Medstar Retrievals
How to organise a retrieval:
Call Medstar on 13 7827 (13-STAR)
Select Option 1
The Nurse Retrieval Coordinator will answer and will take the basic details (like your name, location, patient name, DOB, weight)
The NRC will then connect you to the Retrieval Consultant Neonatologist
The Consultant will want to know the more detailed clinical picture and will then give clinical advice and will plan the Medstar kids retrieval team
ROP Examinations
Screening criteria:
GA at birth < 31 weeks OR
Birth weight < 1500g OR
Otherwise requested by neonatologist
Timing:
First examination at six weeks
Follow up as determined by ophthalmologist
Process:
Eye exams are performed by Dr Swati Sinkar
Examinations on alternate Mondays
Cranial Ultrasound Screening
Criteria for screening for IVH:
GA at birth less than 30 weeks OR
Birth weight less than 1250 grams
Timing of screening
First head ultrasound Day 7 - 10
Follow up scans as indicated
Post-discharge follow-up
Medical (NNR) follow up
Criteria for routine NNR Clinic:
GA at birth less than 32 weeks OR
Birth weight less than 1500 grams
Note that there are many infants outside these criteria who will also be followed up in NNR clinic.
Timing of first review
Generally 8 - 10 weeks post-discharge
Confirm timing with Consultant
Multi-Disciplinary follow up
Criteria for multi-disciplinary Clinic:
GA at birth less than 32 weeks OR
Birth weight less than 1500 grams
HIE Grade 2 or 3
Identified syndromes associated with dev. delay
Schedule of multi-D review
Physiotherapy at 3, 6, 9, 12, and 18 months CGA
Occupational therapy at 12 months CGA
Speech therapy at 18 months CGA
Referral to multi-D clinic
Physiotherapy regularly check our inpatient lists for relevant patients
And will try to see eligible newborn as an inpatient in SCN
Then will arrange MDT follow up
We can also directly refer to MDT via the MR037 (Internal Referral Form for Outpatients)
Blood Tests
Routine Bloods for Convalescent ELBW (birth weight under 1000g)
As a minimum:
FBC, ALP, Ca, PO4 and capillary gas every 4 weeks
Investigation of Hypoglycemia
Use the "Critical Bloods" kit (found in the SCN)
Kit includes detailed list of tests required, and blood volume required
And includes the blood sample tubes you'll need
O2 Therapy & Saturation Targets
Default Saturation Limits for neonate in supplemental oxygen
Newborn <37 weeks corrected GA: High Alarm 96%, Low Alarm 89%
Newborn ≥37 weeks corrected GA: High Alarm 98%, Low Alarm 91%
Newborn in room air: limits per gestation as above but set high alarm to 100%
Why avoid saturations in the high 90's?
When infant is receiving supplemental oxygen, saturations in the high 90s may be associated with hyperoxia
Hyperoxia is a major cause of ROP in preterm infants
Hyperoxia is injurious to the brain (following asphyxia)
Note that infants in room air are not at risk of hyperoxia so sat. upper alarm limits should be set to 100%
Commencing CPAP
Benefits of CPAP:
CPAP recruits alveoli, and reduces work of breathing
CPAP reduces the need for up-transfer compared to incubator oxygen
Threshold for CPAP in newborn with respiratory distress:
FiO2 over 25%
Any supplemental oxygen requirement in newborn under 36 weeks
Any supplemental oxygen requirement in newborn with more than mild indrawing
Indications for Surfactant
Infant less than 32 weeks:
If intubation required, give surfactant
If on CPAP with FiO2 > 30% despite at least 6 cm CPAP to maintain sats 90 - 95% then give surfactant
Dose is 200 mg/kg
Infant ≥ 32 weeks GA:
FiO2 over 30% despite CPAP 6cm
to maintain sats 90 - 95%
give surfactant
Dose is 200 mg/kg
Glidescope Video-laryngoscope
Where is it stored?
Drug room bench on charging dock
Blades (size 0 & 1) in bottom right corner cupboard
Operation:
Simple on/off button
Blades are single use only
Touch screen icons to record video or still image
Further info:
See attached document for information on recording intubations for review
And guidance on optimal use for best results
Intubation Checklist
Extreme Prem Birth Checklist
Unplanned extreme preterm delivery at LMH:
Mechanical Ventilation
Anticipation
Ventilation (beyond just a few minutes) is infrequently required at LMH SCN.
Typical scenarios include extreme preterm infant with RDS, severe meconium aspiration, significant encephalopathy, or severe sepsis.
We keep one of the Drager VN-500 ventilators in "stand-by" ready to use
Ensure the humidifier has been turned on and has water added before ventilating
Heating and humidifying the ventilator gases is essential for health of ventilated lungs
Default Mode: PC-AC
The VN-500 is set on PC-AC mode
PC means the ventilator delivers set pressures
AC means the ventilator allows the infant to trigger additional ventilator breaths
Default Settings
PIP (peak inspiratory pressure) is set at 20 cm H2O
PEEP is set at 5 cm H2O
Rate is 50/min
Ti (inspiratory time) is set at 0.33 seconds
VT: the measured tidal volume
The VN-500 measures the VT - the volume of each breath
This is a very useful real-time insight into adequacy of ventilation
Generally we want VT of 5 mL /kg
Adjust PIP as required to keep VT near this value
How and why to adjust default settings
PIP should be increased or decreased to achieve appropriate VT (based on infant weight)
It's not unusual to need PIP of up to 30 cm in conditions of low lung compliance. Pressures above 35 cm are seldom required.
Remember that the set rate is only a back up rate - if the infant is triggering more breaths then altering the back up rate may have little effect
If saturations are poor despite high FiO2 and sensible VT, consider longer Ti (eg 0.4 seconds) or increased PEEP (to 5.5 or 6)
Monitoring Ventilation & Oxygenation
VT provides real-time insight into ventilation
Capillary (or venous) gases give information about adequacy of ventilation though measured CO2 will somewhat exceed true arterial CO2
Low CO2 may be appropriate compensation in cases with significant metabolic acidosis
Pre-ductal oxygen saturations should be maintained in mid-90s to prevent hypoxia and hyperoxia (noting that hyperoxia is a real risk for both very preterm infants and infants at risk of encephalopathy)
Immunisations
SA Schedule
Immunisations in Nursery
Prescribing Practicalities:
Doctor / NP obtain written consent from parent
Doctor / NP writes prescription in the morning
Pharmacy ring when ready
Midwife collects from pharmacy
Pending administration vaccine stored in vaccine fridge in labour ward (because no suitable fridge in SCN)
Immunisations generally administered around 5 AM - 6 AM
Monitoring after immunisation:
Preterm infants have an increased risk of cardio-respiratory instability after immunisation
Cardio-respiratory monitoring should be performed for the first 48 hours post immunisation
SCN Immunisation Dosing:
Hep B Vaccine after birth
Engerix B Paediatric OR H-B-Vax II Paediatric |
IM |
0.5 mL |
Within 7 days of birth (ideally within 24 hours) |
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No catch-up required |
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6 week and 4 month immunisations
Infanrix Hexa |
IM |
0.5 mL |
hepB-DTPa-HiB-IPV |
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Prevenar 13 |
IM |
0.5 mL |
Pneumococcal conjugate (13vPCV) |
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Rotarix |
oral |
1.5 mL |
Rotavirus |
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Bexsero |
IM (Left leg) |
0.5 mL |
Meningococcal B |
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Prescribe paracetamol also: first dose 30 minutes prior to immunisation, followed by two more doses (see paracetamol guideline for dose and interval details). Note that dosing interval of 6 hours is not appropriate for younger gestations |
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Bexsero is to be administered to LEFT anterolateral thigh |
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Immunisation Handbook
Medications
SA Neonatal Drug Guidelines
Caffeine
Dosing
All doses must be prescribed as caffeine citrate
1 mg caffeine = 2 mg caffeine citrate
Loading Dose
Standard |
20 mg/kg |
Maximum |
80 mg/kg |
Maintenance
5 - 10 mg/kg/dose every 24 hours, commencing 24 hours after the loading dose |
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Maintenance doses of up to 20 mg/kg have been used |
Course & Discontinuation
Discontinue at 34 weeks (unless significant apnoea continues) |
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Monitor infant for 5 days after ceasing caffeine |
Infloran (Probiotic)
Dosing: One capsule (reconstituted in 2 mL milk) po daily
Indications:
Gestation at birth < 32 weeks |
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OR birth weight < 1500 grams |
Course:
Continue until 34 weeks of corrected age
Ferrous sulphate = Ferroliquid
Dosing
Prevention of iron deficiency
≤ 1.5 kg |
3 mg/day elemental iron (0.5 mL/day Ferro-liquid) |
1.5 - 3 kg |
6 mg/day elemental iron (1 mL/day Ferro-liquid) |
> 3 kg |
9 mg/day elemental iron (1.5 mL/day Ferro-liquid) |
Ferro-liquid contains 30mg elemental iron per 5ml |
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Chart as ml of Ferro-Liquid |
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Treatment of Iron Deficiency
2 - 6 mg/kg/day elemental iron (0.3 - 1 ml/kg/day Ferro-liquid) |
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If on preterm formula / fortified EBM consider 3 mg/kg/day elemental iron (0.5 ml/kg/day Ferro-liquid) |
Indications & Course
Prophylactic iron indicated if birth weight < 2000 grams OR GA at birth < 34 weeks |
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Commence at 4 weeks once tolerating full enteral feeds |
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Not needed if on fortified EBM or preterm formula UNLESS iron deficiency / significant anemia |
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Breast fed: Continue to 6 months CGA |
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Formula fed: Continue to 3 months CGA |
Paracetamol
Dosing
Analgesic / antipyretic
250 mg in 5 mL oral liquid
Loading Dose
20 mg/kg
Followed by maintenance at next dosing interval
Maintenance
28 - 32 weeks CGA |
15 mg/kg |
12-hourly |
33 - 36 weeks CGA |
15 mg/kg |
8-hourly |
≥37 weeks CGA |
15 mg/kg |
6-hourly |
Colecalciferol (Ostelin)
Dosing: 0.2 mL = 400 iu po daily
Indications:
Birth weight < 2000 grams OR GA at birth < 34 weeks |
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Mother with known Vitamin D deficiency |
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Mother at risk: dark skin, veiled, house bound, recent refugee arrival |
Ostelin Preparation: 1000u per 0.5 mL
Course:
6 months (or continue for 12 months if maternal risk factors)
Maternal 3rd trimester Vit D Deficiency:
If maternal vitamin D deficiency (< 30 mmol/L) was noted in third trimester (and hence untreated or partially treated) consider Ostelin 0.4 mL daily for the first 3 months, followed by 0.2 mL daily until 12 months
Typical dose: 0.2 mL = 400 units daily
Aptamil Feed Thickener
Dosing: 1/4 scoop (2 g) per 100 mL of milk
Indications: GOR affecting nutrition or cardio-respiratory stability
Caution: Avoid use before 34 weeks CGA
Nutritional Value:
Note that this feed thickener is predominantly maltodextrin which is a fully digestible carbohydrate with 4 kcal per gram
Thus our typical dosage increases caloric value of milk by about 10%
Fluids
Enteral Feeding
If prescribing enteral feeds on Day 1, generally 40 mL/kg/day is sufficient to meet minimal water and energy requirements.
This reduces the risk of feed intolerance and vomiting that might occur with higher rates.
IV Fluids
Day 1 generally 60 mL/kg/day using Glucose 10% without additives
Restrict to 40 mL/kg/day in HIE
For infants with documented hypoglycemia AND at risk of hyperinsulinism, start iv fluids at 90 mL/kg/day Glucose 10% and titrate up or down with blood sugars.
Consider central access (UVC) and use of more concentrated glucose solutions. Discuss with consultant.
Advancing fluids
Usually advance by 20 - 30 mL/kg/day
Serial weight, clinical examination, and serum Na+ results will guide decision-making.
From 48 hours change iv fluids to premix Glucose 10% with KCl 10 mmol/500 mL and NaCl 0.225%.
Note this solution contains 19 mmol NaCl per 500 mL
Early Onset Sepsis
Gestation under 34 weeks:
Gestation 34 weeks and above:
Use the original version of Neonatal Early Onset Sepsis Calculator for infants 34 weeks and above and no more than 12 hours of age.
If using calculator select baseline EOS Incidence of 0.8 per 1000 live births as this reflects the most current Australian data
We don't have data on the EOS rate specifically for infants 34 weeks and up: the figure will be somewhat lower than the all-live-births figure quoted above, since EOS (particularly due to gram negative organisms) is much more common in extreme prematurity.
Blood Culture Technique
Take a minimum of 0.5 mL. Any lower volumes risk a false negative blood culture
Stopping Antibiotics
Blood cultures in EOS will report positive in 80 to 100% of cases within 24 hours of the culture bottle going into the incubator
If the culture is negative 24 to 36 hours after reaching the incubator and the clinical scenario is not otherwise concerning for sepsis we generally cease antibiotics.
Red Cell Transfusion
Emergency Transfusion Process
When red cells are required acutely to treat acute severe hypovolaemia due to blood loss:
- Call the Critical Bleeding Hotline extn 29705:
- State "Critical Bleeding Newborn"
- Provide baby OR mother's identifying data
- Request one unit of un-crossmatched O-Neg Blood
- AND call 33# and state "Critical Bleeding" and state the location (eg Special Care Nursery)
Blood bank will then deliver the requested product urgently to the stated location without the prior need for a transfusion request form
Which red cell product?
Blood Product |
Required |
Recommended |
Uncrossmatched O Neg |
Emergency |
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Leucocyte depleted |
All red cell transfusions |
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Irradiated |
History of in utero transfusion |
Birth weight < 900g or GA at birth < 28 weeks |
CMV Negative |
Immuno - compromised |
Any Preterm |
Transfusion Thresholds
Guidelines for non-acute transfusion in ex-prems:
The table gives the applicable Hb threshold below which transfusion is generally recommended
Usual volume: 15 - 20 mL/kg over three to four hours. Frusemide is seldom required.
Sample |
CPAP > 30% O2 |
Lesser resp support |
Capillary |
100 |
85 |
Art. or venous |
90 |
75 |
| For pre-discharge infants, reduce these thresholds by 5 g if retics ≥ 5%. Reduce by a further 5 g if infant is completely asymptomatic |
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