Small World Master, June, 2007

8/3/2019 Small World Master, June, 2007

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"IT'S A SMALL WORLD"(An Introduction to Neonatology)

William J. Cashore, M.D., EditorNeonatal Attending Staff

Neonatal FellowsNutrition TeamNursing Staff

Nurse PractitionersPharmacy Staff

Respiratory Therapy Team

Division of Neonatal - Perinatal MedicineWomen & Infants Hospital of Rhode Island

The Warren Alpert Medical School of Brown UniversityNever final, always being revised;

Last revision June, 2007


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SmallWorldSpecialCareNurseryOrientationIndexContents PagesI. Organization and Schedules

Team AssignmentsCall Schedules

Plan of the Day

444

5II. General Information and Survival Skills

Neonatal Admission History and Physical FormDelivery Room/Operating Room Stabilization of the

High-Risk Newborn

6 -78 -10

11-15

III. Admission Routines(Includes overview of initial sepsis workup and

respiratory management)

16 -17

IV. Guidelines for Preventing Medication Errors inPediatrics

18-24

V. Fluids, Electrolytes & Nutrition1. IV Fluids and Electrolytes

2. Feeding3. Parenteral Nutrition

25-3825-29

30-3434-38

VI. Respiratory Care1. Blood Gas Guidelines2. Oxygen Administration3. Surfactant4. Neonatal Ventilators5. Guidelines for Non-invasive Oxygen Monitoring

39-4539-40

4040-4141-4444 -45

VII. Infectious Disease Issues1. Infection control2. Management of Neonatal Infections3. GBS Guidelines for Women & Infants Hospital

4. HIV-exposed NewbornProtocol for InitialManagement

46-5446-4747-4950-52

53-54

VIII. Metabolic Screening, Immunizations, Ultrasounds, and EyeExams

55-60

IX. Some Common Clinical Problems1. Hypoglycemia2. Hypocalcemia3. Procedure for Suspected Drug Exposure4. Narcotic Withdrawal5. Blood Pressure in Infants6. Transfer of Drugs to Human Milk7. Hyperbilirubinemia

8. Apneic Spells9. Use of Blood Products in the Special Care Nursery

61-8261

62-6363-6464-6869-7071-7474-78

78-8080-82

X. Discharge Planning and Seasonal RSV Prophylaxis(Synagis) Instructions

83-94

XI. Clinical Practice Guidelines1. Procedure-related Pain Management2. HIE/Hypothermia Guidelines3. Congenital Diaphragmatic Hernia

95-10996-99

100-105106-109


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I. ORGANIZATION AND SCHEDULES

Team Assignments:

Team 1 Team 2 LDR

AttendingFellow

4 NNPs

AttendingFellow

PL-2s (Day and swing)PL-1's (3 or 4)

PL-2

PL-1* (from Team 2)NNP

LDR coverage:*Days: NNP, LDR PL-2, Team 2 PL-1 (per assignment)*Nights: Add Normal Nursery (NNN) PL-1, when on call

Teams 1 and 2 follow their patients in the Special Care Nursery (SCN).Admissions to teams are by census and nursing assignments.

Team alignments may change, depending on the numbers of residents and NNP'savailable.

Each PL-1 has 1 LDR assignment (+normal nursery LDR call). Patient load is reducedduring this assignment.

Resident FunctionsLDR PL-2: High-risk deliveries; day transports; supervises and stabilizes newadmissions.Team PL-2: Regular patient assignments on Team 2; independent for manyprocedures, and supervises and helps PL-1's; shares senior call with delivery PL-2 andswing PL-2.

PL-1: Admits and follows assigned patients; has one daytime LDR rotation, withreduced number of SCN patients. Learns and performs bedsideprocedures with supervision.

Night call: SCN PL-1: q 4th nightPL-2 : q 4 while Team member or on LDR assignment

q 2 when on swing


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"Plan of the Day"

1. Pre-round 6:30 - 7:30 a.m. - check: (earlier when a.m. conference)a. Patient status (update with patients nurse)b. Weight and totalsc. Pending procedures and lab workd. Write new orders, if needed

2. Team rounds at 8:00 a.m. and 4:00 p.m. (9:00 a.m. Wednesdays and someThursdays)

3. Following a.m. rounds:

a. Examine infants and check labsb. Review nutrition orders with nutritionistc. Complete dischargesd. Start progress notese. Telephone follow-upf. X-ray rounds (usually at approximately 1 p.m. Monday, Wednesday, & Friday)

4. Noon conference:

a. Pathology 1st and 3rd Tuesday

b. Perinatal Seminar each Thursday (Mortality and Morbidity, InfectiousDiseases, Nutrition, Journal Club)

c. Social Service Rounds each Fridayd. Interdisciplinary Antenatal Management Conference 1st and 3rd Friday

5. Attending teaching rounds:

Monday, Tuesday, and Wednesday at noon.

6. Sign-out rounds:Weekdays at 4:00 p.m.

a. Brief, business-likeb. Pick up new patientsc. Emphasize active vs. static problems


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II. SURVIVAL SKILLS IN SCN

1. Pre-round at bedside; develop a checklist

2. Present concisely; don't editorialize

3. Progress notes:a. Daily notesb. Note any significant change or procedure, e.g.,

1) Endotracheal intubation*2) Lumbar puncture*3) Arterial or venous catheter placement*4) Chest tube*5) Cultures6) Transfusions7) Significant change in condition*Write Procedure note, and indicate when discontinued

c. Document parent and physician contacts

4. Talk to parents and other physicians and inform parents of pending procedures.

5. Listen to the nurses!

6. Order sheets:a. Bedside - admission, nursing care, respiratory care, medications, andphototherapy.b. Consults, X-rays, regular lab work, etc. in Bay order booksc. Respiratory orders in bedside chart

d. Daily TPN orders - computer printout must be signed by M.D.

7. Labs - everything is on stat linea. Phlebotomy schedule 2-5-8-11b. Computer terminals CERNER Systemsc. STAT and summary print-outsd. Flow sheets - stay current

8. Discharge and Transfer Summariesa. Do as soon as possibleb. Dictate using Cerner (See Discharge Template pages)

c. Stay current1) Penalties for delinquent records2) Avoid overwhelming backlog3) Medicolegal problems - record observations; avoid editorials,

opinions, and undocumented statements, especially aboutobstetrical management


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Patient Presentations

Know your patients, and be concise. Be up to date on daily weights, managementchanges, procedures, and important lab values.

Present a brief obstetrical or interval history. For older patients, a one-sentencesummary may do (e.g., Baby X is a one month old, 25 week, 820g preemie with BPDand feeding intolerance. Try to avoid:

o Calling babies productso Overuse of diminutive or disparaging terms (were not little, small

doctors!).o Former to describe gestational age (The patient is not divorced or

retired). Instead, try Baby Z is a 27 week premature, now 40 daysold...

o Editorializing (as I am doing now!)

Social history is important, but may not require extensive discussion on work rounds.

Follow your brief history and list all problems/diagnoses with a system-oriented

presentation and your therapeutic plan. Unresolved problems and loose ends should bediscussed along with the plan. Check with the bedside nurse during pre-rounds, anddetermine when each nurse will be available for team rounds on her patients.

Afternoon rounds should be concise and deal with new admissions, major managementproblems, and the plan for the next two shifts. A brief check with the night nurses after11:00 p.m. is important.

Write a complete admission or observation note on each patient brought to IntensiveCare Nursery: a complete history, physical exam, diagnostic impressions, and plan inlegible and organized format. Pre-printed admission and progress note templates

evolve over time, but all permanent printed forms should be approved by MedicalRecords (sample on next page).

Progress Notes

Write daily notes on all patients. Describe interval events clearly and concisely.System-oriented notes can be entered on approved pre-printed forms. Recordsignificant exam findings, procedures, changes in the patients condition, andcommunication with the family.

The team attending will write progress notes for all patients of residents going off call.On weekends, daily patient notes are written by the attending and a nurse practitioner.

However, please document any procedures (cultures, transfusions, LPs, catheterplacements, etc.) as well as any changes in the patients condition on weekend days.

Summaries and Signatures

Dont get behind on your records. You will feel overwhelmed, and medical records willchase you!


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Delivery Room/Operating Room Stabilization of the High Risk Newborn: ClinicalCare Considerations, House-staff/NNP Responsibilities, and Educational

Rotations

The following is a summary of expectations for personnel involved in the care of highrisk newborns in the delivery/operating rooms.

A) Members of the Delivery Room team: Providers with responsibility for careand stabilization of newborns in the DR/OR include the Fellow, PL-2 and PL-1on delivery room rotation, NNP, Respiratory Therapist and a representative ofNursing (either the Assistant Nurse Manager or Admission Nurse). Given therelatively short intervals the House-staff have for a dedicated delivery roomrotation and the necessary program requirements that take House-staff out ofthe rotation (post-call, clinic), the NNP will serve as the Coordinator tosupervise the House-staff while on the DR rotation.

B) Communication between patient care areas and the NICU providers

responsible for DR/OR coverage: Dedicated cell phones are used to facilitatecommunication among the DR/OR providers (physicians, nurses, RTs). Thetemplate for communication is that any area requiring NICU staff to respond toa delivery contacts the NICU secretary and the secretary uses the cell phone(single dedicated channel) to contact all members of the team (Fellow, PL-2,PL-1, NP, ANM, RT). This allows providers to communicate with each otherand make sure that the appropriate individual is responding as needed.

C) Preparation of infant warmers: All warmers will be set up in a standardizedfashion in each patient care area where infant resuscitations could occur at orshortly after birth (LDRs, ORs, Newborn Nurseries, ABC, Triage).

D) Providers attending deliveries: There are clear expectations regarding whoshould attend specific deliveries. There is also a clear delineation of an orderlysequence of who is the next person responsible for attending a delivery if theprimary person is unavailable to respond. The following is the current workingtemplate and may be modified as needed:

Guidelines for who is the primary individual(s) responding to specific types ofdeliveries:

Neonatal Fellow:1) Gestational age < 30 weeks

2) Fetal hydrops3) Any potential life threatening congenital anomaly4) Crash cesarean section5) Infants not responding adequately to initial airway management6) Multiples < 34 weeks7) Infants requiring intubation: will depend on competency of the PL-2


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Senior Pediatric Resident (PL-2) or NP:1) Gestational age < 33 weeks2) Urgent cesarean sections (non-reassuring FHR, low biophysical profile, etc.)3) Abruptio placenta4) Placental previa with hemorrhage

5) Shoulder dystocia6) Meconium with a non-reassuring fetal heart rate pattern7) Emergent use of forceps or vacuum*8) Vaginal breech presentation9) Poor respiratory effort at birth (slow to start)10) All indications requiring the presence of a fellow

Pediatric Resident (PL-1):1) Gestational age 33 weeks2) Elective repeat cesarean section (irrespective of presentation)3) Non-emergent use of forceps or vacuum*

4) Suspected growth restriction5) Oligohydramnios6) Chorioamnionitis/PROM7) Maternal medical problems: diabetes, hypertension8) Twins (need second provider)9) Meconium with a reassuring fetal heart rate10) Poor respiratory effort at birth (slow to start) once competent in

bag/mask ventilation11) Absent prenatal care

Respiratory Therapist:1) All indications requiring a Fellow2) All indications requiring a PL-2/3 or NNP3) All deliveries with meconium stained fluid4) Poor respiratory effort at birth (slow to start)

ANM/NICU Nurse:1) All deliveries requiring a fellow

* Assessment of emergent or non-emergent use of forceps/vacuum may only beascertained once in the DR/OR and then should prompt the appropriate personnel

When the primary individual responsible for attendance at a delivery is unable toattend (in another delivery, stabilizing an infant in the NICU etc) the followingsequence should be followed:

1) If a PL-1 delivery: Back-up order is PL-2, NP, fellow2) If a PL-2 delivery: Back-up order is NNP, Fellow (PL-1 should accompanyNP or Fellow)


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E) Training of new providers in the DR/OR setting: New providers to theLDR/ORs (PL-1, NP) need individualized instruction that is consistent from monthto month. As much as possible a trained provider (e.g., fellow, PL-2, NP) willattend deliveries with new personnel and provide on site instruction untilcompetency is demonstrated. For low risk deliveries of the PL-1 list above (e.g.,

elective repeat cesarean sections), preparation of equipment and properhandling/assessment of the infant need to demonstrated. For higher riskdeliveries of the PL-1 list (e.g., meconium stained amniotic fluid) competency inrecognition of the need for more support (e.g., oxygen, bag/mask ventilation),and bag/mask ventilation needs to be demonstrated. PL-1s who are not onDR/OR should also receive mentoring when they fill in for the PL-1 on DR/OR(e.g., during clinic hours and post-call).

F) Responsibilities of the NP for the DR/OR:1. Attend deliveries with the PL-1 until the PL-1 demonstrates competency in

specific functions.

2. Orient PL-1 to the cell phone/communication system.3. Conduct teaching sessions with the PL-14. Facilitate the PL-1 completing their work to allow time for attendance on

rounds, attending deliveries and teaching sessions5. Conduct quality assurance reviews of specific aspects of care in the DR/OR6. Participate in the DR/OR coverage so that rounds can proceed

uninterrupted in the morning and afternoon7. Cover the DR/OR when the PL-2 is admitting a patient, in clinic, or post-call.

8. Be available to help with procedures during rounds so that the teams cancontinue their work.

9. Transport patients within the hospital system and to/from other hospitals.10. Teach and orient the third year medical students on Tuesday and Thursday.

G) Responsibilities of the DR PL-2 for the DR/OR (all responsibilities are shared

with the NP):1. Attend high risk deliveries2. Admit patients to the NICU (perform exam, write history and orders, do

blood work, consult with fellow etc)3. Provide care for infants under observation status and complete the

appropriate paperwork and communication if triaged to the Newborn

Nursery4. Evaluate problems of specific patients in the NICU during morning rounds tominimize rounds having to be stopped. This function should be done underthe guidance and supervision of the Fellow.

5. Teach the PL-1s on DR issues when knowledgeable regarding specifictopics.


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6. Transport patients within the hospital system and to/from other hospitals.7. Teach and orient the third year medical students on Tuesday and Thursday.8. Pick two topics per week on issues timely and pertinent to team II (e.g.,

imperforate anus, NEC etc). After reading neonatal sources, write on theboard an over view of the topic (e.g., definition, pathogenesis, time of

occurrence, risk factors, diagnosis, treatment, prognosis as pertinent foreach topic). Leave on the board for 2-3 days for other team members toview.

H) Responsibilities of the DR PL-1 for the DR/OR1. Attend deliveries appropriate for level of training2. Understand transitional events associated with birth3. Learn how to appropriately triage infants to either the NICU or the Newborn

Nursery4. Learn how to admit new patients to the NICU

I) Educational content of the DR/OR rotation: To ensure that specific basicinformation is conveyed to each house-officer/new NP as they rotate through theDR/OR (two week blocks for the House-staff), attempts should be made to coverfocused topics pertinent to delivery room care. The topics for the PL-1 are asfollows:

1. Orientation to the delivery service: tour of the physical plant (L&D, ORs,triage, ABC area, post-partum floors), communication system (wirelesssystem and all hazards of this technology, measures to not lose phones,back-up system), bed set up as delineated under section A, organization ofthe delivery service as to who goes to what deliveries, expectations beforethey can function independently

2. Airway management part A (use senior RT staff either alone or with NNP):different type of bags (self-inflating, anesthesia, Neopuff), baggingtechniques, seal, position, assessment of adequate ventilation, hands onexperience with manikin/intubation head, airway stabilization for transport

3. Airway management part B(use senior RT staff either alone or with NNP):intubation issues including equipment (including appropriate sizelaryngoscope blade), ET tubes, positioning, visualization of structures (useof video??), indications for intubation

4. Meconium stained amniotic fluid: significance of meconium passage, Obmanagement, pediatric airway management, use of meconium aspirator

5. Temperature control in the DR: consequences of cold stress, preparation fordelivery, use of warm blankets, proper drying and removal of wetblankets/towels, implications of LBW, use of hats, transport issues

6. Initiating CPR: indications for CPR, time expectations, proper sequences,proper chest compressions

7. Maternal pregnancy risk assessments: amniotic fluid volume, biophysicalprofile, fetal cord blood gases, rupture of membranes, chorioamnionitis,


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diabetes, hypertension, growth restriction, breech, fetal heart rateabnormalities

8. Maternal exposure to drugs: anesthesia, analgesia, Mg exposure, otherdrugs given to the mother, illicit drug use, when to avoid narcan

The PL-2 will also benefit from focused discussion of pertinent topics to their levelof training. Some PL-2s may need a refresher of basic concepts covered as a PL-1. The topics for the PL-2 are as follows:

1. Review of airway management(done with Senior RT staff): reviewtechniques of bagging, assessment of adequate ventilation and response tobagging, intubation techniques, use video if necessary

2. Critical airway issues(done with Senior RT staff): proper approach to infantswith critical airway compromise (Pierre-Robin sequence, othermalformations of the upper airway), recognizing your limits, sequence ofback up resources

3. Ambiguous genitalia and other unexpected findings in the DR/OR:

appropriate discussions with families4. Handling infants with abdominal wall defects, myelomeningocoele5. Delivery room management for the premature infant: intubation vs. CPAP,

prophylactic surfactant, initiation of care for infants at the borders of viability


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III. ADMISSION ROUTINES FOR NICU (See NICU Order Sheet)

1. PL-2, LDR PL-1 or LDR NNP admit and stabilize new patients

2. Orders (Refer to the pre-printed sheet, and modify as needed)

a. Admit or "Observe" in NICUb. Admitting Diagnosis and conditionc. Vital signs, monitoring, and glucose screens per NICU protocold. Vitamin K and Hepatitis B vaccinee. X-rays, including indication for requestf. IV fluids (see attached for guidelines) Route of administration (UA, UV, peripheral veins) Specific orders for additional lines Include all fluid intake in daily totals

g. Feeding orders, or NPO

Separate order sheet for parenteral nutrition (see guidelines)h. Admission Blood Work; check off as needed, and consider these asSTAT requests

i. Initial and follow-up metabolic screens j. Other e.g., initial medications, additional bedside procedures, etc.

Urgent consults or special studies may require a separate order form

3. Respiratory Carea. Use bedside order sheet to specify initial orders, follow-up changes, and

blood gas requestsb. O2 concentrations, ventilator settings and changes, and blood gas results

are recorded on the pink bedside flow sheet and in CERNERc. Surfactant, initially for paO2


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IV. Guidelines for Preventing Medication Errors in PediatricsBy Michael R. Muller, Pharm.D., NICU Clinical Pharmacist Specialist

A. Elements of a Medication Order or Prescription

1. Patients full name.2. Patients age (date of birth) and current weight.3. Diagnosis and other appropriate patient-specific data.4. Known allergies.5. Drug name, dosage form, and drug strength. Drug names should be printed for rarely used

medications. Express concentrations in metric units.

6. Number or amount to be dispensed. Express quantity, if appropriate, in metric units.7. Include calculations, or at least mg/kg/day dosing, so calculations can be independently

double-checked; i.e. amoxicillin 40mg po q 8 hrs (40mg/kg/day).8. Prescribers name and pager or telephone number.9. Complete instructions for the patient including indication, directions for use including dose,

frequency of dosing, route of administration, intended duration of therapy, and the numberof authorized refills.

10. Products to be administered by the patient or caregiver in the outpatient environmentshould be labeled expressing the dose in conventional units of measure. Listing equivalentmeasurements may be helpful to clarify the intended dose (i.e., 1 teaspoonful (5 mL) bymouth twice daily). Recommend or supply appropriate measuring devices. Discourage use

of household teaspoons and tablespoons.

Recommendations for Prescribers

1. Legibility (i.e., printed or typed vs handwritten, prescriber computer order entry). Preprintedorders are another option but must be approved by a multidisciplinary team of the P&TCommittee (Service Line Committee, W&I).

2. Drug name should be either the official (generic) or trademarked name clearly spelled. Forthose medications that contain multiple ingredients, the use of the trade name is moreappropriate. Abbreviations of the name, acronyms, and chemically or locally coined namesshould not be used because they may be misunderstood.

3. Instructions should be written out, rather than expressed using abbreviations that areambiguous or not approved within the institution.4. Vague instructions, such as take as directed, should not be used.5. Because many medications are available in varying strengths or concentrations, dosage

strengths or concentrations and volumes should be expressed in exact metric units (e.g.,mg, units), rather than dosage form units (e.g., # tablets, vials, ampules, capsules, mL).

6. A leading zero should always precede decimal expressions less than one (i.e., 0.1 mg), buta trailing zero should never follow a whole number (i.e., 1.0 mg).


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7. To facilitate verification of the appropriateness of the dose by other healthcareprofessionals, any calculations used in determining the dose should be included in themedication order.

8. For medications other than most topically administered, both the calculated dose AND themg/kg or mg/m2 dose upon which the dose is based should appear in all medication ordersfor pediatric patients. This simple step helps assure that a nurse and / or pharmacist do notmisread an order. It also promotes accurate dose calculation by facilitating redundantchecks by nurses and pharmacists.

9. If the order is for a drug product that is not on the formulary or for a new dosage of aformulary medication, the prescriber should provide information with the order or in thepatients chart for other healthcare professionals. Use of a non-formulary medicationintroduces a new drug into the system that healthcare professionals may not recognize;thereby, increasing the risk of error. A healthcare provider may assume that it is anotherdrug that sounds or looks similar to an agent with which they are familiar. Use of non-formulary items should be limited for the above reasons.

10. If orders are changed, a new order should be written. For the ambulatory patient, newprescriptions should be written and remaining refills of previous doses should be canceled.The information should be communicated to the pharmacy providing outpatient services.

11. In situations where the use of verbal prescriptions or orders is necessary, the prescriber

should dictate the order slowly and clearly, spelling the drug name and any other wordsthat may be misheard. Likewise, the prescriber should restate numbers that may beconfused (i.e., 15 as one five). In order to verify accuracy, the prescriber should have therecipient repeat the order back to him or her. The prescriber should also be certain to verifythe transcribed order within a designated time frame.

12. When possible, without compromising patient care, odd dosages should be rounded-off formore convenient and accurate measurement.

13. When appropriate, prescribers should write orders for commercially available drugproducts, rather than dosage forms prepared by manipulation of commercially availableproducts.

14. If at all possible, drugs should be prescribed for oral administration, rather than by injection.

15. Prescribers should consider consolidating styles of managing patients. A variety of ways tomanage a patients medical condition is possible and considered good medicine that is costeffective. However, diversity in writing medication orders may lead to confusion and errors.Consolidating styles in an intensive care unit setting so that all drips are written as eithermcg/kg/minute or mg/kg/hour can avoid calculation errors that occur secondary to movingback and forth between systems.

16. Prescribers should also counsel the patient and his or her caregiver, familiarizing them withthe name, indication, route of administration, dose, dose frequency, potential adverseeffects, and how adverse effects might be managed for each medication the patient isreceiving.

(Adapted from Levine SR, et al. J Pediatr Pharmacol Ther 2001;6:426-42.)

Problem Order

Indocin (0.1/kg) .100mg IV q24 X iii

Better Order

Indocin (0.1mg/kg/dose) 0.1mg IV q24 hours X 3 doses


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Problem Order

Y in D5 w/ 2/2 Na/K 0.25 u hep @ 0.7cc/ocont TPN rate @ 1cc/o

Better Order

Y-site w/ TPN the following solution:

D5W w/ NaCl 2mEq/100mlKCl 2 mEq/100ml

heparin 25 units/100mlRun @ 0.7ml/hr

Run TPN @ 1ml/hr

Problem Order

Decrease Morphine oral solution to 0.06ml po q4o prn finnegans

Better Order

Taper Morphine oral solution 0.4mg/ml to:

0.024mg (0.06ml) po q4 hrsFor withdrawal symptoms

Problem Order

Resume PO meds

Better Order

Resume ADEK vitamins 0.5ml PO BIDFerinsol 5mg PO q day

Ursodiol 17mg PO q8 hrs (10mg/kg/dose)

Problem Order

Indocin 2.7mg IV q12o X 3 doses

Better Order

Indocin 0.27mg IV q12 hrs X 3 doses for PDA(0.2mg/kg/dose, wt=1.35kg)

Problem Order

D10W w/ 2 mEq Na+ 1 mEq K+ /[email protected]/hr for TF=90

Better Order

D10W w/ NaCl 2mEq/100mlKCl 1mEq/100ml

Heparin 25 units/100ml


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Run @ 7.6ml/hr(TF=90ml/kg/day, wt=2.03kg)

Problem Order

Please mix D12.5 w/ Dopamine 5mcg/k/min @ 0.25cc/hrMix 624 mg/50cc

Better Order

Mix Dopamine 62mg/50ml D12.5Run @ 0.25ml/hr

(5mcg/kg/min, wt=1.03kg)

Problem Order

Please increase to 8 mEq NaCl/kg/dDivided into 2 doses

Better Order

Increase NaCl to (8mEq/kg/day in divided doses)

1.1mEq PO q4 hrs w/ feeds (wt=0.825kg)

B. Continuous Infusion Medications

Women & Infants Hospital Patients Name (Addressograph)Neonatal ICU Continuous Infusion

Medication Order SheetDoctors OrdersDate / Time:__________ / __________Allergies:

_______________________________________________________________

Medication OrdersCardiovascular MedicationsMedication Concentration Diluent Dose______(mcg/kg/min) X Weight______(kg) X 60 Rate Alprostadil Standard D

5W___________________________________________ = (mL/hr)

Dobutamine Fluid Restrict D10

W

Dopamine NS Concentration______(mcg/mL)====================================================================================================================

Medication Concentration Diluent Dose______(mcg/kg/min) X Weight______(kg) X 60 Rate Alprostadil Standard D

5W___________________________________________ = (mL/hr)

Dobutamine Fluid Restrict D10

W

Dopamine NS Concentration______(mcg/mL)====================================================================================================================

Neurological MedicationsMedication Concentration Diluent Dose______(mcg/kg/hr) X Weight______(kg) Rate Fentanyl Standard D

5W_____________________________________ = (mL/hr)

Midazolam Fluid Restrict D10

W

Morphine NS Concentration______(mcg/mL)====================================================================================================================

Medication Concentration Diluent Dose______(mcg/kg/hr) X Weight______(kg) Rate


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Fentanyl Standard D5W_____________________________________ = (mL/hr)

Midazolam Fluid Restrict D10

W

Morphine NS Concentration______(mcg/mL)====================================================================================================================

Endocrinologic MedicationsMedication Concentration Diluent Dose______(unit/kg/hr) X Weight______(kg) Rate Insulin, Reg Standard D

5W_____________________________________ = (mL/hr)

Fluid Restrict D10

W

NS Concentration______(unit/mL)=================================================================================================

Signature: ____________________________ M.D. / N.P.

Name: ____________________________ Pager # ___________ ____________________________ R.N.

Authorization is hereby given to dispense a chemicallyidentical drug (According to Hospital Formulary Policy)unless this box is checked. MR-336 (3-2005)

Standardized Infusion Formulary

Cardiovascular Medications Neurological MedicationsMedication Concentration Diluent Medication Concentration DiluentAlprostadil (PGE

1) 10 mcg/mL (Standard) D

5W, D

10W, NS Fentanyl 10 mcg/mL (Standard) D

5W,

D10

W, NS

20 mcg/mL (Fluid Restricted) 40 mcg/mL (Fluid Restricted)Dobutamine 800 mcg/mL (Standard) D

5W, D

10W, NS Midazolam 100 mcg/mL (Standard) D

5W, NS

3200 mcg/mL (Fluid Restricted) 400 mcg/mL (Fluid Restricted)Dopamine 800 mcg/mL (Standard) D

5W, D

10W, NS Morphine 50 mcg/mL (Standard) D

5W, D

10W,

NS

3200 mcg/mL (Fluid Restricted) 200 mcg/mL (Fluid Restricted)

Endocrinologic Medications

Medication Concentration DiluentInsulin, Regular0.1 unit/mL (Standard) D

5W, D

10W, NS

0.2 unit/mL (Fluid Restricted)


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ADDENDUM A: Women & Infants Standardized Concentrations: PediatricContinuous Infusion Medications Formulary

Standard Concentration Fluid Restricted ConcentrationAlprostadil 10 mcg/mL in D5W

Alprostadil 10 mcg/mL in D10WAlprostadil 10 mcg/mL in NS

Alprostadil 20 mcg/mL in D5W

Alprostadil 20 mcg/mL in D10WAlprostadil 20 mcg/mL in NS

Amiodarone 2000 mcg/mL in D5W

Dobutamine 800 mcg/mL in D5WDobutamine 800 mcg/mL in D10WDobutamine 800 mcg/mL in NS

Dobutamine 3200 mcg/mL in D5WDobutamine 3200 mcg/mL in D10WDobutamine 3200 mcg/mL in NS

Dopamine 800 mcg/mL in D5WDopamine 800 mcg/mL in D10WDopamine 800 mcg/mL in NS

Dopamine 3200 mcg/mL in D5WDopamine 3200 mcg/mL in D10WDopamine 3200 mcg/mL in NS

Epinephrine 32 mcg/mL in D5WEpinephrine 32 mcg/mL in D10W

Epinephrine 32 mcg/mL in NS

Epinephrine 64 mcg/mL in D5WEpinephrine 64 mcg/mL in D10W

Epinephrine 64 mcg/mL in NSFentanyl 10 mcg/mL in D5WFentanyl 10 mcg/mL in D10WFentanyl 10 mcg/mL in NS

Fentanyl 40 mcg/mL in D5WFentanyl 40 mcg/mL in D10WFentanyl 40 mcg/mL in NS

Heparin 40 units/mL in D5WHeparin 40 units/mL in D10WHeparin 40 units/mL in NS

Inamrinone 1000 mcg/mL in 1/2NSInamrinone 1000 mcg/mL in NS

Inamrinone 3000 mcg/mL in 1/2NSInamrinone 3000 mcg/mL in NS

Insulin, Regular 0.1 unit/mL in D5WInsulin, Regular 0.1 unit/mL in D10W

Insulin, Regular 0.1 unit/mL in NS

Insulin, Regular 0.2 unit/mL in D5WInsulin, Regular 0.2 unit/mL in D10W

Insulin, Regular 0.2 unit/mL in NSIsoproterenol 10 mcg/mL in D5WIsoproterenol 10 mcg/mL in D10WIsoproterenol 10 mcg/mL in NS

Isoproterenol 40 mcg/mL in D5WIsoproterenol 40 mcg/mL in D10WIsoproterenol 40 mcg/mL in NS

Standard Concentration Fluid Restricted ConcentrationLidocaine 2000 mcg/mL in D5WLidocaine 2000 mcg/mL in D10WLidocaine 2000 mcg/mL in NS

Lidocaine 8000 mcg/mL in D5WLidocaine 8000 mcg/mL in D10WLidocaine 8000 mcg/mL in NS

Midazolam 100 mcg/mL in D5WMidazolam 100 mcg/mL in NS

Midazolam 400 mcg/mL in D5WMidazolam 400 mcg/mL in NS

Milrinone 50 mcg/mL in D5WMilrinone 50 mcg/mL in NS

Milrinone 200 mcg/mL in D5WMilrinone 200 mcg/mL in NS

Morphine 50 mcg/mL in D5WMorphine 50 mcg/mL in D10WMorphine 50 mcg/mL in NS

Morphine 200 mcg/mL in D5WMorphine 200 mcg/mL in D10WMorphine 200 mcg/mL in NS

Nitroprusside 200 mcg/mL in D5W Nitroprusside 1000 mcg/mL in D5W


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Nitroprusside 200 mcg/mL in NS Nitroprusside 1000 mcg/mL in NS

Pancuronium 0.1 mg/mL in D5WPancuronium 0.1 mg/mL in NS

Pancuronium 0.8 mg/mL in D5WPancuronium 0.8 mg/mL in NS

Pentobarbital 5 mg/mL in D5WPentobarbital 5 mg/mL in D10W

Pentobarbital 5 mg/mL in NS

Pentobarbital 10 mg/mL in D5WPentobarbital 10 mg/mL in D10W

Pentobarbital 10 mg/mL in NSPhenylephrine 20 mcg/mL in D5WPhenylephrine 20 mcg/mL in NS

Phenylephrine 60 mcg/mL in D5WPhenylephrine 60 mcg/mL in NS

Potassium Chloride 0.04 mEq/mL in D5W(Peripheral Line)Potassium Chloride 0.04 mEq/mL in D10W(Peripheral Line)Potassium Chloride 0.04 mEq/mL in NS(Peripheral Line)Potassium Chloride 0.08 mEq/mL in D5W(Central Line)

Potassium Chloride 0.08 mEq/mL in D10W(Central Line)Potassium Chloride 0.08 mEq/mL in NS(Central Line)See W&I Policy on Neonatal/Pediatric IVPotassium Administration for additionaldetails.

Potassium Chloride 0.08 mEq/mL in D5W(Peripheral Line)Potassium Chloride 0.08 mEq/mL in D10W(Peripheral Line)Potassium Chloride 0.08 mEq/mL in NS(Peripheral Line)Potassium Chloride 0.15 mEq/mL in D5W(Central Line)

Potassium Chloride 0.15 mEq/mL in D10W(Central Line)Potassium Chloride 0.15 mEq/mL in NS(Central Line)Potassium Chloride 0.2 mEq/mL in D5W(Central Line)Potassium Chloride 0.2 mEq/mL in D10W(Central Line)Potassium Chloride 0.2 mEq/mL in NS(Central Line)See W&I Policy on Neonatal/Pediatric IV

Potassium Administration for additionaldetails.

Standard Concentration Fluid Restricted Concentration

Procainamide 2000 mcg/mL in D5W Procainamide 4000 mcg/mL in D5W

Vecuronium 0.2 mg/mL in D5WVecuronium 0.2 mg/mL in NS

Vecuronium 1 mg/mL in D5WVecuronium 1 mg/mL in NS


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V. FLUIDS, ELECTROLYTES AND NUTRITION

The more premature an infant is, the higher is his/her initial fluid requirement. This isbased on the following principles:

Initial fluid requirement is determined largely by insensible water loss.Sources of insensible water loss:

Skin

Lungs

Smaller infants have larger surface area-to-body weight ratio and much moreimmature skin. Thus, the smaller the baby is, the more fluid is lost through the skin.

Smaller infants are placed in open radiant warmers that increase skin losses.

Smaller infants tend to breathe faster, which increases respiratory loss of fluid.

We try to minimize insensible water loss by:1. Covering infants on warmers with plastic wrap2. Humidifying the surrounding air3. Humidifying ventilator oxygen

4. Using giraffe incubators for tiny babies

Therefore, starting fluid requirements (water requirement) are determined by gestationalage and weight. (Note: not only by weight, because SGA infants will have skin maturitythat resembles their age, not their weight)

SAMPLE STARTING FLUID REQUIREMENTSGestation Warmer Giraffe Incubator

23 24 weeks 100 110 ml/kg/day 90 100 ml/kg/day

25 26 weeks 90 100 ml/kg/day 80 90 ml/kg/day

27 31 weeks 80 90 ml/kg/day 80 ml/kg/day

32 36 weeks 70 80 ml/kg/day 70 80 ml/kg/day37 42 weeks 70 ml/kg/day 60 ml/kg/day

Fluid requirements may change in the subsequent 12-24 hours. Also, try to think ofwater requirements separately from sugar and electrolyte requirements. Set the fluidrate first; then add the glucose and lytes to that fluid.


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Changes in Fluid Requirements That Can Occur In the First Day

1. ELBW infants (


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4. Full term infants with Asphyxia.Moderate-severe asphyxia frequently causes either renal dysfunction or acute renalfailure marked by oliguria or even anuria. Since we say "it's OK" for normal terminfants to not void for 24 hours after birth, renal dysfunction from asphyxia may bedifficult to detect.

STRATEGY: For infants with low Apgar scores, start with 60 cc/kg/day.Keep strict I/O's, even place bladder catheter if necessaryWatch for hematuria or proteinuriaCheck serum Na+ and Weight at 6-12 hrs of age.

If sodium is low, weight is above birth weight, and urine output is low, then fluidrestriction is appropriate. Infants who are anuric and are term (and thus have littlefluid loss through the skin) have very low fluid requirements, on the order of 30-40cc/kg/day. These infants will often need UV lines placed to give fluid with dextroseconcentrations >D12.5 to supply the usual 4-6mg/kg/min of glucose.

N.B.: In the first few days, pressors and inotropes to increase urine output areusually not necessary if 1) oliguria is an expected feature of the infants diseasestate, and 2) peripheral perfusion and SaO2 are adequate. Most infants withrespiratory distress will spontaneously increase renal blood flow and urine output byday 3 4.


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Glucose RequirementsSTARTING POINT 4-6 mg/kg/min of glucose

The Magic Formula: Glucose load provided = (Dextrose Conc)(Rate in cc / kg / day)( mg / kg / min ) 144

EX. FT infant on D10 at 60cc/kg/day receives:(10)(60) = 4.2 mg / kg / min of glucose

144

EX. Preemie on D10 at 80 cc / kg day receives(10)(80) = 5.6 mg / kg / min of glucose

144

EX. an ELBW infant is receiving D10 at 140 cc / kg / day (increased from 120 becauseof weight loss and increasing serum sodium)

(10)(140) = 9.7 mg / kg / min ! ! **144

** Because ELBW and VLBW infants have such high WATER requirements in thefirst few days of life, we often need to give them lower dextrose concentrations to avoidhyperglycemia. Hyperglycemia causes hyperosmolality and increases risk of IVH.

So, give this same infant D5 at 140, to provide the required amount of fluid (water)and glucose of (5)(140) = 4.9 mg / kg / min

144

Electrolyte RequirementsRemember that most infants do not require electrolyte supplementation in the first 24hours of life, with the exception of Ca++ in very small or asphyxiated infants. Low Na+in the first day of life is more likely to reflect fluid overload than sodium depletion.

After the first day, the basic requirements are:Na+ 2-4 mEq / kg / day

CL- 1-2 mEq / kg / day

K+ 1-2 mEq / kg / day

Ca++ 100 - 200 mg / kg / day Elemental Calcium

Phosph= provide s.t. Ca/Phos Ratio = 2 / 1


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Summary

StartingGestational Age Water Requirement Dextrose Conc.

23 - 24 100 110 cc /kg/day D5

25 - 26 90 -100 cc / kg / day D5 - D7.527 - 31 80 - 90 cc /kg / day D7.5 - D1032 - 36 70 - 80 cc / kg / day D1037 - 42 60 - 70 cc / kg / day D10Asphyxia 40 cc / kg / day D12.5 - D 20

A giraffe with high humidity requires ~ 10% less water. Phototherapy, especially on awarmer, requires ~ 10% more; individualized by changes in weight and sodiumconcentration.

Tips:

Keep fluids at the minimum to provide hydration.

(Higher fluids are associated with increased RDS, PDA, BPD and NEC) Increase fluids in response to weight loss and Na+ increases.

Decrease fluids if weight goes above birth weight in the first 3 days of life.

Add electrolytes after 24 hours when they are in normal range, but rememberthat changes in Na+ can reflect water status as well as Na+ requirement. Anddon't add K+ if the infant is not voiding or if a tiny infant is dehydrated with highNa+ and K+.

Remember that the ELBW infant is at risk of hyperglycemia because of the highfluid requirements. Try to think of glucose requirement in terms of mg / kg / min.(nl = 4-6).

Advance feeds slowly in small infants and sick term infants at risk of NEC.

Ultimate goal 120 - 130 cc / kg / day will adequately hydrate infant > 1 week old(Decreased skin loss with keratinization),However, may need up to 150 cc / kg / day (PO) to provide optimal calories forgrowth.


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2. Feeding Infants in the Neonatal Intensive Care Unit

Mothers are encouraged to provide breast milk for their infants. Rather than asking if amother plans to breast feed her infant, ask if she would be willing to provide breast milkwhile her infant is in the NICU. Even if a mother does not plan to breast feed, she maybe willing to provide breast milk. The infants bedside nurse or a lactation consultant isable to help the mother get started pumping. Double pump set-ups are recommendedto help mothers pump more efficiently. In order to establish a good milk supply, it isimportant for mothers to begin pumping as soon as possible after delivery, ideally within

six hours. It is also possible to hand express breast milk while waiting for the pump orinstruction. For most mothers and infants there are no contraindications to using breastmilk.

The neonatal nutritionist participates in interdisciplinary care rounds and suggestsappropriate types and concentrations of enteral feedings based on the treatmentcourse, nutrient needs, and growth progress of the infant. The physician or nursepractitioner determines and writes the feeding order, specifying the name of the feeding,strength (calories per ounce), the feeding schedule (feeding volume and frequency),and the mixing instructions, if necessary. For example, breast milk at 15 mL q 3 hr.

The ultimate goal of feeding enterally- is to provide infants with an adequateintake of essential nutrients and calories via the gastrointestinal tract, to supportgrowth and development. Initially, infants may receive a combination of parenteraland enteral nutrition. Over time, infants are transitioned to full feedings. Atapproximately 32 to 34 weeks post menstrual age, an infant is able to coordinatesucking, swallowing, and breathing. With that ability, an infant will begin tobreastfeed/nipple feed. Prior to that, most infants are fed via a gavage tube every 3or 4 hours. Continuous gavage feedings are used, as appropriate.

Trophic feedings - Infants are fed enterally as soon as medically possible afterbirth, preferably starting within the first day or two of life. Full-strength breast milk,

including colostrum, is preferred. If human milk is not available, an appropriate full-strength infant formula is used. Trophic feedings are small, early feedings of breastmilk or formula at 1-25 mL/kg/d to stimulate gastrointestinal tract development.Infants remain on these small volume feedings until, at the discretion of the medicalteam, they may be advanced.


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Advancing feedings - Feeding plans are individualized. Bolus feedings are usuallyinitiated first. Increasing feedings by more than 20 mL/kg/day has been associatedwith an increased risk of NEC in premature babies. On the other hand, whenfeedings are advanced too slowly, infants remain on parenteral nutrition longer than

necessary. In general for gavage fed infants, 20 mL/kg/d is a reasonable goal.Please note that some infants may need to progress more slowly (


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b. Transitional infant formulas - recommended for infants (>1850g but not yet fullterm) just prior to hospital discharge

c. Full-term infant formulas - recommended for infants > 2500g and > 37 wkgestational age1. Cows milk based

2. Soy protein based3. Specialty infant formulas; e.g., Elemental and semi-elemental formulas Low mineral formulas for renal issues High MCT oil formulas for fat malabsorption Metabolic formulas for inborn errors of metabolism

Increasing calories and nutrients - Infants most often begin feeding with 20kcal/oz breast milk or infant formula. Once an infant is at full feedings (i.e., ~120mL/kg/d), the breast milk or appropriate infant formula may be concentrated to 24kcal/oz. Premature infant formulas are available as 20, 24, and 30 kcal/oz ready-

to-use. Full-term infant formulas are available as 20 and 24 kcal/oz ready-to-use.For preterm infants, fortified breast milk and premature infant formula produce a

composition of weight gain and bone mineralization similar to a fetus of the samepost-conceptional age.

As appropriate, breast milk or formula may be concentrated from 24 kcal/oz to 27or 30 kcal/oz to provide sufficient nutritional intake for growth and development.For bolus feedings, breast milk or fortified breast milk is concentrated further byadding one or more of the following: premature infant formula 30 kcal/oz, infantformula powder, infant formula concentrate, carbohydrate modular, or fatmodulars. When breast milk is not available, ready-to-use infant formula isconcentrated in the same manner as breast milk. Human Milk Fortifier is not

added to infant formula because the GI osmolality and the potential renal soluteload of the mixture may exceed safety limits. For continuous feedings, ready-to-use and/or concentrated infant formula (appropriately diluted) is used wheneverpossible to maximize food safety.

The neonatal nutritionist can advise on ways to concentrate calories andnutrients while maintaining the balance of nutrients, GI osmolality, potential renalsolute load, and free water - all within normal limits.

Recommended daily enteral intakes for stable, preterm infants Water: 150-160 mL/kg/day

Calories: 110-120 Kcal/kg/day Protein: 3-4 gm/kg/day Carbohydrate:15-16 gm/kg/day Fat: 3-4 gm/kg/day Calcium: 120-230 mg/kg/day Vitamin D: 400 IU/d


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Iron: 2-4 mg/kg/d (maintenance)6-8 mg/kg/d (therapeutic)But not greater than 15 mg/d total

Growth progress - The goal of nutritional management is to maintain adequate

growth during hospitalization. While optimal growth for preterm infants has yet tobe defined, it remains important to follow growth - not only weight gain but alsolinear growth and head circumference. The bedside nurse measures bodyweight daily. The neonatal nutritionist plots weights of infants on approvedgrowth grids that are located in each infants bedside chart. It is recommendedthat medical residents and nurse practitioners measure length and headcircumference weekly on their stable patients and record measurements on thegrowth curve.

Vitamin-mineral supplements - Infants are born with some nutrient stores. Forexample, iron stores for a normal, full-term infant may last 4 months without

additional supplementation while iron stores for a preterm infant may last only 1month. When assessing nutrient intake, it is important to include the nutrientsavailable not only from supplements but also from feedings. An infant consumingiron-fortified formula at a volume that provides 110 Kcal/kg/d would receive 2.0mg iron/kg/d from feedings.

In the NICU, vitamin-mineral supplements for preterm infants are generallystarted after an infant is tolerating full enteral feedings. This may be 1 month oflife. Supplements containing iron may be started as early as 14 days of life if aninfant is at full feedings. A reasonable goal is 2-4 mg of iron per kg/d (feedings +supplements). Most infants do not require more than 0.5 mL of Poly-vi-sol with

iron per day. Dividing the dose to give twice per day will reduce GI osmolalityand enhance nutrient absorption.

Common supplements used in the nursery include:

Poly-vi-sol with iron - a multivitamin and mineral supplement thatcontains 10 mg iron and 400 IU vitamin D per 1 mL

Ferinsol - contains only iron, 15 mg iron per 0.6 mL ADEK with Zinc - contains no iron but is a multivitamin that provides

fat-soluble vitamins in a water-soluble form. It is appropriate forinfants with conditions of fat malabsorption.

Drisdol - contains only vitamin D. Two drops provide 400 IU ofvitamin


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3. Parenteral Nutrition for Neonates

The neonatal nutritionist generally orders the parenteral nutrition (PN). The neonatalnutritionist consults with physicians, nurse practitioners and/or pharmacists regardingindividual orders, as needed. The orders are reviewed and signed by the physician or

nurse practitioner. It is recommended that PL1 residents routinely practice entering PNorders with the nutritionists for one or two of their patients during their rotation, tobecome familiar with the process and to understand more fully the effect of medicaldecisions and an infants medical course on the nutritional content of the PN.

On 3 holidays each year (Easter, Thanksgiving, and Christmas) PN orders are placedby the PL1 on call.

The NICU has a computerized method for ordering PN. Daily entries must be made toenable the pharmacy to prepare the solutions. Information needed prior to entering thePN order include: current body weight, IV rate/hour, type of line (PIV or CL), laboratory

results (serum glucose, electrolytes, or other pertinent labs), and whether or not theinfant is on phototherapy. Below are guidelines for ordering PN in the NICU.

The ultimate goal of parenteral nutrition is to provide infants with anadequate intake of essential nutrients and calories to support growth anddevelopment until the infant is able to tolerate full feedings via the gastrointestinaltract. Infants who receive parenteral nutrition for > 4 weeks with little or noenteral feedings are at increased risk of PN-related complications; e.g.,cholestasis and nutrient deficiencies.

Indications for use - Infant will not achieve full oral intake within 4 days.

a. VLBW, extreme prematurity - feedings not tolerated or in conjunction withincreasing oral calories

b. Necrotizing enterocolitisc. Surgical lesions, omphalocele, gastroschisis, GI atresia, complicated

anastomosis, short bowel (18 cm with ileocecal valve, 40 cm withoutileocecal valve)

** PN IS NOT APPROPRIATE FOR INFANTS WITH ADEQUATE INTESTINAL

FUNCTION WHO MAY BE MAINTAINED BY ORAL, TUBE, OR GASTROSTOMY

FEEDINGS.


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Routes of administration

a. Peripheral IV - short term use onlyFor peripheral lines, the osmolality of the PN solution should be maintainedbetween 600 and 1000 mOsm/L. PN ordered for a peripheral IV contains noheparin.

b. Central venous catheter (CVL) - longer term useFor central lines, the osmolality of the PN solution should be < 1500 mOsm/L.PN ordered for a CVL contains 0.5 U heparin/mL.

1. Perc line placed by a team in SCN2. Surgically placed catheter - Broviac

c. Umbilical catheter. PN ordered for a UVC contains 0.25 U heparin/mL.

When to start As soon as possible. Refer to the Early T.P.N. Order Sheet

Early TPN: The goal is to provide parenteral nutrition as the first IV fluid for all

infants with birth weights


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b. Dextrose: rough guideline is to provide 4 to 6 mg/kg/min first day of life, thenadvance as tolerated keeping serum glucose < 200 with minimal glucosuria.

Infusion of up to 12.5% dextrose may be given via peripheral linesInfusion of up to 25% dextrose via central lines

Glucose load: mg/kg/min = (Dextrose Conc) (Rate in mL/kg/d)144

Dextrose provides 3.4 Kcal/gm in monohydrate form.

If an infant develops hyperglycemia, check the glucose load and decrease asnecessary. (Often, decreasing the glucose load by 2 to 3 mg/kg/min from thecurrent glucose load will suffice. In the smallest infants, it may be necessaryto reduce the load to 4 to 6 mg/kg/min.) Any infant who demonstrateshyperglycemia with glucosuria at a concentration of glucose that hadpreviously been tolerated is suspect for sepsis. It is also necessary to

observe infants closely for rebound hypoglycemia following abrupt terminationof PN.

c. Amino Acids: start with 1 to 2 gm/kg/day, increase by 0.5 1.0 gm/kg/day toa maximum of 3.5- 4.0 gm/kg/day. Watch urine output, BUN, metabolicacidosis, hyperammonemia; re-evaluate protein needs when these symptomsoccur. Protein intake should not exceed 17% of total calories in the PN.

d. Lipids: start lipids at 0.5 to 1 gm/kg/day and increase by 0.5 to 1 gm/kg/dayto a maximum of 3.0 gm/kg/day.

In general, check triglyceride levels when the PN lipid is at 2 g/kg/d. If the

triglyceride level is > 200 mg/dL, decrease the lipid taking into account thetotal caloric intake and the nutritional balance between carbohydrate, protein,and lipid.

Lipids are administered as Intralipid. The 20% solution provides 2 Kcal/mL.Lipids are infused over 24 hours or at a rate < 0.15 gm/kg/hour. Provide 0.5-1.0 gm/kg/day within first week of life to prevent essential fatty acid deficiencyin VLBW infants. Lipids should provide less than 55% of total calories toavoid the risk of ketosis.

e. Sodium and Potassium: After second day of life, the usual

recommendations are 2-3 mEq Na+

/kg/day and 1-2 mEq K+

/kg/day.Adjustments will depend on infants serum values and hydration status. Theamounts (ions) of sodium and potassium ordered must match the amounts(ions) of chloride, acetate, and phosphorus ordered. Acetate may be used ifmetabolic acidosis is present, since it is metabolized to bicarbonate.Phosphorus is discussed in the calcium, section f.


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f. Calcium: IV requirements are 60-90 mg/kg/day of elemental calcium, but thisamount is difficult to provide parenterally due to solubility limitations. Bothcalcium and phosphorus are needed for bone mineralization. Calcium isordered in mEq. On day 1 of PN, start with 2 mEq of calcium and nophosphorus. Increase calcium and add phosphorus on day 2. For optimal

bone mineralization, keep the calcium to phosphorus ratio between 1.3:1 and1.7:1. This will allow a maximum of 4 mEq calcium to 2 mmol or phosphorus.

Listed midway on the right side of the order sheet is the conversion of calciumfrom mEq/kg/d to mg/kg/d. Along with that are the mg phosphorus/kg/d, thecalcium to phosphorus ratio, and information about the precipitation limit.

g. Magnesium: the recommendation for Mg+ intake is 0.25-0.5 mEq/kg/day.More may be needed, especially if losing gastric secretions so it is importantto monitor levels. Mg+ is provided as MgSO4. In general, start with 0.4mEq/kg/d MgSO4. If mother received magnesium prior to delivery, check

infant's serum level before administering in PN.

h. Multivitamins: MVI contains all water and fat soluble vitamins. Dose is bodyweight dependent. Infants who weigh:

< 1 kg receive 1.5 mL MVI/day.

1-3 kg receive 3 mL MVI/day.

> 3 kg receive 5 mL MVI/day.

i. Trace elements are provided in a standard dosage of 0.2 mL/kg/day.Neotrace contains zinc, copper, manganese and chromium.

Excretion of copper and manganese requires a normal biliary tract. If theinfant has an elevated direct bilirubin associated with cholestasis, copper andmanganese may build up due to sludging in the biliary tree. These elementsare usually restricted in infants with significant cholestasis. It is possible tohold the trace element (TE) solution to limit copper and manganese intake,but it is important to add zinc separately at 400 mcg/kg/d while the TEsolution is held.

Chromium should be discontinued when renal function is impaired.Glomerular filtration rate has been inversely correlated with chromium intake,serum chromium concentration, and PN duration. Holding the TE solution will

eliminate chromium intake from that source. Zinc may be added separately at400 mcg/kg/d while the TE solution is held.

Zinc is lost in diarrhea and stoma output. Failure-to-thrive patients are also atincreased risk for zinc deficiency. Additional zinc may be indicated in suchcases.


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j. Iron, selenium, iodine, or carnitines are not routinely added to the PN.

k. When the osmolality of the PN solution is too high, consider thefollowing suggestions:

1. Decrease the percent dextrose or decrease the protein (g/kg), keepingthe percent of calories from carbohydrate, protein, and fat WNL.2. Decrease electrolytes (sodium, potassium, and chloride), if

appropriate, as the PN fluids decrease, maintaining serum electrolytelevels WNL.

3. Decrease calcium and phosphorus, keeping the Ca:P ratio WNL. (Ifthe infants only source of calcium is in the PN, use at least 2 mEqCa/kg/d.)

4. Continue to run lipids, keeping the percent of calories WNL. Theadditional fluids that lipids provide will reduce the PN osmolality.

l. Laboratory values to monitor PN are obtained as medically appropriate.About mid-week of the 1st week on PN, obtain calcium, phosphorus, andmagnesium levels. When lipids reach 2 g/kg/d, check a triglyceride level.Finally, a weekly or biweekly parenteral nutrition lab panel allows themonitoring of nutritional intake and the identification of metaboliccomplications. A PN panel includes (blood or plasma): sodium, potassium,chloride, bicarbonate, glucose, BUN, creatinine, total and direct bilirubin,albumin, prealbumin, calcium, phosphorus, magnesium, alkalinephosphatase, ALT/SGPT, GGTP, and triglycerides.


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VI. RESPIRATORY CARE

1. Blood Gas Guidelines

Blood gas measurement should be supplemented in most infants by oxygensaturation monitoring. A blood gas measurement is appropriate in any

respiratory, cardiac or surgical patient who has experienced any significantchange in clinical status.

Capillary Blood Gases: Capillary blood gas values are unreliable in theimmediate newborn period (40 and 50 mmHg

may represent arterial values >100 mmHg. The primary value of capillary

measurements is to evaluate pH and pC02. The saturation monitor is better atassessing oxygenation than is the capillary blood gas.

Arterial Blood Gases: Arterial gases drawn from umbilical or radial lines arethe gold standard for assessment of infant status. General guidelines for

normal values for normal term infants are: pH - 7.30-7.40; p02 - 70-100 mmHg;

pC02 - 35-45 mmHg.

Venous Blood Gases: Initial blood gases on an unstable infant can be drawn

from the umbilical vein or other venous site. The pH and pC02 values will give

an adequate initial assessment of acid-base and ventilatory status.

Documentation of Blood Gases: In many infants with respiratory problems,deviations from normal values are appropriate. In general, preterm infants

with respiratory problems may have p02 values in the 50-80 mmHg range.Significant deviations from the normal range should be intentional (e.g., high

p02 for pulmonary hypertension) or recognized as part of the disease process

(e.g., high pC02 in bronchopulmonary dysplasia).

Initial abnormal blood gas values in an infant require a response. Thatresponse should be documented in the orders and in CERNER - a change in

ventilator settings, a change in Fi02, etc., and the effect of the change

documented in a timely fashion. For example, if p02 is high or low, the

appropriate changes on the sat monitor within 5-10 minutes after Fi02 change

(documented in the record) is sufficient. However, if pC02 or pH is out ofrange, a repeat blood gas is needed in a timely fashion to documentimprovement. If insufficient improvement has occurred, the process ofproblem recognition, response in terms of a change in ventilatory support, anddocumentation of the effect of the change may need to be repeated every 15-30 minutes until the desired endpoint is achieved.


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2. Administration and Monitoring of Oxygen

Oxygen is a drug and should be administered only with a written order from aphysician. The order should include the concentration (volume percentdelivered) or the desired range for p02 or oxygen saturation, and shall be

reviewed, modified or discontinued periodically. The admission orders activaterespiratory care. Initial respiratory care orders and all changes are written inthe bedside order sheets, and the nursing flow sheets provide a continuousrecord of respiratory care at the bedside.

Oxygen should be humidified before delivery to the patient. When assessingthe oxygen concentration, sample the environment just adjacent to the nose ormouth.

Avoid arterial oxygen tensions greater than 100 mmHg. Explicit exceptionsare made for hyperoxia testing and in patients with increased pulmonary

vascular reactivity. All measured arterial oxygen tensions should be in thepatient's permanent record. All oxygen sensor systems should be calibrated toroom air and to 100% oxygen every 8 hours. The alarm on the oxygenanalyzer should be properly set and turned on at all times.

Serial measurements of oxygen concentrations will be taken and recordedevery two hours, before each blood gas is drawn, and at the discretion of thenurse or respiratory therapist. Whenever possible, a continuous oxygenanalyzer-controller will be used to deliver the ordered oxygen concentration.

3. Surfactant Treatment for RDS.

WIH uses Survanta7

(Ross Labs) for the treatment of RDS. This surfactant isfrom bovine lungs and is expensive. Thus, it should be used only in infantswith significant disease. Please check with the neonatal fellow or attendingbefore giving surfactant. Only personnel experienced with its use shouldadminister the drug. The general guidelines for use are as follows.

a. Treat as soon as possible after birth, ideally within 1-3 hours, followinginitial assessment indicating significant respiratory distress. Infants witha late progression of RDS can be treated. There is no birth-weight orgestational age limit.

b. Infants should have significant disease: intubated on a ventilator, usually

with Fi02 > 0.4 and a peak pressure >18 cm H20 for the initial treatment.The CXR should be consistent with RDS.


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c. Surfactant treatments can acutely increase pO2 and lung compliance.Therefore, infants receiving surfactant should be on a saturation monitor.Draw a blood gas within about 30 minutes of treatment to evaluate

clinical response and to direct respiratory management. Treated infantsmay need sequential ventilator adjustments over several hours.

d. Infants can be retreated after 6 hours of the initial treatment if respiratorydistress persists. Generally candidates for re-treatment should still be

intubated, and ventilated with >30% 02. However, if the infant is on very

low pressures (


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congenital malformations and/or masses in the neck can present withsignificant airway obstruction. This includes but is not limited to infantswith thyroid enlargement, cystic hygroma, or teratomas. Surgical airwaymanagement may be required in these infants.

PIP: Lung inflation (inspiratory pressure): Ventilatory support is often begunwith bag and mask ventilation, which may be sufficient to initiate spontaneousbreathing in larger babies. Extremely LBW infants are sometime apneic atbirth. They may respond to:

a) Gentile tactile stimulationb) A few gentle puffs with bag and maskc) Prompt initiation of early postnatal CPAP.

If they remain apneic, or if lung inflation and color do not improve rapidly withbag and mask or nasal CPAP, they should be intubated soon after initialassessment and given surfactant. Assess adequacy of ventilation by physicalexam and pulse oximetry. The most reliable findings are axillary breath sounds

and color. Chest excursions may be helpful, but may not be a reliable earlysign when lung compliance is low. During manual ventilation, monitor peakinspiratory pressure with an in-line manometer. Use the manual PIP sufficientfor effective air exchange as the initial peak inspiratory pressure formechanical ventilation. Listen to the infant again, just after mechanicalventilation, to confirm.

PEEP: End expiratory pressure of 3-4 cm H2O is a reasonable starting pointfor infants on mechanical ventilation. Increasing empirically to an optimalPEEP will improve oxygenation. Increases beyond that point may cause airtrapping, hypercarbia, and all signs of over-inflation on the chest x-ray.

Rate: Set a ventilator rate in the physiologic range sufficient to maintain gasexchange and oxygenation; a rate of 40 breaths/min is a reasonable startingpoint, with bedside adjustments based on blood gases, pulse oximetry, andpatient-driven rate and effort. Avoid over-ventilation (paCO2 < 35-40 mm Hg).

Inspiratory time: I-time in a neonate with adequate pulmonary function onconventional ventilatory support should be set at 0.3 to 0.35 seconds. Oncertain modes of conventional ventilation, I-times may be as short as 0.2seconds; some patients may need longer I-times. Review individual caseswith the respiratory therapists.

c. Conventional rate, pressure-cycled ventilators.

Our 2 conventional ventilators in current use are the Bear Cub 750 andthe Drager Babylog. Both are flow-generated and adjustable atconventional rates (~ 10-100/minute) for pressure, rate, inspiratory time,and patient sensitivity. They have slightly different input controls and


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displays. Because of software and design changes, older and newerversions of these ventilators may differ slightly from each other.

Ventilation may be adjusted, according to examination findings and bloodgas results, for flow, inspiratory and expiratory pressures, inspiratory time,

rate, patient effort, and target tidal volume. In different modes ofventilation, some or all inputs may be fixed, while others may be allowedto vary, e.g., with patient effort or the ventilators mechanics. Severalavailable conventional modes include:

Intermittent/Synchronous intermittent mandatory ventilation: Pressures,I-time, and minimum rate are pre-set. Patient effort may initiateadditional breaths.

Assist/Control: Patient effort initiates full cycles at variable rates. Withtime delay, apneic pauses, or insufficient effort, back-up rate controlsventilation.

Pressure Support/Volume Guarantee: A target tidal volume is set,usually 5 mL/kg, and delivered at variable rates and inflating pressures,proportioned to patient effort (Drager Babylog Ventilator). This modemay facilitate patient controlled weaning from prolonged ventilation orhigh settings.

Conditions adverse to adequate conventional ventilation include highairway resistance, inadequate distal recruitment, air leaks (tube orchest), inadequate patient effort, or severe patient agitation withpatient/ventilator dyssynchrony.

d. High Frequency Ventilators: We have two modes of high frequency ventilation.

Sensormedics3100 A: The Sensormedicsprovides high frequency oscillatoryventilation (HFOV). The excursions are generated by an electromagneticdiaphragm. There are active phases of inspiration and expiration. Settingswhich the operator controls are: mean airway pressure (MAP), the frequency(in cycles per second or Hz), the delta P or amplitude of change in pressure,and the percent I time. We recommend initiating oscillatory ventilation at 10 Hzand with a mean airway pressure that is 2-4 cm. of water above the meanairway pressure on conventional ventilation. A chest x-ray should be obtainedas soon as possible after initiation of this mode of ventilation (no later thanwithin 30 minutes) in order to assess adequacy of inflation. As a generalguideline, chose an initial mean airway pressure that inflates the lung to the8th or 9th intercostal space. Higher mean airway pressures may be needed toimprove oxygenation and allow lower fractional inspired oxygen concentrationsand vice versa. The delta P should be set to generate a clearly visible chestwiggleby the patient. The percent I time is usually set by the respiratorytherapist at 33%. Only in an unusual circumstance is the I time increased, andit should be done in consultation with the attending, fellow or respiratory


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therapy staff. Other settings on this ventilator include control on flow rate,which is generally maintained above 10 liters, and bias flow, which is thebalance between the inspiratory and the expiratory side of the oscillatorybreath. These are set by the therapists. Fractional inspired oxygenconcentration is adjusted to achieve the desired saturation.

pCO2 can be lowered by increasing the P (wiggle), or by lowering thefrequency (Hz) to provide a longer expiratory time.

Bunnell Life Pulse: The BunnellLifePulseis a jet ventilator (HFJV). Itgenerates HFV by pulsing in a jet of air at the desired frequency. The Jetventilator is an appropriate choice for infants with air leaks, severe respiratoryfailure, and ventilatory diseases for which either form of high frequencyventilation is indicated. If one form of HFV (i.e. OscillatororJet) is not working,it is appropriate to try the other mode. The Jetcan be used in low lung volumeor high lung volume strategy. The low lung volume strategy would beappropriate for infants with pulmonary interstitial emphysema or other air

leaks. The high lung volume strategy is more appropriate when lungcompliance is low (RDS, pneumonias). On both the Jetand the Oscillator,lung volume is controlled by regulation of the mean airway pressure. On theJetthis is achieved by adjusting the PEEP setting on the in-line cubventilator.The Jetis usually set at 420 bpm with an on Time (I time) of 0.02 sec whichprovides an I:E ratio of 1:6. As with the Oscillator, the adequacy of inflationshould be gauged by a prompt chest x-ray after initiation of ventilation. Unlikethe oscillator, the jet provides a background AIMV rate via in-line support bythe CubVentilator. The Cubis generally set at 4-12 bpm, using a PIP andPEEP adequate to maintain alveolar recruitment. Fractional inspired oxygenconcentration is adjusted to achieve the desired saturation.

e. We have a sedation and analgesic protocol for elective intubations. However,we do not routinely sedate or paralyze ventilated newborns. An alert newbornwith a short-term ventilator requirement is easier to extubate than a depressedone, and prolonged ventilation of sedated, pre-term infants may increase therisk of volu-trauma or baro-trauma. The art of neonatal ventilation includesfinding comfortable settings for the patient. In some conditions, e.g., post-operative recovery or severe pulmonary hypertension, sedation may beappropriate.

f. Consult with the fellows, bedside nurses, and respiratory therapists about thetiming and type of chest physical therapy and inhalation treatments for yourpatients who require them. Suctioning and chest PT requirements vary forindividuals patients. Scheduled routines of frequent suctioning and chest PTmay paradoxically interfere with patient stability.


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VII. INFECTIOUS DISEASE ISSUES

1. Infection ControlNB: Hand hygiene procedures are summarized inside the front cover.

a. Initial 1 minute scrub with chlorhexidine followed by 1 minuteapplication of alcohol-based antibacterial lotion.

b. Hand washing before and between patient encounters (gloves alone arenot adequate!); or a 30-second application of alcohol-based handdisinfectant lotion.

c. Universal/Body Substance Precautions for blood + body fluid exposure:

1. Gloves for any invasive exam or procedure2. Masks, face shields, goggles, long-sleeved gowns, as indicated

by risk of exposure.3. Contact precautions for risk of exposure and spread by hand

contact; e.g., RSV, open drainage, diarrhea, etc.4. Strict isolation for

a. Maternal active TBb. Maternal or neonatal chicken poxc. Methicillin-resistant Staph. aureus

d. Gloves and gowns are not needed for routine non-invasive exams,routine diaper changes, feeding, holding infants, etc.

e. Attire: Clean scrubs, caps, masks, shoe covers, etc, as required by workarea.

f. When in doubt, consult Infection Control Manual or contact the hospitalsInfection Control Practitioner.

g. MRSA. NICU exposure to MRSA (Methicillin-resistant Staph. aureus ):1. Isolate with gown, gloves, mask, visible barriers, and separate waste

disposal2. Cohort positive patients3. Infection Control Staff will publicize cohorting and isolation

procedures4. Surveillance cultures (usually nasal) of exposed patients, family, and

medical care staff5. Nasal mupiricin prophylaxis for identified carriers6. Follow-up cultures until negative x 2 or 37. Frequent communication with Infectious Disease and Infection

Control services


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2. Management of Neonatal Infections

a. Evaluation:

Laboratory Tests

1. Complete Blood count and Differential (may need follow-upin 12-24 hrs.)

2. Blood culture - also attempt line culture if on TPN3. Cultures of surfaces and secretions are not routine4. Lumbar puncture, if indicated5. Bladder catheterization or tap urine culture, if indicated.

(Even catheter specimens may be false-positive because ofthe small urethral opening and proximity to the GI tract.)

X-rays:

1. Chest, if respirations abnormal

2. KUB, if abdominal exam abnormal3. Special studies by consultation with radiology

(Call Hasbro radiologist for special imaging studies, orultrasounds other than cranial.)

Other studies (e.g., viral studies, PCR, etc.) After consultation withneonatal staff, Infectious Disease service, or laboratory staff.


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When to do lumbar puncture?

1. Low yield immediately after birth (< 4h)2. More important when infant presents after the immediate

post-delivery period

3. Stabilize cardiac output and respirations4. Can look for pleocytosis, 'ed protein, and 'ed glucose afterstart of treatment

5. Suspicion of congenital syphilis or congenital Herpes.6. ID consult is advisable for proven cases of meningitis

b. Treatment

Ampicillin and Gentamicin for:1. "Rule out sepsis" -nearly all cases2. "Rule out NEC" - nearly all cases

3. Non focal "clinical sepsis" - most cases4. Suspicion of meningitis - most cases

Cefotaxime/Ceftazidime/Cefepime for:1. Patient intolerance to Gentamicin2. Coverage of gentamicin - resistant Gram-negative

organisms3. CSF coverage in special cases4. Not routine for Gram-negative coverage.

Vancomycin for:

1. Coagulase-negative Staphylococcus (line sepsis)2. Suspicion of peritonitis or post-op infection (some cases)3. Not routine for broad-spectrum coverage.

Oxacillin, Ticarcillin, Tobramycin, Carbenicillin, Clindamycin, etc., areseldom used, except for specific indications.

Amphotericin B or fluconazole for proven disseminated Candida.Candida prophylaxis is not currently a standard procedure in the NICU.

Antiviral Rx:

1. Acyclovir for high risk of neonatal Herpes2. Retrovir (AZT) per protocol for perinatal HIV exposure

Duration of Treatment:1. "Rule out sepsis": 24-48 hrs.2. Bacteremia: 5-10 days, usually 7


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3. Pneumonia: 5-10 days, usually 7 (confirm by x-ray)4. "Clinical" sepsis: 5-10 days5. NEC: 5-10 days6. Meningitis: Varies with organism and sensitivities

Congenital Syphilis: IV penicillin x 10 days for1. Inadequate maternal treatmentI. History inadequateII. Course incompleteIII. 1 month before delivery

2. 4-fold increase in maternal titer3. Newborn titer 4x greater than mother's4. Symptomatic congenital syphilis5. May need longer treatment and follow-up for CNS syphilis

Antenatal Maternal Treatment for GBS:

1. Appears to reduce perinatal bacteremia and pneumonia2. Does not obligate work-up, treatment for every pre-treated orpartially treated newborn

3. Follow AAP and departmental guidelines if mother untreatedor inadequately treated

4. Individualize according to patient condition

Antibiotics Commonly Used in Newborn Infants

Ampicillin, 200 mg/kg/day in divided doses; can be increased to 300 mg/kg/day inmeningitis

Penicillin, 100,000-300,000 IU/kg/day in divided dosesGentamicin, See NICU protocolCefotaxime, 100-150mg/kg/day in divided dosesOxacillin, 50-150mg/kg/ day in divided dosesVancomycin, 15-30mg/kg/ day in divided doses*+

*Lower dose and longer dose intervals for LBW infants+Follow peak/trough blood levels and serum creatinine; follow pharmacy dosingguidelines.

Check dosage instructions with pharmacy, nursing, and a standard neonatal formulary,

e.g., Neofax.


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See Discharge Planning for instructions regarding seasonal RSVProphylaxis (Synagis).

3. GBS GUIDELINES FOR WIH

a. Obstetrical Considerations

1. Screening is recommended at 36 weeks; however, not all patients havebeen screened, especially those presenting before 36 weeks.

2. Prophylaxis (2 4 doses) in labor is recommended for GBS-positive andunscreened patients. For various reasons, some patients get only onedose, which is still partly protective.

3. Epidural analgesia:a. May prolong ROM and 2nd stage.

b. Is associated with low-grade, short-term fever in 15-20% of cases(cause unknown).

c. The fever may be the reason for maternal antibiotics.

b. Maternal Fever (15-20% with epidural) is more significant if:

1. Pre-term2. Persistent or recurrent3. PROM (> 18 hours)4. No epidural

c. Nursery Practice

1. Published neonatal management guidelines for untreated or partly treatedmothers are not validated (this is acknowledged by the AAP and CDC).

2. One maternal dose is at least partly protective.3. The incidence of GBS bacteremia at WIH is < 0.5/1000 term births.4. Most newborns with GBS sepsis will be symptomatic at birth or in < 12

hrs; most remaining early onset cases become symptomatic between 12& 24 hours.


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5. Most blood cultures for GBS become positive in 12 to 24 hrs (mean isapproximately 13 hrs). Therefore,

6. An observed baby asymptomatic at 12 hrs, or an evaluated babyasymptomatic with a negative blood culture after 24 hours, is a low-riskpatient.

7. If no maternal screen or treatment, but no perinatal problems, we have alow-risk patient and no criteria for action.8. See the following recommended GBS guidelines for the nurseries at WIH.

GBS FOLLOW-UP GUIDELINES

Summary:

a. Culture negative no further screening for GBSb. Culture positive + mother treated no further screening

c. Culture positive, mother not treated:

+ additional risk factorsevaluate- additional risk factorsobserve

d. Culture results unknownreview delivery history:Mother treatedno further GBS screeningMother not treated:

+ additional risk factorsevaluate1

- additional risk factorsobserve


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GUIDELINES FOR MANAGEMENT OF ASYMPTOMATIC NEWBORN(Asymptomatic implies the absence of respiratory distress, tachypnea, tachycardia, temp. insta

Maternal GBS Culture Done? Yes No or Unknown

RESULT Positive Negative

Mother RX with ABX>4 HRS? Yes No# Yes No#

Risk Factors Yes No Yes Present? ##

NEWBORNS AGE 24 hrs 24 hrs

RECOMMENDEDPLANFor Newborn

# Mothers treated for < 4 hours are considered not treated.## Risk Factors defined as one or more of the following: 100.40F), PROM > 18 hourStrategy A Observe for 24 hours, no lab. evaluation, no antibiotics.

B Observe for 48 hours, no lab. evaluation, no antibiotics.

C Observe 48 hours, limited lab evaluation (CBC, differential and blood culture), no antibiotics.

This guideline was formulated based on national recommendations and local data. It was reviewed and approvedDepartment of Pediatrics.The clinician has the option of managing his/her infant differently. If so, it is recommended the rationale for this clthe infants chart

A A B BC C


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3. HIV-EXPOSED NEWBORN - INITIAL EVALUATION AND MANAGEMENT(Division of Pediatric Infectious Disease and Neonatology; Revised 4/16/07)

The following guidelines pertain to all newborns born to HIV-infected mothers.

1. Labor and Delivery or the Operating Room should communicate to the NICU anymother with a diagnosis of HIV. The mothers room number should be listed on thewhite L&D board in the NICU and a note indicating the diagnosis should be tapedfacing the board for privacy. The fellow should monitor the board and be aware of allcases in L&D to appropriately direct the medical staff.

2. Criteria for Pediatric attendance at delivery will be the same as Obstetric criteria fornon-HIV deliveries.

3. If Pediatric providers are not needed at the delivery, L&D should request a Pediatricprovider via the NICU secretary within the first hour following delivery.

4. A Pediatric provider (PL-1, if not available a PL-2 or NNP) will go to L&D or recoveryand do the following:

a. Write orders to start Zidovudine. Zidovudine should be started in all infants bornto HIV infected mothers as soon as possible and within 12 hours of birth.Zidovudine should be started irrespective of medications taken by the mother,presence of maternal resistance to Zidovudine, and maternal viral load and iscontinued for six weeks.

Dose fornewborns 35 weeks: 2 mg/kg po every 6 hoursDose fornewborns < 35 weeks or IV administration: refer to theNeofaxNote: Bactrim PCP prophylaxis is not initiated until 4-6 weeks of life.

Additional retroviral medications to prevent transmission of HIV are not neededimmediately following birth and can be discussed with Pediatric Infectious

Disease at the time of the consult (see below).b. Write orders for the appropriate blood work (see below).c. Write a progress note that Zidovudine has been ordered and the specific blood

work that needs to be obtained.

d. Directly communicate with the Private Pediatrician if designated and sign out tothe House-staff responsible for the Newborn Nursery to insure that the bloodwork gets done. If the infant is triaged to the NICU make sure that the medicalprovider assuming care is aware of pending items for the infant.

5. The primary medical provider in the Newborn Nursery or the NICU should obtain athorough maternal history including mothers viral load, CD4 count, and antiretroviraltreatment (if known), presence of antiretroviral drug resistance (if known), mode of

delivery, duration of rupture of membranes, and newborn physical exam including headcircumference.

6. Blood work does not need to be obtained before starting Zidovudine. Within thefirst 2 days of life the primary medical provider should obtain HIV-1 branchchain DNA. This is a plasma viral load (PVL) test and is performed by branchchain DNA (bDNA) technology. The test will be automatically routed to Lifespan


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Laboratories at Miriam Hospital and is performed Tuesday and Thursday eachweek. A minimum of 2.5cc of blood (for 1 ml of plasma) is needed and placed inan EDTA (purple top) tube. The result will be available in Cerner.

7. Other blood work that should be obtained is a CBC with differential and plateletcount. The CBC does not need to be obtained at the time of the HIV-1 branch

chain DNA and can be obtained by the Laboratory via heel stick.8. The primary medical providers should assess maternal RPR, Hepatitis B and Cstatus: Give Hepatitis B vaccine +/- HBIG depending on risk assessment per thecurrent RedBook. If Hepatitis C status is unknown, request the OB service toobtain an HCV IgG in the mother prior to discharge. Follow the current RedBook recommendations concerning evaluation for congenital syphilis for positivematernal RPR.

HIV exposed infants should not be breastfed.9. Consult Pediatric Infectious Diseases for all HIV-exposed infants. Please page

the pediatric ID fellow at 350-0770 or contact the RIH page operator at 444-5611 and ask for the Pediatric ID fellow on service. Advice is useful in deciding

upon whether the infant requires antiretroviral medications in addition toZidovudine, answering questions, and ensuring adequate follow-up. Thisinformation and consult can be obtained during day time hours.

10. Prior to d/c arrange for follow-up in the "Pedi-II" Clinic. Schedule an appointmentat 1 month after discharge by calling 444-5980. This appointment does not takethe place of primary care via the infants private pediatrician or clinic.

References:

1. American Academy of Pediatrics. Human Immunodeficiency Virus Infection

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Small World Master, June, 2007

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