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Neonatal Ventilation Made Easy
Neonatal Ventilation Made Easy
Made Easy
Neonatal Ventilation
Made Easy
Sujoy Chakravarty
Published by
Jitendar P Vij
Jaypee Brothers Medical Publishers (P) Ltd
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dedicated to
Soumil and
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Foreword
It is a pride and pleasure for me to introduce Dr Sujoy
Chakravarty, my ex-student for his outstanding and
challenging contribution in writing this book on neonatal
ventilation. This book is intended for postgraduate trainees,
junior doctors and medical personnel involved in level I, II,
and III care of children in neonatal resuscitation unit.
Respiratory distress and/or failure is the common cause
of pulmonary arrest in neonates which may be due to
hypoventilation, diffusion mismatch, intrapulmonary
shunting. All these disturbances may finally lead to
respiratory arrest calling for ventilatory support. The two
forms of ventilation practiced in NICU arepressure
controlled and volume controlled typesboth discussed
in this book. The author has also discussed some common
pulmonary and extra pulmonary conditions frequently
encountered in daily neonatal practice.
I again congratulate this young doctor for his sound
knowledge and expertise with a bold attempt in discussing
neonatal ventilation in a concise and yet such user friendly
form. I sincerely wish this book will be of true help to all
concerned and hope he will go a long way in Pediatric
Academy.
Prof (Dr) Manas Mukherjee
Ex-President Indian Academy of Pediatrics
Ex-Head of the Department of Pediatrics,
NRS Medical College, Kolkata
Preface
This book is an effort to share my minimal knowledge
and experience with all my colleagues involved in
neonatal care and in particular with all the junior doctors.
I had my share of running around from one ventilated
baby to another, of running blood gases, and of headscratching with the results. The dilemma to call or not to
call your senior! (Better ask for help in these cases!). A
baby collapses on a ventilator! Of course shout for help
but as a junior doctor I felt it is extremely stressful, if you
are not sure what exactly you are supposed to do
particularly when you are the first port of call. There is no
substitute for hands on experience, but I hope this book
will be your constant companion and aid particularly in
hours when you need urgent help. The book will also be
helpful for aspiring Neonatologists who will be working
in India and abroad. This is not a substitute for a proper
textbook, which should be consulted at the earliest
opportunity.
Sujoy Chakravarty
Acknowledgements
I would like to thank my parents, my family for their
constant inspiration and support. Also I would like to
thank all my teachers and colleagues in neonatal units
from whom I have learnt the ABC of Neonatology. My
special thanks to Dr Rashmi Gandhi without whose help
this book would not have seen the light of the day.
I would like to extend my sincere thanks to the
publishers, and in particular to Mr Sabyasachi Hazra and
Mr Sandip Gupta for their tireless work and tenacity in
getting this book published.
Contents
1. Newborn Life Support .............................................. 1
2. Formulas Commonly Used in NICU ..................... 5
3. Acid-Base Balance ...................................................... 7
4. Continuous Positive Airway Pressure (CPAP) .... 11
5. Positive Pressure Ventilation
Introduction and Terminologies ............................ 17
6. Different Modes of Positive Pressure
Ventilation ................................................................. 23
7. Ventilatory Adjustments According to
Blood Gas Changes .................................................. 27
8. Volume Controlled Ventilation .............................. 31
9. High Frequency Ventilation ................................... 35
10. Nitric Oxide ............................................................... 41
11. Extra Corporeal Membrane Oxygenation
(ECMO) ....................................................................... 45
12. Respiratory Distress Syndrome ............................. 49
13. Chronic Lung Disease .............................................. 53
14. Meconium Aspiration Syndrome .......................... 55
15. Transient Tachypnoea of Newborn ...................... 57
16. Collapse of a Baby on Ventilator ........................... 59
17. Necrotising Enterocolitis ......................................... 63
xiv
Chapter 1
Newborn Life
Support
The care of the newborn in the first few minutes after birth
is extremely crucial with regards to the subsequent flow
of events. The foetus was in a nice and warm atmosphere
inside the womb requiring no effort to breathe and not
having to worry about its nutrition as well. As soon as the
cord is severed the newborn baby has to find ways of
independent existence.
RESUSCITATION AT BIRTH
Preparation
It is always useful to reach for the delivery with a few minutes
to spare (absolute necessity for preterm labours). A brief
maternal history is to be taken and all equipments (the
overhead heater, the laryngoscope, the suction apparatus,
appropriate masks, proper size ET tube) to be checked.
Few dry towels should always be available.
Collecting the Baby
After the baby is born and cord is clamped the baby should
be collected in a dry and clean towel. In case of extreme
prematurity, babies are put in a plastic bag immediately
after birth to minimize further chances of heat loss.
In the Resuscitaire
1. Start the clock.
2. Dry the baby and transfer to a fresh and warm towel.
3. Keeping the baby covered feel or listen for the heart beat.
(Heart rate can be felt by palpating the umbilical cord)
Also assess the respiratory effort, colour and tone of the
baby.
4. If the heart rate is > 100 and regular, all the baby might
need is gentle stimulation and the doctors patience.
5. If the heart rate is slow (< 80), the baby will need
stimulation by inflation breaths with a mask. Before doing
that it is important to check for the patency of the airway.
Blind suction is strongly discouraged. Sometimes
simple airway opening manoeuvres, e.g. head tilt and
chin lift or jaw thrust might do the trick and the
condition of the baby might improve.
6. If these doesnt work and after airway is reassessed
5 inflation breaths are given and each breath should ideally
last for about 2 seconds. These breaths are given with
the aim to displace as much lung fluids as possible.
The inflation breaths should measure about 30 cm H2O
pressure. The important point to note here is the chest
movement with the inflation breaths. If the chest is not
moving then airway needs to be reassessed again. If the chest
rises with each breath, the baby is examined after the
5 breaths. If by this time the heart rate has improved
and the baby is making spontaneous efforts to breathe,
masterly inactivity is what might be needed at this
stage. If heart rate has improved but the breathing is
still not satisfactory, ventilation breaths might be
needed till the baby establishes regular and
spontaneous breathing. The ventilation breaths are of
much shorter duration compared to the inflation breaths.
7. If above methods have failed and the baby is still bradycardiac
with a very poor tone, the baby needs intubation for a definite
and a secure airway. If intubation is difficult (not possible
within 30 seconds, i.e. one attempt) revert to bag and mask
ventilation and ask for help. (According to Scandinavian
studies 1 in 500 babies only need intubation). Once
the ET tube is in place and secured continue ventilation
and reassess the heart rate. If the heart rate is still low
start cardiac compression ( 3:1 ) with one hand or two hand
technique. If there is no improvement in heart rate
Chapter 2
Formulas
Commonly Used in NICU
Chapter 3
Acid-Base
Balance
pH
pO2
pCO2
Bicarbonate
Base excess
:
:
:
:
:
7.35-7.45
10.6-14 kPa
4.7-6 kPa
23-33 mmol/L
+/- 2-3 mmol/L (Metabolic acidosis
is associated with a base excess below
5 mmol/L and metabolic alkalosis
with a base excess above +5 mmol/L
Lactic acid : < 1 mmol/L
Acid-base
abnormality
Primary
disturbance
Effect on
pH
Base
excess
Respiratory
acidosis
Increased
pCO2
Decreased
Negative Increased
HCO3
Metabolic
acidosis
Decreased
HCO3
Decreased
Negative Decreased
pCO2
Respiratory
alkalosis
Decreased
pCO2
Raised
Positive
Decreased
HCO 3
Metabolic
alkalosis
Increased
HCO3
Increased
Positive
Increased
pCO2
Compensatory
response
ACID-BASE BALANCE
10
Chapter 4
Continuous
Positive Airway Pressure
(CPAP)
12
DEFINITION
Continuous Positive Airway Pressure (CPAP) is a form of
non-invasive ventilation in which positive pressure is applied
to the airways both during inspiration and expiration.
BACKGROUND
In early 1970s the use of CPAP was described in premature
babies with respiratory distress. Due to reported incidence
of increased air leaks, gastric distension and also because
of the introduction of more advanced ventilation CPAP fell
out of favour in the 1980s and 1990s. But, because of its
non-invasive nature there has been renewal of interest in
this form of ventilation.
METHODS OF DELIVERING CPAP
1.
2.
3.
4.
DEVICES
1. Infant flow driver: It is a variable flow positive CPAP
device.
2. Bubble CPAP: In bubble CPAP a source of blended gas
is administered to the baby via a nasal prongs and the
distal end of the tube is immersed in fluid to a depth
of the desired level of PEEP.
MECHANISM OF ACTION OF CPAP
The main way CPAP acts is by generating PEEP (positive end
expiratory pressure), which is the pressure, needed to keep the
alveoli open at the end of expiration. Before the advent of
13
14
15
Chapter 5
Positive Pressure
VentilationIntroduction
and Terminologies
18
INTRODUCTION
Positive pressure ventilation is mainly of two types:
1. Volume controlled ventilatorsdelivers the same amount
of tidal volume irrespective of pressure.
2. Pressure controlled ventilatorsdelivers variable amount
of tidal volume depending upon the preset pressure.
Advantages of Pressure Controlled Ventilators
1. Simple design and lower cost.
2. Is simple to operate.
3. As the same pressure is delivered with each breath,
even with changes in lung compliance over-distension
of the lung is less likely.
VENTILATOR CONTROLS
Peak Inspiratory Pressure (PIP)
It is the main factor used to deliver tidal volume. In most
modern ventilators the physician can directly adjust PIP. It
can also be manipulated by changing the flow rate or the I/E
ratio. The initial levels of PIP are selected depending on
the infants weight, gestational age, lung compliance and
airway resistance. As a basic principle the lowest level of
PIP that adequately ventilates a neonate should be used. In most
instances PIP of 20-24 cm H2O is adequate to ventilate a
newborn.
Use of high pressures may be associated with side effects
like bronchopulmonary dysplasia and pulmonary air leaks. On
the other hand uses of low pressures run the risk of the
baby receiving insufficient ventilation (Table 5.1).
19
Adverse effects
1. Insufficient ventilation
2. Generalised atelectasis may
occur
20
21
22
Wave Forms
The two commonly used waveforms in neonatal ventilation
are sine and square.
The sine wave breathing resembles normal spontaneous respiration of infants. There is gradual increase
in inspiratory pressure, which may be helpful in many
neonatal lung diseases.
The square wave breathing improves oxygenation
when used with low rates and longer Ti. It provides a
higher MAP compared to sine wave breathing for identical
PIP. If longer Ti is used it can impede venous return to the
heart and cardiac output may decrease.
Flow Rate
Flow rate is an important determinant of the ability of the
ventilator to deliver expected levels of PIP to the baby.
Minimum flow of at least twice the babys minute
ventilation is usually required but in practise the operating
range can be much higher. (Normal neonatal minute
ventilation ranges from 0.2-1 L/minute).
Chapter 6
Different Modes of
Positive Pressure
Ventilation
24
25
Chapter 7
Ventilatory Adjustments
According to
Blood Gas Changes
28
1. To increase pO2:
a. Increase PIP
b. Increase PEEP
c. Increase I/E ratio
d. Increase flow.
2. To decrease pCO2:
a. Decrease PIP
b. Decrease PEEP
c. Increase rate
d. Decrease flow.
3. To increase pCO2:
a. Increase PIP
b. Decrease rate
c. Increase PEEP.
SCENARIOS
Always remember DOPE before any intervention
(Displaced tube, Obstructed tube, Pneumothorax,
Equipment failure).
1. Baby on ventilator with high pCO2, acceptable pO2
( FiO250%, RR40/m, IT0.35 sec, P22/4). Initial
likely ventilator adjustment to be made Increase rate.
2. Baby on ventilator with low pCO2, acceptable pCO2
(FiO2 80%, RR40/min, P22/4, IT0.35 sec). Initial
likely ventilator adjustment to be made Decrease rate/
Increase PIP.
3. Baby on ventilator with low pCO2, acceptable pO2
(FiO2 50%, RR40/m, P26/4, IT0.35 sec). Initial
likely ventilator adjustment to be made Decrease rate.
4. Baby on ventilator with high pCO2, acceptable pO2
(FiO2 50%, RR60/m, P26/4, IT0.35 sec). Initial
likely ventilator adjustment Decrease PIP.
29
Increase rate.
Increase FiO2/Increase pressure (PIP)think PPHN!
Decrease rate.
Decrease PIP.
Increase FiO2.
WEANING OF VENTILATION
It should be tried when the concentration of inspired
oxygen is 40 percent or less. The PIP is gradually reduced
along with the ventilator rate to allow the baby to breathe
on his/her own. When the rate is weaned to around 10/
minute or less the baby is extubated to CPAP with a PEEP
of 4-6 cm of H2O. The infant should not be stressed before
weaning and usually is kept nil by mouth for 6-8 hours.
A loading dose of caffeine citrate is also administered 12 to
24 hours prior to extubation.
Chapter 8
Volume Controlled
Ventilation
32
INTRODUCTION
The age old concept of pressure related trauma
(barotrauma) is gradually being replaced by the understanding that it is the over distention and stretching of the
lungs (volume-trauma), which is, more damaging to the
alveoli. The repeated stretching of the lungs cause a
shearing stress which might lead to air-leak syndromes.
Why is Tidal Volume Important?
The normal tidal volume in babies is5-8 ml/kg. Volumes
greater than 8 ml/kg will cause over distension.
Tidal volume less than total dead space (inadequate)
will produce insufficient exchange of alveolar gases.
Large tidal volume may produce alveolar over distention
and shear stress damage.
Lung over stretching and over distention are significant
in causing lung injury.
Extreme over distention may lead to impaired venous return
and subsequent cardiac compromise.
Volume Controlled Ventilation
The characteristic feature of this mode of ventilation is
that the ventilator delivers a specific volume of gas to the
baby irrespective of changes in pressure. In this the clinician
sets the tidal volume, frequency (therefore the minute volume)
and inspiratory and expiratory times are set by default. The
most significant advantage of this mode of ventilation is
that even in the face of rapidly changing lung compliance
the actual tidal volume delivered to the patient remains constant.
This is in contrast to pressure-limited ventilators where
pressures are preset but there is no guaranteed tidal
volume delivered. On the other hand because of the
endotracheal tube leaks and poor lung compliance measurement
33
34
Chapter 9
High Frequency
Ventilation
36
INTRODUCTION
This is a form of ventilation that uses small tidal volumes
with very rapid ventilator rates. Lunkenheimer first reported
this method of ventilating babies in the early 1970s. Since
then there has been lot of advancement in this regard and
currently is used extensively worldwide for ventilating
newborns.
The exact mechanism by which HFV works is still not
very clear, but facilitated diffusion is thought to be one of the
major mechanisms for gas exchange. Generally, if the tidal
volume is extremely low, particularly, if lower than the
anatomical dead space, chances of effective alveolar
ventilation is minimal. But, even with such low volume
there is still effective gas exchange in HFV mode of
ventilation.
TERMINOLOGIES USED
1. Mean Airway Pressure (MAP): This is the point about
which oscillation occurs and directly affects oxygenation
as with all other forms of ventilation. It opens up the
atelectatic areas of the lung and thereby minimizes
ventilation-perfusion mismatch and intrapulmonary
right-to-left shunting.
2. Amplitude: Also referred to as delta p. This influences
the CO2 elimination and indicates the size of the swings
(chest bounce) about the MAP. This is also one of the
determinants of the oscillatory volume.
3. Frequency: This is measured in Hertz (1 hertz = 60
breaths/minute) and influences both the oscillatory
volume and the amplitude. Generally frequencies of
around 10 Hz are used in newborns. As the frequency
decreases the volume and amplitude increase resulting
in a drop in pCO2.
37
38
39
Suggested management
High pO 2
Decrease FiO2
Decrease MAP gradually
Low pO2
Increase MAP
Increase FiO 2?
Apply sigh manoeuvre
High pCO 2
Decrease frequency
Increase amplitude
Increase MAP
40
Low pCO 2
Increase frequency
Decrease amplitude
Decrease MAP
Over inflation
Decrease MAP
Decrease frequency?
Discontinue HFV
Hypotension
Give colloid
Give dopamine/dobutamine
Reduce MAP
Chapter 10
Nitric Oxide
42
INTRODUCTION
In 1992, Science magazine named Nitric oxide as the
molecule of the year for its potential as a revolutionary
medical gas therapy. Nitric oxide is a highly diffusible,
colourless gas with a sharp and sweet odour. The NO
molecule is a free radical making it able to react with other
molecules.
Mechanism of Action of NO
NO is produced endogenously as the direct result of the
enzyme nitric oxide synthase which oxidises the nitrogen
atoms of L-arginine.
NO diffuses into the pulmonary vascular smooth
muscles and it activates the soluble form of guanylate
cyclase and thereby increasing the second messenger
cyclic guanosine monophosphate which results in
pulmonary vasodilation. NO is a very potent short acting
vasodilator with a half-life of 3-5 seconds. Once, it combines
with haemoglobin it is quickly inactivated. This results in
the formation of methaemoglobin, inorganic nitrate and
nitrite, which are then renally excreted.
Functions of NO
1. Pulmonary vasodilatation.
2. Kills bacteria and tumour cells in white cells.
3. Acts as a synaptic transmitter in the brain and the spinal
cord.
4. Releases adrenaline from the adrenal medulla.
5. Stimulates gut peristalsis.
6. Inhibits clotting.
Why NO?
NO has the unique ability to achieve potent and sustained
pulmonary vasodilation without decreasing the systemic vascular
NITRIC OXIDE
43
44
Duration of Treatment
In NOVO trial recommends that an increase of 3 kPa in
paO2 above baseline should be considered as an evidence
of a clinical response. If no response is seen within 15-30
minutes of using the highest dose then cessation of therapy
should be considered. In most studies the typical duration
of NO treatment has been less than 5 days. If required longer
than 5 days then investigations into other causes of pulmonary
hypertension should be considered.
WEANING
Continued weaning for inhaled NO should be tried daily
in infants in whom a clinical response is seen. When very
low levels of NO are reached (5 ppm) further reduction
in dose should be very gradual and may take several days.
PATIENT MONITORING
1. Methaemoglobin: It should be measured 8-12 hourly.
Levels above 4-5 per cent may be considered an
indication to reduce NO concentrations and levels
above 7-8 per cent may be an indication to stop NO
therapy. Methaemoglobinaemia is uncommon if lower
doses of NO are used (< 20 ppm).
2. Clotting profile (because of the effect of NO on platelet
function)
3. Environmental levels of NO and NO2 should be
monitored in the relevant clinical areas.
Side-effects of NO
1. Bleeding problems including intracranial haemorrhage.
2. Methaemoglobinaemia.
Chapter 11
Extra Corporeal
Membrane Oxygenation
(ECMO)
46
47
Contraindications
1. Weight < 2000 gm.
2. Gestational age < 35 weeks.
3. Severe pulmonary haemorrhage, gastrointestinal
haemorrhage or intraventricular haemorrhage (Gr II
and greater).
4. Lethal genetic condition.
5. Nontreatable congenital cardiac malformation or
disease.
ADVANTAGE OF ECMO
It helps to avoid the barotrauma of high inspired oxygen
concentration associated with ventilation and gives the
lungs the required time to heal by rendering them almost
non-functioning. All newborn babies receiving ECMO do
have a endotracheal tube in place with minimal mechanical ventilation.
The ECMO is generally successful in treating the
pulmonary hypertension along with the right to left
shunting in the above mentioned group of babies.
Monitoring a Baby on ECMO
The following parameters need vigilant monitoring:
1. FBC
2. Urea and electrolytes
3. Clotting
4. Liver function test
5. Blood culture
6. Endotracheal tube culture
7. Cranial ultrasound.
Side-effects
1. Increased chances if intracranial haemorrhage.
2. Auditory abnormalities
Chapter 12
Respiratory Distress
Syndrome
50
Prematurity
Males
Race-Black babies tend to suffer less from RDS
Maternal diabetes.
Clinical Features
1.
2.
3.
4.
5.
Chest recessions
Tachypnoea
Expiratory grunting
Bradycardia (severe RDS)
Hypotension.
Prevention of RDS
1. Prevention of prematurity (Neonatologists might be
made redundant though!).
2. Antenatal steroidseven a single dose of steroid 12
hours before delivery makes the prognosis better. Two
doses of antenatal steroids are usually given, but
multiple doses have been used though benefit of that
is not very clear.
3. Prophylactic surfactantThe use of surfactant within
the first few minutes of birth has been shown to
improve the oxygenation and also reduces morbidity.
51
INVESTIGATION
Chest radiography Fine diffuse granular shadowing of both
lung fields with air bronchogram (the classical finding).
Treatment
1.
2.
3.
4.
Ventilationif necessary
Fluid balance
Nutrition
Antibiotics (as it is hard to differentiate RDS from early
onset sepsis)
5. Surfactant therapy.
Complications
1.
2.
3.
4.
Air leaks
Intraventricular haemorrhage
Chronic lung disease
PDA ( the incidence of symptomatic PDA increases, if
there is fluid retention).
Chapter 13
Chronic Lung
Disease
54
DEFINITION
Oxygen dependency after 28 days of age with characteristic chest X-ray changes.
AETIOLOGY
1. Volutrauma.
2. Prematurity/surfactant deficiency.
3. Airleaks.
4. PDA.
5. O2 toxicity.
6. Chorioamnionitis.
MANAGEMENT
1. VentilatoryMaintaining steady tidal volume and
ventilating at lower pressure helps.
2. Oxygen therapy.
3. Prompt treatment of chest infections.
4. Blood transfusion.
5. Nutrition.
6. DrugsDiuretics, bronchodilators, corticosteroids.
7. Specialist team for home O2 therapy.
PROPHYLAXIS
1. Antenatal steroids.
2. Avoidance of aggressive respiratory support in initial
stages.
3. Vitamin E.
4. Strict fluid management.
Complications
1. Aspiration pneumonia.
2. Gastro-oesophageal reflux.
3. Right heart failure.
4. Cor pulmonale.
Chapter 14
Meconium Aspiration
Syndrome
56
Hypoxia
Acidosis
Raised pulmonary artery pressure
PPHN.
Treatment
1.
2.
3.
4.
5.
Oxygen
VentilationIPPV, ECMO
Pulmonary vasodilatorsNitrous oxide, Tolazoline
Antibiotics
Fluid balance and acid-base homeostasis.
Complications
1.
2.
3.
4.
Airleaks
PPHN
HIE
Renal failure.
Chapter 15
Transient Tachypnoea
of Newborn
58
Chapter 16
Collapse of a Baby
on Ventilator
60
61
Chapter 17
Necrotising
Enterocolitis
64
Chapter 18
Jaundice
66
JAUNDICE
67
Chapter 19
Neonatal Feeding
Difficulties
70
Chapter 20
Neonatal Vomiting
Common Causes
72
Sepsis (UTI)
Gastro-oesophageal reflux
Over feeding
Lack of burping after feeds.
Chapter 21
Anaemia in
Neonates
74
COMMON CAUSES
1.
2.
3.
4.
5.
Transplacental haemorrhage.
Haemolytic disease of newborn.
Maternal APH prior to delivery.
Anaemia of prematurity.
Repeated phlebotomy in neonatal units.
POLYCYTHAEMIA IN NEONATES
Common Causes
1.
2.
3.
4.
5.
Treatment
Treatment for symptomatic polycythaemia is dilutional
partial exchange transfusion with normal saline. The
formula used is:
Volume of exchange =
Blood volume (Observed Desired Haematocrit)
Observed Haematocrit
Chapter 22
Hypoxic Ischaemic
Encephalopathy (HIE)
76
Chapter 23
Intraventricular
Haemorrhage and
Periventricular
Leucomalacia
78
Chapter 24
Persistent Pulmonary
Hypertension of the
Newborn (Persistent
Foetal Circulation)
80
Perinatal asphyxia.
Neonatal sepsis.
Meconium aspiration syndrome.
Polycythaemia.
Diagnosis
There is universal hypoxia with no or minimal response
to 100 percent O2. Echocardiogram with Doppler studies
is usually diagnostic.
Differential Diagnosis
Congenital cyanotic heart disease.
Treatment
1.
2.
3.
4.
VentilationHFV
Tolazoline
Nitric oxide
ECMO.
Chapter 25
Sepsis in Neonates
82
Streptococcus (Group B)
E. coli
Listeria Monocytogenes
Staphylococcal epidermidis (in babies with central lines
in situ).
Manifestations
1.
2.
3.
4.
5.
Apnoea
Feed intolerance
Desaturating episodes
Not well
Worried nurse.
Investigations
1.
2.
3.
4.
SEPSIS IN NEONATES
83
Chapter 26
Tit-Bits
86
TIT-BITS
1. Three common differentials for an unwell neonate:
a. Sepsis
b. Cardiac
c. Metabolic.
2. Fluid therapy in neonates:
a. D-160 ml/kg/d
b. D-290 ml/kg/d
c. D-3120 ml/kg/d
d. D-4150 ml/kg/d
e. D-5180 ml/kg/d
Fluid therapy started a day ahead in IUGR babies.
3. The mechanism of Rh incompatibility and alloimmune
thrombocytopenia are identical (for details refer to
Robertons Textbook of Neonatology).
4. Baby collapses on D-3 or D-4Think duct dependent
heart problems.
5. Most common cause of organic heart murmur in
neonates:
a PDA
b. Pulmonary stenosis
c. VSD
6. Routine investigations for heart murmur:
a. Chest X-ray
b. ECG
c. Echocardiogram (gives the definitive answer
provided the expertise is present).
7. Weight along with length, OFC and mid-arm circumference is a better indicator of the childs nutritional
status than just weight alone.
8. Baby born to a mother with diabetesremember to
start feeds early to prevent hypoglycaemia. Also
remember hypocalcaemia and cardiomyopathy.
TIT-BITS
87
Chapter 27
Neonatal Formulary
(Commonly Used
Medications)
90
Index
A
Acid-base balance 7
Anaemia in neonates 73
F
Formulas commonly used in
NICU 5
B
Blood gas analysis 9
arterial blood gas
measurement 9
capillary blood gas analysis 9
continuous blood gas
analysis 9
transcutaneous
monitoring of pCO2 10
venous blood gas analysis 9
G
General guidelines for CPAP 14
increasing oxygen
requirement 14
initial PEEP 14
respiratory distress in
newborn baby 14
C
Chronic lung disease 53
aetiology 54
complications 54
management 54
prophylaxis 54
Collapse of a baby on ventilator 59
Continuous positive airway
pressure (CPAP) 11
contraindication 14
indications 13
mechanism of action 12
methods of delivering 12
E
Extracorporeal membrane
oxygenation (ECMO) 45
advantage 47
contraindications 47
indications 46
procedure 46
side effects 47
H
High frequency ventilators 37
advantages 39
complications 39
indication 38
types 37
Hypoxic ischaemic
encephalopathy (HIE) 75
treatment 76
I
Intraventricular
haemorrhage and
periventricular
leucomalacia 77
diagnosis 78
treatment 78
J
Jaundice 65
breast milk jaundice 66
physiologic jaundice 66
treatment 66
L
Limitation of MAP 21
flow rate 22
waveforms 22
92
Management strategies of
babies on HFV 39
Meconium aspiration
syndrome 55
complications 56
effect on the baby 56
prophylaxis 56
treatment 56
N
Nasal ventilation 15
Necrotising enterocolitis 63
clinical findings 64
diagnosis 64
pathogenesis 64
predisposing factors 64
treatment 64
Neonatal feeding 69
Neonatal vomiting 72
Nitric oxide 41
functions 42
indications 43
mechanism 42
patient monitoring 44
side effects 44
treatment strategies 43
Normal arterial blood gas
values 8
P
Persistent pulmonary
hypertention of the
newborn 79
diagnosis 80
differential diagnosis 80
treatment 80
Polycythaemia in neonates 74
common causes 74
treatment 74