Presentation on theme: "Making Sense of Numbers in the NICU"— Presentation transcript:
1 Making Sense of Numbers in the NICU Pediatrics WorkshopNational SOMA Spring ConventionWashington, D.C.March 10, 2012Lisa Marie Piwoszkin, OMS IVNational SOMA VP & SpeakerCCOM
2 Objectives Introduce the basics of the newborn resuscitation period Practice calculations for TPN ordersLearn how to manage basic ventilator settingsHuge topics, I just want to give you the basics so you’ll have a base knowledge on rotations.1,2,3,4 years?A lot will carry over!But we will focus on the newborn….
3 WHY do you care? Complex concepts you may be expected to know Not taught this in classEveryone required to do a pediatric rotation!
4 WHAT is the Newborn Resuscitation? Special skill set used in the period immediately after delivery to assist the newborn transition from intrauterine to extrauterine life
6 WHERE does the Newborn Resuscitation take place? Delivery RoomOperating Room
7 WHO is present during the Newborn Resuscitation? OB crewOB/Neonatal nurse(s)Neonatologist/PediatricianResident(s)Medical Student(s)- YOU!Nurses designated to babyNRP= AAP + AHA
8 WHAT skills are involved in the Newborn Resuscitation? Thermoregulation (37˚C)Airway ManagementStimulationCardiovascular SupportMedicationsThermoregulation (37˚C)- warmer, blankets, plastic wrapAirway Management- Goal- CRY, Suction, Oxygen, Positive Pressure Ventilation, IntubationStimulation- bulb suction, dryingCardiovascular Support- compressions if less than 60bpm after 30 sec of PPVMedications- epi, NS
9 HOW can YOU prepare? Wear gloves and mask Be aware of surroundings Make sure the appropriate help is in the roomMake sure suction kit, intubation kits, and resuscitation medications are in the room and readily availableMake sure oxygen is flowing, bag valve mask working properly and at appropriate pressureMake sure blankets are laid out and warmer is set to 37˚CMake sure timer is reset on warmer
11 HOW can YOU participate? “Catch the Baby!”Start the timer…CONSTANTLY ASSESS THE BABYBulb suctionDry with blanketsCheck for pulseListen to lungsWatch the timer…Quick examPut on the capRecord APGAR scoresSecure side railsCongratulate the parents!Bulb- mouth then nosePulse 60 vs 100
12 APGAR Scores Assessment of newborn viability Pneumonic & Eponym @ 1 min, 5 min, 10 minPneumonic & EponymEach letter represents a sign evaluated in the scoreDeveloped by Virginia Apgar, MD, leader in anesthesiology
25 Calculations Total Fluid (TF) (B) 150ml/kg/dayTotal Daily Fluid Intake (B) ml/kg/day x (A) kg = (C) ml/day150 ml/kg/day x 1 kg = 150 ml/dayNo Non-TPN Infusions or Enteral Rx (D)Parenteral Feeding Allowance (C) ml - (D) ml = (E) ml150 ml – 0 ml = 150 mlTF- every and all fluid received in 24 hrs (TPN, oral, meds, other infusions, etc.)
26 Calculations Fat Emulsion (G) Separate bag! Start with 1 gm/kg Increase by 0.5 gm/kg/day, max 3 gm/kg1 gm fat dispensed in 5 mlFat Emulsion #gm/kg x (A) kg = (F) gm x 5 ml/gm = (G) ml1 gm/kg x 1 kg = 1gm x 5 ml/gm = 5 ml
27 X Total Daily Fluid Separate bag! TPN Dextrose Amino Acids ElectrolytesVitaminsTrace ElementsFAT EmulsionFatXOTHERMedicationsInfusionsOral Feeds
28 TPN Volume/24 hours (E) ml - (G) ml = (H) ml CalculationsTPN Volume over 24 hours (H)Parenteral feeding allowance – intralipid volumeTPN Volume/24 hours (E) ml - (G) ml = (H) ml150 ml - 5 ml = 145 ml
33 Calculations Amino Acids (J) 3 gm/kg x (A) kg = (J) gm Initiate at 3 gm/kg3 gm/kg x (A) kg = (J) gm3 gm/kg x 1 kg = 3 gm
34 Calculations Electrolytes Multivitamin Trace Elements None included in TPN until DOL #3Allow for stabilizationAdjust day to dayMultivitaminCheck DailyTrace Elements
35 X Calculations Enteral Calories (P) Parenteral (TPN) Calories (Q) Fat: (F) x 10 = (K)Dextrose: (I) / 100 x (H) x 3.4 = (L)Protein: (J) x 4 = (M)TPN Kcal/day: (K) + (L) + (M) = (N)TPN Kcal/kg/day: (N) / (A) = (Q)Total CaloriesTotal Kcal/kg/day: (Q) + (P)
36 How will your TPN order change? Keep track of days and ageUpdate weight dailyKnow line accessKnow oral volumes or infusionsIncrease fats and dextroseAdjust fats, dextrose, amino acids, electrolytes*, and additives as needed based on labsElectrolytes… arbitraryChloride and acetone (back)Cholestasis protocol
37 Case 3 29 0/7 weeks premature male Meconium aspiration, absent cry, required intubationBlood Gas:pH 7.21PaCO2 50PaO2 56HCO3 20Base Deficit -4What Acid-Base imbalance does he have?
38 Case 3Respiratory acidosisHow can we help reduce his acidosis?
39 Affected by Ventilation or Oxygenation? pHPaCO2PaO2HCO3Base Deficit
40 Affected by Ventilation or Oxygenation? pHPaCO2PaO2HCO3Base DeficitVentilationOxygenationNeither
41 Ventilator Settings Same indications as adults Modes AC- Assist ControlSIMV- Synchronous Intermittent Mandatory VentilationPS- Pressure SupportCPAP- Continuous Positive Airway PressureBiPAP- Bilevel Positive Airway PressureAssist Control (AC)– respiratory rate (16) is guaranteed at a set tidal volume (500)Patient triggered breath will deliver the same volume as a ventilator triggered breathVentilator will always 16, but pt can breath above vent- SIMV may be indicated or lower rateSynchronized Intermittent Mandatory Ventilation (SIMV) – delivers a guaranteed minimum respiratory rate (12-14) at a set tidal volumePatient may generate additional breathsVentilator will synchronize patient and machine generated breathsPatient generated breaths – the delivered volume is only what the patient can generate – work of breathing is increasedSeeing what your pt can do on their own (strength & rate)Pressure support is a method of assisting spontaneous breathing in a ventilated patient. It can be used as a partial or full support mode(1-3). The patient controls all parts of the breath except the pressure limit. The patient triggers the ventilator – the ventilator delivers a flow up to a preset pressure limiCPAP – continuous positive airway pressureMajor use is in non-intubated patientsPressure maintained above atmospheric pressure – eliminates patient work in generating negative airway pressureDelivered through tightly fitted face masks with adjustable pressurized valves connected to a respiratorBiPAP – bi-level positive airway pressureHas settings for both inspiratory positive pressure and expiratory positive pressure
44 Affects Ventilation or Oxygenation? RateTidal VolumeFiO2PEEPTidal volume is the lung volume representing the normal volume of air displaced between normal inspiration and expiration when extra effort is not applied.FiO2- percent oxygenPositive end-expiratory pressure (PEEP) is the pressure in the lungs (alveolar pressure) above atmospheric pressure (the pressure outside of the body) that exists at the end of expiration.
45 Affects Ventilation or Oxygenation? RateTidal VolumeFiO2PEEPVentilationOxygenation
46 Ventilation Oxygenation Rate Tidal Volume To ↑ pH ↑ To ↓ pH ↓ To ↑ PaCO2To ↓ PaCO2OxygenationFiO2PEEPTo ↑ PaO2↑To ↓ PaO2↓
47 Just remember… What’s abnormal? What’s the problem? What can you change?pH or PaCO2VentilationRate or Tidal VolumePaO2OxygenationFiO2 or PEEP