A Systems Approach for Neonatal Critical Care " 1 thru 10"

“1 THRU 10”

A Systems- Oriented Approach to the Neonate

Dr. David Mendez

Kidz Medical Services

1 thru 10

DISCLAIMER

No one offered to pay me anything for what I am about to say. I did, however, borrow, use and steal almost all of the concepts I am about to talk about.

1 thru 10

1. Fluids, Electrolytes,Nutrition

2. Glucose

3. Respiratory

4. Cardiovascular

5. Hematology

1 thru 10

6. GI/Bilirubin/Liver

7. Infectious Disease

8. Medications

9. Neurological

10.Social

1 thru 10

History

Systems approach is older than me

Babies can’t tell you what’s wrong

Captures all the information

Brings order to chaos

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1.FLUIDS AND NUTRITION

Primary focus of Neonatal Care

Can change hourly

Responsible for decreasing Mortality

Responsible for decreasing Morbidity

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1.FLUIDS AND NUTRITION

ENTERAL vs PARENTERAL

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1.FLUIDS AND NUTRITION

ENTERAL

NPO

OG

GT

PO

Louise Recht

“Aunt Louise, The

Mother of Neonatal

Care”

Taught the French

Technique of Gavage

Feeds

Led the Nursing Staff

and Wet Nurses

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1.FLUIDS AND NUTRITION

PARENTERAL

Central vs. Peripheral

Angiocaths invented in the 60’s

Intra abdominal injections of fluid

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1.FLUIDS AND NUTRITION

INS AND OUTS

IV FLUID URINE

TPN STOOL

FORMULA OSTOMY

LIPIDS REPLOGLE

COLLOIDS

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1.FLUIDS AND NUTRITION

INTAKE

Admission Fluids

D10 at 80 ml/kg/day

Starter TPN--- D10 with 2gm A.A.+ 200mg/100ml of CaGluconate

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EVERYONE STARTS AT 80 – 100 CC/KG/DAY

WHY?

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2. GLUOSE

BASAL METABOLISM

4 – 8 MG/KG/MIN

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2. GLUOSE

QUICK FORMULA TO CALCULATE GLUCOSE INFUSION RATE (GIR)

MG/KG/MIN = (dex conc.) X rate (cc/hr)

Current wt( kg) x 6

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2. GLUOSE

GLUCOSE INFUSION RATE (GIR)

A 3 Kg baby given 80ml/kg day of D10W

10 x 10 ml/hr = 5.5 mg/kg/min

3 kg x 6

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3. RESPIRATORY

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2. RESPIRATORY

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2. RESPIRATORY

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3. RESPIRATORY

Clinical Exam (changes, new problems, O2 sats)

Disease State

Blood Gases

Radiology

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3. RESPIRATORY

LEVEL OF SUPPORT

ROOM AIR

NASAL CANULA,VAPOTHERM

CPAP, ASSISTED VENTILATION

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4. CARDIOVASCULAR

Clinical Exam (changes, new problems, O2 sats)

Disease State

Blood Gases

Radiology

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4. CARDIOVASCULAR

CYANOSIS vs ACYANOSIS

MURMUR vs NO MURMUR

BLOOD PRESSURE, HR, RHYTHM

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4. CARDIOVASCULAR

PDA’S

THE 5 “T”s DO ESP

ARRYTHMMIAS

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5. HEMATOLOGY

HEMOGOLBIN/HEMATOCRIT

WHITE COUNT AND DIFF

PLATELET COUNT

COAGULATION PROFILE

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5. HEMATOLOGY

ANEMIA vs POLYCYHTEMIA

THROMBOCYTOPENIA vs POLYCYTOSIS

NEUTROPENIA vs LEUKEMOID

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5. HEMATOLOGY

TRANSFUSIONS (number, last time)

FRESH FROZEN PLASMA

EPOGEN,NEUPOGEN,FACTORS

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6.GI/BILIRUBIN/LIVER

Most Varied Clinical Exam

Organomegaly

Jaundice

Stool ( output, type, heme +/-)

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6.GI/BILIRUBIN/LIVER

GI

INTOLERANCE TO FEEDS

ABDOMINAL DISTENSION

NEC UNIQUE TO PRE-TERMS

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6.GI/BILIRUBIN/LIVER

BILIRUBIN

UNIQUE TO NEWBORNS

PRETERMS AT RISK

PHOTORX, EXCHANGE, IVIG

ULTRASOUNDS, CT, DOPPLERS

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6.GI/BILIRUBIN/LIVER

LIVER

ORGANOMEGALY

CHOLESTASIS

RESILIENT ORGAN

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7. INFECTIOUS DISEASE

SUBTLE TO CATASTROPHIC PRESENTATION

LITTLE WARNING

MATERNAL ENVIRONMENT

NICU ENVIRONMENT

PUBLIC ENVRIRONMENT

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7. INFECTIOUS DISEASE

CULTURES,CULTURES,CULTURES

CBC,CRP INDICATE TRENDS

TITERS ARE LIMITED

RADIOLOGY

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7. INFECTIOUS DISEASE

BACTERIAL

GROUP B STREP E.COLI

STAPH SPECIES KLEBSIELLA

PSEUDOMONAS H. INFLUENZAE

1 thru 10

7. INFECTIOUS DISEASE

VIRAL

HERPES SPECIES HIV

TOXOPLASMOSIS CMV

ENTEROVIRUS RUBELLA

HEPATITIS PARAMYXOVIRUS

INFLUENZA( H1N1, etc)

1 thru 10

7. INFECTIOUS DISEASE

FUNGAL/OTHER

SYPHILLIS TUBERCULOSIS

CHLAMYDIA CANDIDA

PNEUMOCYSTIS PROTOZOAN

MYCOPLAMSA ACREMONIUM

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8.MEDICATIONS

OFTEN AS NUMEROUS AS AN ADULT

“1 THRU 10” IS YOUR FRIEND

BEGINNING, DOSING, ENDING

TOXICITY

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8.MEDICATIONS

WHILE THIS CATEGORY SERVES AS A PLACEHOLDER TO KEEP TRACK OF

MEDICATIONS, THEY ARE DISCUSSED AS PART OF THE SYSTEM

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8.MEDICATIONS

1. FLUIDS AND NUTRITION

VITAMINS, IRON

HUMAN MILK SUPPLEMENTS

ELECTROLYTE SUPPLEMENTS

1 thru 10

8.MEDICATIONS

2. GLUCOSE

INSULIN

GLUCAGON

HYDROCORTISONE

1 thru 10

8.MEDICATIONS

3. RESPIRATORY

SURFACTANT

DIURETICS

STEROIDS

AERSOLIZED MEDS, INHALED MEDS

APNEA MEDS- CAFFIENE,THEOPHYLLINE

1 thru 10

8.MEDICATIONS

4. CARDIOVASCULAR

BLOOD PRESSURE MEDS( RAISE/LOWER)

DIGOXIN

ANTI-ARRYTHMIC

DIURETICS

1 thru 10

8.MEDICATIONS

5. HEMATOLOGY

EPOGEN

NEUPOGEN

FERRINSOL

FACTORS

1 thru 10

8.MEDICATIONS

6. GI/BILIRUBIN/LIVER

IVIG

ACTIGALL

PHOTOTHERAPY(?)

ANTACIDS

1 thru 10

8.MEDICATIONS

7. INFECTIOUS DISEASE

ANTI-BACTERIAL

ANTI-VIRAL

IVIG

ANTI-FUNGAL

1 thru 10

8.MEDICATIONS

9. NEUROLOGIC

PHENOBARBITAL

PHOSPHENYTOIN

SEDATION MEDS

ANTI-SEIZURE MEDS

PARALYTIC MEDS

1 thru 10

8.MEDICATIONS

10. SOCIAL

MEDICATIONS THAT THE MOTHER IS TAKING THAT CAN BE EXCRETED IN THE BREAST MILK

GENERAL AFFECT OF THE PARENTS THAT MAY RAISE CONCERN

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9. NEUROLOGICAL

SEIZURES AND IVH PRIMARY ISSUES

TONICITY

METABOLIC DISORDERS

EVOLUTIONARY PROCESS vs STATIC

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9. NEUROLOGICAL

STUDIES, STUDIES, STUDIES

HEAD ULTRASOUNDS

EEG, vEEG, CT, MRI

ALMOST ALL STUDIES REQUIRE FOLLOW UP

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9. NEUROLOGICAL

ONE OF THE BEST PREDICTORS FOR NORMAL NEUROLOGIC DEVELOPMENT IS A NORMAL

NEUROLOGIC NEWBORN EXAM

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9. NEUROLOGICAL

BRAIN COOLING (TOTAL BODY COOLING)

RX FOR HIE - TIME SENSITIVE

APPEARS TO REDUCE MORTALITY

APPEARS TO NOT INCREASE MORBIDTY

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10. SOCIAL

IDENTIFICATION OF PRIMARY CAREGIVERS

WHO COMES TO THE BEDSIDE

COMMUNICATE THE “1 THRU 10”

BEST ROLE IN REDUCING MALPRACTICE SUITS

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10. SOCIAL

SOCIAL SERVICE OFTEN KEY

GOSSIP IS DEADLY

NICU PSYCHOSIS

MEDICAL ERRORS- inform, address, apologize