Interpretation of Vital Signs and Labs Values in the NICU.pptx

Interpret normal range of vital signs of neonates in the NICU

1. Interpreting the NICU NICU Bootcamp

2. Our objectives for this NICU Boot Camp session are as follows: Interpret and manage basic vital signs for NICU patients Interpret and manage laboratory values commonly encountered in the NICU Interpret and manage common x-ray findings encountered in the NICU

3. Vital signs

4. Temperature Temperature Normal axillary temperature range: 36.5 - 37°C (97.9 - 98.3°F) Hypo/hyperthermia: environmental factors prematurity sepsis

5. Infant has a HR (heart rate) 190. What are some possible causes?

6. Heart Rate (HR) Normal range 80-160 bpm (beats per minute) Lower when asleep & higher when agitated/crying Gestational Age Bradycardia (HR <80 term infant or <100 preterm infant) = abnormal Vagal response Sepsis, hypothermia, acidosis Respiratory depression/apnea Persistent tachycardia (HR >180) = abnormal Anemia, hypoxemia, sepsis, shock Hyperthermia, pain, agitation, medications (caffeine) Arrhythmia

7. Respiratory rate (RR) Normal range 30-60 breaths/min Apnea = absence of breathing for >20seconds (s) or a shorter pause (>10s) associated with oxygen desaturation or bradycardia (<100bpm) Prematurity CNS injury Sepsis Metabolic abnormalities Anemia Tachypnea = RR >60 breaths/min Pulmonary, cardiovascular, metabolic disease May be unsafe to orally feed infant with tachypnea

8. A one week old former 28 week gestational age infant has blood pressure of 30/15 with mean arterial pressure (MAP) 25. Is this abnormal?

9. Blood Pressure Neonatal blood pressure is affected by gestational age, birth weight, and day of life General rule to determine hypotension  compare the mean arterial pressure (MAP) and the gestational/postconceptional age of the infant. If an infant is 23 weeks and just born then accept a MAP as low as 23 If an infant was born at 23 weeks but is now 4 weeks old, accept a MAP as low as 27 Also look at clinical signs of the infant indicative of perfusion Cap refill Urine output

10. Blood Pressure Hypertension First ensure that Appropriate size cuff is used Infant is quiet Right upper extremity is used Above the 95% confidence interval is considered hypertension Reference curves available in the Harriet Lane Handbook In general, systolic blood pressures above 100 warrant a closer look

11. Pulse Oximetry Measures the relative absorption of light by saturated and unsaturated hemoglobin Premature infants with lung disease – 88-93% Term infants – >90% Too low sats  hypoxia  end organ damage Too high sats  oxygen toxicity  Retinopathy of prematurity (ROP) or Bronchopulmonary Dysplasia (BPD) Infants with congenital heart disease may have different oxygen saturation goals depending on their specific lesion

12. Lab values

13. Infant has a routine CBC with differential of 26 neutrophils and 17 bands. What is the next step?

14. CBC WBC Low <5 High >20-30 Both concerning for infection Differential I:T ratio Immature cells (bands, myelocytes & metas )/( Immature+neutrophils ) Example 26 neutrophils and 17 bands 17/(17+26) = 0.4 >0.2 is concerning for infection

15. CBC Hemoglobin/Hematocrit ( Hct ) Acceptable values depend on the patient’s clinical status In general . . . A premature infant on the ventilator = Hct >35 A premature infant feeding and growing = Hct mid to low 20s with a retic >5% Transfusion is necessary when anemia becomes symptomatic Apneas/bradycardias, tachypnea, tachycardia, poor feeding, poor weight gain An infant with a high oxygen requirement = Hct >40 An infant with congenital heart disease = cardiology dependent Usually 35-45 Always ask a fellow or attending prior to transfusing and discuss prior to rounds if possible

16. Electrolytes Checked often in neonates in the first few days of life and those on TPN All electrolytes are adjusted in TPN daily and can be given as supplements in patients who are feeding Sodium (Na) 134-144 Marker of fluid status Decreased by diuretics Potassium (K) 4-6.3 Elevated in hemolyzed specimen Elevated in renal failure Decreased by diuretics Chloride (Cl) 98-107 Usually follows Na

17. Electrolytes CO2/bicarbonate 18-30 Reviewed in blood gas section Glucose 50-150 Affected by level of illness, presence of diabetes in mother Can be erratic in premature infants Adjusted by dextrose concentration and rate of fluids Blood Urea Nitrogen (BUN) 7-21 Marker of hydration, protein intake Creatinine (Cr) 0.1-1.4 Marker of kidney function

18. Electrolytes Calcium 8.5-10.4 Important for bone growth and cellular function Affected by albumin levels Phosphorus 4-9.5 Important for bone growth and cellular function Magnesium 1.7-2.2 Important for bone growth and cellular function

19. An infant is on Vancomycin for a staphylococcus epidermidis line infection. You are called with a trough of 5. What is the next step?

20. Peaks and Troughs Vancomycin Check trough levels Usually prior to 3 rd or 4 th dose If level is not within goal range and dose is changed, another trough should be checked after receiving 3 doses following the change Wait for level before administering Ideal level 10-15 mcg/mL in sepsis 15-20 mcg/mL in CNS infections Complications Kidney and hearing toxicity

21. Peaks and Troughs Gentamicin Check peak level Usually with 2 nd or 3 rd dose 30 mins after the end of infusion 5-12 mcg/mL Check trough level Usually prior to 3 rd dose 0.5-1 mcg/mL Check prior to administering and recheck following a change Complications Hearing or kidney toxicity

22. Peaks and troughs What does it mean? To adjust trough of medication Shorten or lengthen the interval To adjust peak of medication Increase or decrease the dose

23. Xrays

24. Xrays Image retrieved 23 April 2017 from https://openclipart.org/detail/11700/respiratory-system-2 Creative Commons Liscense : https://creativecommons.org/publicdomain/zero/1.0/ ETT Too Low ETT Too High ETT in ideal position below clavicle and above carina

25. http://emedicine.medscape.com/article/1348931-overview Gastric Tube in stomach UVC in place above diaphragm UAC in place @ T5 Placement of umbilical lines

26. PICC Line Introducer PICC Line with dressing Lower extremity PICC in good position Upper Extremity PICC in good position

27. Weighted tube not transpyloric Weighted tube transpyloric and past midline

28. CXR showing atelectasis in left upper lobe Tools used to provide chest percussive therapy

29. From Atlas of Procedures in Neonatology Large pneumothorax on the right Transillumination of the chest Needle decompression Image of chest tube Resolution of pneumothorax with chest tube in place

30. References Flerlage, Jamie, and Branden Engorn . The Harriet Lane Handbook a Manual for Pediatric House Officers . Saunders / Elsevier, 2015. Gomella, Tricia Lacy, et al. Neonatology: Management, Procedures, on-Call Problems, Diseases, and Drugs . McGraw-Hill Education Medical, 2013. MacDonald, Mhairi G., et al.  Atlas of Procedures in Neonatology . Wolters Kluwer/Lippincott Williams & Wilkins Health, 2013. Micromedex ® NeoFax ® Copyright 2017 Truven Health Analytics LLC. Polin , R. A. “Management of Neonates With Suspected or Proven Early-Onset Bacterial Sepsis.” Pediatrics , vol. 129, no. 5, 2012, pp. 1006–1015., doi:10.1542/peds.2012-0541.