ACoRN Workbook 2012 Update

Size: px

Start display at page:

Download "ACoRN Workbook 2012 Update"

Dustin Montgomery
5 years ago
Views:

ACoRN Neonatal Society Société néonatale ACoRN www.acornprogram.

1 ACoRN Neonatal Society Société néonatale ACoRN A Canadian non-profit Society Vancouver, British Columbia ACoRN Workbook 2012 Update Name:

3 The ACoRN Process

The Resuscitation Sequence Ineffective breathing Heart rate < 100 bpm Central cyanosis No ACoRN Primary Survey Yes Call for help Access equipment Provide warmth Position Clear airway (^) Stimulate

ventilation (^) HR > 100 bpm HR < 60 bpm Initiate chest compressions (^) with 100% O 2 HR < 60 bpm Administer epinephrine (^) HR > 60 bpm Consider intubation at any point indicated by a caret (^) HR

5 The Resuscitation Sequence Ineffective breathing Heart rate < 100 bpm Central cyanosis No ACoRN Primary Survey Yes Call for help Access equipment Provide warmth Position Clear airway (^) Stimulate Administer O 2 as needed Establish monitors: - pulse oximetry (pre-ductal) - cardiorespiratory - blood pressure Ineffective breathing HR < 100 bpm No Yes Initiate/continue positive pressure ventilation (^) HR > 100 bpm HR < 60 bpm Initiate chest compressions (^) with 100% O 2 HR < 60 bpm Administer epinephrine (^) HR > 60 bpm Consider intubation at any point indicated by a caret (^) HR < 60 bpm Ensure 100% O 2, positive pressure ventilation, chest compressions, and epinephrine correctly administered (^) Repeat epinephrine Ensure vascular access Consider volume expansion Draw venous blood gas HR < 60 bpm Consider pneumothorax Transillumination Consider needle aspiration

6 The Respiratory Sequence Respiratory Laboured respiration * Respiratory rate > 60/min * Receiving respiratory support * Yes Respiratory Sequence No Problem List Recheck patent airway/breathing Administer O 2 as needed to maintain SpO % Establish/continue monitors: - pulse oximetry (pre-ductal) - cardiorespiratory - blood pressure - oxygen analyzer Calculate ACoRN Respiratory Score if spontaneously breathing Mild respiratory distress (ACoRN score < 5) lasting < 4 hours Moderate respiratory distress (score 5 to 8) Persistent or new respiratory distress Severe respiratory distress (score > 8) Apnea or gasping Receiving ventilation Consider/adjust respiratory support (CPAP or PPV) Intubate if not already intubated Optimize ventilation Focused history Physical examination Review diagnostic tests done Establish working diagnosis Vascular access Chest radiograph Blood gas Consider consultation TTN Mild respiratory distress RDS Aspiration Pneumonia Pneumothorax (1) PPHN Other Reassess diagnosis and management if unresolved within 4 hours Consider surfactant Supportive care Consider chest drain and followup chest radiograph Repeat ACoRN Respiratory Score if spontaneously breathing Optimize oxygenation Optimize respiratory support (adjust ventilator/cpap settings, wean, or discontinue) (1) drainage of a symptomatic pneumothorax takes precedence over returning to the Problem List

7 The Respiratory Score (p. 3-7): Score Respiratory rate Oxygen requirement 1 Retractions Grunting Breath sounds on auscultation Prematurity 40 to 60/min 60 to 80/min > 80/min none 50% > 50% none mild to moderate severe none with stimulation continuous at rest easily heard throughout decreased barely heard > 34 weeks 30 to 34 weeks < 30 weeks 1 A baby receiving oxygen prior to the setup of an oxygen analyzer should be assigned a score of 1 Adapted from Downes JJ, Vidyasagar D, Boggs TR Jr, Morrow GM 3 rd. Respiratory distress syndrome of newborn infants. I. New clinical scoring system (RDS score) with acid-base and blood-gas correlations. Clin Pediatr 1970; 9(6): Total score: Mild: < 5; Moderate: 5 to 8; Severe: > 8 Interpretation of blood gas results (p. D-4): ph P CO2 BD Interpretation Normal Respiratory acidosis Normal Metabolic acidosis Normal Respiratory alkalosis Normal Metabolic alkalosis 1. Normal, acidosis or alkalosis? 2. Respiratory, metabolic, mixed or compensated? Blood gas values (p. D-4): Normal ph 7.35 to to 7.40 PCO 2 35 to 45 mmhg 45 to 55 mmhg BD - 4 to + 4 mmol/l Acceptable values for acute respiratory distress

8 The Cardiovascular Sequence

9 Signs of circulatory stability / instability (p. 4-8): Sign Stable Unstable Level of alertness, activity and tone Skin colour, and temperature Capillary refill time Pulses Mean blood pressure Heart rate Urine output alert, active and looking well, normal tone well perfused, peripherally warm 3 seconds centrally and peripherally easy to palpate gestational age in weeks listless, lethargic and/or distressed, decreased tone pale, mottled, peripherally cool > 3 seconds weak, absent 100 to 160 bpm > 160 bpm 1 ml/kg/hour < gestational age in weeks < 1 ml/kg/hour Tolerance to various degrees of desaturation in newborns with cyanotic heart disease, assuming normal hemoglobin levels and cardiac output (p. 4-35): SpO 2 Degree of desaturation Stable Circulatory instability or anemia > 75% mild to moderate usually well tolerated usually tolerated 65 to 75% marked usually tolerated not well tolerated < 65% severe poorly tolerated poorly tolerated

10 The Neurology Sequence

11 Therapeutic Hypothermia / Normothermia for HIE The following Alerting Signs identify babies who require observation for the development of hypoxic ischemic encephalopathy. When indicated, therapeutic hypothermia should only be initiated after: completion of Neonatal Resuscitation (NRP), and the ACoRN Primary Survey and Sequences consultation with the clinical transport coordinator and following a strict protocol. Therapeutic normothermia involves active thermal management to avoid hyperthermia. The aim of therapeutic normothermia is to maintain the axillary temperature between 36.0 o C and 36.5 o C. Criteria for Initiation of Therapeutic Hypothermia (Appendix F): The following must all be met prior to initiating therapeutic hypothermia NRP and ACoRN Sequences completed At risk of HIE Alerting Sign present Moderate to severe HIE present as per the Clinical Assessment of Neurological Dysfunction table Gestational age is 35 weeks Postnatal age is 6 hours No absolute contraindications (e.g. cardiorespiratory instability, severe coagulopathy, etc) Tertiary level consultation obtained

12 Clinical assessment of neurological dysfunction (p. 5-9, F-5): The presence of moderate or severe HIE is defined as seizures or signs present in at least three of the six categories below, or by the regionally recommended scoring system. Category Mild Moderate Severe Level of alertness Spontaneous activity Posture Tone hyperalert lethargy stupor or coma normal decreased activity no activity mild distal flexion arms flexed, legs extended normal hypotonic flaccid arms and legs extended Primitive reflexes Autonomic (one of) Pupils Heart rate Respirations Seizures weak suck, strong Moro dilated reactive tachycardia normal weak suck, incomplete Moro constricted bradycardia periodic breathing absent suck, absent Moro dilated or non-reactive variable heart rate apnea none absent or present absent or decerebrate Adapted from Sarnat HB et al: Neonatal encephalopathy following fetal distresss: A clinical and encephalographic study. Arch Neurol 33:695,1976. Jitteriness versus Seizures (p. 5-4): Observation Jitteriness Seizures Abnormal gaze or eye movement no yes Movements exquisitely sensitive to stimuli yes no Predominant movement tremor clonic jerking Movements cease with passive flexion yes no Autonomic changes (e.g., tachycardia, increase in blood pressure, or apnea) Adapted from Volpe JJ. Neurology of the Newborn. 5th Edition. Philadelphia: WB Saunders Company, 2008 no yes Documentation of abnormal movements (p. 5-31): Time/ duration 09:00 h 20 sec Suppress by holding No Origin/ spread Right arm, then all extremities Eye/mouth movements Eyes deviated to left Level of alertness Normal crying, auditory and visual responses when not seizing Autonomic changes No Other signs No

13 The Surgical Conditions Sequence

14 The Fluid & Glucose Management Sequence

15 Guide for enteral and intravenous fluid administration (p. 7-4): Postnatal age Day 1 (72 ml/kg/day) Baseline milk intake (if not breastfed on cue) up to 6 ml/kg 1 q 2h (9 ml/kg q 3h) Baseline intravenous intake (if not feeding) D10%W at 3 ml/kg/hour Day 2 (96 ml/kg/day) Day 3 (120 ml/kg/day) Day 4 (144 ml/kg/day) up to 8 ml/kg q 2h (12 ml/kg q 3h) up to 10 ml/kg q 2h (15 ml/kg q 3h) up to 12 ml/kg q 2h (18 ml/kg q 3h) 1 If hypoglycemic, start with 8 ml/kg q 2h. D10%W at 4 ml/kg/hour D10%W with 20 mmol/l of NaCl at 5 ml/kg/hour D10%W with 20 mmol/l of NaCl at 6 ml/kg/hour (± other electrolytes) Suggested steps for increasing glucose intake if blood glucose checks remain < 2.6 mmol/l or < 47 mg/dl (p. 7-15): Steps Enterally fed IV dextrose infusion Baseline Step 1 Step 2 Breastfeed on cue, or Feed every 2 to 3 hours Feed measured volume 8 ml/kg every 2 hours, or Start IV dextrose infusion at baseline Go to IV dextrose infusion step 1, and proceed from there D10%W, 3 ml/kg/hour (5 mg/kg/minute of glucose) D10%W, 4 ml/kg/hour (6.7 mg/kg/minute of glucose) D12.5%W, 4 to 5 ml/kg/hour (8.3 to 10.4 mg/kg/minute of glucose) Obtain consultation and investigations Consider central access if on > D12.5%W Consider glucagon or other pharmacological intervention if > D12.5%W is needed

16 The Thermoregulation Sequence

17 The Infection Sequence

18 Notes re Infection Sequence A well term baby born to an asymptomatic mother with a negative prenatal GBS screen or > 4 hours of intrapartum antibiotics, does not need specific intervention. Such a baby has no Alerting Signs for infection, and does not enter the Infection Sequence A baby who has ACoRN alerting signs with * should have diagnostic testing for sepsis and antibiotic therapy; except term and late preterm babies with mild respiratory distress lasting < 4 hours who are otherwise well and have no risk factors for infection. First-line antibiotics in sepsis occurring in the first 3 days of life are ampicillin and an aminoglycoside (usually gentamicin). If meningitis cannot be ruled out in an unwell baby, cefotaxime should be added. Notes re Transport The sending facility needs to prepare the following material to go with the baby: a copy of o prenatal, labour and delivery records o the mother s chart with all relevant neonatal history o the baby s chart o laboratory data o o o o radiographs note on the last chest radiograph if the endotracheal tube has been repositioned and no new radiographs have been taken clearly labeled specimens if requested, for example the baby s blood cultures (aerobic ± anaerobic) a maternal blood sample a cord blood sample from the placenta, useful mainly for a direct antibody (Coombs ) test the placenta, wrapped in a sealed plastic bag or placed in a bucket with a lid (no additives or preservatives) signed consent forms for transport, admission and care at the receiving hospital, and for transfusion of blood products contact information for the baby s parents and family physician.

19 Transport Neonatal Pre-Transport Communication Sheet Date & time: Physician calling: Phone Institution calling: City Phone Institution accepting: City Phone Information about the newborn Name: Reason for consultation: Date of birth Time Sex Birth weight Gestation Apgar score Eye prophylaxis? 1 min: 5 min: Vitamin K? Resuscitation: Congenital anomalies: Respiration Cardiac massage Medications / route Spontaneous: Yes ( ) No ( ) Manual ventilation: Yes( ) No ( ) Oxygen: Yes ( ) % No ( ) Intubated: Time ETT size Suctioned for meconium: Yes ( ) No ( ) Postnatal course: Curent condition: IV access / solutions RX results Blood glucose (time) Blood gases (time) Yes ( ) No ( ) Time: Started: Ended: Cord gases: ET/EV ET/EV ET/EV ET/EV HR: RR: BP: Capillary refill: sec FiO 2 : IPPV: SpO 2 : Physical exam: Medications / route: Information about the mother: Name: Age: G: P: LMP / EDC / Blood group: Rh: VDRL: Rubella: HBsAG: TB: HIV: GBS: Pos ( ) Neg ( ) Unknown ( ) Other Focused history: Labor / birth: Fetal monitoring: Yes ( ) No ( ) Internal ( ) External ( ) Auscultation ( ) Normal ( ) Abnormal ( ) Scalp blood gases Duration: 1 st stage 2 d stage SROM ( ) AROM ( ) Duration: Color: AFV: Medications: Analgesia /anesthesia: Birth: Cesarean ( ) Vaginal ( ) Forceps ( ) Vacuum ( ) Presentation: Complications: Date: Name & position: Adapted: PPPESO. Neonatal Transport. Perinatal Nursing Guidelines (3 rd Ed). Ottawa, ON: Perinatal Partnership Program of Eastern and Southeastern Ontario, 2001.

ACoRN Workbook 2010 Update

ACoRN Neonatal Society Société néonatale ACoRN A Canadian non-profit Society Vancouver, British Columbia www.acornprogram.net ACoRN Workbook 2010 Update Name: ACoRN Acute Care of at-risk Newborns The ACoRN