1. Making Sense of Numbers in the NICU
Pediatrics Workshop
National SOMA Spring Convention
Washington, D.C.
March 10, 2012
Lisa Marie Piwoszkin, OMS IV
National SOMA VP & Speaker
CCOM

2. Objectives Introduce the basics of the newborn resuscitation period
Practice calculations for TPN orders
Learn how to manage basic ventilator settings
Huge 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 class
Everyone 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

5. Baby’s 1st Breath

6. WHERE does the Newborn Resuscitation take place?
Delivery Room
Operating Room

7. WHO is present during the Newborn Resuscitation?
OB crew
OB/Neonatal nurse(s)
Neonatologist/Pediatrician
Resident(s)
Medical Student(s)- YOU!
Nurses designated to baby
NRP= AAP + AHA

8. WHAT skills are involved in the Newborn Resuscitation?
Thermoregulation (37˚C)
Airway Management
Stimulation
Cardiovascular Support
Medications
Thermoregulation (37˚C)- warmer, blankets, plastic wrap
Airway Management- Goal- CRY, Suction, Oxygen, Positive Pressure Ventilation, Intubation
Stimulation- bulb suction, drying
Cardiovascular Support- compressions if less than 60bpm after 30 sec of PPV
Medications- epi, NS

9. HOW can YOU prepare? Wear gloves and mask Be aware of surroundings
Make sure the appropriate help is in the room
Make sure suction kit, intubation kits, and resuscitation medications are in the room and readily available
Make sure oxygen is flowing, bag valve mask working properly and at appropriate pressure
Make sure blankets are laid out and warmer is set to 37˚C
Make sure timer is reset on warmer

11. HOW can YOU participate?
“Catch the Baby!”
Start the timer…
CONSTANTLY ASSESS THE BABY
Bulb suction
Dry with blankets
Check for pulse
Listen to lungs
Watch the timer…
Quick exam
Put on the cap
Record APGAR scores
Secure side rails
Congratulate the parents!
Bulb- mouth then nose
Pulse 60 vs 100

12. APGAR Scores Assessment of newborn viability Pneumonic & Eponym
@ 1 min, 5 min, 10 min
Pneumonic & Eponym
Each letter represents a sign evaluated in the score
Developed by Virginia Apgar, MD, leader in anesthesiology

13. APGAR Scores

14. Case 1 Newborn male Full term NSVD Immediate loud cry
Coughs after bulb suction
Moves all four extremities
Face and trunk pink, hands and feet dusky
HR 120

15. Case 1
9/10
1 pt loss for color
Most NORMAL newborns only ever achieve 9/10

16. Case 2 27 5/7 weeks premature female Born to G1P1 26 y/o female
PPROM, NSVD
Newborn required vigorous resuscitation
APGARs: and 5 min
Birth weight:1 kg
Transported to NICU, currently stable, intubated, UVC placed

17. Case 2 Hungry babies are not happy babies!
← 2 arteries, 1 vein
How are we going to feed her?
Options: oral- no, MEF- maybe, TPN

18. Parenteral Nutrition Intravenous nutritional support
Can be started as soon as venous access obtained

19. Parenteral Nutrition TERMINOLOGY TPN- Total Parenteral Nutrition
ALL IV, patient NPO
PPN- Partial Parenteral Nutrition
SOME IV, patient supplementing with PO

20. WHAT is in TPN? Macronutrients „ Micronutrients
‰ Carbohydrate (dextrose)
‰ Protein (amino acids)
‰ Fat (fat emulsion)
„ Micronutrients
‰ Vitamins & Minerals
‰ Electrolytes
‰ Trace elements
„ Miscellaneous constituents
‰ Heparin protects line integrity
‰ Carnitine aids fat metabolism
‰ Famotidine protects stomach mucosa
Vitamins – 4 fat soluble and 9 water soluble vitamins
‰ Macrominerals – calcium, phosphorus and magnesium
‰ Electrolytes – sodium, potassium, chloride
‰ Trace elements – most commonly zinc, copper, chromium and manganese; less commonly selenium and iron; rarely molybdenum and iodine

21. HOW to order TPN?

22. Filling out the TPN Form…
Identifying information
Patient Sticker (be careful with multiples!)
Date
Day # TPN
Current GA (weeks days/7)

23. Filling out the TPN Form…
Daily Information
Dosing weight (kg) (A)
Line Access
Central- UVC, PICC, CVL
Peripheral- PIV
Heparin?
Labs
BMP every 1-2 days
LFTs and TG at least every week

24. Total Daily Fluid TPN Dextrose Amino Acids Electrolytes Vitamins
Trace Elements
FAT Emulsion
Fat
OTHER
Medications
Infusions
Oral Feeds

25. Calculations Total Fluid (TF) (B)
150ml/kg/day
Total Daily Fluid Intake (B) ml/kg/day x (A) kg = (C) ml/day
150 ml/kg/day x 1 kg = 150 ml/day
No Non-TPN Infusions or Enteral Rx (D)
Parenteral Feeding Allowance (C) ml - (D) ml = (E) ml
150 ml – 0 ml = 150 ml
TF- 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/kg
1 gm fat dispensed in 5 ml
Fat Emulsion #gm/kg x (A) kg = (F) gm x 5 ml/gm = (G) ml
1 gm/kg x 1 kg = 1gm x 5 ml/gm = 5 ml

27. X Total Daily Fluid Separate bag! TPN Dextrose Amino Acids
Electrolytes
Vitamins
Trace Elements
FAT Emulsion
Fat X
OTHER
Medications
Infusions
Oral Feeds

28. TPN Volume/24 hours (E) ml - (G) ml = (H) ml
Calculations
TPN Volume over 24 hours (H)
Parenteral feeding allowance – intralipid volume
TPN Volume/24 hours (E) ml - (G) ml = (H) ml
150 ml - 5 ml = 145 ml

29. Calculations Fat Infusion Rate TPN Infusion Rate (G) / 24 hours
5 ml / 24 hours = 0.2 ml/hr
TPN Infusion Rate
(H) / 24 hours
145 ml / 24 hours = 6 ml/hr

30. X Total Daily Fluid Separate bag! TPN Dextrose Amino Acids
Electrolytes
Vitamins
Trace Elements
FAT Emulsion
Fat X
OTHER
Medications
Infusions
Oral Feeds

31. 7 mg/kg/day = (I) % /100 x 145 ml /1.44 / 1 kg
Calculations
Dextrose Concentration (I)
Glucose Infusion Rate (R)
Initiate at 6-8 mg/kg/min
Increase by 1 mg/kg/day, max 13 mg/kg/min
(R) = (I) /100 x (H) /1.44 / (A)
Solve for (I)
7 mg/kg/day = (I) % /100 x 145 ml /1.44 / 1 kg
(I) = 7 %

32. Your New Best Friends!

33. Calculations Amino Acids (J) 3 gm/kg x (A) kg = (J) gm
Initiate at 3 gm/kg
3 gm/kg x (A) kg = (J) gm
3 gm/kg x 1 kg = 3 gm

34. Calculations Electrolytes Multivitamin Trace Elements
None included in TPN until DOL #3
Allow for stabilization
Adjust day to day
Multivitamin
Check Daily
Trace 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 Calories
Total Kcal/kg/day: (Q) + (P)

36. How will your TPN order change?
Keep track of days and age
Update weight daily
Know line access
Know oral volumes or infusions
Increase fats and dextrose
Adjust fats, dextrose, amino acids, electrolytes*, and additives as needed based on labs
Electrolytes… arbitrary
Chloride and acetone (back)
Cholestasis protocol

37. Case 3 29 0/7 weeks premature male
Meconium aspiration, absent cry, required intubation
Blood Gas:
pH 7.21
PaCO2 50
PaO2 56
HCO3 20
Base Deficit -4
What Acid-Base imbalance does he have?

38. Case 3
Respiratory acidosis
How can we help reduce his acidosis?

39. Affected by Ventilation or Oxygenation?pH
PaCO2
PaO2
HCO3
Base Deficit

40. Affected by Ventilation or Oxygenation?pH
PaCO2
PaO2
HCO3
Base Deficit
Ventilation
Oxygenation
Neither

41. Ventilator Settings Same indications as adults Modes
AC- Assist Control
SIMV- Synchronous Intermittent Mandatory Ventilation
PS- Pressure Support
CPAP- Continuous Positive Airway Pressure
BiPAP- Bilevel Positive Airway Pressure
Assist 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 breath
Ventilator will always 16, but pt can breath above vent- SIMV may be indicated or lower rate
Synchronized Intermittent Mandatory Ventilation (SIMV) – delivers a guaranteed minimum respiratory rate (12-14) at a set tidal volume
Patient may generate additional breaths
Ventilator will synchronize patient and machine generated breaths
Patient generated breaths – the delivered volume is only what the patient can generate – work of breathing is increased
Seeing 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 limi
CPAP – continuous positive airway pressure
Major use is in non-intubated patients
Pressure maintained above atmospheric pressure – eliminates patient work in generating negative airway pressure
Delivered through tightly fitted face masks with adjustable pressurized valves connected to a respirator
BiPAP – bi-level positive airway pressure
Has settings for both inspiratory positive pressure and expiratory positive pressure

42. Ventilator Settings
Rate
Tidal Volume
FiO2
PEEP

43. Remember… pH Ventilation PaCO2 Ventilation PaO2 Oxygenation
HCO3 Neither
Base Deficit Neither

44. Affects Ventilation or Oxygenation?
Rate
Tidal Volume
FiO2
PEEP
Tidal 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 oxygen
Positive 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?
Rate
Tidal Volume
FiO2
PEEP
Ventilation
Oxygenation

46. Ventilation Oxygenation Rate Tidal Volume To ↑ pH ↑ To ↓ pH ↓
To ↑ PaCO2
To ↓ PaCO2
Oxygenation
FiO2
PEEP
To ↑ PaO2 ↑
To ↓ PaO2 ↓

47. Just remember… What’s abnormal? What’s the problem?
What can you change?
pH or PaCO2
Ventilation
Rate or Tidal Volume
PaO2
Oxygenation
FiO2 or PEEP

48. Take Home Points

49. Be an active participant in the newborn resuscitation!

50. TPN looks hard, but doesn’t have to be.

51. Know why your blood gasses are abnormal, and fix them!

52. Feel smarter than a 5th grader… and some interns.

53. Have Fun on Peds & Share the wealth!

54. Referneces Emedicine: Neonatal Resuscitation
Neonatology: Newborn and Acid Base Balance.

55. Contact Information
Lisa Marie Piwoszkin
OMS IV, CCOM