (volume guarantee) to SIMV allows

one to control the inspiratory time. The PIP still adjusts to meet the set tidal volume, but the inspiratory time is set by the therapist.

Pro: More supportive and more control of ventilation than with PS + VG. Con: Less control over PIP, infant is still doing most of the work of breathing.

CPAP: Continuous Positive Airway Pressure (like PEEP). Primarily used to maintain airway

distending pressure; major effect is to help to maintain lung volume and improve oxygenation. Can be administered via ETT or nasal prongs. Uses: 1) To prevent alveolar collapse in mild HMD (perhaps avoiding intubation) 2) In mild chronic lung disease (perhaps avoiding reintubation) 3) In severe apneic spells to avoid intubation. Sometimes used in infants as prelude to extubation to ensure adequate respiratory drive. If done for a prolonged time, infants tire out breathing through the relatively high resistance of a 2.5-3.5 ETT.

PRO: Improve oxygenation by maintaining functional residual capacity. CON: Impair ventilation by increasing FRC and increasing work of breathing (exhaling against pressure).


FIGURE 2: RESPIRATORY PATTERN UNDER DIFFERENT MODES

6. Specific Ventilators (types of ventilators and their functions)

NOTE: Each ventilator manufacturer has utilized specific names for mode functions of their specific machine that may not be identical with other machines. For example, PSV of the Servo 300 is not the same as PSV of the Drager Babylog 8000.

Drager Babylog 8000: This ventilator is specifically designed for infants up to 10 kilograms (22 pounds). It is capable of both volume and pressure ventilation. A flow sensor at the patient wye accurately measures tidal volume and senses air flow initiated by the patient allowing triggering of the ventilator cycle. The sensor is able to compensate for small ETT leaks. The Drager Babylog 8000 provides the following modes: AC, SIMV, PSV (pressure support ventilation), Volume guarantee (VG), and independent Expiratory Flow (VIVE). VG is often used with SIMV, PS, and AC. The most important and commonly used modes are SIMV, PSV, VG, and CPAP.

Sensormedics 3100A: High frequency oscillatory ventilator with active inhalation/exhalation driven

by a moving piston and diaphragm. Requires special stiff non-compliant ventilator circuit. Can be utilized for a wide weight range of infants. Some preliminary work using it in smaller infants suggests that it may result in less barotrauma than conventional ventilation.

Siemens Servo 900C: Either a volume or pressure ventilator, no gas flow from ventilator

between breaths. Volume ventilator with IMV, SIMV, AC and pressure modes PC/PS. Has pediatric settings for alarm limits, but no specific infant modes. Used when primarily volume ventilator needed in larger term infant and often for home ventilatory support. Currently, used only in the IICU.

Siemens Servo 300: Either a volume or pressure ventilator, low bias flow from ventilator

between breaths. Does not have continuous high flow through circuit and requires some effort on the part of the infant to trigger significant flow. A "bias" flow of 0.5 LPM is present and the trigger is a 30% disruption in this flow rate sensed at the ventilator. Alternatively it can sense a drop in airway pressure instead, but this requires more effort on the infant's part. The major advantage over Siemens 900C is that it has infant ranges for Vt, flow, pressures, and alarms. Has extensive list of modes: PC, VC, SIMV-VC+PS, SIMV-PC+PS, CPAP and PRVC (pressure regulated volume controlled). Uses include 1) Volume ventilation of small infants, 2) Synchronized/mixed modes, 3) Overcoming resistance of circuit & ETT with PS, 4) Facilitation of weaning by allowing gradual entrainment.


CLINICAL MANAGEMENT PRACTICE GUIDELINES I. SURFACTANT MANAGEMENT GUIDELINES

A. Surfactant Use for RDS in Preterm Infants – First Dose

1. Preterm infants with RDS should receive surfactant as a bolus, and handling during administration should be minimized.

2. Inborn infants < 27 weeks gestation should be automatically intubated immediately after

birth and given prophylactic surfactant in the delivery room or as soon as possible after intubation.

3. Inborn infants ≥ 27 weeks and < 30 weeks gestation should receive surfactant without

delay if they require intubation and supplemental oxygen for respiratory failure. 4. Infants ≥ 30 weeks gestation should receive surfactant therapy if they require

mechanical ventilation and have a diagnosis of RDS.

B. Surfactant Use for RDS in Preterm Infants – Additional Doses

1. Infants < 30 weeks gestation with the diagnosis of RDS should receive a second dose of surfactant as a bolus 6-12 hours after the first dose if they continue intubated on mechanical ventilation, regardless of the FlO2.

2. Infants ≥ 30 weeks gestation with the diagnosis of RDS should receive a second dose of

surfactant as a bolus 6-12 hours after the first dose if they continue intubated on mechanical ventilation and require an FiO2 ≥ 0.3. If the infant remains intubated with an FiO2 0.21-0.29, one should consider a second dose of surfactant.

One may consider continued treatment with additional doses of surfactant (total of 4 doses maximum) for preterm infants with RDS and worsening oxygenation 6-12 hours after the second dose.

II. VITAMIN A THERAPY (RECOMMENDATION)

For all infants < 1000 grams; and 1000-1250 grams if ventilated > 24 hours.

Dose: 5000 IU (0.1 mL) IM on M-W-F x 4 weeks may be discontinued prior to 4 weeks of treatment if the infant reaches full enteral feeds (150 mL/kg of premature formula or 120 mL/kg of premature formula with 1 mL/d Poly-vi-sol).

III. VENTILATORY MANAGEMENT

A. Target Ranges for Blood Gas Values

Since the target ranges are fairly broad, weaning of ventilator settings is strongly encouraged for patients who have PaCO2 values in the lower end of the target ranges. The target ranges for blood gases are as follows:

Saturation (measured by pulse oximeter) 88-96% pH ≥ 7.25 PaCO2 40-55 torr if CXR uncomplicated PaCO2 45-70 torr in patients with PIE or chronic changes in CXR

B. Ventilatory Weaning: As Frequently As Tolerated


Minimum Requirements

PaCO2 in lower target range > 12-24 hours and stable Encourage extubation trial if meets both:

Mean airway pressure ≤ 5 FiO2 ≤ 0.25

Start methylxanthine prior to extubation (caffeine or theophylline) Always extubate to NP CPAP Hamilton AladdinII Nasal CPAP System

Criteria for Reintubation

NCPAP > 8 PaCO2 ≥ 60-65 torr and pH < 7.25 FiO2 requirements rapidly increasing Recurrent apnea/bradycardia

IV. POSTNATAL STEROIDS

A. For Hypotension

1. Consider use of steroids under the following conditions:

Preterm ≤ 28 weeks, ≤ 1000 grams (**Particularly if mother received 3 or more courses of antenatal corticosteroids)

Infant has no sustained response to volume (usually 10 to 20 mL/kg of normal saline)

AND

Infant has inadequate response to pressors including Dopamine to 20 μg/kg/min

(±Epinephrine or Dobutamine when appropriate)

2. Treatment

Hydrocortisone 1 mg/kg IV initially − If infant has clinically significant response, the one dose may be

sufficient − If no response repeat in 3-6 hours − Optional: if infant has significant response may continue as

− 1 mg/kg IV Q 12 hours x 1 − 0.5 mg/kg IV Q 12 hours x 2 − Discontinue

− If hypotension recurs, may repeat sequence or taper more slowly

B. For Severe Life-Threatening PIE Consider the “Short” Course Described Below C. For Chronic Lung Disease – Try to Avoid But

Consider if:

Preterm ≤ 28 weeks, ≤ 1000 grams Care optimized including:

− Fluid restriction − Aggressive management of PDA accomplished − Diuretics − Nutrition established − No clinical evidence of sepsis


If ≤ 7 days of age and severity score > 7 Severity Score = FiO2 x MAP

If ≥ 7 days of age and severity score > 6

D. Postnatal Steroid Treatment Protocol Use Dexamethasone: Choose “short” or “long” course

Short: 3 day course

Day 1: 0.2 mg/kg/day in divided doses every 12 hours Day 2: 0.15 mg/kg/day in divided doses every 12 hours Day 3: 0.1 mg/kg/day in divided doses every 12 hours Stop; May have repeat burst at 7-10 day interval

Long: 7-10 day course

Day 1-2: 0.2 mg/kg in divided doses every 12 hours

STOP! IF NO RESPONSE AFTER 48 HOURS (defined as ability to wean ventilator and oxygen)

Day 3-4: 0.15 mg/kg/day in divided doses every 12 hours Day 5-7: 0.1 mg/kg/day Day 8: off (may stop if 7 day course, give no Dex if 10 day course) Day 9: 0.1 mg/kg/day Day 10: off – Stop

Some of these infants may have relative adrenal suppression. Consider: Stress treatment for surgery, etc. (stress dose 0.5-1.0 mg/kg/day hydrocortisone)

V. TREATMENT OF APNEA OF PREMATURITY

A. INITIATION OF METHYLXANTHINES

Definition of Apneic Event by Type of Intervention Treatment Indication

No Intervention Required

Frequent episodes associated with desaturations (SaO2<80) and/or bradycardia (HR<80); e.g., one or more per hour over a long period of time such as 12-24 hours.

Mild - Light touch, stroke back - Associated with desaturations <80% & bradycardia <90 BPM

Multiple episodes; more than 6 over a 12 hr period or 12 over a 24 hr period.

Moderate - Move infant, i.e. roll over, reposition, etc. - O2 administered

More than 2 episodes in a 24 hr period.

Severe - Prolonged vigorous stimulation - PPV with or without O2

More than 1 episode in a 24 hr period.

ABC’s associated with feeding, handling, suctioning, mucous plugging, etc. should not be counted when determining whether to initiate methylxanthine treatment.


Treatment Recommendation:

Preparation: caffeine citrate 20 mg/mL both IV & PO (20 mg of caffeine citrate = 10 mg of caffeine base) Load IV & PO: 20 mg/kg of citrate (= 10 mg/kg of base) Maintenance IV & PO: 5-7.5 mg/kg QD of citrate (= 2.5 – 3.75 mgkg of base) Acceptable: serum level could range from a low of 5 to an upper limit of 20, depending on patient response

B. WHEN TO TRIAL CPAP

Apnea that continues in spite of optimum methylxanthine treatment may respond to low level CPAP. Accordingly, a trial of CPAP (4-6 cmH2O) is warranted in addition to or as an alternative to ineffective methylxanthine treatment.

B. ASSISTED VENTILATION

Frequent apnea associated with marked bradycardia and/or desaturations refractory to methylxanthines and/or CPAP should be treated with positive pressure ventilation.


Intubation Guideline for Neonates

• Safe, high quality neonatal care and a dedication to resident education are the foundation for neonatal care at the University of Washington.

• Pediatric residents, by the end of their residency training, will be proficient at neonatal airway management including intubation, bag-valve mask ventilation and oral airway placement.

• Neonatal care at the University of Washington is delivered as a team. • These guidelines are flexible on a case-by-case basis

1. Successful neonatal intubation is defined as intubation within 2 attempts. All care providers

should strive to achieve this goal. 2. An intubation attempt is defined as placing the laryngoscope blade in the patient’s mouth

unless the blade is rapidly removed to suction, change ETT, etc. 3. Intubation attempts should not compromise patient stability. Stability is defined as a heart

rate > 100 bpm and an oxygen saturation > 90%. Any team member can declare that the neonate is unstable.

4. If more than one intubation attempt is required, the same person should attempt again after briefly discussing with the resuscitation leader their strategy for performing a successful intubation on the next attempt. (see teaching tips below)

5. In selected cases, neonates may be unstable or are at risk for adverse outcomes if multiple tries at intubation are attempted. These cases include:

a. Extremely Preterm Neonates < 26 weeks gestation b. Unstable neonates (Unable to establish oxygenation with PPV, neonate requiring

CPR) c. Certain congenital anomalies

i. Congenital Diaphragmatic Hernia ii. Known Airway Obstruction iii. Micrognathia iv. Hydrops

In these cases, an experienced care provider should perform the intubation. 6. An experienced care provider is defined as the provider who has had the most experience and

success with neonatal intubation in the past. In general, this will be the NNP, neonatal fellow or

neonatal attending. However, this may also be the senior resident in certain select cases. (eg.:

unexpected decompensation in a term neonate in which the neonatal attending, fellow, or NNP is not

present) 7. If the neonate is unstable and an experienced care provider is unable to successfully intubate the

patient, anesthesia should be stat paged to attempt intubation.

Teaching tips: • Have most senior care provider visualize airway/vocal cords and have resident place ETT. • Perform intubation on stable patients in the NICU (ROP surgery, elective reintubations, etc.)


Delivery of Neonate

Anomalies?*

*Anomalies:1. Congenital Diaphragmatic

Hernia (CDH)2. Airway Obstruction3. Micrognathia4. Hydrops Fetalis

Yes No

Intubation by experienced care provider

> 26 wks andstable

Intubation by Intern

< 26 wks orunstable

Intubation byexperienced care provider

GA?

Goal:All neonatal intubations

successful within 2 attempts

Stable: Pulse > 100 bpm and SaO2 > 90%

Revision By: Eric J. Demers, M.D. Assistant Professor


No

No

Yes Yes

Was mother pretreated with

antibiotics? Yes

1. a. Culture/CRP b. Treat c. Reassess @ 48 hrs

No

2. a. Culture/CRP(optional) b. Treat c. Reassess @ 48 hrs

Is the infant symptomatic?

Does infant have gestation greater than

34 wks or a birthweight greater

than 2 kg?

Start

RULE OUT GUIDELINES FOR POSSIBLE NEONATAL SEPSIS

YesWas mother pretreated

with antibiotics? 3. Observe

No

4. Observe if risk factors

5. a. Culture/CRP b. Treat c. Reassess @ 48 hrs

No 6.

a. Culture/CRP(optional) b. Treat c. Assess @ 48 hrs d. Treat for full course

Yes

No

8. If very premature: a. Culture/CRP(optional) b. Treat c. Reassess @ 48-72 hours

Was mother pretreated with

antibiotics?

YesYes Was mother pretreated

with antibiotics? Is the infant

symptomatic?

No

7. a. Culture/CRP b. Treat c. Reassess @ 48 hours


VII. RULE OUT GUIDELINES FOR POSSIBLE NEONATAL SEPSIS

A. TERM / SYMPTOMATIC Pretreated

Culture Treat Reassess clinical status and culture results at 48 hours (see references 3); if the blood culture is negative, CSF studies and clinical course benign, consider stopping antibiotics. CRP values may be obtained (day 1, day 2) as an adjunct to support the decision to stop antibiotics. Serial normal CRP studies have been reported to have a highly significant negative predictive value for both proven and probable sepsis (see references 5).

If cultures positive or infants continue to be symptomatic with signs of sepsis or strong maternal risk factors for sepsis (See Maternal Risk Factors) treat for 10 days (blood culture positive) or 14 to 21 days (CSF culture positive)

Not Pretreated

Culture Treat Reassess clinical status and culture results at 48 hours (see references 3); if the blood culture is negative, CSF studies and clinical course benign, consider stopping antibiotics.

Optional: CRP values may be obtained (day 1, day 2) as an adjunct to support the decision to stop antibiotics. Serial normal CRP studies have been reported to have a highly significant negative predictive value for both proven and probable sepsis (see references 5).

If cultures positive or infants continue to be symptomatic with signs of sepsis treat for 10 days (blood culture positive) or 14 to 21 days (CSF culture positive)

B. TERM / ASYMPTOMATIC/MATERNAL RISK FACTORS

Pretreated

Observe closely for 48 hours (there is evidence in the literature that if – 98% + of infected infants present within 48 hrs – see reference 4). If there is evidence of maternal amnionitis or other serious infection it would be reasonable to consider a rule out sepsis – blood culture and antibiotics for 48 hours. Evidence in support of routine CSF culture in the asymptomatic term infant is not impressive (see reference 1)

Not Pretreated

No cultures or treatment; observe closely for 48 hours

C. PREMATURE / SYMPTOMATIC

Pretreated

Culture Treat Reassess at 48 hours Generally continue antibiotics for a 10 day treatment course. Can consider stopping antibiotics if infant has a clinical course not suggestive of infection and cultures are negative. Continuation of the signs and symptoms and/or occurrence of new signs or symptoms of infection are indications to continue antibiotics.


Not Pretreated

Culture Treat Reassess at 48 hours. Optional: CRP values may be obtained (day 1, day 2) as an adjunct to support the decision to stop antibiotics. Serial normal CRP studies have been reported to have a highly significant negative predictive value for both proven and probable sepsis (see references 5).

Can consider stopping antibiotics if infant has a clinical course not suggestive of infection and cultures are negative. Continuation of the signs and symptoms and/or occurrence of new signs or symptoms of infection are indications to continue antibiotics.

D. PREMATURE / ASYMPTOMATIC

Pretreated

Culture Treat Reassess at 48 hours Stop antibiotics if infant is asymptomatic or clinical course not suggestive of infection and cultures are negative

Not Pretreated

Consider no workup or treatment for infants >2000 gm birthweight and 34 weeks gestation For infants below 2000 gm birthweight and 34 weeks gestation:

o Culture o Treat o Reassess at 48 hours o Optional: CRP values may be obtained (day 1, day 2) as an adjunct to support the

decision to stop antibiotics. Serial normal CRP studies have been reported to have a highly significant negative predictive value for both proven and probable sepsis (see references 5).

o Stop antibiotics if infant is asymptomatic or clinical course not suggestive of infection and cultures are negative

E. CULTURE

Obtain blood culture (target blood culture volume = 1 mL, (see Blood Culture Volume Study – reference 2)

F. TREATMENT

Start IV antibiotics

if term (> 37 weeks gestation):

o ampicillin 100 mg/kg every 12 hours and gentamicin 4 mg/kg every 24 hours if CSF cell count WNL

o OR ampicillin 150 mg/kg every 12 hours and cefotaxime 50 mg/kg every 12 hours if CSF cell count abnormal or if spinal tap was unsuccessful

if premature (≤ 37 weeks gestation):

o ampicillin 100 mg/kg every 12 hours and gentamicin 4 mg/kg every 36 hours if CSF cell count WNL

o OR ampicillin 150 mg/kg every 12 hours and cefotaxime 50 mg/kg every 12 hours if CSF cell count abnormal or if spinal tap was unsuccessful


G. MATERNAL RISK FACTORS (listed in increasing order of estimated importance)

• PROM (greater than 18 hrs) • GBS colonization • Maternal infection (fever, UTI, chorioamnionitis)

H. INFANT SYMPTOMATIC

Oxygen requirement Respiratory distress Apnea Lethargy Poor feeding Change in responsiveness

I. MOTHER PRETREATED

If mother received antibiotics ≥ 4 hours prior to delivery, this is considered pretreated.

J. REFERENCES

1. When is LP indicated in term infants?

Johnson, et al. Term newborns who are at risk for sepsis: are lumbar punctures necessary? Pediatrics 1997; 99(4):e10

2. Blood culture volume needed.

Schelonka et al. Volume of blood required to detect common neonatal pathogens. J. Peds 1996; 129:275-8.

3. Blood culture time to positivity.

Kumar et al. Time to positivity of Neonatal blood cultures. Arch Dis Child Fetal Neonatal Edition 2001; 85:F182-186

Garcia-Prots et al. Rapid detection of microorganists in blood culture of newborn infants utilizing an automated blood culture system. Pediatrics 2000; 105:523-527

4. Effect of antibiotics on time of presentation

Bromberger et al. The influence of antibiotics on the clinical spectrum of early-onset GBS infection in term infants. Pediatrics 2000; 106:244-250

5. CRP references

Ehl et al. C-reactive protein is a useful marker for guiding duration of antibiotic therapy in suspected neonatal bacterial infection. Pediatrics 1997; 99:216-228

Benitz et al. Serial serum C-reactive protein levels in the diagnosis of neonatal infection. Pediatrics 1998; 102 (4):E41-51 URL

Bomela et al. Use of C-reactive protein to guide duration of empiric antibiotic therapy in suspected early neonatal sepsis. Pediatr Infect Dis J. 200;19(6):531-5.

Primary Author: David E. Woodrum, M.D. Professor Contributing Author: Dennis E. Mayock, M.D. Associate Professor


MORPHINE DRIP GUIDELINES

A. There are no suitable objective pain guidelines scales for the population under consideration; accordingly, treatment criteria listed below are largely empirical.

B. Recommended treatment guidelines include:

High frequency ventilator patients

Any ventilator patient who is not “in sync” with the ventilator

Any pain-associated situation (e.g., postop patients, chest tube/central line placement,

patients with fractures)

C. Documentation of the presence of a morphine drip is not sufficient. It is imperative that the reason the treatment was initiated, the response to initiation of medication, rationale for continuing and/or weaning it, and finally the rationale for discontinuing it should be clearly established in the medical record at the appropriate time. It is the responsibility of the attending physician to monitor and ensure such documentation is present.

D. Documentation should include:

Caremap entry

Nursing note, daily

Resident note, daily

Attending note mentioning the presence of a morphine drip and rationale several

times/week


IX. RBC TRANSFUSION GUIDELINES

A. TRANSFUSE FOR HEMATOCRIT < 20%:

• In an asymptomatic infant, if reticulocytes <100,000/uL. B. TRANSFUSE FOR HEMATOCRIT < 30% IF:

• requires oxygen, but < 35%

• on CPAP or positive pressure ventilation with mean airway pressure < 6 cmH20

• significant apnea and bradycardia while on methylxanthines (>9 episodes in 12 hours or 2 episodes in 24 hours requiring mask and bag ventilation)

• if heart rate > 180 beats/min or respiratory rate > 80/min and persists for 24 h

• weight gain < 10g/d over 4 days despite adequate calories

• sepsis C. TRANSFUSE FOR HEMATOCRIT < 35% IF:

• requires oxygen, > 35%

• intubated on CPAP or positive pressure ventilation with mean airway pressure > 6 cmH20

D. TRANSFUSE FOR HCT LESS THAN OR = 40%

Repeat transfusion from a previously used unit These are guidelines arrived at by a consensus of the Neonatologists of the University of Washington. We encourage any thoughtful variations from these guidelines. Modified from: Shannon KM, et al. Recombinant human erythropoietin stimulates erythropoiesis and reduces erythrocyte transfusions in very low birth weight preterm infants. Pediatrics 1995;95:1-8.


X. GUIDELINES FOR CRANIAL ULTRASOUNDS IN PREMATURE INFANTS

Rationale MRI is the diagnostic method of choice to detect intraventricular hemorrhage (IVH) and white matter disease (WMD) in the premature infant. However, cranial ultrasound can be completed at the infant’s bedside and provides adequate information to guide clinical care.

Intraventricular Hemorrhage The incidence of IVH in infants <1000 gms is 50-60%, and in infants 1000-1500 gms, the incidence is 10-20%. Approximately 90% of IVH occurs by the 4th postnatal day with 50% occurring on the first postnatal day. Approximately 20-40% exhibit progression of hemorrhage over 3-5 days. Infants with IVH are at risk for hydrocephalus and white matter injury.

White Matter Disease White matter disease includes two primary lesions, periventricular leukomalacia (PVL) and periventricular hemorrhagic infarction (PVHI). PVL occurs in about 3-4% of infants of birthweight <1500 gms and PVHI occurs in approximately 10-15% of infants of birthweight <1000 gms. PVL occurs in relatively larger premature infants as the most vulnerable time for white matter injury is between the 28th and 32nd weeks of gestation. PVHI occurs at younger gestational ages and birthweights as it is associated with more severe IVH. WMD is associated with prolonged rupture of membranes and chorioamnionitis and may be associated with maternal cocaine use. WMD is often detectable on early ultrasounds as either an echodensity or echolucency but may not become apparent for 1-3 weeks after the initiating event when cysts begin to form. The echolucencies may then disappear after 1-3 months, leaving enlarged ventricles.

Guidelines for Obtaining Screening Cranial Ultrasounds Day of Life

3-5 10-14 28 prior to discharge

<1000 gms * * * *

1000-1250 gms * * *

1250-1500 gms * *

Selected References 1. Perlman JM. White matter injury in the preterm infant: an important determination of abnormal

neurodevelopmental outcome. Early Hum Dev 1998;53(2):99-120. 2. Volpe JJ. Neurology of the newborn. 3rd Ed. 1995, Philadelphia: WB Saunders. xiv, 876. 3. Volpe JJ. Brain injury in the premature infant – from pathogenesis to prevention. Brain Dev

1997;19(8):519-534. 4. Perlman JM, Risser R, Broyles RS. Bilateral cystic periventricular leukomalacia in the

premature infant: associated risk factors. Pediatrics 1996;97(6 Pt 1):822-827. 5. Perlman JM, Rollins N. Surveillance protocol for the detection of intracranial abnormalities in

premature neonates. Arch Pediatr Adolesc Med 2000;154:822-826.


TIPS ON LINES UAC PLACEMENT

1. Length = 2 cm + (distance from umbilicus to acromio-clavicular joint) 2. X-ray: want tip at T7-T10 (preferred) or L3-4 (low line) 3. Place 2 retention sutures at the time you stitch in the line, but only use one. Leave the other one

in until after the x-ray in case you have to pull the line back. 4. Check line tip position on CXR before using a UAC

PULLING UAC’S

Turn off the line, pull it to within 5 cm of the skin surface, let it sit for 15-20 min. to clot off and then remove it. Have a clamp, forceps, or umbilical tape available. Elevate the umbilical stump to apply pressure to a bleeding UA (it’s harder to stop the bleeding by pushing the stump into the abdomen).

UVC PLACEMENT

1. Length: insert just until you get blood return or to a length = (distance from acromio-clavicular joint to umbilicus minus 4cm).

2. Don’t use a long line in a DR code since they often get coiled up in the liver and other places you didn’t want them to go.

3. Check a CXR before using a UVC (want tip at diaphragm or T9 vertebral body). PAL LINES (PERCUTANEOUS ALIMENTATION LINE), see PICC information sheet

1. Thin, peripherally placed central venous lines for infusion only 2. Used for medium term central IV access 3. Insertion is percutaneously or by cutdown procedure by trained personnel. Contact charge nurse

who will assign PICC team member. 4. Requires ~ 2 units/hour of heparin to keep patent. 5. May be heparin locked like a peripheral IV though this may shorten its lifespan


PICC INFORMATION PICC: PERIPHERALLY INSERTED CENTRAL CATHETER

The neonatal PICC is a venous access device 28g or 24g in diameter 14cm – 30cm in length It is made of soft, flexible polyurethane It is inserted into one of the superficial veins of the arm, leg or scalp, and advanced into the central venous system.

UWMC NICU PICC PLACEMENT TEAM

Specially trained RN’s or NNP’s are available to place PICC’s when medically indicated (and with Attending approval)

IF YOU DESIRE A PICC PLACED IN AN INFANT

Check with Attending for approval Obtain written consent from parent of infant for PICC placement (phone consent is ok if urgent)

**be sure to cover potential complications and indicate this on the consent form** Discuss with Charge Nurse when a PICC nurse will be available to place line. Write orders for PICC placement (see example below)

1. Please place PICC 2. CXR for placement (PA, LAT, or left anterior oblique) with Omnipaque 300 contrast medium 3. Heparin infusion 500 units in 25 mL D5W to run at 0.1 mL/hr (= 2 units heparin/hr)

In addition, the PICC nurse may request a sedation order prior to insertion (for the infant, that is). Typically this would be Morphine IV 0.05 mg/kg – may repeat x1 After placement, the PICC nurse is required to have placement confirmed by having the Resident view the CXR. Ideal placement: catheter tip should be positioned in the SVC (but never in the atrium) If the saphenous vein was used for insertion – the ideal position should be @ T9 - T10

If PICC’s are not in ideal position, discuss options with PICC nurse A PICC line may be heparin-locked but this may last only a few days before the line clots off. 28g PICC’s are very small (twice the diameter of a human hair) and have been known to clot off within/less than 24 hrs after being heparin locked. A PICC nurse should discontinue the PICC when no longer needed (or not functioning properly). If a PICC nurse is not available, the PICC may be discontinued by a Resident (after reading the procedure in the P&P manual).


NICU NUTRITIONAL GUIDELINES I. METHODS OF MONITORING GROWTH AND NUTRITION

A. Daily weights (after 1st week of life, goal should be 15 gm/kg/day weight gain averaged over several days)

B. Weekly length (after 1st week of life, linear growth should average 0.5-1 cm/wk)

C. Weekly OFC (after 1st week of life, head growth should average of 0.5-1 cm/wk)

D. Nutritional panel* (this is a standing order for all infants receiving TPN regardless of

birthweight and is obtained on a weekly basis every Sunday night; then is obtained on a monthly basis when on full enteral feeds). Nutrition panels are drawn with Sunday night weekly blood draws.

* Nutritional panel measures albumin, prealbumin, calcium, phosphate,

alkaline phosphate, direct bilirubin, triglycerides, vitamin A, vitamin E, and retinol binding protein.

II. PARENTERAL NUTRITIONAL SUPPORT (TPN) A. Initial fluid support for infants ≤ 2000 grams birth weight

• D10W with 2.5% Trophamine solution to run at 80 mL/kg/day o Do not exceed 80 mL/kg/day of this solution

• If more fluid support indicated, wye in desired extra fluid in addition to D10W with 2.5% Trophamine solution.

B. Indicated in the following situations:

For any newly born infant including with birthweight <1500 gm unable to tolerate enteral feeds at a rate of at least 75 mL/kg/24h

For any infant with bodyweight <1500 gm unable to tolerate enteral feeds for >24 hr For any infant of any weight unable to tolerate enteral feeds for >48 hr

C. TPN compositional guidelines (Goal for parenteral nutritional support is 90-100 kcal/kg/day)


GLUCOSE*

Birthweight Initial concentration & rate Rate of advance

<1000 gms 4-6 mg/kg/min 1-2 mg/kg/24hr 1001-1500 gms 6-8 mg/kg/min 1-2 mg/kg/24hr

>1500 gms 6-8 mg/kg/min 1-2 mg/kg/24hr

* IV glucose load initiated shortly after birth; the glucose index is used to calculate IV

glucose load: (% glucose) x mL/kg/24hr 144

Blood glucose should be followed following the initial phase of IV glucose infusion with serial blood glucose measurement

LIPIDS (necessary to meet fatty acid requirements & to provide non-carbohydrate calories)

Day of TPN gm/kg/24hr (Intralipid) Comment

1 1 2 1.5 3 2 4 2.5 5 3 (max)

Assess lipid tolerance with triglyceride level >200, hold for 6 hours and restart at 1.5 g/kg/day. Intralipid is decreased to 1.5 gm/kg/24hr when infant is at 50% of full enteral feeds (i.e. 75 mL/kg/24hr); and Intralipid is discontinued when infant is at 75% of full feeds.

AMINO ACIDS

Day of TPN gm/kg/24hr (amino acids)

1 1.5

2 2 3 2.5

4 3 for infants > 1800 grams

3.5 for infants ≤ 1800 grams Term infants may need only 2.5

For more mature infants (in terms of postnatal or gestational age at birth) one might initiate amino acids at a higher level (e.g. 1.5-2 gm/kg/24hr)

D. Electrolytes/vitamins/minerals/trace minerals

See TPN order form for recommended doses III. ENTERAL NUTRITIONAL SUPPORT

A. Consider initiating very small volume enteral feeds during the 1st several days of life (example 10-20 mL/kg/24hrs); depending on infant’s clinical status; such non-nutritive feeds may have beneficial effect on GI function.


B. When increasing enteral feeds, do it slowly (e.g 10-20 mL/kg/24hrs); for mature, stable infants the advance may occur more rapidly, with care. Goal for caloric support via enteral feeding is 120 kcal/kg/day.

C. Formula/Milk

Birthweight ≤ 2000 gm Birthweight ≥ 2001 gm

Initially use breast milk (BM) (20 cal/oz) if possible plus a fortifier*

If no BM, then use Similac Special Care

(24 cal/oz) Generally change to BM or standard

formula (20 or 24 cal/oz) when infant’s weight >2 kg; exception=poor bone mineralization, slow incremental weight gain etc; then continue hypercaloric formula(24 cal/oz) until infant’s weight= 2.5-3 kg.

BM (20 cal/oz) or standard formula (20 cal/oz)

* Fortifiers Similac Natural Care (liquid): add when infant is at ½ full feed; BM + fortifier = 22 cal/oz Similac HMF (powder): change to this at 1 month postnatal age; BM + fortifier = 24 cal/oz

D. Vitamins

For infants with birthweight < 2 kg; UWMC low birthweight vitamins (Trivisol + vitamin E), discontinue this when infant’s weight is 2 kg. For infants with birthweight >2 kg and receiving standard formula or unfortified breast milk; Pediatric Multivitamin.

E. Iron

For infants with birthweight < 2 kg; 2-4 mg/kg/24hr by 1-2 months of postnatal age. For infants with birthweight > 2 kg; standard formula with iron – no supplementation needed.

For infants being fed BM: 2-4 mg/kg/24hr.


NEWBORN HEARING SCREENING

KELLI LAHARGOUE, MS, CCC-A

AUDIOLOGIST Pager: 206-598-1290

Voicemail: 206-598-2597 Box: 356161

E-mail: [email protected]

PATRICK FEENEY, PhD, CCC-A

CHIEF OF AUDIOLOGY Pager: 206-598-8635 Phone: 206-598-4022

Box: 356161 E-mail: [email protected]

ROUTINE COVERAGE Monday 1pm-5pm Tuesday 8am-5pm, including discharge rounds Wednesday 8am-12pm Thursday 1pm--5pm Friday 1pm-5pm NOTE: Additional times may be available (depending on Audiologist availability) *** TO SCHEDULE BAER *** Call KELLI (voicemail: 598-2597) and leave name of baby to be tested RISK INDICATORS (2000 JOINT COMMITTEE) 1. Any illness or condition requiring admission of 48 hours or greater to a NICU 2. Family history of hereditary childhood sensorineural hearing loss 3. In-utero infection, such as cytomegalovirus, rubella, syphilis, herpes, toxoplasmosis 4. Craniofacial anomalies, including those with morphological abnormalities of the pinna and ear canal 5. Hyperbilirubinemia at a serum level requiring exchange transfusion 6. Postnatal serious infections, including meningitis 7. Apgar scores 0-4 at 1 minute or 0-6 at 5 minutes 8. Mechanical ventilation lasting 5 days or longer 9. Aminoglycosides used in multiple courses (greater than 2) 10. Aminoglycosides used in combination with loop diuretics (ethacrynic acid, furosemide) 11. Physician order for reasons other than the above risk criteria 12. Persistent pulmonary hypertension of the newborn 13. Any condition requiring ECMO 14. Syndromes associated with progressive hearing loss such as neurofibromatosis, osteopetrosis, and

Usher’s syndrome (later workup) 15. Stigmata or other findings associated with a syndrome known to include a sensorineural or conductive

hearing loss or Eustachian tube dysfunction (later workup) 16. Neurodegenerative disorders such as Hunter syndrome, or sensory motor neuropathies such as a

Friedreich’s ataxia and Charcot-Marie-Tooth syndrome (later workup) 17. Head trauma (later workup) 18. Recurrent or persistent otitis media with effusion for at least 3 months (later workup) 19. Parental or caregiver concern regarding hearing, speech, language, or developmental delay


FOLLOW-UP PROTOCOL SCHEDULES (NOTE: ages to be followed at are corrected age) Follow-Up of Babies Screened in the NICU

Failures:

An infant who does not pass the initial screening test will be scheduled for a follow-up evaluation at 4-6 weeks after discharge from the hospital.

Pass but at risk:

An infant who passes the initial screening but is at risk for progressive or late onset hearing loss due to a history of PPHN, ECMO support, CMV, or TORCH will be followed at: 3 months, 12 months, and yearly evaluations until school age

Pass but at risk:

An infant who passes the initial screening but there is a family history of congenital hearing loss or is identified with a syndrome that has associated hearing loss will be followed at: 12 months, and yearly evaluations until school age

Clinical Diagnostic/Follow-Up Program for Hearing Impaired Children

1. Initial diagnosis takes at least 2 visits, with counseling session with parents as part of last visit or

separate visit (phone call to parents the week following diagnosis to assist with referrals, answer questions)

2. Monitoring/continuing diagnostics every 3 months until hearing is stable 3. Every 6 months for the first 3 years of life 4. Yearly evaluations in preschool 5. Yearly evaluations during school age

These are basic guidelines for children with sensorineural hearing impairment. If there are concerns that

hearing is changing, evaluations will be scheduled more frequently.


SUGGESTED FORMAT FOR AN ADMIT NOTE ID: Wt, EGA, SGA/AGA/LGA, sex, major problems Referring MD & Hospital and/or OB referring MD & Hospital: MOM: Age, marital status, race, SAB TOP, medical problems, STD Hx, meds, ETOH, cigs, drugs (including IVDA), PN labs, hepatitis status. PREGNANCY: Review of dates, nutrition, wt gain, prenatal care, infections, fevers, Bleeding, PTL. LABOR: Onset, ROM (spontaneous vs. assisted, meconium/clear/bloody), tocolytics, betamethasone, antibiotics, ?amnionitis (temp WBC, tenderness), FHRT/monitor, FP, LS. DELIVERY: Type, forceps, suction, type of suctioning, anesthesia, meconium, nuchal cord, placenta (i.e. abruption, calcification, etc.). RESUSCITATION: Initial HR, color, respiratory effort, suction, blowby O2, bag, ETT, APGARS, transport to NICU. SH: FH: EXAM: LAB: Include Dubowitz, length, and OFC with vitals. A/P: PROGRESS NOTES: There is no single correct format or outline for daily progress notes. The purpose of a progress note is to document 1) your physical exam; and 2) your understanding of the patient’s current problems, their progression and your management plan for this problem. Repeating information gleaned from the nursing flow sheets, the lab computer and the medication list is helpful only as an aid to the above two goals. Merely documenting a physical exam and signing the computer printout is not appropriate. Patients on ICU status need a detailed progress note daily. Patients on IM status need a brief 3 line daily note and 2 times a week or more detailed summary of their current problems, their course and overall plans. DISCHARGE SUMMARIES: The purpose of a discharge summary is primarily to inform the follow-up physician of current issues and their management. Though the follow-up physician may have received copies of all interim summaries it is unlikely they will have read them or that they will ever read them. As a consequence the key problems and events of the infant’s neonatal course should be briefly summarized and current issues concisely addressed in a bit more detail. Discharge summaries should be approximately 2 pages in length or less. Contents: Discharge date and discharge attending physician

Patient identification information Problem List including current and resolved problems List of current medications List of lines and tubes currently in place Summary of current enteral intake Health care maintenance screening examinations completed (ROP, cranial ultrasound, state lab newborn testing results, hearing assessment, etc.) Immunizations administered (hepatitis B, RSV prophylaxis, etc.) History of present illness Maternal history (illnesses, medications, etc.) Labor and delivery summary System review of current active problems Disposition plan (Follow-up physician name, address and phone, scheduled visit date. etc.) Discharge physical examination with current weight, length and OFC Name of individuals to receive copies of discharge summary

If corrections to summary are necessary, please make corrections prior to electronically signing the summary. If corrections are necessary after the summary is finalized and signed, please dictate the corrections as an addendum.


Complete medical record face sheet including list of diagnoses, follow-up arrangements, and listing of discharge medications.


March 17, 2005 Thomas Strandjord, M.D. UWMC, Perinatal/Neonatal CQI Committee Guidelines for when to request availability of anesthesiologist at a newborn resuscitation: Any member of the resuscitation team who has concerns about the airway management of a newborn should request availability of the obstetric anesthesiologist on-duty if a neonatology attending or fellow is not readily available. Examples of when it would be appropriate to request the presence of an anesthesiologist include: anticipated abnormal airway anatomy, failed intubation attempts, or any time a pediatric team would like back-up with managing a depressed newborn. The anesthesiologist will not be expected to manage the resuscitation, but only assist with airway management if that is necessary. March 17, 2005 Thomas Strandjord, M.D. UWMC, Perinatal CQI Committee Who is in charge in a newborn resuscitation: 1. When called to attend a delivery the pediatrics team has primary responsibility for

managing a newborn resuscitation. 2. Pediatrics will be routinely called to attend deliveries in the following situations:

a) Pregnancies less than 34 weeks gestation b) Concerns about a non-reassuring fetal heart rate tracing or fetal condition during

labor c) Any time there is meconium staining d) Any time there is a major congenital anomaly e) Multiple gestation deliveries f) C-section deliveries g) Whenever requested by the delivering physician

3. The senior pediatric resident or neonatology fellow should introduce themselves to the

obstetricians and family (when possible) when they arrive to resuscitate a newborn. 4. In the absence of a pediatric attending or neonatology fellow, if an obstetrics or

anesthesiology attending decides to take responsibility and manage a newborn resuscitation, the pediatric residents should defer to his or her judgment.


Neonatal Attending Physician Attendance at Deliveries The NICU attending should be notified in advance of impending deliveries involving: 1) <30 weeks gestation fetus; 2) multiple gestation delivery; 3) delivery with known fetal anomalies; 4) delivery with documented intrapartum distress; 5) complicated maternal medical problem regardless of gestational age A decision by each attending to be present for other deliveries would be made after taking various impacting issues into consideration (categories 2-5 above). The attending physician should be present if possible at all deliveries of fetuses whose estimated gestation age is under 28 weeks.


INFANT ABDUCTION (“NEWBORN EMERGENCY”) NICU RESPONSIBILITIES I. IF YOU OBSERVE OR ARE TOLD THAT AN INFANT ABDUCTION MAY HAVE OCCURRED

1. Quickly search each room and account for infants. Call 6S and 6E to search for infant. 2. Dial 222 and inform the operator that a suspected abduction has occurred. Request that

the Infant Abduction Announcement be made. Tell the operator the location of the abduction.

3. Then dial 9-911 to report the suspected abduction to UW Police. 4. Overhead page will be announced, “(location) STAT, NEWBORN EMERGENCY TEAM,

(location) STAT” 5. All available Medical Center Staff, including at least one person from each area, will stand

by the exits in their area. 6. Staff should remain at their exit until the “All Clear” is paged.

a. DETAIN ANY PERSON CARRYING WHAT MAY BE THE ABDUCTED INFANT

by stating to that person, “There has been an emergency in the Medical Center and exits are closed at this time. Please wait here until we get clearance.”

b. ALLOW THE PERSON TO PASS THROUGH IF THEY REFUSE TO STAY IN THE BUILDING. Get a physical description and direction of travel . . . report to police at 9-911.

SIMULTANEOUSLY OCCURRING ON THE UNIT WHERE ABDUCTION HAS TAKEN PLACE (These tasks may be delegated to charge nurse, staff nurse, nurse manager, USC, etc.):

7. Call Social Worker 8. Move mother to another room to tell her of the abduction. Stay with her until social worker

arrives. 9. Isolate the bedside (or area where abduction occurred). 10. Assist with Security and Police. 11. Reassure other parents.

II. HOW TO RESPOND

1. When you hear NEWBORN EMERGENCY TEAM STAT you should: Immediately go to the exit assigned to your department State to anyone fitting the profile of an abductor or who may be carrying a large

package or bag: “There has been an emergency in the Medical Center and exits are closed at this time. Please wait here until we get clearance.”

If a person refuses to wait, allow them to pass. Get a physical description and direction they are traveling and report it to security.

III. INFANT ABDUCTION AWARENESS

1. Profile of a typical abductor Female, age 15-45 Often overweight, low self esteem Emotionally disturbed over loss of pregnancy, child, or inability to have

children Seeks an infant to repair a strained relationship Frequently lives in same community where the abduction occurs Has carefully planned the abduction, often impersonating hospital staff to gain

access to an infant


Interpretation of Retinopathy of Prematurity Examination (4/2005)

The international classification of Retinopathy of Prematurity (ROP) is based on three considerations:

A. The location of the area of abnormal vascular growth on the retina in relation to the optic disc.

Zone I: This is the most posterior and intimately related area of the retina to the optic

disc; Abnormal vascular proliferation in this area is associated with worrisome prognosis.

Zone II: Zone II involves the more peripheral area of the retina, extending from the edge of Zone I nasally to the ora serrata. Abnormal vascular proliferation involving Zone II is associated with a variable prognosis, less serious than Zone I, but still of concern.

Zone III: This area of the retina is anterior and even more peripheral to Zone II. It is the last portion of the retina to be vascularized normally. Vascular proliferation noted in Zone III is usually associated with a benign prognosis.

B. The second component of the international classification of ROP is the extent of the

problem circumferentially, recorded in clock hours. The more extensive the involvement, the worse the prognosis.

C. The final component of the international classification is based on the stage of the

problem.

Stage I: The appearance of the demarcation line, a structure that separates the avascularized retina from the vascularized retina is altered in Stage I ROP. Vessels are seen to branch into abnormal arcades leading up to the demarcation line. The prognosis associated with ROP limited to Stage I is benign.

Stage II: The determination of Stage II ROP is made when the height, width and the volume of the demarcation line is increased. Once again, Stage II ROP is usually associated with a benign prognosis and the problem regresses.

Stage III: A determination of Stage III ROP is based on extra-retinal proliferation of vascular material along the demarcation line. A determination of Stage III ROP is associated with an increasingly worrisome prognosis.

Stage IV: Stage IV ROP is a catastrophic determination that indicates retinal detachment and possible severe visual loss.

D. Plus Disease: Is a determination that is made by the ophthalmologist at the time of

retinal examination that indicates increased vascular engorgement in the posterior pole of the fundus. This is a determination that is ominous in terms of progression of ROP; it is indicative of the development of vascular shunts.

E. Threshold ROP: Is the stage and extent of ROP at which the likelihood of severe visual

loss without treatment is 50% and at which treatment (laser or cryo) is indicated according to the 1988 CRYO-ROP study (Typically Stage III plus in 5 contiguous or 8 non-contiguous clock hours.) The CRYO-ROP indications were based on anatomic outcomes but more recently the Early Treatment for Retinopathy of Prematurity Randomized Trial found better visual results with earlier treatment. Treatment should be considered for ROP as follows: Zone I(any stage with plus disease), Zone I (any stage 3), or Zone II (stage 2 or 3 with plus disease).


Web Tools NICU-WEB: http://neonatal.peds.washington.edu/ An online series of protocols and suggested guidelines for care of the

neonate at the University of Washington Neonatal Intensive Care Unit Neonatology on the Web: http://www.neonatology.org/ An online resource for neonatology. Vermont-Oxford Network: http://www.vtoxford.org/ An online database of neonatal care and outcome statistics. University of Washington Healthlinks: http://healthlinks.washington.edu/ An online resource with links to health care information for patients of all

ages. eJournals: http://healthlinks.washington.edu/contentBrowser.jsp University of Washington electronic journal access link. PubMed: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?CMD=Pager&DB=pubmed National Library of Medicine medical literature research tool. NICHD Cochrane Neonatal Reviews: http://www.nichd.nih.gov/cochrane/default.cfm Online resource for systematic reviews of neonatal care. Genetests: www.genetests.org Online resource of genetic information for health care providers.

http://neonatal.peds.washington.edu/

http://www.neonatology.org/

http://www.vtoxford.org/

http://healthlinks.washington.edu/

http://healthlinks.washington.edu/contentBrowser.jsp

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?CMD=Pager&DB=pubmed

http://www.nichd.nih.gov/cochrane/default.cfm

http://www.genetests.org/


6-7-05 BLOOD COMPONENT ORDERING AND ADMINISTRATION GUIDELINES FOR ADMINISTERING BLOOD PRODUCTS AT UWMC A. COMPONENTS

Packed Red Blood Cells (PRBCs)

Divided units of PRBCs (Pedi-packs) Assigned Pediatric Aliquots

Platelet Concentrate Fresh Frozen Plasma Cryoprecipitate

B. COMPONENT-SPECIFIC GUIDELINES FOR ADMINISTRATION 1. COMPONENT: PACKED RED BLOOD CELLS

Description: Concentrated red blood cells with most plasma and platelets removed. (Aka”PRBCs”) No functional platelets. For NICU patients (< 4 mo old) use CMV-safe (either leukocyte-depleted or CMV-negative), Hgb S negative PRBCs, irradiated at time of issue for routine transfusions. O-negative PRBC unit stored for use in a “Bleeding Emergency” is not irradiated to decrease risk of hyperkalemia.

Administration:

• Full (“adult-sized”) RBC units (250 or 350mL) Preservatives: • RBC AS-5 250 ml (Optisol) – standard preservative Average volume 350mL/unit Average Hct=57% • RBC CPD 250 ml - for large volume transfusion to children <4 Mo

and to accompany patient to OR where bleeding is a risk (DO NOT USE FOR ROUTINE TRANSFUSION).

Average volume 250 mL/unit Average Hct=72%

• RBC CPD DIvided, aka “Pedi-packs” (60mL each) • ¼ CPD-preserved PRBC unit • Average Hct =72% • Up to 4 units ordered AT THE SAME TIME will be issued from the

same donor. • RBC AS-5 Divided (30-40mL each)

• 1/8 AS-5-preserved PRBC unit • Average Hct=57% • From the 8 units created in each set, request ONLY the number of

units needed that day • Remaining units not sent to the University are held at PSBC for

exclusive use of the recipient for 40-42 days • Initial order is not available for emergency transfusion • Takes 4 hours to prepare initial order • Donor exposure is minimized, as all 8 aliquots are from the same

donor


Indications: Severe anemia; surgical blood loss; suppression of Erythropoiesis (e.g., thalassemia or sickle cell anemia)

For preoperative orders, where emergency blood may be needed, e.g. PDA ligation,

order: 1 unit Full Packed Red Blood Cells (250 mL), CMV negative, irradiated, Hgb S negative (the “adult-sized” unit is preferred as it can be returned to the Puget Sound Blood Center if not used).

Dose: Usual dose is 10 to 20 mL/kg. (1 mL/kg will increase hematocrit by approximately 0.5 to

0.7%).

Rate: 5mL/kg/hour; 2mL/kg/hour if patient has incipient congestive heart failure. (Note you may not hang blood components greater than 4 hours at room temperature.)

Filter: Hemo-Nate Filter (18 Micron)

Tubing: Hemo-Tap Valve (Blood Bag Spike with stopcock)

Baxter/Blood component straight type blood set (MN 101375) Syringe pump 60-inch macro-bore extension tubing set

2. COMPONENT: PLATELETS

Description: Platelets suspended in small amount of plasma (average volume 50-70 mL/unit). (Cannot be refrigerated)

Indications: Severe thrombocytopenia (platelet count <20,000) Platelets count< 50,000 in patients who require surgery or in patients with active

hemorrhage, risk of imminent bleeding or increased risk for intraventricular hemorrhage (< 32 weeks post-conceptual age).

Dose: 20 mL/kg (1 unit for every 10-kg body weight will increase platelet count by 50,000 per mm3.)

Infants < 3.5 kg

Order 1 unit of CMV-negative, irradiated platelets. administer 20 mL/kg

Infants ≥ 3.5 kg: Order 2 units of CMV-negative, irradiated platelets Administer 20 mL/kg If the infant is volume sensitive, volume reduced platelets can be used. However, full volume platelets are preferred because the process of volume reduction activates platelets, causing degranulation, making them less effective.

Dose for volume reduction: Infants < 2 kg:

Order 1 unit of volume-reduced CMV-negative, irradiated platelets. Reduce volume to 20 mL Administer 10 mL/kg

Infants 2-4 kg: Order 1 unit of volume-reduced CMV-negative, irradiated platelets Reduce volume to 10 mL/kg Administer 10 mL/kg Infants >4 kg:


Order 2 units of volume-reduced CMV-negative, irradiated platelets Reduce volume to 10 mL/kg Administer 10 mL/kg

Rate: Administer no faster than 2-3 mL/minute via syringe pump. If volume overload is a problem,

administer total dose over 1 to 2 hours via pump or request volume reduced platelets.

Tubing: Baxter/Blood Component Straight Type Blood Set (MN 101375) Syringe pump 60-inch macro-bore extension tubing set 3. COMPONENT: FRESH FROZEN PLASMA

Description: Portion of blood that contains clotting factors and proteins. Adult unit = 250 mL, pediatric unit = 50 mL. (May use type AB plasma in emergency. Can be refrigerated up to 24 hours.)

Indications: Massive hemorrhage Multiple clotting deficiencies (e.g. liver disease, disseminated intravascular coagulation) Dose: Acute hemorrhage: 15-30 mL/kg Clotting deficiency: 10-15 mL/kg May be repeated up to 3 times each 24 hours as necessary. Monitor for congestive heart failure secondary to volume overload. Rate: Hemorrhage: As indicated by patient’s condition Clotting Deficiency: over 2 to 3 hours

(Thawed FFP has a 24-hour expiration, as long as it is kept refrigerated, otherwise it expires 4 hours after the bag is spiked.)

Tubing: Baxter/Straight Type Blood Component Recipient Set (MN 101375) Syringe pump 60-inch macro-bore extension tubing set 4. COMPONENT: CRYOPRECIPITATE

Description: Concentrated Fibrinogen (15 mL/unit, must be used within 6 hours of thawing, do not refrigerate)

Indications: Hypofibrinogenemia Disseminated intravascular coagulation

Dose: <2.5 kg => 0.4 unit (6 mL) per kg body weight 2.5 –5 kg => 1 unit (15mL) 5-10 kg => 1-2 units

Infants who can tolerate or who need extra intravascular volume, administer as much of the unit as tolerated to reduce donor exposure.

Rate: Via syringe or drip as rapidly as solution will infuse.

Administer within 6 hours of thawing

Tubing: Baxter/Blood Component Straight Type Blood Set (MN 101375) Syringe pump 60-inch macro-bore extension tubing set


Antiseptic use in the NICU University of Washington Medical Center

3/17/05

Povidone-Iodine swabs: Used for all medical procedures. Please note the following: UAC/UVC placement: Apply povidone-iodine to cord and

1-2 centimeters around base of cord x 3 applications. Sterile towels will be used to cover the untreated areas. Lumbar puncture: Prep as small an area as possible. Completely remove all antiseptic from the skin after the procedure using sterile water or sali-wipes. Goal is to minimize Povidone-Iodine absorption.

Chlorhexidine: Not used for medical procedures at this time. There is an increased risk of abdominal/back burns on premature infants 24 to 26 weeks gestational age. Chlorhexidine is used for PICC line placement, blood draws, and IV placement only. Basically, it is only used for nursing procedures. Alcohol: Not used on the skin of preterm infants.


Guidelines for Management of a Newborn with a Meningomyelocele

Background: These guidelines are based on a combination of evidence, expert opinion and clinical experience. New information may come along at any time. We will do our best to update these guidelines and welcome input.

Most fetuses with meningomyelocele and hydrocephalus are now recognized by prenatal diagnosis. Prenatal diagnosis allows time for counseling and thoughtful consideration by each family about the outlook for each embryo or fetus. These guidelines are intended to assist health professionals in optimally managing the meningomyelocele in fetuses whose parents have chosen to continue pregnancy.

As of February 2003, a national multicenter randomized trial of in utero meningomyelocele repair began recruiting patients. Three centers around the country with experience are involved in the study (Vanderbilt, Childrens Hospital of Philadelphia, University of California at San Francisco). No center in the country plans to provide in utero repair outside the randomized trial in hopes of collecting data as rapidly as possible regarding the relative efficacy of in utero repair at 19-25 weeks compared to term. Infants delivered at or near term will be delivered by C-section without a trial of labor at one of the study sites. For more details see the study website: www.spinabifidamoms.com (good as of February 26, 2004).

All newborns will benefit from sterile management and consideration for closure of their open lesions within 24 to 48 hours of birth. A serious breach of sterility may be a reason to defer treatment. The presence of other life-threatening anomalies may be reason to defer treatment indefinitely. The evidence for a better motor level and ambulatory outcome following prenatal diagnosis, and delivery by C-section without a trial of labor in fetuses who have a bulging lumbosacral meningomyelocele and in utero motor function in the affected spinal cord segments is primarily derived from the ongoing series accumulated by our own group. These fetuses must be distinguished from those who have either a flat meningomyelocele lesion or a large lesion with no motor function below T12. These other types of myelomeningocele often do not benefit from C-section delivery. It is also important to recognize and distinguish fetuses who have secondary neural tube defects. These individuals have skin-covered lesions. Such lesions may be large enough on occasion to require C-section because of obstruction of labor, but there is no evidence that C-section delivery is needed routinely or that any benefit will accrue in terms of motor function. Such fetuses can often be recognized by the absence of any brain involvement (no hydrocephalus, no Chiari II malformation), the location and characteristics of the mass itself and/or the presence of abdominal wall defects such as extrophy of the cloaca that do not occur with meningomyelocele. Neonates with secondary (skin-covered) neural tube defects do not need to be managed under sterile conditions and usually do not need immediate neurosurgical closure. The usual management is to see the neonate on consultation in the newborn nursery to make a diagnosis, and look for other anomalies that may need attention. We see the child back in clinic at about two months of age with plans to surgically intervene when the child is 4 to 8 months of age. It is also very important to recognize that the counseling about recurrence risks is totally different for secondary neural tube defects and that folic acid supplementation is not protective. As folic acid supplementation and prenatal diagnosis/termination reduce the incidence of meningomyelocele, but not secondary neural tube defects, the latter will occupy our attention more of the time. Ron Lemire is a world expert on the embryology and occurrence of secondary neural tube defects and we have developed considerable experience in managing them. If there is ever a question about these issues, please feel free to contact the Congenital Defects and Neurosurgery faculty on the team. 1.) Guidelines for the obstetric provider who is the first to become aware of a fetus with meningomyelocele

Arrange for counseling, including information about fetal repair, delivery by C-section and other maternal care issues if the family is interested in continuing the pregnancy. This can be done through the Prenatal Genetics Clinic at UW, phone number 206-598-8130 or another perinatal center convenient to the family. Patients may be referred from other institutions directly to pediatric faculty in the Neurodevelopmental/Congenital Defects program (usually Dr. Shurtleff) for discussions that focus on the outcome of the infant in relation to obstetrical management. Families wishing to obtain more information about the postnatal care and prognosis for children with meningomyelocele can also be referred to the pediatric faculty in the Neurodevelopmental/Congenital Defects program at CHRMC: 4800 Sand Point Way NE, M2-8, Seattle, WA 98105, 206-987-2204. Some families may wish to have prenatal counseling with Neurosurgery (206-987-2544) or Neonatology, Dr. David Woodrum (206-543-3200) regarding relevant aspects of care.

Collect all ultrasound data. Repeat studies as needed. Collect all available data regarding prenatal testing (AFP, other tests). A fetal karyotype is essential for

complete counseling. Prepare a dictated/written summary including clinical observations, the above information and approximate EDC for the mother's chart, baby’s record (if started), parents, and send to the Neurodevelopmental office at CHRMC, 4800 Sand Point Way NE, M2-8, Seattle, WA 98105,


206-987-2204, the patient’s neurosurgeon, any referring obstetric provider or primary care physician, and send to the Infant OT/PT team in the Rehabilitation Dept. at CHRMC, 4800 Sand Point Way NE, 6I-1, Seattle, WA 98105, 206-987-2114.

2.) Guidelines for UW/CHRMC faculty providing prenatal counseling Ask the transcriptionist to send copies of the consultation to ALL the Neurodevelopmental /Congenital Defects and Neurosurgery attendings at CHRMC. (Please note the names of the Neurodevelopmental and Neurosurgery attendings in dictation.)

If delivery of the child will occur within two weeks, contact the specific attendings on call for Neurosurgery, Neurodevelopmental/Congenital Defects, and Neonatology.

3.) Guidelines for the team of physicians (obstetrics, neonatology) attending birth Notify BOTH the Neurodevelopmental/Congenital Defects and Neurosurgery attendings on call at CHRMC

(physician paging operator: 206-987-7777) when the baby is scheduled for delivery; time and place of Cesarean section. If the newborn has a previously unrecognized meningomyelocele, please contact the Neurodevelopmental/Congenital Defects and Neurosurgery attendings at the time the lesion is discovered. Please provide relevant medical history on the baby and the mother.

The infant should be admitted to the Neurodevelopmental/Congenital Defects service on the ward if term and stable (most infants) or to the Infant ICU (IICU) if pre-term or unstable.

Handle the infant with sterile, non-latex gloves and with sterile clothing and sheets. Institute latex allergy precautions. Cover the lesion with non-adhesive dressing wet with sterile Ringer’s lactate solution or saline. Fill a syringe with the same solution, add a sterile, silastic tube to the tip of the syringe with the syringe

taped to the baby’s back and the distal tip of the tube in the center of the dressing. Cover with a sterile dressing surrounded by a ring of Curlex to prevent pressure on the sac.

Note: Packaged materials and instructions for the dressing described above are available from Patti Jason, RN, Director, CHRMC Transport Team, (206) 987-2632, pager 469-6336. There is also a more detailed set of instructions complete with illustrations on the Neonatology Division website at http://neonatal.peds.washington.edu/NICU-WEB/mcelecov.stm. Anyone unable to directly access this website could ask the IICU unit coordinators to print a copy.

Position the infant in the side lying or prone position only; avoid pressure on the sac or nerves. Arrange transport through normal channels for transport of critically ill newborns. Timing of transport

depends on the stability of the infant and the availability of bed space. Notify the Neurodevelopmental/Congenital Defects attending on call (paging operator at CHRMC (206-987-2000).

Add the prenatal counseling summary to the infant’s chart. Add and complete an appropriate growth chart for head OFC, height and weight.

4.) Guidelines for the CHRMC Infant ICU Attending on Call Term newborns with meningomyelocele can be admitted to the regular ward on the

Neurodevelopmental/Congenital Defects service. Any such newborn billed as having had perinatal asphyxia should be evaluated for severe brainstem dysfunction associated with Chiari II malformation since the initial presentation is quite similar.

Preterm newborns with meningomyelocele usually need IICU respiratory care in the same manner as other prematures. It is best if they can be nursed prone, or at least side-lying, but emergency intubation or related procedures may require a brief period of time supine. Try to keep the open sac sterile and protected from pressure if possible. Preterm newborns with meningomyelocele are more likely to have congenital heart disease and/or syndromic causes (eg Trisomy 13 or 18) than term newborns.

Contact the Neurodevelopmental/Congenital Defects attending on call about the infant after stabilization if no direct contact has occurred prior to the infant’s arrival. Ask the IICU resident to write a consult request.

5.) Guidelines for Neurodevelopmental/Congenital Defects Attending on Call Notify Admitting for admission to the medical floor unless the infant is unstable and requires admission to

the IICU and provide the name of the neurosurgeon on call and your name with how to contact each. Note: The IICU resident may need to be reminded to write an order for a Neurodevelopmental/Congenital Defects consultation. The IICU attendings have always appreciated contributions to management from the Division. Dr Lemire recommends we provide the same management recommendations as if on our service and not wait to be consulted. In view of current billing and documentation issues, a documented consult request is important.

Notify floor and request a call as soon as the infant arrives. Evaluate the infant for contraindications to surgery, alter the prenatal prognosis, advise on treatment of other issues, etc.

Notify neurosurgical service and identify yourself and how to contact you. In general, the children will be on the medical Neurodevelopmental/Congenital Defects service initially, then on Neurosurgery perioperatively


(typically one or two days) and then back on Neurodevelopmental/Congenital Defects service. It is expected that the two services will work collaboratively at all times, regardless of who is attending at the moment.

Request PT and OT meningomyelocele evaluation consults via online orders from the Infant OT/PT Team Referral Line and leaving an email at: Alice Crandall, PCC, Rehabilitation Psychology, available 8:00 am to 5:00 pm [email protected] (206) 987-3371 It is sure to cause delay in involving OT/PT if direct contact is not made. Contact information for each Infant OT/PT Team member, use only after contacting Referral Line: Lynn Wolf [email protected] 206-987-3131 Gail Bonato [email protected] 206-987-1320 Jane Mason [email protected] 206-987-3130 Susan Hutchinson [email protected] 206-987-1467 Nan Street [email protected] 206-987-3148

Record muscle strength examination and sensory level. Notify Neurodevelopmental/Congenital Defects Nurse (206-987-2184) or page 206-469-5733. The nurse is

available from 8:00 am to 4:00 pm Monday through Friday. The Neurodevelopmental/Congenital Defects nurse can provide the floor staff nurses with consultation and instructions as to the infant’s needs. The Neurodevelopmental/ Congenital Defects nurses will provide the family with information on how to obtain a Care Notebook and information about meningomyelocele.

Examine the infant for other malformations and syndromes that will alter the prognosis. Discuss the management plan with the house staff. Institute latex allergy precautions. See hospital protocol. Obtain an ultrasound examination of urinary tract, head for ventricle size, and an echocardiogram on all

patients before surgery. Cardiology consultation should be requested early if an anomaly is present. Request urology and orthopedic consultations if needed. Most infants will have a neurogenic bowel and

bladder and will need urology during the newborn hospitalization. Many infants will have musculoskeletal deformities requiring orthopedic consultation, though rarely on an emergent basis.

Request social work consultation. The social worker assigned to Neurodevelopmental /Congenital Defects is available weekdays through the paging operator (206-987-2000).

If the infant presents with cardio-respiratory distress, apnea, bradycardia, laryngeal stridor or aspiration with swallowing institute a symptomatic Chiari II malformation work up, which may include blood gases and oximetry, an MRI of the brainstem, sleep study, videofluoroscopy of swallowing and ENT evaluation. The workup should be individualized. Neurosurgery should already be following the case.

Spend adequate time with family explaining all aspects of care to inform them and begin to develop the therapeutic alliance that will allow optimal care of the child for the next 21 years.

Assure that basic information on each infant is submitted to the myelodysplasia database. The OTs, PTs and nurses should both have the permanent information data entry form to initiate if they are notified about the infant. A backup procedure is to notify Dr. Shurtleff (206-987-2058, 425-454-1893, e-mail [email protected]) or Sharon Duguay (e-mail [email protected]) directly.

Any of the following faculty will be glad to answer questions: Jeff McLaughlin, Nora Davis, William Walker, Chuck Cowan, David Shurtleff or Sam Zinner. Contact the CHRMC paging operator (206-987-2000) to determine who is on call.

Doctor Phone Number Pager Number Email Address Jeff McLaughlin 206-987-2204 206-469-6704 [email protected] Davis 206-987-2590 206-469-6411 [email protected] Walker 206-987-2204 206-469-3579 [email protected] Cowan 206-987-2204 206-469-5369 [email protected] Shurtleff 206-987-2058 206-469-5485 [email protected] Zinner 206-685-1290 206-469-5157 [email protected]

6.) Guidelines for Neurodevelopmental/Congenital Defects Attending Follow-up Consult with neurosurgeons as to antibiotic management, nutrition and any other appropriate medical

considerations. Accept the infant in transfer if requested by the neurosurgeons or IICU staff. Preferable placement is on a

medical floor with nurses experienced in the management of newborns with neural tube defects. Follow urine post voiding residual for temporary or permanent postoperative retention or infection.


Consider use of phenoxybenzamine for relief of bladder sphincter spasm. Start with 1 mg P. O. every 24 hours as one dose and advance until residual urine is less than 5 mL, or side effects such as stuffy nose or drowsiness occur. Note that the normal urinary bladder capacity of a neonate is 30 mL..

Organize discharge plan for parents and the local health care provider. Begin early in the hospitalization and involve the unit discharge planner if complexity warrant (e.g. need for home health care, special equipment, etc).

Follow carefully for positioning to prevent head weight bearing on the shunt valve or chamber (have a doughnut under the head.)

Manage skin care for perineum in the presence of dribbling urine or stool. Vinegar is an excellent agent for protecting the skin from alkali burns.

Record daily head size, plot on appropriate head size chart and obtain follow-up cranial ultrasounds as needed. In premature infants, always obtain cranial ultrasounds since the brain is more compliant and ventricles may expand with little change in head size.

Every infant should have a nutrition consult. Every infant should have a neonatal hearing evaluation. Notify the Neurodevelopmental/Congenital Defects patient care coordinators, preferably in writing or by e-

mail, of the plan for clinic appointments. These need to be tailored to the needs of each infant and family. DO NOT leave this up to unit assistants or others unfamiliar with our clinic. To do so often results in uncoordinated appointments in many separate clinics.

These guidelines were developed with the assistance of many people, notably David Shurtleff, MD. Please send any questions or suggestions about these guidelines to Jeff McLaughlin, MD at [email protected] or 206.987.2204.

Disclaimer: These guidelines have been developed by the Division of Genetics and Developmental Medicine, Department of Pediatrics, UW, to assist physicians and other healthcare professionals. Practitioners are encouraged to use the information provided in the guidelines. The recommendations contained in the guidelines may not be appropriate for use in all circumstances. Any decision to adopt a particular recommendation must be made by the practitioner based upon available facts and circumstances presented by individual patients.

It is not the intention in promulgating these guidelines to interfere with the provider/patient relationship, nor are these guidelines intended to represent the standard of care in any given circumstance. These guidelines are recommendations to be used at the sole discretion of the provider and are not meant to dictate the manner or style of clinical practice employed in rendering services to a particular patient.


Erythropoietin in the Newborn Intensive Care Nursery How Epo works The production of red blood cells from pluripotent stem cell to mature red blood cell is governed by growth factors that include erythropoietin (Epo). These erythropoietic growth factors decrease apoptosis of progenitor cells and stimulate maturation, growth, and differentiation of red blood cells (Figure). Epo works by binding to a specific cell surface receptor (Epo-R). Although multiple growth factors facilitate production of red blood cells, none plays a more important regulatory role than Epo. Both hypoxia and anemia stimulate erythropoiesis by stimulating Epo production mediated by a transcription factor, HIF-1, or “hypoxia inducible factor”.

Prenatally, Epo is produced in the liver, and postnatally by the kidney. AAddmmiinniissttrraattiioonn ooff rrEEppoo Epo can be given IV or

SQ. It is somewhat more effective when given SQ, unless the IV dose is given over an hour to simulate SQ absorption. It given IV, it can be given either by itself, or mixed in hyperalimentation fluids (TPN).

Epo Receptor Density

Pluripotent Stem cell

CFU-GEMM BFU-E CFU-E Normoblast Reticulocyte Erythrocyte

IL-6IL-3

GM-CSF?

EPO

Dose and dosing schedule When compared to adults, the half life of Epo in preterm infants is shorter, and the volume of distribution greater, necessitating larger doses and more frequent dosing. Effective dosing schemes are as follows: – 200 units/kg/day IV (Can add to HA fluids, or give as single dose injections over 60 min) – 400 units/kg/day SQ, three times a week (eg. M, W, F) • Start iron 6 mg/kg/day elemental iron PO/OG or 1 mg IV iron dextran in TPN when starting Epo therapy. A weekly CBC with differential count, platelet count, reticulocyte count and ZnPP/H should be followed when an infant is receiving Epo treatment. Treatment length is dependent on the therapeutic goals, and can be from 2 weeks to several months in duration. A convalescing preterm infant can be expected to begin producing red blood cells on their own when they reach 36 weeks corrected gestational age. Epo Clearance Epo is cleared by receptor binding, with internalization and subsequent breakdown within the cells. Some Epo is excreted in the urine, but dosing is not effected by hepatic or renal disease. Epo Side effects Side effects of Epo administration reported in adults include hypertension, bone pain, rash, and rarely seizures. Many of these side effects are reported in end stage renal patients, and it is unclear what effect their primary disease state has. None of these side effects have been reported in newborns. Uncommon side effects that appear to be specific to newborns include neutropenia and mild thrombocytosis. WWhhoo mmiigghhtt bbeenneeffiitt ffrroomm EEppoo 1. Even with the use of Epo, infants < 1000 gm are likely to require at least one transfusion in the first weeks of life.

Because we used aliquoted blood here at the UW, and these infants can receive multiple transfusions with only one donor exposure, we do not recommend beginning Epo during the first weeks of life when phlebotomy losses are the highest, and infants are likely to need multiple transfusions.

When infants < 1000 gm become more stable and phlebotomy losses are lower (usually after the first 3 weeks of

life), Epo should be considered.


Consider administering Epo in this population if standard iron therapy has been started and the weekly hematocrit is falling despite infrequent blood draws. If the corrected reticulocyte count is < 6, infants are likely to benefit.

The corrected reticulocyte count is obtained by taking the patient’s reticulocyte (%) x patient’s Hct (L/L) ÷

desired or optimal Hct (L/L). 45 is usually used as the optimal Hct when making this calculation.

2. Infants > 1000 gm who are at risk for a transfusion but who are not in acute need of blood. Following the weekly Hct and reticulocyte count is helpful when making this assessment. If

they are not requiring frequent blood draws, but their Hct is falling despite standard iron therapy, they may benefit from Epo.

Any child who is acutely ill and in need of increased oxygen carrying capacity should be

transfused, not treated with Epo.

GGeenneerraall IInnffoorrmmaattiioonn aabboouutt EEppoo It takes approximately a week to see an increase in Hct after starting Epo. The reticulocyte count

will often double, and gains in Hct are generally in the 2 to 4 point range per week. The most common cause of failure to respond is inadequate iron stores.

Responding to ZnPP/H ratios in VLBW infants

Very little data is available regarding the use of ZnPP/H in preterm infants. One paper has been published, which looked at 15 infants of birthweight 1175 ± 64 gm, when they were 46.7 ± 5.3 days old.1 ZnPP/H ranged from 60 to 175. It is unclear whether they had optimal iron status or not. Those who were transfused had lower ZnPP/H levels than those who were not transfused. Other papers looking at term newborns have reported higher ZnPP/H in the infants than their paired mothers (around 41 in mom, 74 in baby), again with a wide range (see below).2-5 We have recently completed a study in the UW NICU which defined normal ranges of ZnPP/H for preterm infants in the first week of life.6 ZnPP/H was inversely correlated with gestational age, and infants expected to be iron deficient based on the literature (IDM and SGA infants) had very high values. In a follow up study, iron supplementation was given to infants with high ZnPP/H ratios (suggesting iron deficiency). ZnPP/H decreased with iron administration, suggesting it may be a useful indicator of iron status. We therefore have started using the ZnPP/H, together with other clinically relevant data to help decide whether an infant is iron deficient.

References:

1. Winzerling JJ, Kling PJ. Iron-deficient erythropoiesis in premature infants measured by blood zinc protoporphyrin/heme. J Pediatr 2001;139:134-6.

2. Bartels PC, Helleman PW, Soons JB. Changes in size and zinc protoporphyrin/haemoglobin ratio in red cells of infants during the first months of life. Ann Clin Biochem 1990;27:102-6.

3. Farsakh FA, Al-Khalily AS, Mameesh MS. Plasma lead and erythrocyte zinc protoporphyrin in neonates and young children in Kuwait. Ann Nutr Metab 1987;31:292-5.

4. Kilbride J, Baker TG, Parapia LA, Khoury SA. Incidence of iron-deficiency anaemia in infants in a prospective study in Jordan. Eur J Haematol 2000;64:231-6.

5. Milman N, Christensen JM, Ibsen KK. Blood lead and erythrocyte zinc protoporphyrin in mothers and newborn infants. Eur J Pediatr 1988;147:71-3.

6. Juul SE, Zerzan JC, Strandjord TP, Woodrum DE. Zinc protoporphyrin/heme as an indicator of iron status in NICU patients. J Pediatr 2003;142:273-8.

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