Personal notes taken during STABLE course

1. 1 | P a g e
STABLE Course Notes
1. Sugar & Safe Care
Aim for 2.8-6.0 mmol/L
Avoid enteral feeding – insert IVC or UVC
Risks for hypoglycaemia:
1. Prem (<37/40 gestation)
2. SGA
3. LGA
4. IDM
5. Stressed/sick
6. Some meds given to mother
a. β -symps
b. β -blockers
c. Chlorpropamide
d. Benzthiazides
e. TCAs during 3rd
trimester
Foetal glucose is approx 70-80% of maternal value
3rd
trimester = ↑ glycogen storage in liver
Factors affecting BGL after birth:
1. ↓ glycogen stores
2. Hyperinsulinaemia
3. ↑ glucose utilisation
Affecting:
1. Prem, SGA (@ term = 25% risk, prem SGA = ↑ risk) stressed/sick
2. IDM (insulin does not cross placenta. Foetus creates own insulin in response to mother glucose level.
Cutting cord  glucose stopped. May result in ↑insulin  ↓ BGL), LGA (↑ insulin can be cause of
LGA)
3. Prem, SGA, infection/shock/hypothermia/hypoxia (anaerobic metabolism; ↑ glucose consumption
for ↓ ATP output)/cardiac or respiratory disease
Screening:
15-30 min intervals until > 2.8mmol/L on at least 2 consecutive tests
S&S of Hypoglycaemia:
 ASYMPTOMATIC
 Twitching
 Jitteriness
 Irritability
 Hypotonia
 Lethargy
 High pitched cry
 Tachypnoea
 Cyanosis
 Poor suck
 Hypothermia
 Apnoea/irregular resps
Rate x conc x 0.167 = mg/kg/min
Weight
OR
100ml/kg/day = 10g/kg/day
10g / 1.44 =
mg/kg/min

2. 2 | P a g e
 Seizures
Treatment
1. D10W @ 80ml/kg/day via infusion pump (approx 5.5mg/kg/min)
a. Central line for D15W and above
b. Weight x 80ml / 24 = ml/hr
2. Bolus of 2ml/kg of D10W @ 1ml/min
3. Rpt if no improvement
4. Repeat & increase to 100ml/120ml/kg/day (or increase glucose concentration if pt not candidate for
↑ fluids)
NB prem may need ↑ fluids due to loss through thinner skin, radiant warmer, phototherapy lights etc.
Watch for ↑ BGL due to immature endocrine sys (i.e. may need ↑ fluids but ↓ glucose concentration)
UVC/UAC
UVC
 Rapid IV access
 Difficulty gaining Peripheral IV
 More than 1 IVC needed
 CVC access for D12.5W+
 Tip @ RA/IVC junction
 Preterm never more than 5cm; term never more than 7cm. Emergency placement – 3cm you’re in!
UAC
 Continuous ABGs
 ABP monitoring
 NO MEDS – NaCl only to maintain patency
 AP CXR – T6-T9 (high line - preferred); L3-L4 (low line)
 Monitor for arterial spasm/emboli (discolouration of feet/abdo/buttocks/legs/groin)
NB In life threatening emergency – IO access (tibial) 18G
Heparin
0.5-1.0 unit/ml of fluid IV. CUMH – 0.5u/ml
NB Comes in different concentrations! Check packaging first!
Volvulus
Green coloured emesis. Never assume to be normal! Rule out malrotation.
 Pain
 Bloody stool Ischaemia
 Shock & metabolic acidosis
Peripheral IVC
24G or 28G scalp needle

3. 3 | P a g e
STABLE Course Notes
2. Temperature
Maintain whether patient well or unwell
1. EARLY Prem & SGA at ↑ risk of hypothermia
a. ↑ surface area v body mass
b. Less insulating fat
c. Thinner immature skin
d. Little if any brown fat (5% of mass – back/spine/shoulder)
2. SMALL BW <1500g – problem accentuated
3. SICK Infants who require resuscitation or are acutely unwell
a. Hypoxic
b. Hypotonic (unable to flex/↓ activity  ↓ heat generation)
NB Core temp = 36.5°C – 37.5°C
Mild 36-36.4°C
Moderate 32-35.9°C Grades of hypothermia
Severe <32°C
NB Hypothermia is an independent risk factor for mortality
Normal response to cold stress
Peripheral vasoconstriction, ↑ flexion & activity, metabolism of brown fat  ↑ metabolic rate  ↑
utilisation of O2 & glucose
 Prem, SGA & hypoglycaemia are at increased risk of hypothermia
Decreasing heat loss
1. Pre-warm objects before contact (mattress, hands, steth, XR plates, blankets)
2. Insulation between baby & surfaces
3. Clothing, hats (not always practical)
4. Chemical thermal mattress with cover
5. Pre-heat room to 25-28°C
6. Cover chin-to-feet with polyethylene covering (may not be useful >1500g BW)
7. Closed, pre-warmed incubator
8. Heat O2 & humidify
9. Radiant warmer – do not obstruct during resus
10. Quickly dry infant
11. Do not bathe unstable infants – PPHN
12. Minimise air turbulence
13. Warm any IV solutions
14. Thermal shades over windows
15. Move infant away from windows & walls
16. Radiant bed – SERVO-CONTROL MODE!
a. Temp sensor on RUQ

4. 4 | P a g e
Physiological response to hypothermia (term infants)
Cold stress
Hypothalamus stimulated
Norepinephrine released Pulmonary vasoconstriction
Brown fat
metabolism ↑ activity, flexion R-L shunting
(aerobic) ↑ O2 consumption
↑ glucose utilisation
HYPOGLYCAEMIA HYPOXIA HYPOXAEMIA
Physiological response to hypothermia (pre-term infants)
Cold stress
Hypothalamus stimulated
Norepinephrine released Pulmonary vasoconstriction
Brown fat
metabolism ↑ activity & flexion
↑ O2 consumption
Limited glucose stores
HYPOGLYCAEMIA HYPOXIA
Right – left shunting  hypoxemia
Hypoxemia  Hypoxia  Anaerobic metabolism  ↑ lactic acid  ↓pH
Hypothermia
S&S of worsening Hypoglycaemia due to Hypothermia
 Respiratory distress
 ↓ LOC

5. 5 | P a g e
 ↓ resp rate
 ↑ sepsis risk
 DIC
 ARF
NB For re-warming, incubator is best choice. Set to air temperature mode. Set 1-1.5°C above core temp.
Closely monitor – avoid sudden vasodilation & hypotension
 Core temperature
 HR
 ECG
 BP Continuously monitor
 Resp rate & effort
 SpO2 > 90%
 ABB
 BGL
NB Baby can lose 150ml/day in non-sensible, uncontrolled fluid loss through evaporative heat loss. 1ml of
fluid loss = 4 cal energy loss
Prolonged resus – turn off radiant warmer. Possible candidate for therapeutic hypothermia / passive cooling
(33-34°C)
Rewarming – ½°C/hour

6. 6 | P a g e
STABLE Course Notes
3. Airway
Arterial Blood Gases (CUMH)
pH 7.30-7.45 (7.26 acceptable)
pCO2 35-45mmHg (4.5-6 kPa)
pO2 50-80mmHg (6.5-10 kPa)
HCO3- 19-26 mEq/L (18-24)
BE -4 to +4 (-6 to +6)
NB Temperature when taken should be input in order to give accurate results!
Respiratory Distress
 Mild - ↑RR
 Moderate - ↑RR, cyanosis, abnormal ABG
 Severe – central cyanosis, struggling, abnormal ABG
NB N = 30-60 r/min; < 30 = laboured; gasping = pre-arrest (BVM/tube/PPV)
Tachypnoea & ↓ pCO2 (non-respiratory cause)
 Congenital heart disease
 Metabolic acidosis
 Cerebral disorder (meningitis, oedema, haemorrhage)
Tachypnoea & ↑ pCO2 (respiratory cause)
 RDS (surfactant deficiency in immature infant)
 Pneumonia (give ABx until proven otherwise!)
 TTN (retained foetal lung fluid) (↑risk in pre-labour section)
 Aspiration
 Pulmonary haemorrhage
 Airway obstruction
 Chest mass, diaphragmatic hernia, pneumothorax (CXR for definitive Dx)
 Penicillin is cheap, safe & effective – use it!
Gas exchange
Resp  Breathe in  pO2 in alveoli ↑  O2 diffuses into plasma  Diffuses into RBC  O2 binds
to Hb  Hb saturated with O2  Heart  pumped to body  releases O2 to cells  O2 diffuses
into cells  CO2 diffuses from cells into plasma  lungs  CO2 removed
High  Low gradient

7. 7 | P a g e
pO2 blood > pO2 tissues
100mmHg > 23mmHg
↑ HCO3- = compensating respiratory acidosis
↓pCO2 = compensating metabolic acidosis
Metabolic Acidosis (lactic)
 Shock
 Poor perfusion
 Anaerobic metabolism
 Sepsis
 Hypothermia
 Congenital heart disease
 TRAUMA – accidental & intentional
Treatment of Metabolic Acidosis
 Treat the cause!
 ↑ O2
Respiratory Acidosis
 Lung disease
 Pneumothorax
 Airway obstruction
 ↓ resp effort
 Neurological injury
 Apnoea
 Mechanical interference
Treatment of Respiratory Acidosis
 CPAP
 PPV
NB Deterioration with PPV in neonate – consider diaphragmatic hernia.
Intubation
Weight (in kg) + 6 = tube mark @ lips
Ventilation
 Time-cycled mode
 Start low, work up
VLBW LBW Term
Rate 30-60 30-60 20-50
Insp time ≥0.25 Match GA < 0.45

8. 8 | P a g e
PIP 14-22 18-24 20-28
PEEP 3-4 4-5 4-5
↑ PIP = ↑ TV = ↓ pCO2
↑ PEEP = ↓TV (unless ↑ PIP) = ↑pCO2
NB Adjust PEEP first, then PIP, then insp. time
Analgesia
Morphine – ref NEOPAIN study
 0.05-0.1mg/kg per dose
 IV/IM/SC
 15-30 min admin time
Fentanyl
 1-2mg/kg per dose
 IV
 15-30 min admin time
Sucrose
 12-24% solution
 Term – 0.5-2.0ml
 Pre-term – 0.1-0.4ml
NB Sedatives ≠ Analgesia
Needle Aspiration of Pneumothorax
1. Turn 45°, pneumo side up
2. 4th
/5th
IC space
3. Mid-axillary or anterior axillary
CDH
 8/40 gestation – diaphragm develops. Mortality 40-60% with CDH
 Recognition
o Cyanosis
o Resp distress
o Scaphoid/sunken abdomen
 Risk of pneumothorax with PPV
NB DO NOT PPV if CDH – intubate!
Stabilisation of CDH
 Blow-by O2
 10F OG tube

9. 9 | P a g e
 CXR
 Pre & post-ductal SpO2% - observe for PPHN. Greater than 10% difference = R-L shunting
 Vitals
 Volume boluses
 Dopamine
 Observe for pneumothorax
 Analgesia
PPHN
PDA &/ FO remain open
3 main causes
1. ↑ muscularisation
2. Vasospasm – acidosis, hypoxia, hypothermia, sepsis
3. ↓ lung size – pulm hypoplasia, CDH
CPAP
Indications
1. Needs support but not intubation
2. ↑ severity/frequency of apnoea
3. ↑ work of breathing
4. ↑ O2 requirement
5. CO2 retention, acidosis (mild)
6. Atelectasis
7. Tracheobronchomalacia (flaccidity of tracheal cartilage)
Contra-indications
1. Progressive respiratory failure
2. ↑pCO2
3. ↑ acidosis
4. Hypoxemia
5. CDH, TEF, choanal atresia, cleft palate, cardiovascular instability, ↓ resp drive

10. 10 | P a g e
STABLE Course Notes
4. Blood Pressure
Hypovolemic, cardiogenic & septic shock
HR x SV = CO
Fluids
10ml/kg/dose over 15-30 mins (NaCl or Ringers)
Whole blood – over 30mins-2hrs
Sodium Bicarbonate
 4.2% solution
 For tx of severe metabolic acidosis (pH < 7.15)
 1-2mEq/kg/dose over 30-60 mins
 IV
Dopamine
 5-20mcg/kg/min
 IV
Group B Strep – risk factors
 Temp > 38.5°C
 Labour > 18hrs
 UTI / Previous delivery
Double penicillin to treat meningitis.
Ref HIP trial

11. 11 | P a g e
STABLE Course Notes
5. Lab Work
Blood count
Blood culture The 4 B’s
Blood glucose
Blood gas
Risk of infection
 PROM
 POL
 Chorioamnionitis (inflammation of foetal membranes)
 Increased risk of infection with
o Maternal infection
o Maternal fever
o Maternal GU tract infection
o ROM > 18hrs
o Instrumentation use
o Intubation/cannulation etc.
Neutrophils
Mature – Poly, Seg, Neut, PMNs
Immature – Metas, Bands, Stabs
 Immature-to-total (I/T) ratio is important
 Absolute Neutrophil Count (ANC) in important (↓ ANC = ↑ RIP risk in presence of sepsis)
NB ANC ≤ 1800 in term / pre-term is abnormal!
ANC = Segs + Bands + Metas
I/T > 0.25 (25%) – suspect that the infant is fighting infection.
(Meta +band) Immature = I/T Ratio
(Segs + meta + band) Total
NB I/T > 0.8 = ↑ risk of death from sepsis

12. 12 | P a g e
Platelets
100-150k Abnormal
<100k Definitely abnormal, investigate for bleeding
<25k Dangerously low
VLBW (<1.5kg) 275k +/- 60k
LBW (<2.5kg) 290k +/- 70k Normal platelet values
Term 310k +/- 68k
NB NEVER withhold antibiotic therapy on basis of N FBC!
Time between onset of infection & FBC changes can be 4-12 hours!
Antibiotics
Ampicillin
 100mg/kg/dose
 Give over 3-5 mins
 Every 12 hours
Gentamicin
 2.5mg/kg/dose
 Give over 30 mins
 Every 12-24 hours
APGAR
<3 critical
4-6 low
7-10 normal
How Ready Is This Child?
HR, RR, Irritability, Tone, Colour
APGAR
Appearance, Pulse, Grimace, Activity, Respiration

13. 13 | P a g e
IVC & SVC
AORTA
PA
PDA
PFO
RT Subclavian
(pre-ductal)