Catch-All Unit

Nsg 3050

Case Study
Term, uncomplicated pregnancy
21 y.o., no medical problems, G
1
P
0
Group B Streptococcus screening negative
Membranes ruptured 10 hours before birth
Apgar scores 7
1
, 8
5
Birth weight 3.43 kg
Birth time: 1931
Case Study
Pale, grunting and retracting after delivery
Observed in term nursery 5 hours
Taken to NICU for observation at 0100
Tachypnea, RR = 80
Tachycardia, HR = 180
Normotensive, BP = 76/44
Acrocyanosis
Capillary refill 4 seconds
Case Study
Term infant, pale, grunting, retracting

NICU admission diagnosis: R/O Sepsis
NPO, IV fluids
CBC, blood culture, antibiotics
Chest x-ray
Case Study
Case Study
CBC
WBC = 4,100
Total neutrophils (ANC) = 533
Differential
Segmented neutrophils: 13%
Band neutrophils: 0%
Case Study
Normal
Age = 2 hours
Case Study
Following admission to NICU
Progressive deterioration
Falling blood pressure
Given albumin infusion to expand blood volume
Started blood pressure support with dopamine
Deteriorating lung function
Intubated and ventilated with increasing difficulty
Umbilical artery and vein catheters inserted
Transfer to Primary Childrens at age 12 hours
Helicopter Transport
Cardiac Arrest during transport, required chest compression
Case Study
Following admission to NICU
Progressive deterioration
Falling blood pressure
Given albumin infusion to expand blood volume
Started blood pressure support with dopamine
Deteriorating lung function
Intubated and ventilated with increasing difficulty
Umbilical artery and vein catheters inserted
Transfer to Primary Childrens at age 12 hours
Helicopter Transport
Cardiac Arrest during transport, required chest compression
Case Study
Age = 6 hours
Age = 2 hours
Case Study
Following admission to NICU
Progressive deterioration
Falling blood pressure
Given albumin infusion to expand blood volume
Started blood pressure support with dopamine
Deteriorating lung function
Intubated and ventilated with increasing difficulty
Umbilical artery and vein catheters inserted
Transfer to Primary Childrens at age 12 hours
Helicopter Transport
Cardiac Arrest during transport, required chest compression
Case Study
Following admission to NICU
36 hours after blood culture drawn
Group B Streptococcus
In Blood Culture
Case Study
Following Transfer to Primary Childrens
Blood pressure support 5 days
Inhaled Nitric Oxide 9 days
Intubation/Ventilation 11 days
Oxygen 14 days
Antibiotics 21 days
Case Study
Following Transfer to Primary Childrens
Blood pressure support 5 days
Inhaled Nitric Oxide 9 days
Intubation/Ventilation 11 days
Oxygen 14 days
Antibiotics 21 days
Normal MRI of Brain
Normal Neurological Examination
Discharge to parents
Neonatal Sepsis
Perinatal Risk Factors
Physical Appearance
Laboratory Tests
Usual Suspects
Treatment
Outcome
Perinatal Risk Factors
Group B Streptococcus colonization
20% of women are asymptomatic carriers
Prolonged Rupture of Membranes (PROM)
Especially over 24 hours
Maternal Fever
Urinary Tract Infection
Chorioamnionitis
Neonatal Sepsis
Perinatal Risk Factors
Physical Appearance
Laboratory Tests
Usual Suspects
Treatment
Outcome
Physical Appearance
Respiratory Distress
Grunting Respirations
Retractions
Pallor or Cyanosis
Pallor
Hypotension
Delayed Capillary Refill
Hypoxia
Lethargy
Poor feeding
Indifferent to pain/lab testing
Physical Appearance
Vital Signs
Tachypnea
Tachycardia
Hypotension
Temperature
High
Normal
Low
Neonatal Sepsis
Perinatal Risk Factors
Physical Appearance
Laboratory Tests
Usual Suspects
Treatment
Outcome
Laboratory Tests
CBC
WBC
High
Low
Differential
Neutrophils (Bands, Segs) ANC [bands + segs x WBC]
I/T > 0.2 (immature : total neutrophils)

CRP
> 1.0

Blood Culture
Glucose
ANC
*
* Example
Neonatal Sepsis
Perinatal Risk Factors
Physical Appearance
Laboratory Tests
Usual Suspects
Treatment
Outcome
Usual Suspects
GBS
E. coli
S. aureus
Enterococcus
S. epidermidis
Klebsiella
Others
Neonatal Sepsis
Perinatal Risk Factors
Physical Appearance
Laboratory Tests
Usual Suspects
Treatment
Outcome
Treatment
Newly delivered
Ampicillin
Gentamicin
Nosocomial in NICU with central catheters
Vancomycin (Staph)
Amphoteracin (Candida)


IVIG (?)
Granulocytes (for neutropenia?)
Granulocyte-Macrophage Colony-Stimulating Factor (?)
Neonatal Sepsis
Perinatal Risk Factors
Physical Appearance
Laboratory Tests
Usual Suspects
Treatment
Outcome
Outcome
High fatality
Outcome depends on organism
Morbidity from transplacental cytokines

Meningitis
50% mortality
Survivors will have morbidity
Neonatal Seizures
Relatively common
Varying presentations
Often is the first sign of neurological
problems
May be a powerful prognostic sign of long-term
cognitive and developmental impairment

Neonatal Seizures Etiology
If they are present look for an etiology
Familial history of neonatal seizures is good-
These usually resolve
Infectious process (TORCH infections)?
Was the neonate resuscitated- hypoxic?
Any stress during labor and delivery?
Potential electrolyte imbalances (hypoglycemia
too)?
Neonatal Seizures Etiology
Potential for intracranial bleed?
Most often preemies
Sepsis?
Meningitis?
Differential is HUGE!
Neonatal Seizures Workup
Guided to history
Drug screens
Chemistries including glucose
Cranial US or CT scan
EEG
Neonatal Seizures Treatment
Treatment is to underlying cause
Most seizures arent in need of anti-seizure
meds but Ativan or Versed may be used
Phenobarbital is drug of choice for recurrent
seizures
Hydrocephalus
Large amount of CSF that is not properly
taken back in or circulates
Cause is not well understood

Hydrocephalus S/S
Infancy: rapid increase
in head circumfrence
Older children:
headache
Vomiting / nausea
Papilledema
downward deviation of
the eyes- "sunsetting
Problems with balance
Poor coordination
Gait disturbance
Urinary incontinence
Slowing or loss of
development
Lethargy
Drowsiness
Irritability, or other
changes in personality
Changes in cognition
including memory loss.


Hydrocephalus Diagnosis
Serial head circumference measurements
Ultrasonography
CT
MRI
Pressure-monitoring techniques

Hydrocephalus Treatment
Typically a shunt is placed to drain CSF usually to
the abdominal cavity (peritoneal shunt)
Surgery may solve the problem if CSF circulation
is an issue and the blockage can be corrected
Long term is maintenance of shunt and watching
for CNS S/S indicating shunt is blocked
Cerebral Palsy (CP)
A persistent disorder of movement and
posture caused by nonprogressive
defects or lesions of the immature brain
Result from an underlying structural
abnormality of the brain

CP Causes
Vascular insufficiency during early
prenatal, perinatal, or postnatal stages
due to:
Toxins or infections
Pathophysiologic risks of prematurity
70-80% of cases of CP
In most cases, the exact cause is
unknown but is most likely multifactorial

CP Treatment
Usually mainstay is medications for muscle
spasticity
Multiple agents from muscle relaxants to anti-
Parkinsons agents
All cares for wheelchair or bedridden apply
Assess for and prevent contractures
Gastroschisis
Gastroschisis: defect in the abdominal
wall that allows the abdominal contents
to protrude outside the body
No peritoneum covering over the bowel
or other contents with destruction of
bowel possible by amniotic fluid
Located to the right of the umbilicus and
is completely separate from the umbilicus

Gastroschisis
The abnormality is usually very small,
exposed contents can range from the
stomach to the rectum
The stomach may be involved but not the
liver.

Gastroschisis Treatment
Complete repair with the first surgery if the
abnormality is small- 80% of cases
If too large the protrusion is covered with a
Silastic Silo, remainder of the abnormality is left
out, and is covered with silastic.
The Silastic silo is suspended allowing gravity and
daily manual compression of the abnormality to
aid the reduction process
Eventually the defect is closed

Gastroschisis
Silastic silo
Omphalocele
Similar to gastroschisis but bowel enclosed
by peritoneum protecting it from the
amniotic fluid
Less trouble with gut dysmotility or
delayed feeding.

Omphalocele
Tracheoesophageal Anomaly
Esophageal atresia may be present with or
without communication with the trachea
Essentially the esophagus is not complete, it
usually has an upper and lower pouch that
dont communicate
Tracheoesophageal Atresia Tx
Reduce the risk of aspiration
8 French sump tube placed for continuous
suctioning of the upper pouch
Elevate the infant's head
Maintenance IV fluids
O2 to maintain normal oxygen saturation
Surgery

Tracheoesophageal Anomaly
Diaphragmatic Hernia
Simply put, there is a defect in the hernia
allowing the abdominal contents to enter the
thoracic cavity
Presentation:
Respiratory distress (may contribute to alveolar
hypoxia and thus PPHN)
Scaphoid abdomen

Diaphragmatic Hernia
Diaphragmatic Hernia
Diaphragmatic Hernia Tx
Outcome is variable and generally depends
on the amount and maturity of the lung
tissue on the affected side
Ventilator therapy to maintain O2 Sats
Surgery to correct the anomaly

Hypocalcemia
Relatively frequently observed abnormality
seen especially in neonates
Laboratory hypocalcemia is often
asymptomatic, and its treatment in neonates
is controversial
Children with hypocalcemia are reported to
have a higher mortality rate in pediatric
intensive care unit (PICU) settings than
children with normal calcium levels.
Hypocalcemia
Most common is renal failure
Hypoalbuminemia
Increased phosphates (cows milk in an
infant)
Magnesium deficiency
Hypoparathyroidism
Malabsorption syndromes
Hypocalcemia S/S
Newborns
Possibly, no
symptoms
Lethargy
Poor feeding
Vomiting
Abdominal distension


Children
Seizures
Twitching
Cramping
Laryngospasm, a rare
initial manifestation
Hypocalcemia
Treat underlying cause
Administer Calcium
Hypokalemia
Acute causes:
Diabetic ketoacidosis
Severe GI losses from vomiting and diarrhea
Dialysis
Diuretic therapy
Large potassium shifts seen with:
Alkalosis
Insulin
Catecholamines & sympathomimetics
hypothermia

Hypokalemia S/S
Usually diagnosed after suspicion and lab
draw done
Cardiac dysrhythmias may be present and
could be fatal if not corrected in a timely
manner

Hypokalemia S/S
Potassium replacement
BE CAREFUL- if bigger doses, cardiac
monitoring is essential (>0.5mEq/kg/h)
Follow local protocols
Hypoglycemia
Hypoglycemia indicates that something else is
wrong
Certain conditions increase risk for neonatal
hypoglycemia:
Gestational diabetes
Pre-eclampsia
Small or large for gestational age
Fetal distress for any reason
Poor intake for whatever reason
Note: first time mothers with nursing

Hypoglycemia S/S
May be asymptomatic
Tremulous (often one
of the earliest signs)
Listlessness
Irritability
Hypothermia
Respiratory distress

Apnea
Weak or high-pitched
cry
Hypotonia
Poor feeding
Convulsions, tremors,
seizures or coma (late
signs)

Hypoglycemia Tx
Neonates and infants
D10 infusion
Regular feedings
Children
D25 may be used
If no altered LOC, 15 gms of oral carbs until glucose
normal
Consider glucagon for home treatment
Monitor frequently for several hours and ensure
adequate intake