stuff to know about at st. joe’steam 4 tidy-up · 2015-12-11 · stuff to know about at st....

Team 4 Tidy-Upstuff to know about at St. Joe’sKelly Fitzpatrick

Pediatric Practice RoundsOctober 22, 2012

October 22, 2012

LABOUR AND DELIVERY

Hep B/Hep C screening

HIV screening

HSV

GBS screening

Maternal Graves

Maternal Anti-Ro

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hepatitis BHepatitis B Screening Policy

Hep B&C Neonatal Immunization Protocol

CDC Hepatitis B guidelines (2009) 1. Promote safe and timely care. 2. Appropriately immunize babies born to mothers who are Hepatitis B Surface Antigen (HBsAg) positive or status unknown at time of delivery.

Mothers without laboratory documentation of HBsAg status on admission to Birthing will have blood drawn for HBsAg screeningNote: Hep B status written on prenatal form is not adequate

Obstetrical Admission to the Birthing Unit order-set: 13. Validate maternal Hepatitis B status. If not on chart, draw HBsAg and ensure mother’s MRP. If positive or unknown, ensure mother’s MRP orders the required Hepatitis B prophylaxis on the newborn Order set.To order a stat Hep B test, go into HBO STAR and into the Labour and delivery pannel.

Provide parents with Ontario Ministry fact sheet: “Immunization: Hepatitis B Vaccine for Babies” attached to the Clinical Guideline via My St Joes Policies, and available in other languages via the Internet, link on desktops of Birthing desk area computers: HYPERLINK"http://www.health.gov.on.ca/english/providers/pub/pub_menus/pub_immun.html" \t "_parent" http://www.health.gov.on.ca/english/providers/pub/pub_menus/pub_im HYPERLINK"http://www.health.gov.on.ca/english/providers/pub/pub_menus/pub_immun.html" \t "_parent" mun.html

To facilitate specimen processing, phone Virology x36021 to inform them a specimen is coming

When maternal HBsAg is positive or unknown at time of birth: In Birthing, PRIOR TO TRANSFER to 3OBS:

1) Ensure a physician has:

obtained written consent from the newborn’s substitute decision maker (mom or dad) for vaccine (+ HBIG if known positive),

ANDinitialed the appropriate order(s) on the newborn order set.

Newborns Admitted to Maternal Newborn Unit order-set:(Neonatal ) Hepatitis B Vaccine (HBV) 0.5 mL IM to left thigh within 12 hours of birth for positive or unknown maternal HBsAg

Hepatitis B Immune Globulin (HBIG) 0.5 mL to right thigh within 12 hours of birth or as soon as possible when maternal HBsAg is resulted as positive

2) Fax order(s) to Pharmacy

hepatitis B

if HBsAg positive- give Hep B vaccine and HBIG within 12 hrs

if HBsAg unknown-send maternal serology stat-give vaccine butwait on serology to give HBIG

if Hep C positive-nothing

may breast feed

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These policies are for internal use only at SJHH and are CONTROLLED documents as are all management system files on the intranet. Any documents appearing in paper form are not controlled and should ALWAYS be checked against the intranet version (electronic version) prior to use

MANUAL DEPARTMENTAL

Section Maternal Child and NICU, Labour and Delivery

Pages

Number 109-MC

Subject: Clinical Guidelines for Hepatitis B and C

Date April 18, 2012

Supersedes: Dec 20, 2011

Cross Reference: HRLMP 08-347-730 Hepatitis Immune Globulin, 205-NICU Management of Expressed Breast Milk for the Neonate

Issuing Authority: Women’s and Infants’ Operations and Quality Care Committee

Charlton Campus

Table of Contents 1.0 Purpose 2.0 Definitions 3.0 Equipment/Supplies 4.0 Policy 5.0 Procedure 6.0 Documentation 7.0 References 8.0 Sponsor 9.0 In Consultation with 10.0 Posting Dates 11.0 Attachments/Appendix 1.0 Purpose

To eliminate or reduce the transmission of Hepatitis B and Hepatitis C virus to the neonate by ensuring safe and timely care, and appropriate immunization of babies born to mothers who are either Hepatitis B surface antigen positive, Hepatitis B surface antigen status unknown at delivery, and/or Hepatitis C positive.

AREA OF RESPONSIBILITY- Nursing Policies Only

i) Cross-referenced with Perry & Potter? YES NO X ii) Written consent needed YES X NO iii) Physician order needed YES X NO iv) Additional Education Required YES NO X

HIV

maternal serology sent stat - call virology ahead

bathe baby ASAP-prior to any IM injections

HIV serology, CD4,HIV PCR, CBC,diff

start AZT and niverapine intrapartum and post partum

SIS follow up

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MANUAL DEPARTMENTAL

Section Maternal Child and NICU, Labour and Delivery

Pages

Number 109-MC

Subject: Clinical Guidelines for Hepatitis B and C

Date April 18, 2012

Supersedes: Dec 20, 2011

Cross Reference: HRLMP 08-347-730 Hepatitis Immune Globulin, 205-NICU Management of Expressed Breast Milk for the Neonate

Issuing Authority: Women’s and Infants’ Operations and Quality Care Committee

Charlton Campus

Table of Contents 1.0 Purpose 2.0 Definitions 3.0 Equipment/Supplies 4.0 Policy 5.0 Procedure 6.0 Documentation 7.0 References 8.0 Sponsor 9.0 In Consultation with 10.0 Posting Dates 11.0 Attachments/Appendix 1.0 Purpose

To eliminate or reduce the transmission of Hepatitis B and Hepatitis C virus to the neonate by ensuring safe and timely care, and appropriate immunization of babies born to mothers who are either Hepatitis B surface antigen positive, Hepatitis B surface antigen status unknown at delivery, and/or Hepatitis C positive.

AREA OF RESPONSIBILITY- Nursing Policies Only

i) Cross-referenced with Perry & Potter? YES NO X ii) Written consent needed YES X NO iii) Physician order needed YES X NO iv) Additional Education Required YES NO X

herpes simplex virus

usually primary infection but if recurrent consider C/S

moms masks to cover cold sores, gloves to cover whitlow, maybreast feed

Asymptomatic->watch and send at 24-48 hrs urine, stool,rectum,eyes and nose in viral transport medium

Symptomatic-> fluid from vesicles, scraping base of vesicles, swabmouth, nasopharynx, stool culture, rectal swab, CSF

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MANUAL DEPARTMENTAL

Section Maternal Newborn Child Program - BIRTHING

Pages

Number 011-BIRTH

Subject: Herpes Simplex Virus (HSV) in the Perinatal Period

Date Feb 14, 2012

Supersedes: NEW

Cross Reference:

Issuing Authority: Women’s and Infant’s Operations and Quality of Care Committee

Charlton Campus West 5th Campus King Campus Table of Contents 1.0 Purpose & Goals Description 2.0 Definitions 3.0 Equipment/Supplies 4.0 Policy 5.0 Procedure 6.0 Documentation 7.0 References 8.0 Sponsor 9.0 In Consultation with 10.0 Posting Dates 11.0 Attachments/Appendix 1.0 Purpose & Goals Description To ensure safe care for neonates potentially at risk for Herpes Simplex virus infection. AREA OF RESPONSIBILITY- Nursing Policies Only

i) Cross-referenced with Perry & Potter? YES NO ii) Written consent needed YES NO iii) Physician order needed YES NO iv) Additional Education Required YES NO

2.0 Definitions

This section identifies terms used in the document that may be unfamiliar to readers or require clarification.

3.0 Equipment/Supplies

None.

herpes simplex virus

IV acyclovir x 14 days

IV acyclovir x 21 days if meningitis, disseminated

watch ins/outs

trifluidine if ocular involvement

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Group B Strep

Prophylaxis to GBS positive

GBS Unknown < 37 weeks, ROM>18 hrs, temp > 38

GBS bacteriuria in pregnancy

previous affected child

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MANUAL DEPARTMENTAL

Section Maternal Newborn Child Program - BIRTHING

Pages

Number 011-BIRTH

Subject: Herpes Simplex Virus (HSV) in the Perinatal Period

Date Feb 14, 2012

Supersedes: NEW

Cross Reference:

Issuing Authority: Women’s and Infant’s Operations and Quality of Care Committee

Charlton Campus West 5th Campus King Campus Table of Contents 1.0 Purpose & Goals Description 2.0 Definitions 3.0 Equipment/Supplies 4.0 Policy 5.0 Procedure 6.0 Documentation 7.0 References 8.0 Sponsor 9.0 In Consultation with 10.0 Posting Dates 11.0 Attachments/Appendix 1.0 Purpose & Goals Description To ensure safe care for neonates potentially at risk for Herpes Simplex virus infection. AREA OF RESPONSIBILITY- Nursing Policies Only

i) Cross-referenced with Perry & Potter? YES NO ii) Written consent needed YES NO iii) Physician order needed YES NO iv) Additional Education Required YES NO

2.0 Definitions

This section identifies terms used in the document that may be unfamiliar to readers or require clarification.

3.0 Equipment/Supplies

None.

group B strep

Less than37 weeks

ORROM greaterthan 18 hours

Observe for 48 hrs **

Appropriate IV Antibiotics

greater than 4 hours prior to delivery

Negative Positive

Maternal GBS Status

Unknown

IntrapartumRisk Factors Present?Delivery at less than 37 weeks

Rupture of Membranes (ROM) greater than or equal to 18 hrs Intrapartum maternal temp greater than or equal to 38oC

Previous infant with invasive GBSGBS bacteriuria in current

pregnancy

YESNO

YES NO

Routine ClinicalCare

If elective C/S, NO ROM, NO labour,

regardless of GBS status

YESNO

CBC & diff at 12 hrsResults called to:

_____________at ________ hrsI:T ratio ______

Observe greater than or equal to 48 hrs

! Charlton Campus! King Campus ! West 5th Campus

GROUP B STREP (GBS) PROTOCOLFOR HEALTHY NEONATESGREATER THAN 35 WEEKS

PLEASE CIRCLE ALL APPROPRIATE BOXES

FOOTNOTES:1. Any neonate with signs of neonatal sepsis requires a full diagnostic evaluation by Pediatrics.2. Babies born to mothers with diagnosed chorioamnionitis require diagnostic evaluation and treatment by a Pediatrician.3. The ** denote ‘if greater than 37 weeks gestation, observation may occur at home after 24 hours if other discharge criteria

have been met and the caregivers are able to comply fully with instructions for home observation. If any of these conditions are not met, the baby should be observed until at least 48 hours and until discharge criteria are met.

Birthing Unit Printed Nurse: ___________________________ Signature:_____________________ Initials:______ Discipline:_______

Maternal Child Unit Printed Nurse:________________________ Signature:_____________________ Initials:______Discipline:_______Page 1 of 2PD 7767 (2011-11) HIM

maternal grave’s disease0.1-0.4% of pregnancies-1-5% of infants affected

follow maternal TRAB, cord TRAB

vitals q6

tachycardia, goiter, hyperexcitability, poor weight gain,hepatomegaly

TSH, FT4, FT3 at 48 hrs and 5-7 days

treat with PTU, propanolol, Lugol’s solution-iodine

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maternal anti-Ro

if antenatal anatomy and rhythm normal: ECG at 24-48 hrs andthen repeat at 3-4 mo, consider referral to Toronto

if antenatal concerns: ECG and call cardiology at birth todecide about ECHO

if inadequate antenatal investigations: ECG within 48 hrs, callcardiology to decide re further investigations, timing

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RESUSCITATION ROOM

NRP Drugs

NRP Guidelines

BLES administration

Cooling

Placental investigations

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NRP guidelines

Overview and Principles of Resuscitation

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Lesson 1: Equipment CheckPerformance Checklist

N R P

Term gestation?Breathing or crying?

Good tone?

Warm, clear airway if necessary,dry, stimulate

No

Yes—staywith mother

HR below 100 bpm,gasping, or apnea?

Laboredbreathing

or persistentcyanosis?

No

No

PPV,SPO2 monitoring

Yes

Clear airwaySPO2 monitoringConsider CPAP

Post-resuscitationcare

Targeted Pre-ductal SPO2After Birth

1 min

2 min

3 min

4 min

5 min

10 min

60-65%

65-70%

70-75%

75-80%

80-85%

85-95%

Yes

HR below 100 bpm?

HR below 60 bpm?

IV epinephrine

No

Birth

30 sec

60 sec

No

Take ventilationcorrective steps

Yes

HR below 60 bpm?

Consider intubationChest compressionsCoordinate with PPV

Yes

Routine Care• Provide warmth• Clear airway if necessary• Dry• Ongoing evaluation

Yes

The Performance Checklist Is a Learning Tool

The learner uses the checklist as a reference during independent practice, or as a guide for discussion and practice with a Neonatal Resuscitation Program (NRP) instructor. When the learner and instructor agree that the learner can perform the skills correctly and smoothly without coaching and within the context of a scenario, the learner may move on to the next lesson’s Performance Checklist.

This Equipment Check Performance Checklist includes only the most essential supplies and equipment for neonatal resuscitation. You may wish to add supplies or additional safety checks to meet your unit’s standards or protocols. When the learner knows the routine and supplies are present and functioning, the Equipment Check should take approximately 1 minute to complete.

AAP_NRP_Lesson-1_001-036.indd 28AAP_NRP_Lesson-1_001-036.indd 28 3/29/11 8:41 AM3/29/11 8:41 AM

NRP drugsNeonatal Resuscitation Drugs

1 kgLess than30 weeks

2 kg30-35 weeks

3 kgMore than36 weeks

4 kg

Epinephrine1:10,000 0.1 mg/mlq3-5 minutes

IV Route(Preferred route)(0.01mg/kg)

0.1 ml 0.2 ml 0.3 ml 0.4 ml

ETT Route(0.1 mg/kg)

1 ml 2 ml 3 ml 3 ml (max)

Volume Expanders Normal Saline/ Packed red cells

10 ml 20 ml 30 ml 40 ml

Non- resuscitation drugs

Naloxone IV or IM0.4 mg/ml (0.1 mg/kg) *Contraindicated in narcotic dependant mothers

* Not the first corrective therapy for ineffectivebreathing

* Must have established effective ventilation

NRP 2011

0.25 ml 0.5 ml 0.75 ml 1 ml

Glucose D10W IV bolus200 mg/kg for documentedhypoglycemia

2 ml 4 ml 6 ml 8 ml

BLES administration

5 ml/kg of warm, homogenous solution

CXR to confirm RDS and ETT placement prior to administrationvia 5FR feeding tube

watch for chest expansion, O2 sats, gas

may have transient bradycardia, desats, cyanosis, reflux

pulmonary hemorrhage, pneumothorax

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For internal use only at SJHH. This is a CONTROLLED document as are all management system files on the intranet. Any documents appearing in paper form are not controlled and should ALWAYS be checked against the intranet version (electronic version) prior to use.

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St. Joseph’s Healthcare Hamilton

MANUAL DEPARTMENTAL

Section NICU

Page 1 of 6

Number 213-NICU

Subject: BLESTM; BOVINE LIPID EXTRACT SURFACTANT ADMINISTRATION TO THE NEONATE

Date April 13, 2007(R)

Supersedes November 2002

Cross Reference

Issuing Authority Neonatal/Pediatric Operations and Quality Care Committee and Maternal-Child and Women’s Health Steering Committee

Charlton Campus West 5th Campus King Campus STATEMENT OF POLICY

Pulmonary surfactant is necessary for normal lung function throughout post-natal life. Surfactant is a lipid/protein compound formed in alveolar type II cells. Bovine Lipid Extract Surfactant (BLES) restores surfactant activity and improves gas exchange by decreasing alveolar surface tension (increases alveolar expansion) and therefore promotes lung compliance. A primary deficiency in surfactant in pre-term infants prevents the normal transition at birth from a fluid filled to an aerated lung, manifesting as neonatal respiratory distress syndrome. (RDS) A secondary deficiency of surfactant may occur when pulmonary surfactant is inactivated by a protein leak or infection, or aspiration of meconium. Note: Clinical conditions simulating RDS may also develop a secondary surfactant deficiency (e.g. group B strep., pneumonia, birth asphyxia/hypotension, aspiration of meconium) POLICY:

The use of Bovine Lipid Extract Surfactant, or BLES for Respiratory Distress Syndrome or Hyaline Membrane Disease in the newborn will be under the direction of the Pediatrician.

A Nurse, Registered Respiratory Therapist (RRT), and Pediatrician will be in

attendance during administration of BLES and available following drug therapy to oversee ventilator changes and possible complications. The drug will be given by the Pediatrician, or Respiratory Therapist (with a medical order).

Surfactant will be used under the circumstances that the infant is intubated and

being mechanically ventilated.

coolingReferral Physician Guidelines for Therapeutic Hypothermia in Neonatal HIE

INCLUSION CRITERIA

Infant should fulfill all 4 criteria:1. GA ≥35 weeks2. Less than 6 hours post delivery3. Evidence of intrapartum hypoxia defined as:

EITHER Cord or postnatal blood gas within one hour of birth with pH ≤7.00 OR base deficit ≥16

OR If pH 7.01-7.15 or BD -10 to -15.9

OR no blood gas available:Evidence of acute perinatal event that may result in HIE (e.g. abruptio placentiae, cord accident, uterine rupture, maternal trauma or cardiorespiratory arrest, late or variabledecelerations etc.)

AND one of the following:

Apgar score 5 or less at 10 minutes, need for mechanical ventilation or resuscitation at 10 minutes4. Signs of moderate or severe encephalopathy defined as presence of 3 or more of the items in the 6 categories below OR presence of seizures

Category

Moderate EncephalopathySevere Encephalopathy1. Level of consciousnessLethargicStupor or coma2. Spontaneous activity

Decreased activityNo activity3. PostureDistal flexion, truncal extension Decerebrate (arms extended and internally rotated, legs extended with feet in forced plantar flexion)4. ToneHypotonia(focal or general)Flaccid5. UPrimitive reflexes Suck Moro

WeakIncomplete

AbsentAbsent6. UAutonomic system

PupilsGaze

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chorioamnionitis

placenta frozen section

forms available from pathology at MUMC

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supraventricular tachycardia

HR >200

narrow complx

no p waves

no variability

ECG-can FAX to cardiology

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svt

need to get ECG machine

crash cart from CCU

drug cart

proximal IV

ice, adenosine 0.1mg/kg, synchronized cardioversion

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NICU

CPAP

Mechanical ventilation

Intubation meds

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CPAP

CPAP at 4-10 cm H2O

cardioresp, sat monitors- use lowest possible O2-UAC, UVC ifFiO2> 50%

indicated for RDS, atelectasis, pneumonia, apnea ofprematurity, recent extubation, tracheomalacia, TTN, MAS

contraindicated for upper airway anomalies- cleft palate,choanal atresia, TEF, severe cardiovascular instability, frequentapneas

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MANUAL DEPARTMENTAL

Section NICU

Page 1 of 15

Number 209-NICU

Subject: Neonatal CPAP Therapy in NICU

Date 10-06 (R)

Supersedes 11-02

Cross Reference

Issuing Authority; Neonatal and Pediatric Operations and Quality Care Committee, Mat/Child Women’s Health Steering

Charlton Campus West 5th Campus King Campus AREA OF RESPONSIBILITY

i) Cross-referenced with Perry & Potter? YES NO X ii) Basic Nursing Skill YES Added Nursing Skill X iii) Written consent needed YES NO iv) Physician order needed YES NO X

STATEMENT OF POLICY CPAP is defined as the application of positive pressure to the airways of the spontaneously

breathing infant throughout the respiratory cycle. NCPAP is a non-invasive therapy delivered

via a nasal mask or nasal prongs connected to a CPAP-generator, which provides a continuous

positive airway pressure at a precise FiO2. The airway pressure levels are monitored with

alarms for apnea, low/high pressure.

All infants at St Joseph's Healthcare who meet the clinical indications as outlined in this policy, will be initiated on Nasal CPAP therapy via the SensorMedics Infant Flow CPAP Device, or the Advanced Infant Flow Device, so that early necessary intervention is begun to provide the infant with an easier transition into extra-uterine life.

A pediatrician will remain in house at all times when an infant is on NCPAP. Respiratory Therapist (RT) covering the Wards RT pager is responsible for providing

respiratory services to the NICU. All infants receiving NCPAP will be nursed on a 1:1 basis for the first 4 hours or until

the infant is stable. Infants requiring invasive mechanical ventilation will be transferred to a tertiary

center. Clinical CPAP ranges recommended are as follows; CPAP Maximum 10 cm H20, CPAP

Minimum of 4 cm H20

mechanical ventilation

for hypoxia, cyanosis, hypoventilation, apnea, cardiovascularcollapse

PAO2<60, PACO2>60, BE>10

RT and RN to assist

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MANUAL DEPARTMENTAL

Section NICU

Page 1 of 22 Policy Number 214-NICU

Subject: Mechanical Ventilation Guidelines in Neonatal-Paediatric patient populations

Date April 2007 (R)

Supersedes: October 25, 2000

Cross Reference 001-NICU

Issuing Authority Neonatal/Pediatric Operations and Quality Care Committee and Maternal Child Women’s health Steering Committee

Charlton Campus West 5th Campus King Campus I. INTRODUCTION:

The NICU Ventilation guidelines have been developed in an effort to assist the physicians, respiratory therapists and neonatal nurses in providing optimal cardiorespiratory care. This is accomplished by an active means of communication on daily patient rounds and as the need arises.

The policy identifies three acceptable ranges of arterial blood gas results. The Respiratory Therapist will determine the validity of the results through the use of clinical evaluation and the use of invasive and non-invasive monitoring devices. Non-invasive monitoring and trending will be utilized whenever possible to minimize blood letting.

This guideline is not intended to be adhered to rigidly, but merely to provide some rationale behind interpretation of blood gases and possible changes to ventilation settings in response. There are limited randomised clinical trial data, which establishes that any one ventilation strategy or mode is superior. Many ventilation practices are based on individual experience and on evaluating changes in blood gases parameters and the clinical condition of the child in response to changes in ventilator settings. II. GOALS OF MECHANICAL VENTILATION GUIDELINES;

1. To provide optimal ventilator support to the neonatal - paediatric clients using evidence based practice.

2. To minimize time spent on the ventilator. 3. To provide greater consistency of care to the patient. 4. To provide maximum assistance to the health care team in ventilation management. 5. To minimize morbidity related to ventilation.

pre-intubation meds



MANUAL DEPARTMENTAL

Section NICU

Page 1 of 8

Number 210-NICU

Subject: Sedation - Pre-Intubation Sedation of the Neonate

Date April 2007

Supersedes New Practice Guideline

Cross Reference

Issuing Authority Neonatal and Pediatric Operations and Quality of Care Committee and Maternal Child and Women’s Health Steering

Charlton Campus □ West 5th Campus □ King Campus PURPOSE: The purpose of this practice guideline is to facilitate the safe administration, monitoring, recovery of the neonate who has received a sedative agents and or paralytic agent for therapeutic procedures. The choice of medication administered is up to the discretion of the paediatrician (see sedation decision tree). This guideline suggests a systematic approach for the utilization of pharmaceutical agents to provide adequate analgesia/sedation prior to semi emergent or elective intubations or procedures in the neonatal intensive care unit. “Semi-emergent” endotracheal intubation refers to patients in whom:

IV access can be established within a reasonable amount of time (IV catheter or butterfly)

Oxygenation and ventilation can be maintained either spontaneously or with assistance, prior to the insertion of an endotracheal tube. (E.g. elective ETT changes, RDS, apneic spells).

This policy excludes patients who require emergency endotracheal intubation during a cardio-respiratory arrest or if they are already unconscious.

The guideline does not replace clinical judgment and individualization of care. The department of Anesthesia should be called to assist with difficult airway or if a second dose of paralytic agent is required for endotracheal intubation. Respiratory Therapy is available and must be called as required for endotracheal intubation, and as needed for other procedures requiring sedation.

BACKGROUND: Endotracheal intubations are performed in the neonate primarily for respiratory distress, poor respiratory effort, or to maintain a secure airway. The literature provides us with

Departmental procedure NICU Date: Page 6 of 8


Sedation Decision Tree

*** Note: Naloxone (for opioid reversal) Dose: 0.1-0.2 mg/kg/dose

Anticholinergic: Atropine Dose: 20 mcg/Kg IV over 1 minute Action: Rapid onset Peak: 12-16 minutes Duration: action last 6 hours.

Sedative: Morphine Dose: 0.1mg/Kg IV slowly over 5 min. may repeat x1 in 15 min Peak: 5-10 minutes Duration: 2-4 hours

Muscle Relaxant: Succinlycholine Dose: 2mg / Kg IV Action: < 1 min Peak: Duration: 4-6 minutes.

Anticholinergic: Atropine Dose: 20 mcg/Kg IV Action: Rapid onset Peak: 12-16 minutes Duration: action last 6 hours Repeat:

Sedative: Fentanyl Dose: 2-3 mcg / Kg IV slowly (30 seconds) Action: 30-60 seconds Peak: 1-2 minutes Duration: 30-60 minutes Plasma half-life 2-4 hours

Muscle Relaxant: Succinlycholine Dose: 2mg / Kg IV Action: < 1 min Peak: Duration: 4-6 minutes

Initiate Intravenous Access Initiate Appropriate Monitoring

Sedation Algorithm A

Sedation Algorithm B

Ensure infant deeply sedated

Ensure infant deeply sedated

NICU

car seat trend

ROP screening

head ultrasounds

thyroid screening

vacuum protocol

NAS

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growth monitoring

new initiatives:

growth curves placed in front of chart

please measure, record and plot :weight, length, headcircumference on Mondays

adjust TFI on Mondays and Thursdays during rounds

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car seat trend

prem or term with respiratory distress requiring intervention

90 mins with <2 episodes

sats >90%, 90% of the time

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POLICY Departmental

Section NICU

Pages 1 of 5

Number 201-NICU

Subject CAR SEAT TRENDING - NEWBORN AND PREMATURE INFANTS

Date 11/03/2008

Supercedes 11-04 (R)

Cross Reference Issuing Authority: Neonatal and Pediatric Operations and Quality Care Committee Maternal Child and Woman’s Health Steering Committee

Charlton Campus West 5th Campus King Campus

PROCEDURE I PURPOSE

To evaluate cardiopulmonary stability of preterm and full term infants with potential risk factors in an infant car seat prior to discharge home. Evaluation will focus on ability to maintain acceptable levels of oxygen saturation and absence of apnea and bradycardia episodes over a specified period of time.

II ASSESSMENT a) Assess infant for need. Car seat trending will be included in

routine discharge planning on all infants born less than or equal to 36 6/7 weeks gestation and more mature infants with respiratory, neurologic or congenital abnormalities. Trending should be done within 2 to 3 days of impending discharge.

Note: Infants who are greater than 36 6/7 who have gone to

NICU post delivery and required CPAP, mechanical ventilation, oxygen therapy or had respiratory distress requiring intervention then a car seat trend needs to be done prior to going home.

b) Have the parents bring the car seat and check the car seat with

the parents present. The nurse will ensure that:

thyroid screening

for babies <30 and/or <1500 gm

check T4 and TSH at 4 weeks

normal free T4 at 28-40 wks =10-33 pmol

normal free T4 at 2-20 post -term =12-30 pmol

normal TSH<10

treat with thyroxine and call endo if normal T4 and TSH >20;low T4 and TSH>20 or T4 <9

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ROP screening

babies < 31 weeks or <1250 gm

first check at 31-32 weeks corrected

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head ultrasound screening

document from July 2005

if <30 6/7 ->DOL 5-7 to look for IVH, DOL 7-14 to look forIVH or PVL from 4 wks antenatally

2nd U/S DOL 21-28 to follow up IVH that may have occurred

3rd U/S 36-40 wks CA to look for PVL

if 31-32 6/7-> one U/S at term to exclude PVL

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vacuum protocol

risk of subgaleal hemorrhage between epicranial aponeurosisof scalp and periosteum of bone

can hold 260 ml blood

check HC and HR at 30 mins, 2,4,6,12,18,24 hrs then Q6x24-48 hrs

watch for pallor, lethargy, increasing HC by > 0.5 cm ,bogginess

consider CBC at 4 & 12 hrs-Hct <45%, neuro vitals

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bronchopulmonary dysplasia

grade 1->O2 for >28 days and room air at 36 wks PMA

grade 2->O2 for >28 days and extra O2<30% at 36 weeksPMA or D/C

grade 3-> O2 for 28 days and extra O2>30% at 36 weeksPMA or D/C

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bpd

at 36 weeks PMA

needs CXR

gas

ECG

head U/S

ECHO

renal ultrasound

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neonatal abstinence

antenatal consults with social work, family life

for tour, birth plan, written care plan and booklet to parents

baby with mom for 4 hours then to L2N

no drug screen needed if mom has provided a urine sample

breast feed unless marijuana with opiates, any poly-drug use

initiate Finnigans

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NAS

marijuana-watch x 72 hrs

cocaine watch x 72 hrs- no head/renal U/S needed

opiates watch x 72 hrs

methadone watch x 5 days

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NAS

treat if finnegans 3>8 or 2>12

increasing morphine, consider phenobarb once at maximum

on cardioresp monitor once starts morphine until second wean

treat with morphine q4 hrs

consider wean by 10% of dose every 48 hrs

infant-parent, public health, +/- CAS, peds clinic

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3 OBS

hypernatremia

hypoglycemia

hyperbilirubinemia

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hypernatremia

for wt loss>7.5% at <48 hrs -vigilance of breast feeds,elimination and overall status

for wt loss of 10% >48 hrs, consider serum electrolytes,monitor breast feeds

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MANUAL DEPARTMENTAL

Section Maternal Child

Pages 2

Number 106-MC

Subject: HYPERNATREMIA - Management in Term Breast-fed Infant

Date 06/06/2008

Supersedes: NEW

Cross Reference: Supplementary feeding for the newborn infant

Issuing Authority: Maternal Newborn Operations and Quality Care Committee, Maternal Child and Women’s Health Steering

Charlton Campus

West 5th Campus

King Campus

Purpose: The purpose of this guideline is to help direct care of infants with significant weight loss and assess for hypernatremia. Precautions:

Hypernatremic infants look well Will not have typical signs of dehydration Fluid will shift from intracellular space to extracellular space, thus the infant may

look better than they actually are One must rely on history of feeds, weights, urine and stool output At a weight loss greater than 7.5% in infants less than 48 hours of age, close

vigilance of breast feeding, elimination and overall status is needed. Consider overall status and serum electrolytes

At a 10 % weight loss at greater than 48 hours and depending on feeding, elimination and overall status of the baby, serum electrolytes should be considered by the MRP. Please refer to the Supplementation Guideline regarding acceptable patterns of weight loss in breast-fed infants

Na 140-145 mmol/L

No intervention, monitor breastfeeding

Na 145-149 mmol/L At 10% weight loss, monitor breastfeeding, voiding and stooling, and

overall status, consider supplementation

Na 150-155 mmol/L Recommend supplementation and repeat blood work in 6-8 hours

hypernatremia

Na+ 140-145: no intervention, monitor BF

Na+ 145-149: at 10% wt loss, monitor BF, voiding, stooling,overall status, consider supplementation

Na+ 150-155: recommend supplementation, repeat at 6-8 hrs

Na+ 155-160: call peds, consider NICU transfer, supplement,urine and stool output, repeat at 4-6 hrs

Na+ > 160: bolus 10-20 cc/kg, correct slowly

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hypoglycemia

hypothermia <36.5, newborn illness ( resp, sepsis)

maternal hypertension treated with anti-hypertensive, anymaternal beta blocker

any maternal diabetes

prem < 37 weeks

LGA or SGA

prem <37 wks

cold stree, hypothermia < 36.5

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1


MANUAL Departmental

Section NICU

Pages 1 of 8

Number 208-NICU

Subject: Newborn Hypoglycemia Clinical Guidelines

Date 10-06 (R)

Supersedes: 10-05 (R)

Cross Reference:

Issuing Authority: Neonatal and Pediatric Operations and Quality Care Committee, Mat/Child Women’s Health Steering

Charlton Campus West 5th Campus King Campus

Principles 1. Ongoing newborn assessment and timely interventions should not be limited by these guidelines; at

any point the newborn is symptomatic or otherwise unwell, notify MD or midwife 2. If baby is unable to feed at any point in these guidelines, Notify MD or MW, consider use of MD

protocol A Definitions At risk This includes babies with any of the following maternal/newborn criteria

Maternal hypertension treated with antihypertensive agents Any maternal diabetes (gestational, type 1 or II, with or without insulin) Any mother receiving beta blockers (e.g. Atenelol, Labetalol) LGA or SGA Preterm gestation < 37 0/7 weeks Cold stress, hypothermia (newborn temperature < 36.5 C) axilla Newborns with medical illnesses (e.g.: respiratory distress, sepsis)

hypoglycemia


3

Newborn Hypoglycemia Clinical Guidelines Newborn baby Symptomatic Asymptomatic NO Risk Is the baby sympto- Routine care & is the baby at risk? Routine care & feed matic or otherwise initial feed within on demand as long Unwell? 60 minutes of birth baby remains well

YES YES Recheck WBG 60 minutes PC

Notify MD or MW Check WBG

immediately Investigate cause Rx underlying

condition

Routine care and initial feed within 60 minutes of birth. Check WBG at 2 hours post-birth

WBG < 1.0 Notify MD Use MD

protocol B

WBG 1.0-1.7 Asymptomatic Supplement 5-

10 ml/kg

WBG ≥1.8 –2.5 Asymptomatic Feed now

WBG ≥2.6 Asymptomatic Feed q 2-4

hourly, WBG AC If remain > 2.6

x 1; discontinue WBG checks

Preterm & SGA newborns do not require retest after 36 hrs provided stable levels & intakes achieved

IDM or LGA newborns do not require retesting if WBG > 2.6 at > 12 hours post birth

WBG < 1.8 Notify MD

or MW Use MD

protocol A

WBG 1.8-2.5 Supplement

5-10 ml/kg WBG q3h AC

feeds for maximum of 24 hours

Consider use of MD protocol A/B based on newborn Condition and causative factors

1. Ongoing newborn assessment and timely interventions should not be limited by these guidelines; at any point the newborn is symptomatic or otherwise unwell, notify MD or MW

2. If baby is unable to feed at any point in these guidelines, Notify MD or MW, consider use of MD protocol A

Legend: WBG = whole blood glucose MD = Medical Doctor MW = Midwife AC = before feeds PC = After Feeds EBM = Expressed Breast Milk SGA = Small for Gestational Age LGA = Large for Gestational Age IDM = Infant of a Diabetic Mother

hypoglycemia

These policies are for internal use only at SJHH and are CONTROLLED documents as are all management system files on the

intranet. Any documents appearing in paper form are not controlled and should ALWAYS be checked against the intranet version

(electronic version) prior to use

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MD Protocol A

Start Infusion with D10W @

80cc/kg/day (5.5 mg glucose/kg/min)

Check WBG after 30

Minutes

Continue checking BG

every 2 hours. May start to

wean IV 12 hours after

stable WBG and feeding is

established.

Go to MD protocol B Increase IV infusion to 6-8

mg/kg/min, Check BG in half

hour, then every 2 hours. May

start to wean IV 12 hours after

stable BG is and feeding

established.

WBG > 2.6

WBG 1.8-2.5

WBG < 1.8

hypoglycemia


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MD Protocol B

Consider 200mg/kg (2cc/kg) D10W bolus, IV infusion of 6-8 mg/kg/min

BG <1.8

Bolus 200mg/kg (2cc/kg) D10W and Increase infusion to 8-10 mg/kg/min

Recheck WBG in ½ hour

Recheck BG in ½ hour, then hourly, May wean IV once BG stable for 12 hours

Consider glucagon and increase infusion to 10-15 mg/kg/min if continued low WBG

BG > 2.6

Increase infusion to 8-10 mg/kg/min

BG 1.8-2.5

Continue checking BG every 2 hours. May start to wean IV 12 hours after stable BG and feeding is established.

hypoglycemia

supplements-bottle, NG

D10W->D12.5W-> D15W

TFI to 120 cc/kg/day

glucagon, diazoxide, steroids

critical sample if glucose < 1.8-glucose, insulin, GH, cortisol,T4, TSH, gas, lactate, urinary ketones, plasma ktones, pyruvate,FFAs, serum organic and amino acids

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hyperbilirubnemiaHAMILTON REGIONAL HOSPITALS

Hyperbilirubinemia ScreeningAssessment for Newborns

38 or More Weeks Gestation

714509 (2008-04)Labs – Labs Page 1 of 2

BILIRUBIN LEVEL IS ABOVE THE LOWINTERMEDIATE RISK ZONE andMOTHER IS BLOOD GROUP O

Coombs Test Ordered

Yes NoCoombs Test (DAT)

NEGATIVE POSITIVE

COOMBS TEST (See reverse for Algorithm)

50

75

100

125

150

175

200

225

250

275

300

325

0 12 24 36 48 60 72 84 96 108 120 132 144Age in hours

Low Risk Zone

Low Intermediate Risk Zone

High Intermediate Risk Zone

High Risk Zone

50

75

100

125

150

175

200

225

250

275

300

325

0 12 24 36 48 60 72 84 96 108 120 132 144Age in hours

Low Risk Zone



High Risk Zone

18 42 30 54 66 78 90 102 114 126 138

X


High Risk Zone


Low Risk Zone

BILIRUBIN NOMOGRAM X1, X2, X3, X4 = Bilirubin Level

Date(yyyy/mm/dd)

Time(hh:mm)

Age inhours

Bilirubinµmol/L

Bilirubin ScreeningResponse Code

(See Below)Name of MRP /Midwife notified Init.

X1

X2

X3

X4

TSB bloodwork appt verbally Yes Noconfirmed with parentOHIP lab requisition completed Yes No

Jaundice teaching sheet Yes Nogiven and discussed

Initials Printed Name Signature & Designation

Gestational Age: _____ weeksMother’s Blood Group: _____

Baby’s Blood Group: _____

NomogramRisk Zone CODE Bilirubin Screening Response Codes: 38 or more weeks’ gestation

Low Risk Zone LRZ Routine care - No Coombs test requiredLow-Intermediate

Risk Zone LIZ Routine care - No Coombs test required

Follow Coombs test algorithm (see reverse) to determine if Coombs test is required.

CODE Coombs test Negative or Not required CODE Coombs test PositiveHigh-Intermediate

Risk Zone HIZ-N Routine care - care provider consider afollow-up TSB if there is clinical concern HIZ-P Follow-up assessment including TSB

at 24 to 48 h

High Risk Zone HRZ-N Further testing or treatment required HRZ-P Further testing or treatment required

Initial all applicable responses TSB = Total Serum Bilirubin

hyperbilirubinemia

HAMILTON REGIONAL HOSPITALSHyperbilirubinemia Screening

Assessment for Newborns

35 - 37 6/7 Weeks Gestation

714508 (2008-04)Labs – Labs Page 1 of 2

50

75

100

125

150

175

200

225

250

275

300

325

0 12 24 36 48 60 72 84 96 108 120 132 144Age in hours

Low Risk Zone



High Risk Zone

50

75

100

125

150

175

200

225

250

275

300

325

0 12 24 36 48 60 72 84 96 108 120 132 144Age in hours

Low Risk Zone



High Risk Zone

18 42 30 54 66 78 90 102 114 126 138

X

Bilirubin µmol/L


High Risk Zone


Low Risk Zone

BILIRUBIN NOMOGRAM X1, X2, X3, X4 = Bilirubin Level

NomogramRisk Zone CODE Bilirubin Screening Response Codes: 35 - 37 6/7 weeks’ gestation

Low Risk Zone LRZ Routine care - No Coombs test required

Follow Coombs test algorithm (see reverse) to determine if Coombs test is required.

CODE Coombs test Negative or Not required CODE Coombs test PositiveLow-Intermediate

Risk Zone LIZ-N Routine Care LIZ-P Further testing or treatment required

High-IntermediateRisk Zone HIZ-N Follow-up assessment including TSB at

24 to 48 h HIZ-P Further testing or treatment required

High Risk Zone HRZ-N Further testing or treatment required HRZ-P Phototherapy required

Initial all applicable responses TSB = Total Serum Bilirubin

TSB bloodwork appt verbally Yes Noconfirmed with parentOHIP lab requisition completed Yes No

Jaundice teaching sheet Yes Nogiven and discussed

Initials Printed Name Signature & Designation

Date(yyyy/mm/dd)

Time(hh:mm)

Age inhours

Bilirubinµmol/L

Bilirubin ScreeningResponse Code

(See Below)Name of MRP /Midwife notified Init.

X1

X2

X3

X4

BILIRUBIN LEVEL IS ABOVE THE LOWRISK ZONE and MOTHER IS BLOODGROUP O

Coombs Test Ordered

Yes NoCoombs Test (DAT)

NEGATIVE POSITIVE

COOMBS TEST (See reverse for Algorithm)

Gestational Age: _____ weeksMother’s Blood Group: _____

Baby’s Blood Group: _____

HYPERBILIRUBINEMIA - COOMBS TEST ALGORITHMWhen a Coombs test needs to be done as part of the newborn hyperbilirubinemia assessment,please follow the algorithm below based upon the mother’s blood group:

MOTHER O -ve MOTHER O +ve MOTHER A* or B*

Routine Care- Follow-up appointment within 48 hours afterdischarge with MD or MW if infant is greater than48 hours of age on discharge

or

- Follow-up appointment within 24 hours afterdischarge withMD or MW if infant is less than 48hours of age on discharge

If the baby is in the LRZ or LIZ risk zone and thereis no clinical concern, then the TSB result does notneed to be reported to the MD/MW and the babymay be discharged as per Routine Care outlinedabove.

Follow-up assessment including TSB at 24 to 48 h:- Follow-up assessment: babies requireappointment with MD, MW or BANA within 24 -48 hours of discharge,

and

- Follow-up TSB at 24 to 48 h:In region: all babies requiring pre-orderedblood work should have appointment bookedin BANA

Out of region: all babies requiring pre-orderedbloodwork may have an appointment bookedin BANA or an outpatient clinic in theircommunity.

Further testing or treatment – a repeat TSBshould be done or intensivephototherapy should be initiated as perMD / MW orderBANA = Breastfeeding and Newborn Assessment Clinic

Bilirubin Risk Zone Predictive Bilirubin Risk Zone Levels at Follow-up

Low Risk Zone • 94% remain in Low Risk Zone • 6% may jump to Low Intermediate Risk Zone

Low-Intermediate Risk Zone • 2% may jump to High Risk Zone • 5% may jump to High Intermediate Risk Zone

High-Intermediate Risk Zone • 13% may jump to High Risk Zone High Risk Zone • 57% remain in High Risk Zone

714508 (2008-04)Labs – Labs Page 2 of 2

NOTE:If any antibodies aredetected prenatally, then aCoombs’ test must alwaysbe done regardless ofmother’s and baby’s bloodtypes.

* A = A +ve and A –ve B = B +ve and B –ve

Babies of all Rh negativemothers will automaticallyhave their blood group doneat time of birth by TransfusionMedicine Lab to determine ifmother needs another doseof Rh immune globulin.

When the TransfusionMedicine Lab receives anorder to do a Coombs test,the Lab will do the baby’sblood group first.

Coombs Test IS NOT required.

Baby O –veor O +ve

BabyA* or B*

Baby O –veor O +ve

BabyA* or B*

Coombs TestIS NOTrequired

Coombs TestIS required

Coombs TestIS required

Coombs TestIS NOTrequired

The Hospital for Sick Children Phototherapy Guidelines for Infants

<35 weeks and/or <2500g

020406080

100120140160180200220240260280

12h 24h 36h 48h 60h 72h 84h 96h 108h 120hTime (hours in age)

mic

ro m

ol/L

(µm

ol) T

SB (t

otal

ser

um

bilir

ubin

)

<28w or <1000g

28-29w6days or 1000-1249g

30w-31w6days or 1250-1499g

32w-33w6days or 1500-1999g

34w-34w6days or 2000-2400g

1. Use total serum bilirubin. Do not subtract direct or conjugated bilirubin. 2. Use gestational age rather than birthweight if gestational age is

accurate. 3. Start phototherapy when total serum bilirubin (TSB) is = the line according to gestation or weight.4. In the presence of risk factors use one line lower (use gestation below) until <1000grams.5. Risk Factors: isoimmune hemolytic disease, G6PD deficiency, asphyxia, sepsis, acidosis, hypoalbuminemia6. Discontinuing phototherapy: discontinue phototherapy when the bilirubin level falls below the level at which it was initiated.

References:Maisels & Watchko. Arch Dis Child Fetal Neonatal Ed. 2003; 88:F459-F463. Horn et al. South African Medical Journal 2006;96:819-824.

The Hospital for Sick Children Exchange Transfusion for Infants <2500g and/or <35weeks gestation

160170180190200210220230240250260270280290300310320330340350360370380

12h 24h 36h 48h 60h 72h 84h 96h 108h 120h

Time (age in hours)

mic

ro m

ol/L

(µm

ol) T

SB (t

otal

ser

um

bilir

ubin

)

<28w or <1000g

28w-29w6days or 1000-1249g

30w-31w6days or 1250-1499g

32w-33w6days or 1500-1999g

34w-34w6days or 2000-2400g

1. Use total bilirubin. Do not subtract direct or conjugated bilirubin.2. Use gestational age rather than birthweight if gestational age is accurate. 3. In the presence of risk factors use one line lower (gestation below) until <1000g.4. Exchange level for infants <1000g with risk factors: 12hrs:180µmol/L; =24hrs:200µmol/L5. Risk factors: isoimmune hemolytic disease, G6PD deficiency, asphyxia, sepsis, acidosis, hypoalbuminemia.6. Infants who present with total serum bilirubin (TSB) above threshold should have exchange performed if TSB is not expected to be below the threshold after 6 hours of intensive phototherapy.7. Immediate exchange transfusion is recommended if infant shows signs of acute bilirubin encephalopathy (hypertonia, arching, retrocollis, opisthotonos, fever, high pitched cry) and usually if TSB is >85umol/L above threshold at presentation. 8. Exchange if TSB continues to rise >17umol/L/hour with intensive phototherapy.

References:Maisels & Watchko. Arch Dis Child Fetal Neonatal Ed. 2003; 88:F459-F463. Horn et al. South African Medical Journal 2006;96:819-824.

Phototherapy and Exchange Transfusion Guidelines in Premature Infants (<35 weeks gestation and/or <2500grams)

PHOTOTHERAPY & EXCHANGE TRANSFUSION GUIDELINES

GUIDELINES FOR PHOTOTHERAPY IN HOSPITALIZED INFANTS OF 35 OR MORE WEEKS’ GESTATION

GUIDELINES FOR EXCHANGE TRANSFUSION IN INFANTS

35 OR MORE WEEKS’ GESTATION

care of the late pre-term

34-36 6/7 weeks

at risk for : resp distress

temperature instability

hypoglycemia

feeding challenges

jaundice/hyperbilirubinemia

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St. Joseph's Healthcare Bradma

SCREENING PROTOCOLS

Gestational Age: Birthweight:

Issues: 1. 2. 3.

All Babies: Sucrose guidelines as per protocol

Term > 37 weeks: Hearing Result: L R

Car Seat if respiratory distress Passed: Bili at 24 – 48 hrs Result: Newborn screen done at 48 hrs Drawn : O2 ~ 92 – 98% parameters Maintained:

360 – 366: Hearing Result: L R

Car Seat trend Passed: Bili at 24 – 48 hrs Result: Newborn screen done 5-7 days Drawn : O2 ~ 88-95% parameters Maintained:

Hypoglycemia Protocol – 36 hrs Completed:


Car Seat trend Passed: Bili at 48 hrs & Day 5 (with NB screen) Result: Newborn screen done 5-7 days Drawn :

O2 ~ 88-95% parameters maintained:

Hypoglycemia Protocol – 36 hrs Completed: Synagis Scoring Result:


Car Seat trend Passed: Bili at 48 hrs & Day 5 of life Result: Newborn screen done 5-7 days Drawn : O2 ~ 84-93% parameters maintained:

Synagis Application Completed:

Head Ultrasound at 1 month Completed: Calcium and phosphate at 1 month Result:

CBC & Retics at 1 month Completed:


Car Seat trend Passed: Bili at 48 hrs & Day 5 of life Result: Newborn screen done 5-7 days Drawn : O2 ~ 84-93% parameters Maintained:


Head Ultrasound at 1 month Completed: Calcium and phosphate at 1 month Result: CBC & Retics at 1 month Completed: ROP Exam at 4 weeks of age Completed:


Car Seat trend Passed: Bili at 48 hrs & Day 5 of life Result:

Newborn screen done 5-7 days Drawn : O2 ~ 84-93% parameters Maintained:


Head Ultrasound at 5 – 7 days of life Completed: Head Ultrasound at 21 – 28 days of life Completed: Head Ultrasound at term corrected Completed: Calcium and phosphate at 1 month Result: CBC & Retics at 1 month Completed: ROP Exam at 4 weeks of age Completed: TSH & T4 at 1 month and/or < 1500 grams Completed:

< 290 weeks: Hearing Result: L R

Car Seat trend Passed: Newborn screen done 5-7 days Drawn : Synagis Application Completed:

Head Ultrasound at 5 – 7 days of life Completed: Head Ultrasound at 21 - 28days of life Completed: Head Ultrasound at term corrected Completed: Calcium and phosphate at 1 month Result:

CBC & Retics at 1 month Completed: Bili at 48 hrs and DOL 5 Completed: ROP Exam at 4 wks or 32 wks corrected Completed: TSH & T4 at 1 month Completed:

Assess BPD: Ultrasound Completed: ECHO Completed:

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