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8/2005

Division of Neonatology
Department of Pediatrics
University of Washington
Box 356320, RR542 HSB
Seattle, WA 98195-6320
Phone 206.543.3200, FAX 206.543.8926
NICU Resident Packet website: neonatal.peds.washington.edu

Sections Page

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


UWMC NICU Rotation .......................................................................................................... 4
Day-to-Day Tips for the NICU ............................................................................................... 5
Summary of Newborn Plus (NBP) Service Structure & Function ......................................... 6
Mechanical Ventilators .......................................................................................................... 8
Clinical Management Practice Guidelines (surfactant, Vitamin A, ventilatory management,
postnatal steroids, treatment of apnea of prematurity) ...................................................... 15
Intubation Guidelines for Neonates....................................................................................... 19
Rule-out Sepsis guidelines for Possible Neonatal Infections................................................ 21
Morphine Drip Guidelines...................................................................................................... 25
Red Blood Cell Transfusion Guidelines ................................................................................ 26
Cranial Ultrasound Examination in Neonates ....................................................................... 28
Tips on Lines......................................................................................................................... 29
PICC Information................................................................................................................... 30
NICU Nutritional Guidelines .................................................................................................. 31
Newborn Hearing Screening ................................................................................................. 34
Suggested Format for an Admit/Discharge Notes/Face Sheet............................................. 36
Requesting Anesthesiologist at a Newborn Resuscitation Guidelines ................................. 38
“Who is in Charge in a Newborn Resuscitation” ................................................................... 38
Neonatal Attending Physician Attendance at Deliveries....................................................... 39
Consultations in the ISR........................................................................................................ 40
Readmission of Infants Discharged from the Newborn Nursery for Management of Hyperbilirubinemia
................................................................................................................................. 41
Infant Abduction Information ................................................................................................. 42
Interpretation of ROP Exam Results..................................................................................... 43
Web Tools and Online Resources ........................................................................................ 44
Blood Component Ordering and Administration, Guidelines for Administering Blood Products at UWMC
.............................................................................................................................................. 45
Antiseptic Use in the NICU.................................................................................................... 48
Guidelines for Management of a Newborn with a Meningomyelocele………………………. 49
Erythropoietin in the Newborn Intensive Care Nursery………………………………………... 53
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NEONATAL MEDICINE GOALS & OBJECTIVES FOR RESIDENT


TRAINING

GENERAL OBJECTIVES

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

o physiology
o ethics
o reading, critiquing and applying the medical literature
o the use of the National Library of Medicine database to access medical literature:
www.nlm.nih.gov/

SPECIFIC OBJECTIVES

1. Be adept in neonatal resuscitation procedures and obtain AAP/AHA certification in neonatal


resuscitation (NRP) by the end of the R-1 year. Get materials from attending during your first
UW rotation (Newborn or NICU).
2. Accurately obtain a history of pregnancy and perinatal events relevant to the newborn and
understand the unique aspects of the physical examination of the premature and newly born full-
term infant, including gestational age determination and assessment and management of LGA
and SGA infants.
3. Understand the broad medical, social, and economic consequences of prematurity, including
factors related to, or influencing, its incidence and the incidence of disorders unique to
premature infants (e.g., lungs, eyes).
4. Understand the broad medical, social, and economic consequences of congenital defects,
including factors related to, or influencing, its incidence.
5. Be familiar with birthweight and gestational age-related neonatal morbidity and mortality
statistics and comparisons of perinatal, neonatal and infant mortality rates, regionally, nationally
and internationally.
6. Be competent in the assessment and management of the infant in the delivery room with a
background knowledge of transitional physiology (cardiopulmonary, metabolic, and temperature
changes).
7. Recognize the clinical presentation and provide appropriate management of emergencies
presenting the first month of life, including respiratory distress with/without cyanosis, shock,
bleeding, or life threatening neurologic abnormalities.
8. Understand the physiology, pathophysiology, diagnosis, and treatment of acute and chronic
respiratory disorders in the premature and full-term infant, including hyaline membrane disease,
apnea, meconium aspiration, persistent pulmonary hypertension, transient tachypnea,
pneumonia, pneumothorax, pulmonary interstitial emphysema, diaphragmatic hernia, pleural
effusions, congenital pulmonary disorders, and bronchopulmonary dysplasia.
9. Demonstrate knowledge of the clinical and laboratory diagnosis, pathophysiology, and treatment
of the following disorders of premature and full-term infants.

y Infection:
1. Neonatal sepsis (bacterial, viral, fungal)
2. Congenitally acquired infections (HIV, CMV, toxoplasmosis, syphilis, rubella)
3. Localized infections (omphalitis, skin, osteomyelitis, arthritis, urinary tract)
4. Understand the peculiarities of host defense mechanisms in the newborn
y Hyperbilirubinemia (physiologic, hemolytic, obstructive)
y Metabolic disorders (hypoglycemia, infant of diabetic mother, hypo- and hypercalcemia,
inborn errors of protein, organic acid and amino acid metabolism)
y Gastrointestinal disorders (necrotizing enterocolitis, bowel obstruction, gastrointestinal
bleeding, abdominal wall defects)
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y Cardiovascular disorders (presentation of congenital heart disease in the neonatal


period, patent ductus arteriosus, congenital cardiomyopathies, hypertension)
y Hematologic disorders (neonatal coagulopathy, polycythemia, anemia)
y Renal disorders (acute renal failure, congenital malformation of the urogenital tract
including agenesis, dysgenesis, cystic disease, obstructive uropathies, exstrophy of
bladder)
y Endocrine disorders (congenital hypo- and hyperthyroidism, adrenogenital syndrome,
ambiguous genitalia, hypoglycemia). See also Metabolic Disorders
y Thermoregulation
y Neurologic disorders (seizures, hydrocephalus, hypoxic-ischemic injury, neonatal
asphyxia, intraventricular hemorrhage and outcome)
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UWMC NICU ROTATION

SCHEDULE

Daily: 7-8:00 AM Preround – Collect numbers and examine patients


7-8:00 Senior Signout
8:00-10:30 Attending Rounds

Weekly: 11:00 Discharge Conference (Tuesday)


11:00 Prenatal Diagnosis Conference (Friday)
12:30 Obstetrics/Pediatrics/Ethics (Thursday)

GOALS

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

RESOURCES

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

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

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

4. Growth and Nutrition


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

5. Other handouts (also on web)


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

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


Your computer access password will be forwarded to:

<Your Name>,
care of <whoever is Attending>
Neonatology, Box 356320
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DAY TO DAY TIPS FOR THE NICU

INFECTION CONTROL

1. A 3-minute scrub required for all staff when starting their shift
2. Do not wear any jewelry below the elbows
3. Do not wear watches
4. Please wash your hands before baby exams and between babies (use of alcohol hand cleaner is
acceptable also)
5. Scrubs: Only hospital provided scrubs are allowed. Scrubs are not to be taken home and
laundered. You must change into clean hospital-laundered scrubs at UWMC after your arrival or
whenever your scrubs become soiled.
6. ISR or any Operative Delivery Room:
a. wear a yellow waterproof cover gown
b. wear a hat, mask, and gloves
c. wear shoe covers

CONFIDENTIALITY

1. Do not discuss a baby while other parents and visitors are in the room or at the front desk.
2. Do dictation in your sleep room, X-ray room, or in the attending office, preferably not at the front
desk. If you must use the front desk, keep your voice lowered.
3. Tell parents they will be the only individuals receiving information on their infant.
4. Tell parents they must be present with any visitors. Siblings may visit if they’re older than 2 years
of age.
5. Do not discuss personal things or other patients in the labor/delivery rooms. Limit conversations to
the delivery at hand and speak quietly.
6. Please close the labor/delivery door after entering/exiting the room.
7. Dispose of all paper with identifiable health care information in paper recycle bins and not in trash.

ORDERS

1. Upon admission, a standing order sheet needs only to be signed and dated. If a specific order
does not apply to the infant, it must be crossed out.
2. All orders must be signed, timed, and dated.
3. HA & drip orders need to be written by 11:00 am.
4. PRBC’s have a required form that that has to be filled out by nursing or housestaff.
5. Respiratory orders are written on the bedside flow sheet. This includes DC oximetry, etc.
6. Medication doses must be written in mg/kg per day, i.e. 50 mg/kg/day divided every 6 hours.
When writing medication orders please put current weight in the little bear on the order form!
7. We have addressograph cards for morphine, dopamine, dobutamine, Kupfers, immunizations,
indomethacin, and hearing screens. These medication orders include the dose calculations.
8. Leave the infants’ charts in the chart racks in the rooms.
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SUMMARY OF NEWBORN PLUS SERVICE STRUCTURE &


FUNCTION (MIC and NICU Newborn Plus Patients)
HOUSE-STAFF COVERAGE

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

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

y MIC ± 8:30 - 9:30 AM


y NBP ± 11:00 AM – 12:00 Noon

DELIVERY ROOM COVERAGE

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

WEEKEND COVERAGE

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

NIGHT COVERAGE

y NICU House-staff Attending

TEACHING

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

TARGET CENSUS

y 6 stable NICU patients (growers/gainers, stable CLD, or other chronic/convalescent patients)


y 2 level-II type acute patients (R/O sepsis, TTNB, mild RDS)
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NEWBORN PLUS TEACHING PROGRAM GUIDELINES

y Ferret lab intubation procedure will be scheduled on the 1st Thursday late morning following rotation
of NICU interns to the service (occurs on Wednesday).
y Specific discussion topics to be covered, if at all possible, include: see attached schedule.

NEWBORN PLUS TEACHING TOPICS

1. Normal infant nutrition


2. Breastfeeding
3. Substance abuse - alcohol, NAS, etc.
4. CPS utilization
5. D/C teaching, etc.
6. Jaundice
7. Congenital heart disease
8. Heme problems
9. R/O sepsis
10. Hypoglycemia
11. Ethics
12. Fetal Diagnosis
13. NRP
14. Outcome
15. Primary care of the former NICU patient
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MECHANICAL VENTILATORS
1. Introduction to ventilator management and the different types of ventilators available in the NICU

There are three fundamentally different modes of ventilation available in the NICU: "pressure
ventilators", "volume ventilators", and high frequency ventilators. They all serve to support adequate
ventilation and oxygenation, but each has it's own particular niche.

Ventilation (CO2 removal) is a function of minute ventilation which is respiratory rate (RR) multiplied by
tidal volume (Vt).

MINUTE VENTILATION = RATE x TIDAL VOLUME

Arterial Oxygenation usually improves when either the fraction of inspired oxygen concentration (FiO2)
and/or mean airway pressure (MAP) are increased.

The first step in managing a patient on a ventilator is to choose appropriate goals for ventilation and
oxygenation (i.e. blood gases). These goals depend on the patient's disease state. An otherwise
healthy term infant intubated for choanal atresia might have as a goal pH=7.40, PaCO2=40, PaO2=60. In
a small preterm infant (<1000g), to minimize lung injury due to mechanical ventilation, a strategy of mild
permissive hypercapnea may be followed. In a patient with severe chronic lung disease gases with
PaCO2 of 60-65 torr and SaO2 >88% may be acceptable. In contrast, a patient with persistent
pulmonary hypertension of the newborn might have as a goal pH>7.45, PaCO2=30, PaO2>100 in an
attempt to attenuate hypoxic pulmonary vasoconstriction.

Ventilation goals can be a range of pH values and/or a range of PaCO2 values. Extreme acidosis
(pH<7.10) is to be avoided but otherwise mild acidosis alone appears to be relatively well tolerated. Of
greater concern are wide swings in PaCO2 which can have significant effects on cerebral blood flow.
Also of concern is identifying and, if appropriate, treating the underlying cause of the acidosis.
Ventilation can best be monitored using arterial blood gases. Capillary blood gases (and even more so
venous) tend to give low values for pH (~0.05-0.1 lower depending on perfusion). The difference
between arterial and capillary or venous pH is variable over time and between patients. As an estimate
of ventilation, it does not work well in older infants with BPD, infants with hydrops, and other conditions
that impair transcutaneous passage of capillary gas. If using a conventional ventilator (not High
Frequency), end tidal CO2 monitoring (capnography) is another valuable non-invasive method of
estimating ventilation though it may give inaccurate readings with chronic lung disease (e.g. BPD).

Oxygenation goals can either be a range of arterial oxygen saturation or PaO2 values. Oxygen
saturation (SaO2) best reflects arterial blood oxygen content (SaO2 x Hemoglobin x 1.34) and thus is of
direct physiologic interest. PaO2 better reflects degree of shunt, and is more accurate than SaO2 at the
lower range. Oxygenation can best be monitored by pulse oximetry or arterial blood gases. Capillary
and venous blood gases are never useful measures of arterial PaO2.

The appropriateness of initial ventilator support needs to be rapidly confirmed by checking a blood gas
(within 15-20 minutes if possible) and making adjustments accordingly. Initial ventilator settings for
pressure ventilators are typically chosen based on pressures and rates required when hand bagging.
Initial settings on volume ventilators are usually chosen based on typical minute ventilation
requirements (e.g. rate of around 20-30 breaths per minute with tidal volume of ~4-6 mL/kg). When
switching from conventional ventilation to high frequency ventilation, a rule of thumb is to choose a
mean airway pressure (MAP) for the high frequency ventilator that is 2 cmH2O greater than the MAP on
the conventional ventilator. Amplitude starting point is chosen such that there is adequate shake (a rule
of thumb being the umbilical line should be shaking slightly; alternative rule of thumb is to start at twice
the MAP and back down from there until shake appears appropriate).

Blood Gases: When evaluating a blood gas, first determine your goals for pH, PaCO2, and PaO2.
Secondly, determine the type of specimen to decide if any correction for capillary or venous specimen is
in order. Finally, evaluate the blood gas to see if any changes in inspired oxygen concentration or
ventilator settings are needed. Before analyzing the blood gas it is worth determining whether the gas is
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significantly different from previous gases and, if so, why (i.e. was a ventilator wean made, is the patient
extubated, is there a pneumothorax, is the patient showing signs of sepsis, are there signs of persistent
pulmonary hypertension of the newborn, is this an expected change given the patient’s diagnosis). If
PaO2 is low, then FiO2 or MAP need to be increased. If the pH is low, one should determine if the
acidosis is respiratory (PaCO2 high) and/or metabolic (calculated HCO3 low). Increasing ventilation is
merely a temporizing act until the cause of the acidosis is determined. If the pH is low and/or the
PaCO2 is high, indicative of a respiratory acidosis, then ventilation needs to be increased by increasing
rate and/or tidal volume - how this is accomplished again varies from ventilator to ventilator.

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

2. ”Volume Ventilators”

Historically, volume ventilators (time cycled, volume regulated, volume limited) were used in anesthesia
(a bellows of defined tidal volume pumped at a given rate) and as pediatric and adult intensive care
evolved. Initially these ventilators were not used in the NICU due to the difficulty achieving consistent
small volumes (5-7 mL/kg in a 1200g infant!). Current volume ventilators are able to deliver small
volumes consistently. In the past, triggering was inconsistent and increased the work of breathing. The
last generation (Siemens 300) has resolved these problems. In the NICU their use has been primarily in
larger infants with chronic lung disease (partly because SIMV was only available on volume ventilators
until recently) or perioperatively (tradition - likely related to familiarity of operating room personal with
volume ventilators). Their use in the acute NICU setting has extended into the micropremie population.
The newest generation of “volume vents” includes the Drager Babylog 8000. This ventilator delivers
smaller consistent tidal volumes, with minimal WOB problems associated with triggering.

PROS: Stable minute ventilation with known tidal volume. Simpler models available for use outside
hospital setting. Control or SIMV modes are available. Home ventilators currently available are typically
"volume ventilators".

CONS: Tidal volume is maintained at the expense of peak airway pressure. If lung compliance falls by
50% (i.e. ETT slipping down right mainstem), tidal volume is maintained by doubling of peak airway
pressure. This increases the risk of volutrauma or barotrauma. Since these ventilators do not have
constant flow, to breathe spontaneously the infant always has to trigger a valve to allow air flow. Large
leaks around the ETT can be problematic due to difficulty maintaining tidal volume and "triggering"
(patient cycling) of the ventilator causing frequent alarming.
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Adjusting ventilation/oxygenation:

To increase alveolar ventilation: Increase Rate or Increase Tidal Volume

MINUTE VENTILATION = RATE x TIDAL VOLUME

To increase oxygenation: Increase FiO2, or Increase PEEP, or Increase Tidal Volume

OXYGENATION is improved by increasing MAP and/or FiO2


/ \
Vt PEEP

3. High Frequency Ventilators

This is a radical innovation in ventilator design. The rate in "high frequency" is the Hz (range 3-15 Hz)
(i.e. 180-900 breaths per minute). Since the tidal volume generated by these ventilators approximates
dead space, simple pulmonary mechanics, physics, and physiology are inadequate to explain their
operation. Gas exchange occurs by enhanced diffusion.

HFOV (High Frequency Oscillatory Ventilation): (Sensormedics 3100A) uses a piston with a
diaphragm unit to actively move gas in and out of the lung. This type of ventilator requires a special non-
compliant breathing circuit. Indications for use of high frequency ventilation are unclear but include:

1. Initial and subsequent ventilatory support in very low birth weight infants with respiratory
distress syndrome.
2. Air leak (pneumothorax, pulmonary interstitial emphysema).
3. Failure of conventional ventilation (pre-ECMO step) particularly in persistent pulmonary
hypertension of the newborn, meconium aspiration syndrome, pneumonia, pulmonary
hemorrhage.
4. To reduce the risk of volutrauma and barotrauma when conventional ventilator settings are very
high.

PROS: May allow gas exchange when conventional ventilation has failed.

CONS: Unclear which patients will respond and there is some risk involved in "just trying". Switching
ventilators on an unstable patient who is failing conventional ventilation may result in clinical
deterioration. The high airway pressures often seen with high frequency ventilation can be transmitted
to the heart (particularly with compliant lungs) and result in impaired cardiac output requiring volume
boluses and/or inotropes. HFOV makes turning patients, taking x-rays, or performing ultrasounds more
complex due to the heavy, non-flexible tubing. Stopping HFOV for suctioning or administering nebulized
medications may negate its benefit.

Adjusting ventilation/oxygenation: Ventilation is dependent on amplitude much more than rate. In


larger infants paradoxically lowering Hz improves CO2 removal on the Sensormedics. This is postulated
to occur by increased tidal volume (more inspiratory time) and better gas escape (more expiratory time).
Mean airway pressure primarily effects oxygenation. MAP can also influence ventilation: too high a MAP
and ventilation may drop due to decreased compliance from overdistention, too low a MAP and
hypoventilation may occur secondary to atelectasis.

To increase minute ventilation: Increase Amplitude, (although changes in MAP and Hz can sometimes
have significant effects on CO2 also)

MINUTE VENTILATION = RATE x TIDAL VOLUME


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

OXYGENATION is proportional to MAP x FiO2

4. "Pressure Ventilators"

These are the most frequently used ventilators in the NICU. Traditional "pressure ventilators" are
constant flow, time cycled, pressure limited devices. Constant flow implies that there is a constant flow
of gas past the top of the endotracheal tube. Pressure limited means that once the pre-set PIP has been
reached, it is maintained for the duration of the inspiratory cycle. Time cycled implies that breaths are
given at fixed intervals, independent of the infants respiratory efforts. Newer "pressure ventilators" can
sense infant’s breaths and synchronize to them. There may be some added work of breathing due to
the need to trigger breaths - this has been hard to quantify and remains controversial.

PROS: The constant flow permits the infant to easily take spontaneous breaths. Simple, reliable
mechanical design. Pressure limitation prevents sudden changes in PIP as compliance changes (i.e. on
a pressure ventilator if compliance falls by 50% PIP does not change - though tidal volume drops, for
example ETT slipping down right mainstem).

CONS: Variable tidal volume as lung compliance changes. Should lung compliance worsen then Vt will
drop (if the ETT plugs Vt drops to zero, but the ventilator does not sense it). Should compliance improve
(following surfactant for example) this may result in overdistention. If the child is exhaling during a non-
synchronized ventilator breath, then the breath is ineffective.

Adjusting ventilation/oxygenation: Key determinants of oxygenation (mean airway pressure, MAP)


and ventilation (tidal volume) are not directly adjustable, but are derived from related parameters (Bold
faced). Adjustments are thus less straightforward than with either "High Frequency" or "Volume
Ventilators". Furthermore, there are interactions between the various parameters. Driving pressure
conceptually is similar to "amplitude" on high frequency ventilation, but is not directly adjustable: it is
proportional to the difference between PIP and PEEP.

To increase ventilation: Increase Rate, or Increase PIP, or Increase Inspiratory Time, or Decrease
PEEP (rarely done)

MINUTE VENTILATION= RATE x TIDAL VOLUME


/ | \ / \
Ti Te I:E Driving Time
Pressure Constant
| / \
PIP-PEEP Resistance Compliance

To increase oxygenation: Increase FiO2, or Increase MAP (see below)

OXYGENATION is proportional to MAP x FiO2

(Ti x PIP)+(Te x PEEP)


MAP= -------------------------------
Ti + Te

This equation assumes Pressure vs. Time is a square wave.


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Ways to increase MAP (See figure 1):

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

Figure 1: Pressure vs. time

5. Ventilator Modes (terms and types)

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

CON: No synchronization.

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

PRO: Synchronized to patient effort.

CON: None, at worst is like IMV.

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

PRO: Infant can increase minute ventilation easily on demand, based on need.

CON: When weaning can't wean rate, only PIP or Vt.

y SIMV-PC with PS (Pressure Support): Term used on Servo 300 ventilators to describe an SIMV
"pressure ventilator" with set PIP/PEEP. Beyond a set background ventilator rate, spontaneous
breaths are augmented (supported) with pressure - usually relatively low values (+4 to +8 cmH2O)
(See figure 2-PC/PS). Uses: 1) To provide mandatory backup breaths (conceptually large sighs to
prevent gradual progressive atelectasis) while allowing amount of PS to be weaned slowly to "train"
respiratory muscles 2) As a means of providing intermediate respiratory support (less than
conventional modes but more than CPAP or extubation) 3) Pressure support just enough to
overcome resistance of ETT and ventilator circuit and maintain minimum adequate spontaneous
ventilation. Uses as above, but in "pure pressure" support mode. (If set PIP and PS pressures are
the same then essentially you have pressure AC mode).

NOTE ON WRITING PS: Pressure support is above PEEP. At the University of Washington NICU,
writing an order for "PS 5, PEEP of 4" yields inspiratory pressures for assisted breaths of 5+4=9.
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y SIMV-VC with PS (Pressure Support): Term used on Servo ventilators to describe SIMV with set
Vt. Beyond the set rate, spontaneous breaths are augmented (supported) with pressure - usually
relatively low values. The difference between this mode of ventilation (VC/PS) and the mode
described above (PC/PS) is that in VC/PS the SIMV breaths are volume breaths and in PC/PS mode
the SIMV breaths are pressure breaths.

y PC: Pressure Control. Term used on Siemens Servo ventilator to describe AC mode with a set
PIP/PEEP ("pressure ventilator" AC mode).

y VC: Volume Control. Term used on Siemens Servo ventilator to describe AC mode with a set Vt
("volume ventilator" AC mode).

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

y PSVG: Pressure support volume guarantee. This mode is available on the Drager Babylog 8000.
This mode is pressure limited with a set tidal volume. The pressure will stairstep up to meet the set
tidal volume. There are two sets of values: Set (ordered) and Measured (spontaneous). Set values
include tidal volume (4-8 mL/kg), inspiratory time, inspiratory pressure limit (PIP), rate, and PEEP.
The set values are utilized when the infant is apneic. Otherwise, the infant regulates their own PIP to
meet the set tidal volume. As infant's compliance improves, the PIP needed to deliver set tidal
volume decreases.

Pro: Adjusts for compliance automatically, compensates for ETT leaks, no need to correct for tubing
volume

Con: Weaning mode only. If infant needs increasing support, switch to another mode on ventilator.

y SIMV + VG: With the Drager Babylog 8000, the addition of VG (volume guarantee) to SIMV allows
one to control the inspiratory time. The PIP still adjusts to meet the set tidal volume, but the
inspiratory time is set by the therapist.

Pro: More supportive and more control of ventilation than with PS + VG.

Con: Less control over PIP, infant is still doing most of the work of breathing.

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

PRO: Improve oxygenation by maintaining functional residual capacity.

CON: Impair ventilation by increasing FRC and increasing work of breathing (exhaling against
pressure).
NICU Resident Packet Page 14 of 54

FIGURE 2: RESPIRATORY PATTERN UNDER DIFFERENT MODES

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

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

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

y Sensormedics 3100A: High frequency oscillatory ventilator with active inhalation/exhalation driven
by a moving piston and diaphragm. Requires special stiff non-compliant ventilator circuit. Can be
utilized for a wide weight range of infants. Some preliminary work using it in smaller infants suggests
that it may result in less barotrauma than conventional ventilation.

y Siemens Servo 900C: Either a volume or pressure ventilator, no gas flow from ventilator
between breaths. Volume ventilator with IMV, SIMV, AC and pressure modes PC/PS. Has pediatric
settings for alarm limits, but no specific infant modes. Used when primarily volume ventilator needed
in larger term infant and often for home ventilatory support. Currently, used only in the IICU.

y Siemens Servo 300: Either a volume or pressure ventilator, low bias flow from ventilator
between breaths. Does not have continuous high flow through circuit and requires some effort on
the part of the infant to trigger significant flow. A "bias" flow of 0.5 LPM is present and the trigger is a
30% disruption in this flow rate sensed at the ventilator. Alternatively it can sense a drop in airway
pressure instead, but this requires more effort on the infant's part. The major advantage over
Siemens 900C is that it has infant ranges for Vt, flow, pressures, and alarms. Has extensive list of
modes: PC, VC, SIMV-VC+PS, SIMV-PC+PS, CPAP and PRVC (pressure regulated volume
controlled). Uses include 1) Volume ventilation of small infants, 2) Synchronized/mixed modes, 3)
Overcoming resistance of circuit & ETT with PS, 4) Facilitation of weaning by allowing gradual
entrainment.
NICU Resident Packet Page 15 of 54

CLINICAL MANAGEMENT PRACTICE GUIDELINES

I. SURFACTANT MANAGEMENT GUIDELINES

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

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

2. Inborn infants < 27 weeks gestation should be automatically intubated immediately after
birth and given prophylactic surfactant in the delivery room or as soon as possible after
intubation.

3. Inborn infants ≥ 27 weeks and < 30 weeks gestation should receive surfactant without
delay if they require intubation and supplemental oxygen for respiratory failure.

4. Infants ≥ 30 weeks gestation should receive surfactant therapy if they require


mechanical ventilation and have a diagnosis of RDS.

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

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

2. Infants ≥ 30 weeks gestation with the diagnosis of RDS should receive a second dose of
surfactant as a bolus 6-12 hours after the first dose if they continue intubated on
mechanical ventilation and require an FiO2 ≥ 0.3. If the infant remains intubated with an
FiO2 0.21-0.29, one should consider a second dose of surfactant.

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

II. VITAMIN A THERAPY (RECOMMENDATION)

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

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

III. VENTILATORY MANAGEMENT

A. Target Ranges for Blood Gas Values

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

y Saturation (measured by pulse oximeter) 88-96%


y pH ≥ 7.25
y PaCO2 40-55 torr if CXR uncomplicated
y PaCO2 45-70 torr in patients with PIE or chronic changes in CXR
B. Ventilatory Weaning: As Frequently As Tolerated
NICU Resident Packet Page 16 of 54

Minimum Requirements

y PaCO2 in lower target range > 12-24 hours and stable


y Encourage extubation trial if meets both:
Mean airway pressure ≤ 5
FiO2 ≤ 0.25
y Start methylxanthine prior to extubation (caffeine or theophylline)
y Always extubate to NP CPAP Hamilton AladdinII Nasal CPAP System

Criteria for Reintubation

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

IV. POSTNATAL STEROIDS

A. For Hypotension

1. Consider use of steroids under the following conditions:

y Preterm ≤ 28 weeks, ≤ 1000 grams (**Particularly if mother received 3 or more


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

AND

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


(±Epinephrine or Dobutamine when appropriate)

2. Treatment

y Hydrocortisone 1 mg/kg IV initially


− If infant has clinically significant response, the one dose may be
sufficient
− If no response repeat in 3-6 hours
− Optional: if infant has significant response may continue as
− 1 mg/kg IV Q 12 hours x 1
− 0.5 mg/kg IV Q 12 hours x 2
− Discontinue
− If hypotension recurs, may repeat sequence or taper more
slowly

B. For Severe Life-Threatening PIE Consider the “Short” Course Described Below

C. For Chronic Lung Disease – Try to Avoid But

Consider if:

y Preterm ≤ 28 weeks, ≤ 1000 grams


y Care optimized including:
− Fluid restriction
− Aggressive management of PDA accomplished
− Diuretics
− Nutrition established
− No clinical evidence of sepsis
NICU Resident Packet Page 17 of 54

y If ≤ 7 days of age and severity score > 7


Severity Score = FiO2 x MAP
y If ≥ 7 days of age and severity score > 6

D. Postnatal Steroid Treatment Protocol

Use Dexamethasone: Choose “short” or “long” course

Short: 3 day course


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

Long: 7-10 day course


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

STOP! IF NO RESPONSE AFTER 48 HOURS


(defined as ability to wean ventilator and oxygen)

Day 3-4: 0.15 mg/kg/day in divided doses every 12 hours


Day 5-7: 0.1 mg/kg/day
Day 8: off
(may stop if 7 day course, give no Dex if 10 day course)
Day 9: 0.1 mg/kg/day
Day 10: off – Stop

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

V. TREATMENT OF APNEA OF PREMATURITY

A. INITIATION OF METHYLXANTHINES

Definition of Apneic Event by Type of Intervention Treatment Indication

No Intervention Required Frequent episodes associated with


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

Mild - Light touch, stroke back Multiple episodes; more than 6 over a 12 hr
- Associated with desaturations <80% & period or 12 over a 24 hr period.
bradycardia <90 BPM

Moderate - Move infant, i.e. roll over, reposition, etc. More than 2 episodes in a 24 hr period.
- O2 administered

Severe - Prolonged vigorous stimulation More than 1 episode in a 24 hr period.


- PPV with or without O2

ABC’s associated with feeding, handling, suctioning, mucous plugging, etc. should not be
counted when determining whether to initiate methylxanthine treatment.
NICU Resident Packet Page 18 of 54

Treatment Recommendation:

Preparation: caffeine citrate 20 mg/mL both IV & PO


(20 mg of caffeine citrate = 10 mg of caffeine base)

Load IV & PO: 20 mg/kg of citrate (= 10 mg/kg of base)

Maintenance IV & PO: 5-7.5 mg/kg QD of citrate (= 2.5 – 3.75 mgkg of base)

Acceptable: serum level could range from a low of 5 to an upper limit of 20, depending on
patient response

B. WHEN TO TRIAL CPAP

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

B. ASSISTED VENTILATION

Frequent apnea associated with marked bradycardia and/or desaturations refractory to


methylxanthines and/or CPAP should be treated with positive pressure ventilation.
NICU Resident Packet Page 19 of 54

Intubation Guideline for Neonates

• Safe, high quality neonatal care and a dedication to resident education are the foundation for
neonatal care at the University of Washington.
• Pediatric residents, by the end of their residency training, will be proficient at neonatal airway
management including intubation, bag-valve mask ventilation and oral airway placement.
• Neonatal care at the University of Washington is delivered as a team.
• These guidelines are flexible on a case-by-case basis

1. Successful neonatal intubation is defined as intubation within 2 attempts. All care providers
should strive to achieve this goal.
2. An intubation attempt is defined as placing the laryngoscope blade in the patient’s mouth
unless the blade is rapidly removed to suction, change ETT, etc.
3. Intubation attempts should not compromise patient stability. Stability is defined as a heart
rate > 100 bpm and an oxygen saturation > 90%. Any team member can declare that the
neonate is unstable.
4. If more than one intubation attempt is required, the same person should attempt again after
briefly discussing with the resuscitation leader their strategy for performing a successful
intubation on the next attempt. (see teaching tips below)
5. In selected cases, neonates may be unstable or are at risk for adverse outcomes if multiple
tries at intubation are attempted. These cases include:
a. Extremely Preterm Neonates < 26 weeks gestation
b. Unstable neonates (Unable to establish oxygenation with PPV, neonate requiring
CPR)
c. Certain congenital anomalies
i. Congenital Diaphragmatic Hernia
ii. Known Airway Obstruction
iii. Micrognathia
iv. Hydrops
In these cases, an experienced care provider should perform the intubation.
6. An experienced care provider is defined as the provider who has had the most experience and
success with neonatal intubation in the past. In general, this will be the NNP, neonatal fellow or
neonatal attending. However, this may also be the senior resident in certain select cases. (eg.:
unexpected decompensation in a term neonate in which the neonatal attending, fellow, or NNP is not
present)
7. If the neonate is unstable and an experienced care provider is unable to successfully intubate the
patient, anesthesia should be stat paged to attempt intubation.
Teaching tips:
• Have most senior care provider visualize airway/vocal cords and have resident place ETT.
• Perform intubation on stable patients in the NICU (ROP surgery, elective reintubations, etc.)
NICU Resident Packet Page 20 of 54

Delivery of Neonate

Goal:
All neonatal intubations
*Anomalies: successful within 2 attempts
1. Congenital Diaphragmatic
Hernia (CDH)
2. Airway Obstruction Anomalies?
3. Micrognathia *
4. Hydrops Fetalis
Yes No

Intubation by GA?
experienced care provider

< 26 wks or > 26 wks and


unstable stable

Intubation by
experienced care provider Intubation by Intern

Stable: Pulse > 100 bpm and SaO2 > 90%

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


NICU Resident Packet Page 21 of 54

RULE OUT GUIDELINES FOR POSSIBLE NEONATAL SEPSIS


Start

Does infant have Was mother 1.


gestation greater than Is the infant pretreated with a. Culture/CRP
34 wks or a Yes symptomatic? Yes antibiotics? Yes b. Treat
birthweight greater c. Reassess @ 48 hrs
than 2 kg?

No

2.
a. Culture/CRP(optional)
No b. Treat
c. Reassess @ 48 hrs
No

Was mother pretreated 3.


with antibiotics? Yes Observe

No

4.
Observe if risk factors

5.
Is the infant Was mother pretreated a. Culture/CRP
symptomatic? Yes with antibiotics? Yes b. Treat
c. Reassess @ 48 hrs

No

No
6.
a. Culture/CRP(optional)
b. Treat
c. Assess @ 48 hrs
d. Treat for full course

Was mother
pretreated with
antibiotics?
Yes 7.
a. Culture/CRP
No b. Treat
c. Reassess @ 48 hours

8.
If very premature:
a. Culture/CRP(optional)
b. Treat
c. Reassess @ 48-72 hours
NICU Resident Packet Page 22 of 54

VII. RULE OUT GUIDELINES FOR POSSIBLE NEONATAL SEPSIS

A. TERM / SYMPTOMATIC

Pretreated
y Culture
y Treat
y Reassess clinical status and culture results at 48 hours (see references 3); if the blood
culture is negative, CSF studies and clinical course benign, consider stopping antibiotics.
CRP values may be obtained (day 1, day 2) as an adjunct to support the decision to stop
antibiotics. Serial normal CRP studies have been reported to have a highly significant
negative predictive value for both proven and probable sepsis (see references 5).
y If cultures positive or infants continue to be symptomatic with signs of sepsis or strong
maternal risk factors for sepsis (See Maternal Risk Factors) treat for 10 days (blood culture
positive) or 14 to 21 days (CSF culture positive)
Not Pretreated
y Culture
y Treat
y Reassess clinical status and culture results at 48 hours (see references 3); if the blood
culture is negative, CSF studies and clinical course benign, consider stopping antibiotics.
y Optional: CRP values may be obtained (day 1, day 2) as an adjunct to support the
decision to stop antibiotics. Serial normal CRP studies have been reported to have a
highly significant negative predictive value for both proven and probable sepsis (see
references 5).
y If cultures positive or infants continue to be symptomatic with signs of sepsis treat for 10
days (blood culture positive) or 14 to 21 days (CSF culture positive)

B. TERM / ASYMPTOMATIC/MATERNAL RISK FACTORS

Pretreated
Observe closely for 48 hours (there is evidence in the literature that if – 98% + of infected infants
present within 48 hrs – see reference 4). If there is evidence of maternal amnionitis or other
serious infection it would be reasonable to consider a rule out sepsis – blood culture and
antibiotics for 48 hours. Evidence in support of routine CSF culture in the asymptomatic term
infant is not impressive (see reference 1)
Not Pretreated
y No cultures or treatment; observe closely for 48 hours

C. PREMATURE / SYMPTOMATIC

Pretreated
y Culture
y Treat
y Reassess at 48 hours
y Generally continue antibiotics for a 10 day treatment course. Can consider stopping
antibiotics if infant has a clinical course not suggestive of infection and cultures are
negative. Continuation of the signs and symptoms and/or occurrence of new signs or
symptoms of infection are indications to continue antibiotics.
NICU Resident Packet Page 23 of 54

Not Pretreated
y Culture
y Treat
y Reassess at 48 hours.
y Optional: CRP values may be obtained (day 1, day 2) as an adjunct to support the
decision to stop antibiotics. Serial normal CRP studies have been reported to have a
highly significant negative predictive value for both proven and probable sepsis (see
references 5).
y Can consider stopping antibiotics if infant has a clinical course not suggestive of infection
and cultures are negative. Continuation of the signs and symptoms and/or occurrence of
new signs or symptoms of infection are indications to continue antibiotics.

D. PREMATURE / ASYMPTOMATIC

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

Not Pretreated
y Consider no workup or treatment for infants >2000 gm birthweight and 34 weeks gestation
y For infants below 2000 gm birthweight and 34 weeks gestation:
o Culture
o Treat
o Reassess at 48 hours
o Optional: CRP values may be obtained (day 1, day 2) as an adjunct to support the
decision to stop antibiotics. Serial normal CRP studies have been reported to have a
highly significant negative predictive value for both proven and probable sepsis (see
references 5).
o Stop antibiotics if infant is asymptomatic or clinical course not suggestive of infection
and cultures are negative

E. CULTURE

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

F. TREATMENT

Start IV antibiotics

y if term (> 37 weeks gestation):


o ampicillin 100 mg/kg every 12 hours and gentamicin 4 mg/kg every 24 hours if CSF
cell count WNL
o OR ampicillin 150 mg/kg every 12 hours and cefotaxime 50 mg/kg every 12 hours if
CSF cell count abnormal or if spinal tap was unsuccessful

y if premature (≤ 37 weeks gestation):


o ampicillin 100 mg/kg every 12 hours and gentamicin 4 mg/kg every 36 hours if CSF
cell count WNL
o OR ampicillin 150 mg/kg every 12 hours and cefotaxime 50 mg/kg every 12 hours if
CSF cell count abnormal or if spinal tap was unsuccessful
NICU Resident Packet Page 24 of 54

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

• PROM (greater than 18 hrs)


• GBS colonization
• Maternal infection (fever, UTI, chorioamnionitis)

H. INFANT SYMPTOMATIC

y Oxygen requirement
y Respiratory distress
y Apnea
y Lethargy
y Poor feeding
y Change in responsiveness

I. MOTHER PRETREATED

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

J. REFERENCES
1. When is LP indicated in term infants?

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

2. Blood culture volume needed.

Schelonka et al. Volume of blood required to detect common neonatal pathogens. J.


Peds 1996; 129:275-8.

3. Blood culture time to positivity.

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

Garcia-Prots et al. Rapid detection of microorganists in blood culture of newborn


infants utilizing an automated blood culture system. Pediatrics 2000; 105:523-527

4. Effect of antibiotics on time of presentation

Bromberger et al. The influence of antibiotics on the clinical spectrum of early-onset


GBS infection in term infants. Pediatrics 2000; 106:244-250

5. CRP references

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

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

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

Primary Author: David E. Woodrum, M.D. Professor


Contributing Author: Dennis E. Mayock, M.D. Associate Professor
NICU Resident Packet Page 25 of 54

MORPHINE DRIP GUIDELINES

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

B. Recommended treatment guidelines include:

y High frequency ventilator patients

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

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

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

D. Documentation should include:

y Caremap entry

y Nursing note, daily

y Resident note, daily

y Attending note mentioning the presence of a morphine drip and rationale several
times/week
NICU Resident Packet Page 26 of 54

IX. RBC TRANSFUSION GUIDELINES

A. TRANSFUSE FOR HEMATOCRIT < 20%:


• In an asymptomatic infant, if reticulocytes <100,000/uL.
B. TRANSFUSE FOR HEMATOCRIT < 30% IF:
• requires oxygen, but < 35%

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

• significant apnea and bradycardia while on methylxanthines (>9 episodes in 12 hours or


2 episodes in 24 hours requiring mask and bag ventilation)

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

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

• sepsis
C. TRANSFUSE FOR HEMATOCRIT < 35% IF:
• requires oxygen, > 35%

• intubated on CPAP or positive pressure ventilation with mean airway pressure > 6
cmH20
D. TRANSFUSE FOR HCT LESS THAN OR = 40%

y Repeat transfusion from a previously used unit

These are guidelines arrived at by a consensus of the Neonatologists of the University of Washington. We
encourage any thoughtful variations from these guidelines.

Modified from: Shannon KM, et al. Recombinant human erythropoietin stimulates erythropoiesis and
reduces erythrocyte transfusions in very low birth weight preterm infants. Pediatrics 1995;95:1-8.
NICU Resident Packet Page 27 of 54
NICU Resident Packet Page 28 of 54

X. GUIDELINES FOR CRANIAL ULTRASOUNDS IN PREMATURE INFANTS

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

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

White Matter Disease


White matter disease includes two primary lesions, periventricular leukomalacia (PVL) and
periventricular hemorrhagic infarction (PVHI). PVL occurs in about 3-4% of infants of
birthweight <1500 gms and PVHI occurs in approximately 10-15% of infants of birthweight
<1000 gms. PVL occurs in relatively larger premature infants as the most vulnerable time
for white matter injury is between the 28th and 32nd weeks of gestation. PVHI occurs at
younger gestational ages and birthweights as it is associated with more severe IVH. WMD
is associated with prolonged rupture of membranes and chorioamnionitis and may be
associated with maternal cocaine use.

WMD is often detectable on early ultrasounds as either an echodensity or echolucency but


may not become apparent for 1-3 weeks after the initiating event when cysts begin to form.
The echolucencies may then disappear after 1-3 months, leaving enlarged ventricles.

Guidelines for Obtaining Screening Cranial Ultrasounds


Day of Life
3-5 10-14 28 prior to discharge
<1000 gms * * * *
1000-1250 gms * * *

1250-1500 gms * *

Selected References
1. Perlman JM. White matter injury in the preterm infant: an important determination of abnormal
neurodevelopmental outcome. Early Hum Dev 1998;53(2):99-120.
2. Volpe JJ. Neurology of the newborn. 3rd Ed. 1995, Philadelphia: WB Saunders. xiv, 876.
3. Volpe JJ. Brain injury in the premature infant – from pathogenesis to prevention. Brain Dev
1997;19(8):519-534.
4. Perlman JM, Risser R, Broyles RS. Bilateral cystic periventricular leukomalacia in the
premature infant: associated risk factors. Pediatrics 1996;97(6 Pt 1):822-827.
5. Perlman JM, Rollins N. Surveillance protocol for the detection of intracranial abnormalities in
premature neonates. Arch Pediatr Adolesc Med 2000;154:822-826.
NICU Resident Packet Page 29 of 54

TIPS ON LINES

UAC PLACEMENT

1. Length = 2 cm + (distance from umbilicus to acromio-clavicular joint)


2. X-ray: want tip at T7-T10 (preferred) or L3-4 (low line)
3. Place 2 retention sutures at the time you stitch in the line, but only use one. Leave the other one
in until after the x-ray in case you have to pull the line back.
4. Check line tip position on CXR before using a UAC

PULLING UAC’S

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

UVC PLACEMENT

1. Length: insert just until you get blood return or to a length = (distance from acromio-clavicular joint
to umbilicus minus 4cm).
2. Don’t use a long line in a DR code since they often get coiled up in the liver and other places you
didn’t want them to go.
3. Check a CXR before using a UVC (want tip at diaphragm or T9 vertebral body).

PAL LINES (PERCUTANEOUS ALIMENTATION LINE), see PICC information sheet

1. Thin, peripherally placed central venous lines for infusion only


2. Used for medium term central IV access
3. Insertion is percutaneously or by cutdown procedure by trained personnel. Contact charge nurse
who will assign PICC team member.
4. Requires ~ 2 units/hour of heparin to keep patent.
5. May be heparin locked like a peripheral IV though this may shorten its lifespan
NICU Resident Packet Page 30 of 54

PICC INFORMATION

PICC: PERIPHERALLY INSERTED CENTRAL CATHETER

y The neonatal PICC is a venous access device


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

UWMC NICU PICC PLACEMENT TEAM

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

IF YOU DESIRE A PICC PLACED IN AN INFANT

y Check with Attending for approval


y Obtain written consent from parent of infant for PICC placement (phone consent is ok if urgent)
**be sure to cover potential complications and indicate this on the consent form**
y Discuss with Charge Nurse when a PICC nurse will be available to place line.
y Write orders for PICC placement (see example below)

1. Please place PICC


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

In addition, the PICC nurse may request a sedation order prior to insertion (for the infant, that is).
Typically this would be Morphine IV 0.05 mg/kg – may repeat x1

After placement, the PICC nurse is required to have placement confirmed by having the Resident view the
CXR.

Ideal placement: catheter tip should be positioned in the SVC (but never in the atrium)
If the saphenous vein was used for insertion – the ideal position should be @ T9 - T10

If PICC’s are not in ideal position, discuss options with PICC nurse

A PICC line may be heparin-locked but this may last only a few days before the line clots off.
28g PICC’s are very small (twice the diameter of a human hair) and have been known to clot off within/less
than 24 hrs after being heparin locked.

A PICC nurse should discontinue the PICC when no longer needed (or not functioning properly).

If a PICC nurse is not available, the PICC may be discontinued by a Resident


(after reading the procedure in the P&P manual).
NICU Resident Packet Page 31 of 54

NICU NUTRITIONAL GUIDELINES

I. METHODS OF MONITORING GROWTH AND NUTRITION

A. Daily weights (after 1st week of life, goal should be 15 gm/kg/day weight gain averaged over
several days)
B. Weekly length (after 1st week of life, linear growth should average 0.5-1 cm/wk)

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

D. Nutritional panel* (this is a standing order for all infants receiving TPN regardless of
birthweight and is obtained on a weekly basis every Sunday night; then is obtained on a
monthly basis when on full enteral feeds). Nutrition panels are drawn with Sunday night
weekly blood draws.

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


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

II. PARENTERAL NUTRITIONAL SUPPORT (TPN)


A. Initial fluid support for infants ≤ 2000 grams birth weight
• D10W with 2.5% Trophamine solution to run at 80 mL/kg/day
o Do not exceed 80 mL/kg/day of this solution
• If more fluid support indicated, wye in desired extra fluid in addition to D10W with
2.5% Trophamine solution.

B. Indicated in the following situations:


y For any newly born infant including with birthweight <1500 gm unable to tolerate
enteral feeds at a rate of at least 75 mL/kg/24h
y For any infant with bodyweight <1500 gm unable to tolerate enteral feeds for >24 hr
y For any infant of any weight unable to tolerate enteral feeds for >48 hr

C. TPN compositional guidelines (Goal for parenteral nutritional support is 90-100


kcal/kg/day)
NICU Resident Packet Page 32 of 54

GLUCOSE*
Initial
Birthweight Rate of advance
concentration & rate
<1000 gms 4-6 mg/kg/min 1-2 mg/kg/24hr
1001-1500 gms 6-8 mg/kg/min 1-2 mg/kg/24hr

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

* IV glucose load initiated shortly after birth; the glucose index is used to calculate IV
glucose load:
(% glucose) x mL/kg/24hr
144

Blood glucose should be followed following the initial phase of IV glucose infusion
with serial blood glucose measurement
LIPIDS
(necessary to meet fatty acid requirements & to provide non-carbohydrate calories)

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

1 1
2 1.5
3 2
4 2.5
5 3 (max)
Assess lipid tolerance with triglyceride level >200, hold for 6 hours and restart at 1.5
g/kg/day. Intralipid is decreased to 1.5 gm/kg/24hr when infant is at 50% of full
enteral feeds (i.e. 75 mL/kg/24hr); and Intralipid is discontinued when infant is at 75%
of full feeds.

AMINO ACIDS

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

1 1.5
2 2
3 2.5
3 for infants > 1800 grams
4 3.5 for infants ≤ 1800 grams
Term infants may need only 2.5
For more mature infants (in terms of postnatal or
gestational age at birth) one might initiate amino acids at a
higher level (e.g. 1.5-2 gm/kg/24hr)

D. Electrolytes/vitamins/minerals/trace minerals

See TPN order form for recommended doses

III. ENTERAL NUTRITIONAL SUPPORT

A. Consider initiating very small volume enteral feeds during the 1st several days of life
(example 10-20 mL/kg/24hrs); depending on infant’s clinical status; such non-nutritive feeds
may have beneficial effect on GI function.
NICU Resident Packet Page 33 of 54

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

C. Formula/Milk

Birthweight ≤ 2000 gm Birthweight ≥ 2001 gm


y Initially use breast milk (BM) (20 cal/oz) if y BM (20 cal/oz) or standard formula
possible plus a fortifier* (20 cal/oz)
y If no BM, then use Similac Special Care
(24 cal/oz)

y Generally change to BM or standard


formula (20 or 24 cal/oz) when infant’s
weight >2 kg; exception=poor bone
mineralization, slow incremental weight
gain etc; then continue hypercaloric
formula(24 cal/oz) until infant’s weight=
2.5-3 kg.
* Fortifiers
Similac Natural Care (liquid): add when infant is at ½ full feed;
BM + fortifier = 22 cal/oz
Similac HMF (powder): change to this at 1 month postnatal age;
BM + fortifier = 24 cal/oz

D. Vitamins

For infants with birthweight < 2 kg; UWMC low birthweight vitamins (Trivisol + vitamin E),
discontinue this when infant’s weight is 2 kg.

For infants with birthweight >2 kg and receiving standard formula or unfortified breast
milk; Pediatric Multivitamin.

E. Iron

For infants with birthweight < 2 kg; 2-4 mg/kg/24hr by 1-2 months of postnatal age.

For infants with birthweight > 2 kg; standard formula with iron – no supplementation
needed.

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


NICU Resident Packet Page 34 of 54

NEWBORN HEARING SCREENING

KELLI LAHARGOUE, MS, CCC-A PATRICK FEENEY, PhD, CCC-A


AUDIOLOGIST CHIEF OF AUDIOLOGY
Pager: 206-598-1290 Pager: 206-598-8635
Voicemail: 206-598-2597 Phone: 206-598-4022
Box: 356161 Box: 356161
E-mail: klahargo@u.washington.edu E-mail: pfeeney@u.washington.edu

ROUTINE COVERAGE
Monday 1pm-5pm
Tuesday 8am-5pm, including discharge rounds
Wednesday 8am-12pm
Thursday 1pm--5pm
Friday 1pm-5pm

NOTE: Additional times may be available (depending on Audiologist availability)

*** TO SCHEDULE BAER ***

Call KELLI (voicemail: 598-2597) and leave name of baby to be tested

RISK INDICATORS (2000 JOINT COMMITTEE)


1. Any illness or condition requiring admission of 48 hours or greater to a NICU
2. Family history of hereditary childhood sensorineural hearing loss
3. In-utero infection, such as cytomegalovirus, rubella, syphilis, herpes, toxoplasmosis
4. Craniofacial anomalies, including those with morphological abnormalities of the pinna and ear canal
5. Hyperbilirubinemia at a serum level requiring exchange transfusion
6. Postnatal serious infections, including meningitis
7. Apgar scores 0-4 at 1 minute or 0-6 at 5 minutes
8. Mechanical ventilation lasting 5 days or longer
9. Aminoglycosides used in multiple courses (greater than 2)
10. Aminoglycosides used in combination with loop diuretics (ethacrynic acid, furosemide)
11. Physician order for reasons other than the above risk criteria
12. Persistent pulmonary hypertension of the newborn
13. Any condition requiring ECMO
14. Syndromes associated with progressive hearing loss such as neurofibromatosis, osteopetrosis, and
Usher’s syndrome (later workup)
15. Stigmata or other findings associated with a syndrome known to include a sensorineural or conductive
hearing loss or Eustachian tube dysfunction (later workup)
16. Neurodegenerative disorders such as Hunter syndrome, or sensory motor neuropathies such as a
Friedreich’s ataxia and Charcot-Marie-Tooth syndrome (later workup)
17. Head trauma (later workup)
18. Recurrent or persistent otitis media with effusion for at least 3 months (later workup)
19. Parental or caregiver concern regarding hearing, speech, language, or developmental delay
NICU Resident Packet Page 35 of 54

FOLLOW-UP PROTOCOL SCHEDULES (NOTE: ages to be followed at are corrected age)

y Follow-Up of Babies Screened in the NICU

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

Pass but at risk:


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

Pass but at risk:


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

y Clinical Diagnostic/Follow-Up Program for Hearing Impaired Children

1. Initial diagnosis takes at least 2 visits, with counseling session with parents as part of last visit or
separate visit (phone call to parents the week following diagnosis to assist with referrals, answer
questions)

2. Monitoring/continuing diagnostics every 3 months until hearing is stable

3. Every 6 months for the first 3 years of life

4. Yearly evaluations in preschool

5. Yearly evaluations during school age

These are basic guidelines for children with sensorineural hearing impairment. If there are concerns that
hearing is changing, evaluations will be scheduled more frequently.
NICU Resident Packet Page 36 of 54

SUGGESTED FORMAT FOR AN ADMIT NOTE


ID: Wt, EGA, SGA/AGA/LGA, sex, major problems
Referring MD & Hospital and/or OB referring MD & Hospital:
MOM: Age, marital status, race, SAB TOP, medical problems, STD Hx, meds,
ETOH, cigs, drugs (including IVDA), PN labs, hepatitis status.
PREGNANCY: Review of dates, nutrition, wt gain, prenatal care, infections, fevers,
Bleeding, PTL.
LABOR: Onset, ROM (spontaneous vs. assisted, meconium/clear/bloody), tocolytics,
betamethasone, antibiotics, ?amnionitis (temp WBC, tenderness),
FHRT/monitor, FP, LS.
DELIVERY: Type, forceps, suction, type of suctioning, anesthesia, meconium,
nuchal cord, placenta (i.e. abruption, calcification, etc.).
RESUSCITATION: Initial HR, color, respiratory effort, suction, blowby O2, bag, ETT,
APGARS, transport to NICU.
SH:
FH:
EXAM:
LAB: Include Dubowitz, length, and OFC with vitals.
A/P:

PROGRESS NOTES:
There is no single correct format or outline for daily progress notes. The purpose of a progress note is to
document 1) your physical exam; and 2) your understanding of the patient’s current problems, their
progression and your management plan for this problem. Repeating information gleaned from the nursing
flow sheets, the lab computer and the medication list is helpful only as an aid to the above two goals. Merely
documenting a physical exam and signing the computer printout is not appropriate.

Patients on ICU status need a detailed progress note daily. Patients on IM status need a brief 3 line daily
note and 2 times a week or more detailed summary of their current problems, their course and overall plans.

DISCHARGE SUMMARIES:
The purpose of a discharge summary is primarily to inform the follow-up physician of current issues and their
management. Though the follow-up physician may have received copies of all interim summaries it is
unlikely they will have read them or that they will ever read them. As a consequence the key problems and
events of the infant’s neonatal course should be briefly summarized and current issues concisely addressed
in a bit more detail. Discharge summaries should be approximately 2 pages in length or less.
Contents: Discharge date and discharge attending physician
Patient identification information
Problem List including current and resolved problems
List of current medications
List of lines and tubes currently in place
Summary of current enteral intake
Health care maintenance screening examinations completed (ROP, cranial ultrasound, state
lab newborn testing results, hearing assessment, etc.)
Immunizations administered (hepatitis B, RSV prophylaxis, etc.)
History of present illness
Maternal history (illnesses, medications, etc.)
Labor and delivery summary
System review of current active problems
Disposition plan (Follow-up physician name, address and phone, scheduled visit date. etc.)
Discharge physical examination with current weight, length and OFC
Name of individuals to receive copies of discharge summary
If corrections to summary are necessary, please make corrections prior to electronically signing the
summary. If corrections are necessary after the summary is finalized and signed, please dictate the
corrections as an addendum.
NICU Resident Packet Page 37 of 54

Complete medical record face sheet including list of diagnoses, follow-up arrangements, and listing of discharge
medications.
NICU Resident Packet Page 38 of 54

March 17, 2005


Thomas Strandjord, M.D.
UWMC, Perinatal/Neonatal CQI Committee

Guidelines for when to request availability of anesthesiologist at


a newborn resuscitation:
Any member of the resuscitation team who has concerns about the airway management of
a newborn should request availability of the obstetric anesthesiologist on-duty if a
neonatology attending or fellow is not readily available. Examples of when it would be
appropriate to request the presence of an anesthesiologist include: anticipated abnormal
airway anatomy, failed intubation attempts, or any time a pediatric team would like back-up
with managing a depressed newborn. The anesthesiologist will not be expected to
manage the resuscitation, but only assist with airway management if that is necessary.

March 17, 2005


Thomas Strandjord, M.D.
UWMC, Perinatal CQI Committee

Who is in charge in a newborn resuscitation:


1. When called to attend a delivery the pediatrics team has primary responsibility for
managing a newborn resuscitation.

2. Pediatrics will be routinely called to attend deliveries in the following situations:

a) Pregnancies less than 34 weeks gestation


b) Concerns about a non-reassuring fetal heart rate tracing or fetal condition during
labor
c) Any time there is meconium staining
d) Any time there is a major congenital anomaly
e) Multiple gestation deliveries
f) C-section deliveries
g) Whenever requested by the delivering physician

3. The senior pediatric resident or neonatology fellow should introduce themselves to the
obstetricians and family (when possible) when they arrive to resuscitate a newborn.

4. In the absence of a pediatric attending or neonatology fellow, if an obstetrics or


anesthesiology attending decides to take responsibility and manage a newborn
resuscitation, the pediatric residents should defer to his or her judgment.
NICU Resident Packet Page 39 of 54

Neonatal Attending Physician Attendance at Deliveries

The NICU attending should be notified in advance of impending deliveries involving:


1) <30 weeks gestation fetus;
2) multiple gestation delivery;
3) delivery with known fetal anomalies;
4) delivery with documented intrapartum distress;
5) complicated maternal medical problem regardless of gestational age

A decision by each attending to be present for other deliveries would be made


after taking various impacting issues into consideration (categories 2-5 above).

The attending physician should be present if possible at all deliveries of


fetuses whose estimated gestation age is under 28 weeks.
NICU Resident Packet Page 40 of 54
NICU Resident Packet Page 41 of 54
NICU Resident Packet Page 42 of 54

INFANT ABDUCTION (“NEWBORN EMERGENCY”)


NICU RESPONSIBILITIES

I. IF YOU OBSERVE OR ARE TOLD THAT AN INFANT ABDUCTION MAY HAVE OCCURRED

1. Quickly search each room and account for infants. Call 6S and 6E to search for infant.
2. Dial 222 and inform the operator that a suspected abduction has occurred. Request that
the Infant Abduction Announcement be made. Tell the operator the location of the
abduction.
3. Then dial 9-911 to report the suspected abduction to UW Police.
4. Overhead page will be announced, “(location) STAT, NEWBORN EMERGENCY TEAM,
(location) STAT”
5. All available Medical Center Staff, including at least one person from each area, will stand
by the exits in their area.
6. Staff should remain at their exit until the “All Clear” is paged.

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


by stating to that person, “There has been an emergency in the Medical Center
and exits are closed at this time. Please wait here until we get clearance.”
b. ALLOW THE PERSON TO PASS THROUGH IF THEY REFUSE TO STAY IN
THE BUILDING. Get a physical description and direction of travel . . . report to
police at 9-911.

SIMULTANEOUSLY OCCURRING ON THE UNIT WHERE ABDUCTION HAS TAKEN


PLACE
(These tasks may be delegated to charge nurse, staff nurse, nurse manager, USC, etc.):

7. Call Social Worker


8. Move mother to another room to tell her of the abduction. Stay with her until social worker
arrives.
9. Isolate the bedside (or area where abduction occurred).
10. Assist with Security and Police.
11. Reassure other parents.

II. HOW TO RESPOND

1. When you hear NEWBORN EMERGENCY TEAM STAT you should:


y Immediately go to the exit assigned to your department
y State to anyone fitting the profile of an abductor or who may be carrying a large
package or bag: “There has been an emergency in the Medical Center and exits
are closed at this time. Please wait here until we get clearance.”
y If a person refuses to wait, allow them to pass. Get a physical description and
direction they are traveling and report it to security.

III. INFANT ABDUCTION AWARENESS

1. Profile of a typical abductor


y Female, age 15-45
y Often overweight, low self esteem
y Emotionally disturbed over loss of pregnancy, child, or inability to have
children
y Seeks an infant to repair a strained relationship
y Frequently lives in same community where the abduction occurs
y Has carefully planned the abduction, often impersonating hospital staff to gain
access to an infant
NICU Resident Packet Page 43 of 54

Interpretation of Retinopathy of Prematurity Examination (4/2005)

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


considerations:

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

Zone I: This is the most posterior and intimately related area of the retina to the optic
disc; Abnormal vascular proliferation in this area is associated with worrisome
prognosis.
Zone II: Zone II involves the more peripheral area of the retina, extending from the
edge of Zone I nasally to the ora serrata. Abnormal vascular proliferation
involving Zone II is associated with a variable prognosis, less serious than Zone I,
but still of concern.
Zone III: This area of the retina is anterior and even more peripheral to Zone II. It is the
last portion of the retina to be vascularized normally. Vascular proliferation noted
in Zone III is usually associated with a benign prognosis.

B. The second component of the international classification of ROP is the extent of the
problem circumferentially, recorded in clock hours. The more extensive the
involvement, the worse the prognosis.

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

Stage I: The appearance of the demarcation line, a structure that separates the
avascularized retina from the vascularized retina is altered in Stage I ROP.
Vessels are seen to branch into abnormal arcades leading up to the demarcation
line. The prognosis associated with ROP limited to Stage I is benign.
Stage II: The determination of Stage II ROP is made when the height, width and the
volume of the demarcation line is increased. Once again, Stage II ROP is usually
associated with a benign prognosis and the problem regresses.
Stage III: A determination of Stage III ROP is based on extra-retinal proliferation of
vascular material along the demarcation line. A determination of Stage III ROP is
associated with an increasingly worrisome prognosis.
Stage IV: Stage IV ROP is a catastrophic determination that indicates retinal
detachment and possible severe visual loss.

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


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

E. Threshold ROP: Is the stage and extent of ROP at which the likelihood of severe visual
loss without treatment is 50% and at which treatment (laser or cryo) is indicated
according to the 1988 CRYO-ROP study (Typically Stage III plus in 5 contiguous or 8
non-contiguous clock hours.) The CRYO-ROP indications were based on anatomic
outcomes but more recently the Early Treatment for Retinopathy of Prematurity
Randomized Trial found better visual results with earlier treatment. Treatment should
be considered for ROP as follows: Zone I(any stage with plus disease), Zone I (any
stage 3), or Zone II (stage 2 or 3 with plus disease).
NICU Resident Packet Page 44 of 54

Web Tools

NICU-WEB: http://neonatal.peds.washington.edu/
An online series of protocols and suggested guidelines for care of the
neonate at the University of Washington Neonatal Intensive Care Unit

Neonatology on the Web: http://www.neonatology.org/


An online resource for neonatology.

Vermont-Oxford Network: http://www.vtoxford.org/


An online database of neonatal care and outcome statistics.

University of Washington Healthlinks: http://healthlinks.washington.edu/


An online resource with links to health care information for patients of all
ages.

eJournals: http://healthlinks.washington.edu/contentBrowser.jsp
University of Washington electronic journal access link.

PubMed: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?CMD=Pager&DB=pubmed
National Library of Medicine medical literature research tool.

NICHD Cochrane Neonatal Reviews: http://www.nichd.nih.gov/cochrane/default.cfm


Online resource for systematic reviews of neonatal care.

Genetests: www.genetests.org
Online resource of genetic information for health care providers.
NICU Resident Packet Page 45 of 54

6-7-05

BLOOD COMPONENT ORDERING AND ADMINISTRATION

GUIDELINES FOR ADMINISTERING BLOOD PRODUCTS AT UWMC

A. COMPONENTS

Packed Red Blood Cells (PRBCs)


Divided units of PRBCs (Pedi-packs)
Assigned Pediatric Aliquots
Platelet Concentrate
Fresh Frozen Plasma
Cryoprecipitate

B. COMPONENT-SPECIFIC GUIDELINES FOR ADMINISTRATION

1. COMPONENT: PACKED RED BLOOD CELLS


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

Administration:
• Full (“adult-sized”) RBC units (250 or 350mL)
Preservatives:
• RBC AS-5 250 ml (Optisol) – standard preservative
Average volume 350mL/unit
Average Hct=57%
• RBC CPD 250 ml - for large volume transfusion to children <4 Mo
and to accompany patient to OR where bleeding is a risk (DO NOT
USE FOR ROUTINE TRANSFUSION).
Average volume 250 mL/unit
Average Hct=72%
• RBC CPD DIvided, aka “Pedi-packs” (60mL each)
• ¼ CPD-preserved PRBC unit
• Average Hct =72%
• Up to 4 units ordered AT THE SAME TIME will be issued from the
same donor.
• RBC AS-5 Divided (30-40mL each)
• 1/8 AS-5-preserved PRBC unit
• Average Hct=57%
• From the 8 units created in each set, request ONLY the number of
units needed that day
• Remaining units not sent to the University are held at PSBC for
exclusive use of the recipient for 40-42 days
• Initial order is not available for emergency transfusion
• Takes 4 hours to prepare initial order
• Donor exposure is minimized, as all 8 aliquots are from the same
donor
NICU Resident Packet Page 46 of 54

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

For preoperative orders, where emergency blood may be needed, e.g. PDA ligation,
order: 1 unit Full Packed Red Blood Cells (250 mL), CMV negative, irradiated, Hgb S
negative (the “adult-sized” unit is preferred as it can be returned to the Puget Sound
Blood Center if not used).

Dose: Usual dose is 10 to 20 mL/kg. (1 mL/kg will increase hematocrit by approximately 0.5 to
0.7%).

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

Filter: Hemo-Nate Filter (18 Micron)

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


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

2. COMPONENT: PLATELETS

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

Indications: Severe thrombocytopenia (platelet count <20,000)


Platelets count< 50,000 in patients who require surgery or in patients with active
hemorrhage, risk of imminent bleeding or increased risk for intraventricular hemorrhage (<
32 weeks post-conceptual age).

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

Infants < 3.5 kg


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

Infants ≥ 3.5 kg:


Order 2 units of CMV-negative, irradiated platelets
Administer 20 mL/kg

If the infant is volume sensitive, volume reduced platelets can be used. However, full
volume platelets are preferred because the process of volume reduction activates
platelets, causing degranulation, making them less effective.

Dose for volume reduction:

Infants < 2 kg:


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

Infants 2-4 kg:


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

Infants >4 kg:


NICU Resident Packet Page 47 of 54

Order 2 units of volume-reduced CMV-negative, irradiated platelets


Reduce volume to 10 mL/kg
Administer 10 mL/kg

Rate: Administer no faster than 2-3 mL/minute via syringe pump. If volume overload is a problem,
administer total dose over 1 to 2 hours via pump or request volume reduced platelets.

Tubing: Baxter/Blood Component Straight Type Blood Set (MN 101375)


Syringe pump
60-inch macro-bore extension tubing set

3. COMPONENT: FRESH FROZEN PLASMA

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

Indications: Massive hemorrhage


Multiple clotting deficiencies (e.g. liver disease, disseminated intravascular coagulation)

Dose: Acute hemorrhage: 15-30 mL/kg


Clotting deficiency: 10-15 mL/kg
May be repeated up to 3 times each 24 hours as necessary.
Monitor for congestive heart failure secondary to volume overload.

Rate: Hemorrhage: As indicated by patient’s condition


Clotting Deficiency: over 2 to 3 hours
(Thawed FFP has a 24-hour expiration, as long as it is kept refrigerated, otherwise it expires
4 hours after the bag is spiked.)

Tubing: Baxter/Straight Type Blood Component Recipient Set (MN 101375)


Syringe pump
60-inch macro-bore extension tubing set

4. COMPONENT: CRYOPRECIPITATE

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

Indications: Hypofibrinogenemia
Disseminated intravascular coagulation
Dose: <2.5 kg => 0.4 unit (6 mL) per kg body weight
2.5 –5 kg => 1 unit (15mL)
5-10 kg => 1-2 units
Infants who can tolerate or who need extra intravascular volume, administer as much of the
unit as tolerated to reduce donor exposure.

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


Administer within 6 hours of thawing

Tubing: Baxter/Blood Component Straight Type Blood Set (MN 101375)


Syringe pump
60-inch macro-bore extension tubing set
NICU Resident Packet Page 48 of 54

Antiseptic use in the NICU


University of Washington Medical Center
3/17/05

Povidone-Iodine swabs: Used for all medical procedures. Please note the following:

UAC/UVC placement: Apply povidone-iodine to cord and


1-2 centimeters around base of cord x 3 applications. Sterile towels will be used to
cover the untreated areas.

Lumbar puncture: Prep as small an area as possible.

Completely remove all antiseptic from the skin after the procedure using sterile
water or sali-wipes.

Goal is to minimize Povidone-Iodine absorption.

Chlorhexidine: Not used for medical procedures at this time. There is an increased risk
of abdominal/back burns on premature infants 24 to 26 weeks gestational age.

Chlorhexidine is used for PICC line placement, blood draws, and IV placement only.
Basically, it is only used for nursing procedures.

Alcohol: Not used on the skin of preterm infants.


NICU Resident Packet Page 49 of 54

Guidelines for Management of a Newborn with a Meningomyelocele

Background: These guidelines are based on a combination of evidence, expert opinion and clinical experience. New
information may come along at any time. We will do our best to update these guidelines and welcome input.
Most fetuses with meningomyelocele and hydrocephalus are now recognized by prenatal diagnosis. Prenatal
diagnosis allows time for counseling and thoughtful consideration by each family about the outlook for each embryo or
fetus. These guidelines are intended to assist health professionals in optimally managing the meningomyelocele in
fetuses whose parents have chosen to continue pregnancy.
As of February 2003, a national multicenter randomized trial of in utero meningomyelocele repair began
recruiting patients. Three centers around the country with experience are involved in the study (Vanderbilt, Childrens
Hospital of Philadelphia, University of California at San Francisco). No center in the country plans to provide in utero
repair outside the randomized trial in hopes of collecting data as rapidly as possible regarding the relative efficacy of in
utero repair at 19-25 weeks compared to term. Infants delivered at or near term will be delivered by C-section without a
trial of labor at one of the study sites. For more details see the study website: www.spinabifidamoms.com (good as of
February 26, 2004).
All newborns will benefit from sterile management and consideration for closure of their open lesions within
24 to 48 hours of birth. A serious breach of sterility may be a reason to defer treatment. The presence of other life-
threatening anomalies may be reason to defer treatment indefinitely.
The evidence for a better motor level and ambulatory outcome following prenatal diagnosis, and delivery by C-
section without a trial of labor in fetuses who have a bulging lumbosacral meningomyelocele and in utero motor
function in the affected spinal cord segments is primarily derived from the ongoing series accumulated by our own
group. These fetuses must be distinguished from those who have either a flat meningomyelocele lesion or a large lesion
with no motor function below T12. These other types of myelomeningocele often do not benefit from C-section
delivery.
It is also important to recognize and distinguish fetuses who have secondary neural tube defects. These
individuals have skin-covered lesions. Such lesions may be large enough on occasion to require C-section because of
obstruction of labor, but there is no evidence that C-section delivery is needed routinely or that any benefit will accrue
in terms of motor function. Such fetuses can often be recognized by the absence of any brain involvement (no
hydrocephalus, no Chiari II malformation), the location and characteristics of the mass itself and/or the presence of
abdominal wall defects such as extrophy of the cloaca that do not occur with meningomyelocele. Neonates with
secondary (skin-covered) neural tube defects do not need to be managed under sterile conditions and usually do not
need immediate neurosurgical closure. The usual management is to see the neonate on consultation in the newborn
nursery to make a diagnosis, and look for other anomalies that may need attention. We see the child back in clinic at
about two months of age with plans to surgically intervene when the child is 4 to 8 months of age. It is also very
important to recognize that the counseling about recurrence risks is totally different for secondary neural tube defects
and that folic acid supplementation is not protective. As folic acid supplementation and prenatal diagnosis/termination
reduce the incidence of meningomyelocele, but not secondary neural tube defects, the latter will occupy our attention
more of the time. Ron Lemire is a world expert on the embryology and occurrence of secondary neural tube defects and
we have developed considerable experience in managing them. If there is ever a question about these issues, please feel
free to contact the Congenital Defects and Neurosurgery faculty on the team.
1.) Guidelines for the obstetric provider who is the first to become aware of a fetus with meningomyelocele
Arrange for counseling, including information about fetal repair, delivery by C-section and other maternal
care issues if the family is interested in continuing the pregnancy. This can be done through the Prenatal
Genetics Clinic at UW, phone number 206-598-8130 or another perinatal center convenient to the family.
Patients may be referred from other institutions directly to pediatric faculty in the
Neurodevelopmental/Congenital Defects program (usually Dr. Shurtleff) for discussions that focus on the
outcome of the infant in relation to obstetrical management. Families wishing to obtain more information
about the postnatal care and prognosis for children with meningomyelocele can also be referred to the
pediatric faculty in the Neurodevelopmental/Congenital Defects program at CHRMC: 4800 Sand Point Way
NE, M2-8, Seattle, WA 98105, 206-987-2204. Some families may wish to have prenatal counseling with
Neurosurgery (206-987-2544) or Neonatology, Dr. David Woodrum (206-543-3200) regarding relevant
aspects of care.
Collect all ultrasound data. Repeat studies as needed.
Collect all available data regarding prenatal testing (AFP, other tests). A fetal karyotype is essential for
complete counseling.
Prepare a dictated/written summary including clinical observations, the above information and
approximate EDC for the mother's chart, baby’s record (if started), parents, and send to the
Neurodevelopmental office at CHRMC, 4800 Sand Point Way NE, M2-8, Seattle, WA 98105,
NICU Resident Packet Page 50 of 54

206-987-2204, the patient’s neurosurgeon, any referring obstetric provider or primary care
physician, and send to the Infant OT/PT team in the Rehabilitation Dept. at CHRMC, 4800
Sand Point Way NE, 6I-1, Seattle, WA 98105, 206-987-2114.
2.) Guidelines for UW/CHRMC faculty providing prenatal counseling
Ask the transcriptionist to send copies of the consultation to ALL the Neurodevelopmental
/Congenital Defects and Neurosurgery attendings at CHRMC. (Please note the names of the
Neurodevelopmental and Neurosurgery attendings in dictation.)
If delivery of the child will occur within two weeks, contact the specific attendings on call for
Neurosurgery, Neurodevelopmental/Congenital Defects, and Neonatology.
3.) Guidelines for the team of physicians (obstetrics, neonatology) attending birth
Notify BOTH the Neurodevelopmental/Congenital Defects and Neurosurgery attendings on call at CHRMC
(physician paging operator: 206-987-7777) when the baby is scheduled for delivery; time and place of
Cesarean section. If the newborn has a previously unrecognized meningomyelocele, please contact the
Neurodevelopmental/Congenital Defects and Neurosurgery attendings at the time the lesion is discovered.
Please provide relevant medical history on the baby and the mother.
The infant should be admitted to the Neurodevelopmental/Congenital Defects service on the
ward if term and stable (most infants) or to the Infant ICU (IICU) if pre-term or unstable.
Handle the infant with sterile, non-latex gloves and with sterile clothing and sheets.
Institute latex allergy precautions.
Cover the lesion with non-adhesive dressing wet with sterile Ringer’s lactate solution or saline.
Fill a syringe with the same solution, add a sterile, silastic tube to the tip of the syringe with the syringe
taped to the baby’s back and the distal tip of the tube in the center of the dressing.
Cover with a sterile dressing surrounded by a ring of Curlex to prevent pressure on the sac.
Note: Packaged materials and instructions for the dressing described above are available from Patti Jason,
RN, Director, CHRMC Transport Team, (206) 987-2632, pager 469-6336. There is also a more detailed set
of instructions complete with illustrations on the Neonatology Division website at
http://neonatal.peds.washington.edu/NICU-WEB/mcelecov.stm. Anyone unable to directly access this
website could ask the IICU unit coordinators to print a copy.
Position the infant in the side lying or prone position only; avoid pressure on the sac or nerves.
Arrange transport through normal channels for transport of critically ill newborns. Timing of transport
depends on the stability of the infant and the availability of bed space. Notify the
Neurodevelopmental/Congenital Defects attending on call (paging operator at CHRMC (206-987-2000).
Add the prenatal counseling summary to the infant’s chart.
Add and complete an appropriate growth chart for head OFC, height and weight.
4.) Guidelines for the CHRMC Infant ICU Attending on Call
Term newborns with meningomyelocele can be admitted to the regular ward on the
Neurodevelopmental/Congenital Defects service. Any such newborn billed as having had perinatal asphyxia
should be evaluated for severe brainstem dysfunction associated with Chiari II malformation since the initial
presentation is quite similar.
Preterm newborns with meningomyelocele usually need IICU respiratory care in the same manner as other
prematures. It is best if they can be nursed prone, or at least side-lying, but emergency intubation or related
procedures may require a brief period of time supine. Try to keep the open sac sterile and protected from
pressure if possible. Preterm newborns with meningomyelocele are more likely to have congenital heart
disease and/or syndromic causes (eg Trisomy 13 or 18) than term newborns.
Contact the Neurodevelopmental/Congenital Defects attending on call about the infant after stabilization if
no direct contact has occurred prior to the infant’s arrival. Ask the IICU resident to write a consult request.
5.) Guidelines for Neurodevelopmental/Congenital Defects Attending on Call
Notify Admitting for admission to the medical floor unless the infant is unstable and requires admission to
the IICU and provide the name of the neurosurgeon on call and your name with how to contact each.

Note: The IICU resident may need to be reminded to write an order for a Neurodevelopmental/Congenital
Defects consultation. The IICU attendings have always appreciated contributions to management from the
Division. Dr Lemire recommends we provide the same management recommendations as if on our service
and not wait to be consulted. In view of current billing and documentation issues, a documented consult
request is important.
Notify floor and request a call as soon as the infant arrives. Evaluate the infant for contraindications to
surgery, alter the prenatal prognosis, advise on treatment of other issues, etc.
Notify neurosurgical service and identify yourself and how to contact you. In general, the children will be on
the medical Neurodevelopmental/Congenital Defects service initially, then on Neurosurgery perioperatively
NICU Resident Packet Page 51 of 54

(typically one or two days) and then back on Neurodevelopmental/Congenital Defects service. It is expected
that the two services will work collaboratively at all times, regardless of who is attending at the moment.
Request PT and OT meningomyelocele evaluation consults via online orders from the Infant OT/PT Team
Referral Line and leaving an email at:
Alice Crandall, PCC, Rehabilitation Psychology, available 8:00 am to 5:00 pm
alice.crandall@seattlechildrens.org (206) 987-3371
It is sure to cause delay in involving OT/PT if direct contact is not made.
Contact information for each Infant OT/PT Team member, use only after contacting Referral Line:
Lynn Wolf lynn.wolf@seattlechildrens.org 206-987-3131
Gail Bonato gail.bonato@seattlechildrens.org 206-987-1320
Jane Mason jane.mason@seattlechildrens.org 206-987-3130
Susan Hutchinson susan.hutchinson@seattlechildrens.org 206-987-1467
Nan Street nan.street@seattlechildrens.org 206-987-3148
Record muscle strength examination and sensory level.
Notify Neurodevelopmental/Congenital Defects Nurse (206-987-2184) or page 206-469-5733. The nurse is
available from 8:00 am to 4:00 pm Monday through Friday. The Neurodevelopmental/Congenital Defects
nurse can provide the floor staff nurses with consultation and instructions as to the infant’s needs. The
Neurodevelopmental/ Congenital Defects nurses will provide the family with information on how to obtain a
Care Notebook and information about meningomyelocele.
Examine the infant for other malformations and syndromes that will alter the prognosis.
Discuss the management plan with the house staff.
Institute latex allergy precautions. See hospital protocol.
Obtain an ultrasound examination of urinary tract, head for ventricle size, and an echocardiogram on all
patients before surgery. Cardiology consultation should be requested early if an anomaly is present.
Request urology and orthopedic consultations if needed. Most infants will have a neurogenic bowel and
bladder and will need urology during the newborn hospitalization. Many infants will have musculoskeletal
deformities requiring orthopedic consultation, though rarely on an emergent basis.
Request social work consultation. The social worker assigned to Neurodevelopmental /Congenital Defects is
available weekdays through the paging operator (206-987-2000).
If the infant presents with cardio-respiratory distress, apnea, bradycardia, laryngeal stridor or aspiration with
swallowing institute a symptomatic Chiari II malformation work up, which may include blood gases and
oximetry, an MRI of the brainstem, sleep study, videofluoroscopy of swallowing and ENT evaluation. The
workup should be individualized. Neurosurgery should already be following the case.
Spend adequate time with family explaining all aspects of care to inform them and begin to develop the
therapeutic alliance that will allow optimal care of the child for the next 21 years.
Assure that basic information on each infant is submitted to the myelodysplasia database. The OTs, PTs and
nurses should both have the permanent information data entry form to initiate if they are notified about the
infant. A backup procedure is to notify Dr. Shurtleff (206-987-2058, 425-454-1893, e-mail
david.shurtleff@seattlechildrens.org) or Sharon Duguay (e-mail sharon.duguay@speakeasy.net) directly.
Any of the following faculty will be glad to answer questions: Jeff McLaughlin, Nora Davis, William
Walker, Chuck Cowan, David Shurtleff or Sam Zinner. Contact the CHRMC paging operator (206-987-
2000) to determine who is on call.
Doctor Phone Number Pager Number Email Address
Jeff McLaughlin 206-987-2204 206-469-6704 john.mclaughlin@seattlechildrens.org
Nora Davis 206-987-2590 206-469-6411 nora.davis@seattlechildrens.org
William Walker 206-987-2204 206-469-3579 william.walker@seattlechildrens.org
Chuck Cowan 206-987-2204 206-469-5369 charles.cowan@seattlechildrens.org
David Shurtleff 206-987-2058 206-469-5485 david.shurtleff@seattlechildrens.org
Samuel Zinner 206-685-1290 206-469-5157 szinner@u.washington.edu
6.) Guidelines for Neurodevelopmental/Congenital Defects Attending Follow-up
Consult with neurosurgeons as to antibiotic management, nutrition and any other appropriate medical
considerations.
Accept the infant in transfer if requested by the neurosurgeons or IICU staff. Preferable placement is on a
medical floor with nurses experienced in the management of newborns with neural tube defects.
Follow urine post voiding residual for temporary or permanent postoperative retention or infection.
NICU Resident Packet Page 52 of 54

Consider use of phenoxybenzamine for relief of bladder sphincter spasm. Start with 1 mg P. O. every 24
hours as one dose and advance until residual urine is less than 5 mL, or side effects such as stuffy nose or
drowsiness occur. Note that the normal urinary bladder capacity of a neonate is 30 mL..
Organize discharge plan for parents and the local health care provider. Begin early in the hospitalization and
involve the unit discharge planner if complexity warrant (e.g. need for home health care, special equipment,
etc).
Follow carefully for positioning to prevent head weight bearing on the shunt valve or chamber (have a
doughnut under the head.)
Manage skin care for perineum in the presence of dribbling urine or stool. Vinegar is an excellent agent for
protecting the skin from alkali burns.
Record daily head size, plot on appropriate head size chart and obtain follow-up cranial ultrasounds as
needed. In premature infants, always obtain cranial ultrasounds since the brain is more compliant and
ventricles may expand with little change in head size.
Every infant should have a nutrition consult.
Every infant should have a neonatal hearing evaluation.
Notify the Neurodevelopmental/Congenital Defects patient care coordinators, preferably in writing or by e-
mail, of the plan for clinic appointments. These need to be tailored to the needs of each infant and family.
DO NOT leave this up to unit assistants or others unfamiliar with our clinic. To do so often results in
uncoordinated appointments in many separate clinics.
These guidelines were developed with the assistance of many people, notably David Shurtleff, MD. Please send any
questions or suggestions about these guidelines to Jeff McLaughlin, MD at john.mclaughlin@seattlechildrens.org or
206.987.2204.
Disclaimer: These guidelines have been developed by the Division of Genetics and Developmental
Medicine, Department of Pediatrics, UW, to assist physicians and other healthcare professionals. Practitioners
are encouraged to use the information provided in the guidelines. The recommendations contained in the
guidelines may not be appropriate for use in all circumstances. Any decision to adopt a particular
recommendation must be made by the practitioner based upon available facts and circumstances presented by
individual patients.
It is not the intention in promulgating these guidelines to interfere with the provider/patient
relationship, nor are these guidelines intended to represent the standard of care in any given circumstance. These
guidelines are recommendations to be used at the sole discretion of the provider and are not meant to dictate the
manner or style of clinical practice employed in rendering services to a particular patient.
NICU Resident Packet Page 53 of 54

Erythropoietin in the Newborn Intensive Care Nursery


How Epo works
The production of red blood cells from pluripotent stem cell to mature red blood cell is governed by growth factors that
include erythropoietin (Epo). These erythropoietic growth factors decrease apoptosis of progenitor cells and stimulate
maturation, growth, and differentiation of red blood cells (Figure). Epo works by binding to a specific cell surface
receptor (Epo-R). Although multiple growth factors facilitate production of red blood cells, none plays a more important
regulatory role than Epo. Both hypoxia and anemia stimulate erythropoiesis by stimulating Epo production mediated by
a transcription factor, HIF-1, or “hypoxia inducible factor”.
Prenatally,
Epo Receptor Density Epo is
produced in
the liver,
and
postnatally
Pluripotent CFU-GEMM BFU-E CFU-E Normoblast Reticulocyte Erythrocyte by the
Stem cell
kidney.
IL-6
IL-3
Administra
GM-CSF ti o n o f
? rEpo
EPO
Epo can be
given IV or
SQ. It is somewhat more effective when given SQ, unless the IV dose is given over an hour to simulate SQ absorption.
It given IV, it can be given either by itself, or mixed in hyperalimentation fluids (TPN).

Dose and dosing schedule


When compared to adults, the half life of Epo in preterm infants is shorter, and the volume of distribution greater,
necessitating larger doses and more frequent dosing. Effective dosing schemes are as follows:
– 200 units/kg/day IV (Can add to HA fluids, or give as single dose injections over 60 min)
– 400 units/kg/day SQ, three times a week (eg. M, W, F)
• Start iron 6 mg/kg/day elemental iron PO/OG or 1 mg IV iron dextran in TPN when starting Epo therapy.

A weekly CBC with differential count, platelet count, reticulocyte count and ZnPP/H should be followed when an infant
is receiving Epo treatment. Treatment length is dependent on the therapeutic goals, and can be from 2 weeks to several
months in duration. A convalescing preterm infant can be expected to begin producing red blood cells on their own
when they reach 36 weeks corrected gestational age.

Epo Clearance
Epo is cleared by receptor binding, with internalization and subsequent breakdown within the cells. Some Epo is
excreted in the urine, but dosing is not effected by hepatic or renal disease.

Epo Side effects


Side effects of Epo administration reported in adults include hypertension, bone pain, rash, and rarely seizures. Many
of these side effects are reported in end stage renal patients, and it is unclear what effect their primary disease state has.
None of these side effects have been reported in newborns. Uncommon side effects that appear to be specific to
newborns include neutropenia and mild thrombocytosis.

Who might benefit from Epo


1. Even with the use of Epo, infants < 1000 gm are likely to require at least one transfusion in the first weeks of life.
Because we used aliquoted blood here at the UW, and these infants can receive multiple transfusions with only
one donor exposure, we do not recommend beginning Epo during the first weeks of life when phlebotomy losses
are the highest, and infants are likely to need multiple transfusions.

When infants < 1000 gm become more stable and phlebotomy losses are lower (usually after the first 3 weeks of
life), Epo should be considered.
NICU Resident Packet Page 54 of 54

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

The corrected reticulocyte count is obtained by taking the patient’s reticulocyte (%) x patient’s Hct (L/L) ÷
desired or optimal Hct (L/L). 45 is usually used as the optimal Hct when making this calculation.

2. Infants > 1000 gm who are at risk for a transfusion but who are not in acute need of blood.
Following the weekly Hct and reticulocyte count is helpful when making this assessment. If
they are not requiring frequent blood draws, but their Hct is falling despite standard iron
therapy, they may benefit from Epo.

Any child who is acutely ill and in need of increased oxygen carrying capacity should be
transfused, not treated with Epo.

General Information about Epo


It takes approximately a week to see an increase in Hct after starting Epo. The reticulocyte count
will often double, and gains in Hct are generally in the 2 to 4 point range per week. The most
common cause of failure to respond is inadequate iron stores.

Responding to ZnPP/H ratios in VLBW infants


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

References:
1. Winzerling JJ, Kling PJ. Iron-deficient erythropoiesis in premature infants measured by blood zinc
protoporphyrin/heme. J Pediatr 2001;139:134-6.
2. Bartels PC, Helleman PW, Soons JB. Changes in size and zinc protoporphyrin/haemoglobin ratio in red cells of
infants during the first months of life. Ann Clin Biochem 1990;27:102-6.
3. Farsakh FA, Al-Khalily AS, Mameesh MS. Plasma lead and erythrocyte zinc protoporphyrin in neonates and
young children in Kuwait. Ann Nutr Metab 1987;31:292-5.
4. Kilbride J, Baker TG, Parapia LA, Khoury SA. Incidence of iron-deficiency anaemia in infants in a prospective
study in Jordan. Eur J Haematol 2000;64:231-6.
5. Milman N, Christensen JM, Ibsen KK. Blood lead and erythrocyte zinc protoporphyrin in mothers and newborn
infants. Eur J Pediatr 1988;147:71-3.
6. Juul SE, Zerzan JC, Strandjord TP, Woodrum DE. Zinc protoporphyrin/heme as an indicator of iron status in
NICU patients. J Pediatr 2003;142:273-8.