ACoRN Workbook 2010 Update

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Alannah Cunningham
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1 ACoRN Neonatal Society Société néonatale ACoRN A Canadian non-profit Society Vancouver, British Columbia ACoRN Workbook 2010 Update Name:

ACoRN Acute Care of at-risk Newborns The ACoRN Editorial Board Chair: Alfonso Solimano, MD, FRCPC British Columbia: Alfonso Solimano, MD, FRCPC Emily Ling, MD, FRCPC Debra O Flaherty, RN, BScN, MSN

2 ACoRN Acute Care of at-risk Newborns The ACoRN Editorial Board Chair: Alfonso Solimano, MD, FRCPC British Columbia: Alfonso Solimano, MD, FRCPC Emily Ling, MD, FRCPC Debra O Flaherty, RN, BScN, MSN Lynn Beaton, RRT Alberta: Nalini Singhal, MD, FRCPC Manitoba: Judith Littleford, MD, FRCPC Ontario: Jill Boulton, MD, FRCPC Ann Mitchell RN, BNSc, MEd Brian Simmons, MB, FRCPC David Price, BSc, MD, CCFP Newfoundland and Labrador: Khalid Aziz, MBBS, FRCPC Editorial Direction and Project Leadership Alfonso Solimano, MD, FRCPC Judith Littleford, MD, FRCPC Emily Ling, MD, FRCPC Debra O Flaherty, RN, BScN, MSN Managing Editors (first and second revised printing) Managing Editors (updated third printing, 2010 version ) Alfonso Solimano, MD, FRCPC Emily Ling, MD, FRCPC Debra O Flaherty, RN, BScN, MSN Alfonso Solimano, MD, FRCPC Debra O Flaherty, RN, BScN, MSN Horacio Osiovich, MD, FRCPC Elene Vanderpas, RN, BScN

3 The ACoRN Process

4 The Resuscitation Sequence

5 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 - 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

6 The Respiratory Score (p. 3-7): Score Respiratory rate 40 to 60/minute 60 to 80/minute > 80/minute Oxygen requirement 1 none 50% > 50% Retractions none mild to moderate severe Grunting none with stimulation continuous at rest Breath sounds on auscultation easily heard throughout decreased barely heard Prematurity > 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 Acceptable values for newborns with acute respiratory distress (p. 3-42, D-3): ph 7.25 to 7.40 PCO 2 BD 45 to 55 mmhg - 4 to + 4 mmol/l SpO 2 88 to 95%

7 The Cardiovascular Sequence

8 Signs of circulatory stability / instability (p. 4-8): Sign Stable Unstable Level of alertness, activity and tone alert, active and looking well, normal tone listless, lethargic and/or distressed, decreased tone Skin colour, and temperature well perfused, peripherally warm pale, mottled, peripherally cool Capillary refill time 3 seconds centrally and peripherally > 3 seconds Pulses easy to palpate weak, absent Mean blood pressure gestational age in weeks < gestational age in weeks Heart rate 100 to 160 bpm > 160 bpm Urine output 1 ml/kg/hour < 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 Tolerance > 75% mild to moderate usually well tolerated 65 to 75% marked may be less well tolerated if baby otherwise sick < 65% severe poorly tolerated

9 The Neurology Sequence

10 Clinical assessment of severity in HIE (p. 5-25): Mild Moderate Severe Alertness hyperalertness lethargy stupor/coma Tone normal/increased decreased flaccid Tendon reflex increased increased depressed Moro exaggerated incomplete absent Seizures absent present difficult to control Breathing regular variable apnea Suck reflex present weak absent Gag reflex present present absent Adaptado de Sarnat HB et al: Neonatal encephalopathy following fetal distress: A clinical and encephalographic study. Arch Neurol 33:695,1976 Documentation of abnormal movements (p. 5-29): Time/ duration Suppress by holding Origin/ spread Eye/mouth movements Level of alertness Autonomic changes Other signs 09:00 h 20 sec No Arm, then all extremities Eyes deviated to left Normal crying, auditory and visual responses when not seizing No No Management of temperature in newborns with HIE (p. 5-17): In babies with moderate to severe HIE it is important to initiate consultation and to consider transport to the regional referral center as soon as possible. Hyperthermia must be avoided as it increases the risk and severity of neurodevelopmental morbidities. Mild therapeutic hypothermia expertly administered and initiated within the first 6 hours of life in babies 35 weeks gestation with moderate to severe hypoxic ischemic encephalopathy decreases mortality and the severity of neurodevelopmental morbidities.

11 The Surgical Conditions Sequence

12 The Fluid & Glucose Management Sequence

13 Guide for enteral and intravenous fluid administration (p. 7-4): Postnatal age Day 1 (72 ml/kg/day) Baseline oral 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

14 The Thermoregulation Sequence

15 The Infection Sequence

16 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: Yes ( ) No ( ) Time: Started: Ended: Cord gases: ET/EV ET/EV ET/EV ET/EV Curent HR: RR: BP: Capillary refill: sec condition: FiO 2 : IPPV: SpO 2 : Physical exam: IV access / solutions Medications / route: RX results Blood glucose (time) Blood gases (time) Information about the mother: Name: Age: G: P: LMP / EDC / Blood group: Rh: VDRL: Rubeola: 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: Adaptado de: PPPESO. Neonatal Transport. Perinatal Nursing Guidelines (3 rd Ed). Ottawa, ON: Perinatal Partnership Program of Eastern and Southeastern Ontario, 2001.

Infection. Risk factor for infection ACoRN alerting sign with * Clinical deterioration. Problem List. Respiratory. Cardiovascular

Infection. Risk factor for infection ACoRN alerting sign with * Clinical deterioration. Problem List. Respiratory. Cardiovascular The ACoRN Process Baby at risk Unwell Risk factors Post-resuscitation requiring stabilization Resuscitation Ineffective breathing Heart rate < 100 bpm Central cyanosis Support Infection Risk factor for